Grabb and Smith's Plastic Surgery (7th Revised Edition)

Grabb and Smith’s
Plastic Surgery
Seventh Edition
(c) 2015 Wolters Kluwer. All Rights Reserved.

Grabb and Smith’s
Plastic Surgery
Seventh Edition
Editor-in-Chief
Charles H. Thorne, MD
Associate Professor of Plastic Surgery
NYU Medical Center
New York, New York
Editors
Kevin C. Chung, MD, MS Babak J. Mehrara, MD
Charles B. G. de Nancrede Professor of Surgery Associate Attending, Department of Surgery
Section of Plastic Surgery, Department of Surgery Memorial Sloan-Kettering Cancer Center
Professor of Orthopaedic Surgery Associate Professor of Surgery
Assistant Dean for Faculty Affairs Weill Cornell University Medical Center
Associate Director of Global REACH New York, New York
University of Michigan Medical School
Ann Arbor, Michigan J. Peter Rubin, MD
UPMC Endowed Professor and Chair, Department of
Arun K. Gosain, MD Plastic Surgery
Division Head, Plastic Surgery Professor of Bioengineering
Ann & Robert H. Lurie Children’s Hospital of Chicago Director, Life After Weight Loss Body Contouring
Professor of Plastic Surgery Program
Northwestern University Feinberg School of Medicine University of Pittsburgh and UPMC
Chicago, Illinois Pittsburgh, Pennsylvania
Geoffrey C. Gurtner, md Scott L. Spear, md

Professor, Department of Surgery Professor, Department of Plastic Surgery
Stanford University School of Medicine Georgetown University Medical Center
Stanford, California Washington, District of Columbia

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10 9 8 7 6 5 4 3 2 1
Library of Congress Cataloging-in-Publication Data

Grabb and Smith’s plastic surgery. — Seventh edition / editor-in-chief, Charles H. Thorne ; editors,
Kevin C. Chung, Arun Gosain, Geoffrey C. Gurtner, Babak Joseph Mehrara, J. Peter Rubin, Scott
L. Spear.
p. ; cm.
Plastic surgery
Preceded by Grabb and Smith’s plastic surgery / editor-in-chief, Charles H. Thorne ... [et al.] ;
editors Robert W. Beasley ... [et al.]. 6th ed. 2007.
Includes bibliographical references and index.
ISBN 978-1-4511-0955-9
I. Thorne, Charles, 1952- editor of compilation. II. Chung, Kevin C., editor of compilation. III.
Gosain, Arun, editor of compilation. IV. Guntner, Geoffrey C., editor of compilation. V. Mehrara,
Babak Joseph, editor of compilation. VI. Title: Plastic surgery.
[DNLM: 1. Reconstructive Surgical Procedures. 2. Cosmetic Techniques. 3. Surgery, Plastic.
WO 600]
RD118
617.9’5—dc23
2013017779
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To our patients who have inspired, humbled, frustrated,
and taught us, and without whom this book
would have no reason to exist.
——Charles H. Thorne, MD

Contributing Authors
David M. Adelman, MD, PhD Scott P. Bartlett, MD

Assistant Professor Professor, Department of Surgery
Department of Plastic Surgery Perelman School of Medicine at the University of Pennsylvania
The University of Texas MD Anderson Cancer Center Chief, Division of Plastic Surgery
Houston, Texas Children’s Hospital of Philadelphia
Philadelphia, Pennsylvania
Jamil Ahmad, MD
Staff Plastic Surgeon Fritz E. Barton, Jr., MD
The Plastic Surgery Clinic Professor, Plastic Surgery
Mississauga, Ontario University of Texas Southwestern Medical Center
Dallas, Texas
Al S. Aly, MD
Professor Nicholas Bastidas, MD
Aesthetic & Plastic Surgery Institute Attending Physician
University of California Irvine North Shore-LIJ Health System
Orange, California New York, New York
Katerina Anesti, MD, MRCS Bruce S. Bauer, MD

Clinical Fellow Clinical Professor of Surgery, Plastic Surgery
Department of Plastic and Reconstructive Surgery University of Chicago, Pritzker School of Medicine
Guy’s and St Thomas’ NHS Trust Chicago, Illinois
London, United Kingdom Chief, Division of Plastic and Reconstructive Surgery
North Shore University Health System
Mark W. Ashton, MD Highland Park, Illinois
Head, Reconstructive Plastic Surgery
Royal Melbourne Hospital Michael S. Beckenstein, MD
Victoria, Australia Alabama Breast Surgery Center
Birmingham, Alabama
Christopher E. Attinger, MD
Professor, Department of Plastic Surgery Keith M. Blechman, MD
Georgetown University Chief Resident
Washington, District of Columbia Institute for Reconstructive Plastic Surgery
New York University School of Medicine
Kodi Azari, MD New York, New York
Associate Professor
Department of Orthopaedic Surgery and Division of George C. Bohle III, DDS
Plastic Surgery Implant & Prosthodontic Associates
David Geffen School of Medicine at UCLA Oklahoma City, Oklahoma
Los Angeles, California
James P. Bradley, MD
Stephen B. Baker, MD, DDS Professor, Sarnat Chair
Professor and Program Director Division of Plastic Surgery
Department of Plastic Surgery University of California, Los Angeles
Georgetown University Hospital Los Angeles, California
Washington, District of Columbia
Co-Director Gerald Brandacher, MD
Craniofacial Anomalies Program Associate Professor
INOVA Fairfax Hospital for Children Department of Plastic and Reconstructive Surgery
Falls Church, Virginia Johns Hopkins University School of Medicine
Baltimore, Maryland
Karim Bakri, MD
Chief Resident Donald W. Buck II, MD
Division of Plastic Surgery Division of Plastic & Reconstructive Surgery
Mayo Clinic Northwestern University
Rochester, Minnesota Chicago, Illinois
vi
Contributing Authors vii
Louis P. Bucky, MD Daniel J. Ceradini, MD
Clinical Professor Assistant Professor
Department of Surgery Department of Plastic Surgery
University of Pennsylvania School of Medicine New York University School of Medicine
Chief of Plastic Surgery Chief of Plastic Surgery
Pennsylvania Hospital Manhattan Veterans Administration Hospital
Philadelphia, Pennsylvania New York, New York
Duc T. Bui, MD Benjamin Chang, MD

Associate Professor of Surgery Associate Professor of Clinical Surgery
Department of Surgery Division of Plastic Surgery
Director, Reconstructive Breast Surgery The Perelman School of Medicine at the University
Division of Plastic and Reconstructive Surgery of Pennsylvania
Stony Brook School of Medicine Attending Surgeon
Stony Brook, New York Division of Plastic Surgery
The Children’s Hospital of Philadelphia
Renee M. Burke, MD Philadelphia, Pennsylvania
Plastic Surgeon
Department of Surgery James Chang, MD
Good Shepherd Hospital Professor, Departments of Surgery (Plastic Surgery)
Barrington, Illinois & Orthopaedic Surgery
Plastic Surgeon Stanford University Medical Center
Chicago Aesthetic Surgery Institute Chief, Division of Plastic & Reconstructive Surgery
Rosemont, Illinois Stanford University Medical Center
Palo Alto, California
Mary C. Burns, OTR/L, CHT
Assistant Professor Johnny T. Chang, MD, MSME
Southern Illinois University School of Medicine Brown Medical School
Certified Hand Therapist Providence, Rhode Island
Division of Plastic Surgery
Southern Illinois University School of Medicine Hand Therapy Center David W. Chang, MD
Springfield, Illinois Professor, Department of Plastic Surgery
M.D. Anderson Cancer Center
Charles E. Butler, MD
Houston, Texas
Professor with Tenure
Department of Plastic Surgery Harvey Chim, MBBS
The University of Texas MD Anderson Cancer Center Chief Resident, Plastic Surgery
Houston, Texas Case School of Medicine
Cleveland, Ohio
Dominick Cannavo, MD
New York, New York Matthew S.S. Choi, MD
Associate Professor of Plastic Surgery
Joseph N. Carey, MD
Department of Plastic and Reconstructive Surgery
Assistant Professor Hanyang University College of Medicine
Division of Plastic Surgery Seoul, South Korea
University of Southern California Chief, Department of Plastic and Reconstructive Surgery
Chief, Plastic Surgery Hanyang University Guri Hospital
LAC + USC Medical Center Guri, Gyunggi-do, South Korea
J. Guilherme Christiano, MD
Brian T. Carlsen, MD Assistant Professor
Assistant Professor Division of Plastic Surgery
Division of Plastic Surgery, Division of Hand Surgery University of Rochester
Mayo Clinic Rochester, New York
Rochester, Minnesota
Kevin C. Chung, MD, MS
Grant W. Carlson, MD Charles B. G. de Nancrede Professor of Surgery
Professor of Surgery Section of Plastic Surgery, Department of Surgery
Emory University Professor of Orthopaedic Surgery
Wadley R. Glenn Professor of Surgery, Chief of the Division of Assistant Dean for Faculty Affairs
Plastic Surgery Associate Director of Global REACH
Emory University Hospital University of Michigan Medical School
Atlanta, Georgia Ann Arbor, Michigan

viii Contributing Authors
Mark W. Clemens, MD Matthias B. Donelan, MD

Assistant Professor Chief, Plastic Surgery
Department of Plastic Surgery Department of Surgery
MD Anderson Cancer Center Shriners Hospitals for Children—Boston
Houston, Texas Associate Clinical Professor of Surgery
Harvard Combined Plastic Surgery Residency
Mark A. Codner, MD Training Program
Assistant Professor Harvard Medical School
Department of Plastic Surgery Boston, Massachusetts
Emory University
Atlanta, Georgia Susan E. Downey, MD
Associate Clinical Professor
Stephen H. Colbert, MD Department of Surgery (Plastic)
Assistant Professor Keck University of Southern California School of Medicine
Department of Surgery Los Angeles, California
University of Missouri
Head, Hand & Microsurgery Gregory A. Dumanian, MD
Division of Plastic Surgery Professor of Surgery
University of Missouri Health Care Division of Plastic Surgery
Columbia, Missouri Chief of Plastic Surgery
Northwestern Feinberg School of Medicine
Damon S. Cooney, MD, PhD
Chicago, Illinois
Assistant Professor of Plastic and Reconstructive Surgery
Johns Hopkins University School of Medicine Anthony Echo, MD
Baltimore, Maryland Clinical Instructor
Peter G. Cordeiro, MD
Stanford University Medical Center
Chief, Plastic & Reconstructive Surgery Palo Alto, California
Memorial Sloan-Kettering Cancer Center
New York, New York Cherry L. Estilo, DMD
Russell J. Corlett, MD Associate Attending
Department of Surgery
Jack Brockhoff Reconstructive Plastic Surgery Memorial Sloan-Kettering Cancer Center
Research Unit Assistant Attending
Department of Anatomy and Cell Biology Department of Surgery
University of Melbourne New York Presbyterian Hospital/Cornell
Melbourne, Australia New York, New York
Catherine M. Curtin, MD
Derek Fletcher, MD
Staff Physician
Resident, Plastic Surgery
University of Pittsburgh School of Medicine
Palo Alto Veterans Hospital
Pittsburgh, Pennsylvania
Assistant Professor
Division of Plastic Surgery Robert D. Galiano, MD
Stanford University
Assistant Professor
Palo Alto, California
Department of Surgery, Division of Plastic Surgery
Daniel Alexander Del Vecchio, MD, MBA Northwestern University Feinberg School of Medicine
Chicago, Illinois
Associate Clinical Staff
Department of Surgery Mary K. Gingrass, MD
Massachusetts General Hospital
Boston, Massachusetts Assistant Clinical Professor
Department of Plastic Surgery
Christopher A. Derderian, MD Vanderbilt University School of Medicine
Assistant Professor Nashville, Tennessee
Chad R. Gordon, DO
UT Southwestern Medical Center
Pediatric and Craniofacial Surgery Assistant Professor
Children’s Medical Center Johns Hopkins University School of Medicine
Dallas, Texas Clinical Director, Face Transplant Program
The Johns Hopkins Hospital
Joseph J. Disa, MD Baltimore, Maryland
Attending Physician
Department of Surgery Arun K. Gosain, MD
Memorial Sloan-Kettering Cancer Center Division Head, Plastic Surgery
Professor of Surgery Ann & Robert H. Lurie Children’s Hospital of Chicago
Department of Surgery Professor of Plastic Surgery
Wiell Cornell College of Medicine Northwestern University Feinberg School of Medicine
New York, New York Chicago, Illinois

Contributing Authors ix
Nikolaus Gravenstein, MD Scott L. Hansen, MD
The Jerome H. Modell, MD Professor of Anesthesiology Assistant Professor
Professor of Neurosurgery Department of Surgery
Professor of Periodontology University of California, San Francisco
University of Florida College of Medicine San Francisco, California
Gainesville, Florida
Maximilian W.B. Hartmannsgruber, MD
Lorelei J. Grunwaldt, MD Attending Anesthesiologist
Assistant Professor of Surgery Anesthesia Associates of Park Avenue
Department of Plastic Surgery New York, New York
University of Pittsburgh Medical Center
Pittsburgh, Pennsylvania Robert J. Havlik, MD
J.J. Harbaugh Jr. Professor of Surgery and Chief
Geoffrey C. Gurtner, MD
Professor Indiana University
Department of Surgery Director, Cleft and Craniofacial Surgery
Stanford University School of Medicine Riley Hospital for Children
Stanford, California Indiana University School of Medicine
Indianapolis, Indiana
Nicholas T. Haddock, MD
Assistant Professor Larry H. Hollier, Jr. MD
Department of Plastic Surgery Professor, Division of Plastic Surgery
University of Texas Southwestern Medical Center Residency Program Director
Dallas, Texas Baylor College of Medicine
J. Joris Hage, MD, PhD Houston, Texas
Chief, Department of Plastic and Reconstructive Surgery Richard A. Hopper, MD, MS

Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital
Associate Professor
Amsterdam, The Netherlands
Elizabeth J. Hall-Findlay, MD University of Washington
Chief, Division of Plastic Surgery
Plastic Surgeon
Seattle Children’s Hospital
Mineral Springs Hospital
Seattle, Washington
Banff Alberta, Canada
Eric G. Halvorson, MD Erik A. Hoy, MD, MBA

Assistant Professor of Surgery Attending Physician, Plastic Surgery
Residency Program Director UHS
Director of Microsurgery Binghamton, New York
Division of Plastic & Reconstructive Surgery
Joseph P. Hunstad, MD
University of North Carolina
Chapel Hill, North Carolina Associate Consulting Professor
Warren C. Hammert, MD University of North Carolina
Associate Professor Section Head, Department of Plastic Surgery
Department of Orthopaedic Surgery Carolinas Medical Center University Hospital
Associate Professor Charlotte, North Carolina
Joseph M. Huryn, DDS
University of Rochester Medical Center Chief, Dental Service
Rochester, New York Department of Surgery
Memorial Sloan-Kettering Cancer Center
Dennis C. Hammond, MD Professor of Surgery (Oral and Maxillofacial Surgery)
Partners in Plastic Surgery of West Michigan Department of Surgery
Associate Program Director Weill Medical College of Cornell University
Plastic and Reconstructive Surgery New York, New York
Grand Rapids Medical Education Partners
Grand Rapids, Michigan Jeffrey E. Janis, MD
Associate Professor and Program Director
Matthew M. Hanasono, MD Department of Plastic Surgery
Associate Professor University of Texas Southwestern Medical Center
Department of Plastic Surgery Chief of Plastic Surgery
The University of Texas MD Anderson Cancer Center Parkland Health and Hospital System
Houston, Texas Dallas, Texas

x Contributing Authors
Suhail K. Kanchwala, MD Emil J. Kohan, MD

Assistant Professor of Surgery Resident Physician
Department of Plastic Surgery Aesthetic and Plastic Surgery Institute
Hospital of the University of Pennsylvania University of California, Irvine
Philadelphia, Pennsylvania Orange, California
Michael A.C. Kane, MD John C. Koshy, MD

Associate Attending Physician Resident Physician
Department of Plastic Surgery Division of Plastic Surgery
Manhattan Eye, Ear & Throat Hospital Michael E. Debakey Department of Surgery
New York, New York Baylor College of Medicine
Houston, Texas
Nolan S. Karp, MD
Wee Leon Lam, MBChB, M Phil
Associate Professor
Department of Plastic Surgery Consultant Plastic Surgeon
New York University School of Medicine Department of Plastic, Reconstructive and Hand Surgery
Chief, Plastic Surgical Service Royal Hospital for Sick Children
Department of Plastic Surgery Edinburgh, United Kingdom
Tisch Hospital, NYU Langone Medical Center St John’s Hospital at Howden
New York, New York Livingston, United Kingdom
Armen K. Kasabian, MD Angela Song Landfair, MD

System Chief Chief Resident, Plastic Surgery
Department of Plastic Surgery Section of Plastic Surgery at Magee Women’s Hospital
North Shore-LIJ Health System Department of Plastic Surgery
New Hyde Park, New York University of Pittsburgh Medical Center
Henry K. Kawamoto, MD, DDS
Patrick Lang, MD
Clinical Professor
Resident, Division of Plastic and Reconstructive Surgery
University of California, San Francisco
University of California at Los Angeles
San Francisco, California
Howard N. Langstein, MD
Patrick Kelley, MD
Professor of Surgery
Medical Director, Craniofacial Center
Children’s Hospital of Austin
University of Rochester School of Medicine
Austin, Texas
Rochester, New York
Timothy W. King, MD, PhD W. P. Andrew Lee, MD
Assistant Professor Professor and Chairman
Departments of Surgery and Pediatrics Department of Plastic and Reconstructive Surgery
University of Wisconsin School of Medicine and Public Health Johns Hopkins University School of Medicine
Plastic Surgery Section Chief Baltimore, Maryland
William S. Middleton Memorial Veterans Hospital Gordon K. Lee, MD
Madison, Wisconsin Assistant Professor
Matthew B. Klein, MD
Residency Program Director
Assistant Professor Division of Plastic Surgery
Department of Plastic Surgery Stanford University School of Medicine
University of Washington Stanford, California
Associate Director
University of Washington Burn Center Valerie Lemaine, MD, MPH
Harborview Medical Center Assistant Professor of Plastic Surgery
Seattle, Washington Department of Surgery
James Knoetgen III, MD Senior Associate Consultant
Private Practice Department of Surgery
Fresno, California Division of Plastic Surgery
Mayo Clinic
Matthew E. Koepplinger, DO Rochester, Minnesota
Assistant Professor
Department of Orthopaedic Surgery Ashley K. Lentz, MD
University of Texas—Houston Health Science Center Assistant Professor of Surgery
Attending Physician, Division of Hand and Upper Extremity Surgery University of Florida
Houston, Texas Gainesville, Florida

Contributing Authors xi
Salvatore C. Lettieri, MD Susan E. MacKinnon, MD
Assistant Professor of Plastic Surgery Professor and Chief
Rochester, Minnesota Division of Plastic and Reconstructive Surgery
Consultant, Department of Surgery Washington University School of Medicine
Division of Plastic Surgery Surgeon and Chief
Mayo Clinic Department of Surgery, Division of Plastic and
Rochester, Minnesota Reconstructive Surgery
Barnes-Jewish Hospital
Benjamin Levi, MD Saint Louis, Missouri
House Officer
Department of Surgery Evan Matros, MD, MMSC
Division of Plastic and Reconstructive Surgery Assistant Surgeon
University of Michigan Department of Surgery
Ann Arbor, Michigan Memorial Sloan-Kettering Cancer Center
Associate Professor
Steven M. Levine, MD Department of Surgery
Clinical Instructor Weill Cornell Medical School
Institute of Reconstructive Plastic Surgery New York, New York
New York University Langone Medical Center
New York, New York Joseph G. McCarthy, MD
Lawrence D. Bell Professor of Plastic Surgery & Helen Kimmel
Jamie P. Levine, MD
Professor of Reconstructive Plastic Surgery
Associate Professor, Plastic Surgery Department of Plastic Surgery
Chief of Microsurgery, Plastic Surgery New York University School of Medicine
NYU Langone Medical Center Chair, Department of Plastic Surgery
Chief of Plastic Surgery New York University Langone Medical Center
Bellevue Hospital New York, New York
New York, New York
Babak J. Mehrara, MD
Eric C. Liao, MD, PhD
Associate Attending, Surgery
Assistant Professor of Surgery Memorial Sloan-Kettering Cancer Center
Massachusetts General Hospital, Harvard Medical School Associate Professor, Surgery
Principal Investigator Weill Cornell University Medical Center
Center for Regenerative Medicine New York, New York
Harvard Stem Cell Institute
Boston, Massachusetts Frederick J. Menick, MD
Paul K. Lim, MD, FACS Private Practice
Tucson, Arizona
Assistant Professor
Department of Surgery Scott A. Mitchell, MD
University of Minnesota Medical School
Assistant Professor
Minneapolis, Minnesota
Department of Orthopaedic Surgery
Plastic Surgeon
University of California, Los Angeles
Center for Craniofacial Services
Santa Monica, California
Gillette Children’s Specialty Healthcare
St. Paul, Minnesota Steven L. Moran, MD
Michael A. Loffredo, MD Professor, Plastic Surgery and Orthopaedics
Private Practice Chair of Plastic Surgery
Cape and Islands Plastic Surgery Mayo Clinic
Hyannis, Massachusetts Rochester, Minnesota
Z. Paul Lorenc, MD Maurice Y. Nahabedian, MD

Attending Professor, Department of Plastic Surgery
Plastic Surgery Georgetown University
North Shore/LIJ Lenox Hill Hospital Washington, District of Columbia
Lorenc Aesthetic Plastic Surgery Center
New York, New York
James D. Namnoum, MD
Assistant Clinical Professor
David W. Low, MD Department of Plastic Surgery
Professor of Surgery Emory University
Division of Plastic Surgery Partner
Perelman School of Medicine at the University of Pennsylvania Atlanta Plastic Surgery
Philadelphia, Pennsylvania Atlanta, Georgia

xii Contributing Authors
Kate W. Nellans, MD, MPH Ivona Percec, MD, PhD

Hand Fellow Assistant Professor
Division of Plastic Surgery Perelman School of Medicine at the University of Pennsylvania
University of Michigan School of Medicine Philadelphia, Pennsylvania
Ann Arbor, Michigan
Linda G. Phillips, MD
David T. Netscher, MD Truman G. Blocker Distinguished Professor
Clinical Professor Chief, Division of Plastic Surgery
Department of Orthopaedic Surgery and UTMB Galveston
Division of Plastic Surgery Galveston, Texas
Baylor College of Medicine
Chief, Plastic Surgery Benjamin Z. Phillips, MD, MPH
VA Medical Center Chief Resident, Department of Plastic Surgery
Chief, Hand Surgery The Warren Alpert Medical School of Brown University
St. Luke’s Episcopal Hospital Providence, Rhode Island
Chief, Hand Surgery
Department of Orthopaedic Surgery and Karen L. Powers, MD
Division of Plastic Surgery Assistant Professor
Baylor College of Medicine Department of Surgery, Division of Plastic Surgery
Houston, Texas University of Texas Medical Branch
Galveston, Texas
Michael W. Neumeister, MD
Julian J. Pribaz, MD
Professor & Chairman
Division of Plastic Surgery Professor of Surgery, Department of Surgery
Southern Illinois University School of Medicine Harvard Medical School
The Elvin G. Zook Endowed Chair Boston, Massachusetts
Springfield, Illinois
Adrian M. Przybyla, MD
Bianca M. B. Ohana, MD Aesthetic Surgery Fellow
Marina Plastic Surgery Associates
Plastic Surgery Private Clinic
Marina del Rey, California
Salt Lake City, Utah
Leo R. Otake, MD, PhD Mark E. Puhaindran, MBBS, MRCS

Consultant, Department of Hand and Reconstructive Microsurgery
Clinical Instructor
National University Hospital
Singapore
Stanford University School of Medicine
Palo Alto, California Remus Repta, MD
Assistant Clinical Professor
Plastic and Reconstructive Surgery
Department of Surgery, Section of Plastic Surgery
Advanced Aesthetic Associates
Yale University School of Medicine
Scottsdale, Arizona
New Haven, Connecticut
Gary F. Rogers, MD
David M. Otterburn, MD
Division Chief, Plastic and Reconstructive Surgery
Assistant Professor of Surgery (Plastic Surgery) Children’s National Medical Center
Weill Cornell Medical College Washington, DC
Assistant Attending Surgeon
NewYork-Presbyterian Hospital Rod J. Rohrich, MD
New York, New York Professor and Chairman
Crystal Charity Ball Distinguished Chair in Plastic Surgery
Nima P. Patel, MD
Betty and Warren Woodward Chair in Plastic and Reconstructive Surgery
Private Practice Distinguished Teaching Professor
New York, New York Department of Plastic Surgery
Attending Surgeon and Chief of Microvascular Surgery UT Southwestern Medical Center
Department of Surgery Dallas, Texas
Maimonides Medical Center
Brooklyn, New York Harvey M. Rosen, MD, DMD
Associate Professor, Surgery
William C. Pederson, MD University of Pennsylvania School of Medicine
Adjunct Professor Philadelphia, Pennsylvania
University of Texas Health Science Center at San Antonio Stephen Alex Rottgers, MD
Fellowship Director Integrated Plastic Surgery Resident
Hand Surgery Fellowship Department of Plastic and Reconstructive Surgery
The Hand Center of San Antonio University of Pittsburgh School of Medicine
San Antonio, Texas Pittsburgh, Pennsylvania

Contributing Authors xiii
J. Peter Rubin, MD W. Grant Stevens, MD
UPMC Endowed Professor and Chair, Department of Plastic Surgery Clinical Professor of Surgery
Professor of Bioengineering Department of Plastic Surgery
Director, Life After Weight Loss Body Contouring Program Keck School of Medicine of USC
University of Pittsburgh School of Medicine and UPMC Los Angeles, California
Pittsburgh, Pennsylvania Medical Director
USC – Marina del Rey Aesthetic Surgery Fellowship
Pierre B. Saadeh, MD University of Southern California
Residency Program Director Marina del Rey, California
New York University School of Medicine Patrick K. Sullivan, MD
New York, New York Associate Professor, Plastic Surgery
Brown University School of Medicine
Justin M. Sacks, MD Division Chief, Aesthetic Surgery
Assistant Professor Providence, Rhode Island
Department of Plastic and Reconstructive Surgery
Johns Hopkins School of Medicine Geoffrey Ian Taylor, AO, MD
Baltimore, Maryland Professor, Anatomy and Neuroscience
University of Melbourne
Jhonny A. Salomon, MD
Senior Consultant, Reconstructive Plastic Surgery
Private Practice Royal Melbourne Hospital
Coral Gables, Florida Victoria, Australia
Renato Saltz, MD Steven Alan Teitelbaum, MD
Saltz Plastic Surgery and Spa Vitoria Assistant Clinical Professor
Salt Lake City and Park City, Utah Plastic Surgery
Douglas M. Sammer, MD David Geffen School of Medicine at UCLA
Associate Professor, Plastic Surgery
University of Texas Southwestern Medical School Julia K. Terzis, MD, PhD
Dallas, Texas
Adjunct Professor
Hani Sbitany, MD Department of Plastic Surgery
New York University Medical Center
Assistant Professor of Surgery
Clinical Professor
Division of Plastic and Reconstructive Surgery
Department of Surgery, Division of Plastic and
University of California, San Francisco
Reconstructive Surgery
Attending Physician
New York-Presbyterian Hospital, The University of
Columbia & Cornell
San Francisco General Hospital
New York, New York
San Francisco, California
Sandeep Jacob Sebastin, MCh (Plast) Alisa C. Thorne, MD

Consultant, Department of Hand & Reconstructive Microsurgery Professor of Clinical Anesthesia
National University Hospital Memorial Sloan-Kettering Cancer Center
Singapore New York, New York
Kenneth C. Shestak, MD Paul H. Tran, MD

Professor of Plastic Surgery Instructor in Plastic Surgery
Department of Plastic Surgery Division of Plastic Surgery, Department of Surgery
University of Pittsburgh School of Medicine Mayo Clinic
Chief of Plastic Surgery Magee Women’s Hospital Rochester, Minnesota
Robin H. Unger, MD
Jaimie T. Shores, MD Private Practice
Assistant Professor New York, New York
Department of Plastic and Reconstructive Surgery Assistant Clinical Professor
Johns Hopkins University School of Medicine Mount Sinai Hospital
Baltimore, Maryland New York, New York
Scott L. Spear, MD Walter P. Unger, MD., FRCP(C), FACP

Professor, Department of Plastic Surgery Clinical Professor (Dermatology)
Georgetown University Hospital Mount Sinai School of Medicine
Washington, District of Columbia New York

xiv Contributing Authors
Allen L. Van Beek, MD Carlos K. Wesley, MD

Adjunct Professor Private Practice
Department of Surgery New York, New York
University Minnesota School of Medicine
Minneapolis, Minnesota Bradon J. Wilhelmi, MD
Professor and Chief
Andrea E. Van Pelt, MD Division of Plastic Surgery
Clinical Assistant Professor University of Louisville
Surgery/Plastic and Reconstructive Surgery Louisville, Kentucky
Michigan State University
Attending Physician Victor W. Wong, MD
Plastic and Reconstructive Surgery Chief Resident in Surgery
Grand Rapids Medical Education Partners Department of Surgery
Grand Rapids, Michigan Oregon Health Sciences University
Portland, Oregon
Stephen M. Warren, MD
Associate Professor of Plastic Surgery Michael J. Yaremchuk, MD
Department of Plastic Surgery Professor of Surgery
New York University Langone Medical Center Harvard Medical School
New York, New York Chief of Craniofacial Surgery
Surgery
Fu-Chan Wei, MD Massachusetts General Hospital
Professor, Department of Plastic Surgery Boston, Massachusetts
Chang Gung University and Medical College
Taoyuan, Taiwan

Preface
Given the availability of information and images from the The book is intended for medical professionals and train-
Internet, is a hard-bound, single-volume, old-fashioned, com- ees at all levels: practicing plastic surgeons, surgeons in related
prehensive textbook of plastic surgery an anachronism? Having fields such as ophthalmology, otolaryngology, oral surgery,
spent three years on this book, I am afraid to confront the orthopaedics and general surgery, surgery residents in all sub-
answer to that question. What I do know is that there is noth- specialties, medical students, physician’s assistants, nurses,
ing like taking a real book to bed—well, almost nothing. I fell and nurse practitioners.
asleep reading Grabb and Smith when I was a medical student How is the seventh edition different from the sixth edition?
and a surgery resident and a craniofacial fellow and as a young First, the new edition is in color. Second, 55 of the 99 chapters
attending and I will be damned if current students, trainees, and are entirely new with new authors. The remaining chapters
young practitioners will not have that opportunity. I am kid- have been rewritten and are almost all substantively different
ding, of course. My motivation for editing this tome for the third from their predecessors. A new section on Body Contouring
and final time was less altruistic. I derive immense satisfaction has been added. The Transplantation chapter has been
from having a familiarity with the entire body of plastic surgical updated to reflect the extraordinary recent advances in that
knowledge and having read every word herein three times has field. The Hand section is entirely new with a new editor, new
hopefully provided that. I have been known to say to the resi- chapters, and new authors. Other changes such as consolida-
dents, only half in jest, that I will retire when one of them knows tion of chapters and changes in the sections are admittedly
more than I do. If there is anything more fun than learning, I more modest.
would appreciate someone telling me what it is…soon. I would like to thank the coeditors (who designed the sec-
A comprehensive, single-volume textbook of plastic surgery tions, chose the authors, and edited the text), the authors (who
will hopefully accomplish the following: (1) define the spec- put up with ruthless editing so that the book would remain a
trum that is plastic surgery; (2) provide a convenient source single volume), Lippincott Williams & Wilkins, Jenny Koleth,
of information for day-to-day studying; (3) deliver an attrac- and Sarah Granlund for their contributions.
tive introduction to the interested or uninitiated reader; and
(4) serve as the best single source for board exam preparation. Charles H. Thorne, MD
xv
Contents
Preface xv 18 Lasers In Plastic Surgery . . . . . . . . . . . . . . . . . . . . . 163

David W. Low and Ivona Percec
PART 1:
Principles, Techniques, and Basic Science part 3:
Congenital Anomalies and Pediatric
1 Techniques and Principles in Plastic Surgery . . . . . . . . 1 Plastic Surgery
Charles H. Thorne
19 Cleft Lip and Palate: Embryology, Principles,
2 Wound Healing: Normal and Abnormal . . . . . . . . . 13
and Treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173
Geoffrey C. Gurtner and Victor W. Wong
Richard A. Hopper
3 Wound Care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
20 Congenital Melanocytic Nevi . . . . . . . . . . . . . . . . . 200
Donald W. Buck and Robert D. Galiano
Harvey Chim and Arun K. Gosain
4 The Blood Supply of the Skin and Skin Flaps . . . . . . 29
21 Vascular Anomalies . . . . . . . . . . . . . . . . . . . . . . . . 206
Geoffrey Ian Taylor, Russell J. Corlett,
and Mark W. Ashton
22 Single-Suture Craniosynostosis and Deformational
5 Muscle Flaps and their Blood Supply . . . . . . . . . . . . 43
Plagiocephaly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 221
Jamie P. Levine
Gary F. Rogers and Stephen M. Warren
6 Transplantation Biology and Applications to
23 Craniosynostosis Syndromes . . . . . . . . . . . . . . . . . . 232
Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Scott P. Bartlett and Christopher A. Derderian
Damon S. Cooney, Justin M. Sacks, Gerald
Brandacher, and W. P. Andrew Lee 24 Craniofacial Microsomia and Principles
of Craniofacial Distraction . . . . . . . . . . . . . . . . . . . 241
7 Implant Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . 64
Joseph G. McCarthy
Timothy W. King
25 Orthognathic Surgery . . . . . . . . . . . . . . . . . . . . . . . 252
8 Principles of Microsurgery . . . . . . . . . . . . . . . . . . . . 70
Stephen B. Baker
Charles E. Butler and David M. Adelman
26 Craniofacial Clefts and Hypertelorbitism . . . . . . . . 266
9 Principles and Techniques of Peripheral Nerve
James P. Bradley and Henry K. Kawamoto
Repair, Grafts, and Transfers . . . . . . . . . . . . . . . . . . 77
Susan E. Mackinnon and Stephen H. Colbert 27 Ear Reconstruction . . . . . . . . . . . . . . . . . . . . . . . . . 283
Charles H. Thorne
10 Tissue Expansion . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
Ashley K. Lentz and Bruce S. Bauer 28 Miscellaneous Craniofacial Conditions: Fibrous
Dysplasia, Moebius Syndrome, Romberg
11 Principles of Office Sedation for Cosmetic Surgery . . . 94 Syndrome, Treacher Collins Syndrome,
Maximilian W. B. Hartmannsgruber, Dermoid Cyst, and Neurofibromatosis . . . . . . . . . . 295
Dominick Cannavo, and Nikolaus Gravenstein Robert J. Havlik
12 Local Anesthetics . . . . . . . . . . . . . . . . . . . . . . . . . . 100
Alisa C. Thorne
part 4:
Head and Neck
part 2:
29 Soft-Tissue and Skeletal Injuries of the Face . . . . . . 311
Skin and Soft Tissue
Larry H. Hollier Jr., Patrick Kelley, and John C. Koshy
13 Dermatology for Plastic Surgeons I—Skin care 30 Head and Neck Cancer and Salivary
and Benign Dermatologic Conditions . . . . . . . . . . . 105 Gland Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . 327
Renato Saltz and Bianca M. B. Ohana David M. Otterburn and Pierre B. Saadeh
14 Dermatology for Plastic Surgeons II—Cutaneous 31 Reconstruction of the Scalp, Calvarium,
Malignancies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 115 and Forehead . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 342
Daniel J. Ceradini and Keith M. Blechman J.Guilherme Christiano, Nicholas Bastidas, and
15 Thermal, Chemical, and Electrical Injuries . . . . . . . 127 Howard N. Langstein
Matthew B. Klein 32 Reconstruction of the Eyelids, Correction
16 Principles of Burn Reconstruction . . . . . . . . . . . . . . 142 of Ptosis, and Canthoplasty . . . . . . . . . . . . . . . . . . 352
Matthias B. Donelan and Eric C. Liao Nicholas T. Haddock
17 Radiation and Radiation Injuries . . . . . . . . . . . . . . 155 33 Nasal Reconstruction . . . . . . . . . . . . . . . . . . . . . . . 361
James Knoetgen III and Salvatore C. Lettieri Frederick J. Menick
xvi
Contents xvii
34 Reconstruction of Acquired Lip Deformities . . . . . . 372 55 Breast Reduction: Inverted-t Technique . . . . . . . . . 593
Evan Matros and Julian J. Pribaz Scott L. Spear
35 Reconstruction of the Cheeks . . . . . . . . . . . . . . . . . 384 56 Vertical Reduction Mammaplasty . . . . . . . . . . . . . 603
Babak J. Mehrara Elizabeth J. Hall-Findlay
36 Facial Paralysis . . . . . . . . . . . . . . . . . . . . . . . . . . . . 399 57 Gynecomastia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 615
Julia K. Terzis and Katerina Anesti Nolan S. Karp
37 Mandible Reconstruction . . . . . . . . . . . . . . . . . . . . 410 58 Breast Cancer: Current Trends in Screening,
Joseph J. Disa and Evan Matros Patient Evaluation, and Treatment . . . . . . . . . . . . . 620
38 Craniofacial and Maxillofacial Prosthetics . . . . . . . 420
Grant W. Carlson
George C. Bohle III, Cherry L. Estilo, and 59 Breast Reconstruction: Prosthetic Techniques . . . . . 625
Joseph M. Huryn Joseph J. Disa and Nima P. Patel
39 Reconstruction of the Maxilla and Skull Base . . . . . 430 60 Latissimus Dorsi Flap Breast Reconstruction . . . . . 636
Eric G. Halvorson, Duc T. Bui, and Dennis C. Hammond and Michael A. Loffredo
Peter G. Cordeiro 61 Breast Reconstruction: Tram Flap Techniques . . . . 643
40 Reconstruction of the Oral Cavity, Pharynx, James D. Namnoum
and Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . . . . 443 62 Breast Reconstruction: Free Flap Techniques . . . . . 649
Matthew M. Hanasono Maurice Y. Nahabedian
63 Nipple Reconstruction . . . . . . . . . . . . . . . . . . . . . . 662
part 5: Michael S. Beckenstein
Aesthetic Surgery 64 Congenital Anomalies of the Breast: Tuberous
Breasts, Poland’s Syndrome, and Asymmetry . . . . . 668
41 Skin Resurfacing . . . . . . . . . . . . . . . . . . . . . . . . . . . 451 Kenneth C. Shestak, Stephen Alex Rottgers,
Fritz E. Barton Lorelei J. Grunwaldt, Derek Fletcher,
42 Dermal and Soft-Tissue Fillers: Principles, and Angela Song Landfair
Materials, and Techniques . . . . . . . . . . . . . . . . . . . 458
Z. Paul Lorenc
part 7:
43 Botulinum Toxin . . . . . . . . . . . . . . . . . . . . . . . . . . 464
Michael A.C. Kane Body Contouring
44 Fat Grafting in Plastic Surgery . . . . . . . . . . . . . . . . 473 65
Liposuction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 679
Louis P. Bucky, Ivona Percec, and Mary K. Gingrass
Daniel Del Alexander Vecchio 66 Abdominoplasty and Belt Lipectomy . . . . . . . . . . . 688
45 Forehead and Brow Rejuvenation . . . . . . . . . . . . . . 480 Al S. Aly and Emil J. Kohan
Benjamin Z. Phillips, Erick A. Hoy, Johnny T. Chang, 67 Lower Body Lift and Thighplasty . . . . . . . . . . . . . . 696
Jhonny A. Salomon, and Patrick K. Sullivan Joseph P. Hunstad and Remus Repta
46 Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . 487 68 Brachioplasty and Upper Trunk Contouring . . . . . . 707
Mark A. Codner and Renee M. Burke Susan E. Downey
47 Facelift . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 501 69 Principles of Plastic Surgery After Massive
Charles H. Thorne Weight Loss . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 713
48 Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 512 J. Peter Rubin
Jeffrey E. Janis, Jamil Ahmad, and Rod J. Rohrich
49 Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 530 part 8:
Charles H. Thorne
Hand
50 Facial Skeletal Augmentation with Implants . . . . . . 537
Michael J. Yaremchuk and Chad R. Gordon 70 Functional Anatomy and Principles
of Upper Extremity Surgery . . . . . . . . . . . . . . . . . . 721
51 Osseous Genioplasty . . . . . . . . . . . . . . . . . . . . . . . . 544
Kate W. Nellans and Kevin C. Chung
Harvey M. Rosen
71 Anesthesia Techniques . . . . . . . . . . . . . . . . . . . . . . 727
52 Hair Transplantation . . . . . . . . . . . . . . . . . . . . . . . 549
Warren C. Hammert
Carlos K. Wesley, Robin H. Unger,
and Walter P. Unger 72 Treatment of Hand Infections . . . . . . . . . . . . . . . . . 731
Benjamin Chang and Suhail K. Kanchwala
73 Soft Tissue Reconstruction of the Upper Extremity 737
part 6: Scott L. Hansen, Patrick Lang, and Hani Sbitany
Breast 74 Management of Nerve Injuries and Compressive
53 Augmentation Mammaplasty: Principles, Neuropathies of the Upper Extremity . . . . . . . . . . . 750
Techniques, Implant Choices, and Complications . . 565 Scott A. Mitchell and Kodi Azari
Steven Alan Teitelbaum 75 Management of Hand Fractures . . . . . . . . . . . . . . . 758
54 Mastopexy and Mastopexy/Augmentation . . . . . . . 582 Matthew S.S. Choi and James Chang
W. Grant Stevens, Andrea E. Van Pelt, 76 Management of Wrist Fractures . . . . . . . . . . . . . . . 767
and Adrian M. Przybyla Sandeep Jacob Sebastin and Kevin C. Chung

xviii Contents
77 Flexor Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . 784 90 Targeted Muscle Reinnervation and Upper
Bradon J. Wilhelmi Limb Amputation . . . . . . . . . . . . . . . . . . . . . . . . . . 900
78 Extensor Tendon Surgery . . . . . . . . . . . . . . . . . . . . 792 Gregory A. Dumanian
Mark E. Puhaindran 91 Rheumatoid Arthritis . . . . . . . . . . . . . . . . . . . . . . . 908
79 Tenosynovitis Disorders of the Upper Extremity . . . 799 David T. Netscher and Matthew E. Koepplinger
Mary C. Burns and Michael W. Neumeister
80 Principles of Tendon Transfers . . . . . . . . . . . . . . . . 807 part 9:
Douglas M. Sammer Trunk and Lower Extremity
81 Ligament Injuries of the Hand and Wrist . . . . . . . . 817
92 Chest Wall Reconstruction . . . . . . . . . . . . . . . . . . . 921
Karim Bakri, Brian T. Carlsen,
and Steven L. Moran Joseph N. Carey, Leo R. Otake, Anthony Echo,
and Gordon K. Lee
82 Management of Mutilating Injuries of the
Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . 833 93 Abdominal Wall Reconstruction . . . . . . . . . . . . . . . 933
Jaimie T. Shores and W. P. Andrew Lee Gregory A. Dumanian
83 Replantation Strategies of the Hand 94 Lower Extremity Reconstruction . . . . . . . . . . . . . . 941
and Upper Extremity . . . . . . . . . . . . . . . . . . . . . . . 839 Armen K. Kasabian and Nolan S. Karp
Sandeep Jacob Sebastin and Kevin C. Chung 95 Foot and Ankle Reconstruction . . . . . . . . . . . . . . . 955
84 Thumb Reconstruction . . . . . . . . . . . . . . . . . . . . . . 854 Christopher E. Attinger
Wee Leon Lam and Fu-Chan Wei and Mark W. Clemens
85 Dupuytren’s Disease . . . . . . . . . . . . . . . . . . . . . . . . 863 96 Reconstruction of the Perineum . . . . . . . . . . . . . . . 971
Catherine M. Curtin Paul H. Tran and Valerie Lemaine
86 Hand Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 868 97 Lymphedema: Diagnosis and Treatment . . . . . . . . . 980
Benjamin Levi and Kevin C. Chung Steven M. Levine, David W. Chang,
and Babak J. Mehrara
87 Management of Vasoconstriction . . . . . . . . . . . . . . 878
Paul K. Lim and Allen L. Van Beek 98 Pressure Sores . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 989
Karen L. Powers and Linda G. Phillips
88 Management of the Burned Hand . . . . . . . . . . . . . . 885
William C. Pederson 99 Reconstruction of the Penis . . . . . . . . . . . . . . . . . . 998
J. Joris Hage
89 Common Congenital Hand Anomalies . . . . . . . . . . 890
Robert J. Havlik Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1003

PART I
Principles, Techniques, and

n Principles, Techniques, and Basic Science
Basic Science
Chapter 1 n Techniques and Principles
in Plastic Surgery
Charles H. Thorne
Plastic surgery is the single most diverse specialty in the This chapter outlines basic plastic surgery principles
medical field, dealing with problems from the top of the and techniques that deal with the skin. Cross-references
head to the tip of the toes and with patients ranging in to specific chapters providing additional information are
age from the newborn to nonagenarian. Plastic surgeons are provided. Subsequent chapters in the first section will dis-
the ultimate specialists but are also the modern day general cuss other concepts and tools that allow plastic surgeons to
practitioners, unrestricted by organ system, disease process, tackle complex problems. Almost all wounds and all pro-
or patient age. Without an organ system of its own plastic cedures involve the skin, even if it is only an incision, and
surgery is based on principles rather than specific proce- therefore the cutaneous techniques described in this chapter
dures in a defined anatomic location. Because of this free- are applicable to virtually every procedure performed by
dom, whole subspecialties can be added to the field when every specialty in surgery.
new ideas, procedures, and techniques are developed. Since
the previous edition less than a decade ago plastic surgery
has enlarged significantly, adding, for example, vascularized
Obtaining a Fine-Line Scar
composite allotransplantation (Chapter 06), fat grafting to “Will there be a scar?” Even the most intelligent patients
the breast (Chapter 44), and a variety of perforator flaps to ask this preposterous question. When a full-thickness injury
its armamentarium. occurs to the skin or an incision is made, there is always a
What is plastic surgery? No adequate definition exists. scar. The question should be, “Will I have a relatively incon-
What is the common denominator between craniofacial spicuous, fine-line scar?”
surgery and hand surgery and between pressure sore sur- The final appearance of a scar is dependent on many fac-
gery and cosmetic surgery? McCarthy from NYU defines tors, including the following: (a) Differences between indi-
it as the “problem-solving specialty.” A grandiose defi- vidual patients that we do not yet understand and cannot
nition from a plastic surgery states: “Plastic surgery is predict; (b) the type of skin and location on the body; (c) the
surgery of the skin and its contents.” The phrase, plastic tension on the closure; (d) the direction of the wound; (e)
surgery, is derived from the Greek “Plastikos,” meaning other local and systemic conditions; and, lastly, (f) surgical
to mold or to shape. While many plastic surgical pro- technique.
cedures deal with reshaping, the majority do not, mak- The same incision or wound in two different patients will
ing even the title of the specialty somewhat misleading. produce scars that differ in quality and aesthetics. Oily or pig-
No wonder the public has difficulty understanding what mented skin produces, as a general rule, more unsightly scars
plastic surgery is! (Chapter 2 discusses hypertrophic scars and keloids). Thin,
No specialty receives the attention from the lay press that wrinkled, pale, dry, “WASPy” skin of patients of English or
plastic surgery receives. At the same time, no specialty is less Scotch-Irish descent usually results in less conspicuous scars.
well understood. Although the public equates plastic surgery Rules are made to be broken, however, and an occasional
with cosmetic surgery, the roots of plastic surgery lie in its patient will develop a scar that is not characteristic of his or
reconstructive heritage. Cosmetic surgery, an important com- her skin type.
ponent of plastic surgery, is but one piece of the plastic surgi- Certain anatomic areas tend to produce unfavorable scars
cal puzzle. that remain hypertrophic or wide. The shoulder and sternal
Plastic surgery consists of reconstructive surgery and area are such examples. Conversely, eyelid incisions almost
cosmetic surgery but the boundary between the two, like always heal with a fine-line scar.
the boundary of plastic surgery itself, is difficult to draw. Skin loses elasticity with age. Stretched-out skin, combined
The more one studies the specialty, the more the distinction with changes in the subcutaneous tissue, produces wrinkling,
between cosmetic surgery and reconstructive surgery disap- which makes scars less obvious and less prone to widening in
pears. Even if one asks, as an insurance company does, about older individuals. Children, on the other hand, may heal faster
the functional importance of a particular procedure, the but do not heal “better,” in that their scars tend to be red
answer often hinges on the realization that the function of the and wide when compared with scars of their grandparents.
face is to look like a face (i.e., function = appearance). A cleft In addition, as body parts containing scars grow, the scars
lip is repaired so the child will look, and therefore hopefully become proportionately larger. Beware the scar on the scalp
function, like other children. A common procedure such as a of a small child!
breast reduction is enormously complex when one considers Just as the recoil of healthy, elastic skin in children may
the issues of appearance, self-image, sexuality, and woman- lead to widening of a scar, tension on a closure bodes poorly
hood, and defies categorization as simply cosmetic or neces- for the eventual appearance of the scar. The scar associated
sarily reconstructive. with a simple elliptical excision of a mole on the back will
1
2 Part I: Principles, Techniques, and Basic Science
likely result in a much less appealing scar than an incisional Minimizing damage to the skin edges with atraumatic tech-
wound. The body knows when it is missing tissue. nique, debridement of necrotic or foreign material, and a ten-
The direction of a laceration or excision also determines the sion-free closure are the first steps in obtaining a fine-line scar.
eventual appearance of the scar. The lines of tension in the skin Ultimately, however, scar formation is unpredictable even
were first noted by Dupuytren. Langer also described the normal with meticulous technique.
tension lines, which became known as “Langer lines.” Borges Two technical factors are of definite importance in increas-
referred to skin lines as “relaxed skin tension lines” (Figure 1.1). ing the likelihood of a “good” scar. First is the placement
Elective incisions or the excision of lesions are planned of sutures that are not excessively tight and are removed
when possible so that the final scars will be parallel to the promptly so disfiguring “railroad tracks” do not occur. In
relaxed skin tension lines. Maximal contraction occurs when other words, removing the sutures may be more important
a scar crosses the lines of minimal tension at a right angle. than placing them! Plastic surgeons have been known to mock
Wrinkle lines are generally the same as the relaxed skin ten- other specialists for using heavy-gauge suture for skin clo-
sion lines and lie perpendicular to the long axis of the underly- sure, but the choice of sutures is irrelevant if the sutures are
ing muscles. removed soon enough and if they have not been tied so tightly
Other issues, which are not related to the scar itself but that they tear through the skin. Sutures on the face can usually
to perception, determine if a scar is noticeable. Incisions and be removed in 3 to 5 days and on the body in 7 days or less.
scars can be “hidden” by placing them at the junction of aes- Except for wounds over joints, sutures should rarely be left in
thetic units (e.g., at the junction of the lip and cheek and along for more than 1 week. A subcutaneous layer of closure and
the nasolabial fold), where the eye expects a change in contour Steri-Strips are usually sufficient to prevent dehiscence.
(Chapter xx). In contrast, an incision in the midcheek or mid- The second important technical factor that may affect the
chin or tip of the nose will always be more conspicuous. appearance of scars is wound-edge eversion. While there is no
The shape of the wound also affects ultimate appearance. evidence to support this statement, it is the author’s clinical
The “trapdoor” scar results from a curvilinear incision or experience that everted wound closures never look worse and
laceration that, after healing and contracture, appears as a often result in a less conspicuous scar than their non-everted
depressed groove with bulging skin on the inside of the curve. counterparts. In wounds where the skin is brought precisely
Attempts at “defatting” the bulging area are never as satisfac- together, there is a tendency for the scar to widen. In wounds
tory as either the patient or surgeon would like. where the edges are everted, or even hyper-everted in an exag-
Local conditions, such as crush injury of the skin adja- gerated fashion, this tendency may be reduced, possibly by
cent to the wound, also affect the scar. So, too, will systemic reducing the tension on the closure. In other words, the ideal
conditions such as vascular disease or congenital conditions wound closure is not perfectly flat, but rather bulges with an
affecting elastin and/or wound healing. Nutritional status obvious ridge, to allow for eventual spreading of that wound.
can affect wound healing, but usually only in the extreme Wound-edge eversion always goes away. The surgeon need not
of malnutrition or vitamin deficiency. Nutritional status is ever worry that a hyper-everted wound will remain that way.
overemphasized as a factor in scar formation.
Technique is also overemphasized (by self-serving plas-
tic surgeons) as a factor in determining whether a scar will Closure of Skin Wounds
be inconspicuous, but it is certainly of some importance. While the most common method of closing a wound is with
sutures, there is nothing necessarily magic or superior about
sutures. Staples, skin tapes, or wound adhesives are also useful
in certain situations. Regardless of the method used, precise
approximation of the skin edges without tension is essential to
ensure primary healing with minimal scarring.
Wounds that are deeper than skin are closed in layers. The
key is to eliminate dead space, to provide a strong enough clo-
sure to prevent dehiscence while wound healing is occurring,
and to precisely approximate the skin edges without tension.
Not all layers necessarily require separate closure. A closure
over the calf, however, is subject to motion, dependence, and
stretching with walking, requiring a stronger closure than the
scalp, which does not move, is less dependent, and not subject
to tension in daily activities. Placing deep absorbable sutures
is not always desirable. The author tends to use only Nylon
skin sutures without any deeper sutures when approximating
pediatric facial lacerations because of an impression that there
is less inflammation and erythema and certainly less chance of
suture abscess.
Except for dermal sutures, which are placed with the knot
buried to prevent it from emerging from the skin during the
healing process, sutures should be placed with the knot super-
ficial to the loop of the suture (not buried), so that the tissue
layers can be everted (Figure 1.2A).
Buried dermal sutures provide strength so the external
sutures can be removed early, but do not prevent the scar from
spreading over time. There is no technique, even the technique
of eversion described above, that reliably prevents a wound
that has an inclination to widen from doing so.
Figure 1.1. Relaxed skin tension lines. (Reproduced with permis- Suturing Techniques
sion from Ruberg R. L. In: Smith DJ, ed. Plastic Surgery, A Core
Curriculum. St. Louis, MO: Mosby, 1994.) Techniques for suturing are illustrated in Figure 1.2 and are
listed below.

Chapter 1: Techniques and Principles in Plastic Surgery 3

Basic Science
A B C
D E F
G H
Figure 1.2. Types of skin closure. A. Simple interrupted. B. Vertical mattress. C. Horizontal mattress. D. Subcuticular continuous. E. Half-
buried horizontal mattress. F. Continuous over-and-over. G. Staples. H. Skin tapes (skin adhesive performs a similar function).
Simple Interrupted Suture. The simple interrupted suture sutures tend to leave the most obvious and unsightly cross-
is the gold standard and the most commonly employed suture. hatching if not removed early.
The needle is introduced into the skin at an angle that allows
it to pass into the deep dermis at a point further removed from Horizontal Mattress Suture. Horizontal mattress sutures
the wound edge. This allows the width of suture at its base in have been much maligned but are the author’s favorite suture
the dermis to be wider than the epidermal entrance and exit for reliable skin edge approximation and eversion. They are
points, giving the suture a triangular appearance when viewed particularly advantageous in thick glabrous skin (feet and
in cross section. It also everts the skin edges. Care must be hand). In the author’s opinion, horizontal mattress sutures are
taken to ensure that the suture is placed at the same depth on far superior to their vertical counterparts.
each side of the incision or wound, otherwise the edges will
overlap. Sutures are usually placed approximately 5 to 7 mm Subcuticular Suture. Subcuticular (or intradermal) sutures
apart and 1 to 2 mm from the skin edge, although the location can be interrupted or placed in a running fashion. In a run-
and size of the needle and caliber of the suture material make ning subcutaneous closure, the needle is passed horizontally
this somewhat variable. through the superficial dermis, parallel to the skin surface,
to provide close approximation of the skin edges. Care is
Vertical Mattress Suture. Vertical mattress sutures may taken to ensure that the sutures are placed at the same level.
be used when eversion of the skin edges is desired and cannot Such a technique obviates the need for external skin sutures
be accomplished with simple sutures alone. Vertical mattress and circumvents the possibility of suture marks in the skin.

Absorbable or nonabsorbable suture can be used, with the lat-

ter to be removed at 1 to 2 weeks after suturing.
Half-Buried Horizontal Mattress Suture. Half-buried

horizontal mattress sutures are used when it is desirable to
have the knots on one side of the suture line with no suture
marks on the other side. For example, when insetting the are-
ola in breast reduction, this method leaves the suture marks
on the dark, pebbly areola instead of on the breast skin.
Continuous Over-and-Over Suture. Continuous over-

and-over sutures, otherwise known as running simple sutures,
can be placed rapidly but depend on the wound edges being
more or less approximated beforehand. A continuous suture
is not nearly as precise as interrupted sutures and the author
almost never uses them on the face. Continuous sutures can
also be placed in a locking fashion to provide hemostasis by
compression of wound edges. They are especially useful in
scalp closures.
Skin Staples. Skin staples are particularly useful as a time-

saver for long incisions or to position a skin closure or flap
temporarily before suturing. Grasping the wound edges with
forceps to evert the tissue is helpful when placing the staples
to prevent inverted skin edges. Staples must be removed early
to prevent skin marks and are ideal for the hair-bearing scalp.
Skin Tapes. Skin tapes can effectively approximate the

wound edges, although buried sutures are often required in
addition to skin tape to approximate deeper layers, relieve
tension, and prevent inversion of the wound edges. Skin tapes
can also be used after skin sutures are removed to provide Figure 1.3. Elliptical excision. A. If the ellipse is too short, dog-ears
added strength to the closure. (arrows) form at the ends of the closed wound. B. Correct method
with length of ellipse at least three times the width.
Skin Adhesives. Skin adhesives have been developed and
may have a role in wound closure, especially in areas where
there is no tension on the closure, or where strength of clo-
sure has been provided by a layer of buried dermal sutures. shown in Figure 1.4. Dog-ears are the bane of plastic surgical
Adhesives, by themselves, however, do not evert the wound existence and one must be facile with their elimination. Dog-
edges. Eversion must be provided by deeper sutures. ears do not disappear on their own.
Wedge Excision. Lesions located at or adjacent to free

Methods of Excision margins can be excised by wedge excision. In some elderly
Lesions of the skin can be excised with elliptical, wedge, circu- patients, one third of the lower lip and one fourth of the upper
lar, or serial excision. lip can be excised with primary closure (Figure 1.5).
Elliptical Excision. Simple elliptical excision is the most Circular Excision. When preservation of skin is desired
commonly used technique (Figure 1.3). Elliptical excision (such as the tip of the nose) or the length of the scar must be
of inadequate length may yield “dog-ears,” which consist kept to a minimum (children), circular excision might be desir-
of excess skin and subcutaneous fat at the ends of a closure. able. Figure 1.6 shows some closure techniques. Figure 1.6 is
There are several ways to correct a dog-ear, some of which are included because these techniques may be of value, as well
Figure 1.4. Three methods of removing a dog-ear caused by making the elliptical excision too short. A. Dog-ear excised, making the incision
longer, or converted to a “Y.” B. One method of removing a dog-ear caused by designing an elliptical excision with one side longer than the
other. Conversion to an “L” effectively lengthens the shorter side.


Basic Science
Figure 1.5. Wedge excisions of the ear, lower eyelid, and lip.
as for historical purposes. Circular defects can also be closed

with a purse-string suture that causes significant bunching of
the skin. This is allowed to mature for many months and may
result in a shorter scar on, for example, the face of a child.
Serial Excision. Serial excision is the excision of a lesion

in more than one stage. Serial excision and tissue expansion
(Chapter xx) are frequently employed for large lesions such
as congenital nevi. The inherent viscoelastic properties of skin
are used, allowing the skin to “stretch” over time. Serial exci-
sion enables wound closure to be accomplished with a shorter
scar than if the original lesion was elliptically excised in a
single stage.
Skin Grafting
Skin grafts are a standard option for closing defects that can-
not be closed primarily. A skin graft consists of epidermis and
some or all of the dermis. By definition, a graft is something
that is removed from the body, is completely devascularized, Figure 1.6. Closure of wounds following circular excision.
and is replaced in another location. Grafts of any kind require A. Skin graft. B. Sliding triangular subcutaneous pedicle flaps can be
vascularization from the bed into which they are placed for advanced to close the circular defect; the triangular defect is closed in a
survival. Any tissue that is not completely removed prior to V–Y fashion. C. Transposition flaps based on a skin pedicle and rotated
placement is not a graft. toward each other can also be used. Circular defects can also be closed
by other local flaps (Figures 1.10–1.15) or by purse-string suture.
Skin Graft Types
Skin grafts are classified as either split-thickness or full-thick-
ness, depending on the amount of dermis included. Split- heal secondarily, without any skin grafting, demonstrate the
thickness skin grafts contain varying amounts of dermis, greatest degree of contracture and are most prone to hyper-
whereas a full-thickness skin graft contains the entire dermis trophic scarring.
(Figure 1.7). The number of epithelial appendages transferred with a
All skin grafts contract immediately after removal from the skin graft depends on the thickness of the dermis present.
donor site and again after revascularization in their final loca- The ability of grafted skin to sweat depends on the num-
tion. Primary contraction is the immediate recoil of freshly ber of glands transferred and the sympathetic reinnerva-
harvested grafts as a result of the elastin in the dermis. The tion of these glands from the recipient site. Skin grafts are
more dermis the graft has, the more primary the contraction reinnervated by ingrowth of nerve fibers from the recipient
that will be experienced. Secondary contracture, the real nem- bed and from the periphery. Full-thickness skin grafts have
esis, involves contraction of a healed graft and is probably the greatest sensory return because of a greater availability
a result of myofibroblast activity. A full-thickness skin graft of neurilemmal sheaths. Hair follicles are also transferred
contracts more on initial harvest (primary contraction) but with a full-thickness skin graft. In general, full-thickness skin
less on healing (secondary contracture) than a split-thickness grafts demonstrate the hair growth of the donor site whereas
skin graft. The thinner the split-thickness skin graft, the split-thickness skin grafts, especially thin split-thickness skin
greater the secondary contracture. Granulating wounds left to grafts, are generally hairless.

Figure 1.7. Skin graft thickness.
of the dermis, the original donor site may be used again for a
Requirements for Survival of a Skin Graft subsequent split-thickness skin graft harvest. Thus, the num-
The success of skin grafting, or “take,” depends on the ability ber of split-thickness skin grafts harvested from a donor site is
of the graft to receive nutrients and, subsequently, vascular directly dependent on the donor dermis thickness. Full-thickness
ingrowth from the recipient bed. Skin graft revascularization skin graft donor sites must be closed primarily because there are
or “take” occurs in three phases. The first phase involves a pro- no remaining epithelial structures to provide re-epithelialization.
cess of serum imbibition and lasts for 24 to 48 hours. Initially, Skin grafts can be taken from anywhere on the body,
a fibrin layer forms when the graft is placed on the recipient although the color, texture, thickness of the dermis, vascularity,
bed, binding the graft to the bed. Absorption of nutrients into and donor site morbidity of body locations vary considerably.
the graft occurs by capillary action from the recipient bed. The Skin grafts taken from above the clavicles provide a superior
second phase is an inosculatory phase in which recipient and color match for defects of the face. The upper eyelid skin can
donor end capillaries are aligned. In the third phase, the graft also be used, as it provides a small amount of very thin skin.
is revascularized through these “kissing” capillaries. Because Full-thickness skin graft harvest sites are closed primarily and are
the full-thickness skin graft is thicker, survival of the graft is therefore of smaller size. The scalp, abdominal wall, buttocks,
more precarious, demanding a well-vascularized bed. and thigh are common donor sites for split-thickness skin grafts.
To optimize take of a skin graft, the recipient site must be Surgeons should avoid the mistake of harvesting split-thickness
prepared. Skin grafts require a vascular bed and will seldom skin grafts from the most accessible locations such as the anterior
take in exposed bone, cartilage, or tendon devoid of their perios- thigh. Although donor sites heal by re-epithelialization, there is
teum, perichondrium, or paratenon. There are exceptions, how- always visible evidence that an area was used as a donor site.
ever, as skin grafts are frequently successful inside the orbit or This can vary from keloids to simple hyper- or hypopigmenta-
on the temporal bone, despite removal of the periosteum. Close tion. Less conspicuous donor sites are the buttocks or scalp.
contact between the skin graft and its recipient bed is essential. Split-thickness skin grafts harvested from the scalp will have hair
Hematomas and seromas under the skin graft will compromise in them initially but no hair follicles and therefore will ultimately
its survival, and immobilization of the graft is essential. be hairless. The hair in the scalp donor site will return after re-
epithelialization because the hair follicles were left undisturbed.
Skin Graft Adherence
For the skin graft to take, it must adhere to the bed. There Postoperative Care of Skin Grafts
are two phases of graft adherence. The first begins with place-
ment of the graft on the recipient bed, to which the graft and Donor Sites
adheres because of fibrin deposition. This lasts approximately Causes of graft failure include collection of blood or serum
72 hours. The second phase involves ingrowth of fibrous tis- beneath the graft (raising the graft from the bed and prevent-
sue and vessels into the graft. ing revascularization), movement of the graft on the bed inter-
rupting revascularization (immobilization techniques include
Meshed versus Sheet Skin Grafts the use of bolster dressings as shown in Figure 1.8), and
infection. The risk of infection can be minimized by careful
Multiple mechanical incisions result in a meshed skin graft,
preparation of the recipient site and early inspection of grafts
allowing immediate expansion of the graft. A meshed skin
applied to contaminated beds. Wounds that contain more than
graft covers a larger area per square centimeter of graft har-
105 organisms per gram of tissue will not support a skin graft.
vest and allows drainage through the numerous holes. Meshed
In addition, an infection at the graft donor site can convert
skin grafts result in a “pebbled” appearance that, at times, is
a partial-thickness dermal loss into a full-thickness skin loss.
aesthetically unacceptable. In contrast, a sheet skin graft has
The donor site of a split-thickness skin graft heals by re-
the advantage of a continuous, uninterrupted surface, often
epithelialization. A thin split-thickness harvest site (less than
leading to a superior aesthetic result, but has the disadvan-
10/1,000 of an inch) generally heals within 7 days. The donor
tages of not allowing serum and blood to drain through it and
site can be cared for in a number of ways. The site must be
the need for a larger skin graft.
protected from mechanical trauma and desiccation. Xeroform,
OpSite, or Adaptic can be used. Because moist, occluded
Skin Graft Donor Sites wounds (donor sites) heal faster than dry wounds, the older
The donor site epidermis regenerates from the immigration of method of placing Xeroform and drying it with a hairdryer
epidermal cells originating in the hair follicle shafts and adnexal is not optimal. An occlusive dressing, such as semipermeable
structures left in the dermis. In contrast, the dermis never regen- polyurethane dressing (e.g., OpSite), will also significantly
erates. Because split-thickness skin grafts remove only a portion decrease pain at the site.
Skin Flaps

Unlike a skin graft, a skin flap has its own blood supply. Flaps
are usually required for covering recipient beds that have poor
vascularity; covering vital structures; reconstructing the full
Basic Science
thickness of the eyelids, lips, ears, nose, and cheeks; and pad-
ding body prominences. Flaps are also preferable when it may
be necessary to operate through the wound at a later date to
repair underlying structures. In addition, muscle flaps may
provide a functional motor unit or a means of controlling
infection in the recipient area. Muscle flaps and microvascular
free flaps are discussed in Chapters xx and xx.
In an experimental study, Mathes et al. compared muscu-
locutaneous flaps with “random” skin flaps to determine the
bacterial clearance and oxygen tension of each (Figure 1.9).
Placement of 107 Staphylococcus aureus underneath random
skin flaps in dogs resulted in 100% necrosis of the skin flaps
within 48 hours; the musculocutaneous flaps, however, dem-
onstrated long-term survival. The quantity of viable bacteria
placed in wound cylinders under these flaps demonstrated an
immediate reduction when placed deep to musculocutaneous
Figure 1.8. Tie-over bolster dressing for skin grafts. flap. Oxygen tension was measured at the distal end of the
random flap and compared with that underneath the muscle
of the distal portion of musculocutaneous flap as well as in its
subcutaneous area. It was found that the oxygen tension in
the distal random flap was significantly less than in the distal
Biologic Dressings muscular and cutaneous portions of the musculocutaneous flap.
Skin grafts can also be used as temporary coverage of wounds This study has been used to justify transfer of muscle flaps in
as biologic dressings. This protects the recipient bed from infected wounds. It may be that well-vascularized skin flaps
desiccation and further trauma until definitive closure can would be equally efficacious as muscle flaps.
occur. In large burns where there is insufficient skin to be har- Finally, a flap may be chosen because the aesthetic result
vested for coverage, skin substitutes can be used (Chapter 18). will be superior. For example, a nasal defect from a skin can-
Biologic skin substitutes include human allografts (cadaver cer could be closed with a skin graft, leaving a visible patch.
skin), amnion, or xenografts (such as pig skin). Allografts A local skin flap may require incisions in the adjacent nasal
become vascularized (or “take”) but are rejected at approxi- tissue, but may be aesthetically preferable in the long term.
mately 10 days unless the recipient is immunosuppressed There is no better tissue to replace nasal tissue than nasal tis-
(e.g., has a large burn), in which case rejection takes longer. sue. Replace like with like.
Conversely, xenografts are rejected before becoming vascular- A skin flap consists of skin and subcutaneous tissue that
ized. Synthetic skin substitutes such as silicone polymers and are transferred from one part of the body to another with a
composite membranes can also be applied, and new skin sub- vascular pedicle or attachment to the body being maintained
stitutes are constantly being developed. Human epidermis can for nourishment. Proper planning of a flap is essential to the
be cultured in vitro to yield sheets of cultured epithelium that success of the operation. All possible sites and orientations for
will provide coverage for large wounds. The coverage is frag- the flap must be considered so that the most suitable option
ile as a result of the lack of a supporting dermis. is selected.
Figure 1.9. “Old-fashioned” classification of skin flaps. A. Random pattern. B. Axial pattern.

Planning the flap in reverse is an important principle. A

pattern of the defect is transferred onto a piece of cloth towel-
ing. The steps in the operative procedure are carried out in
reverse order, using this pattern until the donor site is reached.
The flap is designed slightly longer than needed, as some
length will be lost in the rotation process and slight redun-
dancy may avoid kinking of the flap blood supply. The pro-
cess is repeated, being certain each time the base is held in a
fixed position and not allowed to shift with the flap. Measure
twice, cut once. It is easier to trim a flap that is slightly long
than to add to one that is too small.
Planning a transposition or rotation flap requires atten-
tion to ensure that the line of greatest tension from the pivot
point to the most distal part of the flap is of sufficient length
(Figures 1.10, 1.11, and 1.12).
Local skin flaps are of two types: flaps that rotate about a
pivot point (rotation, transposition, and interpolation flaps)
(Figures 1.10 and 1.11) and advancement flaps (single-pedicle
advancement, V–Y advancement, Y–V advancement, and
bipedicle advancement flaps) (Figures 1.17 and 1.18).
Flaps Rotating about a Pivot Point

Rotation, transposition, and interpolation flaps have in
common a pivot point and an arc through which the flap is
rotated. The radius of this arc is the line of greatest tension of
Figure 1.11. Transposition flap. (A) The secondary defect is often

closed by a skin graft. (B) A back-cut can be used if the flap is under
excessive tension.
Figure 1.10. Rotation flap. The edge of the flap is four to five times Figure 1.12. Importance of the pivot point. A skin flap rotated
the length of the base of the defect triangle. A back-cut or a Bürow tri- about a pivot point becomes shorter in effective length the farther
angle can be used if the flap is under excessive tension. A. Pivot point it is rotated. Planning with a cloth pattern is helpful when designing
and line of greatest tension. B. Back-cut. C. Bürow’s triangle. such a flap.

the flap. The realization that these flaps can be rotated only

about the pivot point is important in preoperative planning.
The rotation flap is a semicircular flap of skin and subcuta-
neous tissue that rotates about a pivot point into the defect to
be closed (Figure 1.10). The donor site can be closed by a skin
Basic Science
graft or by direct suture of the wound.
A flap that is too tight along its radius can be released by
making a short back-cut from the pivot point along the base of
the flap. Because this back-cut decreases the blood supply to the
flap, its use requires some degree of caution. With some flaps
it is possible to back-cut only the tissue responsible for the ten-
sion, without reducing the blood supply to the flap. Examples
of this selective cutting are found in the galea aponeurotica of
the scalp and in areas over the trunk where the fascia within
the thick subcutaneous layer can be divided. The necessity for a
back-cut may be an indication of poor planning. A triangle of
skin (Bürow triangle) can be removed from the area adjacent
to the pivot point of the flap to aid its advancement and rota-
tion (Figure 1.10C). This method is of only modest benefit in
decreasing tension along the radius of the flap.
The transposition flap is a rectangle or square of skin and
subcutaneous tissue that also is rotated about a pivot point
into an immediately adjacent defect (Figure 1.11). This neces-
sitates that the end of the flap adjacent to the defect be des-
ignated to extend beyond it (Figures 1.12 and 1.13). As the
flap is rotated, with the line of greatest tension as the radius
of the rotation arc, the advancing tip of the flap will be suf-
ficiently long. The flap donor site is closed by skin grafting,
direct suture of the wound, or a secondary flap from the most
lax skin at right angles to the primary flap. An example of this
latter technique is the ingenious bilobed flap (Figure 1.14).
The key to a successful bilobed flap is an area of loose skin to Figure 1.13. Transposition flap that can be used to close defects on
permit direct closure of the secondary flap defect. Pinching the the anterior cheek. A. Small defects can be closed by a single transpo-
skin between the examiner’s fingers helps find the loosest skin, sition cheek flap that follows the skin lines. B. Large defects can be
closed by a double transposition flap that uses a flap of postauricular
for example, in the glabellar area and lateral to the eyelids.
skin to close the secondary defect left by the cheek flap.
The Limberg flap is a type of transposition flap. This
flap, like the bilobed flap and the Z-plasty (discussed below),
depends on the looseness of adjacent skin, which can be
located by pinching various areas of skin between the thumb
and the forefinger. Fortunately, most patients who require that are the same length as the short axis of the rhomboid
local skin flaps are in the older age group and therefore have defect (Figures 1.15 and 1.16).
loose skin. A Limberg flap is designed for rhomboid defects
with angles of 60° and 120°, but most wounds can be made Advancement Flaps
rhomboid, or imagined as rhomboid, so the principle is appli- All advancement flaps are moved directly forward into
cable to most facial wounds. The flap is designed with sides a defect without any rotation or lateral movement.
Figure 1.14. Bilobed flap. After the lesion is excised, the primary flap (P) is transposed into the initial defect. The secondary flap (S) is then
transposed into the defect left after the primary flap has been moved. The primary flap is slightly narrower than the defect caused by excision of
the initial lesion, and the secondary flap is half the diameter of the primary flap. For the bilobed flap to be successful, the secondary flap must
come from an area of loose skin so that the defect remaining after moving the secondary flap can be closed by approximation of the wound edges.
Three possible choices for the secondary flap (S1, S2, and S3) are depicted. The surgeon chooses the location of the secondary flap based on the
skin laxity and the location of the eventual scar.

Figure 1.15. Planning a rhomboid (Limberg) flap. The rhomboid defect must have 60° and 120° angles. The flap is planned in an area of loose
skin so that direct closure of the wound edges is possible. The short diagonal BD (which is the same length as each side) is extended by its own
length to point E. The line EF is drawn parallel to CD and is of the same length. After the flap margins have been incised, the flap is transposed
into the rhomboid defect.
Modifications are the single-pedicle advancement, the The V–Y advancement technique has numerous applica-
V–Y advancement, and the bipedicle advancement flaps. tions. It is not an advancement in the same sense as the forward
Advancement flaps are also used in the movement of movement of a skin flap just described. Rather, a V-shaped
expanded skin (Chapter 10). incision is made in the skin, after which the skin on each side of
The single-pedicle advancement flap is a rectangular or the V is advanced and the incision is closed as a Y (Figure 1.18).
square flap of skin and subcutaneous tissue that is stretched This V–Y technique can be used to lengthen such structures as
forward. Advancement is accomplished by taking advantage the nasal columella, eliminate minor notches of the lip, and, in
of the elasticity of the skin (Figure 1.17A) and by excising certain instances, close the donor site of a skin flap.
Bürow triangles lateral to the flap (Figure 1.17B). These trian-
gular excisions help to equalize the length between the sides of
the flap and adjacent wound margins. Z-Plasty
Geometric Principle of the Z-Plasty
The Z-plasty is an ingenious principle that has numerous
applications in plastic surgery (Chapter 18). Z-plasties can be
applied to revise and redirect existing scars or to provide addi-
tional length in the setting of scar contracture. The principle
involves the transposition of two triangular flaps (Figure 1.19).
The limbs of the Z must be equal in length to the central limb,
but can extend at varying angles (from 30° to 90°) depend-
ing on the desired gain in length. The classic Z-plasty has an
angle of 60° (Table 1.1) and provides a 75% theoretical gain
in length of the central limb by recruiting lateral tissue.
Gain in length is in the direction of the central limb of the
Z and depends on the angle used and the length of the central
limb. Although the theoretical gain can be determined math-
ematically, the actual gain is based on the mechanical proper-
ties of the skin and is always less.
Planning and Uses of the Z-Plasty

The resulting central limb, after flap transposition, will
be perpendicular to the original central limb. In scar revi-
sion, the final central limb should lie in the direction of the
skin lines and should be selected first. The Z-plasty is then
designed.
The Z-plasty principle can be used to increase the length
of skin in a desired direction. For example, it is useful for
release of scar contractures, especially in cases in which the
scar crosses a flexion crease. Any number of Z-plasties can
be designed in series, especially in cosmetically sensitive areas
Figure 1.16. Four Limberg flaps are available for any rhomboid (such as the face) to break up the appearance of a straight
defect with 60° and 120° angles. The choice is made based on the line or to release a contracture. Large Z-plasties, however, do
location of the eventual scar, skin laxity, and blood supply of the flap. not look good on the face and it is better to use many tiny
Z-plasties. Congenital skin webs can also be corrected with


Basic Science
Figure 1.19. Classic 60° angle Z-plasty. Inset shows the method of
finding the 60° angle by first drawing a 90° angle, then dividing it in
thirds by sighting. The limbs of the Z must be equal in length to the
central member. A. Design. B. Transposition of flaps. C. Final result.
Note that the central limb has changed the direction by 90°.
and universality that Z-plasty has. This technique simply

involves excising the scar in multiple small triangles that are
so situated that they interdigitate (Figure 1.20). Although the
W-plasty changes the direction of the linear scar, it would only
be by chance that one of the limbs of the W would lie in the
same direction as the skin lines. Because a W-plasty does not
lengthen a contracted scar line, it is best to use the Z-plasty for
this purpose.
Both the Z-plasty and the W-plasty have the additional
attribute of breaking up a linear scar into an accordion-like
Figure 1.17. Single-pedicle advancement flaps. A. Advancement by scar that has some degree of elasticity to it. This change per-
taking advantage of the skin elasticity. B. Advancement by excising mits the skin to be more mobile in its contribution to facial
Bürow triangles of skin laterally to equalize the length of the flap and expressions. To their detriment, both techniques more than
the adjacent wound edge. C. Pantographic expansion. This method is double the length of the scar. If the W-plasty is employed,
frequently used after the skin expansion but is risky as the back-cuts the triangles must be made very small to avoid worsening the
decrease the blood supply. appearance of the scar.
Reconstructive Ladder
Z-plasties. U-shaped or “trapdoor” scars may be improved The techniques described above are applicable to cutaneous
by breaking up the contracting line. Circumferential scars are defects. Plastic surgeons often are consulted regarding clos-
amenable to lengthening using Z-plasties, especially in coning more complex defects. When analyzing a wound, whether
stricting bands of the extremities. These deformities are best
released one-half at a time because of concern over interrup-
tion of blood supply to the extremity.
Borges described the W-plasty as another method of revis- Table 1.1
ing a scar. It is useful occasionally, but lacks the applicability
Z-Plasty, Angles, and Theoretical Gain
n Angels of z-plasty n theoretical gain

(degrees) in length (%)
30–30 25
45–45 50
60–60 75
Figure 1.18. V–Y advancement. It is the skin on each side of the V 75–75 100
that is actually advanced. 90–90 120

cutaneous or more complex, the options for closure are eval-

uated beginning with the simplest and progressing up the
“reconstructive ladder” to the more complex (Figure 1.21).
This progression from primary closure to skin graft, to local
flap, to regional flap, and to microvascular free flap pro-
vides a framework that can be applied to any reconstructive
situation. Application of the simplest option that meets the
reconstructive requirements ensures a “lifeboat” should the
procedure fail. In many situations, however, a higher “rung”
on the ladder is intentionally chosen. For example, a local
flap may be selected over a skin graft for a defect on the nose
because it may provide a superior result, or a free flap may be
chosen for a breast reconstruction when an attached, pedicled
flap would suffice because the blood supply of the former is
superior.
Figure 1.20. The W-plasty can also be used to break up a long scar
that does not lie in the direction of the skin lines.
Conclusion
The application of fundamental principles in the practice of
plastic surgery allows the surgeon to approach even the most
FREE TISSUE complex problem in an organized, systematic fashion. This
TRANSFER chapter presents fundamental principles that can be applied to
any wound closure situation.
REGIONAL TISSUE Suggested Readings

TRANSFER Birch J, Branemark PI. The vascularization of a free full thickness skin graft: a
vital microscopic study. Scand Plast J Surg. 1969;3:1.
Borges AF. Elective Incisions and Scar Revision. Boston, MA: Little, Brown;
1973.
Capla J, Ceradini D, Tepper O, et al. Skin graft vascularization involves pre-
LOCAL TISSUE cisely regulated regression and replacement of endothelial cells through
TRANSFER both angiogenesis and vasculogenesis. Plast Reconstr Surg. 2005.
In press.
Converse JM, Rapaport FT. The vascularization of skin autografts and homo-
grafts: an experimental study in man. Ann Surg. 1956;143:306.
Edgerton MT. The Art of Surgical Technique. Baltimore, MD: Williams &
SKIN GRAFT Wilkins; 1988.
Edgerton MT, Hansen FC. Matching facial color with split thickness skin grafts
from adjacent areas. Plast Reconstr Surg. 1960;25:455.
Furnas DW, Fischer GW. The Z-plasty: biomechanics and mathematics. Br J
Plast Surg. 1971;24:144.
Krizek TJ, Robson MC. Evolution of quantitative bacteriology in wound man-
agement. Am J Surg. 1975;130:579.
DIRECT TISSUE CLOSURE Mathes S, Alpert B, Chang N. Use of the muscle flap in chronic osteomy-
elitis: experimental and clinical correlation. Plast Reconstr Surg. 1982;
69:815.
Robson MC, Krizek TJ, Heaggars JP. Biology of surgical infections. In:
Ravitch MM, ed. Current Problems in Surgery. Chicago; 1973.
ALLOW WOUND TO HEAL BY SECONDARY Rudolph R. Inhibition of myofibroblasts by sham skin grafts. Plast Reconstr
Surg. 1979;63:473.
INTENTION
Tanner JC, Vandeput J, Olley JF. The mesh skin graft. Plast Reconstr Surg.
1964;34:287.
Figure 1.21. Reconstructive ladder demonstrating the fundamental Vogt PM, Andree C, et al. Dry, moist and wet skin wound repair. Ann Plast
principle in planning closure of a defect from simple to more complex. Surg. 1995;34:493.

Chapter 2 n Wound Healing: Normal

and Abnormal
Basic Science
Geoffrey C. Gurtner and Victor W. Wong
the myriad events occurring in wound healing, the reader is

The Response to Injury referred to a number of excellent recent reviews.3-5 However,
What is wound healing? Definitions might include the repair given the inherent lag in book publication and the rapid pace
or reconstitution of a defect in an organ or tissue, commonly of the field, the reader should refer to Medline (http://www
the skin. However, it is clear that the process of wounding acti- .ncbi.nlm.nih.gov/entrez/query.fcgi) and search for the
vates systemic processes that alter the physiology far beyond latest reviews in the field of wound healing to obtain the most
the confines of the defect itself. Inflammatory cascades that up-to-the-minute information.
impact nearly every organ system and have potentially dire
consequences for survival are initiated, as illustrated by multi-
system organ failure. Furthermore, recent research implicating Scar Formation Versus Tissue
the participation of stem and progenitor cells in the wound
healing process requires a broader perspective than one that
Regeneration
focuses solely on the defect itself.1,2 Wound healing may be As discussed, wound healing is an extremely broad and com-
best understood as an organism’s global response to injury, plex topic covering a variety of responses to injury in a variety
regardless of whether the location is in the skin, liver, or heart. of different organ systems. However, some common features
Seen from this perspective, it is certainly not an exaggeration exist. Generally, wound healing represents the response of an
to regard the response to injury as one of the most complex organism to a physical disruption of a tissue/organ to re-estab-
physiologic processes occurring during adult life. lish homeostasis of that tissue/organ and stabilize the entire
The complexity of this process is easily demonstrated in organism’s physiology. There are essentially two processes by
cutaneous wound healing. During the progression from a which this re-establishment of homeostasis occurs. The first
traumatic injury to a stable scar, the intrinsic and extrinsic is the substitution of a different cellular matrix as a patch to
clotting system are activated; acute and chronic inflamma- immediately re-establish both a physical and physiologic conti-
tory responses occur; neovascularization proceeds through nuity to the injured organ. This is the process of scar formation.
angiogenesis and vasculogenesis; cells proliferate, divide, and The second process is a recapitulation of the developmental
undergo apoptosis; and extracellular matrix (ECM) is depos- processes that initially created the injured organ. By reactivat-
ited and remodeled. These (as well as other events) occur ing developmental pathways, the architecture of the original
simultaneously and also interact and influence each other at organ is re-created. This is the process of regeneration.6
the level of gene transcription and protein translation in a The dynamic balance between scarring and tissue regenera-
dynamic and continuous fashion. Further, normally sterile tis- tion is unique to different tissues and organs (Figure 2.1). For
sues encounter and interact with bacteria and other elements example, neural injury is characterized by little regeneration
of the external environment in a way that never occurs except and much scarring, whereas hepatic and bone injury usually
following injury. Thus, it is not surprising that wound heal- heals primarily through regeneration. It is important to note,
ing and the response to injury are still poorly understood by however, that the liver can respond to injury with scarring as
scientists and clinicians alike, except at a purely descriptive it does in response to repetitive insults during the progression
or empiric level. The sheer number of commercially avail- of alcoholic cirrhosis. Moreover, the same injury in phyloge-
able products of unproven efficacy is a testament to the lack netically related species can result in very different responses.
of mechanistic understanding regarding this most common Thus, limb amputation in newts results in limb regeneration,
surgical problem. whereas in humans, only scarring can occur.
Most textbook chapters on wound healing are an ency- It is important to realize that the balance between scar
clopedic catalog of the phenomenology of wound healing. and regeneration is likely subject to evolutionary pressures
They list the multitude of cytokines and growth factors that and may, in fact, be functional. Thus, a cutaneous injury in
are observed during wound healing, usually based on experi- our prehistoric predecessors disrupted their homeostasis with
mental models or in vitro systems that may be prone to arti- respect to thermoregulation, blood loss, and, most impor-
fact. With the increasing sensitivity of new technologies such tantly, prevention of invasive infection. In an era before anti-
as quantitative polymerase chain reaction and microarray, the biotics and sterility, invasive infection was clearly a threat to
list of cytokines, growth factors, chemokines, etc. that appear life. As such, a very rapid and dramatic recruitment of inflam-
during wound healing continues to grow at an alarming rate. matory cells and a proliferative/contractile burst of activity
How will we ever make sense of this mountain of data so that to close the wound as quickly as possible were adaptive. The
we can intervene and alter the outcome of wound healing/ more leisurely pace of tissue regeneration was a luxury that
response to injury? In this chapter, a theoretical framework could not be afforded. However, in the modern world, these
with which to classify wound healing will be proposed. The adaptive responses often lead to the disfigurement and func-
broad biologic transitions that occur during cutaneous wound tional disability characteristic of burn scars. What was once
healing (i.e., inflammatory phase, proliferative phase, and functional has become unwanted, in part because of our abil-
remodeling phase) will be described within this context. An ity to close wounds with sutures, circumventing the need for a
abbreviated list of major “factors” will be provided but not vigorous contractile response following injury.
discussed in detail since it remains unclear which of these fac- In the same way that scar formation is not always bad,
tors are of primary or incidental importance in either func- tissue regeneration is not always good. Peripheral nerve neu-
tional or abnormal wound healing. Finally, an attempt will romas are dysfunctional and harmful attempts at regeneration
be made to understand abnormal human healing within the of organ systems that have been damaged. They often result in
proposed theoretical context. For a more detailed list of disabling conditions that threaten the livelihood of an entire
13
Semantics of Wound Healing

The nomenclature of both scientific and clinical wound
healing research is at times imprecise and confusing. For
example, what is the difference between a chronic wound
and a non-healing wound? For purposes of this chapter, sev-
eral terms should be defined. The vast majority of surgical
wounds are incisional wounds that are re-approximated by
sutures or adhesives and in the absence of complications will
heal “primarily” or by “primary intention.” Generally such
wounds heal with a scar and do not require special wound care
or the involvement of a specialist in wound healing. This is in
contrast to wounds that are not re-approximated (for any rea-
son) and left “open.” The subsequent defect is “filled in” with
granulation tissue and then re-epithelialized. This is referred
to as healing by secondary intention and generally results in a
Figure 2.1. The different ways organisms and organ systems delay in the appearance of a healed or “closed” wound. Often
respond to injuries. Scar formation refers to the patching of a defect these wounds require special dressings and treatments (to
with a different or modified tissue (i.e., scar). Tissue regeneration be discussed in detail in Chapter 3) and have a higher likeli-
refers to the complete re-creation of the original tissue architecture. hood of progressing to a chronic wound. In the discussion of
Obviously, most processes involve both, but usually one predominates normal wound healing that follows, we will be discussing
and may be the source of undesirable side effects that we would like healing by secondary intention, although the same phases
to prevent or modify. For cutaneous wounds, scar formation usually occur in all wounds.
predominates (except in the unique situation of fetal wound healing)
An acute wound is a wound for which the injury has
and is the source of many of the problems plastic surgeons address.
occurred within the past 3 to 4 weeks. If the wound persists
beyond 4 to 6 weeks, it is considered a chronic wound, a term
that also includes wounds that have been present for months
organism. In these cases, scar formation would be preferable. or years. “Non-healing, recalcitrant,” and “delayed healing”
Indeed, the ablative measures used to treat these neuromas are are terms used interchangeably to describe chronic wounds.
attempts to prevent further regeneration. Wounds that are “granulating” represent the formation of
Thus, when analyzing an undesirable or dysfunctional highly vascular granulation tissue during the proliferative
response to injury in a tissue or organ system, it is useful phase of healing (see below).
to consider a) what the undesirable portion of the response
to injury is and b) whether substitution of a new tissue (scar)
or re-creation of the pre-existing tissue (regeneration) is Phases of Normal Wound
responsible for this undesirable effect. It is important to con- Healing
sider the possible adaptive role the dysfunctional process
The normal mammalian response to a break in cutaneous
might have. In the event of a neuroma, the case can be made
integrity occurs in three overlapping but biologically distinct
that the occasional return of protective or functional sensibil-
phases (Figure 2.2). Following the initial injury, there is an ini-
ity following a partial nerve injury is more adaptive and has
tial inflammatory phase, the purpose of which is to remove
a survival advantage over the occurrence of complete anes-
devitalized tissue and prevent invasive infection. Next, there
thesia in a peripheral nerve territory. Similarly with respect
is a proliferative phase during which the balance between
to fetal wound healing, in the sterile intrauterine environment
scar formation and tissue regenerations occurs. Usually, scar
the predominance of regenerative pathways may be adaptive,
formation predominates, although in fetal wound healing an
whereas for the adult organism existing in a microbe-filled
impressive amount of regeneration is possible. Finally, the lon-
environment, it may not be.
gest and least understood phase of wound healing occurs in
Such an analysis immediately suggests strategies to correct
the remodeling phase, whose main purpose is to maximize the
the undesirable end result in a given tissue or organ. If the
strength and structural integrity of the wound.
problem is overexuberant scar formation, then it is likely that
measures to decrease scarring would be helpful. However,
since this balance is dynamic, efforts at accelerating regen- Inflammatory Phase
eration might also be effective. And perhaps even better still The inflammatory phase (Figure 2.3) of wound healing begins
would be the simultaneous decrease in scar formation and immediately following tissue injury. The functional priori-
increase in tissue regeneration. ties during this phase of wound healing are attainment of
It is clear that the response to injury in different tissues hemostasis, removal of devitalized tissues, and prevention of
involves different proportions of scar formation and tis- colonization and invasive infection by microbial pathogens,
sue regeneration. By understanding the differences using the principally bacteria.
approach described above, we may be able to begin to under- Initially, components of the injured tissue, including
stand why different organs and tissues respond to injuries fibrillar collagen and tissue factor, act to activate the clot-
in very different ways. Just as a corneal ulcer, a myocardial ting cascade and prevent ongoing hemorrhage. Disrupted
infarction, and a stage IV decubitus ulcer have different func- blood vessels allow circulating elements into the wound
tional implications for the organism, the dynamic balance of while platelets clump and form an aggregate to plug the disrupted
scarring and regeneration will be different in the attempt to vessels. During this process, platelets degranulate to release
re-establish homeostasis. The failure of either scar formation growth factors such as platelet-derived growth factor (PDGF)
or regeneration may lead to similar appearing clinical prob- and transforming growth factor β (TGF-β). The end result of the
lems that have a completely different underlying etiology. coagulation cascade is the conversion of fibrinogen to fibrin and
Hopefully, this type of analysis will lead to a more organized subsequent polymerization into a mesh. This provisional matrix
approach to the classification and treatment of injuries in a provides the scaffolding for cell recruitment and attachment
variety of different organ systems. Most importantly, it may required during the subsequent phases of wound healing.
suggest strategies for intervention to optimize the response to Almost immediately, inflammatory cells are recruited to
injury and prevent the undesirable sequelae of wound healing. the wound site. During the initial stages of wound healing,

Chapter 2: Wound Healing: Normal and Abnormal 15
and later stages of wound repair.10 Circulating monocytes

traffic to wounds and egress into the tissue to become macro-
phages. By 3 days post-wounding, they are the predominant
cell type in the healing wound. Macrophages phagocytose
debris and bacteria, but are especially critical for the orches-
Basic Science
trated production of the growth factors necessary for the
production of the ECM by fibroblasts and the production of new
blood vessels in the healing wound. A partial listing of chemo-
kines, cytokines, and growth factors present in the healing wound
is provided in Table 2.1, but the list grows daily. The exact func-
tion of each of these factors is incompletely understood, and the
literature is filled with contradictory data. However, it is clear
that unlike the neutrophil, the absence of monocyte/macro-
phages has severe consequences for healing wounds.11
The lymphocyte is the last cell to enter the wound and
enters between days 5 and 7 post-wounding. Its role in wound
healing is not well defined, although it has been suggested that
populations of stimulatory CD4 and inhibitory CD8 cells may
usher in and out the subsequent proliferative phase of wound
Figure 2.2. The three phases of wound healing (inflammatory, pro- healing.12 Similarly, the mast cell appears during the later part
liferative, and remodeling), the timing of these phases in adult cutane- of the inflammatory phase, but again its function remains
ous wound healing, and the characteristic cells that are seen in the unclear. Recently, it has become an area of intense research
healing wound at these time points. inquiry because of a correlation between mast cells and some
forms of aberrant scarring.
Given the consistent and precise appearance of different
inflammatory cells are attracted by numerous biophysical subsets of inflammatory cells into the wound, it is likely that
cues, including activation of the complement cascade, TGF-β soluble factors released in a stereotypic pattern underlie this
released by degranulating platelets, and bacterial degradation phenomenon. The source of these factors, the upstream regu-
products such as lipopolysaccharide.7 For the first 2 days fol- lators for their production, and the downstream consequences
lowing wounding, there is an impressive infiltration of neu- of their activity are extraordinarily complex topics and the
trophils into the fibrin matrix that fills the wound cavity. The subject of intense ongoing research. Again in Table 2.1, a
primary role of these cells is to remove dead tissue by phagocy- partial list of growth factors thought to be important during
tosis and prevent infection by oxygen-dependent and oxygen- wound healing is provided. All are targets for the development
independent killing mechanisms. They also release a variety of of therapeutics to either accelerate wound healing or decrease
proteases to degrade remaining ECM to prepare the wound for scar formation.5 However, the biologic relevance of any one
healing. It is important to realize that although neutrophils play factor in isolation remains unclear.
a role in decreasing infection during cutaneous wound healing,
their absence does not appear to prevent the overall progress of Proliferative Phase
wound healing.8 However, their prolonged persistence in the
wound has been proposed to be a primary factor in the conver- The proliferative phase of wound healing is generally accepted
sion of acute wounds into non-healing chronic wounds.9 to occur from days 4 to 21 following injury. However, the
Monocyte/macrophages follow neutrophils into the wound phases of wound healing are not exclusive and have features
and appear 48 to 72 hours post-injury. They are recruited to that overlap. Certain facets of the proliferative phase such as
healing wounds primarily by expression of monocyte che- re-epithelialization probably begin almost immediately fol-
moattractant protein 1. Monocyte/macrophages are a hetero- lowing injury. Keratinocytes adjacent to the wound alter their
geneous population of cells that critically regulate both early phenotype in the hours following injury. Regression of the
desmosomal connections between keratinocytes and to the
underlying basement membrane frees cells and allows them
to migrate laterally. Concurrent with this is the formation
of actin filaments in the cytoplasm of keratinocytes, which
provides them with the locomotion to actively migrate into
the wound. Keratinocytes then move via interactions with
ECM proteins (such as fibronectin, vitronectin, and type I
collagen) via specific integrin mediators as they proceed
between the desiccated eschar and the provisional fibrin
matrix beneath (Figure 2.4).
The provisional fibrin matrix is gradually replaced by a new
platform for migration: granulation tissue. Granulation tissue
is largely composed of three cell types that play critical and
independent roles in granulation tissue formation: fibroblasts,
macrophages, and endothelial cells. These cells form ECM
and new blood vessels, which histologically are the ingredients
for granulation tissue. Granulation tissue begins to appear in
human wounds by about day 4 post-injury. Fibroblasts are
the workhorses during this time and produce the ECM that
fills the healing scar and provides a scaffold for keratinocyte
Figure 2.3. The inflammatory phase of wound healing begins migration. Eventually this matrix will be the most visible
immediately following tissue injury and serves to achieve hemostasis, component of cutaneous scars. Macrophages continue to pro-
remove devitalized tissues, and prevent invasive infection by microbial duce growth factors such as PDGF and TGF-β1 that induce
pathogens. fibroblasts to proliferate, migrate, and deposit ECM, as well
as stimulate endothelial cells to form new vessels. During the

Table 2.1
GROWTH FACTORS, CYTOKINES, AND OTHER BIOLOGICALLY ACTIVE MOLECULES IN WOUND HEALING
n Name n Abbreviation n Source n Description

Vascular endothelial VEGF Endothelial cells Promotes angiogenesis
growth factor
Fibroblast growth FGF-2 Macrophages, mast cells, Promotes angiogenesis. Stimulates
factor 2 endothelial cells, endothelial cell migration and growth
T lymphocytes Promotes epithelialization via
keratinocyte and fibroblast migration
and proliferation
Platelet-derived PDGF Platelets, macrophages, Enhances proteoglycan and collagen
growth factor endothelial cells synthesis
Recruits macrophages and fibroblasts
Keratinocyte growth KGF Fibroblasts Controls keratinocyte growth and
factor maturation
Induces epithelial secretion of other
growth factors
Epidermal growth EGF Platelets, macrophages Stimulates collagenase secretion by
factor fibroblasts to remodel matrix
Transforming growth TGF-β Platelets, macrophages, Promotes angiogenesis
factor beta T and B cells, hepatocytes, Establishes chemoattractant gradients,
thymocytes, placenta induces adhesion molecule expression,
and promotes proinflammatory
molecules that stimulate leukocyte
and fibroblast migration
Induces extracellular matrix synthesis
by inhibiting protease activity and
upregulating collagen and proteoglycan
synthesis
Tumor necrosis TNF-α Macrophages, T and B cells, Induces collagen synthesis in wounds
factor alpha NK cells Regulates polymorphonuclear neutro-
phil leukocyte (PMN) margination and
cytotoxicity
Granulocyte G-CSF Stromal cells, fibroblasts, Stimulates granulocyte proliferation,
colony-stimulating endothelial cells, survival, maturation, and activation
factor lymphocytes Induces granulopoiesis
Granulocyte- GM-CSF Macrophages, stromal cells, Stimulates granulocyte and macrophage
macrophage colony- fibroblasts, endothelial cells, proliferation, survival, maturation, and
stimulating factor lymphocytes activation
Induces granulopoiesis
Interferon alpha IFN-α Macrophages, B and Activates macrophages. Inhibits
T cells, fibroblasts, fibroblast proliferation
epithelial cells
Interleukin 1 IL-1 Macrophages, keratinocytes, Proinflammatory peptide
endothelial cells, lympho- Induces chemotaxis of PMNs,
cytes, fibroblasts, osteoblasts fibroblasts, and keratinocytes
Activates PMNs
Interleukin 4 IL-4 T cells, basophils, mast cells, Activates fibroblast proliferation
bone marrow stromal cells Induces collagen and proteoglycan
synthesis
Interleukin 8 IL-8 Monocytes, neutrophils, Activates PMNs and macrophages to
fibroblasts, endothelial cells, begin chemotaxis
keratinocytes, T cells Induces margination and maturation
of keratinocytes
Endothelial nitric eNOS Endothelial cells, neurons Synthesizes NO in endothelial cells with
oxide synthase multiple downstream effects
Inducible nitric iNOS Neutrophils, endothelial Synthesizes NO by macrophages
oxide synthase cells and basal keratinocytes, multiple
downstream effects

In humans, remodeling is characterized by the processes of

wound contraction and collagen remodeling (Figure 2.5). The
process of wound contraction is produced by wound myofi-
broblasts, which are fibroblasts with intracellular actin micro-
filaments capable of force generation and matrix contraction.14
Basic Science
It remains unclear whether the myofibroblast is a separate cell
from the fibroblast or whether all fibroblasts retain the capac-
ity to “trans-differentiate” to myofibroblasts under the right
environmental conditions. Myofibroblasts contact the wound
through specific integrin-mediated cell–matrix interactions
with the dermal environment.
Collagen remodeling is also characteristic of this phase. Type
III collagen is initially laid down by fibroblasts during the prolif-
erative phase, but over the next few weeks to months this will be
replaced by type I collagen. This slow remodeling phase is largely
mediated by a class of enzymes known as matrix metalloprotein-
ases that are secreted in large part by macrophages, fibroblasts,
and endothelial cells.15 The breaking strength of the healing wound
improves slowly during this process, reflecting the turnover in col-
Figure 2.4. The proliferative phase of wound healing occurs from
lagen subtypes and increased collagen cross-linking. At 3 weeks,
days 4 to 21 post-wounding. During this phase, granulation tissue fills
the wound and keratinocytes migrate to restore epithelial continuity. the beginning of the remodeling phase, wounds have only about
20% of the strength of unwounded skin and will ultimately only
possess 70% to 80% of the breaking strength of unwounded skin
at 1 year.
proliferative phase, the provisional matrix of fibrin is replaced
with thinner type III collagen, which will in turn be replaced Abnormal Response to Injury
by thicker type I collagen during the remodeling phase.
Endothelial cells are a critical component of granulation tis-
and Abnormal Wound Healing
sue and form new blood vessels through angiogenesis and the Just as it is overly simplistic to consider all the different
newly described process of vasculogenesis, which involves the responses to injury seen in different tissues as simply “wound
recruitment and assembly of bone marrow–derived progenitor healing,” it is naïve to try to classify all the manifestations
cells.13 Proangiogenic factors that are released by macrophages of abnormalities in this process as simply “abnormal wound
include vascular endothelial growth factor, fibroblast growth healing.” To more accurately classify all the different types of
factor 2, angiopoietin 1, and thrombospondin. The upstream abnormal wound healing, it is useful to consider the balance
activator of gene transcription of these growth factors may be between attempts to replace tissue defects with new, substitute
hypoxia via hypoxia-inducible factor 1α protein stabilization. tissues (scar formation) against the re-creation of the original
The relative importance of these different vascular growth tissue in situ (regeneration), as illustrated in Figure 2.1. It is
factors and the precise timing of their arrival and disappear- also helpful to determine where within the normal phases of
ance are areas of active investigation. However, it is clear that wound healing the problem occurs. The goal is to understand
the formation of new blood vessels and subsequent granula- each abnormal process in terms of dynamic balance and to
tion tissue survival is important for wound healing during the propose therapeutic strategies to restore homeostasis on a cel-
proliferative phase of wound healing. lular, tissue, and organ level.
One interesting element of the proliferative phase of wound Such a process is not merely a semantic exercise but has
healing is that at a certain point all of these processes need to be potential therapeutic implications. Thus, although a corneal
turned off and the formation of granulation tissue/ECM halted. ulcer, a peripheral neuroma, and stage IV sacral decubitus
It is clear that this is a regulated event because once collagen
matrix has filled in the wound cavity, fibroblasts rapidly dis-
appear and newly formed blood vessels regress, resulting in a
relatively acellular scar under normal conditions. So how do
these processes turn off? It seems likely that these events are
programmed and occur through the gradual self-destruction
of cellular apoptosis. The signals that activate this program
are unknown but must involve environmental factors as well
as molecular signals. Since dysregulation of this process is
believed to underlie the pathophysiology of fibrotic disorders
such as hypertrophic scarring, understanding the signals for
halting the proliferative phase is of obvious importance for
developing new therapeutics for these disabling conditions.
Remodeling Phase
The remodeling phase is the longest component of wound
healing and in humans is thought to last from 21 days up to
1 year. Once the wound has been “filled in” with granulation
tissue and after keratinocyte migration has re-epithelialized
it, the process of wound remodeling occurs. Again, these pro-
cesses overlap and the remodeling phase likely begins with Figure 2.5. The remodeling phase of wound healing is the longest
the programmed regression of blood vessels and granulation phase and lasts from 21 days to 1 year. Remodeling, though poorly
tissue described above. Despite the long duration of the remod- understood, is characterized by the processes of wound contraction
eling phase and the obvious relevance to ultimate appearance, it and collagen remodeling.
is by far the least understood phase of wound healing.

ulcer are all examples of abnormal healing, the treatment as

guided by an understanding of the underlying mechanism
Excessive Regeneration Underlying
will be completely different. Thus, for a corneal ulcer, which an Abnormal Response to Injury
represents a defect in epithelial regeneration, growth factor These situations are relatively rare. In these cases, pathways of
therapy would make sense to augment the potential for regen- tissue regeneration lead to the re-creation of the absent tissue,
eration, whereas it would make less sense for a defect such but there are functional problems reintegrating the tissue into
as a peripheral neuroma. For a neuroma, treatments aimed the systemic physiology. They often occur in peripheral nerve–
at preventing nerve regeneration would seem to make more like tissue, such as peripheral nerve regeneration leading to
sense. In the following paragraphs, we will attempt to clas- neuroma. Other examples might include the hyperkeratosis
sify the various types of abnormal wound healing using the that occurs in cutaneous psoriasis or granuloma formation
dynamic balance between scar formation and regeneration. in healing wounds. It seems plausible that many conditions
It is hoped that such an analysis might elucidate and clarify we consider “precancerous” are the result of overexuberant
new therapeutic opportunities targeting one component or the attempts at tissue regeneration following minor traumatic
other, as illustrated in Figure 2.1. insults. This then leads to disordered and uncontrolled
growth. Clearly, in these situations, scar formation would be
Inadequate Regeneration Underlying preferable to regeneration because of the risk of loss of growth
an Abnormal Response to Injury control and possible transformation to overt cancer.
In these disease states, therapeutic measures are targeted
The classic example of this is found in central nervous system toward decreasing cellular proliferation and blocking or
injuries that occur following traumatic injury or following tumor impeding the aberrant regenerative pathways. Irritant strate-
ablation. The response to injury in these cases is usually char- gies to maximize scar formation may also play a role, as when
acterized by virtually no restoration or recovery of functional alcohol is injected into a neuroma. The goal is to limit the
neural tissue. The absence of neural regeneration is compensated ability of the tissue to activate pathways leading to regenera-
by a normal physiologic process of replacement with scar tis- tion. It is sobering to realize that although much current effort
sue, but in most cases this process does not appear excessive or is focused on maximizing tissue regeneration, there are cir-
overexuberant. Although efforts to decrease scar formation have cumstances where this already occurs and has proven to be
been attempted, it is currently thought that these will be ineffec- dysfunctional. It also illustrates the need to strictly control the
tive unless neural regeneration can also be achieved. Thus, cur- growth and development of tissue generation using emerging
rently efforts are focused on strategies to increase regeneration of stem and progenitor cell technologies.
neural tissue to treat this abnormal response to injury.16 Current
modalities under investigation include the use of implanted neu-
ral stem/progenitor cells or the use of developmental morphogens Excessive Scar Formation Underlying
to recapitulate the processes of neural development. Techniques
to decrease neural scar formation might also be useful to provide an Abnormal Response to Injury
a window of opportunity for regeneration to occur, but they are When these conditions affect the skin, they are very commonly
unlikely to be successful in and of themselves. Other examples treated by plastic surgeons, but they can occur elsewhere as in
of inadequate regeneration would include bone nonunions and pulmonary fibrosis or cirrhosis. “Excessive” cutaneous scar
corneal ulcers. formation remains a poorly understood and ubiquitous dis-
ease for which there are few treatment options. Abnormal
Inadequate Scar Formation Underlying scarring is classified as either hypertrophic scarring or keloid
formation. Both are manifestations of overexuberant scarring,
an Abnormal Response to Injury although the upstream etiology is probably different.18 Keloids
Many examples of impaired wound healing seen by plastic are less common and have a genetic component that limits
surgeons belong in this category. In most cases, these diseases them to <6% of the population, primarily the black and Asian
result from a failure to replace a tissue defect with a substitute populations. Histologically, keloids are differentiated by the
patch of scar (i.e., inadequate scar formation). In these condi- overgrowth of dense fibrous tissue beyond the borders of the
tions, stable scar tissue would be sufficient to restore cutane- original wound, with large thick collagen fibers composed of
ous integrity and eliminate the pathology. Regeneration of the numerous fibrils closely packed together. Hypertrophic scars
skin, although perhaps ideal, is not required for an adequate are also characterized by the formation of dense collagen fibers
functional outcome. Examples of these types of conditions following injury but, in contrast to keloids, do not extend
include diabetic foot ulcers, sacral decubiti, and venous sta- beyond the original wound margins. They are more prone to
sis ulcers. In all these cases, restoration of cutaneous integ- forming disabling contractures and are a near-universal out-
rity would be sufficient, and as such, efforts must be made come following extensive deep burn injury.
to understand and correct the defects in scar formation that The etiology and pathophysiology of both hypertrophic
occur in these disease states. scarring and keloid formation remain unknown. Many theo-
Once the defect in scar formation is understood, therapeu- ries have been proposed to account for the fibroproliferation
tics can be rationally designed to correct these defects. At times, observed in hypertrophic scar and keloid formation, includ-
it is useful to subdivide the scar formation defects further and ing mechanical strain, inflammation, bacterial colonization,
examine whether the primary defect occurs in the inflamma- and foreign body reaction. Unfortunately, investigation of the
tory, proliferate, or remodeling phases of wound healing. For mechanisms underlying these diseases has been hindered by the
instance, in humans and experimental models, diabetic ulcers absence of animal models that reproduce the characteristics of
occur because of defects in the inflammatory and prolifera- human overscarring. Decreasing the process of scar formation
tive phases of wound healing. Accordingly, therapeutics are is the prime goal of therapy for both disease states. Modalities
targeted toward these phases.17 In contrast, wounds occurring employed include steroid injections, pressure therapy with sili-
because of vitamin C depletion (i.e., scurvy) are due to abnor- cone sheeting, and external beam irradiation. However, with
mal collagen cross-linking, which occurs during the remodel- current treatment modalities, recurrence rates approach 75%.19
ing phase of wound healing. Therapeutics should be directed The prolonged secretion of inflammatory cytokines has been
at this later phase. While in both cases therapeutic efforts are shown to induce fibrosis in numerous in vitro and animal mod-
focused on correcting defects in scar formation (as opposed els. Thus, researchers have long sought to manipulate the cyto-
to augmenting tissue regeneration), the therapeutic targets kine environment to prevent scar formation. Most recently, a
will be different. phase III clinical trial based on the use of recombinant human

TGF-β3 (an antagonist of profibrotic TGF-β1) to improve scar These responses can be conceptualized as favoring replace-

revision outcomes was terminated after failing to reach primary ment of injured tissue with a patch, otherwise known as
endpoints. Given the known complexity of wound healing, it scar formation, or recapitulating developmental processes to
should not be surprising that targeting a single cytokine would duplicate the original architecture, otherwise referred to as
be inadequate to reduce organ-level fibrosis. regeneration. The dynamic balance between these two pro-
Basic Science
Recent research has also implicated a key role for mechani- cesses may underlie the myriad abnormal responses to injury
cal force in promoting both hypertrophic scarring and keloid that occur in human disease states. It is hoped that such a
formation.20,21 Plastic surgeons have long recognized the framework will suggest new therapeutic strategies to correct
importance of tension during wound healing, and several imbalances, by either augmenting or suppressing one component
current treatments for scarring (e.g., silicone sheeting and or the other. This may provide a basis for accelerated prog-
compression garments) may have a “mechanomodulatory” ress in the care of patients with abnormal or dysfunctional
mechanism of action. Mechanical cues are known to activate responses to injury that result in human disease.
fibroproliferative pathways in skin cells, and the underlying
molecular pathways are only beginning to be uncovered in
vivo.22 Further, the ability of physical forces to control clini-
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cues controlling wound repair and fibrosis. mice. Mol Biotechnol. 2004;28:147-166.
4. Singer AJ, Clark RA. Cutaneous wound healing. N Engl J Med.
1999;341:738-746.
Emerging Concepts in 5. Werner S, Grose R. Regulation of wound healing by growth factors and
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Wound Healing 6. Woolley K, Martin P. Conserved mechanisms of repair: from damaged single
cells to wounds in multicellular tissues. Bioessays. 2000;22:911-919.
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the bad and the ugly. Trends Cell Biol. 2005;15:599-607.
opment and in response to injury and disease. This suggests the 8. Simpson DM, Ross R. The neutrophilic leukocyte in wound repair: a study
intrinsic ability of the skin to “regenerate.” Several stem cell with antineutrophil serum. J Clin Invest. 1972;51:2009-2023.
populations have been identified in the skin and are increas- 9. Yager DR, Nwomeh BC. The proteolytic environment of chronic wounds.
ingly studied as potential therapies for wound repair. These Wound Repair Regen. 1999;7:433-441.
10. Gordon S, Taylor PR. Monocyte and macrophage heterogeneity. Nat Rev
progenitor populations include epidermal stem cells, hair fol- Immunol. 2005;5:953-964.
licle stem cells, and adipose-derived stem cells that have the 11. Leibovich SJ, Ross R. The role of the macrophage in wound repair.
capacity to restore almost all skin compartments.2,24,25 Further, A study with hydrocortisone and antimacrophage serum. Am J Pathol.
studies in mammalian digit tip regeneration suggest that the 1975;78:71-100.
12. Park JE, Barbul A. Understanding the role of immune regulation in wound
biologic machinery necessary to regrow damaged soft tissues healing. Am J Surg. 2004;187:11S-16S.
may already be present in adults in the form of tissue-specific 13. Asahara T, Murohara T, Sullivan A, et al. Isolation of putative progenitor
adult stem cells.26 Thus, it is clear that stem cells play a key endothelial cells for angiogenesis. Science. 1997;275:964-967.
role in normal wound healing; the question for researchers 14. Desmouliere A, Chaponnier C, Gabbiani G. Tissue repair, contraction, and
the myofibroblast. Wound Repair Regen. 2005;13:7-12.
is how to exploit these powerful cell populations to promote 15. Page-McCaw A, Ewald AJ, Werb Z. Matrix metalloproteinases and
cutaneous repair in disease states. the regulation of tissue remodelling. Nat Rev Mol Cell Biol. 2007;8:
Another component of the wound environment that has 221-233.
been largely overlooked is the ECM. As stated earlier, wound 16. Harel NY, Strittmatter SM. Can regenerating axons recapitulate devel-
opmental guidance during recovery from spinal cord injury? Nat Rev
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ing but appears to involve regulation of extracellular enzymes 17. Brem H, Tomic-Canic M. Cellular and molecular basis of wound healing in
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been shown that the ECM is a dynamic and active component 18. Kose O, Waseem A. Keloids and hypertrophic scars: are they two different
sides of the same coin? Dermatol Surg. 2008;34:336-346.
of the wound that can directly control cell activity,27 resulting 19. Mustoe TA, Cooter RD, Gold MH, et al. International clinical rec-
in a “dynamic reciprocity” between cells and their immediate ommendations on scar management. Plast Reconstr Surg. 2002;110:
environment that maintains skin homeostasis.28 This concept 560-571.
underlies the development of tissue engineering strategies to 20. Gurtner GC, Dauskardt RH, Wong VW, et al. Improving cutaneous scar by
controlling the mechanical environment: large animal and phase I studies.
deliver and re-create the precise biophysical cues that promote Ann Surg. 2011;254:217.
biologic programs conducive to healing.29,30 21. Ogawa R. Keloid and hypertrophic scarring may result from a mecha-
The three traditional phases of wound healing were estab- noreceptor or mechanosensitive nociceptor disorder. Med Hypotheses.
lished decades ago, and since then, research in wound repair has 2008;71:493-500.
22. Wong VW, Rustad KC, Akaishi S, et al. Focal adhesion kinase links
continued to build upon these fundamental concepts. However, mechanical force to skin fibrosis via inflammatory signaling. Nat Med.
as modern research continues to elucidate the complexity of 2011;18:148-152.
tissue repair processes, we will undoubtedly need to redefine 23. Orgill DP, Manders EK, Sumpio BE, et al. The mechanisms of action of
what normal wound healing is in terms beyond just inflam- vacuum assisted closure: more to learn. Surgery. 2009;146:40-51.
24. Blanpain C, Fuchs E. Epidermal stem cells of the skin. Annu Rev Cell Dev
matory cell trafficking and a handful of cytokines. Traditional Biol. 2006;22:339-373.
approaches to wound healing will also need to be integrated 25. Yang L, Peng R. Unveiling hair follicle stem cells. Stem Cell Rev.
with our improved understanding of the molecular pathophysi- 2010;6:658-664.
ology of aberrant cutaneous repair. Plastic and reconstructive 26. Rinkevich Y, Lindau P, Ueno H, Longaker MT, Weissman IL. Germ-layer
and lineage-restricted stem/progenitors regenerate the mouse digit tip.
surgeons need to be intimately familiar with these evolving con- Nature. 2011;476:409-413.
cepts to ensure the optimal care of our patients. 27. Hynes RO. The extracellular matrix: not just pretty fibrils. Science.
2009;326:1216-1219.
28. Schultz GS, Davidson JM, Kirsner RS, Bornstein P, Herman IM. Dynamic
Conclusions reciprocity in the wound microenvironment. Wound Repair Regen.
2011;19:134-148.
29. Glotzbach JP, Wong VW, Gurtner GC, Longaker MT. Regenerative medi-
In this chapter, a theoretical framework has been proposed cine. Curr Probl Surg. 2011;48:148-212.
with which to understand and classify the normal responses 30. Metcalfe AD, Ferguson MWJ. Bioengineering skin using mechanisms of
to injury that occur in different tissues and different species. regeneration and repair. Biomaterials. 2007;28:5100-5113.

Chapter 3 n Wound Care
Donald W. Buck and Robert D. Galiano
addressing these factors, the surgeon will be able to manage

Introduction most wounds.
The wound is a microcosm of the patient. While most wounds
heal without intervention in healthy individuals, patients with Age and Wound Healing
systemic diseases or acute illnesses can develop non-healing Although most wounds heal without incident in aged
wounds that require evaluation by a plastic surgeon. In gen- patients, there is a slight, but consistent, decline in wound
eral, the plastic surgeon is consulted to evaluate three types of healing rates in the elderly. This decline is exacerbated when
wounds: (1) the acute wound where the final appearance may ischemia and infection are superimposed. Laboratory studies
be the principal concern, (2) the wound in a patient whose reveal a functional decline in aged fibroblasts and endothelial
medical status and/or mode of injury predisposes him or her to cells that leads to accelerated senescence, diminished growth
wound healing difficulties and the threat of a problem wound, factor production, decreased stress response to hypoxia and
or (3) the chronic wound refractory to past interventions. toxins, and a reduction in collagen and matrix production.
In recent years, significant strides have been made in our Interestingly, aged cells share many of the same molecular
overall understanding of problem wound physiology. This has derangements as those seen in diabetic patients and irradiated
led directly to clinical advances that have resulted in better wound beds. Obviously age cannot be reversed; however,
treatments and overall wound care. With the staggering prev- it should be considered an important component of wound
alence of chronic wounds and an ever-increasing armamen- pathology and prompt the surgeon to aggressively optimize
tarium of wound care tools, it is imperative that the plastic appropriate systemic parameters in these patients (nutri-
surgeon maintain an updated understanding of wound healing tion, infection, ischemia, etc.). The use of growth factors or
biology and the principles of wound care. In this chapter we advanced wound protocols should be considered earlier in
will focus on the basics of wound care and highlight some of the elderly patient.
the recent advances in this dynamic and expanding field.
Ischemia and Wound Healing
Fundamentals The role of hypoxia in wound healing is well established.
In fact, local tissue hypoxia is a common characteristic of
All wounds, whether acute or chronic, should be evaluated most chronic wounds. The diffusion of oxygen and nutri-
by a physician to determine their mechanism and to outline ents from capillaries to cells is limited to a distance of 60
an approach to treatment. Tetanus prophylaxis is adminis- to 70 µm in a person breathing room air. Therefore, any-
tered when prior immunity is unknown or the most recent thing that increases tissue diffusion requirements or limits
booster vaccine is over 5 years old. A thorough history and
physical examination should be performed, with particular
emphasis on any aspect that relates to the wound cause and/
or persistence (e.g., comorbidities, systemic diseases, and Table 3.1
medications). The term wound encompasses a broad range of
lesions without consideration to etiology, and the list of pos- Factors That Contribute to Wound
sible etiologies is vast. Table 3.1 lists some of the major fac- Healing Impairments
tors, both systemic and local, that can have profound effects
Age
on wound healing.
Adjunctive diagnostic tests are guided by history and phys- Ischemia
ical examination of the wound. Some useful studies include Reperfusion injury
laboratory tests that reflect nutritional status (albumin,
prealbumin, and transferrin levels), the level of physiologic Infection or bacterial bioburden
inflammation (C-reactive protein and erythrocyte sedimen- Malnutrition
tation rate), and the degree of diabetes control (plasma glu-
Foreign bodies
cose and hemoglobin A1c). In addition, patients should have
a recent complete blood count and basic chemistry panel to Diabetes
assess for leukocytosis, anemia, and renal disease. Other use- Steroids
ful laboratory tools include transcutaneous oxygen pressure
(tcPo2) measurements, toe pressures, neurofilament testing, Uremia
and ankle-brachial index (ABI) (Chapter 95). Results of these Jaundice
tests may direct the need for procedures such as surgical
Cancer
revascularization. Wound parameter documentation is also
useful to monitor the progression of wound healing in an Genetic causes (e.g., Ehlers-Danlos, Werner syndromes)
objective manner. Irradiation
The main fundamentals of wound care are summarized in
Table 3.2. To attain these goals, it is useful to emphasize the Chemotherapy
common causative factors that are shared by problem wounds, Tobacco use
as opposed to isolating the differences between diverse types of
Alcohol use
wounds. With this more simplistic view, it is possible to link the
majority of problem wounds to a combination of three factors: Edema
age, ischemia (including repeated episodes of ischemia–reper- Pressure
fusion injury), and bacterial infection. By understanding and
20
Chapter 3: Wound Care 21
Table 3.2 Bacteria and Wound Healing

Basic Fundamentals of Wound Care All wounds are contaminated, but excessive numbers of bacte-
ria will interfere with wound healing. A quantitative culture of
n Optimize systemic parameters 105 bacteria per gram of tissue is usually diagnostic of infection.
Basic Science
Nutrition However, this tool is rarely used because few microbiology lab-
oratories perform the test reliably. Furthermore, the value of
Glucose control
105 is relative and not universally applicable. In fact, more viru-
Smoking cessation lent strains of bacteria can establish systemic infections at much
n Debride nonviable tissue lower densities. The presence of diabetes, ischemia, or other
comorbidities will also lower the threshold needed to estab-
n Reduce wound bioburden lish a true infection to an unknown extent. Likewise, as more
n Optimize blood flow research on the physiology of bacterial biofilms is introduced, it
is likely that only a fraction of the 105 bacterial count is actually
Warmth necessary to establish a biofilm and create a significant barrier
Hydration to wound healing.
Surgical revascularization An important mechanism by which tissue hypoxia pre-
disposes wounds to infection is by impairing the “oxidative
n Reduce edema burst” essential to microorganismal killing by leukocytes. This
Elevation enormously elevated production of oxygen-derived radicals
is a self-regulated process that is important in clearing the
Compression wound off bacteria. Notably, this process of radical produc-
n Use appropriate dressings tion, which is normally limited to the early stages of wound
Moist wound healing repair, can be aberrantly prolonged in the setting of persis-
tent infection or inflammation (Figure 3.1). This can result
Exudate removal in bystander damage to the body’s normal cells and in many
Avoidance of trauma to wound or patient
n Use pharmacologic therapy when necessary Break in skin integrity,
bacterial inoculation
n Close wounds surgically with grafts or flaps as indicated
Wound
INJURY hypoxia
available capillary delivery systems will establish a hypoxic Bacterial

colonization
environment. For example, oxygen tension in wound tissues Inflammatory
mediators
is reduced an average of 15 to 20 mm Hg (25 vs. 40 mm Resolution
Hg) as a result of the damage to small vessels in periwound (healed wound)
areas. Likewise, the tissue fibrosis commonly encountered in Neutrophils,

macrophages
chronic wounds can create a significant barrier to oxygen dif-
fusion that subsequently produces persistent tissue hypoxia Progression of
wound to later Oxidative burst
and further fibrosis. stages of healing ROS
Clearance
While hypoxia alone is an important component of of bacteria
chronic wounds, most problem wounds are characterized by
repeated episodes of ischemia followed by reperfusion. The Angiogenesis,
ROS
reversal of
detrimental effects of ischemia–reperfusion injury have been ischemia Resolution of
inflammation
Proteases
well established in cardiac pathology and organ transplanta- A

tion, but are underappreciated in cutaneous wound healing.
Reperfusion injury is particularly important in lower extrem-
INJURY
ity wounds, where walking and standing can lead to local-
ized ischemia in pressure-bearing areas, or through increased Insufficient oxidative
edema in patients with venous stasis. Pressure relief, through Wound hypoxia
burst due to regional ischemia
and immune dysfunction
+
sitting, rest, and foot elevation, leads to resumption of ade- Regional ischemia
(PVD, diabetes, radiation) Inflammation Persistent hypoxia
quate tissue perfusion and a vicious cycle ensues. Repeated due to regional
ischemia
episodes, sometimes multiple per day, result in gradual cel- Bacteria
lular damage and a chronic milieu of persistent inflamma-

Bacteria
tion. Similar cycles of ischemia–reperfusion may also occur (critical colonization)
in patients with pressure sores as they shift about in bed or Perpetuation and Elaboration
amplification of of biofilm,
wheelchairs. proinflammatory state pseudoeschar
Surgical and nonsurgical interventions can be undertaken Hypoxia

Inflammation,
to maximize oxygen delivery to tissues. Examples include ele- Proteases
persistence of
neutrophils
vation of edematous extremities, off-loading pressure points, ROS
Growth factors
debridement of necrotic tissue or foreign bodies that act as a Proangiogenic
milieu
physical barrier to diffusion, pain control that reduces sympa- Edema Wound
thetic constriction of peripheral vasculature associated with Exudate stasis
Cellular
the “fight-or-flight” response, heating that will result in vaso- damage Proteases
in wound Acidity
dilatation of cutaneous vasculature, and smoking cessation Zone of Free radicals
injury B
and hydration that increase oxygen delivery at the cellular
level. Recent research indicates that the benefits of ensuring Figure 3.1. The normal healing milieu. A. Normal response to
adequate oxygen delivery to a wound not only are restricted injury. B. Response to injury in the problem wound. ROS, reactive
to established wounds but may also be useful in preventing oxygen species; PVD, peripheral vascular disease.
wound complications.

cases characterizes the microenvironment of the indolent appetizing nutrients for most bacteria. Therefore, any pseu-
wound. This explains the benefit of dressings and the avoid- doeschar or eschar should be debrided as it accumulates. An
ance of foreign debris (and highlights the importance of deli- effective way to do this is through the proper use of dressing
cate tissue handling and the proper choice of suture material) and debriding agents, as detailed below and in Table 3.3.
in expediting healing. Debridement is typically considered a surgical tool, but
Bacteria exert adverse effects on wound healing in several it may also be accomplished through the use of enzymatic,
ways. As mentioned above, through a persistent inflamma- mechanical, or autolytic (through host leukocyte action)
tory response, they establish an environment of free radicals, means. Wound care manufacturers have produced numer-
secreted toxins, and proteases that act to degrade growth fac- ous enzymatic and pro-autolytic agents. While they have been
tors, prevent ordered assembly of matrix proteins, and result proven effective in mildly debriding wounds, their use should
in the creation of proteinaceous debris that constitutes a pseu- not supplant sharp surgical debridement as the method of
doeschar. In addition, they place a significant metabolic strain choice for more heavily contaminated wounds or wounds with
(bioburden) on the wound that the host may not be able to thicker levels of slough or eschar. Enzymatic and pro-autolytic
overcome. Importantly, wound bioburden is often stratified as agents work through preventing the cross-linking of exudated
a prognostic indicator and to assist in management decisions. components and impede the bacteria-sequestering pseudoe-
Wounds may be considered contaminated (bacteria present schar and biofilms from forming. Mechanical debridement
without proliferation), colonized (bacteria present and mul- can be achieved through dressings, or newer pressurized water
tiplying without overt host reaction), critically colonized (the devices, such as the VersaJet (Smith & Nephew, Largo, FL),
tipping point where host response is overcome by bacterial Waterpik (Waterpik Technologies, Fort Collins, CO), pulse-
proliferation), or infected (expanding bacterial quantity with lavage, or shower spray devices. Mechanical debridement is
ongoing host reaction). Critical colonization of a wound or effective at reducing bacterial counts and should be consid-
infection is often heralded by stasis in the progression of a ered adjuncts to surgical debridement. Similarly, a syringe
wound that was previously healing. In fact, if the rate of heal- with a 20-gauge needle will generate the 15 psi necessary to
ing decreases in any wound, it should be considered infected lower bacterial counts in tissue.
until proven otherwise. Other signs of bioburden progres- For historical purposes, another effective means of achiev-
sion and/or overt wound infection include increasing pain in ing wound debridement is through the use of maggot therapy.
the periwound area, increased wound edema, malodorous Maggots preferentially feed on devitalized tissue and spare via-
discharge, increased drainage, or purulence. ble, well-perfused tissue; their secretions also target bacterial bio-
Systemic antibiotics are unnecessary for most wounds. By films. Although they are used sparingly throughout most parts
definition, most wounds are open and thus adequately man- of the country, some centers utilize maggot therapy extensively.
aged through “drainage” and proper debridements. In addi-
tion, systemic antibiotics are only delivered to adequately
perfused tissues; therefore, in the setting of most problem Negative-Pressure Wound Therapy
wounds, they are ineffective. However, there are settings where
Negative-pressure wound therapy (NPWT) has been a signifi-
systemic antibiotics are important. In general, any wound that
cant advance for the wound care practitioner. It consists of
is complicated by surrounding cellulitis should be treated with
the use of a porous sponge within the wound, covered by an
adjunctive antibiotics. As mentioned, any wound where the
airtight occlusive dressing, to which a vacuum is applied. This
rate of healing decreases is considered infected. Increased
modality has many uses and has found its way into the arma-
pain is another indication of a worsening infection. Another
mentarium of a wide array of surgical and nonsurgical spe-
sign of infection is the appearance of straw-colored “oozing”
cialties. It should best be thought of as an adjunct to assist in
from the skin; this is actually likely evidence of an underlying
surgical closure of a problem wound. It can and has been used
Staphylococcus cellulitis or lymphangitis. Antibiotics should
to completely heal a wound, but use in this manner is time-
also be considered in wounds contaminated by oral flora or
consuming, expensive, labor-intensive, and not always effec-
animal bites, as well as in patients with mechanical implants.
tive. A more practical indication is to expeditiously prepare a
In general, surface irrigation and lavage with saline may be
wound bed for surgical closure by tertiary intent.
all that is necessary for truly contaminated wounds, whereas
NPWT works through multiple important mechanisms
topical antibiotics and surgical debridement are often essential
including reduction of edema and removal of wound fluid rich
management tools for overtly infected wounds.
in deleterious enzymes, both patient and bacteria derived. In
addition, the cyclic compression and relaxation of the wound
Adjuncts to Wound Care tissue likely stimulates mechanotransduction pathways that
result in increased growth factor release, matrix production,
Debridement and cellular proliferation.
Debridement is the single most important wound care tool Common clinical scenarios amenable to NPWT include
to reduce bioburden and promote healing. Without adequate lymphatic leaks, venous stasis wounds, diabetic wounds,
debridement, a wound is persistently exposed to cytotoxic wounds with fistulae, sternal wounds, orthopedic wounds, and
stressors and competes with bacteria for scarce resources such abdominal wounds. Likewise, NPWT is used frequently as an
as oxygen and nutrients. Many surgeons underappreciate the alternative to bolster dressings for split thickness skin grafts.
importance of adequate debridement in the management of Notably, by reliably encouraging granulation tissue formation
both acute and chronic wounds. While most surgeons rec- and reducing wound edema, NPWT has permitted normally
ognize the importance of debridement of grossly necrotic or emergent wounds to be managed in a nonemergent fashion,
foreign material, many still allow wounds to “heal” under a allowing for medical stabilization and optimization prior to
“biologic dressing” or eschar. advanced reconstructive procedures. In some instances, it has
An eschar begins as a pseudoeschar, which is a provisional even enabled avoidance of free tissue transfer.
matrix of exudated serum components at the wound–air inter- There are several contraindications to the use of NPWT,
face. If allowed to dry, the gelatinous pseudoeschar will harden and these include the presence of a malignancy, use on wounds
to form a true eschar, or scab. Pseudoeschars and eschars may characterized by ischemia, as well as inadequately debrided or
play a role in prolonging the inflammatory stage of wound badly infected wounds. There have been reports of extension
healing, and hence establish an environment ripe for bacterial of the zone of necrosis when used on ischemic wounds; for
colonization in the compromised patient or susceptible wound this reason, these patients should be revascularized prior to
bed. Likewise, the proteinaceous components of the eschar are application of NPWT.

Table 3.3

Common Dressings in Wound Care
n D
ressing n D
ressing onformability n Clinical
n C n C
ommonly Used
Basic Science
Material Characteristics (Surface Application Products
Anatomy versus.
Cavity)
Gauze Moderate absorption Surface Superficial wounds Many, can be

Nonadhesive Light exuding wounds impregnated with
Light hydration As a secondary antimicrobials and gels
(if moistened with dressing
saline) Optimal for skin graft
donor sites and
surgical incisions
Films Nonabsorbing Surface Superficial wounds Tegaderm (3M, St.
Fully adhesive Light exuding wounds Paul, MN)
Slow hydration As a secondary Op-Site (Smith &
dressing Nephew, Largo, FL)
Optimal for skin graft
donor sites and
surgical incisions
Hydrogel Low absorption Surface Superficial wounds NU-GEL (Johnson &
sheets Nonadhesive or Light exuding Johnson, Somerville, NJ)
adhesive borders wounds Curafil (Kendall/Covidien,
Moderate hydration Painful wounds Mansfield, MA)
(once a day Flexigel (Smith &
application) Nephew)
Amorphous Low to moderate Cavities Clean, superficial to Curasol (Healthpoint,
hydrogels absorption deep wounds Fort Worth, TX)
Nonadhesive Light to moderately Tegagel (3M)
Quick hydration exuding wounds
Hydrocolloids Low to moderate Surface Superficial wounds DuoDERM (ConvaTec,
absorption Light to moderately Skillman, NJ)
Fully adhesive exuding wounds Replicare (Smith &
Moderate hydration May exacerbate Nephew)
wound odor Tegasorb (3M)
Ultec (Kendall/Covidien)
Foams High absorption Both depending on Superficial to deep Allevyn (Smith &
Full to nonadhesive dressing type wounds Nephew)
Not hydrating Moderately to Copa (Kendall/Covidien)
heavily exuding Lyofoam (ConvaTec)
wounds Optifoam (Medline,
Mundelein, IL)
Restore (Hollister,
Libertyville, IL)
Alginates High absorption Cavities Superficial or deep Algisite (Smith & Nephew)
Nonadhesive wounds Curasorb (Kendall/
Not hydrating Moderately to Covidien)
heavily exuding Kaltostat (ConvaTec)
wounds Maxorb (Medline)
Restore Alginate
(Hollister)
Collagens Moderate to high Cavities Superficial or Fibracol (Johnson &
absorption deep wounds Johnson)
Nonadhesive Light to moderately Colactive (Smith &
Not hydrating exuding wounds Nephew)
Puracol (Medline)
Negative- Moderate absorption Both Lymphatic leaks, V.A.C. (Kinetic Concepts
pressure wound Adhesive venous stasis wounds, Inc., San Antonio, TX)
therapy Not hydrating diabetic wounds, Renasys (Smith &
wounds with fistulae, Nephew)
sternal wounds, ortho-
pedic wounds, and
abdominal wounds

rapidly degrade the protein. In addition, its use in patients

Hyperbaric Oxygen with malignancy has been cautioned.
Hyperbaric oxygen (HBO) has been shown to raise the dis- Although not growth factors per se, there has been an
solved oxygen saturation in plasma from 0.3% to nearly increase in the use of neonatal fibroblasts as a “carrier” for
7%, resulting in a four- to fivefold increase in the interstitial essential growth factors to the wound environment. Commonly
diffusion distance of oxygen. Historically, the initial enthu- used products include Apligraf (Organogenesis Inc., Canton,
siasm to HBO led to indiscriminate and unscientific use, MA) and Dermagraft (Advanced BioHealing, Westport, CT).
which created significant controversy with regard to safety These products are commonly used in patients with a sub-
and efficacy. Despite early disappointment, the use of HBO optimal wound environment, including venous stasis ulcers,
has gained increasing traction. In order to optimize results, diabetic wounds, and wounds in aged patients.
it is important to recognize which patients benefit the most
from such therapy. The use of transcutaneous oximetry Enzymes
has permitted evaluation of wound microcirculation, such
The rationale for using enzymatic debriding agents is that
that surgeons can accurately predict responders and non-
they offer a noninvasive means to selectively digest necrotic,
responders. In general, patients who demonstrate a rise in
devitalized tissue and prevent slough and eschar from accumu-
the wound tcPo2 when inspiring supplemental oxygen will
lating (Table 3.4). Papain-based products are no longer avail-
benefit from HBO. Patients that will not benefit from HBO
able in the United States since they were determined by the
include those with normal environmental perfusion and
FDA to be unapproved drugs with significant side effects. The
those with ischemic limbs who require a revascularization
sole enzymatic agent available for use is collagenase (Santyl,
procedure to restore adequate blood flow to the limb. It is
Healthpoint Ltd., Fort Worth, TX), which works by digest-
important to note that HBO use remains largely empiric as
ing necrotic collagen within wounds. Santyl is currently mar-
there is a paucity of prospective randomized trials support-
keted for patients with chronic dermal ulcers and burns and is
ing its use.
used frequently by wound care practitioners. It is important to
recognize that enzymatic debridement products are not sub-
Growth Factors stitutes for adequate mechanical debridement; however, when
properly used, they are often less traumatic to healthy sur-
The first growth factor approved by the Food and Drug rounding tissue. In general, these products should be used in
Administration (FDA) in the United States is platelet-derived wounds with small areas of eschar or necrotic debris.
growth factor (PDGF) or becaplermin (Regranex, Johnson &
Johnson, Somerville, NJ) (Table 3.4). Although it is only FDA
approved for use in the treatment of diabetic foot ulcers, is has Dressings
been widely used “off-label” for the treatment of a variety of Wound care dressings (Table 3.3) can be broadly divided
other wound types including irradiated wounds and wounds into seven classes: films, composites, hydrogels, hydrocol-
in elderly patients. Importantly, PDGF is only effective in the loids, alginates, foams, and absorptive dressings including
context of a well-prepared wound bed. Contaminated and/ NPWT. Unfortunately, within each class, there are a dizzying
or infected wound beds are filled with proteases, which will number of options and a paucity of prospective, randomized
Table 3.4
Common Growth Factors and Enzymes in Wound Care
n Name n G
rowth n Uses n Comments
Factor/Enzyme
Regranex (Johnson & Platelet-derived Diabetic foot ulcers Degraded in contaminated or

Johnson, Somerville, NJ) growth factor (FDA approved, “off-label” infected wound beds
for irradiated wounds,
elderly patients)
Accuzyme Papain-urea Superficial wounds with Expensive; not useful in
Panafil presence of necrotic debris wounds with large amounts
(Healthpoint Ltd, or eschar of necrotic tissue
Fort Worth, TX)
Santyl Collagenase Superficial wounds with Expensive; not useful in
(Healthpoint Ltd) presence of necrotic debris wounds with large amounts
of necrotic tissue
Skin substitutes Neonatal fibroblasts, Poor wound environment Expensive; often used as a
Apligraf (Organogenesis, hyaluronic acid (e.g., elderly, venous stasis “growth factor” carrier
Canton, MA) wounds)
Dermagraft (Advanced
Biohealing, Westport, CT)
Integra (Integra Life Sciences, Collagen-GAG bilayer Coverage of partial and Useful in burns and to cover
Plainsboro, NJ) full-thickness wounds exposed tendon and bone
Biobrane (Mylan Laboratories, Silicone-nylon Coverage of partial thickness Useful as barrier to
Canonsburg, PA) bilayer with wounds, burns, skin grafts contamination for skin
imbedded collagen graft coverage, burn wound
coverage

clinical trials that definitively prove superiority of one type come in various physical forms including gels, sheets, and

versus the other. With the seemingly endless options avail- impregnated into gauze. They are nonadhesive and therefore
able, it can often become overwhelming. To assist with this cause minimal pain with dressing changes. However, because
decision, it is best to consider the overall wound characteris- of this, they usually require a secondary dressing (e.g., gauze).
tics and treatment goals and match them to the appropriate
Basic Science
dressing class. Hydrocolloids. Hydrocolloids typically come in pastes,
The goal in clean wounds that are to be closed primarily, powders, or sheets that are placed within the wound and cov-
or in wounds that are granulating well, is to provide a moist ered with a dressing to form an occlusive barrier that gels as
healing environment to facilitate cell migration and prevent it absorbs mild amounts of exudates. Hydrocolloids consist of
desiccation. Consequently, films can be used for incisions, and gel-forming agents (typically gelatin, carboxymethyl cellulose,
hydrogels or hydrocolloids can be used for open wounds. The or pectin) that are impermeable to gases and liquids. They
amount and type of exudate that is present in the wound will may be left on the wound for 3 to 5 days; during this time,
determine the dressing used in wounds that have some degree they provide a moist environment that promotes cell migra-
of bacterial colonization. In general, hydrogels, films, and tion and wound debridement by autolysis. However, because
composite dressings are best for wounds with lighter amounts of their occlusive nature, they should not be used in wounds
of exudates; hydrocolloids are used for wounds with moderate heavily colonized by bacteria, especially those with anaerobic
quantities; and alginates, foams, and NPWT are best used for strains. They are not highly absorbent and hence should not
wounds with heavier volumes of exudates. As mentioned pre- be used in highly exudative wounds.
viously, NPWT is also useful for wounds with heavy amounts
of lymph drainage as a consequence of a lymphatic leak, as Foam Dressings. Foam dressings are made of nonadhering
well as for fistulae. Wounds with large amounts of necrotic polyurethane, which is hydrophobic, and an occlusive cover.
material should not be treated with dressings until a surgical The polyurethane is highly absorptive and acts as a wick
debridement has been performed. for wound fluids, making them useful for highly exudative
wounds. However, because of their high wicking ability, they
Gauze. Gauze dressings are the traditional first choice for are not to be used on nonexudating or minimally exudating
generic wound care. The realization that the practice of moist wounds.
to dry dressings for wound care is actually traumatic and pro-
inflammatory has led to a decline in the use of these dressings Alginates. Alginate dressings are derived from brown sea-
in the arena of wound care. In addition, the costs associated weed and are particularly useful in wound characterized by
with these dressings, particularly in personnel expenses, are significant amounts of exudate. Their use permits the desired
high compared with modern dressings that require less fre- removal of exudated fluids from the wound environment and
quent dressing changes. Gauze dressings are often painful to yet frees the practitioner from the burden of daily dressing
remove and are nonselective debriders that cause significant changes or multiple dressing changes per day. These products
collateral damage to healthy surrounding tissue. Furthermore, should also not be used in nonexudative wounds, as they can
many gauze dressings leave behind fine microfibers that can dry out the wound bed. They come in several forms, includ-
act as an irritant or a source of infection. ing a rope/ribbon form that is useful for packing wounds
Advantages of gauze dressings include a low material with deep pockets. These dressings can absorb approximately
expense and a readily available supply. Likewise, they may 20 times their dry weight in fluid. They should be covered
be purchased impregnated with petrolatum, iodinated com- with a semiocclusive or gauze dressing. If the surgeon desires
pounds, or other material useful in keeping the wound bed to use these alginate dressings on dry wounds, they should
moist. They make excellent surgical bandages and can be used be hydrated with sterile saline prior to being placed on the
in small, noncomplicated wounds or as secondary dressings. wound to maintain wound moisture and permit epithelializa-
Gauze dressings remain the “gold standard” to which the tion and autolysis. Some alginates are impregnated with silver.
FDA compares most dressings. There is no definitive evidence
that other dressings will heal a wound faster than moist gauze, Antimicrobials. Antimicrobial dressings are a generic
although they may offer other advantages. term for a dressing that contains an antimicrobial agent.
The most beneficial agent appears to be silver. Silver is ion-
Semiocclusive Dressings. These are sheets that are ized in the moist environment of the wound, and it is the
impermeable to fluids but permit the passage of small gas silver ion that has biologic activity. This agent has a broad
molecules. They are typically used in combination with spectrum of bactericidal activity with low toxicity to human
gauze or other dressings and act to maintain the moisture cells. Because of silver’s tri-pronged mechanism of action
content of clean wounds. Semiocclusive dressings are com- (cell membrane permeabilizer, inhibitor of cellular respira-
monly used to cover and protect freshly closed incisions and tion, and nucleic acid denaturer), it is active against a broad
skin graft donor sites and will enhance epithelialization when range of microorganisms in vitro, including highly resistant
used this way. They should not be used in wounds known to organisms such as VRE (vancomycin-resistant enterococcus)
be contaminated and wounds with moderate or higher exu- and MRSA (methicillin-resistant Staphylococcus aureus).
date levels and should be used cautiously in patients with There are a number of silver-impregnated dressings on the
fragile skin prone to tearing. market today, including Acticoat (Smith & Nephew, Largo,
FL), Aquacel Ag (ConvaTec, Skillman, NJ), and Silvasorb
Hydrogel Dressings. Hydrogel dressings are useful in (Medline, Mundeleine, IL). Despite the expanding incorpo-
maintaining a moist wound bed and rehydrating wounds to ration of silver into many types of dressings, reliable indica-
facilitate healing through autolytic debridement. Thus, they tions for their use remain to be determined, and much of
are often useful in wounds with small amounts of eschar the use of silver-containing dressings is based on anecdotal
or that are predisposed to desiccation. Their usefulness is experience.
achieved by their intrinsic moisture content and hydrophilic Cadexomer iodine is another antimicrobial agent and is a
nature. They are usually composed of complex polysaccha- slow-release form of iodine formulated to achieve consistent
rides (e.g., starch). Unlike alginates and hydrocolloids, they are bactericidal levels within the wound bed without the wound
not dependent on the wound bed to maintain moist wound cell damaging effects seen with the use of povidone-iodine
microenvironments. Yet, like the other dressings, they can products. Other antimicrobials include silver sulfadiazine,
absorb moderate amounts of fluid from the wound. An addi- mafenide acetate, and preparations of sodium hypochlorite
tional benefit is that they can be used in infected wounds. They solution (Dakin’s solution).

Intact skin
Skin Substitutes or Human Tissue Equivalents =100% Curve of ideal healing
These were among the first tissue-engineered products applied Curve of normal healing
to clinical use. As mentioned previously, besides providing
wound coverage, some of these products contain living cells Problem
that are cellular factories, secreting a panoply of growth fac- wound curve
tors and other bioactive molecules that assist the wound heal-
50% Augmented
ing cascade. One major disadvantage to their use is cost. They
Skin tensile strength

healing Delayed
(Degree of healing)
must be applied to meticulously clean wounds with adequate (hypothetical) healing
vascularity, and for certain products the site needs to be immo-
bilized to prevent shearing and graft loss. Representative prod-
ucts include cultured autologous keratinocyte sheets (Epicel,
Genzyme Corp, Cambridge, MA); dermal constructs such as
0%
Biobrane (Mylan Laboratories, Canonsburg, PA), Oasis (Cook 0 20 40 60 80
Biotech, West Lafayette, IN), Integra (Integra LifeSciences Time following injury (days)
Corp, Plainsboro, NJ), TransCyte (Smith & Nephew, Largo,
FL), and Dermagraft (Advanced Biohealing, Westport, CT); Figure 3.2. The healing trajectories of a normal wound, a problem
and bilayered tissue-engineered constructs consisting of kera- wound, and a hypothetical ideal wound are depicted. Most normal
wounds heal with a slight lag phase, an exponential phase of active
tinocytes and fibroblasts such as OrCel (Ortec International,
gain in tensile strength with active matrix deposition, and a protracted
New York, NY), and Apligraf (Organogenesis, Canton, MA). resolution phase. Note that the normal wound heals with a scar that
The indications for their use are highly patient and center spe- does not achieve the tensile strength of unwounded skin (hypothetical
cific. Integra has proven especially useful for sites prone to wound curve). The curve on the right represents a problem wound
contracture (neck and axilla) and to replenish contour in burn curve. The exact shape of the curve is dependent on the patient
wounds and donor sites. In addition, it can enable coverage of and clinical scenario; however, prolongation of the lag phase, a more
tendons, bone, and surgical hardware and in select situation shallow exponential phase, and a reduction in final tensile strength
can obviate the need for more complex wound closures, such are to be expected.
as flaps.
Scar Modulating Therapies. The use of silicone sheets wounds that will not heal is of tremendous importance and is an
improves the appearance of scars. This is likely the result of area of promising research. This also has practical importance, as
the increased moisture and slightly increased warmth pro- many third-party reimbursement agents will not cover specialized
vided by the continuous application of the silicone sheet, as care of wounds unless they have been present for a defined period
this increases slightly the rate of collagenolysis. Other useful of time. The standard definition of a chronic wound is one that
tools include steroids and pressure garments. Calcium channel has been present for 3 months but such a definition may be seized
blockers are used, but they are unproven, as are topical formu- upon by insurance carriers to deny specialized care to impaired
lations of salicylic acid, an anti-inflammatory agent, although wounds. Unfortunately, this condemns the patient to months of
the theoretical basis underlying the use of this agent appears unnecessary waiting, morbidity, and time away from work and
sound. Drugs targeting growth factors thought to be impor- may even worsen the outcomes in cases of threatened limb
tant in fibrosis are currently in clinical trials. loss, for example, by allowing the progression of osteomyelitis.
It is, therefore, perhaps time to redirect the conceptualization of
Common Clinical Wound Care Scenarios a problem wound to de-emphasize chronicity and re-emphasize
its fall off the trajectory of expected healing. The majority of
The Uncomplicated Wound. Much is known about the problem wounds seem to share the traits of advanced age, infec-
healing rates of clean surgical incisions. The rate of healing tion, and ischemia with reperfusion injury, as described above. In
is a direct reflection of the kinetics of collagen deposition addition, many problem wounds suffer from one or more unique
and remodeling within the wound. When the healing cascade traits that retard the healing process further, including radiation
progresses normally, approximately 30% to 50% of the final exposure and systemic comorbidities such as diabetes.
strength of the wound is achieved in 42 days. It is for this
reason that elective surgery patients are told to refrain from Wounds in Patients on Steroids. Wounds in patients
strenuous activity or heavy lifting for at least 6 weeks. This receiving steroids are prone to infection and show decreased
progression represents the expected course of healing. In rates of angiogenesis, collagen deposition, and cellular prolifer-
patients with underlying comorbidities, including renal failure, ation. It is important to remember that steroids may exert their
ischemia, and steroid use, this curve is delayed and shifted to impairments to healing even longer after their use is discon-
the right (see Figure 3.2). In these particular patients, postoper- tinued. Maintenance of a clean wound with minimal bacterial
ative instructions should be adjusted to reflect the anticipated colonization should be the main goal of care for these patients.
delay in healing. Note that in healthy patients, no pharmaco- In addition, experimental models of steroid-impaired healing
logic agent has been demonstrated to shift the curve to the left; have shown vitamin A to be a useful adjunct. The typical dose
that is, healing rates are for the most part maximized in healthy of vitamin A in patients receiving steroids is 25,000 IU daily
people. However, it may be possible to modify the quality by mouth or 200,000 IU topically three times a day.
of healing, and research on scar modulation and manipula-
tion is currently an area of significant future promise. Below Wounds in Patients with Irradiated Skin (Chapter
we will discuss common complicated wounds encountered by 17). Patients with irradiated wounds represent a chal-
the plastic surgeon. General management plans can be found lenging problem. The progressive endarteritis obliterans
in Figure 3.3. and microvascular damage, along with fibrotic interstitial
changes, result in a wound marked by ischemia and cellu-
The Problem Wound. Problem wounds are important enti- lar senescence and prone to infection. In addition, aggres-
ties that are frequently seen by plastic surgeons. In an ideal world, sive surgical debridement of these wounds often results in
these wounds would be seen by a wound care specialist as soon larger non-healing wounds. Thus, any surgical debridement
as possible. Unfortunately, in practice it is difficult to identify the should be conservative. Antimicrobial dressings capable of
incipient problem wound. Furthermore, not all problem wounds maintaining moist wound healing while promoting autolysis
are actually chronic wounds. The development of biomarkers for are also useful, as is the use of growth factors and even HBO

Patient has possible problem wound

Thorough history and
Basic Science
physical examination, and
appropriate diagnostic
adjuncts:
- Labs
- Vascular studies
- Imaging
Optimize systemic Debridement Control of bioburden Care of wound

parameters
- Smoking cessation - Remove slough, eschar, - Remove nonviable, - Choose appropriate

- Treat or minimize obesity, debris, and biofilm via colonized tissue dressings to ensure moist
edema, and medical surgical or autolytic/ - Establish presence and healing and control exudation
comorbidities enzymatic debridement type of infection with cultures (see Table 3.4)
- Educate patient regarding - Give topical antimicrobials - If wound healing is stalled
wound when warranted or slow, consider growth
factors or biologic dressings
- Initiate preventative - Give systemic antibiotics if
measures as appropriate there is surrounding cellulitis - Administer NPWT as
or worsening infection appropriate
Figure 3.3. A general algorithm for approaching the patient with a problem wound. After a thorough history and physical examination,
appropriate adjunctive diagnostic studies are obtained. Although each wound will vary, the approach should focus on four general themes:
optimization of systemic parameters, debridement, control of wound bioburden, and creation of a moist healing environment through appropriate
dressings. NPWT, negative-pressure wound therapy.
therapy. In general, these wounds will often need a microvas- stage II), a moist, clean environment is ideal. Films or hydrogels
cular free flap to attain stable wound coverage. are often useful in this situation. In deeper, more exudative pres-
sure sores (stage II to stage IV), more absorptive dressings can
The Pressure Sore Wound (Chapter 98). Pressure be used, including hydrocolloids, alginates, or foams. Likewise,
sores represent a common problem affecting nearly 20% of in dirty or contaminated wounds, antimicrobial dressings or
all hospitalized patients. Patients who are prone to develop Dakin’s solution can be used to help reduce bioburden.
pressure sores are often debilitated and elderly or suffer from A tremendous advance in the care of pressure sore patients
some neurologic injury. Although successful healing can occur has been the evolution of support surface therapies. These
in the motivated patient, recurrence is more often the rule. therapies are both pressure reducing (reduction of pressure at
The underlying etiology of these wounds is, by definition, the ulcer site to a level that is less than that exerted by a regular
pressure over a bony prominence. Although pressure relief is surface) and pressure relieving (relief of pressure to a level less
paramount in promoting healing, aggressive management of than the capillary closing pressure). These devices include air-
comorbidities is critical to establish an adequate healing envi- fluidized beds, air mattresses, air flotation and water flotation
ronment. Most patients with pressure sores are malnourished devices, and low air-loss beds. The variables they control, in
and cachectic, which makes them more susceptible to wound addition to pressure, include moisture retention, shear force,
healing deficits. As a result, they should be aggressively nour- and temperature. A major drawback is their expense, which
ished (to an ideal albumin level > 3) and receive vitamin can be significant.
supplementation. Consideration should also be given to the
administration of growth hormone or anabolic steroids, such Wounds in Patients with Diabetes (Chapter 95). The
as oxandrolene, as this steroid counteracts the catabolic state foundation of care in the patient with diabetes is recogni-
of these patients. tion that most of the ulcers seen are physiologically similar
Thorough surgical debridement of nonviable tissue is to pressure sores that have occurred in the setting of neu-
important to alter the biology of the wound from its chronic ropathy. The neuropathic ulcer is a multietiologic lesion,
state, creating a more acute wound. Given that many of these with components of pressure necrosis, functional micro-
patients are debilitated or insensate, debridement at the bedside angiopathy, and true neuropathic derangements. The term
is possible. Once a thorough debridement has been performed, “functional microangiopathy” is preferred because, although
adjunctive wound care tools can be used to promote healing. diabetics do not have anatomic abnormalities in their arte-
Many of these patients may ultimately require flap reconstruc- rioles and capillaries, they nevertheless do have a dysfunc-
tion to obtain a closed wound. A frustrating aspect of the tional microvasculature, with impairments in vasodilatation
care to these patients is the high rate of recurrence despite the and compensatory angiogenesis in response to ischemia.
best efforts of the surgeon, which often is a reflection of the The treatment of the diabetic foot is tailored to address
patient’s social situation and support system. these varied components. Management considerations in
Muscle spasms in these patients should be controlled either these patients include selective debridement, tight glucose
medically or, in extreme cases, surgically. Dressings should be control, pressure off-loading (either through noncontact
used strategically. In more superficial pressure sores (stage I or orthotics or surgically through Achilles tendon lengthening),

revascularization when there is a significant arterial lesion, use perforating system. All patients with venous stasis ulcers resis-
of growth factors such as Regranex, and, in certain circum- tant to compression therapy merit vascular studies to deter-
stances, tibial nerve decompression. Given the complexity of mine suitability for these interventions. The use of subfascial
the derangements found in the so-called diabetic foot, and the endoscopic perforator surgery is under intensive study in asso-
plethora of treatment options, these patients are best served ciation with more traditional vascular approaches such as vein
by dedicated multidisciplinary wound/limb salvage centers. stripping.
Venous Stasis Wounds. Venous stasis wounds develop

in the extremities of patients with incompetent veins, which The Future of Wound Care
leads to a complex physiologic environment consisting of Significant research is underway in the biology and tissue-
venous hypertension and relative ischemia from reduced capil- engineering potential of autologous stem cells. In the future,
lary flow gradients. Compression therapy is essential for these it may be possible to augment the wound healing deficits
wounds. This is true for patients who have undergone vas- seen in problem wound patients with the use of topical stem
cular surgery as for those who have not. More sophisticated cells. In addition, scar modulation and manipulation therapies
and individualized compression garments have been devel- will likely become available to assist in minimizing the cutaneous
oped. One caveat to the use of compression therapy is that this stigmata of surgery.
modality is contraindicated in patients with an ABI < 0.7 and
should be used under close medical supervision in extremities
with an ABI between 0.7 and 0.9.
Conclusion
Rigid compression products include the Unna boot-paste Wound care is an important component of plastic surgery. As
dressings and low-stretch bandages. Elastic compression students of soft-tissue anatomy, tissue healing, and surgical
dressings are more applicable for non-ambulatory patients, as reconstruction, plastic surgeons are equipped with the tools
they have a higher resting pressure than rigid products. Types necessary to treat most wounds. Understanding the fundamen-
of compression products include stockings, elastic wraps, and tal aspects behind the chronic and problem wound, strategies
multilayer wraps. Use of combination dressings incorporating can be employed to alter the wound environment and tip the
an elastic component and an absorptive minimally stretching balance toward healing. Plastic surgeons can also judiciously
component has achieved widespread acceptance as superior intervene surgically to promptly close appropriate wounds. Basic
to the traditional Unna boot, which does not achieve optimal science research and translational findings continue to advance
pressure by itself. However, when combined with elastic com- our knowledge of wounds and assist in the development of
pression wraps, the Unna boot can be quite useful. novel treatment approaches. Unfortunately, many of the wound
Compression garments should be individualized to the care products in use today are market and industry driven, with
patient. Although ideally the pressures exerted should be little prospective, randomized comparative studies evaluating
between 30 and 40 mm Hg, there are situations where more or efficacy. In addition, the concept of wound care centers has been
less pressure can be used. The rationale for 30 to 40 mm Hg aggressively marketed. While this concept can benefit patients,
therapy is experimental evidence showing that venous stasis many centers are company organized and are biased in treat-
ulceration is greatly increased when the ambulatory venous ments delivered. In addition, these centers are often staffed by
pressure rises above 30 mm Hg. Care should be taken not to personnel with limited backgrounds in surgery and/or wound
exceed the pressure recommended for the clinical indication, healing. The ideal wound care center is multidisciplinary, with
as secondary ulcerations can develop. A key to the use of com- participation of committed plastic surgeons who work closely
pression therapy is patient compliance and commitment. As with other team members for the benefit of the patient.
treatment progresses, the extremity becomes less edematous
and thus limb girth decreases. Patients must recognize when Suggested Readings
garments are not fitting appropriately and return to the clinic 1. Falanga V, ed. Cutaneous Wound Healing. London: Martin Dunitz; 2001.
to be resized. Therapy should be continued for several weeks 2. Galiano RD. Lower extremity ulcers. In: Souba W, et al., eds. ACS Surgery:
following successful closure of the wound to permit remodeling Principles and Practice. Hamilton: Decker Publishing; 2008.
3. Hess CT, ed. Clinical Guide: Wound Care. Philadelphia, PA: Lippincott
and strengthening of the neomatrix, and maintenance hosiery Williams & Wilkins; 2005.
needs to be instituted, often for the lifetime of the patient. 4. Hunt TK, Hopf HW. Wound healing and wound infection. What surgeons
Dressings are frequent adjuncts to compression therapy. and anesthesiologists can do. Surg Clin North Am. 1997;77:587.
The choice of dressing is dictated by the amount of drainage 5. Mustoe T. Understanding chronic wounds: a unifying hypothesis on their
pathogenesis and implications for therapy. Am J Surg. 2004;187:655.
present. Because many compression products are worn for 6. Park H, Copeland C, Henry S, Barbul A. Complex wounds and their man-
days at a time, the dressing chosen must be capable of absorb- agement. Surg Clin North Am. 2010;90:1181.
ing high levels of exudates and transudate. When edema and 7. Ramasastry SS. Acute wounds. Clin Plast Surg. 2005;32:195.
bioburden are controlled, closure is often expedited by the use 8. Ramasastry SS. Chronic problem wounds. Clin Plast Surg. 1998;25:367.
9. Robson MC, Steed DL, Franz MG. Wound healing: biologic features and
of tissue-engineered skin substitutes. approaches to maximize healing trajectories. Curr Probl Surg. 2001;38:72.
The indication for vascular surgical intervention remains 10. Wu SC, Marston W, Armstrong DG. Wound care: the role of advanced
superficial venous insufficiency with insufficiency of the wound healing technologies. J Vasc Surg. 2010;52:59S.

Chapter 4 n The Blood Supply of the Skin

and Skin Flaps
Basic Science
Geoffrey Ian Taylor, Russell J. Corlett, and Mark W. Ashton
Knowledge of the anatomy of the cutaneous arteries and way between the lobules of the subcutaneous fat, ultimately
veins is fundamental to the design of skin flaps and incisions. reaching the subdermal plexus, where they again travel for
Although detailed studies of these vessels were performed by variable distances to supply the overlying skin, being longest
Manchot,1,2 Spalteholz,3 Pieri,4 Esser,5 and Salmon,6,7 they where the skin is mobile.26 During their subcutaneous course,
were published in either German, Italian, or French. In the the cutaneous arteries (and veins) often travel with the cutane-
English-speaking world, little attention was paid to the precise ous nerves, either as long channels or as a chain-linked system
anatomy of the cutaneous vessels so that surgeons designed of vessels.28,29
skin flaps randomly on whatever vessels happened to be in the The density, size, and direction of the cutaneous perfora-
area, assigning rigid length-to-breath ratios to the flaps. It was tors vary from region to region, being modified by growth,
not until the last four decades, with the introduction of the differentiation, and the functional demands of the body part,
microsurgical free skin flap,8,9 the revival of the musculocu- factors that provide the basis for the various anatomic con-
taneous flap,10 the description of the fasciocutaneous flap,11,12 cepts that follow. In general, the vessels of the head, neck,
and the use of tissue expansion13 and flap prefabrication,14 torso, and proximal limbs are larger and more widely spaced
that surgeons and anatomists have returned to the anatomic than their counterparts in the forearms, legs, hands, and feet
dissecting room to search and research the intricacies of the (see Figure 4.1). Although the size and length of the cuta-
vascular pathways to and from the skin. This has been and neous perforators may vary, they all interconnect to form
still is an exciting period of anatomic renaissance, especially a three-dimensional “body carpet” that has a particularly
with the emergence of “perforator flaps.”15-22 well-developed horizontal strata of vessels in the dermis, in
Although much original data have been provided, there has the subdermis, on the undersurface of the subcutaneous fat,
been a concurrent bewildering explosion of new terms and and on the outer surface of the deep fascia (Figure 4.2).
attempts to classify the cutaneous circulation, often based on The connections between adjacent cutaneous arteries are
flap design rather than vascular anatomy. It is worth stating, either by true anastomoses, without change in caliber, or by
however, that many of the “new” flaps, whether island, fascial, reduced-caliber choke anastomotic vessels (Figure 4.3). The
neurocutaneous, direct, indirect, axial, random, super, septal, latter are plentiful in the integument (skin and subcutaneous
arterial, musculocutaneous, perforator, or otherwise, are each tissues) and may be important in regulating the blood flow
simply the product of a surgical insult inflicted on the same to the intact skin (Figure 4.1C). These choke vessels play an
basic vascular pattern that exists throughout the body, though important role in skin flap survival, where, like resistors in
viewed through different eyes. Converse23 stated that “there is an electrical circuit, they provide an initial resistance to blood
no simple and all encompassing system which is suitable for flow between the base and the tip of the flap. When a skin flap
classifying skin flaps.” He went on to state that “it is now is delayed by the strategic division of cutaneous perforators
generally agreed that the anatomical vascular basis of the flap along its length, these choke vessels dilate to the dimensions
provides the most accurate approach for classification.” Time of true anastomoses (see later), thus enhancing the circulation
has supported the veracity of this statement, emphasized by the to the distal flap. Although some dilatation of the choke ves-
recent refocus of attention on the anatomy of the cutaneous sels occurs because of the relaxation of sympathetic tone, the
perforators as the basis for skin flap design.15,17,18,20-22,24-27 major effect is seen between 48 and 72 hours after surgery.30,31
This is due to an active process resulting in hypertrophy and
hyperplasia of the elements of the vessel wall and a permanent
Overview increase in diameter of its lumen.30
The skin is the largest organ of the body. Temperature regu- The cutaneous veins also form a three-dimensional plexus
lation to maintain homeostasis is one of its major roles. This of interconnecting channels with dominant strata in the sub-
important function is provided by a rich network of cutaneous dermis (Figures 4.4–4.7). Although many of these veins have
arteries and veins, especially in the dermal and subdermal plexi, valves that direct the blood in a particular direction, they are
which supply the sweat glands and allow for heat exchange by often connected by avalvular veins.32 These avalvular (oscillat-
convection, conduction, and radiation. Although the cutaneous ing) vessels allow bidirectional flow between adjacent venous
circulation is rich and vast, the metabolic demands of the skin territories whose valves may be oriented in opposite direc-
elements are low so that only a small fraction of the potential tions, thus providing for the equilibration of flow and pressure
cutaneous circulation is necessary for skin viability—a fact that (Figure 4.6). Indeed, there are many veins whose valves direct
is pertinent to the design and survival of various skin flaps. flow initially in a distal direction, away from the heart, before
The cutaneous arteries arise directly from the underly- joining veins whose flow is proximal. The superficial inferior
ing source (segmental or distributing) arteries or indirectly epigastric veins (SIEVs) that drain the lower abdominal integ-
from branches of those source arteries to the deep tissues, ument toward the groin are good examples. In some regions,
especially the muscles (Figures 4.1 and 4.2). From here the valved channels direct flow radially away from a plexus of
cutaneous arteries follow the connective tissue framework of avalvular veins as, for example, in the venous drainage from
the deep tissues, either between or within the muscles, and the vertex of the scalp or the nipple-areolar summit of the
course for a variable distance beneath the outer layer of the breast. In other areas, valved channels direct flow toward a
enveloping “body suit” of deep fascia. They then pierce that central focus, seen in the groin or in the stellate limbs of the
structure, usually at fixed skin sites as cutaneous perforators. cutaneous perforating veins (Figures 4.4 and 4.6).
After emerging from the deep fascia, the arteries course on its In general, the cutaneous veins partner the arteries.
superficial surface for a variable distance, supplying branches However, the venous drainage of the skin is established in
to it and the deep surface of the fat. They then worm their the embryo in two stages, which interconnect but which are
29
Figure 4.1. A. Montage of the cutaneous arteries of the body. The skin has been incised along the ulnar border in the upper extremities, and
the integument has been removed with the deep fascia on the left side and without it on the right. B. A closer view of the vessels of the head and
neck from the side. C. The angiosome territory of a single cutaneous perforator (perforator angiosome) defined by a perimeter of reduced-caliber
“choke” anastomotic vessel. Note (1) the direction, size, and density of the perforators, which are large on the torso and head and get progressively
smaller and more numerous toward the periphery of the limbs; (2) the reduced-caliber (choke) anastomotic arteries, which link the perforators
into a continuous network, with an area highlighted (arrow) and enlarged in (C). (Reproduced with permission from Taylor GI, Palmer JH. The
vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113).
Figure 4.2. A schematic diagram shows a single direct septocutaneous

perforator (B) and various indirect musculocutaneous perforators of
varying sizes that pierce the muscle (or other specialized deep tissues)
early (C) or late (A and D) to supply the overlying integument. In each
case, the perforator supplies all adjacent tissues between the source
artery and the skin.
Figure 4.4. The venous network of the integument of a female

Figure 4.3. Schematic representation of choke anastomoses (A) and subject. (Reproduced with permission from Taylor GI, Caddy CM,
true anastomoses (B) between adjacent arteries. (Reproduction with Watterson PA, Crock JG. The venous territories (venosomes) of the
permission from Taylor GI, Minabe T. The angiosomes of the mammals human body: experimental study and clinical implications. Plast
and other vertebrates. Plast Reconstr Surg. 1992;89:181). Reconstr Surg. 1990;86:185).
30
Chapter 4: The Blood Supply of the Skin and Skin Flaps 31

Basic Science
Figure 4.6. Schematic diagrams of the basic venous module (A), its
modified arrangement in different areas (B), and how these modules
interconnect to form a continuous network (C). In the integument,
this network of venous perforators of the secondary venous system
Figure 4.5. Diagram of developing arteries and veins in the forelimb is connected in the subdermal plexus with the longitudinal channels
of one of our quail embryos where approximately 1 day in the quail of the primary venous system (D). The valved segments in blue and
equates to 1 week in the human embryo. Note the primary venous sys- the avalvular oscillating veins in yellow are highlighted. (Reproduced
tem that develops first, drains the ectoderm (later the dermis) and with permission from Taylor GI, Caddy CM, Watterson PA,
the deep tissues along the surface of the embryo, whereas the sec- Crock JG. The venous territories (venosomes) of the human body:
ondary venous system develops centrally, connects with the primary experimental study and clinical implications. Plast Reconstr Surg.
system, and drains areas of the ectoderm (dermis) radially and then 1990;86:185).
axially along the limb in company with the arteries. (Reproduced
with permission from Taylor GI. The Angiosome Concept and Tissue
Transfer, Publisher Quality Medical Publications (QMP) Jul 2013).
(Figures 4.2 and 4.4–4.7). Thus, from the dermal and subder-
mal venous plexi, the veins collect into a horizontal “freeway”
of large-caliber veins, where they are often related to the cutane-
separated in time by approximately 1 week of development ous nerves and a longitudinal system of chain-linked arteries, or
(Figure 4.5).25,33-35 alternatively they collect in centripetal or stellate fashion into a
The primary system of veins develops first in the human common channel that passes vertically down in company with
embryo at about 5 weeks in the subectodermal region and the cutaneous arteries to pierce the deep fascia (Figures 4.6 and
is represented in the adult by large-caliber veins, such as the 4.7). Thereafter, these perforating veins remain in company with
cephalic, saphenous, and external jugular. These veins course the direct and indirect cutaneous arteries, draining ultimately
often at some distance from the cutaneous arteries, they into the venae comitantes of the source arteries in the deep tissue.
are accompanied frequently by cutaneous nerves, 28,33,34 and Importantly, these two systems interconnect, especially in
they travel for long distances before piercing the deep fascia the subdermal plexus. This explains why, for example, the
(Figures 4.4, 4.5, and 4.6). radial forearm free flap will survive on either the secondary
The secondary system of veins develops approximately system of venae comitantes of the radial artery or the primary
1 week later in the embryo. This network consists of central axial cephalic or basilic veins.
source veins that accompany the axial source arteries and receive Thus, the skin is fed and drained by a continuous network
perforating veins from the subectodermal region that accompany of arteries and of veins formed by vessels whose size, shape,
the developing cutaneous arteries (Figure 4.5D). In the adult, density, and direction vary from region to region in the body.
they are represented by the venae comitantes of the cutaneous The following observations provide for a better understanding
perforating arteries with which they travel in close proximity of this variation in vessel anatomy.

Figure 4.7. Composite diagram of the integument and underlying muscle (shaded) illustrating the primary superficial (S) and secondary deep
(D) venous systems with their interconnections in the superficial and the deep tissues. A large vena communicans (C) connects these systems, and
the alternative pathways of four venae comitantes of the perforating arteries are shown. Note the bidirectional system of veins (yellow) within the
superficial fascia and the muscle (small arrows) and the diverging direction of flow of the muscular veins as determined by the orientation of their
valves. (Reproduced with permission from Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories (venosomes) of the human body:
experimental study and clinical implications. Plast Reconstr Surg. 1990;86:185).
and venosomes (venous territories). Initially we described 40

Anatomic Concepts angiosomes, but this was an intentional oversimplification as
many of these territories can and have been subdivided fur-
The Angiosome Concept ther into smaller composite units, for example, the intercostal
A review of the works of Manchot1,2 and Salmon6,7 combined and lumbar angiosomes, and we took this concept down to
with our own studies of the blood supply to the skin and the final branches in the vascular tree, which in the skin is
the underlying deep tissues enabled us to segregate the body the cutaneous perforator (Figure 4.1C).26,29 In the same way,
anatomically into three-dimensional vascular territories that we subdivided the deep tissues, for example, the muscles, into
we named “angiosomes.”26 These three-dimensional anatomic their component anatomical territories.
territories are supplied by a source (segmental or distributing) These composite blocks of skin, bone, muscle, and other
artery and its accompanying vein(s) that span between the soft tissue fit together like the pieces of an intricate jigsaw
skin and the bone (Figures 4.8–4.11). Each angiosome v can puzzle. In some angiosomes, there is a large, overlying cutane-
be subdivided into matching arteriosomes (arterial territories) ous “crust” and a relatively small deep tissue region; in others
Figure 4.8. The sites of emergence of an average of 376 direct and indirect cutaneous arterial perforators of 0.5 mm or greater averaged from all studies.
Note their concentration near the dorsal and ventral midlines, around the base of the skull, and over or near the intermuscular septa. Direct perforators are
more common in the limbs, whereas indirect perforators predominate in the torso. The vessels were color coded to match their underlying source arteries
and to correlate with the angiosomes of the body. Compare with Figure 4.10.

tissue in the adjacent angiosome can usually be captured with

safety when combined in the flap design.22,30,31,37,38
In the skin, the anatomical territory of each cutaneous
perforator forms a basic angiosome module, defined by a
perimeter of anastomotic vessels that connects it with its neigh-
Basic Science
bor in all directions (Figures 4.1C and 4.11), and we charted an
average of 376 such vessels of 0.5 mm or greater.26 In the skin
and subcutaneous tissues, these connections were usually, but
not always, by reduced-caliber vessels that we named “choke”
because of their narrowed lumen. Alternatively, these con-
nections were “true” anastomoses without change in caliber,
especially where vessels accompanied cutaneous nerves, but
seen more commonly in other tissues, especially the muscles
and the nerve trunks, or after a flap has been delayed.30,31,37,38
These basic skin modules (cutaneous perforator angiosomes)
link together like a patchwork quilt to form a continuous net-
work of vessels that surfaces the entire body (Figure 4.11). In
our original article where we charted 376 of these skin mod-
ules supplied anatomically by 40 bilateral (total 80) source
arteries, there was an average of 4.7 cutaneous angiosomes
per source artery.26 However, the size and number of these
skin modules vary within and between source arteries. In
some angiosomes, the cutaneous portion of the source artery
was represented by multiple skin perforators (defined as ves-
sels that pierce and emerge from the outer layer of the deep
fascia), for example, the perforators of the internal thoracic
and the deep inferior epigastric artery, whereas in other source
artery angiosomes just one, usually large, cutaneous vessel was
represented, for example, the superficial inferior epigastric
artery (SIEA), superficial circumflex iliac artery (SCIA), and
the lateral thoracic perforator (Figure 4.12). It should be
noted that in each case the cutaneous perforator supplied not
only the skin but also a block of tissue between the outer layer
of the deep fascia and the epidermis. In the chest, it includes
the breast tissue and in the neck the platysma muscle, for
example, as well as the subcutaneous fat.
This brings us to the next point—the clinical territory of
a cutaneous perforator. In a number of experiments, and in a
range of animals that included the pig,39 dog,37 guinea pig,31
and rabbit,30 as well as observations in patients undergo-
ing various surgical procedures,19,38,40 especially those that
Figure 4.9. Schematic diagram of the cutaneous perforators (left) involved flap delay, we have observed and concluded on many
and their interconnections. The underlying source arteries, their inter-
occasions that one adjacent anatomical cutaneous perforator
connections, and the sites of origin of the cutaneous vessels (dots)
are shown on the right of the diagram. Only the major perforators territory (skin module) can be captured with safety radially
are illustrated. The vascular territories of the source arteries have in any direction on the perforator at the flap base. We have
then been defined in the integument (left) and in the deep tissues noted that necrosis, when it occurs, does so usually in the
(right) by lines drawn around their perimeter, across the choke, choke zone between this captured territory and the one
or true connecting arteries and arterioles. Note how the territories beyond, but sometimes an additional territory in the series will
correspond in each layer. When taken together they constitute the survive (Figure 4.13).
angiosomes. The safe length of such a flap depends, therefore, on the
size, direction, and span of the anatomical territory of each
perforator—the perforator on which the flap is based and the
next in the series. This is, therefore, the reliable clinical ter-
the reverse pattern exists. In some regions, the territory does ritory of the cutaneous perforator at the flap base where the
not reach the skin and is confined to the deep tissues as seen, anastomotic connections are by usually reduced-caliber choke
for example, in more recent studies of the head and neck.36 arteries (Figures 4.13–4.15). However, if the connections are by
Each angiosome is linked to its neighbor, in each tissue, by “true” anastomoses without change in caliber, then the survival
a fringe of either true (simple) anastomotic arteries without length of the flap will be longer with function similar to a flap
change in caliber or by reduced-caliber choke (retiform) anas- that has been delayed,38,40 seen especially in the skin where
tomotic vessels (Figure 4.1C). On the venous side, avalvular vessels accompany the cutaneous nerves.28
(bidirectional or oscillating) veins often match the anasto- (2) Because the junctional zone between adjacent angio-
motic arteries and define the boundaries of the angiosome, somes in deep tissues occurs usually within the muscles, rather
especially in the deep tissues. than between them, these muscles provide a vital anastomotic
detour if a main source artery or vein is obstructed.
Clinical Applications. The angiosome concept has many (3) Similarly, because most muscles span two or more
implications. For example: angiosomes and are supplied from each territory, one is able to
(1) Each angiosome defines the safe anatomic boundary of capture the skin island from one angiosome via the muscle
tissue in each layer that can be transferred separately or com- supply in the adjacent territory.
bined together on the underlying source artery and vein as a This anatomic fact provides the basis for the design of many
composite flap. Furthermore, the anatomic territory of each musculocutaneous flaps.

6
4 39
7
9 3 38
9 8
10 2 16
11 1
11 12 15
13
14 12 14
15 37 11 13
16 17 36
35
18
34
19 33
20 32
31
21
28
40
21 22
22 27
23 23 22A
24
30
26
25
29
Figure 4.10. The three-dimensional vascular territories—angiosomes—encompassing all tissues between skin and bone from (1) thyroid, (2) facial,
(3) buccal (internal maxillary), (4) ophthalmic, (5) superficial temporal, (6) occipital, (7) deep cervical, (8) transverse cervical, (9) acromiothoracic,
(10) suprascapular, (11) posterior circumflex humeral, (12) circumflex scapular, (13) profunda brachii, (14) brachial, (15) ulnar, (16) radial,
(17) posterior intercostals, (18) lumbar, (19) superior gluteal, (20) inferior gluteal, (21) profunda femoris, (22) popliteal, (22A) descending geniculate
(saphenous), (23) sural, (24) peroneal, (25) lateral plantar, (26) anterior tibial, (27) lateral femoral circumflex, (28) adductor (profunda), (29) medial
plantar, (30) posterior tibial, (31) superficial femoral, (32) common femoral, (33) deep circumflex iliac, (34) deep inferior epigastric, (35) internal tho-
racic, (36) lateral thoracic, (37) thoraco-dorsal, (38) posterior interosseous, (39) anterior interosseous and (40) internal pudendal source territories.
The deep fascia is also a honeycomb of connective tissue

Vessels Follow the Connective Tissue that is usually more rigid that its superficial counterpart. It has
Framework of the Body a tough outer layer that surrounds and sometimes provides
The fact that vessels follow the connective tissue framework is origin to the muscles as a sheath on the torso and a stocking
fundamental to the design of all flaps, especially the “fasciocu-
taneous” and “septocutaneous” perforator flaps.
Developmentally, the vascular system appears in the meso-
derm of the embryo as a continuous network of vessels. The
specialized tissues develop within the interstices of that vascu-
lar network. As growth and differentiation progress, vessels
become encased within the various tissues and are continuous
with vessels coursing between the tissues by way of vascular
pedicles at various sites. These sites, in turn, are determined
by the relative mobility of those tissues. The connective tissue
can be regarded as what is “left over” after the specialized
tissues have developed.41 Like a honeycomb, the connective
tissues house and support the specialized tissues and in so
doing support the vascular system of the body, with which
they have developed an intimate relationship.
It is important to differentiate between the superficial and
the deep fascia as these terms are often confused (Figure 4.16).
The superficial fascia is a loose connective tissue honeycomb
that connects the dermis to the outer layer of the deep fascia.
It houses the subcutaneous fat, the breast, and remnants of
the panniculus carnosus where it still exists (for example, the Figure 4.11. Schematic representation of the cutaneous perforator
muscles of facial expression in the head, the platysma in the angiosomes showing the basic skin module (left) and several modules of
neck, the palmaris brevis in the hand, and the dartos muscle in different sizes combined to represent the cutaneous territory of a source
the scrotum). In the lower abdomen, it is separated into two artery (right).
layers by the fascia of Scarpa.

Transverse cervical artery

Thoracoacromial
axis
Basic Science
Internal thoracic
artery
Lateral thoracic artery
Thoracodorsal artery
Superior
epigastric
artery
Posterior and lateral intercostal

perforators
Deep inferior
epigastric artery
Superficial inferior epigastric artery
Deep circumflex
iliac artery
Superficial circumflex iliac artery
Superficial external
pudendal artery
Deep external pudendal artery Perineal branches of internal pudendal artery

Figure 4.12. The angiosome territories of the anterior chest and abdominal regions of the torso—each territory mapped to match the under-
lying source arteries with lines drawn through the perimeter of usually choke anastomotic arteries. Note that the SIEA and the lateral thoracic
angiosomes are supplied by a single large cutaneous perforator compared, for example, with the internal thoracic, lateral intercostal, and DIEA
angiosomes that have multiple cutaneous perforators, each of which could be subdivided further into individual cutaneous (angiosome) territo-
ries. This has been done on one side of the internal thoracic–superior epigastric territory to illustrate this point. SIEA, superficial inferior epigas-
tric artery; DIEA, deep inferior epigastric artery.
in the limbs. Often referred to as the deep fascia, this is only superficial fascia to reach another connective tissue structure,
the outer layer. Radiating intermuscular septa of the deep the dermis of the skin.
fascia, dense in some areas and looser in other, anchor the In some regions, the connective tissue is loose areolar, in
outer layer to the skeleton where the deep fascia becomes con- which case the vessels travel within the connective tissue to
tinuous with the periosteum. From these septa and from the allow the arteries to pulsate and the veins to dilate, for example,
periosteum, the deep fascia is continued into the muscles as within the carotid sheath. In other regions, the connective
intramuscular septa. tissue forms dense fibrous sheets, such as the outer layer of
In the adult, the major arteries are closely related to the the deep fascia, some intermuscular septa, and the periosteum
bones of the axial skeleton. Their branches follow the inter- of the bone. In these cases, the vessels course beside or on the
muscular connective tissues, where they divide to supply the dense fasciae, not within them.
muscles, bones, tendons, nerves, and deep fat deposits, in each
instance following the connective tissue framework of that Clinical Applications. This vessel relationship to the dif-
structure down to the cellular level. ferent types of connective tissue achieves special significance
The cutaneous perforators exhibit the same pattern. They when the surgeon raises a cutaneous flap that includes the
usually arise from the source artery or from one of its muscle outer layer of the deep fascia (termed fasciocutaneous flap) or
branches, either before or after entering the muscle, and follow when the design is extended to include the intermuscular or
the intermuscular or intramuscular connective tissues of the intramuscular septa (the septocutaneous flaps).
deep fascia as direct or indirect cutaneous perforating vessels, In the former case, the deep fascia should be included in
respectively, as they pierce the outer layer of the deep fascia the design of the fasciocutaneous flap in those sites where the
(Figures 4.2, 4.16, and 4.17). Some cutaneous perforators, skin is relatively fixed to the deep fascia, for example, in the
however, are derived from branches to other deep structures, limbs or the scalp (Figures 4.16 and 4.17B). In these instances,
such as the nerves, the periosteum of bones, the joints, and the dominant cutaneous vessels course on, or lie adjacent to,
some glands. After emerging from the deep fascia, the cuta- the deep fascia. Although they can be dissected free in some
neous vessels follow the connective tissue framework of the cases, it is safer or more expedient to include the deep fascia

Figure 4.13. Skin from the torso of the dog that was removed by midline dorsal incision after the raising of a large island flap on one side (outlined)
1 week previously on a single arteriovenous pedicle (arrow). Comparable vessels are identified with dots and arrows on each side of the ventral
midline. Note the anatomical territory of this perforator (shaded yellow) and that (1) the choke vessels have enlarged to the size of true anasto-
moses within the flap, (2) the scalloped necrosis border is evident inside the flap margins (dotted), and (3) at least one adjacent vascular territory
has been captured radially on the artery in the flap pedicle to define the clinical territory of this perforator. (Reproduced with permission from
Callegari PR, Taylor GI, Caddy CM, Minabe T. An anatomical review of the delay phenomenon: 1. Experimental studies. Plast Reconstr Surg.
1992;89:397).
with the flap. However, where the skin and subcutaneous tis- than a true anatomic structure. This may occur, for exam-
sues are mobile over the deep fascia, for example, in the iliac ple, when the cutaneous perforators of a radial or an ulnar
fossa or the breast, it is unnecessary to include this fascial flap are dissected within an envelope of loose areolar tissue
layer as the major cutaneous vessels have already left its sur- between the flexor tendons. Furthermore, the septocutane-
face (Figure 4.17A). ous flap may provide traps for the unwary surgeon. In some
The term septocutaneous is sometimes misleading, espe- cases, the cutaneous artery and its accompanying vein leave
cially when used to describe a surgically created entity rather the underlying source vessels and course toward the surface
in a surgically favorable position, adjacent to a true white
fibrous intermuscular septum. This is typical of the blood
supply to the skin of the lateral arm flap, where cutaneous
perforators arise from descending branches of the profunda
brachii vessels and follow the lateral intermuscular septum
toward the skin. This pattern of supply usually exists where
the muscles glide on either side of the intermuscular septum.
However, if the muscles attach to either side of the intermus-
cular septum, then the course of the cutaneous perforator
may be quite variable.
a b c
A
a b c
B
Figure 4.15. Diagrammatic representation of the same flap raised

Figure 4.14. Schematic representation of the safe clinical territory with and without a surgical delay to illustrate the necrosis line and the
of a cutaneous perforator (arrow) where anatomical territories of changes in the choke vessels—in the choke-vessel interface with vessel
adjacent perforators are captured radially. Note beyond the captured “b” or the one beyond. In B, vessel “a” has been delayed by a previous
perforators the irregular circumference of the necrosis line. (Compare operation before raising the flap. Note the effect on the choke vessels
with Figure 4.17). and the site of the necrosis line.


Basic Science
A
Superficial
fascia
Deep
B fascia C
Femoral artery
Femoral artery
Lateral
Profunda circumflex
D artery artery E
Figure 4.16. Cross-sectional studies to illustrate the origin and the course of the cutaneous perforators from their source arteries in the deep tis-
sues. A. Oblique section of the anterior abdominal wall showing the supply to the integument and the underlying muscle, derived laterally
from a posterior intercostal artery (i) and medially from vessels arising in the groin. The latter vessels are the superficial inferior epigastric
artery (e) and the ascending branch of the deep circumflex iliac artery (D). Note the choke vessels that connect these angiosomes and that they
correspond in position in the superficial and the deep layers. B–E. Schematic diagrams and radiographic study at mid-thigh level of (B). The connective
tissue network of the superficial and deep fascia (C). The same as (B) but the vessels have been added that follow this connective tissue framework,
(D) the angiosomes supplied by each of the source vessels and (E) the lead oxide cadaver injection study that corresponds with (C). Note the
large direct cutaneous perforators that follow the intermuscular septa (s) and the large and small indirect musculocutaneous perforators (m).
(Reproduced with permission from Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical
applications. Br J Plast Surg. 1987;40:113).
This variability of anatomy is evident, for example, in Vessels Radiate from Fixed to Mobile Areas
the lateral aspect of the upper calf. If a compound skin and Vessels cross tissue planes at or near their fixed margins and
bone flap is designed over the lateral intermuscular sep- radiate to mobile areas. This concept is well illustrated in
tum, based on the cutaneous perforators of the peroneal the blood supply to the skin since vessels emerge from the
vessels, these skin vessels may course directly to the sur- deep fascia where the skin is fixed or tethered. From here, they
face, traveling in a favorable position, adjacent to the sep- travel for variable distances depending on the mobility of the
tum. Alternatively, they may arise indirectly from branches skin. The more mobile the integument, the longer the vessels.
to the soleus muscle as terminal twigs of muscle branches These fixed skin sites are seen in a well-muscled individual
that have arisen from the peroneal vessels at considerable at skin crease lines, over intermuscular septa, or near the
distance from the lateral intermuscular septum. In these fixed attachments of muscles to bone (see Figures 4.8, 4.9,
instances, a painful and laborious intramuscular dissection and 4.17).
of the cutaneous supply awaits the unfortunate surgeon.
These two pathways provide the basis for classifying the Clinical Applications. It follows that long robust flaps
various “perforator flaps.” should be based where the skin is fixed, with their axes oriented

Figure 4.17. Sectional strip radiographic studies from above down, of the breast (A), thigh (B), sole of the foot (C), and buttock (D). D includes
the underlying gluteus maximus muscle. The schematic diagram illustrates the dominant horizontal axis of the vessels, which provides the
primary supply to the skin in each case and its relationship to the deep fascia (arrow). In type A, they predominate in the subdermal plexus.
Note from left to right the internal thoracic perforator and lateral thoracic artery converging on the nipple (arrow) in the radiograph of the loose
skin region of the torso. In type B, they are seen coursing on the surface of the deep fascia in this relatively fixed skin area. In type C, the source
artery itself is the dominant horizontal vessel supplying the skin, coursing beneath the deep fascia in this rigidly fixed skin region. In type D,
the horizontal vessel is again the source artery (inferior gluteal), but this time its branches have to pierce muscle indirectly to reach this fixed skin
region. Small arrows define the deep fascia, and the large arrow indicates the large fasciocutaneous branch of the gluteal artery, which descends
with the posterior cutaneous nerve of the thigh. (Reproduced with permission from Taylor GI, Palmer JH. The vascular territories (angiosomes)
of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113).
along the lines of maximal skin mobility. The further the distance Whether the nerves pierce the deep fascia together with the
between fixed points, the longer the safe dimensions of the flap. vessels, emerge separately and cross the vessels at an angle, or
There are many instances in which this applies in practice. For approach the vessels from opposite directions, in each case, as
example, long flaps can be based at the groin, the paraumbilical if drawn by a magnet, the main trunk of the vessel or some of its
region of the abdomen, or the parasternal region of the chest branches “peel off” to course parallel to the nerve. These vessels
(Figures 4.12 and 4.18). Additional precision to flap design can either course in close proximity to the nerve or they travel
be obtained before surgery by the use of Doppler ultrasonic probe nearby (Figure 4.18).
to locate these perforators19 in thin individuals as they emerge
from the deep fascia or more recently with CT angiography.42 In Clinical Applications. This neurovascular relationship
this way, a viable flap can be designed by basing it on a signifi- presents the basis for designing long flaps with the added
cant perforator that is located with the probe, by finding the next potential for sensation at the repair site. Many of the current
dominant perforator along the desired flap axis and then simply “axial” or “fasciocutaneous” flaps are in fact neurovascular
joining these two points, since we have found experimentally that flaps. The original long and short saphenous flaps in the calf
one adjacent vascular territory can be captured with safety described by Ponten12 are cases in point.
(Figure 4.13).22,30,31,37,38
Vessel Size and Orientation Are a Product
Vessels Hitchhike with Nerves of Tissue Growth and Differentiation
Our research has confirmed that the intimate relationship More than two centuries ago, John Hunter43 suggested that
between nerves and blood vessels that is known to exist in at some stage of fetal development, and certainly at birth, an
the deep tissues and in some areas of the integument is in fact individual has a fixed number of arteries in the body, the size,
present in all regions of the skin and subcutaneous tissues length, and direction of which are modified by subsequent
of the body.28 The cutaneous nerves are accompanied by a growth and differentiation of the parts. This helps explain
longitudinal system of arteries and veins that are often the why long vessels radiate from the skull base toward its vertex
dominant blood supply to the region. The veins in company as the brain and skull expand, why long vessels course on the
with the nerves are frequently large “primary” venous free- torso as the lungs expand and the fetus extends from the flexed
ways, such as the cephalic, basilic, long saphenous, and short position, and why long vessels converge on the nipple from the
saphenous systems. The arteries are either long vessels—for periphery as the breast develops in the female (Figure 4.19).
example, the supraorbital, lateral intercostal, or saphenous
arteries—or they exist as a chain-linked system of cutaneous Clinical Applications. This information provides the basis
perforators, often joined in series by true anastomoses without for the logical planning of the various breast reduction opera-
change in caliber (Figure 4.18). tions. Each technique revolves around the design of a flap of skin


Basic Science
B
A
Figure 4.18. Arterial injection studies of the (A) right upper limb and (B) torso. Note the chain-linked systems of arteries (arrows) that course
with the cutaneous nerves in the upper limb. On the torso, the nerves are marked green on the arterial study. They either course with the cutaneous
arteries, cross them at angles, and collect arterial branches or approach the arteries from opposite directions (arrows). (Reproduced with permis-
sion from Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories of the skin and muscles: anatomic study and clinical implications.
Plast Reconstr Surg. 1994;94:1).
and subcutaneous tissue (including breast) that is based on one territories of adjacent arteries bear an inverse relationship
or more vessels as they pierce the deep fascia around the perim- to each other yet combine to supply the same region.” If one
eter of the pectoralis major muscle. Tissue expansion is another vessel is small, its partner is large to compensate and vice
example. Here existing vessels in the skin and subcutaneous tis- versa. This is well illustrated in the variability in size between
sues, like the vessels in the abdominal wall during pregnancy, each of the parasternal perforators of the internal mammary
hypertrophy and elongate as the fluid is introduced into the artery and between the internal mammary perforators and
expander. Therefore, if possible, the expander should be placed the cutaneous perforator of the adjacent angiosome: the
beneath mobile skin and between fixed skin sites to take maxi- thoracoacromial (see Figure 4.1). It is likely that the same
mal advantage of the inherent vascular anatomy of the region. relationship occurs between the cutaneous veins, for exam-
ple, between the venous perforators of the deep inferior epi-
gastric venae comitantes (DIEV) and the usually large SIEV.
Vessels Obey “The Law of Equilibrium” This may be critical in the design of a deep inferior epigastric
This concept was described by Debreuil-Chambardel and is perforator flap where the DIEV perforating vein is unexpect-
referred to constantly by Michel Salmon6,7 in his description of edly small. Hence the reason for preserving the SIEV, espe-
the cutaneous arteries. Basically, this states that “the anatomical cially on the contralateral side, as a potential “lifeboat.”

vessel, or from one of its branches.28 Whichever is the case,

A their destination is constant to supply the integument of the
lower abdomen and the hip (see Figures 4.1 and 4.12).
X Y
Clinical Application. Although this variability in vessel
origin may not be important when designing a pedicled flap at
the groin, it certainly becomes so if the flap is to be isolated on
its feeding vessels for microvascular transfer.8,9,44
B The Vessels Form a Continuous

Unbroken Network
X Y
This fact has been referred to already but is highlighted
because it is fundamental to the understanding of the vari-
ous skin flap designs where, for example, the same area of
skin and subcutaneous tissue can be raised as a “cutaneous”
C flap, a “fasciocutaneous” flap, a “septocutaneous” flap, a
“musculocutaneous” flap, or a “perforator flap.” In each
X Y case, regardless of the flap design, the vessels that enter the
flap at its base connect into the same vascular network. What
may vary between flap designs, however, are the size and site
of entry of the cutaneous perforators, thus influencing flap
D survival (see Figure 4.2).
X Y Clinical Applications. There are numerous instances

whereby the surgeon knowingly or unwittingly takes advantage
of this anatomic fact. For example, the skin and subcutaneous
E fat over the pectoralis major muscle can be designed (1) as a
musculocutaneous flap on small perforators emerging from the
X Y underlying muscle, (2) as a fasciocutaneous flap based either
medially on the large internal thoracic (internal mammary) per-
Figure 4.19. Schematic diagram to illustrate John Hunter’s hypothesis forators or laterally on the dominant perforator(s) of the thora-
of a fixed number of cutaneous arteries in the fetus and how growth coacromial axis, or (3) as a neurovascular fasciocutaneous flap
and differentiation of the tissues could modify the definitive size and when based superiorly on the supraclavicular neurovascular
relationship of the arteries x and y in different regions of the body pedicles that flow down over the clavicle from the neck.
after they pierce the deep fascia. A. The “resting state.” B. The vessels
are stretched by expansion of structures beneath the deep fascia, for
Other important considerations are the anastomotic vas-
example, the skull and brain. C. The vessels are stretched and com- cular “keystones” usually formed by reduced-caliber choke
pressed toward the dermis by the developing breast above the deep arteries that link adjacent perforating cutaneous perforators
fascia. D. The vessels are stretched apart by the developing long bones to form the arterial network. When a flap is elevated, these
but still retain a dominant relationship to the deep fascia. E. Growth choke vessels, which initially impede flow from one arterial
again stretches the vessels apart, but this time a gliding plane develops territory to the next along the flap, enlarge to the caliber
between the deep fascia and the subcutaneous fat in this loose skin of the cutaneous arteries they connect (Figure 4.13).30,31,37,38
area, for example, the iliac fossa. However, this process of vessel enlargement is an active
event and takes time. It involves multiplication and elon-
gation of the cells in each layer of the vessel wall, with its
Clinical Applications. The deltopectoral flap of Bakamjian maximal effect occurring between 48 and 72 hours after
is an excellent example. It is based medially over the second to operation.30
fourth intercostal spaces so as to embrace the variable size of Experimentally and clinically, it has been noted that one
the internal thoracic (internal mammary) perforators. Designed adjacent anatomic vascular territory can be safely captured
below and parallel to the clavicle, it is usually dissected in a in any direction on the cutaneous artery at the flap base that
medial direction from its tip at the shoulder. If small perfora- defines its reliable clinical territory (Figures 4.13–4.15).30,31,37
tors are noted over the deltoid muscle, and in particular from If necrosis occurs, it usually does so at the level of the next
the deltopectoral groove, the dissection is continued to the choke anastomosis in the arterial network or the one beyond.
flap base on the assumption that the internal thoracic perfora- Surgically, flap survival can be extended by the strategic division
tors will be large. If, however, a large cutaneous perforator is of vascular pedicles at various time intervals along the length of
seen emerging from the deltopectoral groove, then this pedicle the proposed flap—the “flap delay” procedure (Figure 4.15).
is usually ligated and further dissection of the flap is delayed
for 1 week because of the possibility that the adjacent inter-
nal thoracic perforators will be small. This delay procedure is
employed because of the risk of flap necrosis, especially if the
Classification of the
flap tip spans beyond the point of the shoulder. Cutaneous Blood Supply
We have left the contentious subject of classification of the
Vessels Have a Relatively Constant cutaneous blood supply until the end, as we believe it is more
Destination but May Have important to understand the pure and the applied (functional)
anatomy of the cutaneous arteries than to be concerned about
a Variable Origin which classification is the best. It is essential, however, to
This is typical of the vessels that emanate from the groin to differentiate between classifications based correctly on the
supply the skin of the lower abdomen and upper thigh. The anatomy and physiology of the cutaneous supply rather than
SIEA and the SCIAs, for example, may arise separately from those that focus on flap design, such as axial, random, cutane-
the common femoral artery, as a combined trunk from that ous, fasciocutaneous, septocutaneous, and musculocutaneous,

each of which describes the method by which the flap is
Conclusions

planned and dissected.
One of the oldest, simplest, and best classifications was Knowledge of the basic anatomy of the cutaneous vessels
offered by Spalteholz3 in 1893. He subdivided the cutane- coupled with an appreciation of the factors that influence
ous vessels into two groups, depending on whether they its structure in different regions of the body provides for the
Basic Science
were the main (dominant) supply to the area or whether they logical planning of flaps and incisions. In the sage words
had a relatively minor (supplementary) role (see Figure 4.2). of Michel Salmon, “Entre l’anatomie et la physiologie, il y
Recently this classification has been modified, stimulated by a place pour une anatomie de fonction, pour une anatomie
the resurgence of interest on the anatomically based “perfo- physologique”—“Between anatomy and physiology there is
rator flaps.”22,24,27,42 room for a functional anatomy, for a physiologic anatomy.”
Direct Cutaneous Perforator Vessels

References
These vessels contribute to the primary (dominant) cutaneous
supply to the area and are particularly well developed in the 1. Manchot C. Die Hautarterien des Menschlichen Korpers. Leipzig: F.C.W.
Vogel; 1889.
limbs. They arise from the underlying source artery or from 2. Manchot C. The Cutaneous Arteries of the Human Body. New York, NY:
one of its muscle branches before they enter the muscle. They Springer-Verlag; 1983.
pass between the muscles and other deep structures in the 3. Spalteholz W. Die Vertheilung der Blutgefasse in der Haut. Arch Anat; 1893.
intermuscular septa and rapidly reach and perforate the outer 4. Pieri G. La Circolazione Cutanea Degli Arti e del Tronco in Rapporto
alla Tecnica della Chirurgia e Plastica Cinematica. Chir Organi Mov.
layer of the deep fascia where their main destination is the 1918;2:37.
skin (Figures 4.2, 4.7, and 4.16). They are usually large and 5. Esser JFS. Artery Flaps. Antwerp: De Vos-van Kleef; 1929.
spaced well apart in the torso, head, neck, arms, and thighs, 6. Salmon M. Arteres de la Peau. Paris: Masson; 1936.
especially where the skin is mobile. They are smaller and more 7. Salmon M. Arteries of the Skin. In: Taylor GI, Tempest M, eds. London:
Churchill-Livingstone; 1988.
numerous in the forearms and legs except where they accom- 8. Daniel RK, Taylor GI. Distant transfer of an island flap by microvascular
pany cutaneous nerves. In the palms of the hands and the soles anastomoses. Plast Reconstr Surg. 1973;52:111.
of the feet, they are evident as a dense network of small vessels 9. Taylor GI, Daniel RK. The free flap: composite tissue transfer by vascular
(Figures 4.1 and 4.18). anastomosis. Aust N Z J Surg. 1973;43:1.
10. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of independent
In each case, these direct cutaneous vessels follow the myocutaneous vascular territories. Plast Reconstr Surg. 1977;60:341.
connective tissue framework of the deep tissue to the skin. 11. Cormack GC, Lamberty BGH. The Arterial Anatomy of Skin Flaps.
They pass between the muscles and tendons supplying Edinburgh: Church-Livingstone; 1986.
branches to them as they pass, sometimes closely related 12. Ponten B. The fasciocutaneous flap: its use in soft tissue defects of the lower
leg. Br J Plast Surg. 1982;34:215.
to true intermuscular septa, as “septocutaneous vessels.” 13. Radovan C. Breast reconstruction after mastectomy using the temporary
If the source artery is close to the surface, for example, expander. Plast Reconstr Surg. 1982;69:195.
the radial, ulnar, or common femoral arteries, then their 14. Baudet J, Rivet D, Martin D, Boileau R. Prefabricated free flap transfers.
course to the outer layer of the deep fascia may be short. Presented at the 3rd Annual Meeting of the American Society for
Reconstructive Microsurgery, San Antonio, Texas, September 12-13, 1987.
Conversely, if the source artery is deeply situated then their 15. Allen RJ, Treece P. Deep inferior epigastric flap for breast reconstruction.
length is longer, for example, the direct cutaneous perfo- Ann Plast Surg. 1994;32(1):32-38.
rators of the profunda brachii, lateral femoral circumflex, 16. Blondeel PN, Boeckx WD. Refinements in free flap breast reconstruction:
and peroneal arteries. the free bilateral deep inferior epigastric perforator flap anastomosed to the
internal mammary artery. Br J Plast Surg. 1994;47(7):495-501.
When the cutaneous perforators are traced to the under- 17. Blondeel PN, Van Landuyt KHI, Monstrey SJM, et al. The “Gent” consensus
lying source vessels to provide “septocutaneous” perforator on perforator flap terminology: preliminary definitions. Plast Reconstr Surg.
flaps, the septum may be well formed, as seen in the lateral 2003;112(5):1378.
arm and thigh, or consist of loose areolar tissue as occurs in 18. Hallock GG. Direct and indirect perforator flaps: the history and the con-
troversy. Plast Reconstr Surg. 2003;111:855.
the forearm over the radial or ulnar vessels. 19. Taylor GI, McCarten G, Doyle M. The use of the Doppler probe for
planning flaps: anatomical study and clinical applications. Br J Plast Surg.
Indirect Cutaneous Perforator Vessels 1990;43:1.
20. Taylor GI. The angiosomes of the body and their supply to perforator flaps.
These vessels arise from the source arteries and penetrate the Clin Plastic Surg. 2003;30:331-342.
21. Taylor GI. Discussion on the “Gent” consensus on perforator flap terminology:
deep tissues, usually muscle, vertically or obliquely before preliminary definitions. Plast Reconstr Surg. 2003;112:5.
piercing the outer layer of the deep fascia (Figures 4.2, 4.7, 22. Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angio-
and 4.16). They may be quite large and contribute to the some) and clinical territories of the cutaneous perforating arteries: what
primary (dominant) blood supply to the skin and are particu- goes around comes around. Plast Reconstr Surg. Apr 2011;127(4):
1447-1459.
larly well developed on the torso (for example, the internal 23. Converse JM, ed. Reconstructive Plastic Surgery. 2nd ed. Philadelphia, PA:
thoracic, intercostal, and deep inferior epigastric musculo- Saunders; 1977:193.
cutaneous perforators). Alternatively, they may emerge as 24. Blondeel PN, Morris SF, Hallock GG, Neligan PC. Perforator Flaps:
small “spent” terminal branches to provide the secondary Anatomy, Technique and Clinical Applications. St Louis, MO: Quality
Medical Publications; 2006.
(supplementary) supply to the skin. These are small vessels, 25. Rozen WM, Ashton MW, Le Roux CM, Pan WR, Corlett RJ. The perfo-
often quite numerous, which emerge as terminal twigs of ves- rator angiosome: a new concept in the design of deep inferior e pigastric
sels whose predominant supply is to the various deep tissues, artery perforator flaps for breast reconstruction. Microsurgery 2010;
especially the muscles. 30(1):1-7.
26. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the
Whatever their origin and size, these indirect cutaneous body: experimental study and clinical applications. Br Plast Surg. 1987;
perforators provide the basis for the musculocutaneous per- 40:113.
forator flaps that require a more tedious dissection with the 27. Saint-Cyr M, Wong C, Schaverien M, Mojallal A, Rohrich RJ. The perfo-
potential to preserve muscle function. Large or small, they rasome theory: vascular anatomy and clinical implications. Plast Reconstr
Surg. 2009;124(5):1529-1544.
enter, and become continuous with, the same vascular net- 28. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories of the
work that is formed by the direct cutaneous arteries. Often skin and muscles: anatomic study and clinical implications. Plast Reconstr
the smaller indirect cutaneous vessels are the main blood sup- Surg. 1994;94:1.
ply to some musculocutaneous flaps, especially where the skin 29. Taylor GI, Palmer JH, McManammy D. The vascular territories of the body
(angiosomes) and their clinical applications. In: McCarthy J, ed. Plast Surg
island is sited over muscle to which it is loosely attached. For Vol. 1. Philadelphia, PA: Saunders; 1990.
example, the gracilis and the gastrocnemius musculocutane- 30. Dhar SC, Taylor GI. The delay phenomenon: the story unfolds. Plast
ous flaps. Reconstr Surg. 1999;104(7):2079-2091.

31. Morris SF, Taylor GI. The time sequence of the delay phenomenon: when 37. Callegari PR, Taylor GI, Caddy CM, Minabe T. An anatomical review
is a surgical delay effective? An experimental study. Plast Reconstr Surg. of the delay phenomenon: 1. Experimental studies. Plast Reconstr Surg.
1995;95:526. 1992;89:397.
32. Taylor GI, Caddy CM, Watterson PA, Crock JG. The venous territories 38. Taylor GI, Corlett RJ, Caddy C, Zelt RG. An anatomical review of the delay
(venosomes) of the human body: experimental study and clinical implications. phenomenon: II. Clinical applications. Plast Reconstr Surg. 1992;89:408.
Plast Reconstr Surg. 1990;86:85. 39. Taylor GI, Corlett RJ. The cutaneous vascular territories in pig and man.
33. Bates D, Taylor GI, Newgreen D. The pattern of neurovascular development Surgical Forum #67 of ASPRS Meeting, New York; 1981.
in the forelimb of the quail embryo. Dev Biol. 2002;249:300-320. 40. Taylor GI. The delayed TRAM flap for breast reconstruction: why, when
34. Bates D, Taylor GI, Minichiello J, et al. Neurovascular congruence and how. Oper Tech Plast Surg. 1999;6:74-82.
results from a shared patterning mechanism that utilises semaphorin 3A 41. Johnson TB, Davies IES, Davies F, eds. Gray’s Anatomy. 32nd ed. London:
and neuropilin-1. Dev Biol. 2003;255:77-98. Longmans; 1958.
35. Taylor GI, Bates D, Newgreen DF. The developing neurovascular anatomy 42. Rozen WM, Palmer KP, Suami H, et al. The DIEA branching pattern and its
of the embryo: a technique of simultaneous evaluation using fluorescent relationship to perforators: the importance of preoperative CT angiography
labelling, confocal microscopy and 3D reconstruction. Plast Reconstr Surg. for DIEA perforator flaps. Plast Reconstr Surg. 2008;121(2):367-373.
2001;108:597-604. 43. Hunter JA. Treatise on the Blood, Inflammation and Gunshot Wounds.
36. Houseman ND, Taylor GI, Pan W-R. The angiosomes of the head and London: John Richardson; 1974.
neck; anatomic study and clinical applications. Plast Reconstr Surg. June 44. Taylor GI, Daniel RK. The anatomy of several free flap donor sites. Plast
2000;105(7):2287-2313. Reconstr Surg. 1975;56:243.

Chapter 5 n Muscle Flaps and Their

Blood Supply
Basic Science
Jamie P. Levine
vascular connections to the skin, it became possible to include

Flaps a segment of skin with the muscle flap.3 Prior to identification
A flap is a unit of tissue that is transferred from a donor to a of the muscle skin territory, which allows its design as a mus-
recipient site with its blood supply. Numerous classification culocutaneous flap, the muscle flap was inset into the wound
schemes exist. Flaps may be characterized by their component and exposed portions were skin grafted for coverage. With a
parts (e.g., cutaneous, musculocutaneous, and osteocutane- composite of muscle and its overlying skin, defect closure can
ous), their special relationship to the defect (local, regional, be accomplished with muscle, subcutaneous tissue, and skin.
distant, or free), the nature of the blood supply (random vs. The ability to take an island of skin can also increase the cov-
axial), and finally by the movement that is required for the erage area of a single flap if it is designed appropriately and
flap to fill the desired defect (e.g., advancement, pivot, trans- also allows for improved postoperative monitoring as either a
position, and interpolation). This chapter will focus on the free or pedicled flap (Figure 5.1).
blood supply and classification systems for muscle flaps and As understanding of cutaneous blood supply increased, fas-
their associated uses. The blood supply to the muscle is inti- ciocutaneous flaps were also described.4 Finally, Ian Taylor
mately involved with the overlying fascia and skin. In general, was able, through ink injection analysis, to put the various
muscle flaps are “axial” pattern flaps, with a known blood concepts of skin circulation together in its most coherent form
vessel oriented longitudinally within the flap. These vessels and defined the concept of the angiosome (Chapter 4). These
will have perforating branches that then supply contiguous studies helped to define the vascular territories of the body
territories including the overlying skin. With the advancement (with an average of over 300 cutaneous perforators)5 and pro-
of and enthusiasm for perforator flaps, the knowledge of the vide a reliable guide to composite flap design based on cutane-
muscle blood supply has expanded into blood supply for ter- ous vascular anatomy. These concepts of vascular anatomy
ritories of tissues (Chapter 4). These territories can be har- have opened a new era of flap transfer by defining perforator
vested as composite flaps incorporating all of the tissue layers anatomy. The separation between pure fasciocutaneous and
or individual components can be taken separately based on muscle flaps has also been erased. It was believed that the ped-
the perforator blood supply. icle to fasciocutaneous flaps was always along the intermuscu-
lar septae. With the knowledge of perforator vessel dissection,
fasciocutaneous flaps can be dissected from muscle-based
History vessels and perforators.
Skin and subcutaneous tissue was initially elevated as “random” The next step in utilizing this knowledge of muscular vas-
pattern flaps either from a site adjacent to the wound or from a cular anatomy has been the creation of specially designed,
distant site. Due to unpredictable circulation, these flaps often chimeric flaps that can include segments of as much muscle,
went on to partial or complete necrosis. This era of flap sur- skin, and other tissues as needed for the reconstruction. This
gery required adherence to length and width ratios in hopes knowledge of vascular anatomy has also developed the con-
of maintaining adequate vascularity for flap survival. “Delay” cept of the free form perforator flap.6 These flaps can contain
techniques (Chapter 1) were also utilized to augment the vascu- any tissue zone supplied by a regional vascular perforator and
lar supply. The great advance in this area was the identification allows individualization of tissue thickness and texture to the
of specific vascular pedicles in consistent and reliable locations specific needs of the defect.
(dorsalis pedis, groin flap, etc.). Since these flaps could be ele-
vated with a defined vascular pedicle, it became possible to trans-
fer larger flaps.1 These early axial flaps were a vast improvement
with regard to size and reliability, but because they remained
pedicled, they were limited to specific topographic locations.
Next, the identification of muscle flaps as a source of tissue
offered tremendous flexibility and more options for wound
coverage and defect reconstruction.2 Muscles are available in
almost all topographical areas. As the vascular anatomy to
these muscles was elucidated, it became possible to detach the
muscle origin, insertion, or both and to transfer the muscle to
a new site while maintaining vascular perfusion. The decision
of which muscle to utilize for a given defect takes into account
multiple factors: the size and location of the defect, damage to
regional tissues, and the presence of exposed vital structures.
The ability to transfer muscles changed the way we are able to
manage complex wounds of any variety.
With increasing interest in muscle circulation, the contri-
bution of muscle flap circulation to the overlying skin was
then recognized. This further advanced our ability to close Figure 5.1. Myocutaneous latissimus free flap for scalp coverage.
complex, composite defects with improved function, cosmetic Although skin grafting of the muscle is still required, the skin island
appearance, and donor site variety. Each superficial muscle provides extra coverage and an area for improved monitoring
provides vascular connections via musculocutaneous perfo- postoperatively.
rating vessels to the overlying skin. With the identification of
43
Vascular delay can also be utilized to extend the size of

Blood Supply axial flaps. By pre-incising the skin and subcutaneous tissue in
a musculocutaneous or fasciocutaneous flap, or dividing the
Blood Supply: Random Flaps nondominant or codominant vascular pedicles, the tissue in a
Any flap requires an adequate blood supply after transfer to pedicled axial flap is maximized. An example is the delay of a
survive. “Random” cutaneous flaps are based on unnamed pedicled transverse rectus abdominis myocutaneous (TRAM)
smaller vessels. It was observed historically that the ratio of flap. Since the inferior epigastric vessels are the primary vascu-
flap length to width was a critical variable for flap survival. lar supply to the TRAM, division of this pedicle and attempts
These restrictions limit their reliability for use with large to transfer the flap based on the superior pedicle often lead to
defects. When utilized appropriately, however, random flaps areas of ischemia in the skin beyond the primary skin terri-
can be reliable first choices for coverage of smaller defects tory (zone one). By ligating the deep inferior epigastric vessels
throughout the body. The term “random” really means that with or without incising the skin paddle 1 to 2 weeks prior to
the surgeon does not know for sure if there is enough longitu- breast reconstruction surgery, a much larger and more reliable
dinally oriented (axial) vessels to keep the flap alive. skin paddle can be transferred.
Blood Supply: Axial Flaps Patterns of Muscle

In contrast to random pattern flaps, axial pattern flaps are Circulation
based on a reliable, anatomically defined vascular territory
that is oriented longitudinally within the flap and that extends The most universally accepted system of muscle flap blood
beyond the base of the flap. Since the description of the first supply was developed by Mathes and Nahai. Every muscle, in
axial flap (the deltopectoral flap) nearly four decades ago, part or as a whole, has the potential for use as a muscle flap.
the knowledge of the body’s various cutaneous angiosomes Muscle circulation is based on specific pedicles that enter the
and subsequent exploitation of axially based flaps has grown muscle between its origin and insertion and consist of an artery
significantly.7 The advances in anatomic vascular knowledge and single or paired venae comitantes.10 The position, number,
have increased the type and the reliability of axial pattern and size of the vascular pedicles influence both the likelihood of
flaps and have fostered the development of microsurgical free flap survival and the flap design. The relative importance of each
flap transfer. Because of their significantly greater reliability, vascular pedicle to muscle circulation has been determined in
axial flaps (flaps with known blood supply) are preferred for cadavers by colored latex and barium injections, allowing evalu-
coverage of moderate to large defects. ation of each vascular pedicle with regard to its length, diameter,
The reliability and volume of tissue that can be placed into location, and regional source. Subsequent use of the muscles as
a defect is markedly greater than with any type of random pat- flaps has confirmed the relative importance of each pedicle to
tern flap. Due to the axially oriented circulation, delay proce- muscle survival and the potential for various flap modifications.
dures are often not necessary even when mobilizing large tissue If a pedicle to a muscle is critical to muscle survival based on its
volumes in one procedure based on this direct circulation. The size and distribution to the internal vascular architecture of the
only limitation, when pedicled, is the limited topographic arc of muscle, it is specified as a dominant (where multiple pedicles are
rotation. These limitations have been essentially overcome by present) or major (where more than one pedicle is dominant)
microvascular free tissue transfer techniques (Chapter 8) that pedicle. Nondominant pedicles are labeled as minor pedicle(s).
are limited only by the availability of recipient blood vessels. When a series of segmental smaller vessels are identified that
may support muscle flap survival despite ligation of dominant
or major pedicles, these minor pedicles are considered second-
Blood Supply: Delay Phenomenon ary pedicles. Variations in major and dominant pedicle anatomy
In order to extend the somewhat restricted size of random are uncommon, although the location and number of minor
flaps, surgeons rely on the delay phenomenon. This is most pedicles is quite variable.
commonly achieved by interrupting a portion of the normal Five patterns of circulation to the muscle have been identi-
blood supply to the flap without transferring the flap from fied and are the basis of the classification system (Figure 5.2):
its native position. The associated sublethal ischemia results Types I to V.
in (1) opening of “choke” vessels that are normally closed As noted above, Taylor et al. performed injection studies
allowing blood flow into the ischemic region of the flap, leading to the angiosome concept of the body. They noted that
(2) reorientation of the vessels within the flap to a more lon- vessels frequently accompany nerves and described a classi-
gitudinal pattern, and (3) sprouting of new vessels within the fication system based on these observations.11 These studies
flap through angiogenesis, and perhaps via vasculogenesis.8 revealed that many of the currently used flaps can be consid-
Vessels within the flap also respond to the stress of delay by ered neurovascular flaps. Muscles were classified into four
increasing in caliber. Most surgeons find it prudent to delay a types according to their extrinsic and intrinsic neurovascular
flap for at least 7 days to 3 weeks prior to final transfer, thereby supplies. Type I muscles are supplied by a single unbranched
permitting a maturation of the process of neovascularization. nerve. In Type II muscles, the nerve branches before entering
Incorporating a planned delay can significantly improve the the muscle. Type III muscles receive multiple motor nerves
chances of complete survival of a large random pattern cuta- from the same nerve trunk, and Type IV muscles are supplied
neous flap,9 as in patients with an impaired microcirculation from multiple nerve trunks. This system provides the clinical
(e.g., smokers and diabetics). Furthermore, delay is always information necessary to divide muscles into functional neuro-
considered if a flap demonstrates signs of ischemia or venous vascular units for local and distant transfer.
congestion after elevation. In such cases the procedure is best
performed in a staged manner, following a period of delay.
Obviously, a planned surgical delay requires appropriate stag-
Mathes and Nahai
ing. In these cases intermediate coverage of critical structures Classification
may be required to bridge the gap between surgeries. If at all
possible, the resection or exposure of any critical structures Type I: Single Vascular Pedicle
such as bone, tendon, nerve, or vessels should be delayed till A single vascular pedicle enters the muscle and the muscle may
the final coverage is ready. This is not always possible, espe- be safely elevated on this pedicle.
cially in traumatic wounds. In these cases a delay procedure Muscles identified with this pattern of circulation include
may not be possible and another flap is chosen. the abductor digiti minimi (hand), abductor pollicis brevis,

Chapter 5: Muscle Flaps and Their Blood Supply 45

Basic Science
Figure 5.2. Patterns of vascular anatomy: Type I, one vascular pedicle; Type II, dominant pedicle(s) and minor pedicle(s); Type III, two dominant
pedicles; Type IV, segmental vascular pedicle; Type V, one dominant pedicle and secondary segmental pedicle. (From Mathes SJ, Nahai F.
Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67:177, with permission.)
anconeus, first dorsal interosseous, gastrocnemius, genioglossus, which generally enter the muscle at its opposite end from the
hyoglossus, longitudinalis linguae, styloglossus, tensor fascia site of entry of the dominant vascular pedicle. These second-
lata, transversus and verticalis linguae, and vastus lateralis. ary pedicles will also support the muscle if the dominant vas-
cular pedicle is divided. Thus, the muscle may be utilized as a
Type II: Dominant Vascular Pedicle(s) and flap based on either of the two sources of circulation. Muscles
with a Type V pattern include the following: internal oblique,
Minor Vascular Pedicle(s) latissimus dorsi, pectoralis major.
Use of a Type II flap generally requires division of part or
all of the minor pedicles with preservation of the dominant
pedicle. The muscle survives when elevated based on the Arc of Rotation
dominant vascular pedicle. Muscles with a Type II vascular Each muscle and myocutaneous flap has a limited arc of rota-
pattern include the following: the abductor digiti minimi tion when transferred as a pedicle flap. The distance from
(foot), abductor hallucis, brachioradialis, coracobrachiora- the point where the pedicle enters the flap to the distal end
dialis, flexor carpi ulnaris, flexor digitorum brevis, gracilis, of the flap defines the capability of that flap. A muscle flap
hamstring (biceps femoris), peroneus brevis, peroneus longus, that can be based on a dominant vascular pedicle can reach
platysma, rectus femoris, soleus, sternocleidomastoid, trape- adjacent areas that fall within the radius created by the ped-
zius, triceps, and vastus medialis. icle and the most distal portion of muscle that is supplied by
that circulation. Generally, the muscle is released from either
Type III: Dominant Pedicles its origin or its insertion. The muscle is then mobilized on
the major or dominant pedicle being utilized. In pedicle flap
Type III muscles contain two large vascular pedicles, each of
elevation, the pedicle is not usually skeletonized in order
which may support the entire muscle. Muscles with a Type III
to avoid vascular injury and kinking. These rotational limi-
vascular pattern include the following: gluteus maximus,
tations should be incorporated into the surgical plan so that
intercostal, orbicularis oris, pectoralis minor, rectus abdomi-
defect coverage will be maximized. With progressive mobi-
nis, serratus, and temporalis.
lization of the pedicle, the arc of rotation of the flap can
be increased. Release of the bony attachments overlying the
Type IV: Segmental Vascular Pedicles point of entry of the vascular pedicle will also allow the
This group of muscles contains a series of segmental pedicles— muscle to be elevated as an island flap based only on its vas-
generally of equal size—that enter the muscle along its course. cular pedicle with subsequent increase in its arc of rotation
Each segmental pedicle provides circulation to a portion (seg- (Figure 5.3A–C).
ment) of the muscle. Generally, division of two or more ped- Specific knowledge of anatomic landmarks including
icles is feasible for transposition of a portion of the muscle as muscle insertion and origin and where the vascular pedicle
a flap. However, the muscle generally will not survive if an enters the muscle will allow for better planning. A template
excessive number of the segmental pedicles are divided dur- can be made of the defect and then the arc of rotation of
ing flap elevation. Muscles with a Type IV vascular pattern potential regional muscles can be plotted. Certain defects
include the following: the extensor digitorum longus, exten- require two or more regional flaps, but knowledge of the
sor hallucis longus, external oblique, flexor digitorum longus, muscular anatomy will allow reliable planning Muscle flap
flexor hallucis longus, sartorius, and tibialis anterior. elevation based on the dominant pedicle is designated as the
standard flap. If a muscle flap is elevated on its secondary
Type V: Dominant Vascular Pedicle and pedicle, which requires division of the dominant pedicle,
the flap is classified as a “reverse” flap. An example of this
Secondary Segmental Vascular Pedicles is a pectoralis muscle flap that is normally elevated on its
In this pattern of circulation, the muscle receives a large vascu- dominant axial pedicle, the thoracoacromial vessels. The flap
lar pedicle that will reliably provide circulation to the muscle can also be raised as a turnover flap based on the secondary
when it is elevated solely based on this particular vascular vessels from the internal mammary circulation, to cover a
pedicle. However, the muscle has secondary vascular pedicles, midline sternal defect.

A B C
Figure 5.3. Arc of rotation. A. Arc of rotation with flap elevation to point of entrance of vascular pedicle to flap. B. Extended arc of rotation
based on flap elevation with dissection of pedicle to regional source. C. Extended arc of rotation based on flap elevation with pedicle dissection
and release of proximal fascia and/or muscle origin or insertion. (From Mathes SJ, Nahai F. Reconstructive Surgery Principles, Anatomy and
Technique. Vol 1. New York, NY: Churchill Livingstone; 1997:115, with permission.)
In a rotation advancement flap such as a gluteal flap for trade-off. Knowledge of the vascular territory of the donor
sacral wound coverage, the arc of rotation is based more on muscle based on either dominant or segmental supply helps
the pivot point of the cutaneous incision and any associated define which portion of the muscle can successfully be trans-
backcut rather than on the vascular pedicle. Clearly, these ferred or survive regional mobilization. Limiting the amount
flaps are limited by distance since a large cutaneous compo- of fascial harvest and muscle dissection can offer a functional
nent remains attached. benefit in certain donor regions. A classic example of this is
muscle and fascial harvest in TRAM flaps and the associated
Skin Territory risks of abdominal wall laxity and weakness. Although the
standard design of the muscle flap often represents the most
Musculocutaneous flaps are composite axial flaps that consist appropriate method to reach these goals, alterations in flap
of muscle and overlying subcutaneous tissue and skin. In most design may avoid problems at the donor site. Muscle spar-
cases, the muscle at the base of the flaps is supplied by a sin- ing and perforator approaches help to decrease the abdomi-
gle dominant vessel, which gives off one or more perforating nal wall morbidity associated with this type of flap harvest
vessels to supply the overlying subcutaneous tissue and skin. and minimize the need for alloplastic (mesh) reconstruction of
Examples of musculocutaneous flaps include the TRAM flap the donor site. Certainly, when harvesting bilateral flaps for
and the latissimus dorsi flap. Topographically, nearly any mus- breast reconstruction, a perforator dissection will minimize
cle in the direct subcutaneous location provides perforators to the overall tissue loss on the donor site and allow for an easier
the skin either directly through or adjacent to the muscle. This primary closure of the abdominal wall.
subcutaneous tissue and overlying skin can be incorporated
into a multilayered type of reconstruction. The skin territory of Segmental Flap
each superficial muscle is defined anatomically as that segment
of skin extending between the origin and insertion of the mus- As noted above, transferring a portion of a muscle has poten-
cle and located between its edges along the course of the muscle tial advantages, including functional preservation, decreased
and can even be extended beyond this territory. The pedicled bulk at the recipient site, and potential use of the remain-
musculocutaneous flap may be designed with the skin left intact ing muscle as a secondary flap.12 Type III muscles, especially
(rotation flap) at the flap base or a skin island (island flap) may the gluteus maximus, are ideally suited for segmental design
be designed over the flap. Generally, the more narrow muscles because these muscles have a dual blood supply. Thus, it is pos-
(i.e., gracilis) have a greater limitation in skin territory because sible to split the muscle, leaving half of it attached to its origin,
of the decreased number of perforating vessels to the overlying insertion, and motor nerve. The other half of the muscle can
skin and the increased importance of septocutaneous vessels to then be elevated as a transposition flap. This type of muscle
the skin territory in proximity to the muscle. flap modification may be used for both Type I and Type II
muscles because the muscle is divided based on branches of the
dominant vascular pedicle. Type V muscles, because of their
Flap Modifications blood supply, have the ability to be split and taken as smaller
The goals of reconstructive surgery include safety along with flaps based on the main or secondary circulations (Figure 5.4).
restoration of form and function. The donor site must also A Type IV muscle, in particular, requires elevation as a seg-
be considered. Repair of a defect in one region by creating an mental flap, because the entire flap generally does not survive
equally problematic defect in the donor site is not a satisfactory based on a single segmental vascular pedicle. Only a portion

adjacent to the dominant or major vascular pedicle, the nerve

may require division during pedicled or free flap elevation. If
divided, a neurorrhaphy may be performed to another sensory
nerve at the recipient site. Examples of this exist with breast
reconstruction. Neurorrhaphies can be performed between
Basic Science
the 11th intercostal nerve, which is involved in sensation to
the rectus flap, or the cutaneous branches of the 7th thoracic
nerve, which provides sensibility to the cutaneous component
of the latissimus flap, and the lateral cutaneous branch of the
4th intercostal nerve, which provides the major contribution
to sensation of the breast. Clinical and research studies have
shown more consistent sensory return to the recipient site when
a sensory neurorrhaphy is performed.16 The difficulty with this
approach is that sensory return is not a functional requirement
in all territories of the body. Even in areas such as the plantar
aspect of the foot where sensation is important for protection
and proprioception, function can be preserved without direct
Figure 5.4. Split latissimus, along with other muscular flaps being
used to obliterate a bronchopleural fistula and empyema cavity.
sensory reconstruction. Many patients regain deep sensation
Latissimus was split and used superiorly and inferiorly to help fill the from local neural growth into the transplanted tissue. Also,
space in this reconstruction. sensory nerves supplying a given cutaneous territory may not
be clearly visible or consistent on dissection. The indications
for sensory reconstruction in these flaps must be individualized
and should be planned to help guide the flap dissection and the
of the muscle can be divided and used as a transposition flap. patient’s expectations. Division of sensory nerves must be per-
Use of the superior part of the sartorius muscle for groin ves- formed appropriately to avoid neuroma formation. Regional
sel coverage is an example of segmental muscle flap design. dysesthesia is a potential consequence with injury to, or harvest
The sartorius is elevated by ligating one or two (as many as of, sensory nerves supplying a cutaneous area.
needed) perforators and rotating the proximal muscle medi-
ally to cover the femoral vessels. More ligation of distal perfo- Vascularized Bone
rators may compromise the blood supply to the proximal flap,
which is required for the vessel coverage. Vascular connections between the muscle and bone are gener-
ally observed at the muscle–bone interface. If these vascular
connections are preserved, it is possible to elevate a segment of
Distally Based Flaps vascularized bone with the flap. A segment of the 6th rib with
Design of a flap on minor pedicles located opposite to the the pectoralis major muscle and a segment of the iliac bone
base of the standard flap is classified as a distally based flap.13 with the internal oblique muscle (deep circumflex iliac artery
Generally, the entire muscle will not survive division of the flap) are examples of muscle flaps that may include bone. In
dominant pedicle and, therefore, only a small part of the muscle a free fibula flap, the flexor hallucis longus is supplied by the
is elevated on a specific identified minor pedicle. Delay by liga- peroneal vessels and interconnected through this vasculature
tion of the dominant pedicle prior to flap elevation helps in suc- with the fibula bone (Figure 5.6A–C). Although the muscle
cessful elevation of distally based flaps, including the proximal dissection can be limited during the flap harvest, it is often
muscle. The main problem for these distally based flaps can be incorporated to supply extra internal or cutaneous coverage,
venous drainage, especially in the lower extremity. Elevation of bulk, and vascular supply.
the extremity to allow for postural drainage and surgical delay,
as mentioned above, helps the distally based flap to adapt the Tissue Expansion
venous circulation to its new circuitous pathway. An example
Although rarely used because of surgical staging difficulties and
of this is the use of the medial hemisoleus as a reversed flap
risk of complications, insertion of a tissue expander beneath
based on the distal posterior tibial perforators for coverage of
a musculocutaneous flap allows for an increase in skin island
ankle and distal third defects of the lower extremity.14
dimensions and assists in donor site closure (Chapter 10).17
In flap coverage surgery, tissue expansion is more commonly
Neurotized-Functional Muscle Flap utilized in preparation of fasciocutaneous advancement flaps.
A muscle flap may be used to provide motor function at the Tissue expansion can be utilized to increase the useable skin
site of reconstruction.15 Flap design requires preservation island in a latissimus musculocutaneous flap and also allow for
of both the dominant vascular pedicle and the motor nerve primary closure of the defect. When used for breast reconstruc-
(examples include the latissimus and the gracilis). In order to tion, the tissue expander increases the dimensions of both the
maintain effective muscle function, the muscle must be inset remaining skin envelope and the associated overlying pectora-
so that its resting length and tension is the same as it was in lis major muscle.
the donor site. A muscle may be designed both to provide cov-
erage of a defect and to restore function. An example of this Free Flaps
is the use of the latissimus dorsi muscle in the biceps region.
Free flaps are the natural extension of axially based muscle
It may be used as a pedicled flap on its motor nerve (thora-
and musculocutaneous flaps and have further advanced our
codorsal nerve) or a neurorrhaphy can be performed to the
ability to provide reconstructive options. Pedicled flaps are
musculocutaneous nerve. In the forearm region it can be used
limited by their arc of rotation. Microvascular free tissue
as a free flap (Figure 5.5A–E).
transfer broadens the flaps’ usefulness to all areas of the body.
Free tissue transfer should, like all reconstructive techniques,
Sensory Flap be performed in a well-planned fashion and should not be per-
Sensory reinnervation of cutaneous islands after transfer is formed in lieu of appropriate regional options. The reasons for
unpredictable. A musculocutaneous flap may be designed to using muscles as free flaps are essentially fourfold. First, to over-
include a sensory nerve to the cutaneous portion of the flap. If come limited regional options such as in distal tibial and foot
the sensory nerve does not enter the skin territory of the flap defects. Second, the volume of the defect is larger than regional

A B
C D
Figure 5.5. Chimeric flap for thigh reconstruction. A. Massive thigh

sarcoma during resection, removing most of the anterior thigh muscu-
lature and skin. B. Contralateral thigh chimeric flap including vastus
lateralis, tensor fascia lata, and anterolateral thigh tissue along with the
accompanying motor and sensory nerves. C. The pedicle and associated
nerves are seen. D. Placement of the flap into the defect and neuror-
rhaphy between the muscular nerve branches and the recipient site
nerve branches for eventual neurotization. E. Six months postoperatively
with return of nerve function and improving knee extension.
E
tissues can reconstruct. Microvascular transplantation is fre- Flap design is essentially the same for both regional trans-
quently utilized in the head and neck region where there is a position and microvascular transplantation of muscle and
lack of suitable regional muscles to satisfy the reconstructive musculocutaneous flaps. The reconstructive needs are ana-
need for combined facial, oral, and nasal cavity defects. Third, lyzed and treated in a composite fashion. Like tissues are
when functional deficits from utilizing the regional muscle chosen to reconstruct the defect for both functional and aes-
supply may limit the outcome, nonessential distant muscle can thetic purposes. The consistent, long vascular pedicle to most
be utilized to provide a functional outcome. Fourth, for infec- Type I, II, and V muscles allows rapid elevation of the muscle
tions or prosthetic coverage when flap re-elevation is likely, with its vascular pedicle for microvascular transplantation
even when local, fasciocutaneous coverage can be performed. (Figure 5.7A–E).


Basic Science
A
Figure 5.6. A. Fibula harvest for mandible reconstruction including

a portion of the flexor hallucis longus muscle, which is supplied by
the peroneal vasculature. B. Fibula osteotomized and plated while
remaining attached to its pedicle in situ. C. Fibula transferred and
revascularized. Bone inset has been performed and soft tissue inset
is next. Included is a skin island (osteomyocutaneous) for intraoral
reconstruction.
C
to all parts of the body. Defects in the head and neck can be
Perforator Flaps complex involving mucosal loss from the oral, nasal, and pha-
A muscle’s axial blood vessel provides perforators, which first ryngeal cavities; structural loss of either the bony or cartilagi-
supply the muscle and then proceed superficially to supply the nous skeleton; and cutaneous loss. In larger defects there is
overlying skin and subcutaneous tissue. These vessels can be no one flap that can provide all of these missing layers. By
meticulously dissected from the surrounding muscle to produce either incorporating multiple flaps (e.g., free osteocutaneous
a direct cutaneous perforator flap (Figure 5.8). These perfo- fibula free flap with a pedicled pectoralis myocutaneous flap
rator flaps are cutaneous flaps, which are based on the ves- for a composite mandibular defect) or by precise, planned flap
sels known to traverse various muscle flaps such as the deep prefabrication, these defects can be reconstructed. The use of
inferior epigastric, thoracodorsal, and superior gluteal vessels. thinned flaps with the pre-grafting of autologous or bioengi-
These flaps demonstrate that the unnamed cutaneous/perforat- neered structural elements such as bone and cartilage and the
ing vessels arise from larger, named vessels and travel through creation of new vascular bundles in desired donor sites are
the muscle or muscular septum to supply a large cutaneous well established in the literature. The advancement of in vivo
region. The reliability of these flaps is clearly more robust and ex vivo tissue engineering, with, and ultimately without,
than previously thought. The problem of anatomic variability immune modulation, is one of the next frontiers for recon-
to these cutaneous perforators is greater when not following structive surgery.
known muscle territories. Perforator flaps, while technically
challenging, may decrease some of the functional morbidity Combined Flaps
associated with the harvest of muscles and overlying muscle
Combined flaps are used when either a large volume of tis-
fascia in myocutaneous flap harvest. These flaps have become
sue is required, more than a single flap can provide, or when
widely utilized for breast reconstruction but can be used for
multiple tissue types are required in a complex position or ori-
any location throughout the body.18
entation. Instead of taking multiple pedicled or free flaps to
perform a given reconstruction, conjoined or chimeric flaps
Prefabricated Flaps can be used. Each of these groups has subcategories and indi-
Prefabrication represents the future of flap-based reconstruc- vidualized terminology within them but the basic principles
tion and is in essence in vivo tissue engineering. The goal of remain the same.21 The flaps in these groups are either attached
this type of reconstruction is to provide all missing compo- by a common vascular supply or are directly attached, each
nents of a given defect by positioning support, lining, and with its own vascular supply. Conjoined flaps are individual
coverage tissues in preplanned positions and allowing them flaps that have their own vascular territory but are attached
to vascularize prior to transfer, and minimize donor site mor- by a soft tissue bridge to form a larger flap with multiple vas-
bidity.19,20 Descriptions of prefabrication have been mostly cular territories being incorporated. An example of this is the
focused on the head and neck region but can be translated bridging of an extended myocutaneous latissimus flap with a

A B
C D
Figure 5.7. A. Open ankle defect after orthopedic trauma. Bone

and hardware were exposed after debridement. B. Design of a same-leg
gracilis flap that approximated the defect size well and with lim-
ited donor site morbidity. C. Harvest of the gracilis (Type II) flap.
D. Intraoperative coverage of this small defect with well-vascularized
muscle. E. Several months postoperative picture showing excellent
healing and recontouring.
E
superficial inferior epigastric flap, which was first described since islands of tissue can be created on each perforator branch
by Harii et al., back in 1981.22 These flaps could be rotated on that emanates from the source supply of the lateral circumflex
either pedicle, with the other pedicle being attached microsur- femoral vessels. A final subtype of the chimeric flaps is the fab-
gically to enhance the blood supply and create a tremendously ricated chimeric flap. These are flaps that are attached to each
large flap for cutaneous coverage. These massive flaps can also other by microanastomosis either at branch points or at the dis-
be taken further as a pure free flap with double microvascular tal (flow-through) end to create a hybrid flap.
anastomoses. The use of these flaps obviously depends on the
defect. A flap can be considered conjoined between individual
perforators because each of these territories can be separated
Complex Wound Management
and can act as an individual flap unit. Muscle and musculocutaneous flaps are ideal for treating dif-
Chimeric flaps are individual flaps that are fully separated ficult soft tissue and bony or prosthetic infections. Although
from each other but linked together by a common source vessel. treatment to decrease the bacterial concentration below 105
The classic examples come from the subscapular system and per gram of tissue is necessary, subsequent coverage with
from the lateral circumflex femoral system. The subscapular well-vascularized muscle appears to further decrease the
system has a variety of tissue types from bone to skin that can all bacterial load, protect against recurrence of infection, and
be taken as separate flaps or in multiple combinations (Figure maintain wound closure. Planned treatment of complex
5.9A–E). The vascular supply for these flaps is from large inde- wounds with staged debridements followed by coverage with
pendent subfascial vessels that connect to the same source ves- well-vascularized tissue and appropriate antibiotic therapy has
sel. The anterolateral thigh chimeric flaps are perforator based revolutionized wound management and is the standard of care

common and problematic example of osteomyelitis (Figure 5.11A

and B). Treatment with serial debridement and antibiotics and
coverage with a muscle flap such as the pectoralis major and/or
the rectus abdominis are necessary for ultimate wound closure,
chest wall stabilization, and patient survival.
Basic Science
Vascular Insufficiency
Nonhealing wounds associated with vascular insufficiency
frequently require extremity amputation. Revascularization
of the leg may salvage the extremity, but the wound will still
necessitate flap coverage. Although revascularization provides
macroscopic blood flow to an extremity, the area of a specific
wound may still have insufficient microvascular perfusion or
be too large to heal on its own. Muscle flap placement pro-
vides transplanted microcirculation and tissue bulk to allow
these wounds to heal and ultimately provide for limb salvage.
Either simultaneous or delayed muscle flap transplantation
will allow preservation of a functional extremity despite
wound complexity.28 In certain circumstances, a flap can be
chosen that has a flow-through ability. With this type of flap
design, the vascular supply, more often, from a traumatic
injury or atherosclerotic disease can be augmented and flap
tissue placed to cover the defect. This type of reconstruction
requires precise planning and execution.
Radiation Wounds
Wounds associated with radiation injury do not respond
to local wound care and can be some of the most difficult
wounds to treat (Chapters 3 and 17). Tissue that has under-
gone high-dose ionizing radiation therapy has limited resis-
Figure 5.8. Perforator TRAM (transverse rectus abdominis myocu- tance to injury and ability to regenerate. The effects of this
taneous) flap anastomosed to the internal mammary vessels. type of radiation are longstanding. Radiated tissue can remain
intact for decades but any form of tissue stress or injury can
form a chronic wound with critical structures ultimately being
exposed. Treatment of these wounds usually requires wide
in most situations. Historically, experimental studies compar- debridement of necrotic skin, affected soft tissue, and scle-
ing bacterial resistance in musculocutaneous as compared with rotic or infected bone and results in a complex wound usually
cutaneous and fasciocutaneous flaps have demonstrated superior associated with exposure of vital structures. If adjacent muscle
resistance to bacterial invasion and subsequent flap necrosis in units have vascular pedicles located distant to the radiation
the muscle and musculocutaneous flaps.23,24 Since muscle flaps port, regional muscle flaps may be useful for vascularized
appear to provide protection from progressing bacterial injury coverage (Figure 5.12A–C).29 In areas with poor local muscle
to the soft tissues and improved tissue vascularity, it has allowed availability such as the head and neck region, particularly in
for the management of complex wounds that traditionally did the skull, microvascular transfer of a muscle flap is generally
not respond well to local wound care. There have also been required for coverage.
studies showing no difference between muscle and fasciocuta-
neous flaps in infected wounds.25 It remains widely accepted,
however, that muscle flaps provide an excellent option for
coverage. Also, when comparing the use of muscle and fascio- Exposed or Infected Prosthesis
cutaneous free flaps in traumatic wounds, there does not appear When wound coverage overlying the site of a vascular or
to be an increased incidence of long-term postoperative infec- orthopedic prosthesis fails, early wound debridement, mus-
tion when appropriate debridement is performed.26 Muscle cle flap coverage, and culture-specific antibiotic therapy fre-
flaps are extremely useful in three-dimensional defects, which quently allow salvage of the prosthesis and simultaneously
require the flap to contour to irregular or complex topography. provide stable defect coverage.30 Once infection has been
established in the prosthesis, however, it is usually necessary
to remove the prosthesis. More common areas of exposure
Osteomyelitis for vascular grafts are in the groin and lower extremity. Groin
Following debridement of the infected bone associated with coverage is usually accomplished reliably with a sartorius
chronic osteomyelitis, a muscle flap is transposed as a regional muscle flap, but larger flaps can also be mobilized if needed.
flap or transplanted by microvascular technique into the defect. Orthopedic hardware is more commonly exposed in the mid-
The flap fills the area of bone debridement with well-vascularized line from spine surgery or over joint with limited coverage
tissue and provides stable wound coverage (Figure 5.10A–D). such as the knee. Spine hardware can usually be well covered
As noted above, short-term culture-specific antibiotic therapy with myocutaneous advancement flaps, whereas joint cover-
is utilized simultaneously. With this approach, successful manage usually requires rotation flaps such as the gastrocnemius
agement of chronic infection in the site of bone or cartilage muscle. Lastly, hardware exposure can occur in combination
injury has been observed.27 Debridements can be performed in with trauma such as in lower extremity injuries or after radia-
a staged fashion depending on the amount of infection and sta- tion injury leading to exposure of underlying bony or vascular
bility of the patient. Coverage with the muscle flap is planned prostheses. In any of these cases, reconstruction with either a
immediately after the final debridement. Sternal wounds are a local or free muscle flap is almost always indicated.

Figure 5.9. Chimeric flap reconstruction in the head and neck.

A. Exposed mandibular plate along with an underlying mandibular
defect. B. Chimeric flap design from the subscapular system including
bone, muscle, and fasciocutaneous tissue. C. Flap harvested with the
separate components visualized, all attached to the main subscapular
system. D. Flap being placed into the bony and soft tissue defect prior
to microvascular reanastomosis. E. Closure of the cutaneous defect at
the end of the procedure.
E


Basic Science
A B
C D
Figure 5.10. Reconstruction of osteomyelitis of the heel. A. Chronic draining heel wound with refractory calcaneal osteomyelitis. Prior
debridement was performed. B. The heel was opened transversally along its lateral surface to expose the calcaneal wound fully and allow for
debridement and subsequent coverage. The incision was carried up to the posterior tibial vessels where a muscle flap was anastomosed and
then placed inside of the heel for complete coverage of the debrided osteomyelitic space. C. Muscle in place after inset and prior to skin graft
placement. D. Six months postoperatively with a well-healed and contracted wound reconstruction.
plastic surgery. Their use has allowed for bolder, more effec-
Conclusions tive oncologic resections, limb salvage in previously irreparable
Muscle and musculocutaneous flaps are available in all body situations, improved functional restoration with motor unit
regions. With the selection of muscles with a suitable vascular loss, contracture release in secondarily healed or scarred joint
pedicle, the muscle may be safely elevated to provide cover- and soft tissue contractures, and improved aesthetic outcome
age and simultaneously restore form and function. Thorough for contour defects including breast reconstruction. Nearly
knowledge of the muscular anatomy, vascular circulation, and any defect can be closed with a careful analysis and a planned
the arc of rotation is required in order to select the optimal mus- approach for reconstruction. Use of muscle and musculocutane-
cle unit for specific defects throughout the body. When regional ous flaps broadens the options for defect closure in every area
muscle flaps are unavailable or undesirable, the surgeon may of the body. The future of flap reconstruction is also advancing
elect to transfer distant muscle or musculocutaneous flaps and becoming more refined with the use of perforator flaps,
microsurgically. Muscle and musculocutaneous flaps also pro- flap prefabrication, and chimeric flaps to more precisely recon-
vide a method to treat complex wounds—such as osteomyelitis, struct the most complex defects. All of these modifications and
radiation necrosis, traumatic defects, and exposed hardware— advancements in flap surgery have positioned the reconstruc-
that in the past were recalcitrant to wound care. Use of muscle tive surgeon at the forefront of clinical tissue engineering and
and musculocutaneous flaps has revolutionized reconstructive vascularized composite allotransplantation.

A B
Figure 5.11. Reconstruction of sternal osteomyelitis. A. Sternal osteomyelitis after wire removal and an initial debridement. Significant
debridement of the pectoralis muscle was also performed. B. Pedicled rectus abdominis flap placement into the defect.
A B
Figure 5.12. (Continued)


Basic Science
Figure 5.12. Reconstruction of a radiated groin wound. A. Excision
of a radiated open tumor wound in the groin along with underlying
lymph node dissection and removal of surrounding radiated skin.
B. Elevation of a vertical rectus abdominis myocutaneous flap.
C. Placement of the flap through a subcutaneous tunnel with excellent
coverage of the defect including muscle over the entire wound bed and
complete cutaneous closure with the overlying skin paddle.
C
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free transverse rectus abdominis myocutaneous flap. Plast Reconstr Surg.
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1973;26(3):202-213. 17. Radovan C. Tissue expansion in soft-tissue reconstruction. Plast Reconstr
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1984;13(6):495-503. reconstruction. Clin Plast Surg. 2001;28(2):261-272, vii.
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114(4):910-916. 23. Calderon W, Chang N, Mathes SJ. Comparison of the effect of bacterial
7. Bakamjian VY, Long M, Rigg B. Experience with the medially based delto- inoculation in musculocutaneous and fasciocutaneous flaps. Plast Reconstr
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1971;24(2):174-183. 24. Gosain A, Chang N, Mathes S, Hunt TK, Vasconez L. A study of the relationship
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Reconstr Surg. 2007;119(6):1735-1744. cutaneous flaps. Plast Reconstr Surg. 1990;86(6):1152-1162; discussion 1163.
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surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast versus nonmuscle flaps in the reconstruction of chronic osteomyelitis
Surg. 2009;63(4):383-388. defects. Plast Reconstr Surg. 2006;118(6):1401-1411.
10. Mathes SJ, Nahai F. Classification of the vascular anatomy of muscles: 26. Yazar S, Lin CH, Lin YT, Ulusal AE, Wei FC. Outcome comparison
experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-187. between free muscle and free fasciocutaneous flaps for reconstruction of
11. Taylor GI, Gianoutsos MP, Morris SF. The neurovascular territories of the distal third and ankle traumatic open tibial fractures. Plast Reconstr Surg.
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Surg. 1994;94(1):1-36. 27. Mathes SJ, Alpert BS, Chang N. Use of the muscle flap in chronic osteo-
12. Mathes SJ, Vasconez LO. Myocutaneous free-flap transfer. Anatomical and myelitis: experimental and clinical correlation. Plast Reconstr Surg.
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Technique. New York, NY: Churchill Livingstone; 1997. Combined arterial reconstruction and free tissue transfer for limb salvage.
14. Pu LL. The reversed medial hemisoleus muscle flap and its role in reconstruc- J Vasc Surg. 1999;29(5):814-818; discussion 818-820.
tion of an open tibial wound in the lower third of the leg. Ann Plast Surg. 29. Mathes SJ, Alexander J. Radiation injury. Surg Oncol Clin N Am. 1996;
2006;56(1):59-63; discussion 63-64. 5(4):809-824.
15. Terzis JK, Sweet RC, Dykes RW, Williams HB. Recovery of function in 30. Greenberg B, LaRossa D, Lotke PA, Murphy JB, Noone RB. Salvage of
free muscle transplants using microneurovascular anastomoses. J Hand Surg jeopardized total-knee prosthesis: the role of the gastrocnemius muscle flap.
Am. 1978;3(1):37-59. Plast Reconstr Surg. 1989;83(1):85-89, 97-99.

Chapter 6 n Transplantation Biology and
Applications to Plastic Surgery
Damon S. Cooney, Justin M. Sacks, Gerald Brandacher, and W. P. Andrew Lee
The transplantation of tissue from one location to another is a survived indefinitely. World War II accelerated progress in
fundamental concept in plastic surgery. It is not surprising that allotransplantation. Gibson, a plastic surgeon at the Glasgow
the first successful transplantation of tissue from one person Royal Infirmary, described the accelerated rejection of skin
to another in the form of a kidney transplant was performed grafts in pilots due to the presence of humoral antibodies
by a plastic surgeon, Dr. Joseph E. Murray. Other pioneer- after repeat exposure to the same donor, also known as the
ing plastic surgeons helped spawn the new field of allogeneic “second-set rejection.” Medawar joined Gibson to investigate
organ transplantation, and with the development of improved this phenomenon and, in combination with Billingham and
surgical techniques and modern immunosuppression, trans- Brent, laid the foundation for modern immunology. In 1954,
plantation has become the treatment of choice for end-stage Dr. Joseph E. Murray and colleagues performed the first
organ failure of the liver, heart, lung, pancreas, and kidney. successful kidney transplant between identical twins.
It is fitting that transplantation has returned to the field of Furthermore, the introduction of a novel immunosuppressive
plastic surgery more than 50 years later with the development drug, 6-mercaptopurine and its precursor azathioprine (AZT)
of reconstructive transplantation, the new era in transplant by Charles Zukosi and Roy Calne in 1960, was responsible
medicine. It is only within the last decade that transplantation for improvements in the field of organ transplantation.
of vascularized composite allografts (VCAs), such as hand and With the discovery of the first human leukocyte antigen
face transplants, has become a clinical reality. VCAs involve (HLA) in 1958, the matching of tissue beyond simply match-
transplantation of composite structures for reconstructive ing blood types became possible. Knowledge of these antigens
surgery and thereby fulfill a prime mandate of plastic sur- allowed the avoidance of graft-versus-host disease. The first
gery: to replace and restore devastating tissue defects using successful human bone marrow transplant was performed
“like-with-like.” The ability to transfer vascularized allografts in 1968. A 4-month-old boy who had Wiskott-Aldrich syn-
through microvascular surgical techniques, restoring form drome received a bone marrow transplant from his sibling that
and function for complex cutaneous and musculoskeletal effectively restored his immune system, duplicating Medawar’s
defects, is revolutionizing the field of reconstructive surgery animal findings that had previously resulted in immune tolerance
and has added another rung to the “reconstructive ladder.” in chimeric mice. Medawar’s chimeric mice contained genetically
Long-term allograft survival, however, can only be achieved, distinct cells originating from separate and unique zygotic cells.
as for any solid organ transplant, through the use of systemic Coinciding with these first successful human bone mar-
immunosuppression with its associated sequela of organ tox- row transplantations, all major components of human clinical
icity, opportunistic infections, and potential for malignancy. allotransplantation including immunosuppression, tissue pres-
Current research on immunomodulation and induction of ervation and matching, and complex microvascular techniques
tolerance holds promise for reducing the need for long-term were elucidated. Following the first kidney transplantation,
high-dose immunosuppression. Although reconstructive other solid organs such as the heart, liver, lung, and pancreas
allotransplantation in humans is a relatively new area with were transplanted and nonspecific immunosuppressive agents
small numbers of patients, there are reasons to think that such as cyclosporine A (CsA) and FK506 were developed.
new innovations in immunomodulation and tolerance may In the last two decades, over 150 different VCAs including
come from the field of VCAs. For example, reconstructive more than 80 upper extremities and 24 partial faces, as well as
transplant patients usually do not suffer from life-threatening abdominal walls, larynx, tongue, uterus, penis, vascularized bone
illness or comorbidities and therefore the impetus to minimize and joint, and individual tissue components like peripheral
side effects from immunosuppressive medications is stronger. nerve, flexor tendon, and skin have been successfully trans-
Also, the ability to directly and continuously observe transplanted using conventional immunosuppressive protocols. Of
planted tissue that includes a skin component allows for the the upper extremity transplants performed to date, only one
use of novel experimental protocols as rejection is seen earlier graft was lost while patients were on high-dose immunosup-
and can potentially be reversed by topical agents. Finally, the pression. In the combined American and European experience,
presence of vascularized bone marrow in many VCA grafts the early to intermediate allograft survival is greater than 95%
raises the possibility of unique modulatory strategies, as will (Figure 6.1).
be discussed. Current immunosuppression protocols developed within
the last century have allowed these transplantation ideas to
become a surgical reality. The risk/benefit ratio that must be
Introduction optimized when transplanting a piece of tissue that optimizes
Human tissue transplantation is an ancient concept. According form and function but does not preserve or prolong life poses
to legend from the fourth century AD, Saints Cosmos and an ethical dilemma. Exposure to life-long immunosuppres-
Damian—twin brothers—replaced the gangrenous leg of a sion comes with risk that must be articulated to the patient.
parishioner with the leg of a deceased Ethiopian Moor. The Current immunologic research focuses on ways to obviate the
earliest reliable, documented outcomes of allogeneic and use of systemic immunosuppression for both solid organ and
xenogeneic skin grafts in human recipients were published reconstructive transplantation procedures. The field of recon-
by Schone in 1912 and Lexer in 1914. Schone and Lexer structive transplantation will become ubiquitous once toler-
demonstrated that these grafts did not survive more than ance can be achieved. Currently, great strides are being made
3 weeks after transplantation. Padgett provided further evi- in large animal studies and in the first clinical trials, moving
dence in 1932, when he reported rejection of all skin allografts ever closer to elucidating the immunologic processes that will
within 35 days in 40 patients. However, Padgett also dem- unlock these barriers and allow the next revolution in plastic
onstrated that skin grafts exchanged between identical twins surgery to begin.
56
Chapter 6: Transplantation Biology and Applications to Plastic Surgery 57
25

20
Basic Science
90
Hands Patients
80 78
15
Years
70
10 60
52
50
5
40 37
30
24 24
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20 17
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al
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ru
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12
Fe
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ee
a
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es
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e
he
na
SA
or
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ac
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U
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A B
10
Hands Face
9
7
Number of transplants
3 Figure 6.1. A–C. International experience with reconstructive

transplantation 1999 to 2012. A. The cumulative total for all types of
2
reconstructive transplant by type of transplant (except upper extrem-
ity) as of 2012. B. The cumulative total for upper extremity transplants
by region as of 2012. Upper extremity continues to be the most com-
1
monly performed vascularized composite allograft. C. The number of
hand and face transplants performed per year in the United States since
0 1999 broken down by year. Note the dramatic increase in reconstruc-
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 tive procedures in the last half-decade.
Hand and face transplants performed/year in the United States
C
A graft is tissue completely separated from its donor bed

Nomenclature and moved to a separate recipient bed, its survival relying
Proper nomenclature will help clarify subsequent discus- on ingrowth of new vessels from the surrounding recipient
sions. Certain terms such as transplant, flap, and graft are tissue (Chapter 1). A vascularized graft or flap either remains
often used to refer to a VCA. However, these terms should be attached to its native blood supply or becomes revascular-
used carefully with their true meaning in mind to ensure clear ized via microvascular anastomoses to recipient vessels (aka
communication. free flap). An autograft refers to tissue transplanted from one
Transplantation can be defined as the transfer of tissue or location to another within the same individual. An isograft is
an organ to another person or to a different location in the tissue transplanted between genetically identical individu-
same person. According to this definition, much of what recon- als, such as transplants between syngeneic mice or human
structive surgeons do can be classified as a type of transplant. monozygotic twins. An allograft or homograft is tissue trans-
However, in its usual medical usage, the term transplant is used planted between unrelated individuals of the same species. A
to describe an allotransplant or tissue transferred from a living xenograft or heterograft is tissue transplanted between differ-
or deceased human donor to another genetically not identical ent species.
human patient. Within this chapter, our discussion of transplan- Transplantation can also be described according to the site
tation will be focused mostly on the topic of allotransplantation, into which the tissue is transferred. An orthotopic transplant is
as the transfer of autologous tissue locally or distantly is covered transferred into an anatomically similar site, whereas a hetero-
elsewhere in the text. topic transplant is transferred into a different site from its donor

origin. The term reconstructive transplantation is used to differ- Once T cells are activated, they become effector T cells and
entiate the transfer of composite tissues such as the hand or face migrate to the graft and mediate rejection. This is aptly named
from more traditional solid organ transplants. During the devel- the direct pathway of allorecognition. In contrast to the direct
opment of reconstructive transplantation, this novel field was pathway, host APCs play a significant role in the indirect path-
commonly referred to as composite tissue allotransplantation way of allorecognition where they present processed donor
(CTA). Unfortunately, the use of this term has caused some con- antigens to host T cells. Both pathways of allorecognition are
fusion and has largely fallen out of favor. In particular, the use important in mediating graft rejection; however, the indirect
of the word tissue raised the concern that reconstructive trans- pathway is thought to be of greater significance in the physiology
plantation could be confused by regulatory bodies (such as the of chronic graft rejection.
FDA) with non-vascular tissue transplantation, with potentially DCs are the most efficient APCs and have the capacity to
negative regulatory consequences. Therefore, vascularized com- take up, process, and present antigens to T cells in vivo. DCs
posite allograft (VCA) transplantation has supplanted the term rapidly respond to inflammatory stimuli, microbial products,
CTA to avoid this confusion. or alloantigens following transplantation and express high
levels of MHC class II and costimulatory molecules essential
Transplant Immunology for T-cell activation.
Transplantation Antigens Immunosuppression

Transplantation of organs or tissues between genetically All allotransplant recipients require some form of immuno-
disparate individuals of the same species (allogeneic indi- suppression. Without these immunosuppressive modalities,
viduals) leads to recognition and rejection of the allogeneic rejection would inevitably occur in individuals unless they
tissue by the recipient’s immune system. This “alloimmune were genetically identical (identical twins). The immunosup-
response” that discriminates between self- and non-self tis- pression used for transplantation of VCAs has for the most
sues remains the main barrier to successful transplantation. part mirrored the regimens for solid organ transplantation.
These immunologic responses are initiated by graft antigens Several pharmacological drugs are used to prevent and
that are genetically encoded polymorphic proteins. The result control graft rejection (Table 6.1). It is important to note that
of this interaction determines the acceptance or rejection of these drugs lack selectivity and cause generalized immuno-
allograft tissue. For this reason, learning how to suppress suppression rendering transplant patients highly susceptible
these responses is a major goal of transplant immunologists. to opportunistic infections and certain types of malignancies.
Transplant tolerance, as discussed, can be mediated by central Based on their mode of action, there are four main groups
or peripheral mechanisms and can be acquired with the assis- of immunosuppressive drugs: (1) steroids, (2) cytotoxic/anti-
tance of either immunosuppression or immunomodulation. proliferative drugs, (3) anti–T-cell agents (calcineurin inhibi-
Antigens are cell surface glycoproteins that are encoded tors), and (4) induction agents (polyclonal and monoclonal
in the major histocompatibility complex (MHC), a multigene antibodies). One of the first immunosuppressant used was
cluster located on chromosome 6 in humans. There are two steroids with broad anti-inflammatory actions (i.e., pred-
classes of MHC molecules, class I and II, that differ in their nisone and prednisolone). These medications inhibit acti-
structure, function, and tissue distribution. MHC class I anti- vation of several transcription factors, thus modifying
gens are expressed on all nucleated cells, whereas class II gene transcription and inhibiting cellular activation and
expression is restricted to antigen presenting cells (APCs), cytokine production. Prednisolone was one of the first
such as B lymphocytes, monocytes, macrophages, dendritic pharmacological agents used in allogeneic organ transplan-
cells (DCs), endothelial cells, and activated human and rat tation. Despite the well-known side effects of long-term
T cells. In humans, the MHC antigens are known as HLA. use, steroids are still widely used today in combination
Each individual has two MHC regions, one of paternal and with other immunosuppressive agents in most solid organ
one of maternal origin. Each MHC contains an inherited group and VCA protocols. Short courses of high-dose steroids
of HLA genes or haplotypes: HLA class I genes known as continue to be the frontline treatment for acute rejec-
HLA-A, -B, -C and HLA class II genes known as HLA-DR, -DP, tion episodes in all types of transplantation. Cytotoxic/
and -DQ. The HLA antigens determine the compatibility of all anti-proliferative drugs include cyclophosphamide, metho-
organ and tissue transplants. trexate, AZT, and mycophenolate mofetil (MMF). These
medications interfere with DNA replication and kill/arrest
Allogeneic Transplantation proliferating lymphocytes that are activated by alloantigens.
Billingham, Brent, and Medawar demonstrated in their semi- Earlier, nonspecific anti-proliferative agents such as AZT
nal 1953 Nature article that neonatal mice and irradiated had many side effects and increased the risk of transplant-
adult mice developed donor-specific tolerance to skin grafts associated malignancy. MMF has replaced the other agents in
subsequent to successful engraftment of splenic and bone mar- many protocols due to its ability to block purine synthesis selec-
row cells into the recipient. These animals were considered tively in T and B cells, which dramatically decrease side effects.
chimeras consisting of both donor and recipient T cells. This Agents that selectively inhibit the activation pathways of
built the foundation for the concept that cell-based therapies T cells are typically fungal or bacterial products (i.e., CsA,
in clinical transplantation could potentially modify the host tacrolimus [FK506], and rapamycin [RAPA; sirolimus]). CsA
immune system to allow minimization or even avoidance of and tacrolimus inhibit the signaling pathways of T-cell activa-
pharmacological immunosuppression. Since then, immune tol- tion by interfering with calcineurin activation and interleu-
erance has been the “Holy Grail” of transplantation research. kin (IL)-2 gene transcription (Figure 6.2). CsA is a metabolic
Rejection of transplanted tissue occurs through both extract from the fungus Tolypocladium inflatum gamus
cellular and humoral immune responses. These responses are described in 1976. Its discovery revolutionized the field of
generated when host APCs and T lymphocytes respond to solid organ transplantation by significantly increasing the sur-
the genetic differences in the MHC molecules expressed by vival of kidney, heart, and liver allografts. CsA was shown to
the donor cells. T cells have fundamental roles in graft rejection, prolong limb allograft survival in experimental animal mod-
and their responses are rapid and vigorous and ultimately will els and thereby encouraged clinicians to pursue VCA in the
lead to inflammation and tissue destruction. There are two main 1980s and 1990s. Tacrolimus is a macrolide lactone antibi-
pathways by which host T cells recognize donor alloantigens. otic isolated from soil fungus and also inhibits the calcineu-
Following transplantation, donor APCs migrate toward host rin/IL-2 pathway of T-cell activation, although at a different
lymphoid tissues and can directly activate recipient T cells. point in the pathway from cyclosporine. It has a favorable

Table 6.1

IMMUNOSUPPRESSIVE AGENTS. MANY OF THE DRUGS CURRENTLY BEING USED FOR ORGAN AND
RECONSTRUCTIVE TRANSPLANTATION AND THEIR SIDE EFFECTS
Basic Science
n Type of Drug n Agents n Mechanism n Side Effect
Steroids Methylprednisolone, Multiple, Hip necrosis, dyslipidemia, weight gain,

prednisone anti-inflammatory DM, fluid retention
Calcineurin Cyclosporine, Blocks IL-2 production Nephrotoxicity, hypertension, hyperlipid-
inhibitors tacrolimus/FK506 emia, hirsutism, gingival hyperplasia
Anti-proliferative Azathioprine, Blocks DNA synthesis Myelosuppression, GI complaints, viral
drugs mycophenolate mofetil, and proliferation reactivation
cyclophosphamide
mTOR Rapamycin, Blocks cell receptor Wound healing problems,
inhibitors everolimus signaling cascade hyperlipidemia, thrombocytopenia
Depleting Antithymocyte Antibodies to lymphocytes Cytokine release syndrome, anemia,
antibodies globulin, OKT3, remove cells from bleeding, thromboembolism
alemtuzumab circulation
mTOR, mammalian target of rapamycin; IL, interleukin; DM, diabetes mellitus; GI, gastrointestinal.
side-effect profile as compared with CsA, with less transplant-

associated malignancy, although it has significant nephro-
toxicity when used for long periods of time. Tacrolimus
has replaced cyclosporine in many protocols for solid organ
Immunosuppressive Targets of T-Cell Activation transplantation and has been a mainstay in all the clinical
reconstructive transplantation treatment regimen. RAPA is
an inhibitor of the mammalian target of rapamycin (mTOR),
APC which in turn inhibits multiple biochemical pathways criti-
cal for cellular proliferation with the main target being
T cells. RAPA is an attractive alternative to CsA and FK506,
having a significantly different side-effect profile in particu-
lar with regard to its nephrotoxicity, promoting tolerance
B7 in some circumstances, and having anti-proliferative and anti-
neoplastic properties. It does, however, suffer from the draw-
MHC Rapamycin back of having profound negative effects on wound healing
Ag CD 28 that may preclude its use in the early postoperative period.
IL-2R
These immunosuppressive agents have been reported to allow
successful allogeneic transplantation in clinical solid organ
TCR transplantation and VCA such as extremity transplantation and
face transplants with both high graft and patient survival rates.
Cyclosporine mTOR In addition to the three classes of drugs used for maintenance
T-cell immunosuppression, many protocols include the addition of
Calcineurin an induction agent, which causes the depletion of T cells in the
FK506 Steroids perioperative period. The goal of this therapy is to decrease the
FKBP12 NF B chance of acute rejection immediately after the transplant,
but to allow the recovery of the immune system and repopu-
lation of the T-cell compartment in the presence of the new
graft and immunosuppressive medications. This may alter the
NF3 T-cell population toward a more tolerant phenotype allowing
MMF Cell cycle
NFAT less immunosuppression. Polyclonal anti-thymoglobulin and
Nucleotide AP-1 anti-lymphocyte sera have been used in several studies for the
systhesis depletion of recipient T cells and prevention of graft rejection.
IL-2 gene Furthermore, studies using monoclonal antibodies against
AZT T-cell receptors (TCRs), anti-CD3 immunotoxin, an anti-CD3
T Cell activation
monoclonal antibody conjugated to a mutant form of the
Figure 6.2. Immunosuppressive targets of T-cell activation. diphtheria toxin protein, and Campath-1H (alemtuzumab),
Immunosuppressive medications interrupt T-cell activation at various an anti-CD52 monoclonal antibody, have been used to deplete
pathways. Cyclosporine A and FK506 interrupt the T-cell receptor lymphocytes yielding beneficial results for prolongation of
(TCR) signaling cascade by blocking calcineurin activation, the latter by graft survival. Total body, thymic, and graft irradiation have
interaction with FK binding proteins. Rapamycin blocks the mammalian all been used as induction treatments in the early days of solid
target of rapamycin signaling from both interleukin 2 receptor activation organ transplantation in both clinical and experimental studies,
and TCR coreceptors interrupting the “second signal” pathway. Steroids
alter gene transcription by modulating the effects of transcription factors
although they are not commonly used in current protocols.
including several necessary for T-cell activation. Azathioprine and myco- The ultimate success and further acceptance of the field
phenolate mofetil inhibit the production of nucleotides in lymphocytes of reconstructive transplantation will depend on develop-
blocking the cell cycle and proliferation. ments that reduce immunosuppressive sequela. Immunologic
tolerance and the abrogation of the need for chronic

immunosuppression will be the ultimate refinement in this auto- and allografts in sheep laid the groundwork for research
ongoing process. in the fields of both skin grafting and transplant immunology.
Baronio’s contributions are considered fundamental to the
Immunologic Tolerance field of plastic surgery. Experimental use of skin allografts
helped to elucidate and define the process and mechanisms
The precise definition of transplantation tolerance, often dis-
of allograft rejection. At first, a skin allograft is accepted just
cussed and rarely agreed upon, can be regarded as the lack
as any skin autograft. However, once the skin allograft is
of a destructive immune response toward the allograft in the
revascularized, the recipient immune system mounts a cellular
absence of ongoing immunosuppressive therapy. However,
immune response. Two to three weeks following placement,
implicit in this definition is that such a state must coexist
the allograft is rejected through an antigen-specific T cell–
with general immune competence, including normal immune
mediated response resulting in loss of the skin allograft, neces-
responses to pathogens and cancer risks no different than the
sitating alternative wound coverage most typically with skin
general population.
autograft.
Acceptance or tolerance of one’s own tissues first develops
The most frequent clinical use for skin allografts is in the
in utero, along with an immunologic ability to recognize for-
treatment of extensive burns. The ability to place temporary
eign tissue. The ability of the immune system to distinguish
skin grafts without jeopardizing limited autogenous donor
between self and foreign antigens is controlled by two mecha-
sites in these patients has resulted in dramatic improvements
nisms called central and peripheral tolerance. The thymus
in the survival of high total body surface area burn wounds
plays a major role in the maintenance of tolerance to self and
(Chapter 16). In some patients who are immunosuppressed
also the induction of tolerance to alloantigens. The mechanism
either through medications or through severe illness, skin
of T-cell tolerance in the thymus is based on the deletion of self
allografts have been shown to be tolerated with continued
or alloreactive T cells upon interaction with bone marrow–
immunosuppression. Anecdotal reports of patients who have
derived APCs. Since such clonal deletion causes the elimina-
undergone slow withdrawal of immunosuppression have not
tion of donor reactive T cells, it is considered one of the most
required re-grafting either through permanent tolerance of the
robust mechanisms for tolerance induction. In experimental
graft or more likely through slow substitution of the allograft
models, deletion of antigen-specific T cells can be induced by
with recipient cells.
direct injection of donor antigens into the thymus. Following
Skin allografts will continue to be one of the most com-
intrathymic injection, donor antigens will be presented by
mon forms of human allotransplantation. These grafts are
APCs to thymocytes, and this will allow for activation of allo-
vital to the treatment of wounds and burns. However, the
reactive T cells in the thymus and their deletion. Although
health status of patients presenting with these types of wounds
intrathymic injection has been successful in rodent models, it
precludes the use of long-term immunosuppression to achieve
has been of limited efficacy in larger animals. Another widely
graft maintenance due to the additional risk of opportunistic
researched approach for the induction of tolerance is the use of
infection. Future research developments that enable prolonged
hematopoietic bone marrow transplantations to induce mixed
skin graft survival in the absence of immunosuppression
chimerism. The term chimera is derived from the Greek myth-
would precipitate a significant paradigm shift in the treatment
ological figure comprised of the parts of different animals. The
of severe wounds and burns.
chimeric animals develop an immune system that is tolerant of
both donor and recipient antigens.
Immunologic tolerance is also controlled in the periphery. Skin Xenograft
The mechanisms of peripheral tolerance include T-cell anergy Porcine xenograft has been used as a temporary dressing
(non-responsiveness), induction of T regulatory/suppressor for large burns. It is applied with a technique similar to that
cells, or T-cell deletion. The induction of T-cell anergy has been used for human allograft, with seeding of autologous grafts
demonstrated by the blockade of costimulatory signals using beneath it. The application of xenogeneic dermis has also been
monoclonal antibodies during T-cell activation. The induc- found valuable in preparing a wound for subsequent grafting
tion of T regulatory/suppressor cells is another mechanism to by stimulation of granulation tissue formation. Xenogeneic
induce T-cell tolerance specific to donor antigens. T regulatory tissue has limited uses in skin grafting at present and its cellu-
cells play a key role in the maintenance of tolerance to both lar components are susceptible to hyperacute rejection typical
self and foreign antigens. Furthermore, studies in recent years of all xenograft materials.
have demonstrated the potential role for particular subtypes of
DCs such as plasmacytoid to promote and maintain peripheral
tolerance to transplantation antigens. Bone Allograft
As discussed previously, immunologic tolerance is defined Reconstruction of large bony defects in the axial and periph-
as specific unresponsiveness of the immune system to donor eral skeleton with non-vascularized allogeneic bone has been
antigens. However, this definition does not allow for the widely practiced. Well-organized tissue banks and improved
differentiation of systemic tolerance from the clinical situ- methods of bone sterilization and preservation have made
ation of immunosuppression-free long-term graft acceptance. this possible. Very few of the donor cells, if any, in the non-
Mononuclear cell infiltration and the induction of alloantibodies vascularized bone allograft survive. These donor cells express
have been observed in long-term renal allograft rhesus monkey antigens similar to other allogeneic tissues and are rejected.
recipients that were weaned off immunosuppression. Based The remaining bone acts as a scaffold for ingrowth of recipient
on this and similar observations, it is critical to define immu- mesenchymal stem cells (osteocyte precursors), which repopu-
nologic tolerance using stringent criteria as well as to develop lates the donor by “creeping substitution.” Although technically
assays and tools to monitor for donor-specific nonreactivity in an allogeneic tissue transplant, non-vascularized allografts are
operationally tolerant transplant recipients in the future. totally replaced by recipient cells once the healing process is
complete and no immunosuppression is given. Due to slow
Current Transplantation union, long-term fixation is required of bone allograft, which
is prone to stress fracture and loosening of fixation hardware.
in Plastic Surgery In studies of retrieved human allografts, however, union was
seen at the graft–host interface.
Skin Allograft Vascularized bone allograft on the other hand contains
Skin allografts are the most commonly performed human living donor cells and is susceptible to immunologic rejec-
allotransplant and were the basis of the first transplantation tion. The humoral and cellular responses generated by the
research. Pioneering experiments by Guiseppe Baronio on transplanted bone was found to be similar in intensity and
timing as that generated by other vascularized allogeneic tis- neurorrhaphy without tension. The nerve graft undergoes the

sues such as the skin and muscle. Although individual bone same degenerative process as in the distal nerve after division.
cells express antigens, the predominant antigenic stimulus in The myelin sheath remains with Schwann cells that act as a bio-
a bone allograft is thought to be derived from the marrow. logical conduit for the regenerating axons. Vascularized nerve
Removal of bone marrow by irradiation or replacement with grafts are theoretically advantageous, particularly in scarred
Basic Science
recipient marrow has been shown experimentally to prolong beds. Other “conduits” used as nerve grafts have included
allograft survival. Like any other allogeneic tissue, this rejec- autologous vein, silicone tubes seeded with Schwann cells,
tion process can be ameliorated with immunosuppression, and and freeze-fractured autologous muscle. Autologous nerve
long-term survival of orthotopic vascularized skeletal allograft grafts with acceptable donor site morbidity are limited, and
has been achieved in animal models. However, the adverse extensive nerve reconstruction may require other sources such
effects of prolonged immunosuppression required for survival as nerve allografts. Immunologic rejection of nerve allograft
of a vascularized bone allograft preclude its clinical applica- can be ameliorated experimentally with immunosuppressive
tion currently as autologous sources of vascularized bone and drugs, and axons were found to traverse the allogeneic nerve
non-vascularized allograft are usually sufficient to reconstruct graft in rodents. A similar result has also been demonstrated
most simple bone defects. A series of knee vascularized com- in primates. Immunosuppression was necessary during axonal
posite allotransplants have been performed with poor results. regeneration but could be terminated afterward in some studies
Allografts failed in five of the six patients, presumably due with satisfactory nerve functions. In the only clinical experience,
to rejection and the lack of the ability to adequately monitor Mackinnon reported return of motor and sensory functions in
the immunologic status of the graft without an externalized the upper or lower limbs of six out of seven patients following
skin component. nerve allograft reconstruction.
Cartilage Allograft
Clinical Reconstructive Transplantation
Cartilage is composed of chondrocytes within lacunae dispersed
throughout a water-laden matrix. The matrix is composed Upper Limb Transplantation. The field of reconstructive
predominantly of proteoglycans and type II collagen. Water is transplantation has been led by hand transplantation
important as cartilage has no intrinsic blood supply and relies (Figure 6.3). The first attempted hand transplantation
on diffusion of nutrients and oxygen through this matrix. occurred in 1964 in Ecuador by Dr. Robert Gilbert. Although the
The combination of water and proteoglycans imparts the surgery was successful, the immunosuppressive regime available at
characteristic of viscoelasticity depending on the relative that time was insufficient to prevent acute rejection and the trans-
concentrations of both elements. The variable water content planted hand was lost after only 3 weeks. This led to the conclu-
in the matrix causes a balanced tension within it and helps sion that hand transplantation or any transplant containing skin
maintain its three-dimensional shape. The viscoelastic property was not immunologically feasible. This attitude prevailed until
of the matrix confers “memory” such that cartilage returns to the late 1990s. The rapid growth of immunosuppressive medica-
its original shape after deformation. Surgical manipulation tions and the remarkable success of solid organ transplantation
or scoring disrupts this equilibrium. In contrast to osteocytes, in the 1980s and 1990s led to renewed interest in VCA.
chondrocytes have little reparative ability and heal by form- Through the pioneering work of Dr. Jean-Michel Dubernard
ing fibrous scar tissue. There are histologically three types of in France (1998) and Dr. Warren Breidenbach in the United
cartilage: hyaline, elastic, and fibrocartilage. States (1999), hand transplantation was shown to be possible
Chondrocytes express HLA antigens on their surface and with highly encouraging immunologic and functional results.
are thus immunogenic in isolation. Cartilage, however, is Furthermore, hand transplants could be maintained on conven-
immunologically privileged due to the shielding of chondro- tional triple-drug immunosuppression at levels similar to that
cytes by its matrix, which is only weakly antigenic. Surgical used in solid organ transplantation and patients had functional
scoring or dicing of cartilage allograft with the resultant expo- recovery similar to that seen with replantation. Although the
sure of allogeneic cells has been shown to hasten cartilage French patient became noncompliant with medication therapy
resorption. and subsequently required the removal of his transplant, the
Cartilage allografts have been used successfully for similar American patient has had almost a decade and a half of use
applications as autologous cartilage. Allogeneic cartilage can be from his transplanted hand and remains a vocal advocate of
either preserved or fresh. Preserved cartilage has the advantage of hand transplantation.
a more abundant supply and decreased risk of infection in com- In the intervening decades since the beginning of the mod-
parison to fresh cartilage. Although immunologically privileged, ern era of hand transplantation, there have been over 70
cartilage allografts are still susceptible to loss of volume through transplants performed worldwide in centers across the United
resorption. Whether this is due to immunologic rejection or States, Europe, and Asia. In general, the results have been
lack of viable cells following preservation is a matter of debate. excellent with very few grafts lost, good hand function,
It has also been noted that small allografts are less prone to and relatively few side effects. Of the centers participat-
volume loss than larger grafts. ing in the International Registry on Hand and Composite
Tissue Transplantation, results from 1998 to 2010 included
Cartilage Xenograft 49 transplanted hands in 33 patients. Of these patients, one
patient died due to sepsis following combined hand and face
Some authors have advocated the use of bovine-derived carti-
transplantation and three additional grafts were lost: one
lage xenografts. However, both chondrocytes and matrix are
from infection, one from patient noncompliance, and one
subject to xenogeneic mechanisms of rejection with a gener-
from intimal hyperplasia possibly representing a form of
ally poorer outcome in comparison to autologous or allogeneic
chronic rejection. All patients who have maintained their
cartilage grafts. Attempts to modify these xenogeneic responses
grafts developed protective sensation, 82.3% had discrimi-
by altering the graft’s immunologic stereotactic structure have
native sensation, and 75% reported significant improvement
been reported as being beneficial.
in quality of life. Immunosuppressive side effects included
opportunistic infection (i.e., cytomegalovirus reactivation),
Nerve Allograft diabetes, avascular necrosis of the hip, and post-transplant
The best clinical outcome following nerve transection is malignancy including one case of post-transplant lymphop-
achieved with primary repair. More extensive injuries or a delay roliferative disease.
in repair may result in a nerve gap following debridement of Although the risk/benefit ratio of placing a patient on
damaged nerves, and a nerve graft may be necessary to achieve long-term immunosuppressive medications must always
Recipient arm
Volar skin flap
Brachioradialis muscle
Cephalic vein
Radial artery
Radius Flexor carpi radialis muscle
Flexor digitorum
superficialis muscle
Bone plate
Palmaris longus muscle
Flexor pollicis longus tendon Basilic vein
Flexor carpi radialis tendon Flexor carpi ulnaris muscle
Median nerve Flexor digitorum profundus tendon
Ulna
Ulnar artery
Ulnar nerve
Dorsal skin flap
Flexor carpi ulnaris tendon
Skin flap
Donor hand
Flexor digitorum profundus tendon
Flexor Policis tendon
Flexor digitorum superficialis tendon
Figure 6.3. Hand transplantation. Schematic diagram showing the technique of mid-forearm hand transplantation. All structures are prepared
and labeled prior to transplantation and osseous fixation. Note the opposing, interdigitating skin flap design. Inset: photograph of allograft pre-
pared for transplant.
be considered, advances such as minimization protocols With an ever-increasing number of centers performing
using donor bone marrow infusion and monotherapy main- hand transplantation worldwide and more than a decade
tenance are currently being studied in humans and are of experience with the techniques, hand transplantation has
anticipated to favorably alter this balance in the future. become less novel. It is increasingly being seen as another
The senior author and his team have performed eight limb alternative in the reconstructive armamentarium used to
transplants in five patients using alemtuzumab induction treat patients with upper extremity amputation (Chapter 90).
therapy at the time of transplantation followed by an infu- Upper limb transplantation restores the structure and func-
sion of bone marrow cells collected from the vertebral tion of the hand in a way not possible with any other recon-
bodies of the limb donor. In four of the five patients, the structive technique with a reasonable level of safety. It appears
immunomodulation caused by the donor bone marrow that reconstructive transplantation will continue to play an
infusion has reduced the need for systemic immunosup- increasing role in the treatment of patients with upper limb
pression and allowed the use of single-agent therapy with amputations. However, as always the risk/benefit ratio for the
tacrolimus. use of systemic immunosuppression, regardless of whether it

is single drug or multidrug, must be considered when deciding
Other Areas of Reconstructive

whether to operate on patients with complex injuries of the
upper extremity. Transplantation
Developments in reconstructive transplantation have
Facial Transplantation. No other area of reconstructive clearly been led by upper extremity and facial transplan-
Basic Science
transplantation captures the imagination of patients, clinicians,
tation. However, there have been much smaller series
and the public like face transplantation. Human beings’ per-
of patients treated with transplantation of several other
ception of “self” is tied to one’s facial appearance; transferring
composite structures including vascularized knee joints,
these tissues from one person to another raises major questions.
lower extremities, trachea, larynx, abdominal wall, and
However, for some patients with severe and devastating injuries
reproductive organs. With the exception of vascularized
to the craniofacial skeleton and soft tissues of the face, there
knee joints (which have failed in five of the six patients
is no other acceptable, effective option using standard recon-
attempted), reconstruction with these varied types of
structive techniques. For these patients, transplantation of
transplants has met with some qualified success. In gen-
allogeneic cadaveric facial structures may be the only way of
eral, patients are maintained on standard types of immu-
regaining normal facial appearance and being able to reintegrate
nosuppression (i.e., triple-drug therapy) with no more or
into society in a meaningful way.
less complications from these regimens than those of solid
Dr. Dubernard and Dr. Devauchelle in France performed
organ transplant patients. While these less common types of
the first transplantation of facial tissue in 2005. Between 2005
transplants continue to be highly experimental, they dem-
and 2012, eighteen partial or full-face transplantations have
onstrate the possibilities that reconstructive transplantation
been performed worldwide. These were done by centers in
offers. Traditional plastic surgery techniques are unable to
the United States, France, Spain, and China. Transplanted
restore complex tissues and anatomical structures with
grafts have consisted of soft tissue (the nose and lips) up to
the fidelity equal to that of reconstructive transplantation,
and including all facial soft tissue and portions of facial bones
as evidenced by recipients’ functional and aesthetic out-
and the tongue (entire face, maxilla, anterior portion of the
comes. As clinical experience with these techniques is accu-
mandible, and tongue). Indications for these procedures have
mulated and immunosuppressive and immunomodulatory
included ballistic trauma sustained by military personnel and
protocols are optimized, the risk–benefit ratio of reconstruc-
civilians, animal bites, tumor resection, neurofibromatosis,
tive transplantation will continue to shift in favor of these
and burns. All of the patients’ transplants have included either
procedures, making these techniques an increasingly avail-
portions of the orbicularis oris or oculi; loss of the sphincter
able and important part of plastic surgeons’ reconstructive
function of the mimetic muscles of the face is generally con-
options for treating these crippling defects.
sidered to be one of the indications for facial transplantation.
In general, face patients have been maintained on immuno- Suggested Readings
suppression similar to that used in solid organ transplanta-
1. Brandacher G, Gorantla VS, Andrew Lee WP. Hand allotransplantation.
tion, with all patients receiving induction therapy followed by Semin Plast Surg. 2010;24(1):11-17.
triple-drug immunosuppression. 2. Chang J, Davis CL, Mathes DW. The impact of current immunosuppression
Overall, patient outcomes have been excellent. All strategies in renal transplantation on the field of reconstructive transplantation.
patients receiving facial transplantation have dramatically J Reconstr Microsurg. January 2012;28(1):7-19.
3. Devauchelle B, Badet L, Lengele B, et al. First human face allograft: early
improved their aesthetic appearance, allowing easier inte- report. Lancet. July 2006;368(9531):203-209.
gration back into society. All patients for whom outcomes 4. Hettiaratchy S, Melendy E, Randolph MA, et al. Tolerance to composite
have been reported in the literature report nearly normal sen- tissue allografts across a major histocompatibility barrier in miniature swine.
sory recovery, with return of normal two-point discrimina- Transplantation. 2004;77(4):514-521.
5. Lee WP, Yaremchuk MJ, Pan YC, Randolph MA, Tan CM, Weiland AJ.
tion between 3 and 8 months after transplantation. Motor Relative antigenicity of components of a vascularized limb allograft. Plast
recovery has been slower, but all patients have recovered Reconstr Surg. 1991;87(3):401-411.
some degree of motor function allowing for oral compe- 6. Levi DM, Tzakis AG, Kato T, et al. Transplantation of the abdominal wall.
tence. Typical motor recovery begins at 3 months, with Lancet. 2003;361(9376):2173-2176.
7. Mackinnon SE, Doolabh VB, Novak CB, Trulock EP. Clinical outcome
maximum recovery around 18 months after transplant. following nerve allograft transplantation. Plast Reconstr Surg. 2001;
Unfortunately, there have been 2 deaths (a 15% mortality 107(6):1419-1429.
rate) associated with facial transplantation among these 13 8. Madani H, Hettiaratchy S, Clarke A, Butler PE. Immunosuppression in an
patients. The first death was in a Chinese patient; however, emerging field of plastic reconstructive surgery: composite tissue allotrans-
plantation. J Plast Reconstr Aesthetic Surg. 2008;61(3):245-249.
this death has not been reported in the literature and so the 9. Petruzzo P, Lanzetta M, Dubernard J-M, et al. The International Registry
etiology remains unclear. The second death occurred in a on Hand and Composite Tissue Transplantation. Transplantation. 2010;
patient who received a combined bilateral hand and face 90(12):1590-1594.
transplant for the treatment of extensive burns. This patient 10. Pomahac B, Pribaz J, Eriksson E, et al. Three patients with full facial
transplantation. N Engl J Med. February 2012;366(8):715-722.
reportedly succumbed to overwhelming infection following 11. Sacks JM, Keith JD, Fisher C, Lee WP. The surgeon’s role and responsibility
immunosuppression. No surviving patients have lost their in facial tissue allograft transplantation. Ann Plast Surg. 2007;58(6):595-601.
grafts due to rejection to date. 12. Sacks JM, Horibe EK, Lee WP. Cellular therapies for composite tissue
Facial transplantation is following hand transplanta- allograft transplantation. Clin Plast Surg. 2007;34(2):291-301.
13. Shores JT, Brandacher G, Schneeberger S, Gorantla VS, Andrew Lee WP.
tion as the next success story of reconstructive transplan- Composite tissue allotransplantation: hand transplantation and beyond.
tation. Although technically demanding and potentially J Am Acad Orthop Surg. 2010;18(3):127-131.
dangerous, facial transplantation has the potential to 14. Shores JT, Imbriglia JE, Andrew Lee WP. The current state of hand trans-
reintegrate patients into society who have been injured plantation. J Hand Surg. 2011;36(11):1862-1867.
15. Siemionow M, Agaoglu G. Tissue transplantation in plastic surgery. Clin
so severely that they are simply unable to function in Plast Surg. 2007;34(2):251-269, ix.
or contribute to society in their current state. As more 16. Siemionow M, Ozturk C. An update on facial transplantation cases performed
and more centers perform this groundbreaking tech- between 2005 and 2010. Plast Reconstr Surg. 2011;128(6):707e-720e.
nique, the number of patients treated per year has steadily 17. Strome M, Stein J, Esclamado R, et al. Laryngeal transplantation and
40-month follow-up. N Engl J Med. 2001;344(22):1676-1679.
increased. There is a clear indication that for carefully 18. Wendt JR, Ulich TR, Ruzics EP, Hostetler JR. Long-term survival of
selected patients, facial transplantation offers a procedure human skin allografts in patients with immunosuppression. Ann Plast Surg.
that, while not life saving, is potentially life restoring. 2004;113(5):411-417.

Chapter 7 n Implant Materials
Timothy W. King
be inert and withstand the corrosive environment within the

Introduction human body. Since metals cannot repair themselves after
While autogenous tissues are often the first choice, implant deformation or fatigue, they must have mechanical properties
materials have wide application in plastic surgery including that exceed the properties of the natural tissue they are sup-
reconstruction or augmentation of soft-tissue defects, bony porting or replacing (i.e., the metal must be both stronger and
deformities, or the fixation of fractures. Selecting the implant stiffer than the natural tissue).
material depends on the specific requirement for its applica-
tion. For example, tissue ingrowth into a polypropylene mesh Stainless Steel
or the rigid incorporation of a bone substitute is often desir- Stainless steel has been used as a biological implant since the
able, while the encapsulation (or lack of tissue ingrowth) of 1920s. Medical-grade stainless steel, alloys of iron–chromium–
a silicone Hunter rod allows for free gliding of a subsequent nickel, have a relatively high tensile strength but are easily
tendon graft. deformed (bent). While this is useful in some applications, such
Autologous tissue may be more appropriate in many clini- as the application of arch bars for maxillomandibular fixa-
cal scenarios including patients with a history of radiotherapy, tion, overall these mechanical properties are less desirable than
marginal blood supply of the surrounding tissue, or tenuous other currently available materials such as cobalt–chromium
soft-tissue coverage over the implant. In these cases, the risk and titanium. In addition, stainless steel leaches metallic ions
of implant-related complications, including infection and into the surrounding tissues, causing an inflammatory reac-
implant extrusion, is significant, and the use of an alloplastic tion and pain. Stainless steel is currently used in surgical wire
implant should be avoided if possible. and in arch bars. In the past, bone fixation systems utilized
Implant materials, however, can be used as alternatives to stainless steel, but other alloys have replaced stainless steel in
autogenous tissue in selected cases and in specific situations this application.
are superior to autogenous tissue. Implant materials can be
created to undergo no resorption and are preferable to autolo- Cobalt–Chromium
gous grafts that will resorb when used as onlay grafts. For
example, implants have been successfully used as bone graft Historically, cobalt–chromium alloys have been one of the
substitutes in orbital floor reconstruction, cranioplasty, and most significant biomaterials used in humans. Vitallium, a
maxillofacial reconstruction. They have the advantage of cobalt–chromium–molybdenum (Co-Cr-Mo) alloy, was first
avoiding operative time for graft harvesting and the absence described in 1932 to address some of the problems experi-
of donor site morbidity. enced with stainless steel. Co-Cr-Mo alloy was used in early
craniofacial miniplates and screws and revolutionized the field.
The major disadvantage of Co-Cr-Mo alloys is the scatter
History artifact on computed tomography (CT) imaging. Because
The first recorded use of an artificial material can be traced to of this, and other benefits, titanium has essentially replaced
30,000 B.C. where these materials were used as sutures. The Co-Cr-Mo alloys in most biomedical applications.
first recorded implant was thought to date back to 3,000 B.C.
where pre-Incan Peruvians used materials such as gold, silver, Titanium
or nut shells to repair trephination defects. However, recent Commercial-grade medical titanium implants were intro-
investigations have brought these reports into question. duced in the early 1980s and have almost entirely replaced the
Regardless, over the next 5,000 years, implant use was spo- other alloys in medical applications because they are stronger,
radic and limited by infection and foreign body reaction. The are lighter, have higher resistance to corrosion, and cause
modern era of medical implants is often attributed to British
ophthalmologist Harold Ridley who noted that Spitfire canopy
plastic unintentionally implanted in the eyes of pilots healed
without adverse reaction. Based on this finding he developed Table 7.1
and implanted the first artificial lens into a human in 1949. Properties of an Ideal Implant
As surgeons, engineers, and scientists continued to create
new implant materials, it became clear that there were certain Minimal foreign body reaction
properties that an ideal implant would impart. Cumberland1 Elastic or supple
and Scales2 described the properties of an ideal implant, which
are shown in Table 7.1. Remarkably, although these criteria Easily tailored
were published almost 60 years ago, they are still the funda- Good tissue incorporation
mental properties that manufacturers of modern biomaterials
Allow collagen ingrowth
attempt to achieve.
For the purpose of this chapter, implant materials will be Promote permanent tissue repair
divided into the following general categories: metals, poly- Good tensile strength
mers, ceramics, glues, skin substitutes, and bioprosthetic
meshes (Table 7.2). Tolerate infected environments
Minimal wound complications
Metals Data from Cumberland VH. A preliminary report on the use of
In order to achieve the mechanical and biophysical properties prefabricated nylon weave in the repair of ventral hernia. Med J Aust.
1952;1:143-144 and Scales JT. Materials for hernia repair. Proc R
desired for applications in medicine, combinations of metals Soc Med. 1953;46:647-652.
(alloys) have been developed. These alloys are designed to
64
Chapter 7: Implant Materials 65
Table 7.2

Implant Materials
Metals
Basic Science
Stainless steel
Cobalt–chromium
Titanium
Gold
Platinum
Polymers
Silicone
Polytetrafluoroethylene
Polyester
Polypropylene (Prolene, Marlex)
Figure 7.1. Titanium plates for midface reconstruction. L-shaped
Polyethylene (Medpor) and curvilinear 2.0 mm plates with a 7, 5, and 3 mm length 2.0 mm
Polymethylmethacrylate screw (left to right).
Biodegradable polyesters
Polyamides (Supramid, Nylamid)
Ceramics Gold
Hydroxyapatite Although gold is chemically inert, it has poor mechanical
Tricalcium phosphate properties in its pure form. When strength is required (for
example, in dental fillings), a gold alloy is used. For applica-
Adhesives and glues
tions such as eyelid weights in patients with lagophthalmos,
Fibrin tissue adhesives where strength is not an issue, 24-carat gold alloy (99.9% w/w
Cyanoacrylates purity) is used to ensure chemical inertness.
Biologic materials Platinum
Skin substitutes Platinum is an inert metal and is the material of choice for
Integra patients with gold sensitivity in need of eyelid implants
for lagophthalmos. Platinum has a higher density than gold,
Epicel
thus the eyelid implants have a lower profile and are less
Dermagraft noticeable than gold implants. Some formulations containing
Apligraf platinum, however, have been shown to be immunogenic and
have raised concerns about long-term exposure. Platinum is
Bioprosthetic mesh also used as a catalyst in the formation of some polymers,
Small intestinal submucosa including the production of medical-grade silicone used in gel
breast implants.
Human acellular dermal matrix
Porcine acellular dermal matrix
Polymers
Bovine pericardium
Polymers are molecules composed of repeating monomer sub-
Bovine fetal dermis units. The physical characteristics of a polymer are defined
by the structure of the monomer, the number of monomer
units in the polymer chain, and the degree of cross-linking. As
polymer chains are cross-linked, the ability for them to move
less inflammation. Titanium also has less stiffness, which
independently is decreased. Thus, a polymer with little cross-
results in less stress shielding (localized osteopenia second-
linking might exist as a liquid while the same polymer with
ary to the implant protecting the bone from normal loading).
abundant cross-linking becomes a “gel” or “solid.”
More recently, some companies have also introduced titanium
alloy implants. The alloys are stronger than the pure titanium,
allowing for thinner plates without compromising their overall Silicone
strength. Pure titanium or titanium alloys (which have less Silicone is likely the most maligned and misunderstood
than 0.5% iron) have two additional beneficial properties: implant material today secondary to its use in breast implants.
they do not set off metal detectors, and they do not create Silicone gel–filled breast implants were first introduced in the
a significant artifact on CT or magnetic resonance imaging United States in 1962. Multiple variations and modifications
studies. Finally, titanium can form chemical bonds with the to the shell and gel were made over the years in an attempt to
surrounding mineralized bone without fibrous tissue form- improve the outcomes of breast augmentation and reduce the
ing between the implant and the bone. This unique charac- associated complications. In 1992, the U.S. Food and Drug
teristic allows titanium to be used to create osseointegrated Administration (FDA) stated that there was “inadequate
implants. Plastic surgery applications of these alloys include information to demonstrate that breast implants were safe
plates and screws for fixation of bone and titanium mesh for and effective” and placed a moratorium on silicone gel breast
use in applications such as orbital wall reconstruction (see implants for cosmetic purposes but allowed their continued use
Figure 7.1). for reconstruction after mastectomy, correction of congenital

deformities, or replacement of ruptured silicone gel–filled

implants due to medical or surgical reasons.3 The Department Polytetrafluoroethylene
of Health and Human Services (HHS) subsequently appointed Polytetrafluoroethylene (PTFE) also known as Teflon was acci-
the Institute of Medicine (IOM) of the National Academy of dentally invented by Roy Plunkett in 1938 while he was trying
Science to begin one of the most extensive research studies to develop a refrigerant. It consists of a carbon backbone with
in medical history. In 1999, the IOM released a comprehen- fluorine side chains. Expanded PTFE (ePTFE or Gore-Tex) was
sive report on both saline-filled and silicone gel–filled breast created by Bob Gore in 1969. It is very chemically stable, cannot
implants finding that “evidence suggests diseases or condi- be cross-linked (which makes it flexible), and has a non-adher-
tions such as connective tissue diseases, cancer, neurological ent surface. It has been used for a wide variety of applications
diseases or other systemic complaints or conditions are no from hiking boots to coatings on frying pans. Within the medi-
more common in women with breast implants than in women cal field it is used for vascular grafts, as a mesh for abdominal
without implants.”3 wall reconstruction, and as implants for facial augmentation.
In 2006, the ban imposed by the FDA was lifted. As part
of the approval process, the FDA required the two approved Polyester
manufacturers to perform a 10-year study on the safety of the
Polyester contains an ester functional group in its main chain.
devices in 40,000 women.3 Extensive investigations by several
Mersilene is a knitted polyester mesh for use in hernior-
prestigious scientific bodies (e.g., the IOM4 and the British
rhaphy. Polyester mesh is softer and more hydrophilic than
Ministry of Health5) have failed to show that systemic illness
polypropylene and in animal studies has shown better tissue
is associated with silicones. For a discussion of the recently
ingrowth. Dacron is another form of polyester that has been
described anaplastic large cell lymphoma in breast implant
used for vascular grafts.
recipients, please see Chapter 53.
With all of this research into “silicone” one might ask
“what exactly is silicone?” Silicone is a family of polymers Polypropylene
consisting of alternating silicon (Si) and oxygen (O) molecules. Polypropylene has a carbon backbone and side chains of
Poly-dimethylsiloxane (PDMS), the polymer used in most hydrogen and methyl groups. It has been used in hernia and
medical applications, is made up of the silicone backbone with pelvic organ prolapse repair, but polypropylene mesh can
two methyl side chains. It is one of the most inert biomateri- erode through the soft tissues over time. Therefore, the FDA
als available for use in medical devices. Altering the length has issued warnings on the use of polypropylene mesh in pelvic
and molecular weight of PDMS can change the mechanical organ prolapse. It is also used as suture material because of its
properties and behavior of the silicone gel. Low-molecular- strength and low foreign body reaction within the body.
weight PDMS (<30 monomers) has a viscosity similar to
baby oil, while high-molecular-weight formulations ( >3,000 Polyethylene
monomers) are solids. Other methods of altering the mechani-
Polyethylene consists of a carbon backbone with hydrogen
cal properties include controlling the degree of cross-linking,
side chains (ethylene). A high-density porous form of polyeth-
changing the additives, and altering the curing process. For
ylene (Medpor) is used for facial implants (see Figure 7.2).
example, the silicone gel used in breast implants is cured in a
hydrosilation reaction where some of the methyl side chains
(CH3) are replaced with vinyl side chains (CH“CH2), which
then allows the silicone chains to cross-link with each other.
The silicone shell of a breast implant consists of fully polym-
erized silicone and an amorphous (noncrystalline) silica filler
added for strength.
Medical-grade silicone is ubiquitous, being found in more
than 1,000 medical products as a component or as a resid-
uum from the manufacturing process. For example, every
disposable needle, syringe, and intravenous tubing is lubri-
cated with silicone. Medications in stoppered vials contain
residual silicone from its use in the manufacturing process.
Silicone elastomers, in their solid form, are used for pace-
maker coatings, tubing, prosthetic joints, hydrocephalus
shunts, and penile implants. Like breast implants, some tes-
ticular and chin implants are made of a silicone gel in a sili-
cone envelope.
Silicones are also found in some medications. Ingredients
with the name “methicone” (e.g., simethicone) are silicones that
have been modified for human consumption. Silicones are
also used in household items such as lipstick, suntan/hand
lotion, hairspray, processed foods, and chewing gum. Medical-
grade silicones invoke a nonspecific foreign body response,
resulting in macrophage invasion, giant cell formation, and
eventual scarring.
Other plastic surgery applications of silicone include facial
implants for malar, nasal, and chin reconstruction or augmen-
tation and orbital floor reconstruction. Hand surgeons use
silicone implants for arthroplasty, flexor tendon replacement,
and bone block spacers. Silicone is beneficial in these appli-
cations because it is relatively inert, malleable, and deform-
able. Low-molecular-weight silicone was used in the past as
an injectable soft tissue filler but is not FDA approved for Figure 7.2. High-density porous polyethylene (Medpor) implants for
medical use. This application should be avoided because it can facial augmentation.
cause tissue reactions or migrate.

The porosity allows for tissue and vascular ingrowth. It can also physical properties for biomedical use including decreased

be carved to customize the implant for individual patients. The foreign body response, resisting bacterial colonization, a high
implants are more difficult to place than the ePTFE implants compressive strength, and tissue ingrowth into porous materi-
because they are firmer and stiffer. In addition, the soft-tissue als (100 µm pore size for bone and 30 µm pore size for soft
ingrowth makes the implant more difficult to remove. Porous tissue). However, their benefits are overshadowed by their
Basic Science
polyethylene alone or in combination with titanium mesh is weaknesses, namely they are brittle and easily fracture under
available for reconstruction of the orbital floor. One of the tensile, torsional, or bending loads. Their main uses in plastic
disadvantages of polyethylene alone for orbital floor recon- surgery are for bone augmentation and replacement. Calcium
struction is that the implant is not visualized on CT scans, phosphates are the most common ceramics used in plastic sur-
making it difficult to evaluate implant position. gery. In addition, calcium phosphates have been shown in the
laboratory to be both osteoinductive and osteoconductive, but
Polymethylmethacrylate this has not been demonstrated in the clinical setting.
Calcium phosphates come in two formulations for medical
Polymethylmethacrylate (PMMA) is a high-molecular-weight
use: hydroxyapatite (Ca10(PO4)6(OH)2) and tricalcium phos-
polymer commonly used as a replacement for bone. The
phate (Ca3(PO4)2). Tricalcium phosphate has a faster rate of
final product is created by adding liquid methylmethacrylate
resorption and replacement by bone when compared with
monomer to powdered methylmethacrylate polymer, which
hydroxyapatite. They are available as granules for injection
then forms a moldable putty. The monomer polymerizes, binds
and as blocks (both solid and porous), and hydroxyapatite
with the polymer particles, and hardens in about 10 minutes.
is also available as a cement paste. These implants are com-
The polymerization process is an exothermic reaction, which
monly used to reconstruct non–load-bearing bones of the face
generates high temperatures. Saline irrigation is used to cool
and cranium. The cement paste is beneficial in select cases,
the surrounding tissues during the curing process to avoid
such as a cranioplasty, because it is malleable and can be
local tissue damage such as bone necrosis or soft-tissue injury.
molded during the case. For a discussion on dermal and soft-
Applications in plastic surgery include cranial bone recon-
tissue fillers, please see Chapter 42.
struction. PMMA can be used alone or in combination with
wire or mesh reinforcement. The immobility and relatively
low stresses intrinsic to the calvarium contribute to the low Adhesives and Glues
morbidity of PMMA cranioplasty.
Fibrin Tissue Adhesives
Biodegradable Polymers The first fibrin tissue adhesive was described in 1944 and was
Biodegradable polymers were developed to overcome some of used to aid in the adherence of skin grafts to the recipient tissue
the disadvantages associated with permanent implants. Most bed. Fibrin sealants consist of two parts: fibrinogen and throm-
biodegradation occurs through a combination of chemical bin derived from screened donors. A small amount of factor XIII
reactions, such as hydrolysis or oxidation, and biological pro- and calcium is included to catalyze the reaction and form polym-
cesses (e.g., enzymatic or cellular). Both the biodegradable poly- erized fibrin. The strength of the fibrin glue is directly propor-
mer and all of its breakdown products must be biocompatible.6 tional to the concentration of fibrinogen in the mixture, while
Although there are a multitude of materials that will degrade in the rate of polymerization is regulated by the concentration
vivo, there are only a few that are clinically relevant as biodegrad- of the thrombin. Plastic surgery applications for fibrin sealants
able polymers. α-Hydroxy acids, specifically poly (lactic acid), include brow lift, facelift, abdominoplasty, the latissimus dorsi
poly (glycolic acid) (PGA) and combinations, or copolymers, donor site, DIEP/TRAM flap donor sites, and chronic seromas.
of these individual polymers known as poly (lactic-co-glycolic
acid) (PLGA) are the most common biodegradable polymers Cyanoacrylate
used in clinical applications. These polymers degrade through Cyanoacrylates were accidently discovered in 1942 by Dr. Harry
hydrolysis, ending in lactic or glycolic acid. Surgeons are familiar Coover and were marketed as “super glue.” During the Vietnam
with this polymer as it is used to make Vicryl (Polyglactin 910; War, surgeons saved many lives after they discovered that spray-
Ethicon, Somerville, NJ) sutures. These polymers have been used ing cyanoacrylates over open wounds would stop bleeding and
to create a biodegradable mesh for use in abdominal wall recon- allowed injured soldiers to be transported for treatment.
struction and plating systems for craniofacial or hand applica- The exothermic polymerization begins when the cyanoac-
tions as well as in the fabrication of resorbable scaffolds for rylate is exposed to moisture (there is enough moisture in the
tissue engineering and regenerative medicine applications. air to allow polymerization to occur). Applications in plastic
The rate of degradation can be modified by altering the surgery include skin closure. The superficial layer of the skin,
ratios of lactic to glycolic acid, adding carbon fibers or other where the product is applied, has no sutures to hold it together
polymers. In general, increasing the concentration of lactic so it is important to approximate the deep layers and provide
acid decreases the rate of degradation. Manufacturers modify a tension-free abutment of the two sides. Studies comparing
the ratio of lactic and glycolic acid, as well as the specific traditional suturing to octyl-2-cyanoacrylate showed that the
manufacturing protocol, to optimize the degradation rate and outcomes were equivalent.7
strength of the polymer. For example, LactoSorb (Biomet,
Warsaw, IN) consists of 82% poly-l-lactic acid and 18%
PGA, while Resorb-X (KLS Martin, Jacksonville, FL, used in Skin Substitutes
the SonicWeld system) is 100% poly-d, l-lactic acid. The
Over the past two decades, bioengineered skin substitutes
Endotine products (Coapt Systems, Inc., Palo Alto, CA) have
have become a mainstream therapy for wound management.
the same formulation as LactoSorb. At implantation, their
Originally designed to replace skin grafts for patients with
strength is equal to that of titanium plating and then decreases
severe burns, they are now also used in the treatment of chronic
with time. Typically their structural integrity is preserved for
venous and chronic diabetic ulcers. It is likely that applications
the first 8 weeks to allow for bony healing to occur.
for these products will broaden as they become more advanced.
The ideal skin substitute would8:
Ceramics • Adhere to the wound bed rapidly
Medical applications of ceramics were developed in the 1960s. • Recapitulate the physiologic and mechanical properties of
Ceramics have a crystalline structure and are made up of normal skin
inorganic, nonmetallic molecules. They have some appealing • Be inexpensive

• Avoid immune rejection by the host Table 7.3

• Be highly effective in accelerating tissue regeneration and
wound repair Characteristics of the Ideal Bioprosthetic Mesh
A variety of cells, mediators, and polymers have been tested Resistant to bacterial colonization and infection
in various combinations to engineer cultured skin substitutes.9
Biocompatible
We review the most common of these below and in Chapter 3.
Noncarcinogenic
Integra Readily available
Integra (Integra LifeSciences Corporation, Plainsboro, NJ) Inexpensive
is a bilayer skin substitute consisting of a “dermal” (lower)
layer (bovine collagen base with the glycosaminoglycan Withstand physiological stresses for long periods of time
chondroitin-6-sulfate) and a silicone sheet (upper) layer.10 As Promote strong tissue ingrowth
the wound heals, the dermal layer is replaced with the patient’s Maintain its original size
own cells. The silicone sheet, which acts as a temporary epi-
dermis, is removed and a thin split-thickness skin graft is Inhibit adhesions to visceral structures
applied to the neo-dermis. Integra is used in complex wounds Provide host cells with the framework and signals to grow and
such as partial or full thickness burns and multiple types of differentiate
ulcers. Studies evaluating the efficacy of Integra showed that it
has a higher infection rate compared with autograft, allograft, Remodel as the wound gains strength and new tissue is formed
or xenograft, but appeared to have a faster rate of wound Data from Bellows CF, Alder A, Helton WS. Abdominal wall reconstruc-
healing time.10 Integra can also be used in wounds where a tion using biological tissue grafts: present status and future opportunities.
skin graft would not adhere.10 The neo-dermis will attach to Expert Rev Med Devices. 2006;3:657-675.
the underlying bed, vascularize over 2 weeks, and then will
allow adherence of a split-thickness skin graft.
Epicel (Cultured Epidermal Autografts) Small Intestinal Submucosa

Epicel (Genzyme, Cambridge, MA) is a cultured epidermal Small intestinal submucosa (SIS or Surgisis; Cook Biotech,
autograft grown from the patient’s own keratinocytes derived West Lafayette, IN) is created from the small intestine of pigs.
from a small skin biopsy. The keratinocytes are grown in a co- The submucosa of the small intestine provides mechanical
culture with fibroblasts. Once the keratinocytes are 2 to 8 cell strength to the intestine and contains a biochemically rich
layers thick, the approximately 50 cm2 autograft is attached to and diverse extracellular matrix. First described as a vascular
a petrolatum gauze backing with stainless steel surgical clips graft in 1989, SIS has been applied to over 20 applications
and applied to the patient. in humans including multiple types of hernia repair, dural
Epicel is used in patients with deep dermal or full thickness repair, bladder reconstruction, and stress urinary incontinence
burns involving a total body surface area of ≥ 30%. It can be treatment.13
used with or without split-thickness skin grafts, depending on
the severity and extent of their burns. Human Acellular Dermal Matrix
There are several products classified as human acellu-
Dermagraft lar dermal matrix (HADM) including AlloDerm (LifeCell
Dermagraft (Advanced Biohealing, Westport, CT ) is a poly- Corp, Branchburg, NJ), Allomax (Bard Davol, Murray
glactin mesh seeded with neonatal fibroblasts. The mesh is Hill, NJ), and FlexHD (Ethicon360, Somerville, NJ). Each
resorbed and replaced with the patient’s own tissue. It is used manufacturer uses a proprietary technique to produce the
as both a temporary and permanent dressing to increase the HADM from donated allograft human dermis. In general,
successful take of meshed split-thickness skin grafts on excised after the epidermis and subcutaneous tissue are removed,
burn wounds and for venous and pressure ulcers. Dermagraft the dermis is processed, either with freeze-drying or chemi-
is equivalent to allograft with respect to infection, healing cal detergents, to eliminate everything but the collagen
time, time to closure, and graft take.11 structure of the dermal matrix. Applications of HADM
include implant-based breast, abdominal wall, chest wall,
Apligraf pelvis reconstruction, and lip augmentation.14,15 Micronized
HADM (Cymetra; LifeCell, Branchburg, NJ) is also avail-
Apligraf (Organogenesis, Canton, MA) is a bilayered skin
able and has been used for laryngoplasty and as soft-tissue
equivalent. The lower “dermal” layer consists of type I bovine
filler.
collagen and fibroblasts obtained from neonatal foreskin,
while the upper “epidermal” layer is derived from keratino-
cytes. It has a shelf life of 5 days at room temperature. It is used Porcine Acellular Dermal Matrix
for venous ulcers and diabetic foot ulcers as well as a tempo- Porcine acellular dermal matrix (PADM) has been developed
rary covering over meshed autografts in excised burn wounds. for applications similar to HADM. To inhibit immunogenicity
and reduce collagenase-dependent matrix degradation, first-
generation PADMs (CollaMend; Bard Davol, Cranston, RI
Bioprosthetic Mesh and Permacol; Covidien, Norwalk, CT) undergo chemical
Currently available bioprosthetic mesh materials are derived cross-linking of the collagen fibers during the manufactur-
from decellularized mammalian tissues, either human (allo- ing process, which changes the extracellular matrix structure
geneic) or animal (xenogeneic). Bioprosthetic mesh materials and inhibits cellular infiltration, revascularization, and matrix
are processed to remove cells and other potentially immuno- remodeling potential.
genic components while preserving the native extracellular A newer generation of PADMs (Strattice; LifeCell Corp,
matrix architecture. An ideal mesh possesses the characteris- Branchburg, NJ) is processed without chemical cross-linking.
tics shown in Table 7.3.12 Several bioprosthetic mesh materials The [galactose-α (1,3)-galactose] antigen, which is the major
are available. These materials are commonly used for complex cause of the immune response associated with acellular xeno-
torso reconstruction and breast reconstruction. grafts, is enzymatically removed.

It is not entirely clear which of these products has a better
References

outcome. In a recent in vivo animal study comparing cross-
linked PADM with non–cross-linked PADM for abdominal 1. Cumberland VH. A preliminary report on the use of prefabricated nylon
weave in the repair of ventral hernia. Med J Aust. 1952;1:143-144.
wall reconstruction, non–cross-linked PADM appeared to have 2. Scales JT. Materials for Hernia Repair. Proc R Soc Med. 1953;46:647-652.
early clinical advantages.16 No comparative human studies, 3. Bondurant S, Ernster V, Herdman R, eds. Safety of Silicone Breast Implants.
Basic Science
however, have been preformed to date. Washington, DC: Institute of Medicine, National Academy Press; 1999.
4. Janowsky EC, Kupper LL, Hulka BS. Meta-analyses of the relation between
silicone breast implants and the risk of connective-tissue diseases. N Engl J Med.
Other Bioprosthetic Mesh Products 2000;342:781-790.
5. Nicolai JP. EQUAM Declaration on Breast Implants, July 4, 1998.
Bovine pericardium (Veritas; Synovis, St. Paul, MN) is a non– European Committee on Quality Assurance and Medical Devices in Plastic
cross-linked collagen matrix. Decellularization and reduction Surgery. Plast Reconstr Surg. 1999;103:1094.
of immunogenicity is achieved by capping free amine groups 6. Kohn J, Abramson S, Langer R. Bioresorbable and bioerodible materials.
In: Ratner BD, Hoffman AS, Schoen FJ, Lemons JE, eds. Biomaterials
using a proprietary chemical process. Science: An Introduction to Materials in Medicine. San Diego, CA: Elsevier
Bovine fetal dermis (SurgiMend; TEI, Boston, MA) is an Academic Press; 2004:115-125.
acellular matrix derived from fetal calves. It is not cross-linked 7. Toriumi DM, O’Grady K, Desai D, Bagal A. Use of octyl-2-cyanoacrylate for
and can facilitate cell penetration, revascularization, and inte- skin closure in facial plastic surgery. Plast Reconstr Surg. 1998;102: 2209-2219.
8. Eisenbud D, Huang NF, Luke S, Silberklang M. Skin substitutes and wound
gration with host tissues. healing: current status and challenges. Wounds. 2004;16:2-17.
9. Langer R, Vacanti JP. Tissue engineering. Science. 1993;260:920-926.
10. Pham C, Greenwood J, Cleland H, Woodruff P, Maddern G. Bioengineered
Future Materials skin substitutes for the management of burns: a systematic review. Burns.
2007;33:946-957.
Biomaterials and implants have made huge impacts in medi- 11. Purdue GF, Hunt JL, Still JM Jr, et al. A multicenter clinical trial of a biosyn-
cine and surgery. Some implants are designed to have little thetic skin replacement, Dermagraft-TC, compared with cryopreserved
human cadaver skin for temporary coverage of excised burn wounds. J Burn
interaction with the body. Others are designed to interact Care Rehabil. 1997;18:52-57.
with the body in a passive way (e.g., biodegradable PLGA 12. Bellows CF, Alder A, Helton WS. Abdominal wall reconstruction using
polymers). Recent biomaterials are being designed to modu- biological tissue grafts: present status and future opportunities. Expert Rev
late their environment to create a tissue-specific response. Med Devices. 2006;3:657-675.
13. Ansaloni L, Catena F, D’Alessandro L. Prospective randomized, double-
Furthermore, hybrid biomaterials containing cells, poly- blind, controlled trial comparing Lichtenstein’s repair of inguinal hernia
mers, growth factors, etc. are currently being developed in with polypropylene mesh versus Surgisis gold soft tissue graft: preliminary
in vivo models. These biomaterials will eventually “sense” results. Acta Biomed. 2003;74(suppl 2):10-14.
their surroundings and change their biochemical/mechani- 14. Adetayo OA, Salcedo SE, Bahjri K, Gupta SC. A meta-analysis of outcomes
using acellular dermal matrix in breast and abdominal wall reconstructions:
cal properties in response to the needs of the environment. event rates and risk factors predictive of complications. Ann Plast Surg.
The ultimate goal is the creation of biomaterials with tis- 2011;[epub ahead of print].
sue-specific properties individualized to the exact biologic, 15. Kim JY, Davila AA, Persing S, et al. A meta-analysis of human acellular dermis
chemical, and functional needs of the reconstruction. The and submuscular tissue expander breast reconstruction. Plast Reconstr Surg.
2012;129:28-41.
continued evolution of the biomaterial field depends upon 16. Butler CE, Burns NK, Campbell KT, Mathur AB, Jaffari MV, Rios CN.
an interdisciplinary collaboration between engineers, scien- Comparison of cross-linked and non-cross-linked porcine acellular dermal
tists, clinicians, and industry. matrices for ventral hernia repair. J Am Coll Surg. 2010;211:368-376.

Chapter 8 n Principles of Microsurgery
Charles E. Butler and David M. Adelman
These technical advances, along with increased interest in

Introduction and knowledge of fine vascular anatomy, have made avail-
Microsurgery refers to a set of surgical techniques performed able the wide variety of microsurgical reconstructive options
beyond the limits of human eyesight. These procedures included in the armamentarium of reconstructive surgeons
require magnification by either surgical loupes or an operating today.
microscope. Contemporary procedures that use microsur-
gical techniques include nerve and blood vessel repairs and
grafts, free tissue transfers, limb replantation, and composite Indications for Free
tissue allotransplantation. Technical expertise is essential for Tissue Transfers
success, but preoperative planning and postoperative moni-
The reconstructive “ladder” algorithm advocates repair-
toring are also critical in achieving a successful microsurgical
ing tissue defects with the least invasive option that will
reconstruction.
produce successful results. The simplest technique is direct
closure, and the most complex technique—with the great-
History est potential morbidity—is free tissue transfer. Free tissue
transfers, located at the “top” of the reconstructive ladder,
The first successful end-to-end arterial anastomosis was reported
are usually considered when local or regional tissues are
in 1889 by Jassinowski.1 He used fine, curved needles and
insufficient or suboptimal for reconstruction. The unavail-
silk sutures to join the cut ends of carotid arteries in sheep.
ability of local or regional tissues may be a result of infec-
In 1897, Murphy reported an invagination method in which
tion, inflammation, trauma, radiation, insufficient volume
two double-ended silk sutures were used to intussuscept one
or surface area, insufficient vascular pedicle length, and/
blood vessel end into another, following which interrupted
or the unacceptability of morbidity at that donor site.
sutures were used to oversew the overlapping ends. This
In these situations, free tissue transfer becomes the best
technique led to anastomotic narrowing and thrombosis in
option. Free tissue transfer is also the most suitable option
animal experiments but was used clinically for human femoral
when highly vascularized tissue is required, when special-
artery repair.
ized tissues (such as functional muscles) are not available
Prior to the standardization of vascular repair tech-
locally, or when specialized components (such as vascular-
niques, there was controversy regarding whether to include
ized bowel or bone) are required. Table 8.1 outlines com-
the tunica intima vasorum in vascular sutures. Carrel, Burci,
mon indications for free flap reconstruction.
and Jassinowski favored excluding the intima, whereas Briau,
A detailed discussion of the factors involved in choosing a
Dofler, Jensen, and Hopfer recommended including the intima
specific free flap for a particular reconstruction is beyond the
in anastomoses. Guthrie and Carrel examined various tech-
scope of this chapter but is covered elsewhere in this book.
niques for anastomoses and found that inclusion of the intima
Generally speaking, the operating surgeon should ensure that
promoted “uniformly successful results,” thus laying the foun-
the tissue chosen for free tissue transfer is of sufficient size to
dations for standardization of anastomotic techniques.1, 2
cover or fill the defect, is associated with acceptable donor
Carrel, who received the 1912 Nobel Prize in Medicine
and Physiology for his work in this field, first described the
technique of placing triangulating sutures to ensure equal
traction on the blood vessels being anastomosed. In 1966, Table 8.1
Buncke3 reported rabbit ear replantations with anastomosis of Common Indications for Free Tissue Transfer
vessels approximately 1 mm in diameter. This microsurgical in Reconstructive Surgery
procedure was made possible by the use of fine instruments
adapted from those used by watchmakers and jewelers and n Indication n Example
the development of thin sutures swaged on suitably small-
gauge needles. Obliteration or reduction Reconstruction after exten-
Advances in magnification technology often par- of dead space sive soft tissue resection
alleled those in surgical technique and were essential Coverage of exposed Reconstruction for
to the evolution of modern microsurgical techniques. bone and/or neurovascular calvarial, thoracic, or lower
Janssens invented the first compound microscope in the tissue extremity defects
1590s. However, it would be more than 300 years before
Nylen introduced the operating microscope for otolar- Volume and contour Reconstruction of the
yngologic surgery in 1921. The term microvascular sur- reconstruction breast
gery was coined by Jacobson, who wished to operate on Vascularized enteral Reconstruction for pharyn-
small blood vessels under microscopic magnification conduits geal or esophageal defects
and later demonstrated a 100% patency rate in vessels
from 1.6 to 3.2 mm in diameter.1 Further developments Composite reconstruction Combined mandibular and
included foot-operated microscope controls that freed the floor-of-mouth reconstruction
surgeons’ hands, a beam-splitting device to allow the use Functional muscle Facial reanimation for
of a second set of eyepieces for a surgical assistant during reconstruction paralysis
procedures, optical zoom and independent focus controls, Reconstruction and/or Digit, penile, and limb
and cooler fiberoptics with a reduced likelihood of tissue replacement of appendages reconstructions/replantation
desiccation and improved signal transmission.
70
Chapter 8: Principles of Microsurgery 71
site morbidity (i.e., the benefits of the reconstruction outweigh
Preoperative Planning

the disadvantages of the flap harvest), and replaces “like with
like,” as with any reconstruction. Additionally, factors such Careful preoperative planning is essential. This is particularly
as color, pedicle length, and vessel size similarity must be true in microsurgery, since the donor sites are limited and the
considered. consequences of flap failure are considerable. Often, the type
Basic Science
of reconstruction needed is known prior to surgery (e.g., breast
reconstruction). Other times, the extent of resection is altered
Patient Selection based on intraoperative findings and pathologic examina-
and Education tion (e.g., resection of head and neck tumors). In these latter
situations, having discussed multiple possible flap options
The reconstructive surgeon should establish that the patient
with the patient during consultation will allow for the most
is medically fit for the proposed procedure, which may be
appropriate reconstruction to be performed without the need
complex and lengthy. Microsurgical procedures are not
for delay or additional conversation. It is the responsibility of
specifically contraindicated by age, provided the patient
the microsurgeon to anticipate as many reconstructive variables
is in reasonable health. However, the surgeon should rule
as possible.
out the presence of significant cardiovascular, respiratory,
Multiple flap options are usually available and the micro-
hepatic, or renal dysfunction and abnormal bleeding or
surgeon must consider which to use. Donor site morbidity and
clotting states.
replacing “like with like” are critical. Patient positioning is
The proposed procedure should be discussed at a level of
also important. Certain flaps may be harvested simultaneously
detail suitable for the patient. This includes a discussion of
with the ablative resection or wound preparation; this may
the likely donor sites for the tissue transfer, anticipated mor-
decrease overall operative time and patient turning. Keeping
bidity at each site, expected intraoperative and postoperative
ischemia time to a minimum is equally important, and timing
course, possible donor and recipient site complications,
flap harvest with recipient site preparation is key. In cases in
expected level of discomfort and scarring, and expected post-
which the flap may be rendered ischemic by the ablative team
operative recovery times needed to regain preoperative function
(e.g., when using a filet of extremity plap for a proximal
and activity levels.
defect), dissection of the flap prior to disease resection may
maximize flap viability after reperfusion.
Equipment and Operative In the event of flap injury or flap failure, certain backup
flap options may become important. Planned vein grafts may
Preparation allow a short pedicle to reach the recipient vessels or bypass
The correct instrumentation should be available for the oper- an area of vessel injury or disease. Ensuring potential vein
ating team, along with additional sets in case of accidental graft harvest sites are appropriate for use and included in the
damage or contamination of the instruments during the pro- sterile surgical field will facilitate their use during surgery, if
cedure. A microsurgical instrument set minimally includes fine needed. Furthermore, in the case of recurrent disease or late
jeweler’s forceps, vessel-dilating forceps, straight and curved flap loss, backup options need to be considered for later use.
microsurgical scissors, and microsurgical needle holders. Communication with the ablative team preoperatively is
Heparinized saline solution is frequently used for irrigation of essential to understand the anticipated defect characteristics,
the vessel lumen. optimize flap choice, and, consequentially, maximize the out-
The choice of magnifying equipment depends on individual comes of the reconstruction.
surgeon preference. Surgical loupes, which typically range from
2.5 × to 5.5 × magnification, can be used for fine dissection
and the preparation of vessels. Some surgeons also prefer to
Operative Technique
use loupes rather than operating microscopes when performing Once the recipient site is available (e.g., after debridement or
the vascular anastomoses.4 The advantages of the operating tumor resection), the defect is evaluated, and the final deci-
microscope are that it provides wide-field adjustable magni- sion regarding the type of reconstruction is made. Surgical
fication and allows significant depth-of-field perception. The templates can be helpful in determining the exact dimensions
microscope should have two sets of eyepieces to allow the sur- and shape of the defect, particularly if it has a complex three-
geon and the assistant to operate simultaneously. The use of dimensional form.
a video output device allows viewing of the operative field on Prior to free flap harvest, the recipient vessels are evalu-
a separate monitor and is helpful for the scrub team in following ated. Factors to evaluate include the presence of vessels;
the anastomotic activity. their distance from the defect (i.e., pedicle length required);
The free tissue transfer procedure should be outlined pre- their size, patency, and flow; and their condition (including
operatively to the anesthetic and nursing teams, as well as the previous radiation damage, atherosclerotic change, previous
ablative surgical team. This ensures that all parties are aware trauma, and/or infection). If the initially chosen vessels are
of the donor and recipient sites and helps to streamline opera- inadequate, alternative recipient vessels are sought. Vein grafts
tive activity. The need for (or avoidance of) anticoagulation, may be required to bridge the distance between the donor
neuromuscular paralysis, vasopressors, and antibiotic prophy- and recipient vessels. Free tissue transfer requires a thorough
laxis should be discussed with the anesthesiologist. Patient understanding of the relevant donor and recipient site anat-
positioning and preparation, the expected length of the proce- omy, including the main arterial and venous supply, major
dure, and any resultant physiologic or anatomic risks should vessel variations, important associated structures, and associ-
also be discussed. Intravenous and intra-arterial access should ated nerve supply. The flap’s vascular pedicle is dissected under
be planned in conjunction with the anesthetic and nursing magnification, with care taken to avoid injury to the flap
teams to avoid interference with potential flap harvest and blood supply. The required pedicle length should be appar-
recipient sites. ent from operative planning and intraoperative measurement.
The patient should be positioned for easy access to the Ideally, the donor and recipient are vessels of similar diameter.
flap donor and recipient sites. Dependent and pressured The vessels are handled minimally and with care by holding
areas on the patient should be padded to avoid pressure the adventitial tissue on the outermost aspect of the vessel
damage, and the patient should be well secured on the oper- wall. It is equally important to avoid significant traction on
ating table to allow limited change of position without the the vessels. Manipulation of the lumen is avoided to minimize
risk of a fall. intimal injury.

The microscope setup is one of the most important aspects

of an anastomosis. The operating table height is adjusted so
that the operative field is approximately level with the sur-
geons’ elbows. The height of the microscope is adjusted for
adequate focal length of the objective lens but in such a way
that the surgeons can avoid excessive flexion or extension of
their cervical spines or ligamentous and muscular strain. Both
eyepieces are set to neutral optical correction or adjusted for
each surgeon’s vision if corrective lenses are needed.
The recipient site is positioned for optimal exposure. This
includes retraction of the skin flaps or tissue using retrac-
tors, tension sutures, or skin hooks. The orientation of the
flap pedicle is checked to ensure that the anastomoses will
not be under excessive tension and the pedicle is checked for
acute bends or twists both before and after completion of
the anastomoses. The phrase “macro before micro” is a use-
ful reminder to check that the pedicle has an appropriate lie
within the recipient bed, prior to losing the wide perspective
under the microscope. To aid visualization during anastomo-
sis, a small sheet of plastic polymer “background material”
in a contrasting color can be placed under the vessels. If the Figure 8.1. Donor and recipient vessel preparation. The excess
operative field is deep, placing surgical sponges at the base of adventitial tissue near the cut edge of the vessel is removed with dissect-
the defect can elevate it. ing scissors to prevent intrusion into the lumen during the anastomosis.
The vessels to be anastomosed are positioned to allow Care is taken to avoid excessive thinning, which can result in vessel tears
during the placement of sutures. Visual Art © 2004 The University of
tension-free, surface-to-surface apposition. Once the pedicle Texas M. D. Anderson Cancer Center. Used with permission.
length and orientation of the donor and recipient vessels
are decided, low-pressure microvascular clamps are applied
for vascular control. Application of vessel clamps on the donor
vessels can help eliminate oozing from arterial inflow and distance apart to distribute the tension evenly around the cir-
venous backflow. The recipient artery and vein are checked cumference of the anastomosis.6
for open branches near the planned anastomoses; these are The method of suturing depends on surgeon preference.
then ligated. The cut edges of the donor and recipient vessels A popular method is to start with two orientation sutures
are checked for a clean, uniform edge and trimmed as neces- placed 180° apart (Figure 8.3A) or three orientation sutures
sary to avoid stray tissue ends encroaching into the lumen; placed 120° apart (Figure 8.3B). Some surgeons believe
these can be foci for thrombus formation. For an end-to-end that placing the correct number of sutures between the orien-
anastomosis, both the donor vessel and recipient vessel are tation sutures is easier when there are two; others believe that
most commonly cut perpendicular to the vascular axis. An using three orientation sutures reduces the risk of including the
oblique cut results in a larger circumference and can be used to
minimize vessel size mismatch when coapting vessels of different
diameters.
The quality of the luminal intima is then inspected for irreg-
ularities such as thrombi, atherosclerotic plaques, and friable,
calcified walls. Any detected debris is gently irrigated away.
If a satisfactory internal surface cannot be obtained by gentle
irrigation, the vessel should be cut back a suitable distance,
with care taken not to jeopardize the flap pedicle length or cali-
ber. It is also important to ensure that the recipient vessels are
outside any zone of injury or infection; using inflamed vessel
segments increases the risk of post-anastomotic thrombosis.5
If the recipient vessels do not appear suitable for microsurgical
anastomosis, then new recipient vessels are located. If they are
some distance from the original recipient vessels, vein grafts
may be needed to bridge the gap.
Once a satisfactory vessel segment is attained, adventitial
cleaning is carried out with sharp, curved microsurgical scissors
(Figure 8.1). It is important to avoid separation of the intima
from the media in arteries and to avoid excessive thinning of
the vessel walls. Excessive stripping of adventitia can result in
vessel tearing during suture placement. Judicious tangential
sharp excision is carried out for a distance of approximately
1 mm from the edge of each vessel. Some surgeons prefer to
maintain luminal apposition by careful vessel positioning
and/or the use of anastomotic retraction sutures; others prefer
to use double-approximating vascular clamps (Figure 8.2).6 Figure 8.2. Use of double-approximating microvascular clamps.
After adequate preparation, the vessels are aligned for The donor and recipient vessels are placed within the clamps, and the
vessel ends are approximated along the direction of the arrows. This
suture placement. Fine, non-absorbable sutures appropriate to
technique maintains the correct orientation of the vessels and facili-
the size and thickness of the vessels are used (most commonly tates suture placement. After the anterior suture line is complete, the
8-0, 9-0, or 10-0 nylon). Ideally, suture entry is perpendicular clamps are turned over to allow access to the posterior suture line.
to the vessel wall surface. Each bite should be of a sufficient Visual Art © 2004 The University of Texas M. D. Anderson Cancer
distance away from the edge so that the suture will not cut Center. Used with permission.
through the wall. These sutures should be placed an equal


Basic Science
A B
Figure 8.3. Orientation sutures. A. Bisecting interrupted sutures are placed 180° apart, dividing the vessel circumference in half. This technique is
particularly useful when there is a vessel size mismatch. B. Triangulating interrupted sutures are placed 120° apart, dividing the vessel circumference
into thirds. This technique helps prevent inadvertent inclusion of the opposite wall of the vessel in the remaining sutures; the surgeon applies gentle
downward traction on the posterior orientation suture while the other two sutures are gently retracted upward and laterally during placement of
the remaining anastomotic sutures. Visual Art © 2004 The University of Texas M. D. Anderson Cancer Center. Used with permission.
opposite wall in a suture (known as “backwalling”), as traction is carefully checked for active leaks, which are managed
on the third suture holds the opposite wall away from the by accurate placement of additional sutures. Small leaks
anterior suture line. from needle holes often stop on their own, and sometimes
The remaining sutures are then placed, usually beginning the anastomosis can be draped with a pledget of fat, which
on the posterior wall to facilitate visualization of the lumen provides tissue thromboplastin to further facilitate the process.
and continuing to the anterior wall. These sutures can be
interrupted or continuous (running). Interrupted sutures are
preferred when the size match of the two vessel ends is not
ideal. Continuous sutures require less knot tying, are faster,
and distribute the tension line evenly between the orientation
knots (Figures 8.4 and 8.5). In practice, arterial anastomoses
are often performed with interrupted sutures and venous anas-
tomoses with continuous sutures. Several studies have shown
no significant difference in thrombosis rates between the two A
suturing techniques.2,7,8
Accidental penetration into, or inclusion of, the opposite
(back) wall of a vessel in a suture is unacceptable and must
be avoided by careful visualization and meticulous technique.
Backwalling is prevented by a combination of luminal irri-
gation to distend the vessel (particularly thin-walled veins)
and ensuring the vessel edges are everted. The tips of jeweler’s
forceps can be placed just inside the vessel lumen to provide
counterpressure to facilitate external-to-intraluminal passage
of the needle (Figure 8.6A) and against the adventitial sur-
face of the vessel wall to facilitate intraluminal-to-external
passage of the needle (Figure 8.6B). B
Square knots are used whenever possible. For sutures under
some tension, such as the initial orientation sutures, a surgeon’s
knot is frequently preferred. Three square throws are usually
sufficient for interrupted suture knots. Ideally, sutures are tied
with a degree of tension sufficient to adequately coapt the vessel
edges but not to cause excessive bunching. However, sutures
that are tied too loosely may result in a thrombosis and/or
leakage at the anastomosis.
Nakayama introduced a vascular anastomotic coupling
device, which Ostrup and Berggren subsequently modified,
consisting of polyethylene rings secured with steel pins.9 The use
of such a device requires everted vessel walls and may not be C
possible with vessels that have a small diameter or athero-
sclerotic changes. Commercially available anastomotic cou-
pling systems are available for vessels 1 to 4 mm in diameter.
The patency rates achieved using anastomotic coupling Figure 8.4. End-to-end anastomosis using continuous (running)
devices are comparable to those using hand-sewn techniques. sutures. A. Donor and/or recipient vessel ends may be cut at an oblique
angle to increase their circumference and facilitate suturing, particu-
Figure 8.7 illustrates the technique for using an anastomotic larly for small vessels. B, C. Interrupted traction sutures are placed at
coupling device. 180° (shown) or 120° (not shown) to orient the vessels and facilitate
Antispasmodic agents, such as papaverine, can be used placement of the running sutures. Visual Art © 2004 The University of
throughout the dissection and anastomosis to reduce vaso- Texas M. D. Anderson Cancer Center. Used with permission.
spasm. After the vascular clamps are released, the anastomosis

A B
Figure 8.7. Use of an anastomotic coupling device. A. With the device’s lateral wings open, each vessel is passed through a plastic ring, and the
vessel walls are everted and impaled on pins mounted on the rings. B. After both vessels are mounted, the knob is turned to close the wings and
secure the rings with the vessels in opposition. The rings are securely attached to each other by the pins of one ring interlocking with the opposite
plastic ring. After the anastomosis, the coupled rings are released in the direction of the arrow by continuing to turn the knob. Visual Art © 2004
The University of Texas M. D. Anderson Cancer Center. Used with permission.
bleeding at the flap edges, hematoma formation, and even- is easily accessible (such as a buried flap), an implant-
tual concomitant loss of arterial inflow. These signs may be able Doppler ultrasonic probe can be used. This con-
easier to detect on a skin paddle than on a skin-grafted por- sists of a small probe attached to a polymer sleeve that
tion of muscle. Also, problems are detected more easily and is placed around a pedicle vein or artery adjacent to the
earlier when a large flap surface area is available for physical anastomosis; a thin probe lead wire exits through the inci-
examination. sion.12 The lead wire easily detaches from the probe and is
A Doppler ultrasonic probe is helpful for flap moni- removed through the incision with gentle traction on the
toring. The external pencil probe, which is applied on wire. Doppler signals have a characteristic pattern that
the skin paddle over a known cutaneous perforator can, with experience, be identified as arterial (pulsa-
location (often marked with a suture during surgery) tile) or venous (undulating). A change in the character
is one option. For flaps in which no perforator signal of the signals from strong to diminished or undetectable
A C
B D
Figure 8.8. Use of the Acland test to confirm antegrade vascular flow through an anastomosis. A. The direction of blood flow is indicated by the
arrow. B. Two jeweler’s forceps are used to gently occlude the vessel distal to the venous anastomosis. C. Blood is milked out of the vessel between
the two forceps by gently sliding the distal forceps along the vessel without injuring it. This results in a segment of collapsed vessel between the
proximal and distal forceps. D. Releasing the proximal forceps allows the collapsed vessel segment to be filled by antegrade flow if the anastomosis
is patent. The distal forceps prevent retrograde filling of the collapsed segment. This test should be performed sparingly to minimize potential
trauma to the vessel intima. Visual Art © 2004 The University of Texas M. D. Anderson Cancer Center. Used with permission.

During ischemia, the flap is often kept cold to minimize

the metabolic demands of the tissue. However, once reperfu-
sion is established, the flap is warmed to decrease vasospasm
and thrombosis and to restore cellular activity to normother-
mic levels.
Basic Science
Postoperative Monitoring and
Troubleshooting
The anesthetic is reversed gently to avoid sudden changes in
blood pressure, which may cause unwanted bleeding. The
patient is kept warm, well hydrated, and pain free during
and after the procedure. The use of vasoconstrictive agents is
avoided. Blood pressure, oxygenation, ventilation, and fluid
balance are carefully monitored. The postoperative use of an
anticoagulant agent (such as dextran, heparin, or aspirin) is
dependent on surgeon preference. These anticoagulating agents
are usually used only if there is a higher-than-normal risk of
thrombosis, such as with procedures involving small-caliber
Figure 8.5. End-to-side anastomosis using continuous (running) vessels, poor quality vessels, friable vessel walls, previously
sutures. An elliptical opening is created on the recipient vessel wall, irradiated tissue, or patients who are heavy smokers.7,11
and the end of the donor vessel is anastomosed to this opening. The Experienced personnel are essential for monitoring the flap
end-to-side technique maintains distal flow in the recipient vessel and
is frequently performed when there is a donor and recipient vessel
postoperatively. The gold standard for assessing the viability
diameter mismatch. Visual Art © 2004 The University of Texas M. D. of transferred tissue is clinical examination.10 Identification
Anderson Cancer Center. Used with permission. of a failing or insufficiently perfused flap can occasionally
be challenging for even the most experienced microsurgeon.
Pattern recognition is essential to identify compromised flaps
within a “window of salvageability.” The threshold for opera-
The entire pedicle is examined to ensure there is no tension, tive re-exploration of a flap for suspected arterial or venous
torsion, or bleeding, particularly from vessel branches or the insufficiency should be extremely low, as salvage rates are
flap itself. The time at which flow resumes is then recorded significantly increased by early identification and treatment.
and the flap ischemia time totaled. One never regrets a “take back” but one may definitely regret
A gentle Acland (vessel strip) test can be carried out near postponing a “take back.”
an arterial or venous anastomosis to confirm anastomotic A number of clinical signs, when present either singly or
patency (Figure 8.8). Flap color, capillary refill, tissue bleeding, in combination, may suggest a perfusion problem. These
and flap temperature are all assessed to ensure adequate flap include pale flap color, reduction in flap temperature, loss of
perfusion.2,10 A Doppler probe can be used to assess vascu- capillary refill, and loss of flap turgor; all may indicate arte-
lar flow within the pedicle and/or specific areas of the flap. rial insufficiency. Venous insufficiency, on the other hand, can
These areas can be marked with a fine, non-absorbable suture result in a purple or blue hue in the flap, congestion, swell-
on the skin paddle for ease of location during postoperative ing, and rapid capillary refill in the early stages followed by
monitoring. eventual loss of capillary refill. There may be increased dark
A B
Figure 8.6. Forceps counter-traction to facilitate needle placement and penetration. A. In select cases, partially open blunt jeweler’s forceps tips are
placed into the vessel lumen to evert the vessel wall, avoid inclusion of the back wall in sutures, and provide counter-traction for needle penetration.
Extreme care must be taken to avoid traumatizing the vessel intima; some microsurgeons avoid this technique for this reason. B. When the needle is
passed from inside the vessel lumen to outside the lumen, it is often useful to use the tips of the forceps to provide counter-traction on the adventitial
surface of the vessel to facilitate needle penetration. Visual Art © 2004 The University of Texas M. D. Anderson Cancer Center. Used with permission.

may indicate vascular occlusion. Doppler monitoring is, flap salvage. Unfortunately, salvage rates decrease with cumu-
however, subject to error (both false-positive and false- lative injury to the flap. If the flap ultimately fails, it should
negative) and thus should never replace clinical assessments. be immediately debrided to prevent it from becoming a nidus
The time between the clinical diagnosis of a vascular prob- for infection. Concurrent with debridement, decisions must be
lem in the flap and the return to the operating room is criti- made regarding temporary versus definitive wound coverage.
cal for flap salvage. Beyond a certain period, depending on the Factors to consider include patient stability, presence of infec-
type of flap and clinical conditions, salvage of a compromised tion, availability of pedicled and free flap backup options, and
flap becomes impossible. It is therefore advisable to be overly quality of recipient vessels.
cautious when assessing flap status, as the consequences of an
undiagnosed problem may result in partial or complete flap
loss.7 When in doubt, operative exploration can be both diag-
Conclusions
nostic and therapeutic. The use of microvascular techniques has revolutionized recon-
Once the patient is back in the operating room, the flap struction and expanded the range of options for repairing large
may be released from its inset if the pedicle is beneath it anatomic defects. Microsurgery is complex and technically
(e.g., breast reconstruction), or the pedicle may be exposed demanding, but with careful preparation, proper execution,
first through a separate incision (e.g., neck exploration for a and postoperative monitoring, it is beneficial to the patient and
compromised intraoral free flap). A tight flap inset can lead to rewarding to the surgeon.
decreased perfusion, and release alone may adequately restore
perfusion. If not, the position of the pedicle is examined, spe- References
cifically looking for a twist, kink, stretch, or compression that 1. Lee S, Frank DH, Choi SY. Historical review of small and microvascular
may have impeded flow. This can often happen postoperatively vessel surgery. Ann Plast Surg. 1983;11:53-62.
2. Weiss DD, Pribaz JJ. Microsurgery. In: Achauer BM, Eriksson E, Guyuron B,
secondary to swelling, patient activity, and/or infection. Flow et al., eds. Plastic Surgery: Indications, Operations and Outcomes. Vol 1.
across both the arterial and venous anastomoses is checked, St. Louis, MO: Mosby; 2000:163-183.
using any or all of the aforementioned techniques (Acland 3. Buncke HJ. Microsurgery—retrospective. Clin Plast Surg. 1986;13:315-318.
test, Doppler probe, palpation, etc.). If no flow is detected, 4. Shenaq SM, Klebuc MJ, Vargo D. Free-tissue transfer with the aid of
loupe magnification: experience with 251 procedures. Plast Reconstr Surg.
the anastomosis is opened and examined. Common findings 1995;95:261-269.
include thrombosis, suture occlusion of the lumen (by pre- 5. Johnson PC, Barker JH. Thrombosis and antithrombotic therapy in micro-
viously undiagnosed back wall placement), and dissection. vascular surgery. Clin Plast Surg. 1992;19:799-807.
Once the problem is determined, it can be repaired. Simple 6. Acland R. Microsurgery: A Practice Manual. St. Louis, MO: Mosby; 1980.
7. Chao JJ, Castello JR, English JM, et al. Microsurgery: free tissue transfer
revision of the anastomosis or thrombectomy via mechanical and replantations. Sel Read Plast Surg. 2000;9:1-32.
(e.g., Fogarty catheter) and/or chemical (e.g., thrombolytics) 8. Samaha FJ, Oliva A, Buncke GM, et al. A clinical study of end-to-end versus
means may be required. If inflow and/or outflow is diminished end-to-side techniques for microvascular anastomosis. Plast Reconstr Surg.
despite anastomotic patency, new recipient vessels may be 1997;99:1109-1111.
9. Ostrup LT, Berggren A. The UNILINK instrument system for fast and safe
required, along with new vein grafts to reach them. microvascular anastomosis. Ann Plast Surg. 1986;17:521-525.
Once the ischemia is eliminated and perfusion restored, 10. Neligan PC. Monitoring techniques for the detection of flow failure in the
additional monitoring of the flap is crucial. Increased post- postoperative period. Microsurgery. 1993;14:162-164.
reperfusion swelling of the flap tissue is common, and often 11. Reus WF 3rd, Colen LB, Straker DJ. Tobacco smoking and complications in
elective microsurgery. Plast Reconstr Surg. 1992;89:490-494.
the flap inset needs to be adjusted to avoid pressure-induced 12. Swartz WM, Izquierdo R, Miller MJ. Implantable venous Doppler microvas-
ischemia of the flap and surrounding tissues. In some situa- cular monitoring: laboratory investigation and clinical results. Plast Reconstr
tions, multiple trips to the operating room may be required for Surg. 1994;93:152-163.

CHAPTER 9 n Principles and Techniques

of Peripheral Nerve Repair,
Grafts, and Transfers
Basic Science
Susan E. Mackinnon and Stephen H. Colbert
Injuries to peripheral nerves may be devastating due to the phagocytosed in a process termed Wallerian degeneration.
incomplete nature of nerve healing and the possibility of Neurotrophism, which literally means food for nerves, is
permanent functional impairment. Peripheral nerve injuries the ability of neurotrophins secreted in an autocrine or para-
require appropriate management to optimize motor and sen- crine fashion to enhance the elongation and maturation of
sory recovery and to minimize pain. The surgeon must accu- nerve fibers. Schwann cells assume a pro-regenerative pheno-
rately identify the injury, determine the primary therapeutic type instrumental in remyelinating and guiding regenerating
goal, and decide if and when to operate. The management of axons to their appropriate targets along residual endoneurial
peripheral nerve injuries has benefited from clinical experience tubes. The orderly arrangement of these Schwann cells along
gained in World War II, the evolution of microsurgical tech- the endoneurium forms the bands of Bungner. Functional
nique, improvements in surgical equipment, and the consis- recovery depends on the number of motor fibers correctly
tently advancing field of neuroscience. matched with motor endplates and the number of sensory
fibers correctly matched with sensory receptors.
Experimental studies show that regenerating fibers can
Nerve Anatomy and demonstrate both tissue and end-organ specificity.5 This pro-
Physiology cess is called neurotropism. The preference of a nerve fiber to
In the normal nerve (Figure 9.1), axons are either unmyelinated grow toward a nerve versus other tissue depends on a criti-
or myelinated. Unmyelinated axons are ensheathed by a single cal gap across which the fiber responds to the influences of
Schwann cell–derived double basement membrane, whereas the distal nerve. Current research suggests that the expression
myelinated axons are surrounded by a multilaminated, of various Schwann cell and myelin-associated glycoproteins
laminin-rich, myelin sheath with stacks of individual Schwann may facilitate or impede the regeneration of damaged axons
cells along the length of the axon. Individual nerve fibers are to their correct targets.6
surrounded by the thin collagen of the endoneurium. Fibers
destined for a specific anatomic location are grouped together Classifying Nerve Injuries
in fascicles surrounded by the perineurium. The connective tis-
The classification of nerve injuries, originally proposed by
sue that surrounds the peripheral nerve is the epineurium. A
Seddon in 19437 and Sunderland in 1951,8 was subsequently
thin layer of loose areolar tissue, the mesoneurium, connects
expanded by Mackinnon9 to include a sixth category rep-
the epineurium to the surrounding structures and allows for
resenting a mixed injury pattern (Figure 9.2). The level and
the uninhibited excursion of nerves within the extremities.
degree of injury are important in determining treatment.
Regional arteries and veins supply the vasa nervorum, longi-
First-, second-, and third-degree injuries have the potential for
tudinal vessels running along the epineurium that communi-
recovery and for the most part do not require surgical inter-
cate with intraneural vessels running within the perineurium
vention. A first-degree injury recovers function quickly (within
and the endoneurium. Bidirectional axonal transport within
3 months). A second-degree injury recovers slowly (1 inch per
the nerve fiber is responsible for structural support of the
month) but completely, whereas recovery after third-degree
nerve and delivery of neurotransmitters and trophic factors. In
injuries is slow and incomplete. Fourth- and fifth-degree
the normal nerve, the intrinsic blood supply is substantial,
injuries will not recover without surgical intervention. A sixth-
allowing mobilization and elevation of nerves over a long dis-
degree injury shows a variable recovery.
tance (bipedicle width:length ratio of 64:1).
First-degree injury (neurapraxia). A localized conduc-
tion block is produced that may result in segmental
Nerve Injury demyelination. Because the axons are not injured,
Traumatized peripheral nerves are characterized by spe- regeneration is not required and remyelination and
cific changes both proximal and distal to the site of injury. complete recovery occur within 12 to 16 weeks.
Proximally, axons retract a variable distance depending on
Second-degree injury (axonotmesis). Axonal injury
the degree of injury and after a brief period of quiescence
occurs and the distal segment undergoes Wallerian
elongate as a hydra-like regenerating unit in which a single
degeneration. Proximal nerve fibers will regenerate at a
parent axon gives rise to multiple daughter axons. In myelin-
rate of 1 inch per month. By definition, the connective
ated nerves, axons sprout at unsheathed gaps known as the
tissue layers are uninjured. Recovery will be complete.
nodes of Ranvier and progress to their sensory or motor tar-
The progress of regeneration can be followed by the
gets. Observations and elegant studies by Cajal, Sunderland,
advancing Tinel sign.
Lundborg, Brushart, Mackinnon, and others have shown that
regenerating axons do not always take a direct course but do Third-degree injury. Wallerian degeneration is
preferentially target their appropriate end-organ receptors.1-5 combined with some fibrosis of the endoneurium.
Once a functional synapse is made, the remaining daughter Recovery will be incomplete because scar within the
axons degenerate, or are “pruned back.” In the distal nerve endoneurium may block or cause mismatching of
segment, Schwann cells, fibroblasts, myocytes, and injured regenerating fibers with the appropriate end organs.
axons express a host of neurotrophic factors, including glial Surgery is indicated if the lesion localizes to a known
and brain-derived neurotrophic factors at discrete concentra- area of entrapment where nerve regeneration is
tions and time points as the degrading neural elements are delayed. The recovery is uniformly better than that
77
Endoneurium
Perineurium
Epineurium
Mesoneurium Nerve fiber
Microvessels
Fascicles Nuclei of
Schwann cells
Axon
Vasa nervorum
Myelin sheath
Node of Ranvier Basement membrane
Axon
Basement membrane
Schwann cell
Axon
um
uri
ne
do
En
Fibroblast
Nerve fiber
m Regeneration sprout
u riu
ne
do Growth cone
En
with filopodia
Wallerian degeneration
in distal nerve fiber
B C
Fibroblasts
Myelin sheath
Basement
membrane
Axon
Individually myelinated
sprouts
D E
Figure 9.1. Nerve regeneration. A. The normal nerve consists of myelinated and unmyelinated axons. B. When a myelinated axon is injured,
degeneration occurs distally and for a variable distance proximally. C. Multiple regenerating fibers sprout from the proximal axon forming
a regenerating unit. A growth cone at the tip of each regenerating fiber samples the environment and advances the growth process distally.
D. Schwann cells eventually myelinate the regenerating fibers. E. From a single nerve fiber, therefore, a regenerating unit is formed that contains
several fibers, each capable of functional connections.
seen with a repair or graft unless it is associated with Sixth-degree injury. This represents a combination of
severe causalgia. any of the previous five levels of injury. Because of the
Fourth-degree injury. The nerve is in continuity but longitudinal nature of crushing injuries, different levels
with complete scar block resulting from injury to the of nerve injury can be seen at various locations along
endoneurium and perineurium. Regeneration will the nerve. This is the most challenging nerve injury for
not occur unless the block is excised and the nerve is the surgeon as some fascicles will need to be protected
repaired or grafted. and not “downgraded,” whereas others will require sur-
gical reconstruction.
Fifth-degree injury (neurotmesis). The nerve is com-
pletely divided and must be repaired before any regen- Proper clinical assessment is paramount to development
eration can occur. of a treatment plan. The extent of motor nerve injury is
Chapter 9: Principles and Techniques of Peripheral Nerve Repair, Grafts, and Transfers 79

Intact
Intact
endoneurium
Axon endoneurium Intact axons
Myelin sheath Cavities of injured axons
and myelin sheaths
Basic Science
Endoneurium Cavities of injured
Perineurium myelin sheaths
Normal fascicle First-degree injury Second-degree injury
Scarred
endoneurium
Intact
perineurium Intact ext.
Third-degree injury epineurium
A Fourth-degree injury Intact

mesoneurium
First
Second degree
degree
Intact nerve Fourth

degree Fourth
fibers Fifth degree degree
Third Third
degree degree
First
Second degree
degree
B Sixth degree
Figure 9.2. Classification of nerve injuries. A. Uninjured nerve consists of myelinated axons, surrounded by the endoneurium, grouped into
fascicles surrounded by the perineum. The outer layer of the nerve is the epineurium. In a first-degree injury, the axons are only demyelinated,
whereas in a second-degree injury, the axons are injured and undergo degeneration. A third-degree injury includes damage to the axons, myelin,
and endoneurium. A fourth-degree injury is a complete scar block that prevents any regeneration, and a fifth-degree injury is a division of the
nerve. B. The pattern of injury may vary from fascicle to fascicle along the nerve. This mixed pattern of injury is considered a sixth-degree injury.
determined by an evaluation of weakness, loss of motion, “Ten Test.”10 Patients rank the quality of sensation in the
and atrophy. The extent of sensory nerve injury is deter- affected digit compared with that in the normal contralateral
mined by moving and static two-point discrimination, which digit using a scale from 0 to 10. Vibration instruments and
are measurements of innervation density and the number of Semmes-Weinstein monofilaments are also used as threshold
fibers innervating sensory end organs. Light moving touch, tests to evaluate the performance level of nerve fibers and
for example, evaluates the innervation of large A-β fibers are more useful in evaluating chronic compressive neuropa-
and can be quickly screened with the valid and reliable thies. Testing is also performed after nerve repair to assess
the quality of nerve repair, determine the need for revision, fascicles. These fascicles are then visually traced back to the
and monitor recovery. level of injury.
Sharp nerve injuries are treated with repair or reconstruc- Knowledge of the usual internal topography of the periph-
tion in a timely fashion, generally with minimal delay unless eral nerves can direct proper alignment of fascicles at the
required to achieve a healthy wound bed. Closed injuries are time of nerve repair. For example, the fascicles of the ulnar
treated expectantly up to 12 weeks to allow for first-, second-, nerve in the mid- and distal forearm are divided into a dorsal
and third-degree injuries to show signs of recovery. Recovery sensory group, a volar sensory group, and a motor group.
is assessed with serial physical examinations and electrodi- In the mid-forearm, the motor group is positioned between
agnostic nerve studies at 6 and 12 weeks. This allows for the the ulnar dorsal sensory group and the radial volar sensory
accurate assessment of the degree of injury and appropriate group (Figure 9.3). The dorsal sensory group separates from
subsequent treatment plan. Fibrillations on electromyogra- the main ulnar nerve approximately 8 to 10 cm proximal to
phy (EMG) indicate axonal injury and will be present around the wrist. The motor group remains ulnar to the volar sen-
6 weeks postinjury (second-, third-, fourth-, and fifth-degree sory group until the Guyon canal, at which time it passes
injuries). By contrast, the presence of motor unit potentials dorsally and radially to become the deep motor branch to
(MUPs) does not occur until about 12 weeks postinjury. the intrinsic muscles. The motor group is two-thirds the size
MUPs are present in second- and third- but not fourth- and of the sensory group at this level. The median nerve topog-
fifth-degree injuries. The presence of MUPs on EMG is a raphy is more complex because it contains more fascicles. In
contraindication to surgery except for a simple decompres- the forearm, the anterior interosseous nerve is situated in the
sion at distal sites of compression. MUPs indicate collateral radial or posterior aspect of the median nerve as a distinct
sprouting of intact nerve fibers. Nascent units will occur later group. The distal internal topography of the median nerve
as actual injured axons regenerate to motor targets. MUPs approximates the distal anatomy; the motor fascicles to the
and nascent units are not present in fourth- and fifth-degree thenar muscles are on the radial side and the sensory fibers
injuries. to the third web space are on the ulnar side. Our web site,
nerveinjury.wustl.edu, details the internal topography of the
various nerves.
Principles of Nerve Repair
Basic principles of nerve repair include the use of meticu-
lous microsurgical techniques with adequate magnification,
microsurgical instruments, and sutures. When the clinical
and surgical conditions allow, a primary nerve repair is per-
formed in a tension-free manner. To facilitate the repair, the
injured segments of the nerve can be mobilized or, in the case
of the ulnar nerve at the elbow, transposed, to obtain length.
Intrinsically, peripheral nerves do afford a limited degree of
excursion. This property of intrinsic redundancy or elastic-
ity gives the peripheral nerves a horizontal or spiral banded
appearance called the bands of Fontana.11 The bands of
Fontana are created by laxity in nerve fibers. Thus, their pres-
ence in an injured nerve will let the surgeon know that nerve
fibers (first-, second-, or third-degree injury) are present. This
finding is helpful in evaluation of in-continuity nerve inju-
ries. These bands disappear when the nerve is compressed or
stretched. Extremes in the range of motion of joints in the
vicinity of the repair and facilitation of an end-to-end repair
with postural positioning of the extremity are discouraged.
If a tension-free repair cannot be achieved, an interposition
nerve graft is preferable with the limb in a neutral position.
In an effort to match sensory and motor modalities and to
optimize the specificity of nerve regeneration, a grouped
fascicular repair should be performed whenever the internal
topography of the nerve is segregated into motor, sensory, or
regional components. Otherwise an epineural repair is per-
formed. Postoperative motor and sensory reeducation maxi-
mizes the surgical result.
Fascicular Identification
Ulnar n.
The object of peripheral nerve repair is to restore the conti- Ulnar sensory Motor group
nuity of motor and sensory fascicles in the proximal segment group
with the corresponding fascicles in the distal segment. The

internal organization of nerves is distinct even in the proxi-
mal extremity, although nerves in the proximal extremity Radial volar
sensory group
are monofascicular. There is considerable plexus formation
between the fascicles, which decreases in the distal extremity. Figure 9.3. Ulnar nerve fascicular topography. A. At the mid-
As nerves progress distally, they become polyfascicular and forearm, the ulnar nerve is composed of three distinct fascicular
the fascicles are further differentiated into motor or sensory groups. The dorsal sensory branch separates from the motor branch
and the main sensory group. The motor branch remains ulnar to the
components.12,13 In the proximal segment of the nerve, motor sensory group until the Guyon canal, at which time it passes dorsally
fibers are distinguished from sensory fibers by knowledge of to the sensory branches of the little and ring fingers to innervate the
the internal topography, intraoperative stimulation, or “neu- intrinsic muscles. B. Knowledge of this topography can be used to
rolysis with the eyes.”14 Using this technique, the distal stump accurately reconstruct distal forearm nerve injuries.
of the injured nerve is dissected to discern motor from sensory

When repairing the radial nerve at or above the elbow, the Fascicular identification can also be used to assist with

priority is motor rather than sensory recovery (Figure 9.4). nerve reconstruction after tumor extirpation.16 If it appears
The distal sensory fascicles should be identified and can be likely that a functioning nerve will have to be sacrificed during
excluded from the repair or harvested and used as a graft tumor extirpation, the individual fascicles proximal and distal
to repair the motor fibers. In a similar fashion, the sensory to the resection site should be mapped. By performing direct
Basic Science
fibers of the peroneal nerve should be excluded from repair nerve-to-nerve stimulation and recording, the proximal and
and all efforts directed toward repairing the motor fibers to distal corresponding fascicles can be identified. After resection
the anterior tibialis muscle (Figure 9.4). The motor fibers of the involved nerve, the proximal fascicles are repaired to
to the anterior tibialis are located medially within the nerve their corresponding distal fascicles using nerve grafts.
as it crosses the knee and turns abruptly around the head
of the fibula. Several histochemical techniques have been
described that allow motor (acetylcholinesterase and choline
Timing of Nerve Repair
acetyltransferase) or sensory (carbonic anhydrase) discrimi- The best results are obtained after immediate repair of a
nation. However, these techniques require experienced histo- sharply transected nerve. The fascicular pattern and vas-
chemical personnel, are cumbersome, and are not universally cular landmarks guide the proper orientation of the nerve
available. ends. Retraction and neuroma formation, which may result
After the work of Sunderland, it was assumed that the in the need for grafting, are avoided, and within the first
motor and sensory fibers were diffusely scattered across 72 hours after injury, motor nerves in the distal nerve seg-
the different fascicles and followed a tortuous course of ment still respond to direct electrical stimulation because of
plexus formation until they finally organized themselves the presence of residual neurotransmitters within the nerve
into specific motor and sensory groups distally in the terminals. If the nerve was injured by a crush, avulsion,
extremity (Figure 9.5). Recent work contradicts this the- or blast injury, however, the surgeon must be cognizant
ory, showing that fibers destined for a specific territory of nerve injury proximal and distal to the site of transec-
organize themselves into distinct groups proximally within tion. In the acute setting, the extent of injury is difficult
the nerve.12,15 to determine even using the operating microscope. In this
Common
peroneal n.
Fibula
Motor branch to
Common ant. tibialis m.
peroneal n.
Radial n.
Sensory portion
as graft Motor branch to
Deep
Motor Sensory ant. tibialis m.
peroneal n.
fascicles fascicles
Superficial
peroneal n. Superficial
Deep
peroneal n.
peroneal n.
Common
peroneal n.
Motor branch to
ant. tibialis m.
Deep
peroneal n.
Superficial
peroneal n.
A B
Figure 9.4. Radial and peroneal nerve fascicular anatomy. A. In the radial nerve, the motor and sensory components are separated into dis-
crete fascicles. Awake stimulation can be used to identify the motor and sensory components of the proximal nerve, whereas anatomic dissection
is used to identify them distally. The sensory portion should be excluded from the repair and can be used as a source of donor graft material. If
the sensory component cannot be separated from the distal stump because of plexus formation with the motor fascicles, it can be turned into the
extensor carpi radialis brevis to neurotize this muscle. This ensures that regenerating motor fibers will not be lost in the sensory territory of the
radial nerve. B. Foot dorsiflexion is the essential goal of peroneal nerve repair. Grafting may be limited to the motor branch of the anterior tibi-
alis, which lies on the medial side of the nerve as it rounds the head of the fibula and travels transversely to reach the anterior tibialis. Again, the
sensory portions of the nerve can be used as donor material.

a nerve, healthy individual fascicles tend to herniate out from

the epineural sheath because of the normally high endoneu-
rial fluid pressure. At the time of epineural repair, the fascicles
may bend inward or outward, causing a misdirection of the
regenerating fibers (Figure 9.8). Appropriate trimming of the
fascicles will allow them to lie end-to-end within the epineural
sheath. The epineural sutures should be placed loosely so as
not to cause any additional bunching of the fascicles and so
that the nerve can be realigned appropriately.
Nerve Grafts
During the primary repair of a nerve, the two ends of the
nerve should lie in approximation without tension. If the
repair will not hold with 9-0 suture, or if postural position-
ing is required, a nerve graft is preferable. One challenge
with nerve grafting is to restore proper sensory/motor align-
ment. Often the internal topography of a nerve changes
across a gap. The proximal nerve may contain mixed motor
and sensory fascicles or a different number of fascicles com-
pared with the distal nerve, and thus the alignment of the
grafts cannot be specific. Proper orientation is aided by
knowledge of the internal anatomy, longitudinal epineural
vessel location, distal dissection, and “neurolysis with the
eyes.” A second challenge is to maximize the number of
axons that can traverse the nerve graft through both proxi-
mal and distal neurorrhaphy sites. To divert the maximal
number of axons distally, nerve grafts are reversed in ori-
entation. This maneuver is particularly important when a
long graft that possesses branches is utilized. If the graft is
placed anatomically, some regenerating axons travel along
these branches instead of to the distal neurorrhaphy site. If
the graft is reversed in orientation, it will funnel all regener-
ating axons distally.
When repairing long nerve defects, the surgeon may wish
to prioritize the functions of the nerve and consider exclud-
ing nonessential branches. In both the radial and peroneal
nerves, but not the median and tibial nerves, the sensory
components are expendable and the surgeon can concentrate
Figure 9.5. Nerve topography. Early surgeons believed that the
fibers destined for a distinct fascicular group in the distal limb gradu- on restoring the motor function. If necessary, the sensory
ally came together as the plexus formation decreased. Recent work fascicles can be used as graft material. The distal end of the
shows that fibers of a distinct fascicular group are actually located excluded sensory component may be repaired in an epineu-
adjacent to each other, even in the proximal limb. ral, end-to-side fashion to a nearby donor sensory nerve,
not necessarily to restore excellent sensation, but to provide
some sensation and limit the potential for distally medi-
ated nerve pain by allowing reinnervation of some sensory
situation, the two nerve ends should be tacked together to receptors.17
prevent retraction and repair delayed for 3 weeks or until
the wound permits. At the time of re-exploration, the extent
of injury will be defined by neuroma and scar formation.
Neuroma in Continuity
The neuroma must be excised in a bread loaf fashion until A complete neuroma in continuity that has no transmis-
a healthy fascicular pattern is seen proximally and dis- sion of signals and no functioning component is treated
tally. The resultant defect usually requires nerve grafting. with resection and nerve grafting. However, an incomplete
Occasionally, when there are other associated significant neuroma in continuity or a mixed, sixth-degree injury may
injuries that require acute management that might be com- arise after a partial nerve injury or a previous nerve repair
promised with secondary surgery, we will do an acute nerve in which portions of the nerve are functioning while other
graft. In these cases, we will make sure that we bread loaf critical components are not. The surgeon must be careful not
proximally and distally enough to be well outside the zone to downgrade the patient’s function by sacrificing the func-
of injury. Our current algorithms for the timing of nerve tioning components in an attempt to repair the remainder
repair are shown in Figures 9.6 and 9.7. of the nerve. Careful preoperative assessment will determine
Clinical studies have not shown a clear superiority of fascic- which fascicular components are functioning and should be
ular repair over an epineural repair. If the internal topography preserved.
of the nerve is known to be segregated in discrete motor/sen- At the time of repair, the neuroma in continuity may
sory groups, however, a grouped fascicular repair should have involve the complete circumference of the nerve. Individual
benefit over an epineural repair; otherwise, the extra manipu- fascicles proximal and distal to the neuroma can be sepa-
lation and suture material may actually decrease the functional rated using a microneurolysis technique. A hand-held nerve
results. Unless the surgeon is specifically trying to direct motor stimulator or intraoperative nerve conduction testing is
and sensory alignment because of a favorable internal topog- used to help identify functioning motor fascicles. If sensory
raphy, an epineural repair is standard. Bleeding from epineural fascicles are to be protected, intraoperative nerve conduc-
vessels should be controlled with gentle pressure or fine bipolar tion testing proximal and distal to the neuroma may be
coagulation under microscopic guidance. After transection of required.18


Basic Science
Figure 9.6. Algorithm for the management of closed nerve injuries. EMG, electromyography; MUPs, motor unit
potentials; NAP, nerve action potential; NCS, nerve conduction studies.
Separating the functioning fascicles from within the neu- the lateral malleolus and is usually harvested in a retrograde
roma may cause additional injury to functioning components. direction. The resultant area of numbness on the lateral side
In this situation, the neuroma possessing functioning fascicles of the foot decreases in size over time. The disadvantages of
should be preserved, whereas the nonfunctioning proximal the sural nerve are the separate distal donor site and the less
and distal fascicles can be reconstructed with nerve grafts favorable neural-to-connective tissue ratio as compared with
“black boxing” around the neuroma (Figure 9.9). upper extremity donor nerves.
When a limited amount of graft material is required, the
medial or lateral antebrachial cutaneous nerve can be har-
Donor Nerve Grafts vested from the injured upper extremity. The lateral ante-
The sural nerve in the adult can provide 30 to 40 cm of nerve brachial cutaneous nerve is found adjacent to the cephalic
graft. In 80% of dissections, it is formed by a union of the vein along the ulnar border of the brachioradialis muscle.
medial sural cutaneous nerve and the lateral peroneal com- A maximum of 8 cm of nerve graft can be obtained and the
municating branch. When a large amount of graft material loss of sensation is negligible as a result of the overlap in
is needed, the communicating branch can contribute an addi- distribution by the radial sensory branch. The donor scar
tional 10 to 20 cm. It can also be neurolyzed from the tib- on the volar aspect of the forearm may be objectionable to
ial and peroneal nerves well proximal to the popliteal fossa. some patients. The medial antebrachial cutaneous (MABC)
The nerve is found adjacent to the lesser saphenous vein at nerve, found in the groove between the triceps and biceps
Figure 9.7. Algorithm for the management of open nerve injuries. asurgeon uncertain as to proximal and
distal extent of injury; bas soon as soft tissue status permits.

Sensory fascicles
of median n.
Motor group
of median n.
Figure 9.8. Nerve repair. A. In an epineural repair, the fascicles

must be appropriately trimmed so that they do not buckle, which will
result in misdirection of the regenerating fibers. Excessive tighten-
ing of the epineural sutures can also cause buckling of the fascicles.
B. Well-performed nerve repairs will result in good alignment of
fascicles without the need for fascicular sutures.
muscles adjacent to the basilic vein, has a posterior and

Neuroma
an anterior division. Harvesting of the anterior branch is
preferred because this results in loss of sensation over the
anterior aspect of the forearm, whereas loss of the posterior Median n.
branch causes numbness over the elbow and the resting por-
tion of the forearm. If necessary, up to 20 cm of nerve graft
can be obtained with the MABC, and the donor scar on the
medial side of the upper arm is more acceptable. Patients are
A C
instructed that an initial broad area of donor sensory loss
will gradually decrease in size over 2 to 3 years. We do an Figure 9.9. Neuroma in continuity. A. When reconstructing a neu-
end-to-side transfer from the distal stump of the MABC to roma in continuity with intact motor function, the motor fascicles
the sensory side of the median nerve to rapidly decrease sen- through the neuroma must be preserved. B. Intraoperative nerve test-
sory donor deficit. ing can identify the motor fascicles proximal and distal to the neu-
roma. C. The remaining sensory fibers are divided proximally and
Patients with complete median nerve sensory loss have loss
distally, then reconstructed with grafts bypassing the neuroma. Any
of sensation in the first, second, and third web spaces. Because attempt to dissect the motor fascicles out of the neuroma will only
sensation is not critical in the third web space, the third web downgrade the function.
space nerve can be harvested to reconstruct the median nerve
defect, avoiding any additional morbidity caused by nerve
harvesting. The third web space nerve can be neurolyzed from
the main median nerve, providing up to 24 cm of nerve graft indicated in very proximal peripheral nerve injuries or root
(Figure 9.10). In a similar manner, the dorsal branch of the avulsions where a proximal stump is unavailable for pri-
ulnar nerve can be harvested to reconstruct the ulnar nerve. mary repair or grafting. Even when grafting is possible, the
When possible, the distal stump of the donor nerve is sewn injury may be so proximal that a nerve transfer facilitates
end-to-side to an adjacent normal nerve to restore improved better reinnervation of motor endplates than does a nerve
sensation to the donor territory. Vascularized nerve grafts graft. Nerve transfers are also indicated to avoid operating
have a limited role in peripheral nerve reconstruction, and in regions of severe scarring, when nerve injuries present in
their use is typically limited to lengthy, large caliber nerve a delayed fashion, when partial nerve injuries present with a
grafts such as the ulnar nerve. well-defined functional deficit, or when the level of injury is
Expendable motor nerves that can be used as motor nerve unclear such as in idiopathic neuritides or radiation-induced
grafts include the distal anterior interosseous nerve to the nerve injury.19
pronator quadratus, the obturator nerve branch to the graci- Motor nerve transfers require an expendable donor
lis, and the thoracodorsal nerve branches to the latissimus motor nerve with a large number of pure motor axons that
dorsi. In fact, any nerve innervating a free muscle transfer are located in close proximity to motor endplates, thus
could be used as a motor nerve graft. We use these motor minimizing the distance and time regenerating axons need
nerve grafts for reconstruction of critical motor function to travel to reinnervate their targets. It is also preferable
when nerve transfer does not provide a better option, such that the donor nerve innervates a muscle that is synergis-
as the intrinsic motor fascicle of the ulnar nerve at the hand tic with its target.13 The criteria for sensory nerve transfers
or wrist. include an expendable donor sensory nerve that innervates
a noncritical sensory distribution, contains a large number
of pure sensory axons, and is located near its sensory end
Nerve Transfers organs.
The use of nerve transfers has expanded over the last decade The most common applications of motor nerve transfers
based on a more detailed knowledge of the intraneural include the restoration of elbow flexion, shoulder abduc-
topography and branching patterns of peripheral nerves tion, ulnar-innervated intrinsic hand function, forearm
in the upper and lower extremities. Nerve transfers are pronation, and radial nerve function. 13 To restore elbow

to the median nerve–innervated pronator teres can restore

forearm pronation. Alternatively, the flexor digitorum
superficialis, or palmaris longus branches of the median
nerve, can be transferred to its pronator branch. The radial
nerve may be reconstructed by transferring median nerve
Basic Science
donors including redundant flexor digitorum superficialis
branches and flexor carpi radialis branches to the nerve to
extensor carpi radialis brevis and the posterior interosseous
nerve, respectively, perhaps in combination with a prona-
tor teres to extensor carpi radialis brevis tendon transfer.20
The site nervesurgery.wustl.edu has all our nerve transfers
available.
Nerve Conduits
Studies show that nerves will regenerate across a short
nerve gap through various conduits, such as veins, pseu-
dosheaths, and bioabsorbable tubes.21 The characteristics of
the ideal nerve conduit include low antigenicity, availability,
Figure 9.10. Median nerve at the wrist. The nerve to the 3rd web-
space can be used as a nerve graft to assist in the reconstruction of
and biodegradability. Vein grafts have been used to recon-
the more critical nerves. The proximal portion is harvested as a graft struct distal sensory nerve defects of less than 3 cm. Sensory
(green). The distal end of the 3rd webspace nerve is repaired in an end- results with vein grafts have been acceptable but not as good
to-side epineural fashion to the nerve to the 2nd webspace (yellow). as conventional grafting. For this reason vein grafts are
recommended only for reconstruction of noncritical nerve
gaps of less than 3 cm.22
Nerve regeneration across a 3-cm gap through a biode-
flexion, the medial pectoral, thoracodorsal, or intercostal gradable polyglycolic nerve tube has been demonstrated in the
nerves can be transferred to the musculocutaneous nerve. primate model and in a clinical trial.13 Clinical recovery was
The flexor carpi ulnaris branch of the ulnar nerve and the comparable to that across a standard nerve graft. The inser-
flexor digitorum superficialis/flexor carpi radialis branch tion of a short piece of nerve graft material into the center
of the median nerve can also be transferred to the biceps of the conduit will enhance regeneration by providing a local
and brachialis branches of the musculocutaneous nerve source of trophic factors. The ready availability of biodegrad-
to more specifically restore elbow flexion and limit donor able synthetic grafts to span short nerve gaps would eliminate
nerve morbidity (Figure 9.11). To restore shoulder abduc- the morbidity associated with nerve graft harvest and would
tion, the distal accessory nerve can be transferred to the capitalize on the potential benefits of neurotropism in direct-
suprascapular nerve, or the medial head triceps branch of ing nerve regeneration. Synthetic nerve conduits are now
the radial nerve can be transferred to the axillary nerve. To available for reconstruction of small diameter nerves with a
restore intrinsic hand function, the distal anterior interosse- gap ≤3 cm, or with large diameter nerves with gaps ≤0.5 cm.
ous nerve can be transferred to the ulnar nerve. Transferring We recommend limiting the use of nerve conduits to bridging
redundant fascicles of the flexor carpi ulnaris branches of small sensory gaps and as nerve wraps and we would advise
the ulnar nerve or the extensor carpi radialis brevis nerve the addition of some proximal minced nerve to the center of
Ulnar n.
Ulnar n.
Musculocutaneous n.
Musculocutaneous n.
Median n. Median n.
Biceps brachii branch Redundant FCR fascicle

Biceps brachii branch Redundant FCU fascicle
Redundant FCU fascicle

Redundant FCR fascicle
Brachialis branch
Brachialis branch
A B
Figure 9.11. A double fascicular transfer for elbow flexion. A. Transfer of a redundant fascicle of the ulnar nerve to the biceps
branch of the musculocutaneous nerve and a redundant fascicle of the median nerve to the brachialis branch of the musculocutaneous
nerve. B. Transfer of a redundant fascicle of the median nerve to the biceps branch of the musculocutaneous nerve and a redundant
fascicle of the ulnar nerve to the brachialis branch of the musculocutaneous nerve. FCR, flexor carpi radialis; FCU, flexor carpi ulnaris.

the conduit to provide a source of Schwann cells and trophic

factors. Conclusion
Nerve repair and grafting have benefited from the development
Nerve Allografts of microsurgical techniques and advances in the neurosciences.
State-of-the-art nerve repair requires not only precision tech-
Nerve allografts have demonstrated clinical usefulness in the niques but also additional measures to direct nerve regenera-
setting of extensive peripheral nerve injuries where there is a tion to its original function. Although nerve grafting remains
paucity of donor nerve material. Because the nerve allograft the standard for reconstruction of the nerve gap, synthetic
serves as a scaffold that is repopulated by host axons and conduits, allografts, and nerve transfers now play a limited
Schwann cells over time, its challenge to the immune system role in the peripheral nerve surgeon’s armamentarium.
is of limited duration. The agent FK506 (tacrolimus) is most
ideally suited for treating patients with peripheral nerve References
allografts based on its dual role as an immunosuppressive
and a neuroregenerative agent. By accelerating the rate at 1. Cajal SRY. Degeneration and Regeneration in the Nervous System. Vol 1.
London: Oxford University Press; 1928.
which axons traverse the nerve allograft, FK506 shortens 2. Sunderland S. The capacity of regenerating axons to bridge long gaps in
the duration of immunosuppression and the period dur- nerves. J Comp Neurol. 1953;99:481-497.
ing which complications can develop. The optimal timing 3. Lundborg G, Hansson HA. Nerve lesions with interruption of continuity:
and dose of FK506 therapy has been identified in rodents, studies on the growth pattern of regenerating axons in the gap between
the proximal and distal nerve ends. In: Gorio A, Millesi H, Mingrino S,
and a synergistic effect with nerve allograft cold preserva- eds. Posttraumatic Nerve Regeneration: Experimental Basis and Clinical
tion, as well as an ability to rescue nerve allografts under- Implications. New York, NY: Raven Press; 1981:229-239.
going acute rejection, established. Based on these findings, 4. Mackinnon S, Dellon L, Lundborg G, Hudson A, Hunter D. A study of
FK506 is now the mainstay of clinical peripheral nerve neurotropism in the primate model. J Hand Surg [Am]. 1986;11:888-894.
5. Brushart TM, Seiler WD. Selective reinnervation of distal motor stumps by
allotransplantation. peripheral motor axons. Exp Neurol. 1987;97:289-300.
Potential candidates for peripheral nerve allotransplan- 6. Jabaley ME, Wallace WH, Heckler FR. Internal topography of major nerves
tation receive nerve allografts from donors that have been of the forearm and hand: a current view. J Hand Surg [Am]. 1980;5:1-18.
screened for ABO blood typing, HIV, and cytomegalovi- 7. Seddon HJ. Three types of nerve injury. Brain. 1943;66:237-288.
8. Sunderland S. A classification of peripheral nerve injuries producing loss of
rus. These grafts are stored in the University of Wisconsin function. Brain. 1951;74:491-516.
cold storage solution at 41°F (5°C) for at least 7 days. 9. Mackinnon SE, Dellon AL. Surgery of the Peripheral Nerve. New York,
This solution is supplemented with penicillin G, dexa- NY: Thieme; 1988.
methasone, and insulin. Immunosuppression of the nerve 10. Strauch B, Lang A, Ferder M, et al. The ten test. Plast Reconstr Surg.
1997;99:1074-1078.
allograft recipient begins 3 to 5 days prior to nerve trans- 11. Clarke E, Bearn JG. The spiral nerve bands of Fontana. Brain. 1972;95:1-20.
plantation and consists of FK506 whose dose is titrated 12. Williams HB, Jabaley ME. The importance of internal anatomy of the peripheral
to appropriate steady-state blood levels, azathioprine, and nerves to nerve repair in the forearm and hand. Hand Clin. 1986;2:689-707.
prednisone. The prednisone dose is tapered in the first 4 to 13. Dvali L, Mackinnon S. Nerve repair, grafting, and nerve transfers. Clin
Plast Surg. 2003;30:203-221.
8 weeks after surgery. Pneumocystis carinii prophylaxis is 14. Hallin RG. Microneurography in relation to intraneural topography:
performed at the time of immunosuppression to minimize somatotopic organization of median nerve fascicles in humans. J Neurol
opportunistic pulmonary infections. Immunosuppression Neurosurg Psychiatry. 1990;53:736-744.
continues for 6 months after a Tinel sign is noted to pass 15. Greenberg MM, Leitao C, Trogadis J, et al. Irregular geometries in normal
unmyelinated axons: a 3D serial EM analysis. J Neurocytol. 1990;19:978-988.
the last distal neurorrhaphy site and some functional 16. Lundborg G, Dahlin LB, Danielsen N, et al. Tissue specificity in nerve
recovery has occurred. Peripheral nerve allograft rejec- regeneration. Scand J Plast Reconstr Surg. 1986;20:279-283.
tion resembles a superficial phlebitis with inflammation 17. Dorsi[Q15] MJ, Chen L, Murinson BB, Pogatzki-Zahn EM, Meyer RA,
and tenderness, but is localized over the underlying nerve Belzberg AJ. Pain. 2008;134(3):320-334.
18. Lee GW, Mackinnon SE, Brandt K, et al. A technique for nerve recon-
allograft and not a vein. struction following resection of soft-tissue sarcoma. J Reconstr Microsurg.
Processed acellular cadaveric nerve allografts have 1993;9(2):139-144.
become available for clinical use recently (AxoGen, Inc., 19. Mackinnon SE, Novak CB, eds. Nerve transfers. Hand Clin. November
Alachua, FL). These grafts are available in different diam- 2008;24(4):319-488.
20. Ray WZ, Mackinnon SE. Clinical outcomes following median to radial
eters and lengths, are not immunogenic, and thus do not nerve transfers. J Hand Surg [Am]. 2011;36(2):201-208.
require immunosuppression. Some studies suggest that these 21. Weber RV, Mackinnon SE. Bridging the neural gap. Clin Plast Surg.
allografts allow regeneration over longer nerve gaps than 2005;32(4):605-616.
empty conduits, but they fail to be equivalent to nerve auto- 22. Moore AM, Kasukurthi R, Magill CK, Farhadi HF, Borschel GH, Mackinnon
SE. Limitations of conduits in peripheral nerve repairs. Hand. 2009;4(2):180-186.
graft.23 These acellularized allografts have largely replaced 23. Whitlock EL, Tuffaha SH, Luciano JP, et al. Processed allografts and type
nerve conduits, but we limit their use to noncritical sensory I collagen conduits for repair of peripheral nerve gaps. Muscle Nerve.
nerve deficits ≤3 to 4 cm. 2009;39(6):787-799.

CHAPTER 10 n Tissue Expansion

Ashley K. Lentz and Bruce S. Bauer
Basic Science
Tissue expansion provides additional cutaneous tissue, allow- tapering of tissue. In terms of shape, they follow three basic
ing the surgeon to optimize contour and color match in a given patterns: round, rectangular, and crescent. The more com-
reconstructive effort. Careful planning and follow-through monly used include the round and rectangular types. The cres-
are necessary to achieve the desired outcome and minimize cent-shaped prostheses were originally designed in an effort
complications. to minimize dog-ears at the donor site, but have fallen out of
favor. It has been recognized that the rectangular expanders
allow for additional expanded tissue, thereby increasing the
Background possible choices for flap design (Figure 10.1).
Although the genesis of modern-day tissue expansion is cred- Expander volumes have a wide range and the choice var-
ited to Radovan1 and Austad,2 the technique takes some of ies according to the anatomic site of expansion and need for
its roots from early lessons in distraction osteogenesis. Bone gained tissue. Round and rectangular expanders range in size
traction with either internal or external devices at the turn of from less than 100 cc to greater than 1,000 cc in volume.
the 20th century paved the way for the concept that mechan- Sterile technique is used to deliver saline to the valve port,
ical stress on tissue leads to lengthening. In the mid-1950s, which may be integrated into the expander device or attached
Neumann 3 became the first surgeon to use an expansile to the expander via silicone tubing of customized length.
implant when he used a latex balloon to enlarge periauricu- An integrated system is favorable if only one single pocket
lar skin for a traumatic ear deformity. Despite these early is undermined; however, the implant may be more prone to
efforts, it was not until 20 years after Neumann’s report that rupture during expansion. Remote ports avoid the danger of
tissue expansion was revisited. Charles Radovan, 1 a resi- inadvertent prosthesis rupture, but have their own set of com-
dent at Georgetown, reintroduced the concept of expansion plications including flipping or migration of the device in vivo,
when he inserted a contemporary device with an internally as well as tube obstruction. In an effort to avoid these compli-
placed port. Shortly thereafter, Eric Austad2 produced a self- cations, the port tunnel should be conservative in size and the
inflating device. In 1982, the first National Tissue Expansion port should be placed over firm supportive tissue and secured
Symposium was sponsored by the Plastic Surgery Educational with sutures if needed.
Foundation. This marked the recognition of a new advance
in reconstructive surgery. Since that time, expansion has
been applied to a multitude of reconstructive problems, with
Surgical Planning
applications demonstrated in both local expansion and dis- One aspect cannot be overemphasized: The design for flap
tant expansion for subsequent graft and flap transfer. Better expansion should be planned prior to surgery. Consideration
understanding of expansion has allowed modifications in for the incisions, expander placement, flap movement in rela-
flap design, increasing its value as a reconstructive option.4 tion to the defect, and postoperative scars require appreciable
preoperative planning. Thorough discussions with the patient
and family are critical for successful reconstruction. If home
Physiology tissue expansion is planned, then we suggest a separate clinic
When mechanical stress is applied to skin over time, two session devoted to education of the patient and family with
phenomena occur: mechanical creep and biologic creep. The regard to the goals of expansion, expansion technique, and the
former is based on morphologic changes that occur on a cel- need for keen observation of the skin throughout the process.
lular level in response to the applied stress. Mechanical creep
is essentially cellular stretch. However, biologic creep is a cel-
lular proliferation that results from the disruption of gap junc-
tions and increased tissue surface area. Growth of the tissue by
cellular proliferation restores resting tension of the stretched
tissue to baseline.5 The epidermis gets thicker with concurrent
thinning of the dermis and alignment of collagen fibrils. These
effects are maximized at 6 to 12 weeks post-expansion. On a
molecular level, various cytokines are induced in response to
expansion.6
The vascularity of an expanded flap is superior to its non-
expanded counterpart in both number and caliber of vessels.7
Moreover, angiogenic factors such as vascular endothelial
growth factor are expressed in expanded tissue at a signifi-
cantly higher level when compared with nonexpanded con-
trols. This augmentation in blood flow is attributable to the
capsule that forms around the prosthesis. Because of the simi-
larity between expanded and delayed flaps in vessel caliber,
tissue expansion is regarded as a form of the delay phenom-
enon. An expanded flap, therefore, is a delayed flap.
Expansion Devices
Figure 10.1. Rectangular tissue expanders. Size 350 and 500 mL
Tissue expanders differ in size, shape, and type of filling tissue expanders with rectangular shape, thicker base plate, tubing,
valve. Expanders can be standard, customized to the donor and a small and large remote filling port.
site (breast), or can be designed to fill differentially to provide
87
Donor site choice plays an important role in expansion as inserting the expanders, they should be placed in the subga-
the surgeon strives to provide a good match for color, texture, leal plane above the periosteum. Flaps should be designed with
and contour for an optimal aesthetic and functional outcome. careful attention to the dominant vessels of the scalp, includ-
Infection, unstable scars, and traumatized tissue of the donor ing the superficial temporal, postauricular, and occipital arter-
site may lead to implant failure or extrusion. When placing ies and contributions from the supraorbital arteries. Finally,
expanders, attention is paid to the location of the incision. port placement in the preauricular region produces the least
If the purpose is removal of a lesion, we recommend plac- migration.
ing the incision within the lesion borders. Gentle handling of
the skin flaps is mandatory, as rough or aggressive retraction Forehead
of the flaps can lead to skin edge necrosis. The port should
Expanded flap reconstruction of the forehead provides some
be placed in a region of firm skeletal support, such as rib,
of the most challenging cases because of the potential morbid-
iliac crest, or anterior thigh. Partial fill of the expander at the
ity and disfigurement of the brow and hairline. One must have
time of placement (approximately 10% to 20% of its listed
great respect for the aesthetic subunits to avoid late complica-
volume) assures that the expander is properly positioned
tions. We reported an aesthetic complication rate of 24% in
and without surface folds. Soft, flexible expanders should be
forehead tissue expansion, including brow asymmetry, brow
used and the redundant expander should be folded under-
ptosis, altered hair direction, and anterior hairline asymme-
neath the expander in order to avoid future interference with
try.10 Over the years, principles have been developed to mini-
the port during filling. Large expanders measuring greater
mize these complications: (a) bilateral expansion of normal
than 250 mL prove more effective and we routinely use
forehead tissue is often successful for midforehead lesions;
500 mL or larger expanders. We recommend the use of larger
(b) serial expansion of the forehead is often required for hemi-
ports for even the smaller expanders in order to avoid flip-
forehead nevi; (c) supraorbital and temporal nevi are man-
ping of the port and easier palpability. Small closed s uction
aged using a transposition of expanded normal skin medial
drains are used to close the potential dead space. In most
to the nevus; (d) with minimal involvement of the temporal
cases, the expander pocket incisions are closed in a watertight
region, expanded parietal skin can be advanced to reconstitute
fashion with 4-0 clear Nylon sutures and 4-0 Prolene running
the hairline; and (e) in cases of brow elevation, the abnormal
continuous sutures. Skin flaps are dressed with Bacitracin
brow can be returned to its preoperative position by interpos-
and Xeroform gauze followed by soft 4 × 4 fluffs. Patients
ing non–hair-bearing forehead skin.
may or may not require overnight admission for pain control
and monitoring of the skin flaps for potential compromise or
hematoma formation. Face and Neck
Serial expansion begins 7 to 10 days post-insertion, pro- Once again, strict adherence to the aesthetic subunit prin-
vided that the skin flaps are in excellent condition. Drains ciples is required to achieve optimal results. Careful plan-
are removed within 10 days of surgery. After detailed ning for expander placement and flap incision will ensure
training and education, pediatric patients participate in a that the final scars are “hidden” in natural creases such
home expansion protocol directed by the parent or guard- as the nasolabial fold. Undue tension on the middle and
ian. It has been demonstrated that home expansion is safe lower third of the face can result in lower lip droop, oral
and equivalent to office expansion with regard to success- incontinence, and an asymmetric smile. The advancement of
ful outcome.8 Expansion should render the skin tense, but cervical skin flaps has an exceptional tendency to result in
one should not expand until it is extremely painful to the these complications. Therefore, we prefer to expand trans-
patient or cause skin compromise. Both suggest overly position and rotation flaps from the lateral cheek or neck
aggressive expansion. The home expansion protocol typi- and postauricular region. The use of multiple prostheses
cally lasts 8 to 12 weeks in preparation for transfer of the and overexpansion is recommended in order to further min-
expanded tissue. imize these complications.
Although early dogma of tissue expansion emphasized Expansion may also be applied to donor sites in prepara-
expansion as a means of generating large advancement flaps, tion for full-thickness skin grafting.11 This technique elimi-
experience demonstrates that expanded transposition and nates the size of the graft as a limitation for reconstruction.
rotation flaps are frequently preferable. Clearly, the increased A portion of the expansion provides for the graft tissue, while
vascular supply of the expanded flap places little limitation the remainder serves to allow for primary closure of the donor
on the ingenuity of the surgeon in designing flaps unique to site. Expansion of the abdomen results in aesthetic wound clo-
the varied recipient defects. Although requiring more planning sure with the ability to hide the donor site scars. The supracla-
and forethought, transposition of the flap provides greater vicular skin is ideal for grafts on the face due to the excellent
versatility in flap design and range.4,9 color and texture match. Once expanded, these full-thickness
grafts have the same characteristics as their unexpanded
counterparts in terms of durability, texture, contraction, and
Head and Neck growth.
Scalp
Large areas of the scalp can be reconstructed using tissue expan- Trunk
sion to replace the defect with hair-bearing scalp. The scalp is Beyond the obvious indications for breast deformities, tissue
also the second most common site of reconstruction using tissue expansion has multiple applications on the trunk for treat-
expansion as well as the area with which surgeons have the most ment of giant congenital nevi, vascular malformations, and
familiarity. Scalp reconstruction is warranted in three scenarios: contour defects.
large congenital melanocytic nevi, scar and skin graft alopecia
(Figure 10.2), and traumatic or iatrogenically caused craniofacial
abnormalities. It has been thought that scalp tissue expansion Abdomen
may permanently affect cranial vault morphology; however, this The lower abdomen may be the most easily expanded ana-
is not the case. Temporary cranial molding occurs, but corrects tomic site. It can be used for full-thickness graft donor sites,
within 3 to 4 months. In the treatment of congenital melanocytic as mentioned above, or as donor tissue for transposition flaps
nevi, larger expanders are placed serially in order to distribute for coverage of the anterior thigh. Expansion may also be used
the expansile forces evenly over the hair follicles. The scalp to expand free tissue transfers. We have successfully used the
can double in size without causing obvious alopecia. When expanded free transverse rectus abdominis musculocutaneous

Chapter 10: Tissue Expansion 89

Basic Science
B
E
Figure 10.2. Cranial defect after a train accident. A. Right cranial
defect. B. Multiple expanders were placed. C. Elevation of scalp flaps
after expansion. D. Placement of titanium mesh. E. Postoperative result.
C

(TRAM) flap to treat shoulder defects as well as those of the time. Aesthetic surgeons also use this trick to adjust breast
upper extremity below the elbow.13 While the lower abdomen size over time. Use of either an expander or an expander-
can be successfully used as a donor site, the upper abdomen implant in these cases may constitute an off-label use for
and anterior trunk must be cautiously regarded, as there exists these devices. Expanders are not constructed for prolonged
the unwanted potential for breast distortion. use (i.e., over the 6 to 8 years of breast development).
Postoperatively adjustable permanent implants are designed
Back for longer term use but are supposed to have their ports
removed promptly after complete fill to prevent implant
Expansion of the posterior trunk is the preferred modality
deflation. As such, a discussion of these possibilities needs
for the treatment of congenital nevi of the back and buttock
to occur prior to placement. The postoperatively adjust-
(Figure 10.3). Whether advancing the skin caudally or ceph-
able implants come in sizes, shapes, and volumes particu-
alad, serial expansion is frequently required for excision of
larly suited to use in this situation. Depending on how much
extensive lesions. Expansion can begin as early as 6 months of
native breast exists, these expanders can be placed subglan-
age for treatment of pediatric nevi and proves easier in early
dularly or submuscularly.
childhood as compared with later age. The lower back may
Once the patient reaches maturity, the expander can be
be expanded to develop large transposition flaps for coverage
replaced with a permanent implant and balancing procedures
of the buttock. The use of large expanded transposition flaps
to match breast shape can be performed on the opposite
has allowed the excision and reconstruction of giant nevi with
breast for “out-of-a-bra” symmetry. In the case of a patient
fewer procedures and more aesthetic and functional position-
with Poland syndrome with significant infraclavicular soft-
ing of the final scars.13
tissue deficiency, a latissimus dorsi flap can be transferred or a
custom permanent implant manufactured at the time of defini-
Breast tive reconstruction.
Expanders and expandable implants are used in breast surgery
for postmastectomy reconstruction and treatment of congeni- Extremities
tal anomalies.
Classically, the extremity is viewed as an unfavorable donor
for an expanded flap. Complication rates in the limb are
Postmastectomy Reconstruction higher than those compared with other sites, and simple
Implant-based breast reconstruction remains the most common expansion does not provide a large amount of surface area
choice after mastectomy (Chapter 59). The relative ease and with which to work. These facts have led us to find alternative
rapidity of subpectoral expander placement make it a highly options and creative methods for successful reconstruction of
requested surgical option among women. Tissue expanders are the extremity. Additionally, extremity expansion should be
typically placed under the pectoralis muscle superiorly, while a avoided in unstable or infected wounds.
sling of acellular dermis or serratus anterior muscle covers the
expander inferiorly. Exchange of the expander for a perma- Upper Extremity
nent prosthesis may be performed after the patient has under-
gone serial outpatient expansion to a desired breast volume. A useful algorithm for complex defects has been devised
This topic is covered in detail in Chapter 59. for upper limb reconstruction.12,13 Based on our experience,
Expanders have been used as spacers during “delayed successful contour and color match of the upper extremity
primary” breast reconstruction. The expander placed at comes from approaching it in thirds (proximal to elbow;
the time of mastectomy preserves the skin envelope while midforearm; and the hands, web spaces, and fingers) and
awaiting final pathology results. If radiation is war- from whether or not the lesion is circumferential or non-
ranted, the expander holds the original skin envelope circumferential. For proximal noncircumferential defects,
until delayed reconstruction can be performed. If no post- expanded transposition flaps from the back or shoulder serve
mastectomy radiation is indicated, then the patient may the purpose well. If the lesion is large and circumferential,
proceed with either implant-based or autologous breast covering the majority of the proximal arm, expanded free
reconstruction. TRAM flaps are the method of choice. Distally, for large
circumferential mid- or lower forearm lesion, expansion of
Tissue Expansion in the Treatment of the flank creates a pedicled carrier “sling” through which
the forearm can be placed for 3 weeks prior to pedicle divi-
Congenital Breast Anomalies sion (Figure 10.4). As previously reported, expanded full-
Expanders can be helpful as “spacer” in the correction of thickness skin grafts from the abdomen or the groin remain
congenital breast anomalies. Requests for breast habilita- the treatment of choice for reconstruction of fingers, webs,
tion come from patients with breast agenesis associated with and hands.
Poland syndrome, idiopathic unilateral breast hypoplasia,
and iatrogenic breast asymmetry as a consequence of juve-
nile breast bud damage. Traditional wisdom has been to wait
Lower Extremity
for maturity prior to correcting breast asymmetries. This Skin of the lower extremity lacks flexibility and requires
strategy assures that the surgeon knows what needs to be complex solutions for wound closure. We have developed an
matched on the opposite side. Although this solution may algorithm for the treatment of congenital nevi of the lower
have been acceptable previously, today’s adolescent female extremity.14 This algorithm takes into consideration the size
has problems with changing in locker rooms, participat- and location of the defect, as well as the age of the patient.
ing in sports activities, and wearing fashionable clothing. Creative approaches for wound closure include expanded free
Questions of developing self-esteem, body image, and sexual flaps, expanded local transposition flaps (Figure 10.5), serial
identity further compound the issue of waiting. Expanders excision, and full-thickness skin grafts.
can function as an intermediate solution. This topic is cov-
ered in Chapter 64.
Many young women are happy with breast volume sym-
Complications
metry so that they appear normal in a bra. With this goal As mentioned above, site-specific complications may occur.
in mind, an expander can be placed as early as the oppo- Major complications include infection, implant exposure,
site breast begins to develop and can be expanded over and flap ischemia. Traditional dogma suggests that an


Basic Science
B
Figure 10.3. Giant congenital nevus of the back and buttock.

A. Preoperative appearance. B. Expander placement. C. Multiple
stages of expansion were required. D. Postoperative result.
C

early postoperative infection requires expander removal. antibiotics may be administered until the wounds close
However, an infection occurring late in the expansion secondarily.
course can occasionally be salvaged with antibiotic ther- Minor complications with expansion include transient pain
apy. 15 Exposure of the implant may be treated the same during the expansion process, seroma formation, dog-ears at
way, especially if the expander is located in a dependent the donor site, and widening of the scars. The majority of these
portion of the open wound. Local wound care and oral complications resolve in time or with minor surgical revision.
A
D
E
Figure 10.4. Congenital giant nevus of the upper extremity.
A. Preoperative appearance. B. Expansion of the flank. C. Removal
of the upper extremity nevus. D. Pocket created to cover the upper
extremity defect. E. Postoperative result.
B


Basic Science
A
C
Figure 10.5. Lower extremity nevus. A. Posterior thigh tissue
expansion. B. The expander was removed, the nevus was excised, and
the posterior thigh flap was used to anchor the leg in a position of
flexion in order to cover the defect. C. After flap division and inset.
B
8. Mohmand MH, Sterne GD, Gower JP. Home inflation of tissue expanders:
References a safe and reliable alternative. Br J Plast Surg. 2001;54:610-614.
9. Bauer BS, Vicari FA, Richard ME. The role of tissue expansion in pediatric
1. Radovan C. Adjacent Flap Development Using Expandable Silastic
plastic surgery. Clin Plast Surg. 1990;17(1):101-113.
Implants. Paper presented at the Annual Meeting of the American Society of
10. Bauer BS, Few JW, Chavez CD, et al. The role of tissue expansion in the
Plastic and Reconstructive Surgeons, Boston, MA, September 1976. management of large congenital pigmented nevi of the forehead in the
2. Austad ED, Rose GL. A self-inflating tissue expander. Plast Reconstr Surg. pediatric patient. Plast Reconstr Surg. 2001;107(3):668-675.
1982;70:588. 11. Bauer BS, Vicari F, Richard ME, et al. Expanded full thickness skin grafts
3. Neumann CG. The expansion of an area of skin by progressive distention of in children: case selection, planning and management. Plast Reconstr Surg.
a subcutaneous balloon. Plast Reconstr Surg. 1957;19:124. 1993;92:59-69.
4. Bauer BS, Margulis A. The expanded transposition flap: shifting paradigms 12. Margulis A, Bauer B, Fine N. Large and giant congenital pigmented nevi of
based on experience gained from two decades of pediatric tissue expansion. the upper extremity: an algorithm to surgical management. Ann Plast Surg.
Plast Reconstr Surg. 2004;114:98-106. 2004;52:158-167.
5. DeFilippo RE, Atala A. Stretch and growth: the molecular and 13. Bauer BS. Commentary on Gosain AK et al. Giant congenital nevi: a 20 year
physiologic influences of tissue expansion. Plast Reconstr Surg. experience and an algorithm for their management. Plast Reconstr Surg.
2001;109(7):2450-2461. 2001;108:632-636.
6. Takei T, Mills I, Arai K, et al. Molecular basis for tissue expansion: 14. Kryger ZB, Bauer BS. Surgical management of large and giant con-
clinical implications for the surgeon. Plast Reconstr Surg . genital pigmented nevi of the lower extremity. Plast Reconstr Surg.
1998;102(1):247-258. 2008;121:1674-1684.
7. Cherry GW, Austad E, Pasyk K, et al. Increased survival and vascularity 15. Adler N, Dorafshar AH, Bauer B, et al. Tissue expander infections in
of random pattern skin flaps elevated in controlled, expanded skin. Plast pediatric patients: management and outcomes. Plast Reconstr Surg.
Reconstr Surg. 1983;72:680. 2009;124:484-489.

CHAPTER 11 n Principles of Office Sedation
for Cosmetic Surgery
Maximilian W. B. Hartmannsgruber, Dominick Cannavo, and Nikolaus Gravenstein
The integrity of defense: “A defense that is expecting many surgical procedures. These platelet-active drugs should
an attack has an advantage. If the element of surprise is not be modified without involving the patient’s cardiologist/
added, it is usually because the defenders ignored warn- internist as acute perioperative stent thrombosis has been
ings and did not take the attackers seriously” reported after discontinuation of antiplatelet therapy. 3 On
the other hand, if the patient has had coronary revascular-
–Samurai: “The Art of War” 2,500 years ization within 5 years and is asymptomatic, the risk of a
ago by the Chinese general Sun Tzu1 cardiac event is decreased and does not normally require
While the standard of care theoretically allows for compli- additional workup. If revascularization was performed more
cations related to sedation for cosmetic surgery, everyone’s than 5 years previously or the patient is symptomatic, car-
expectation is for perfect results. After all, cosmetic proce- diac risk is increased and a more extensive evaluation is
dures, especially office-based, are the most elective of all mandated.
procedures. Worse still, complications are not only debated Cardiac risk factor modification frequently includes beta
in grand rounds or journals but rather in newspapers and blockade and cholesterol statin therapy throughout the peri-
on television. Careful intra- and postoperative care in an operative period.4
accredited, properly equipped facility by adequately trained
practitioners is assumed. When complications do occur, they Pulmonary
are often the result of inadequate planning and/or improper With respect to pulmonary status, smoking, chronic obstruc-
patient selection. tive pulmonary disease (COPD), reactive airway disease, and
obesity are the major risk factors. As with cardiac evaluation,
Preoperative Evaluation patients should be screened based on symptoms and exer-
tional capacity. If they are asthmatic, the goal is to stabilize
and Optimization them and avoid an exacerbation. Pulmonary function tests are
The purpose of preoperative evaluation is not simply to pro- rarely indicated or useful for preoperative screening. Because
vide “medical clearance,” but rather to identify and modify cosmetic surgery is elective, there is an opportunity to imple-
any risk factors. A comprehensive discussion of every possible ment smoking cessation in order to reduce pulmonary and
risk factor is beyond the scope of this chapter; we limit the thromboembolic complications and improve wound healing
discussion to cardiovascular and pulmonary/smoking, obesity, and flap perfusion. Maximum benefit, however, is probably
and the risk of deep vein thrombosis (DVT). not achieved until at least a month after smoking cessation.
Shorter term smoking cessation actually causes some increase
Cardiac in pulmonary secretions.
The American Heart Association and the American College
of Cardiology guidelines advocate an approach that relates Obesity
major, intermediate, and minor cardiovascular risk fac- The comorbidities in obese patients include atherosclerotic
tors to the planned procedure. 2 For example, if a major heart disease, adult-onset diabetes, congestive heart fail-
cardiovascular predictor is present, nonemergency surgery ure, systemic hypertension, cardiac arrhythmias, pulmonary
should be delayed until risk factor modification has been hypertension, obstructive sleep apnea, gastroesophageal
accomplished. reflux (GERD), a predisposition to DVT, and sensitiv-
Clinical predictors for a major adverse cardiac event ity to narcotic analgesics. The excess adipose tissue on the
include recent (<1 month) myocardial infarction, unstable chest and abdominal wall compresses the lungs. The resul-
angina, decompensated congestive heart failure, severe valvu- tant increased intrathoracic pressure is magnified by exces-
lar heart disease, and significant arrhythmias. The presence of sive adipose tissues within the peritoneal cavity leading to
one of these major clinical predictors mandates postponement a further reduction in the functional residual capacity and
of any cosmetic surgical procedure. total lung capacity. Asthma, chronic cough, and pulmonary
Intermediate predictors include mild stable angina, previ- fibrosis may be manifestations of GERD, another common
ous myocardial infarction, compensated congestive heart fail- accompanying effect of the increased intra-abdominal pres-
ure, diabetes mellitus (especially type I), renal insufficiency, sure of obesity. It is important to appreciate that following
and poor exertional capacity. Adequate cardiovascular fit- an abdominoplasty, with plication of the rectus abdomi-
ness to undergo an elective procedure, especially office-based, nis muscles, intra-abdominal pressure is acutely increased,
can be estimated by the patient’s ability to climb one flight of which exacerbates any preexisting pulmonary compromise.
stairs or walk one block on level ground without shortness In addition, lower extremity venous flow is impeded by
of breath and/or angina. This equates to 4 METs (metabolic increased intra-abdominal pressure, creating venous stasis
equivalents) in a completed exercise test.2 and an environment conducive to venous thrombosis. The
With respect to ischemic heart disease, it is advisable to physiologic changes imposed by rectus plication are often
wait at least 6 months after a myocardial infarction and/ underappreciated and persist without concomitant weight
or revascularization, angioplasty, stent placement, or bypass loss. While the cosmetic result obtained with an abdomino-
before considering elective surgery.2 Patients with a coro- plasty might give the perception of actual weight loss, the
nary stent(s) are universally on at least one and often two intraperitoneal fat remains and is compressed into a smaller
platelet inhibitors (e.g., aspirin and clopidogrel). This ther- space, exacerbating all the underlying pulmonary and venous
apy is important for the stents but is a contraindication to stasis aberrations.5
94
Chapter 11: Principles of Office Sedation for Cosmetic Surgery 95
4. preserved protective airway reflexes and
Deep Vein Thrombosis

5. amnesia
As with cardiac risk factor stratification/modification, the risk
In contrast, unconscious or deep sedation is a state in
of DVT is considered and mechanical and/or pharmacologic
which the patient’s airway may require support and, although
prophylaxis implemented as indicated. Risk factors for DVT
Basic Science
the patient may be arousable, the stimulus required to gener-
include birth control pills or hormone replacement therapy,
ate a patient response is more vigorous or even noxious. Given
protein C or S deficiency, antithrombin III deficiency, lupus
the variability to patient response with respect to sedation,
anticoagulant, factor V Leiden along with acquired risk fac-
careful monitoring is essential.
tors that include smoking, diabetes, congestive heart failure,
obesity, and history of prior DVT. A history of DVT superim-
poses additional risk on the intrinsic thromboembolic risk of Monitoring
the procedure. Basic monitoring calls for compliance with the American
Surgery-specific risks can also be stratified as high, medium, Society of Anesthesiologists Monitoring Standards.7
and low. High risks for DVT are prolonged procedures and those
associated with significant blood loss or fluid shifts. Examples 1. Standard I
in plastic surgery include major flap procedures, abdomino- Qualified anesthesia personnel present throughout the
plasties and/or lower body lifts, and large volume liposuction. procedure.
Intermediate-risk procedures include facelifts. Blepharoplasty 2. Standard II
and excision of small lesions present a low risk for DVT. Patient’s oxygenation, ventilation, circulation, and tem-
The aggressiveness of DVT prophylaxis is dictated by perature shall be continually evaluated.
preexisting risk factors superimposed on the inherent risk 2.1 Oxygenation
of the procedure. Using Virchow’s triad (endothelial dam- Inspired gas: When an anesthesia machine is used, the
age, stasis of blood flow, and hypercoagulability) as a model, concentration of oxygen in the breathing system shall
the latter two components of the triad can be addressed. be measured by an oxygen analyzer with a low oxy-
Sequential compression devices are utilized when possible to gen concentration limit alarm in use.
prevent stasis and ideally are applied prior to initiation of the Blood oxygenation: During all anesthetics, a quantita-
sedation/anesthetic. Neuraxial anesthesia (spinal and/or epi- tive method of assessing oxygenation such as pulse
dural) should be considered for abdominoplasty. Neuraxial oximetry shall be employed. When the pulse oximeter
anesthesia provides a sympathetic block that promotes is utilized, the variable pitch pulse tone and the low
venous return and decreases the likelihood of stasis and an threshold alarm shall be audible.
environment conducive to thrombosis. In terms of hyperco- 3. Ventilation
agulability, pharmacologic prophylaxis is achieved with pre- During regional anesthesia (with no sedation) or local
incision prophylactic administration of subcutaneous heparin anesthesia (with no sedation), the adequacy of ventila-
or factor Xa inhibitors such as enoxaparin (Lovenox) and tion shall be evaluated by continual observation of
fondaparinux (Arixtra). qualitative clinical signs. During moderate or deep seda-
tion, the adequacy of ventilation shall be evaluated by
Preoperative NPO Guidelines continual observation of qualitative clinical signs and
monitoring for the presence of exhaled carbon dioxide
Fasting from solid food should be at least 8 hours. Milk is unless precluded or invalidated by the nature of the
allowable up to 6 hours before initiation of sedation. Oral patient, procedure, or equipment. If invoking the preclu-
medications may be taken with a sip of water up to the time sion option, a statement in the record to explain why is
of surgery. To increase patient satisfaction, decrease gastric recommended.
liquid volume, and to decrease the risk of dehydration or 4. Circulation
hypoglycemia from fasting, we encourage clear liquids up to 4.1 Continuous display of the electrocardiogram
2 hours before the anticipated anesthesia start time in the first (ECG). A helpful intraoperative ECG montage is to
patient of the day and 3 hours for all following patients. Even use at least one precordial electrode (except in breast
though the minimum fast time for clear liquid is 2 hours, this surgery). If the ECG monitor has only three leads,
allows for timely induction of the subsequent patients should this is readily accomplished by placing the left leg
the earlier procedures be shorter than anticipated. Examples lead into the V5 position—anterior axillary line in
of clear liquids include water, fruit juices without pulp, car- the fifth intercostal space—and monitoring lead two
bonated beverages, clear tea, and black coffee. Gatorade (right shoulder-left leg). This configuration results in
or other clear liquid electrolyte sports drinks are attractive a modified V5 lead and is considerably more sensitive
because the stomach empties many times faster after these for identifying ischemia than any other single lead.
than after water alone because they contain sugar and salt that 4.2 Arterial blood pressure and heart rate determina-
accelerate absorption from the proximal gastrointestinal tract tion and evaluation at least every 5 minutes. Cautious
and the sugar also prevents hypoglycemia in patients who are interpretation of the patient’s blood pressure is
on a diabetes medication.6 essential, especially when the blood pressure cuff is
Pretreatment beginning the night before with H2 blockers placed lower than the heart (e.g., around the calf in a
such as ranitidine (150 mg po), especially in obese patients, patient who is in a semi-sitting position).8 Conversely,
should be considered. This class of drugs is inexpensive, avail- hypertension secondary to stimulation or inadvertent
able over the counter, and well tolerated. intravascular injection of local anesthetics with epi-
nephrine can lead to intra- and post-op bleeding and
Conscious and Deep Sedation wound hematoma as well as myocardial ischemia.
Perioperative treatment of blood pressure can help
The goal of both conscious and deep sedation is to provide
avoid ischemia as well as reduce intra- and post-op
safe, titrated sedation and analgesia to a patient undergoing a
bleeding as well as bruising. In general, it is desirable
surgical procedure.
to continue all cardiac and antihypertensive medi-
Conscious sedation is characterized by:
cations according to the patient’s normal regimen,
1. depressed consciousness as hypertension is much more likely to occur than
2. independent airway hypotension during procedures performed under local
3. responsiveness to verbal stimuli anesthesia with intravenous sedation.

5. Body temperature 8
To aid in the maintenance of appropriate body tem-
perature during all anesthetics, every patient receiving
anesthesia should have temperature monitored when
clinically significant changes in body temperature are
anticipated or suspected.
Sedation Principles
Fentanyl (µg/kg–1)
Clinical experience has shown that even small amounts of
benzodiazepines, narcotics, or propofol may result in uncon-
sciousness. As an example, the minimum effective plasma 4
concentration for midazolam (Versed) ranges from 30 to
1,000 ng/mL between individuals and generally decreases with
1
00
age (Figure 11.1). Paradoxically, at identical plasma concen-
0.
trations of midazolam, an oral dose induces more marked
<
P
effects than an intravenous administration, presumably
because of the active α-hydroxy metabolite.9 Given that there M+F
is such wide inter-patient response variability, the administra-
tion of sedatives is therefore titrated to effect.
An important cause of unintended, unconscious sedation is
drug interaction. When benzodiazepines, propofol, and nar-
cotics are used in combination, a potent drug synergy occurs, 0.10 0.20
i.e., the drug effect is many times greater than if the drugs’
Midazolam (mg/kg–1)
effects were simply additive. It is important to appreciate that
narcotics in conjunction with either propofol or midazolam Figure 11.2. Drug synergy: by combining drugs, their effect is
disproportionately enhance the independent sedative effect of many times greater than if the drugs’ effects were simply additive.
either drug alone (Figure 11.2). From Ben-Shlomo I, Abd-El-Khalim H, Ezry J, et al. Midazolam acts
Conscious sedation may easily progress to unconscious synergistically with fentanyl for induction of anesthesia. Br J Anaesth.
1990;64(1):45-47.
sedation following incremental dosing of sedative or as pain-
ful stimulation diminishes or ends. The loss of the painful
stimulus that serves as an arousal mechanism results in deeper
sedation. Clinically, sedation should be considered a con-
recovery (10 to 20 minutes). It provides antegrade, dose-
tinuum from conscious to unconscious with both monitoring
dependent amnesia and is reversible with the specific ben-
and vigilance being employed to achieve the desired state.
zodiazepine antagonist flumazenil. When implemented, the
pharmacologic antagonism is effective quickly and only takes
Medications approximately one arm-brain circulation time (i.e., 30 to
The most commonly used sedatives are midazolam, fentanyl, 60 seconds). Midazolam causes less compromise of airway
ketamine, propofol, and recently dexmedetomidine. Local tone than propofol and less respiratory depression than nar-
anesthesia is used to provide the analgesia and occasionally cotics like fentanyl. Even though 1 mg of intravenous mid-
narcotic is added as a supplement. If the sedatives are used azolam in the elderly patient may cause severe respiratory
to anesthetize (i.e., provide the analgesia), then it is no longer depression and prolonged hypnosis, younger patients typically
“sedation.” Each of the sedative drugs listed with the excep- receive 5 mg intravenous (IV) midazolam once intravenous
tion of dexmedetomidine is also capable of inducing general access has been established. The clinical response ranges from
anesthesia when given in larger doses. no apparent effect to sleep. The response to this initial bolus
Midazolam (Versed) is a water-soluble benzodiazepine gives important clues to the anticipated drug requirement dur-
agonist characterized by rapid onset (30 to 60 seconds), with ing the remainder of the procedure.
peak effect (2 to 3 minutes) and, after small doses, also rapid Fentanyl is a synthetic opioid agonist also characterized by
rapid onset (30 to 60 seconds) and recovery (15 to 20 minutes).
Its peak effect is reached at approximately 10 minutes. Other
100 synthetic opioids include, from short to longer acting, remifent-
90 Age
anil (3 to 5 minutes), alfentanil and sufentanil (5 to 10 minutes).
Percent of patients demonstrating
Fentanyl when given as an infusion via an electronic pump at

no response to verbal command
80 80
70
2 µg/kg/h decreases the requirement for other sedative agents
70 60
50
by approximately 50% but increases the likelihood of postop-
60
erative nausea and vomiting. To decrease the incidence of nau-
40
50 sea, the complete avoidance of narcotics should be given serious
40 consideration because a large percentage of patients will be
30 substantially free of pain due to residual local anesthetic
effects at the end of the procedure and during their recovery
20
room period. This strategy markedly decreases motion-induced
10
nausea during the patient’s trip home or to the hotel.
0 While propofol was developed as an induction agent for
0 200 400 600 800 1,000 1,200
general anesthesia, it has become the mainstay for most mod-
Steady-state plasma midazolam concentration (ng/mL)
erate and deep sedation protocols where it is given as a titrated
infusion. Commonly, a level of sedation is initially achieved
Figure 11.1. Inter-patient variability of minimum effective plasma
concentration in individual subjects and decrease with age. From with midazolam and then titrated small incremental bolus or
Jacobs JR, Reves JG, Marty J, et al. Aging increases pharmacody- continuous infusion propofol is added to facilitate the pro-
namic sensitivity to the hypnotic effects of midazolam. Anesth Analg. gression from mild sedation to deeper sleep. Propofol has a
1995;80:143-148. very rapid onset of effect <1 minute. When titrating to the
desired effect, about 2 minutes should be allowed after bolus

administration for peak drug effect to occur. Propofol is a Pulse oximetry is the method by which oxygenation is

profound depressant of central respiratory drive and decreases objectively, continuously, and noninvasively assessed, and
airway tone and as a result further interferes with respiration. its use, as previously noted, is the standard of care during
In terms of pharmacokinetics, the elimination half-life of pro- sedation. The pulse oximeter is best utilized in the fastest
pofol is 30 to 60 minutes, while its duration of action is much response (usually not the factory default setting) and applied
Basic Science
shorter, <10 minutes, as a result of redistribution to muscle to a finger rather than a toe.
and fat. This short duration of action makes propofol given Ventilation is the other component of respiration. A coher-
as a continuous infusion an ideal drug for providing moder- ently talking patient is adequately ventilating. With rare excep-
ate to deep sedation. It is important to appreciate that with a tions, therefore, provided the presence of an adequate surgical
continuous infusion, as the volume of redistribution becomes block, reducing sedation and thereby getting the patient to fol-
saturated over time, a progressively greater portion of infused low complex commands (i.e., hold still) may be a safer choice
drug becomes bioavailable and the level of anesthesia deepens. than deepening a squirming/restless patient. If lightening the
A steady-state propofol infusion will continue to progressively patient is not an option, a pre-tracheal stethoscope is helpful
increase the plasma and effect site concentration of the drug to identify airway obstruction, wheezing, as well as the pres-
for over 25 minutes before a relative steady state tends to be ence or absence and frequency of ventilatory efforts.
reached.10 This requires constant assessment of the patient Ventilation can be simply monitored by chest wall imped-
and then tapering of the rate of infusion. The concept of titra- ance in which the ECG transduces a respiratory waveform,
tion to effect does not simply apply to achieving an appropri- allowing assessment of both rate and quality of respiration.
ate level of sedation but maintenance of that level as well. Specifically, chest wall impedance utilizes an electrical current
It is also important to appreciate the resultant synergy transmitted between the ECG electrodes through the thorax.
when propofol, benzodiazepines, and narcotics are used in Gas is a poor conductor of electrical current and with inspira-
combination. tion, the volume of gas increases in the chest and conduction
Benzodiazapines do not compromises airway tone to falls. This change in conduction or increasing impedance with
nearly the same extent as propofol but clinically the combi- inspiration is transduced into a waveform and rate so that res-
nation of the two facilitates deep sedation with relative pres- piration can be qualitatively and semiquantitatively assessed
ervation of airway tone. The combination of the two drugs simply and noninvasively. Impedance monitoring does not
is not fixed in terms of dose. Obese patients or patients with work in all patients and may fail to differentiate a patient who
a history of sleep apnea should generally receive relatively has chest movement but an obstructed airway from one who
more benzodiazepine and less proprofol. The addition of is not obstructed.
dexmedetomidine (Precedex) is useful to consider in these Capnography, end tidal carbon dioxide sampling with a
patients as well. It is a highly specific α2-adrenoceptor ago- carbon dioxide waveform display, is a more definitive form
nist with centrally mediated sympatholytic effects.11 Onset of of monitoring ventilation and can be accomplished with cap-
effect can be expected at 5 to 8 minutes, with a peak effect at nograph attached to a specially designed CO2 sampling nasal
10 to 20 minutes, and a duration of effect of 2 to 4 hours. It cannula or one that has been modified with a sampling cath-
has sedative and analgesic effects without respiratory depres- eter inserted through one of the nasal prongs. Capnography
sion and when titrated at rates between 0.4 and 0.1 µg/kg/h allows the most accurate monitoring of both rate and qual-
allows an approximately 30% to 40% reduction in anes- ity of ventilation. This technique will often underestimate but
thetic requirements. never overestimate arterial CO2. Capnography has recently
Ketamine is also an attractive medication in that it is both also become a formally stated standard of care during moder-
an analgesic and a sedative and is essentially devoid of respira- ate or deep sedation.7
tory depressant effects. It is important to be aware that ket- Contrary to the knowledge of many anesthesiologists,
amine can cause dysphoria and increases salivation. These side pulse oximetry (the monitor of oxygenation) can function as
effects are mitigated if a benzodiazepine such as midazolam a monitor of ventilation as well. During normal ventilation,
and an antisialagogue such as glycopyrrolate (0.2 mg) are while breathing room air, a person typically has a PaO2 ≈
used in combination. Intramuscular effects peak at 10 min- 75 mmHg, which translates to a saturation (SpO2) of ≈ 98%
utes, intravenous effects at 2 to 3 minutes. Intravenous ket- as displayed by the pulse oximeter. This places the PaO2 and
amine in doses of 10 to 20 mg has a short duration of action SpO2 at the point on the oxyhemoglobin saturation curve
(5 to 10 minutes) and is a potent integumental analgesic, so its where there is a nearly linear relationship between PaO2
administration should be timed to anticipate any particularly decrease and O2 saturation (Figure 11.3). At normal and
painful stimuli such as the infiltration of local anesthetic. low PaO2 values, there is great resolution for PaO2 changes
via the accompanying SpO2 changes. This has considerable
Monitoring impact in relation to PaCO2. Consider the simplified alveolar
Monitoring the level of sedation includes both subjective and gas equation:
objective assessments. With respect to subjective assessment, PaO2 ≈ PIO2 − PaCO2/R
does the patient appear comfortable, anxious, or drowsy?
Thus, a critical first element of monitoring conscious seda- (PIO2 = partial pressure of inspired oxygen; R = respiratory
tion is inspection and conversation to allow titration. A quotient calculated from the ratio of CO 2 eliminated/O2
common sedation endpoint is when the patient feels a drug consumed—typically 0.8)

effect, manifests a change in speech, or the appearance of In the patient breathing room air, a 10 torr increase in
lateral nystagmus. The same monitoring technique (i.e., con- PaCO2, as commonly occurs with narcotic administration,
versation) is also used to establish the second goal, namely therefore results in an approximately 12 mmHg decrease
verifying that the sedation is still of a conscious nature. It is in PaO2. In the patient who is significantly hypercarbic,
prudent to document conversation on the case record in the the increase in PaCO2 will, therefore, result in a significant
list of monitors used. decrease in SpO2, but only if the patient is breathing room air.
Respiration consists of two components, oxygenation and Thus, when applied in this context (without administration
ventilation. It is important to understand that with overseda- of supplemental O2 oxygen), ventilation can be monitored
tion, desaturation occurs secondary to decreased ventilation with a single device—the pulse oximeter. The pulse oxime-
and shallow breathing. In the conscious patient, ventilation is ter’s ability to detect changes in ventilation disappears when
somewhat more difficult to monitor continuously than in the PaO2 is increased to >75 mmHg and the patient is on the flat
unconscious, intubated patient. part of the oxyhemoglobin curve (Figure 11.3). It is therefore

Oxyhemoglobin dissociation “curve” 2. Provided the SpO2 is normal and the patient is on room
SpO2 air, the PaCO2 must be essentially normal.
120 3. When even a small amount of oxygen is administered, the
pulse oximeter no longer functions as a monitor of ventilation.
100 75 600 4. With the titration of benzodiazepines and/or opioids in the
60 context of a saturation of >90% on room air, the patient
80 cannot be in CO2 narcosis.
50
40
5. Should desaturation occur, the airway is optimized and
60 supplemental oxygen is utilized while the level of sedation
is titrated downward.
40 With respect to respiratory physiology and its relation-
ship with sedation, narcotics and sedatives individually as
20 well as together depress the CO2 response curve. Under nor-
0 mal circumstances, ventilation increases as PaCO2 increases.
0 Sedatives, especially narcotics, desensitize the central respira-
0 100 200 300 400 500 700
600 tory centers to CO2, thereby shifting the CO2 response (thresh-
PaO2 old) to the right. The practical implication is less increase in
Figure 11.3. Oxyhemoglobin dissociation curve. Y-axis = percent ventilation per unit increase in CO2. In addition, the slope
of arterial blood saturated with oxygen, X-axis = partial pressure of (sensitivity) of the CO2 response curve is shallower following
oxygen in arterial blood. sedative or narcotic administration.
All narcotics have similar efficacy, although within the
class there are marked differences in potency and duration
of action. Specifically with respect to duration of action:
advisable in our opinion to avoid routine use of supplemen- morphine > fentanyl > sufentanil > alfentanil > remifentanil.
tal oxygen in patients receiving conscious sedation so that the Alexander14 has shown that decreased awareness (sedation)
pulse oximeter is a more sensitive monitor of ventilation— also markedly decreases the slope of ventilation in response to
not just oxygenation. In overview, it is preferable to think hypoxia following midazolam. Furthermore, the ventilatory
of supplemental oxygen as a method to treat desaturation. response to CO2 in a patient receiving midazolam is dimin-
One needs to be cognizant that supplemental oxygen masks ished to a greater extent and for longer duration in patients
oversedation with hypoventilation and makes desaturation a with COPD.15 Thus, individual titration to effect with careful
late and precipitous sequel of oversedation. Besides the clini- monitoring is again the mainstay of sedative dosing.
cal advantage of converting the pulse oximeter from a pure Amnesia, an additional component of sedation, is pre-
oxygenation monitor into both a ventilation and oxygenation dominantly achieved through the use of benzodiazepines. It
monitor, the withholding of oxygen (when it is not necessary) must be appreciated though that actually achieving amnesia is
has additional advantages: 1) improved individual titration by inconsistent. Specifically, in the absence of pain, little sedation
early feedback via minor desaturations; 2) less likelihood of is required to achieve amnesia. Pretreatment with a benzodi-
combustion with the use of electrocautery and laser as is com- azepine, for example, 5 to 10 mg Valium, orally prior to OR
mon during head and neck cosmetic procedures.12 To reduce entry should be considered. If benzodiazepines are adminis-
the incidence of airway fire, provided a patient has a normal tered after the patient feels pain, amnesia is not predictable.
saturation on room air, it is acceptable practice to abandon Lastly, it is important to appreciate that while propofol and
CO2 monitoring with head and neck procedures, because the narcotics are not amnestic agents, they do synergize with ben-
required plastic components would increase the chance for zodiazepines to help achieve this goal.
combustion in the field. If supplemental oxygen is used during In terms of monitoring the depth of anesthesia and there-
procedures on the head or thorax done with sedation, then fore awareness and amnesia, bifrontal referential EEG (BIS)
either the airway should be protected (e.g., laryngeal mask or has been used with variable success.16 The inconsistent results
endotracheal tube) or the oxygen concentration coming out of are likely a consequence of the muscle movement electromyo-
the nasal cannula should not exceed 30%. The latter approach gram artifact.
requires an air oxygen blender or separate flow meters.
If a patient manifests decreased oxygen saturation and can- Oversedation
not be encouraged to ventilate, the initial intervention is that
A final consideration with respect to sedation is that of excess
of airway optimization followed by adding supplemental oxy-
drug effect from a drug administration error, drug synergy, or
gen and alerting the surgeon. This can include jaw lift, neck
a loss of offsetting noxious stimulus. In such a circumstance,
extension, and insertion of an oral or nasal airway. After the
the treatment approach is:
airway has been optimized, supplemental O2 can be phased
out while sedation is titrated downward. During the use of 1. stimulate the patient and support the airway;
supplemental O2, the drop in oxygenation is delayed in rela- 2. administer supplemental oxygen;
tion to the hypoventilation, but once it occurs, the speed of 3. discontinue sedative drug administration; and lastly
deterioration is independent of the presence or absence of sup- 4. consider an intravenous drug antagonist if the excess effect
plemental oxygen. Quite simply, supplemental oxygen masks is not attenuated or resolved by 1 to 3.
oversedation until it is late and intervention then must be
Toward that end, it is ideal to preferentially use sedative
faster and more definitive, which often involves violating the
drugs with a short half-life or for which a specific antagonist
surgical field. Because CO2 has an anesthetic potency about
is available. Narcotics can be antagonized with naloxone typi-
four times that of N2O,13 by the time desaturation occurs in
cally only requiring 20 to 40 µg (0.5 to 1 cc of 0.4 mg nalox-
the presence of oxygen, the patient may already be in CO2
one drawn up to a total volume of 10 cc). Benzodiazepines
narcosis and therefore less likely to respond to complex com-
are antagonized with flumazenil typically requiring 0.1 to
mands or to stimulation. Severe consequences may ensue if
0.3 mg (1 to 3 cc of standard concentration of 0.1 mg/cc).17 No
the patient subsequently is difficult to mask or intubate. It is
facility where sedation is performed should be without these
useful to stress several observations:
antagonists readily available. If only benzodiazepine has been
1. Above a PaO2 of 75 mmHg supplemental oxygen creates a administered, flumazenil should be utilized as naloxone would
false sense of security. be of no benefit. If a patient has received both benzodiazepine

and narcotic sedation, it is common to use naloxone first as
Conclusion

the narcotic component is the more likely cause of the respi-
ratory depression. Two other considerations are important. A safe outcome from an office procedure performed under
First, when possible, titrate the antagonist to avoid a sympa- IV sedation is predicated on patient preparation, planning,
thetic surge from acute withdrawal. Second, if several rounds and technique. Further, in the same way that understanding
Basic Science
of antagonist do not have the desired effect, consider other the operation helps the anesthesiologist optimize outcome,
diagnoses, for example, metabolic derangement or stroke. understanding the sedation can afford the same benefit to the
surgeon. While what we have written may seem unnecessarily
Postoperative Nausea and Vomiting detailed in some regards and superficial in others, our goal is
An important consideration with respect to any surgery is to provide a conceptual understanding of procedural sedation
postoperative nausea and vomiting (PONV). This is particu- beyond a simple knowledge of drug dosage and effect.
larly important in cosmetic surgery as PONV can detract from
the perception of the overall experience, no matter how ideal References
the outcome. Beyond the subjective implications, nausea and 1. Sun Tzu S. In: Griffith SB, ed. The Art of War. Oxford: Oxford University
vomiting can also undermine the outcome, especially in proce- Press; 1971.
dures involving the head and neck. Specifically, during vomit- 2. Fleisher LA, Beckman JA, Brown KA, et al. ACC/AHA 2007 guidelines on
ing, as the intra-abdominal pressure is increased with a closed perioperative cardiovascular evaluation and care for noncardiac surgery: a
report of the American College of Cardiology/American Heart Association
glottis, the intrathoracic pressure increases, thus impeding Task Force on Practice Guidelines. Circulation. 2007;116(17):e418-e500.
venous return. This may translate into oozing and more sig- 3. Dalal AR, D’Souza S, Shulman MS. Brief review: coronary drug-eluting
nificantly the development of a wound hematoma. Vomiting stents and anesthesia. Can J Anaesth. 2006;53:1230-1243.
is often accompanied by an increase in the blood pressure as 4. Le Manach Y, Ibanez E, Cristina M, et al. Impact of perioperative statin
therapy on adverse postoperative outcomes in patients undergoing vascular
well, which can further predispose to these complications. surgery. Anesthesiology. 2011;114:98-104.
Prophylactic pretreatment is essential as preventing nausea is 5. Kral JG. Surgical treatment of obesity. In: Bjorntorp P, ed. International
more easily accomplished and reliable than treating it. The use Textbook of Obesity. Hoboken, NJ: John Wiley & Sons Ltd; 2001.
of low-dose intraoperative corticosteroids has become routine 6. Practice guidelines for preoperative fasting and the use of pharmacologic
agents to reduce the risk of pulmonary aspiration: application to healthy
in plastic surgery and dexamethasone 10 mg has been shown patients undergoing elective procedures. A report by the American Society
to be efficacious in both preventing and treating PONV. The of Anesthesiologists Task Force on Preoperative Fasting. Anesthesiology.
antiemetic mechanism of action is not well understood. It is 1999;90:896-905.
thought that dexamethasone may antagonize prostaglandin 7. Basic Anesthetic Monitoring, Standards for (Effective July 1, 2011). www.
asahq.org. Accessed December 11, 2012.
or release endorphins that elevate mood, improve one’s sense 8. Papadonilolatis A, Wiesler ER, Olympio MA, et al. Avoiding catastrophic
of well-being, and stimulate appetite. A useful multimodal complications of stroke and death related to shoulder surgery in the sitting
algorithm also includes intraoperative administration of position. Arthroscopy. 2008;24(4):481-482.
Ondansetron 4 to 8 mg IV along with the Decadron. Diabetes 9. Crevoisier C, Ziegler WH, Eckert M, et al. Relationship between plasma
concentration and effect of midazolam after oral and intravenous adminis-
is a relative contraindication to Decadron as even this small tration. Br J Clin Pharmacol. 1983;16:51S-61S.
amount of Decadron can play havoc with blood glucose con- 10. Simulation of Propofol Pharmacokinetics. http://vam.anest.ufl.edu.
trol for 12 to 24 hours. A careful history should be taken Accessed December 11, 2012.
preoperatively, and if a history of motion sickness is elicited, 11. Bekker A, Kaufman B, Samir H, et al. The use of dexmedetomidine infusion
for awake craniotomy. Anesth Analg. 2001;92:1251-1253.
dimenhydrinate ½ tablet po or a scopolamine patch applied 12. Joint Commission on Accreditation of healthcare organizations: Sentinel Event
preoperatively can also be very helpful. Alert 29: preventing surgical fires, June 24, 2003. www.jointcommission.org
13. McAleavy J, Way W, Altstatt A, et al. The effect of PCO2 on the depth of
Postoperative Pain anesthesia. Anesthesiology. 1961;22(2):260-264.
14. Alexander CM, Gross JB. Sedative doses of midazolam depress hypoxic
While the mainstay of pain management has always been ventilatory responses in humans. Anesth Analg. 1988;67:377-382.
narcotics, this class of drugs is not without side effects such 15. Gross JB, Zebrowski ME, Carel WD, et al. Time course of ventilatory depres-
sion after thiopental and midazolam in normal subjects and in patients with
as constipation and more importantly nausea and vomiting. chronic obstructive pulmonary disease. Anesthesiology. 1983;58:540-544.
The COX-2 inhibitors as nonsteroidal anti-inflammatory 16. Glass PS, Bloom M, Kense L, et al. Bispectral analysis measures sedation
drugs decrease the mediators of pain and inflammation with- and memory effects of propofol, midazolam, isoflurane, and alfentanil in
out affecting platelet function. Beginning these drugs preop- healthy volunteers Anesthesiology. 1997;86:836-847.
17. Carter AS, Bell GD, Coady T, et al. Speed of reversal of midazolam-
eratively and continuing them for 3 days postoperatively can induced respiratory depression by flumazenil—a study in patients
greatly decrease narcotic usage and the resultant narcotic- undergoing upper G.I. endoscopy. Acta Anaesthesiol Scand. 1990;34
related adverse side effects. (suppl 92):59.

Chapter 12 n Local Anesthetics
Alisa C. Thorne
The clinically useful local anesthetics are either amino amides local anesthetic. In clinical settings, however, other fac-
or amino esters. These agents are effective when applied topi- tors, such as vasodilatory activity and the tissue redistribu-
cally, injected subcutaneously, or injected in the area of major tion properties of the different local anesthetics, influence
peripheral nerves. potency to some extent.
Onset of Action. The onset of action is primarily a result

Mechanism of Action of the pKa, but the dose and the concentration are also fac-
Local anesthetics cause a blockade in nerve condition. The tors. In vitro studies confirm the relationship between pKa
local anesthetic diffuses passively through the neuronal cell of a local anesthetic compound and the onset of anesthesia.
membrane in the nonionic state, becomes charged, and blocks Lidocaine has a pKa of 7.4 and a more rapid onset of action
the sodium channel within the neuron. With sodium con- than tetracaine, which has a pKa of 8.6.
ductance inhibited, threshold potential is not reached and an
action potential is not generated.
Duration of Action. In the clinical arena, the duration of
local anesthesia is principally influenced by the vasodilator
effects of the individual drugs. With the exception of cocaine,
Pharmacology all local anesthetics cause some degree of vasodilation. The
greater the degree of vasodilation, the greater the amount of
The molecular structure of local anesthetic agents consists of the drug that is absorbed by the vascular system, leaving less
an aromatic moiety at one end, an amine moiety at the other drug to act on the nerve cell. Therefore, the degree of vasodila-
end, and an intermediate chain between. The latter contains tion is inversely related to the duration of action. See the sec-
either an amide or an ester linkage, allowing local anesthet- tion “Addition of Epinephrine.”
ics to be classified as either amides or esters. Commonly used
esters are procaine (Novocain), chloroprocaine, tetracaine, Duration and Potency Summary. In summary, agents
and cocaine. Commonly used amides are lidocaine, mepiva- with low potency and short duration are procaine (Novocain)
caine, prilocaine, bupivacaine (Marcaine), and etidocaine. and chloroprocaine; agents with moderate potency and dura-
Differences in the metabolism of local anesthetics, their stabil- tion are lidocaine (Xylocaine), mepivacaine, and prilocaine;
ity in solution, and differences in allergenicity are all related to agents with a high potency and a long duration are tetracaine,
the presence of an ester or amide linkage. bupivacaine (Marcaine), and etidocaine.
Metabolism Effect of Total Dose

Esters undergo hydrolysis in the plasma by pseudocholinester- Other factors determine a local anesthetic agent’s activity in
ase, whereas the amides are metabolized in the liver. The rate the clinical setting. Total dose is probably the single most
of metabolism of local anesthetics is related to the number of important factor in determining satisfactory local anesthesia.
additional carbon atoms on the aromatic or amine side of the Also, as mentioned earlier in the section “Onset of Action,” the
molecule. greater the dose, other factors being equal, the faster the onset
of action.
Stability in Solution
Esters are unstable in solution. Amides are stable in solution. Addition of Epinephrine
The addition of vasoconstrictors is another factor deter-
Allergenicity mining the performance of the local anesthetic. Epinephrine
Esters are also more likely to cause allergenic reactions than markedly prolongs the duration of action of all local anes-
amides. A true allergic reaction to lidocaine is extremely rare, thetics when used for local infiltration or peripheral nerve
although many patients will state, incorrectly, that they have blocks. By decreasing the rate of vascular absorption, vaso-
such an allergy. constrictors cause a higher concentration of local anes-
thetic molecules to be available to act on the nerve cell
membrane.
Potency and Toxicity Epinephrine is frequently used in combination with local
Potency and toxicity are determined by the structure of the anesthetics at concentrations of 1:100,000 or 1:200,000. In
aromatic and the amine group. fact, epinephrine is probably equally effective at much lower
doses (1:1,000,000) and might decrease the danger of an
intravascular injection.
Anesthetic Profile
The profile of a particular local anesthetic agent is related to Location of Injection
its lipid solubility, protein binding, acid strength (pKa), and
vasodilator activity. The anatomy of the site of injection also has a role in deter-
mining the activity of a local anesthetic. Intradermal injec-
tion allows for the most rapid onset of action but the shortest
Potency duration of these agents, whereas brachial plexus block injec-
Anesthetic potency is determined primarily by the degree tions yield some of the longest durations and slowest onsets
of lipid solubility. The local anesthetic molecule must pen- of action seen with local anesthetics. Although intradermal
etrate the nerve cell membrane to have an effect. In vitro, injection provides the most rapid onset, it is more painful than
hydrophobicity alone determines the potency of a given subcutaneous injection.
100
Chapter 12: Local Anesthetics 101
Peripheral Nerve Blocks Infiltration of Local

There are two general types of peripheral nerve blockade: Anesthetics
major and minor. Blocks of individual nerves, such as radial The most common method of achieving local anesthesia
nerve block, are referred to as minor, and blocks of two or
Basic Science
for minor office procedures is infiltration anesthesia, in
more nerves or a plexus of nerves are called major nerve which the agent is injected into the operative site without
blocks. A wide variety of local anesthetics can be used for selectively blocking a specific nerve. Any local anesthetic
minor nerve blocks. The drug is usually selected based on the can be used for infiltration except cocaine. Injection may
duration of anesthesia that is required. The duration of action be intradermal, subcutaneous, or both. Again, the dura-
of minor nerve blockade is prolonged by the addition of epi- tion of action will vary and the addition of epinephrine
nephrine to the local anesthetic solution. will prolong the duration of analgesia. Dilute anesthetic
A commonly used major nerve block is the brachial solutions are recommended for large areas to avoid toxic-
plexus (or axillary) block (see Chapter 71). Although the ity. Infiltration of local anesthetic causes a painful, burn-
onset of action for minor nerve blocks is generally rapid ing sensation. Injection into the dermis is the most painful
for all the local anesthetics, there are differences in onset and provides the fastest onset of action. Addition of sodium
between the various anesthetic agents when major nerve bicarbonate decreases the pain associated with infiltration.
blocks are performed. Epinephrine, in general, will prolong Table 12.3 shows the maximal dose and duration of local
the duration of brachial plexus blockade. The longer acting anesthetics when used for infiltration anesthesia. When
local anesthetics do not demonstrate as much prolongation maximal doses are employed, the onset is very rapid regard-
of action with epinephrine as do the shorter acting agents. less of which agent is selected.
Tables 12.1 and 12.2 show the maximal dose, onset, and
duration of action of the commonly used local anesthetics
for minor and major nerve blocks. Toxicity of Local Anesthetics
To avoid toxicity, local anesthetics must be administered
within a safe dose range and in the correct anatomic location.
Topical Anesthesia During local anesthesia, when toxic reactions occur, they are
Topical anesthesia is increasingly important in pediatric intra- almost always the result of inadvertent intravascular injec-
venous insertion and is used by some surgeons to lessen the tion or the administration of an excessively large dose. Many
discomfort of injectables such as Restylane and Botox. These patients report an “allergy” to local anesthesia that was prob-
topical agents will provide dermal anesthesia if applied far ably actually symptoms related to an intravascular injection
enough in advance but do nothing to lessen the burning asso- and probably related to the epinephrine rather than the local
ciated with subcutaneous injection. anesthetic. Every effort should be made to avoid intravascular
Eutectic mixture of local anesthetics (EMLA) is a combi- injection. The syringe should always be aspirated before the
nation of 25 mg lidocaine and 50 mg prilocaine per gram of local anesthetic is injected, regardless of the anatomic site of
EMLA. L-M-X4 contains 4% lidocaine per gram. These for- injection. Repeat aspirations should be made after injecting 2
mulations decrease pain secondary to intravenous insertion to 3 mL of local anesthetic. If blood is seen in the syringe, the
and also provide adequate analgesia for split-thickness skin needle must be repositioned. An intravascular injection of an
graft harvesting. L-M-X4 may have a slightly faster onset but epinephrine-containing solution may produce a dangerously
both preparations are best applied between 30 and 60 minutes hypertensive response.
prior to the procedure and are best covered with an occlusive As mentioned earlier, the addition of epinephrine to the
dressing such as Tegaderm or OpSite. anesthetic solution delays absorption and results in lower
Several other topical local anesthesia preparations are anesthetic blood levels, as well as a longer duration of action.
available that provide brief periods of anesthesia when they Epinephrine is especially useful when local anesthetic is
are applied to mucous membranes or abraded skin. The most being injected into highly vascular areas such as the face. It
common local anesthetic agents used topically are lidocaine, was previously believed that epinephrine should be omitted
dibucaine, tetracaine, and benzocaine. from anesthetic solutions injected in proximity to end arteries
Table 12.1
Dosage and duration Characteristics of the Local Anesthetics when used for Minor Nerve
Blocks (e.g., Median Nerve Block at the Wrist)
Epinephrine-Containing
Plain Solutions Solutions
n Usual n Usual n Average n Average
Concentration Volume Duration Duration
n Drug (%) (mL) n Dosage (mg) (min) (min)
Procaine 2 5-20 100-400 15-30 30-60
Chloroprocaine
Lidocaine
Mepivacaine 1 5-20 50-200 60-120 120-180
Prilocaine
Bupivacaine 0.25 5-20 12.5-50 180-360 240-480
Etidocaine 0.5 5-20 25-100 120-240 180-420
Reprinted with permission from Strichartz GR, Covino BG. Local anesthetics. In: Miller RD, ed. Anesthesia. 4th ed. New York, NY: Churchill
Livingstone; 1994.

Table 12.2
Dosage and duration Characteristics of the Local Anesthetics when used for Major Nerve
Blocks (e.g., Axillary Block of the Brachial Plexus)
n Drug With n Usual n Usual n Usual n Usual

Epinephrine Concentration Volume n Maximal Onset Duration
1:200,000 (%) (mL) Dose (mg) (min) (min)
Lidocaine 1–1.5 30–50 500 10–20 120–240

Mepivacaine 1–1.5 30–50 500 10–20 180–300
Prilocaine 1–2 30–50 600 10–20 180–300
Bupivacaine 0.25–0.5 30–50 225 15–30 360–720
Etidocaine 0.5–1.0 30–50 400 10–20 360–720
Tetracaine 0.25–0.5 30–50 200 20–30 300–600
Reprinted with permission from Strichartz GR, Covino BG. Local anesthetics. In: Miller RD, ed. Anesthesia. 4th ed. New York, NY: Churchill
Livingstone; 1994.
(e.g., fingers, toes, and penis) because of the danger of isch- CVS toxicity is the result of direct myocardial depres-
emic necrosis. Recent studies cast doubt on this dictum. sion by the local anesthetic. A depressant effect on vascular
The toxicity of local anesthetic agents affects the central smooth muscle, as well as on the conducting system, is seen.
nervous system (CNS) and the cardiovascular system (CVS). This effect is rarely observed in the clinical setting. Cardiac
CNS toxicity occurs at a lower dose range than does CVS tox- stimulation is the more common result of toxic levels of local
icity. Whereas CNS toxicity is more common, CVS toxicity is anesthetics and is the result of an increase in CNS activity.
more dangerous and more challenging to treat. CVS toxicity may present itself as a drop in blood pressure,
Local anesthetics freely cross the blood–brain barrier. an increase or decrease in heart rate, ventricular fibrillation,
The initial result of toxic levels of local anesthetics is depres- or cardiac arrest.
sion of cortical inhibitory pathways, which allows excitatory The inadvertent intravenous injection of bupivacaine
pathway activity to be unopposed. When even higher blood (Marcaine) or etidocaine can result in severe cardiovascular
levels are reached, generalized CNS depression occurs. Early compromise and collapse, frequently refractory to attempts
signs of CNS toxicity include light-headedness, restlessness, at resuscitation. This is because of the high degree of tis-
tinnitus and other auditory or visual disturbances, slurred sue binding of these two local anesthetics. Consequently,
speech, tremors, metallic taste in the mouth, and numbness bupivacaine (Marcaine) should probably not be used when
of the lips or tongue. If more local anesthesia is given, grand an intravascular injection is likely. For example, it should
mal seizures may result. At even higher blood levels, loss of probably not be used for subcutaneous injection prior to
consciousness, apnea, and cardiovascular collapse are seen. a facelift where large volumes of solution are injected in a
If a large dose of local anesthetic is anticipated, pretreat- vascular area. Also, the pregnant patient is more sensitive
ment with a benzodiazepine may prevent toxicity. Diazepam to CVS toxicity of bupivacaine (Marcaine) than is the non-
doubles the seizure threshold for lidocaine. pregnant patient.
Table 12.3
Dosage and duration Characteristics of the Local Anesthetics when used for Infiltration
Anesthesia (e.g., Infiltration around the Periphery of a Skin Lesion before Excision)
Plain Solution Epinephrine-Containing Solution

n Concentration n Max Dose n Duration n Max Dose n Duration
n Drug (%) (mg) (min) (mg) (min)
Short duration
Procaine
Chloroprocaine 1.0–2.0 800 15–30 1,000 30–90
Moderate duration
Lidocaine 0.5–1.0 300 30–60 500 120–360
Mepivacaine 0.5–1.0 300 45–90 500 120–360
Prilocaine 0.5–1.0 500 30–90 600 120–360
Long duration
Bupivacaine 0.25–0.5 175 120–240 225 180–420
Etidocaine 0.5–1.0 300 120–180 400 180–420
Reprinted with permission from Strichartz GR, Covine BG. Local anesthetics. In: Miller RD, ed. Anesthesia. 4th ed. New York, NY: Churchill
Livingstone; 1994.

Chapter 12: Local Anesthetics 103
is lowered with increasing dose, and seizures can result. The
Tumescent Technique for

adrenergic effects of cocaine are responsible for the increased
Liposuction heart rate, hypertension, mydriasis, tremors, and perspiration
seen with an overdose.
Experience with the “tumescent technique” of local anes- Traditionally, the most common clinical use of cocaine in
Basic Science
thesia infiltration casts doubt on previous “facts” regard- plastic surgery is as a topical anesthetic and vasoconstrictor in
ing maximal local anesthetic dose. This technique involves rhinoplasty. It is no longer often used as other agents are safer
the infiltration of large volumes of a dilute solution of and cheaper and have less potential for abuse. The addition
lidocaine (0.1% or 0.05%) and epinephrine (1:500,000 to of epinephrine to the topical cocaine may enhance vasocon-
1:1,000,000) into the subcutaneous adipose tissue prior to striction but is not safe. The combination can cause danger-
liposuction procedures. Studies demonstrate that doses up ous arrhythmias. It is not even clear that adding epinephrine
to 35 mg/kg lidocaine (five times the manufacturer’s recom- to topical cocaine enhances the operating conditions. Studies
mended dose) can be given safely. Serial serum lidocaine have not demonstrated a consistent benefit from adding epi-
levels drawn postoperatively appear to verify the safety of nephrine to either 10% cocaine or to lower concentrations of
this technique, which has been extended to other procedures topical cocaine.
such as abdominoplasty (see Chapter 53). The safety of this General anesthesia and topical cocaine are frequently
technique probably depends on the anatomy of the site of used together, and there are multiple studies and case reports
injection and the dilute nature of the solution injected. The describing the complexity of drug interactions that occur.
face is not the same as the body. Although the exact dose These reports offer conflicting views of the effect that cocaine
of lidocaine that can be used safely in the face has not been has on anesthetic requirements as well as the effect of the com-
clarified, it is clear that doses such as 35 mg/kg, which are bination of cocaine and varying anesthetics on their arrhyth-
safe in the subcutaneous tissues of the trunk, are far too large mogenic potential. Studies on the combination of cocaine and
for the face. Until a safe maximum dose is defined, surgeons general anesthetics suggest that anxious or unpremeditated
are advised to use no more than the 7 mg/kg recommended patients are more prone to arrhythmias and that cocaine
by the manufacturer. should not be applied before induction or soon after induc-
tion, before the achievement of a deep level of anesthesia. In
Treatment of Local those patients in whom topical cocaine was used after induc-
Anesthetic Toxicity tion, and after a deep level of anesthesia was achieved, there
were no arrhythmias. Therefore, a patient’s endogenous cat-
The first step in the treatment of a patient who is convulsing echolamines are involved in these complex drug interactions.
as a consequence of local anesthetic toxicity is hyperventi- There is also widespread agreement that ketamine sig-
lation with an Ambu bag and face mask using 100% oxy- nificantly enhances the arrhythmogenicity of cocaine.
gen. Hypercarbia can worsen CNS toxicity. If the patient Additionally, patients receiving monoamine oxidase (MAO)
has a full stomach, an endotracheal tube should be placed inhibitors are especially at risk for dangerous interactions
as soon as possible to prevent aspiration. Hyperventilation with cocaine. Topical cocaine should be avoided unless
may terminate the seizure, but if it does not, diazepam, the patient has been taken off the MAO inhibitor 2 weeks
0.1 mg/kg, or thiopental, 2 mg/kg, intravenously is usually before the surgical procedure. Because of its sympathomi-
effective. metic effects, cocaine also should be avoided in hypertensive
In the patient who is hypotensive as a result of local anes- patients. Unfortunately, individual response to cocaine varies.
thetic toxicity, the treatment is intravenous fluids, peripheral In some patients, ventricular fibrillation and cardiac arrest can
vasoconstrictors (e.g., phenylephrine), and Trendelenburg occur as a result of a dose as small as 0.4 mg/kg.
positioning. An inotropic agent (e.g., dopamine) may also The safe maximum dose for nasally administered 4%
be required. The patient in whom arrhythmias develop as a cocaine solution is 1.5 mg/kg. Each drop of 4% cocaine solu-
consequence of toxicity may be refractory to therapy. If the tion has approximately 3 mg cocaine. Given the above disad-
arrhythmia is causing the cardiac output to be significantly vantages of cocaine, however, there may no longer be a good
compromised, or if cardiac arrest occurs, a prolonged period indication for its use.
of resuscitation may be necessary, as these conditions are
known to resolve over time as redistribution of the local anes- Suggested Readings
thetic occurs.
1. Covino BG. Pharmacology of local anesthetic agents. Ration Drug Ther.
1987;21:1.
Cocaine 2. De Jong RH, Heavner JE. Diazepam prevents local anesthetic seizures.
Anesthesiology. 1971;34:523.
Cocaine is unique in that it has both local anesthetic and vaso- 3. Fleming JA, Byck R, Barash PG. Pharmacology and therapeutic applications
constrictive action. It has considerable potential for abuse and of cocaine. Anesthesiology. 1990;73:518.
4. Hallen B, Uppfeldt M. Does lidocaine-prilocaine cream permit pain free
addiction. Over the past several decades, the illegal use of insertion of IV catheters in children? Anesthesiology. 1982;57:340.
cocaine has become epidemic. Cocaine is a crystalline, water- 5. Kelton PL Jr. Local anesthetics, cocaine, and CPR. Sel Read Plast Surg.
soluble powder (pKa 8.6) that is readily absorbed through 1992;7(5):1.
mucous membranes. It undergoes hydrolysis by plasma pseu- 6. Klein JA. Tumescent technique for regional anesthesia permits lidocaine
doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16:248.
docholinesterase. A small percentage of cocaine is metabolized 7. Koehntop DE, Liao J-C, Van Bergen FH. Effects of pharmacologic altera-
in the liver. tions of adrenergic mechanisms by cocaine, tropolone, aminophylline, and
As with the other local anesthetics, the mechanism of ketamine on epinephrine-induced arrhythmias during halothane-nitrous
action of cocaine involves inhibition of conduction in nerve oxide anesthesia. Anesthesiology. 1977;46:83.
8. Lynch C. Depression of myocardial contractility in vitro by bupivacaine,
fibers by blockade of sodium channels, which, in turn, pre- etidocaine, and lidocaine. Anesth Analg. 1986;65:551.
vents an action potential from being generated. Cocaine is 9. Ohlsen L, Englesson S, Evers H. An anaesthetic lidocaine/prilocaine cream
the only local anesthetic that is a potent sympathomimetic. (EMLA) for epicutaneous application tested for cutting split skin grafts.
It blocks reuptake of norepinephrine and epinephrine, both Scand J Plast Reconstr Surg. 1985;19:201.
10. Strichartz GR, Covino BG. Local anesthetics. In: Miller RD, ed. Anesthesia.
in the CNS and systemically. Cocaine has multiple effects on 3rd ed. New York, NY: Churchill Livingstone; 1990:437.
the CNS, resulting in intense behavioral stimulation, eupho- 11. Swerdlow M, Jones R. The duration of action of bupivacaine, prilocaine
ria, and arousal. The seizure threshold is initially raised, but and lignocaine. Br J Anaesth. 1970;42:335.

part II
n Skin and Soft Tissue
Chapter 13 n Dermatology for Plastic

Surgeons I—Skin care and

Benign Dermatologic
Conditions
Renato saltz and Bianca M. B. Ohana
Introduction location as junctional (at the epidermal–dermal junction),

intradermal, or compound (both in the dermis and at the
The skin is the largest organ in the human body. It serves junction). Junctional nevi are frequently found on the
as a mechanical and immunologic barrier and is responsible palms and soles and tend to be uniform, macular, and
for thermoregulation and sensibility. Healthy skin imparts round with smooth and regular borders. Intradermal
the impression of health and beauty, while unhealthy skin nevi are found on the face and are usually homogeneous,
suggests premature aging and illness. Plastic surgeons elevated, dome-shaped, skin-colored lesions. Compound
require a working knowledge of both benign and malignant nevi are raised above the epidermal surface and may be
skin conditions; appropriate treatment can only be rendered round or oval. The color varies with the natural pigmen-
if the correct diagnosis is made. This chapter reviews the tation of the patient and may be very dark. There is usu-
most common benign skin changes and presents a protocol ally little if any pigment on the flat surrounding epidermis
for skin care that can be applied before or after facial aes- in a classic, non-dysplastic, compound nevus. 1 Nevi are
thetic surgery or independent of aesthetic surgery. The next rarely premalignant. See dysplastic (atypical) nevi below
chapter addresses malignant skin conditions. (Figure 13.2).
Anatomy Congenital Melanocytic Nevus. Congenital nevi are

present at birth, usually singular and small. They are clas-
The skin is composed of two layers: the thin epidermis and the sified in three types depending on the size: small, intermedi-
thicker dermis (Figure 13.1). Deep to the dermis is subcutane- ate, and giant (>20 cm) (Chapter 20). They have some poten-
ous fat. There are two types of human skin: skin with hair and tial to develop melanoma, although this risk is low except
glabrous skin (without hair). The latter is found on the palms in the giant variety. Except for size, the overall appearance
and soles and has a much thicker epidermis. of congenital melanocytic nevi and acquired nevi is simi-
The epidermis consists of four layers: stratum corneum, lar.2 Congenital nevi, however, may have dark, thick hair.
stratum granulosum, stratum spinosum, and stratum basale. Histologically, congenital nevi are distinguished by the pres-
In glabrous skin, an additional layer (stratum lucidum) lies ence of nevomelanocytes in the epidermis and in the dermis
between the stratum corneum and the stratum granulosum. as sheets, nests, cords, or single cells.2 For treatment, see
The epidermis contains predominantly keratinocytes, melano- Chapter 20 (Figure 13.3).
cytes, Langerhans cells and Merkel cells.
The dermis is divided into the more superficial papillary Blue Nevus. Blue nevi appear bluish because the nevus
dermis and the deeper reticular dermis. The dermis contains cells are deep in the dermis. These lesions are usually benign
predominantly fibroblasts, mast cells, histiocytes, monocytes, but the literature suggests they can be malignant. Clinically,
lymphocytes, and Langerhans cells. The integrity of the der- blue nevi are solitary, nodular lesions with a smooth sur-
mis is maintained by a supporting matrix containing ground face that tend to be blue or blue-gray. These lesions are
substance and two types of protein fibers: collagen, which has generally treated conservatively unless there has been a
great tensile strength and forms the major constituent of the change in their appearance or the patient requests excision
dermis, and elastin, which makes up only a small proportion for cosmetic reasons. The excision should include the sub-
of the bulk.1 The skin appendages like hair follicles, seba- cutaneous component to ensure complete removal of deep
ceous glands, and apocrine and eccrine glands are also found dermal melonocytes.3
in the dermis.
Halo Nevus. When a melanocytic nevus is surrounded by a
hypopigmented halo, it is termed a halo nevus. These lesions
Benign Lesions tend to occur on the torso in older children and teenagers.
They are common, frequently multiple, usually acquired and
Pigmented Lesions asymptomatic. The central nevus tends to gradually disap-
Nevus or Melanocytic Nevus. Nevi are acquired pear leaving a macular area of non-pigmented skin. This
lesions that present after birth and consist of a concentra- hypopigmented area may persist for years and may gradu-
tion of nevus cells that are classified according to their ally return to a normal color. When biopsies are performed,
105
106 Part II: Skin and Soft Tissue
Figure 13.1. Cross-section view of skin.
there may be no trace of the original lesion.1 The treatment using the Q-switched ruby, neodymium:yttrium-aluminum-
is expectant, avoiding sun exposure at the hypopigmented garnet (Nd:YAG) or alexandrite lasers,4 or make up camou-
areas unless there are cosmetic concerns or the lesions have flage (Chapter 18).
atypical features.
Atypical Moles—Dysplastic Nevi. Dysplastic nevi are
Spitz Nevus. This is a common and usually acquired lesion melanocytic nevi that have the clinical features of mela-
predominantly in children and young adults but can be found noma: asymmetry, border irregularity, color variability, and
in older people as well. Spitz nevi are usually firm, domed- diameter greater than 6 mm (Chapter 14). When patients
shaped, reddish or dark brown nodules, frequently on the present with many atypical moles, they are at higher risk
head and neck. They are compound nevus variations, which for melanoma. Patients who present with many atypical
have distinctive histologic features that make the differen- moles and a strong family history of malignant melanoma
tiation from malignant melanoma difficult.1 The treatment are at much higher risk for melanoma and must have at
is surgical excision. There is controversy over whether an least annual full body examinations for their entire lives. It
entity known as a malignant Spitz nevus exists or if these is difficult for even an experienced dermatologist to know
lesions are malignant melanomas. For these reasons, Spitz
nevi require complete excision with histologic confirmation
of clear margins.
Nevus of Ota. Nevi of Ota are hamartomatous melanocytic

lesions that occur on the face in the distribution of the oph-
thalmic and maxillary division of the trigeminal nerve. They
are much more common in women. The sclera is involved in
two-thirds of cases.1 The treatment consists of laser therapy,
Figure 13.2. Melanocytic nevus. Figure 13.3. Congenital melanocytic nevus.

Chapter 13: Dermatology for Plastic Surgeons I—Skin Care and Benign Dermatologic Conditions 107
when to recommend excisional biopsy. The best indica-
tion for biopsy is a change in clinical appearance. The ideal
surveillance involves total body photographs, which are
compared annually with the patient’s current condition in
order to determine if any lesions have changed over time.
The treatment is excisional biopsy. If step-sectioning of the
entire specimen reveals melanoma, then further treatment is
required (Chapter 14).
Solar Lentigo. Solar lentigines occur on sun-exposed areas

of the face, arms, and dorsum of hands, especially in lighter
skinned white people with light eye color. These acquired
lesions are pigmented macules that can be small or large,
with a tendency to confluence and range in size from 0.2
to 2 cm. They become more numerous with advancing age.
Treatment is not required. A biopsy is taken to exclude
melanoma from any lentigo that develops a highly irregu-
lar border, a localized increase in pigmentation, or localized
thickening.2 Bleaching agents like hydroquinone are not par-
ticularly effective. Topical tretinoin, microdermabrasion, or Figure 13.4. Seborrheic keratosis.
cryotherapy can be used.
Ephelides (Freckles). These are small, less than 3 mm, red

or light brown macules that appear on sun-exposed areas pre- Verrucous Nevus. These are congenital lesions that pres-
dominantly in fair skinned people with red or blond hair, but ent as verrucous p apules or plaques that are skin colored
can appear in darker skinned individuals as well. There is no or brown. A linear configuration is common and it can be
increase in the number of melanocytes, but rather an increase found in any body site. Malignant transformation is very rare.
in the amount of melanin in the skin. They are common in The treatment options due to cosmetic concerns are surgical
childhood; however, they can be seen at any age. They are excision, laser, electrodissection, dermabrasion, cryotherapy,
usually confined to the face, arms, and back. The number TCA, or topical retinoic acid.
varies from a few spots on the face to hundreds of confluent
macules on the face and arms. Treatment is not required, but Skin Tags (Acrochordon). Skin tags are composed of
sunscreen is recommended. Bleaching agents such as hydro- loose fibrous tissue and usually occur as multiple skin-colored
quinone, peels, and intense pulsed light (IPL) can be used for or tan, filiform or smooth-surfaced papules that are 2 to 3
cosmetic reasons. mm in diameter. These small, soft, pedunculated lesions are
frequently located on the neck or major flexures. The simplest
Epidermal Lesions and most expeditious treatment is shave excision with scissors
or a scalpel blade.
Seborrheic Keratosis. This is a common benign, usu-
ally pigmented, neoplasm in elderly people, arising from the
basal layer of the epidermis and consisting of keratinocytes. Premalignant Lesions
The etiology is unknown, and factors like virus infection, Actinic Keratosis. Actinic keratoses may be the most com-
genetics, and sun exposure can be related. Usually sebor- mon of the premalignant skin conditions. Caused by sun
rheic keratoses are not photoinduced. These lesions occur exposure in people with Fitzpatrick skin types I, II, and III,
in any body site (frequently in the face and upper trunk) and they are macules or papules with a scaly surface, generally
are usually asymptomatic or associated with itching. They between 1 mm and 2 cm in diameter. Actinic keratoses occa-
are superficial verrucous plaques, smooth or rough, varying sionally evolve into squamous cell cancers and are therefore
from 1 mm to several centimeters in size and varying from considered premalignant. These lesions frequently require
dirty yellow to dark brown. Histologically, they are char- biopsy to rule out a carcinoma. Multiple lesions are usually
acterized by hyperkeratosis, acanthosis, and papillomatosis. treated with 5-fluorouracil or the immune stimulator imiqui-
The classic description is of a “stuck-on,” waxy appear- mod (Aldara) (Figure 13.5).
ance. Surgical excision or shave excision is appropriate if the
patient complains of cosmetic appearance. Other treatment Leukoplakia. Leukoplakia is white intraoral plaque and
options include curettage, cryotherapy, or trichloroacetic is the most common precancerous lesion of the oral cavity.
acid (TCA). There are times when the lesion is atypical and These lesions do not frequently become squamous cell cancer
an excisional biopsy is indicated for diagnostic purposes but must be followed and biopsied if they persist or undergo a
(Figure 13.4). change in appearance.
Keratoacanthoma. This is a common epithelial tumor Cutaneous Horn. A cutaneous horn is different from a
related to sun exposure than may be better placed in the skin tag and is considered a premalignant lesion. They are
next chapter on malignant lesions. It is more common in usually yellowish brown protuberant “horns” and are found
white phototypes and is usually found on the face or upper on the face and ears. Histologically, they are characterized by
limbs. Classically, it presents as a solitary papule that devel- a compact proliferation of keratin. The treatment is surgical
ops a crater-like central, keratotic core.5 The history is one excision.
of rapid growth over a few weeks. Spontaneous regres-
sion is said to occur, but most lesions are excised before Bowen’s Disease. Bowen’s disease is squamous carcinoma
it becomes clear if regression would have ever occurred. in situ of the skin. This tumor presents as a slowly grow-
The histology is similar to squamous cell carcinoma and ing, red lesion with a scaly surface and irregular borders.
many consider it a low-grade squamous cell cancer. Surgical Ulceration or bleeding may be a sign of invasive malignancy.
excision is usually the treatment of choice. Other potential The treatment of choice is surgical excision, but cryotherapy,
treatment options are curettage, coagulation, and topical curettage, cauterization, topical agents like 5-fluorouracil, and
5-fluorouracil. topical photosensitizer can also be considered.

and bleeding may occur at points of pressure. The treatment

is surgical excision.
Cylindroma
Cylindromas can be solitary or multiple. The multiple lesion
type has a genetic component. They are classically found on
the scalp as numerous small papules or large nodules with
smooth surfaces. Sometimes they cover the entire scalp like
a turban explaining the name turban tumor. They are usu-
ally benign, but malignant development has been reported.
Treatment options include surgical excision, electrosurgery,
and carbon dioxide laser.
Clear Cell Hidradenoma

Clear cell hidradenoma is an eccrine sweat gland tumor.
It occurs as a slow growing usually solitary nodule.
Classically, it is a firm nodule, 0.2 to 5 cm in size. Some
of these tumors discharge serous material, whereas others
Figure 13.5. Actinic keratosis.
tend to ulcerate. Lesions may occur on any body part, but
are most frequently found on the arms, thigh, and scalp.
They can develop malignant tumors. The treatment is surgi-
cal excision.
Hair Follicle Tumors
Trichofolliculoma Apocrine Tumors
This is a rare hamartoma of the pilosebaceous follicle. They Apocrine Cystadenoma
are typically solitary, small, raised nodules with two or three This lesion results from a cystic dilatation of an apocrine
hairs, usually white, protruding together in a tuft. They secretory gland. It is generally a solitary, nodular lesion on the
frequently appear on the face and scalp. Malignant change face that tends to be skin colored to bluish. The treatment is
is not typical but has been reported in a single case with surgical excision.
perineural invasion.1 The treatment recommended is surgical
excision.
Chondroid Syringoma
Pilomatricoma, or Benign Calcifying This tumor is a firm intradermal nodule usually found on the
head and neck that is composed of both sweat gland elements
Epithelioma of Malherbe and cartilaginous elements.4 It is rare and there can be malig-
A pilomatricoma is a hamartoma characterized by a firm, nant degeneration. Surgical excision is recommended.
solitary nodule covered with intact but often discolored skin.
The calcification makes the lesions particularly firm. They Syringocystadenoma Papilliferum
can occur on any body part but are most commonly found
These lesions are benign tumors, present at birth, usu-
on the face and upper extremities. In general, the lesions are
ally on the scalp and neck, that present as multiple trans-
0.5 to 5 cm in diameter. There is no malignant potential. The
lucent or pigmented plaques or papules. The lesions
treatment is surgical excision.
can be verrucous with a central depression that oozes
fluid. Treatment options include surgical excision and
Trichoepitheliomas electrocoagulation.
Trichoepitheliomas are hamartomas of the hair follicle
typically found in the center of the face. They tend to be
small, skin-colored or slightly pink papules that are usually
Sebaceous Tumors
distributed symmetrically on the cheeks, eyelids, and the Sebaceous Nevus
nasolabial region. Treatment is not required; excision may
be contemplated for cosmetic reasons. Other options include Sebaceous nevi are common tumors of childhood. Two-
electrodissection and curettage or cryotherapy. Recurrence thirds are present at birth; the remaining one-third develop
is common. in infancy or early childhood. The lesions are usually soli-
tary, oval to linear, yellowish in color, varying from 0.5
cm to s everal c entimeters, and frequently present on the
Eccrine Tumors scalp. Surgical excision is recommended before adoles-
cence because of the potential for development of basal
Syringomas cell carcinoma (BCCA) and other malignant tumors. The
This is a benign tumor that usually presents as firm, skin- rare nevus sebaceous of Jadassohn syndrome consists of the
colored to yellowish dermal papules on the lower eyelids, pre- triad of a linear sebaceous nevus, convulsions, and mental
dominantly in females. Syringomas can be sporadic or familial retardation.
and are frequently associated with Down’s syndrome. The
treatment is punch or surgical excision for cosmetic reasons Sebaceous Epithelioma
only. Electrodissection, curettage, and carbon dioxide laser
This lesion looks like a BCCA, but tends to be more yel-
can be considered.
lowish because of the sebaceous cellular elements. It is most
frequently located on the scalp and face. Treatment is recom-
Eccrine Poroma mended for cosmetic reasons only. Options include surgical
An eccrine poroma is a solitary, firm, skin-colored or erythem- excision, radiation, electrocoagulation, curettage, and carbon
atous papule, usually on the sole or palm in adults. Ulceration dioxide laser.

Sebaceous Hyperplasia
This is a small tumor composed of sebaceous glands that is
commonly located on the forehead, cheeks, lower eyelids, or
nose. It begins as a pale yellow and slightly elevated papule
and can become dome shaped, and sometimes umbilicated.
Sebaceous hyperplasia does not have any relationship with
solar exposure. Treatment options are electrodissection, curet-
tage, cryosurgery, or surgical excision.

Rhinophyma
Rhinophyma is a localized telangiectatic enlargement of the
nose, most often in men. Histologically, it is characterized
by sebaceous gland hyperplasia, fibrous infiltration, and
lymphedema. Rhinophyma is considered a glandular form of
acne rosacea. The reported incidence of occult cancer in the
setting of rhinophyma varies from 15% to 30%. BCCA is
the most common malignant neoplasm.2 Treatment options
include dermabrasion or other form of deep resurfacing or
surgical excision with reconstruction using a forehead flap
(Figure 13.6).
CYSTS
Epidermal Cyst (or Sebaceous Cyst)
This is the most common type of cyst and occurs because
of proliferation of surface epidermal cells within the der-
mis. Epidermal cysts are rare in children but common in
adults. They are generally round, protruding, smooth-
surfaced masses, varying in size from a few millimeters
to several centimeters. Epidermal cysts grow slowly and
are not symptomatic unless they become infected. Once
infected, rupture is common. The only effective treatment
is surgical excision. If infected, a course of antibiotics is
recommended in an effort to prevent rupture and drain-
age so that excision can be accomplished. Staphylococcus
aureus is the most common pathogen. The entire capsule Figure 13.6. Rhinophyma.
must be removed to avoid recurrence. Genetic syndromes
like Gorlin and Gardner may be associated with epidermal
cysts.
Pyogenic Granuloma
Milium This lesion is a common vascular nodule that exhibits rapid
growth, not unlike a keratoacanthoma, but pyogenic granu-
A milium (plural: milia) is a superficial, white epidermal cyst lomata are totally benign. They can appear at any age and
that appears immediately beneath the epidermis. They are vary in color from brown to bluish-black. They are com-
most common on the eyelids and cheek and often appear pressible and do not pulsate, with a thin surface. Treatment
along a healing upper blepharoplasty incision. The treatment options include curettage and surgical excision.
is unroofing and removal of the central kernel with a #11
blade or needle, or light electrodissection.
Fibrous Tumors
Pilar Cyst Dermatofibroma
A pilar cyst is similar to an epidermal (sebaceous) cyst and is This lesion is a myofibroblast proliferation, characterized by a
a common scalp lesion containing keratin. The treatment of firm, skin-colored or reddish brown sessile papule or nodule,
choice is surgical excision. Like epidermal cysts, if they pres- more commonly in women. They vary in number from 1 to
ent in an inflamed, infected state, they may require drainage. 10 and can be found anywhere on the extremities and trunk.
A course of antibiotics to “cool off” and shrink the lesion is They appear as 3- to 10-mm slightly raised, pink-brown,
worth an attempt, in hopes that the lesion can be excised. dome-shaped, sometimes scaly, hard growths that retract
beneath the skin surface during attempts to compress and
Smooth Muscle Tumors and elevate them. They tend to remain stable for years as discrete
Mesenchymal Tumors solitary lesions. Treatment options include surgical excision
for cosmetic reasons only, cryotherapy, or 600-nm pulsed dye
Leiomyomas laser (Figure 13.7).5
Like leiomyomas elsewhere, these benign smooth muscle
tumors present as solitary, firm, round, flesh-colored nodules, Generalized Disorders
more commonly in the limbs, which are either subcutaneous,
or in the deep dermis. The recommended treatment is surgical Telangiectasias
excision to eliminate what can be a tender lesion and rule out Telangiectasias are vascular malformations characterized
a malignant lesion. by chronically dilated capillaries or small venules. They are

Pseudoxanthoma Elasticum
This can be an autosomal dominant or recessive disorder
causes calcification of elastic tissues and blood vessels arte-
riosclerosis. Skin lesions generally appear as yellow papules
or plaques and skin laxity. The most important aspect of
treatment is to ensure that complications from vascular
involvement are prevented or dealt promptly.1 Plastic surgi-
cal procedures can be performed to improve appearance.
Ehlers-Danlos
This is a connective tissue disorder, characterized by skin
and blood vessel fragility, hyperextensibility, and hyper-
mobility. There are 11 subtypes.1 Patients must avoid preg-
nancy and trauma to soft tissues and be referred for genetic
counseling.
Acne Rosacea
This is a common chronic disorder of the face, usually in
Figure 13.7. Dermatofibroma. white skin characterized by flushing, erythema, and telangi-
ectasias. Bouts of inflammation with swelling, papules, and
pustules may occur. The goal is to avoid skin irritation and
use sunscreen creams. Oral medications like tetracycline and
small, red and linear and may appear like a spider or star isotretinoin (retin-A) can be effective. Topical treatment with
design (Figure 13.8). metronidazole 1%, phototherapy, and makeup camouflage
are also helpful.
Xeroderma Pigmentosum
This is an autosomal recessive disorder, characterized by Hidradenitis Suppurativa
damage to DNA repair. These patients have extreme sun This is a disorder of apocrine glands, more commonly in dark
sensitivity and develop many cutaneous malignancies. The skin, and usually in the axilla, perineal regions, or beneath
lesions require surgical excision, but the outcome is usually the breasts. The disease can be devastating with numerous,
poor. interconnecting comedones or subcutaneous pustules. Local
care and antibiotics tend to keep the lesions somewhat quies-
Dystrophic Epidermolysis Bullosa cent but the only definitive treatment is surgical excision. The
This disorder is characterized by fragility and blistering after heavily contaminated wounds usually have to heal by second-
trauma to the skin. It can be autosomal recessive or domi- ary intention, which is a slow, painful process.
nant. It does not have any specific treatment, except to avoid
trauma. The slightest friction or scrape may result in skin Pyoderma Gangrenosum
lesions that are also prone to infection.1,3 This is rare disorder, which is not infectious in origin, and
presents as solitary or multiple, fragile papules that can
Cutis Laxa progress to ulcers and necrosis. Treatment options include
This is a rare elastolysis disorder with lax skin and loss antibiotics, topical or systemic steroids, and immunosuppres-
of elastic tissue. It can be autosomal dominant or reces- sant agents.
sive. The skin develops large redundant folds. Treatment
consists of plastic surgical procedures such as facelift and Skin Care
blepharoplasty.
Nonsurgical skin care plays a role in the preoperative and
postoperative management in many aesthetic surgery prac-
tices. Some plastic surgeons choose to provide services and
treatments to complement surgical rejuvenation procedures.
Topical treatments, soft tissue fillers, neurotoxins, skin tight-
ening devices, chemical and laser peels, facial treatments,
makeup consultations, lymphatic drainage massage (LDM),
and a wide variety of other medical spa services have become
integral components of many practices. Other plastic surgeons
develop relationships with dermatology colleagues who pro-
vide these treatments.
The nonsurgical treatments mentioned above appeal to
several groups of patients:
1. Younger patients who seek preventive measures to “slow”
the aging process.
2. Patients who cannot afford or who do not have the time
to recover from expensive and more extensive surgical
procedures.
3. Patients who do not want surgical intervention and prefer
Figure 13.8. Telangiectasias. procedures with reduced morbidity, rapid recovery, and a
more rapid return to work.

The Complete Aesthetic Hydration

Package Water is required to maintain the smoothness of the skin. The
simplest and most important way to maintain hydration is
In the senior author’s practice, surgical and nonsurgical by drinking water. Moisturizers are a helpful adjunct by aug-
treatments are integrated in a comprehensive team approach. menting the barrier function of the epidermis. Moisturizers
The “consulting team” includes the plastic surgeon, surgi- contain humectants, emollients, and occlusives. The emol-
cal nurse, medical aesthetician, and patient coordinator. The lients are lipids that hydrate the skin. The occlusives decrease
extended team of providers includes a massage therapist, transepidermal water loss. Humectants enhance water absorp-
micropigmentation artist, personal trainer, nutritionist, and tion from the dermis into the epidermis, and in humid con-

others (Figure 13.9, Case 1). Admittedly, this form of prac- ditions they also help the stratum corneum to absorb water
tice does not appeal to all plastic surgeons who prefer to con- from the external environment.6
centrate on surgical procedures or who perceive the benefit of
cross-referral from other specialists who offer these modalities.
Repair
To achieve repair, the formulations must reach the basal
The Consultation and layer of the epidermis and the superficial dermis. The most
Evaluation effective are alpha-hydroxy acids (AHA) and topical tretinoin
(retin-A).
The objectives of the consultation are to evaluate the patient Glycolic acid (sugarcane), lactic acid (milk), malic acid
and provide education and recommendations on the different (apple), citric acid (citrus fruits), and tartaric acid (grape)
nonsurgical and surgical alternatives including a discussion of are examples of AHA. Glycolic and lactic acid are the most
risks, complications, and the financial implications of the vari- commonly used and are safe and effective. AHAs are indi-
ous options. cated for dryness, rough texture, acne, rosacea, photodam-
The evaluation, or aesthetic consultation, is performed by age, melasma, and hyperpigmentation disorders. They can
the plastic surgeon accompanied by the nurse and the aestheti- be found in different vehicles and concentrations, such us
cian. A facial evaluation regarding skin type (dry, oily, or a within moisturizers or in the form of peels. They can also be
combination), texture, thickness, photoaging damage, wrin- used in dark skin types. In the case of melasma and hyperpig-
kles, and age-related and gravitational changes is included mentation disorders, AHAs can be used in combination with
in every patient. A skin care regimen may be recommended bleaching agents.
before or after the surgical procedure. Tretinoin (retin-A) is a vitamin A derivative that, when
used for the long term, is extremely effective in reversing sun
damage. It promotes histologic changes such as increased
Comprehensive Skin Care epidermal and granular layer thickness, decreased mela-
Program nin content, compaction of the stratum corneum, decreased
cytologic atypia, increased collagen synthesis, an increase in
A skin care program consists of cleansing, hydration, moistur-
collagenous anchoring fibrils, and an increase in the number
izing, repair, protection, and prevention.
of blood vessels. Tretinoin can be found in cream, gel, and
liquid preparations. Available concentrations include 0.02%,
Cleansing 0.025%, 0.05%, and 0.1%.
Dirt, oil, grease, makeup, and microorganisms are removed The clinical changes from long-term tretinoin use include
from the skin in order to allow skin care renewal and cos- smoother skin texture, reduced fine wrinkles, decreased sal-
metic creams to be absorbed. Cleanser is prescribed according lowness, improved skin appearance, and a decrease in actinic
to the skin type and is applied in the morning and again at keratoses. The treatment can cause irritation, and some
night. Application of cleanser is important at night because patients find tretinoin difficult to tolerate. During the treat-
the lower pH increases microcirculation and allows greater ment sunscreen is mandatory. If patients undergo a facelift,
absorption of the skin products. the tretinoin can be restarted after 3 to 4 weeks.
Figure 13.9. Case 1—Complete aesthetic package. This 56-year-old woman presented with significant sun damage and facial aging. The
complete aesthetic package was performed. She had an aggressive skin care treatment preoperatively, with intense pulsed light treatments to the
face and neck every 21 days, alternated with facial peels. She then underwent an endoscopic brow lift, bilateral ptosis repair, rhytidectomy with
SMASectomy, and cervicoplasty. The lymphatic drainage massage treatment was started 5 days postoperatively and continued once a week for
3 weeks. She is shown 1 year postoperatively.

Bleaching agents may be helpful in some patients, such as

hydroquinone, kojic acid, azelaic acid, and also retinoic acid.
Hydroquinone is used for reversible pigmentation of skin,
usually at 4% concentration. It can be combined with other
agents, such as prepeeling creams. The 1% kojic acid and
20% azelaic acid may be equally effective.1 All these topical
agents can cause skin irritation and should applied first as a
patch test.
Protection and Prevention

Antioxidants and sunscreen are used to protect what has been
achieved and prevent further damage. Antioxidants act to
eliminate the free radicals caused by sunlight. The most popu-
lar are vitamins C (ascorbic acid) and E (tocopherol and toco-
trienols), alpha-lipoic acid, soy isoflavones, tea extracts, grape
seed extracts, niacinamide, and coenzyme Q 10.
Vitamin C is a topical antioxidant agent that stimulates Figure 13.10. Case 2—Sunscreen. This 70-year-old woman
p resented with a combination of sun damage and facial aging.
collagen synthesis, inhibits elastin synthesis, reduces pig-
A complete aesthetic package was performed, with sun protectors
mentation, improves epidermal barrier function, regenerates daily, avoidance of sun exposure and skin care treatment preoper-
the oxidized forms of vitamin E, and has anti-inflammatory atively, and microdermabrasion treatments. Surgically, she under-
effects. Smoking cigarettes appears to deplete vitamin C from went an endoscopic brow lift, rhytidectomy with SMASectomy,
the skin. and cervicoplasty. The lymphatic drainage massage was intro-
Vitamin E (tocopherol) is an antioxidant found in veg- duced during the first week postoperatively. She is shown 1 year
etables, seeds, and meat. Vitamin E prevents lipid peroxi- postoperatively.
dation and therefore protects the cellular membrane from
free radicals. Vitamin E is a helpful ingredient in daytime
moisturizers and sunscreen, because of its photoprotective
properties and also as an anti-inflammatory agent. Alpha- surgical procedures on the face. The best indications are oily
lipoic acid is another strong antioxidant with anti-inflamma- skin, dilated pores, thick skin, mild acne scarring, melasma,
tory proprieties. It is stable and easily absorbed and should and solar lentigines. Contraindications include severe acne
be applied every other day initially and then daily when the rosacea, telangiectasias, uncontrolled diabetes, active acne,
skin permits.7 skin cancer, dermatitis, sunburned skin, oral isotretinoin, and
Isoflavones work by raising hyaluronic acid production, blood thinners.
increasing the thickness and collagen of the skin.7 Topical
green tea and grape seed extracts are antioxidants with anti- Dermabrasion
inflammatory action.7,8 Vitamin B improves protein produc- Dermabrasion is the mechanical removal of epidermis and
tion, decreases melanosome transfer, and reduces redness.7 superficial dermis that will stimulate re-epithelialization. This
Coenzyme Q10 is used to combat sun damage and therefore can be performed with sandpaper, wire brush, or diamond
reduces wrinkles, reducing oxidation levels.7,8 fraise powered by a hand engine. The technique is performed
Sunscreens are important to protect the skin from ultravio- under anesthesia in the operation room. Indications include
let light. The sun protection factor indicated on the container wrinkles, facial scars, rhinophyma, syringoma, and epidermal
only indicates the extent to which that product blocks UVB. nevus (Chapter 41).3
Since UVA causes wrinkles and skin cancer, it is also impor-
tant to use a product that also blocks UVA. Unfortunately,
UVA blocking agents are not as well developed as UVB block- Intense Pulsed Light
ers. At best, the current UVA blocking agents only partially
The IPL is a noninvasive system used for photorejuvena-
block UVA. The only complete sun blocker is zinc oxide, but
tion (Chapter 18). It is a system that emits a broad spec-
it is thick and greasy and not practical to cover all of one’s
trum of non-coherent, polychromatic light in the range of
exposed skin. Sunscreen should be applied daily, before
500 to 1,200 nm. These features allow great variability in
makeup, and reapplied during the day (Figure 13.10, Case 2;
adapting to different skin types and indications by vary-
Tables 13.1–13.3).
ing the light spectrum, impulse length, impulse sequence,
and fluence.7 Three to six sessions are recommended, every
2 to 3 weeks.
Nonsurgical Treatments The best indications are photoaging, telangiectasias, port
For Skin Quality wines stains, poikiloderma, red hypertrophic scars, hyper-
trichosis, irregular pigmentation (lentigines, melasma, and
The most effective nonsurgical procedures are microderm-
ephelides), and postinflammatory hyperpigmentation. The
abrasion, dermabrasion, IPL, laser resurfacing, chemical
contraindications are an abnormal response to sunlight, cur-
peels, neurotoxins, and fillers. The procedures will be men-
rent treatment with oral tretinoin, suspicious lesions, preg-
tioned briefly because they are covered in depth in other
nancy, conditions that affect wound healing, and blood
chapters.
thinners.
Before treatment, the skin is cleansed and topical anesthetic
Microdermabrasion applied for comfort. The skin can look like a sunburn and
Microdermabrasion is a nonsurgical procedure that uses alu- have some swelling from 2 to 48 hours after the p rocedure.
minum oxide (AL2O3) or sodium chloride (NaCl) crystals to The pigmented lesions appear much darker immediately
exfoliate the skin. Topical anesthesia is not required and it after treatment. After a week, the skin starts to clear and
is a safe and well-tolerated procedure. The treatment may microdermabrasion can be added to expedite this process
be helpful for three to six sessions, every 2 weeks, before (Figure 13.11, Case 3).

TA B LE 1 3 . 1
Fitzpatrick Classification
n Skin Type n Skin Color/Sun Exposure

I Highly sensitive, never tans, always burns and severely, fair skin
II Usually burns, tans minimally, very sun sensitive
III Burns moderately, tans moderately, sun-sensitive skin
IV Tans moderately and easily, burns minimally

V Rarely burns, dark brown skin, sun-insensitive skin
VI Never burns, dark brown or black skin, sun insensitive
TA B LE 1 3 . 2
glogau Classification
n Photoaging Group n Degree of Skin Wrinkling and Photoaging

I Mild (age 28–35 y) Minimal wrinkles; no keratosis; requires little or no makeup
II Moderate Rarely wrinkling, mild scarring; sallow color with early
(age 35–50 y) keratosis; requires little makeup
III Advanced Persistent wrinkling; discoloration with telangiectasias and
(age 50–65 y) visible keratosis; wears makeup always
IV Severe Wrinkling: photoaging, gravitational, dynamic; actinic kera-
(age 60–75 y) tosis with or without skin cancer; wears makeup with poor
coverage.
TA B LE 1 3 . 3
Skin Care
n A.M. n P.M.
Cleansing Cleansing
Hydrate and moisturizers Hydrate and moisturizers
Protection (antioxidants and Repair (alpha-hydroxy acids, topical tretinoin, bleaching
sun protectors) agents)
Radiofrequency
Radiofrequency is a nonsurgical treatment for skin rejuvena-
tion. It causes a thermal injury to the dermis, stimulates the
fibroblasts, increases collagen production, and provides some
skin tightening.
The indications are skin laxity in the face, neck, limbs, and
abdomen. The best candidates are patients between 30 and 60
years and who have reasonably good skin quality and have no
history of smoking. The response is variable.7
Lasers
Lasers produce stimulation of fibroblasts and increase col-
lagen deposition. They can be used for rejuvenation, hair
removal, and treatment of vascular lesions.
The most popular lasers for skin resurfacing are carbon
dioxide and erbium:YAG, which, as described in Chapter 18,
can be fractional or not (Chapters 18 and 41). Figure 13.11. Case3—Intense pulsed light (IPL). This 65-year-
old woman was concerned about her appearance after a cutaneous
Chemical Peels facelift. An aggressive skin care regimen of IPL treatments to the face
and neck every 21 days was initiated and continued after surgery. An
Chemical peels can be superficial, medium, or deep endoscopic brow lift, rhytidectomy with SMASectomy, and cervico-
depending on their penetration into the dermis where they plasty were performed. The lymphatic drainage massage treatments
result in improvement of collagen organization. A vari- were started 5 days postoperatively and continued once a week for 3
ety of chemical peels can be used, such as glycolic acid, weeks. She is shown 7 years postoperatively.
TCA, beta-hydroxy acid, Jessner solution, and Croton

oil. Each one has specific characteristics and indications increase blood flow, and provide the psychological benefit of
(Chapter 41). reducing stress/anxiety and focusing the patient on positive
results. Postoperatively, the technique decreases inflamma-
Neurotoxins tion, speeds up recovery time, reduces bruising, opens lym-
Botulinum toxin is a temporary paralyzing agent that works phatic channels, reduces the scar tissue buildup, and continues
by causing a chemical denervation at the neuromuscular junc- to reduce stress and tension.7
tion providing temporary improvement in dynamic wrinkles.
Patients should be informed that wrinkles that are present at References
rest will not be improved by botulinum toxin, although they 1. Burns T, Breathnach S, Cox N, Griffiths C. Rook’s Textbook of
will not get deeper with animation (Chapter 43). Dermatology. Malden, MA: Blackwell Publishing; 2004.
2. Mathes SJ, ed. Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders
Fillers Elsevier; 2006.
3. Wolff K, Goldsmith LA, Katz ST, Gilchrest BA, Paller AS, Leffell DJ.
Fillers are designed to replace volume in dermis or subcutane- Fitzpatrick’s Dermatology in General Medicine. Columbus, OH: The
McGraw Hill Companies; 2008.
ous tissue of the face. The most commonly used are hyaluronic 4. Thorne CH, Beasley EW, Aston SJ, Bartlett SP, Gurtner GC, Spear SL,
acid (such as Juvederm and Restylane), calcium hydroxyapa- eds. Grabb & Simth Plastic Surgery. 6th ed. Philadelphia, PA: Lippincott
tite (Radiesse), poly-lactic acid (Sculptra), and others men- Williams & Wilkins; 2007.
tioned in Chapter 42. 5. Lee EH, Nehal KS, Disa JJ. Benign and premalignant skin lesions. Plast
Reconstr Surg J. 2010;125(5):188-198.
6. Kraft JN, Lynde CW. Moisturizers: what they are and a practical approach
Lymphatic Drainage Massage to product selection. Skin Therapy Lett. 2005;10(5):1-8.
7. Saltz R, ed. Cosmetic Medicine & Aesthetic Surgery. Strategies for Success.
LDM is a helpful tool that can be started before or after sur- St Louis, MO: Quality Medical Publishing, Inc.; 2009.
gery. It is meant to decrease swelling, bruising, and recovery 8. Bogdan Allemann I, Baumann L. Antioxidants used in skin care formula-
time. Preoperatively, LDM helps to remove stagnant fluids, tions. Skin Therapy Lett. 2008;13(7):5-8.

Chapter 14 n Dermatology for Plastic
Surgeons II—Cutaneous
Malignancies
Daniel J. Ceradini and Keith M. Blechman

or black macules, which can be easily confused with sebor-
Introduction rheic keratosis or nodular malignant melanoma. Superficial
Skin cancer is the most common form of cancer diagnosed in BCC is the second most common tumor type. It appears as
the United States, exceeding the combined incidence of breast, a demarcated multi-centric erythematous patch, frequently
prostate, lung, and colon cancer cases annually. It is estimated occurring on the trunk and extremities. The surface of this
that one in five Americans will be diagnosed with skin cancer lesion is often scaly and ulcerated and can be misdiagnosed
during their lifetime.1 The incidence of cutaneous malignan- as a cutaneous fungal infection, discoid eczema, actinic
cies has increased dramatically over the past several decades. keratosis, or psoriasis. Although there is frequently “normal”
The most recent analysis of the incidence of non-melanoma appearing skin between the tumor foci suggesting that each
skin cancer in the US population suggests that nearly 3.5 mil- arises separately, this subtype exhibits a significant radial
lion new cases are diagnosed annually in 2 million patients.2 growth pattern and each focus is actually connected, likely
This figure has tripled from the estimated annual incidence of arising from a single primary focus. Morpheaform or scleros-
cutaneous malignancy from 1994 and signifies a major pub- ing BCC is the most aggressive tumor type, usually found in
lic health problem that accounts for over 2 billion dollars in the head and neck. It is the most difficult type to diagnose
healthcare spending annually. The treatment of skin cancer and manage due to its insidious onset and infiltrative growth
comprises over 75% of all procedures performed by plastic characteristics. It frequently appears as a poorly defined flat
surgeons in the United States.3 indurated plaque that resembles a scar without a history of
trauma. Histologically, this tumor exhibits numerous thin
linear extensions that can reach into the deep dermis, making
Basal Cell Carcinoma surgical resection difficult and recurrence frequent.
Epidemiology and Risk Factors Tissue biopsy definitively establishes the diagnosis and
characterizes the histologic subtype. Additional workup is
The vast majority of skin cancer cases diagnosed in the United generally not required due to the very low rate of metasta-
States are either basal cell carcinoma (BCC) or squamous cell sis (<0.05%) and should be reserved for patients where a
carcinoma. BCC is by far the most common cutaneous malig- genetic disorder or clinical syndrome is suspected. The over-
nancy worldwide and accounts for nearly 80% of all skin can- all cure rate for BCC can exceed 90%; however, recurrence
cers. There is marked worldwide geographic variability, most is frequent and more difficult to manage. The likelihood of
often affecting light-skinned populations in locations with curative treatment is determined by several prognostic factors,
the highest UV exposure. Although mortality is rare, locally which allows clinicians to identify high-risk lesions that have
aggressive BCC can result in significant patient morbidity. an increased likelihood for recurrence of a more aggressive
The predominant risk factor for BCC is intense sunlight and course (Table 14.1). Risk stratification guides selection of an
UV exposure. Other risk factors include Fitzpatrick skin types appropriate treatment modality for tumor eradication. Staging
I–II, a family history of skin cancer, male sex, smoking, human of BCC is rarely performed due to the very low frequency of
papilloma virus (HPV), exposure to arsenic or hydrocarbons, spread to lymph nodes or distant sites.
previous radiation, and immunodeficiency resulting from
either acquired immunodeficiency syndrome or systemic drugs
required for transplant recipients. While most arise sporadi-
cally, BCC is also associated with several clinical syndromes,
including Bazex syndrome, Gorlin syndrome (basal cell nevus
syndrome), and xeroderma pigmentosum. Constitutive acti-
vation of the sonic hedgehog signaling pathway is thought to
play a significant role in BCC pathogenesis.
Diagnosis and Staging

Most BCCs arise in the head and neck and sun-exposed
extremities and can be categorized into one of several dif-
ferent tumor types that exhibit distinct growth patterns.
Tumor type is a key prognostic factor and guides selec-
tion of treatment options. Nodular BCC is the most com-
mon tumor type that classically presents as a dome-shaped
nodular papule with a pearly surface, scattered telangiec-
tasias, and rolled borders. As it enlarges, it typically ulcer-
ates centrally, giving it the classic rodent ulcer appearance
(Figure 14.1). Cystic BCC is a variation of the nodular type FIGURE 14.1. Nodular basal cell carcinoma. Central ulceration
characterized by a cystic mucin-filled central core that retains gives rise to the classic rodent ulcer appearance. (Right photo
the clinical appearance of the nodular tumors. Pigmented courtesy of Christine Liang, MD.)
BCC is another variation of a nodular tumor that has brown
115
Table 14.1 randomized clinical trial comparing Mohs’ surgery to direct

excision of BCC, Mohs’ surgery resulted in better outcomes
Features of High-Risk Basal Cell Carcinoma and for treatment of recurrent basal cell tumors, while there were
Cutaneous Squamous Cell Carcinoma no significant statistical differences in the treatment of pri-
mary BCC.6
Anatomic site BCC generally carries a good prognosis as the tumors tend
Central face, periorbital region, ears/postauricular region, to grow slowly and metastasize very rarely, but can result
hands, feet in significant morbidity due to local invasion. One-third of
recurrences occur in the first year following treatment, half in
Tumor size the second year, and two-thirds in the third year regardless of
>5 mm on high-risk sites of central face, ears, hands, feet the treatment modality.7 Patients should be monitored every
6 months for the first year following treatment and annually
>10 mm on scalp, forehead, cheek, neck
thereafter.
>20 mm on trunk, extremities
Histologic characteristics
Squamous Cell Carcinoma
Morpheaform/sclerosing, infiltrative, or micronodular
subtypes (BCC) Epidemiology and Risk Factors
Basosquamous differentiation Cutaneous squamous cell carcinoma (cSCC) is the second
most common skin cancer, accounting for 15% to 20% of
Perineural invasion all cases of skin cancer in the United States. Similar to BCC,
Clinical features there is marked geographic variability in the incidence of
cSCC, with more patients affected in areas with increased sun
Recurrent tumors exposure. Although primary tumors can be locally invasive, it
Previously irradiated site is frequently diagnosed in the early stages when it is a highly
curable disease. Approximately 3,000 patients die from cSCC
Poorly defined clinical borders
annually in the United States,8 and the incidence of more
Immunosuppression aggressive or advanced tumors is increasing.
Chronic cumulative sun exposure is the prevalent risk
Site of chronic inflammation
factor for cSCC, and both UVA and UVB are implicated
BCC, basal cell carcinoma. in tumor pathogenesis. This is significant because the sun
protection factor in sunscreens only measures protection
against UVB. The incidence of cSCC increases signifi-
cantly with age, likely reflecting an increased cumulative
Surgical Management exposure to sunlight. Other environmental risk factors for
cSCC include a history of radiation, chronic inflamma-
The options for primary tumor eradication of BCC can be tion (as in Marjolin’s ulcer), and exposure to arsenic and
divided into destructive or surgical/excisional modalities. hydrocarbons. Chronic immunosuppression secondary to
Destructive treatment options are generally reserved for low- organ transplantation markedly increases the risk of cSCC
risk basal cell tumors and use a variety of methods to destroy up to 250 times the general population and is closely cor-
neoplastic tissue including electrosurgery, cryosurgery, topi- related to the type of transplant, immunosuppressive drug
cal 5-fluorouracil, topical imiquimod, intralesional interferon, burden, and time since transplantation.9,10 Host risk factors
radiation, and photodynamic therapy. Notably, these modali- for cSCC include Fitzpatrick I–II skin types, fair hair, pre-
ties do not definitively ensure a margin clear of neoplasm. vious history of non-melanoma skin cancer, and infection
However, in selected low-risk cases, the overall success rate with HPV. Additionally, certain inherited disorders such as
can be excellent. xeroderma pigmentosum, epidermolysis bullosa, and albi-
Surgical or excisional treatment of BCC can be used in nism confer a genetic susceptibility to developing cSCC.
low-risk and high-risk cases. Simple excisional biopsy of UV-induced mutations in the p53 tumor suppressor gene
low-risk lesions in anatomically simple areas (trunk and are thought to be the molecular mechanism of malignant
extremities) can result in success rates over 95%.4 In order transformation of keratinocytes.
to achieve histologically negative margins, guidelines exist
to assist the surgeon: for tumors <1 cm a clinical margin of
4 to 5 mm, and for tumors >1 cm a clinical margin of 5 Diagnosis and Staging
to 10 mm is recommended.5 In high-risk cases, especially The majority of cSCC is diagnosed on sun-exposed skin of
on the face where obtaining adequate margins may result the head and neck, dorsum of hands, lower arms, and legs.
in significant deformity, direct excisional biopsy allows for Unlike BCC, however, cSCC can arise from a premalignant
histologic evaluation of the surgical margins to ensure that actinic keratosis, identified as an area of erythematous, rough,
they are free of tumor to maximize the aesthetics of recon- scaly plaque that exhibits dysplastic growth and malignant
struction. Mohs’ micrographic surgery is the most definitive potential. Up to 80% of cSCC tumors arise in association
modality and treatment of choice in high-risk BCC of ana- with a preexisting actinic keratosis, although overall <1% of
tomically complex areas on the face. High-risk tumors are all actinic keratoses undergo malignant transformation annu-
serially excised and the entire margin of resection is exam- ally.11-13 Features of actinic keratosis that are associated with
ined histologically by the Mohs’ surgeon. Presence of tumor malignant transformation include inflammation, diameter >1
at the margins is mapped, and further excision of affected cm, rapid growth, ulceration, bleeding, and erythema.14 A
areas is serially performed and examined until the margins cutaneous horn is a clinical variant of actinic keratosis that
are clear. Mohs’ surgery achieves over 98% cure rate in pri- presents as a hyperkeratotic protuberance shaped like a cone
mary tumors and over 95% in recurrent cases, although it extending above the plane of the skin. Approximately 15%
is more expensive and time consuming to perform. The pri- of cutaneous horns actually contain cSCC,15 and excision is
mary advantage of Mohs’ surgery is that it spares normal tis- indicated.
sue and anatomic structures in complex areas while ensuring cSCC in situ, also referred to as Bowen’s disease, fre-
negative margins and excellent cure rates. Based on a recent quently presents as a slowly growing, erythematous, scaly

Chapter 14: Dermatology for Plastic Surgeons II—Cutaneous Malignancies 117
patch. It is most frequently diagnosed in older patients (>60
years) and can occur anywhere on the body including the
mucosal surfaces. When cSCC in situ occurs on the mucocu-
taneous epithelium of the glans of the penis or labia majora,
it is referred to as erythroplasia of Queyrat. It occurs most
often in uncircumcised men and is thought to be associated
with chronic irritation, infection with HPV, and immuno-
suppression. It classically appears as a velvety red plaque on
the glans of the penis. Progression to invasive cSCC occurs
in up to 33% of cases over variable periods of time.16 When

cSCC in situ occurs in the oral or genital mucosa, it pres-
ents as adherent white patches clinically referred to as leu-
koplakia. Notably, this must be differentiated from other FIGURE 14.3. Invasive cutaneous squamous cell carcinoma.
causes of leukoplakia such as chronic irritation (usually
from smoking), candidal infection, and HPV infection. This
often requires a biopsy of suspicious lesions. Squamous cell Diagnosis of cSCC is made by tissue biopsy to distinguish
carcinoma develops in 10% to 20% of all patients with it from other neoplasms or cutaneous inflammatory condi-
leukoplakia. tions. In addition to definitive tumor diagnosis, patients with
Keratoacanthoma is a rapidly growing nodule (over cSCC should undergo clinical examination of the appropri-
weeks to months) with a central ulceration or keratin plug ate draining lymph node basins. Palpable nodes should be
that is found mainly in sun-exposed skin (Figure 14.2). Left biopsied by fine needle aspiration. Routine imaging studies
untreated, it may spontaneously involute. Keratoacanthoma is for cSCC is not indicated, but should be obtained in patients
felt to be a low-grade variant of cSCC, but is clinically difficult that exhibit specific neurological symptoms or regional
to distinguish from high-grade invasive cSCC. Shave biopsies lymphadenopathy.
are not helpful in making this distinction; therefore, surgical For the first time, the American Joint Committee on
excision is recommended. Cancer (AJCC) has introduced a completely separate stag-
Invasive cSCC penetrates the basement membrane to reach ing system for cSCC, which was formerly incorporated into
the dermis and either arises de novo or is associated with the “Carcinoma of the Skin” comprised of 80 different non-
actinic keratosis (Figure 14.3). Characteristic lesions are firm, melanoma skin cancers. This new TNM staging system uti-
raised, pink- or flesh-colored papules with frequent keratini- lizes a multidisciplinary evidence-based experience to more
zation, scaling, ulceration, or crusting on the surface. These accurately describe the history and prognostic outcomes of
most often represent well-differentiated tumor types. Poorly cSCC (Tables 14.2 and 14.3).18 Due to the fact that most
differentiated lesions are typically soft, granulomatous nodules cSCC occurs in the head and neck, this system is meant to
with areas of hemorrhage, necrosis, and ulceration and lack- be consistent with the AJCC Head and Neck Staging system.
ing in keratinization. Invasive cSCC associated with actinic The new cSCC staging system has several notable changes.
keratosis in sun-exposed areas has a low metastatic risk and The T staging (Tumor Characteristics) of the TNM system
a favorable prognosis. De novo invasive cSCC, however, is a has been modified to eliminate the 5 cm size criteria and inva-
high-risk variant typically occurring in immunocompromised sion of extradermal structures criteria to define a T4 lesion.
hosts or in areas of chronic irritation (such as burns) and has Instead, a new list of “high-risk” features has been added,
a metastatic rate as high as 14%.17 which impacts the overall T staging. Of these features, tumor
grade now also contributes to the overall stage groups. The
N component (Regional Lymph Nodes) of the TNM system
has been totally revised to incorporate data indicating that
overall survival decreases with increased node size and num-
ber involved.
While the majority of cSCC is diagnosed and cured in the
early stages, the reported rate of regional metastasis ranges
from 0.5% to 10%. While there is no consistent defini-
tion or stratification of what features of a primary tumor
are considered “high risk” for regional spread, there are a
number of tumor- and patient-specific characteristics that
can be used to guide management. Tumor-specific features
that are considered “high risk” include tumors located on
the ears, lips, or within chronic wounds or scars, horizontal
size >2 cm, thickness of 2 to 6 mm (low risk) or >6 mm
(high risk), poorly differentiated cell types, perineural inva-
sion, and rapidly growing or recurrent lesions. 19 Patients
who are organ transplant recipients or who are diagnosed
with chronic lymphocytic leukemia, small lymphocytic lym-
phoma, epidermolysis bullosa, or HIV/AIDS are more likely
to exhibit more aggressive tumor types and disease progres-
sion (Table 14.1).
Surgical Treatment
The surgical treatment options for cSCC are similar to those
FIGURE 14.2. Keratoacanthoma with characteristic umbilicated cen-
ter and keratin plug. If left untreated, it typically undergoes a period of BCC and are based on assessing the risk of local regional
of rapid growth followed by spontaneous regression over several recurrence or distant metastasis. In selected low-risk cases,
months; however, it can progress to squamous cell carcinoma with destructive treatment modalities can be used with excellent
metastases. results. Direct surgical excision can be used for both low-
risk and high-risk lesions. In order to increase the chance of

TABLE 1 4 . 2
TNM Staging Categories For Cutaneous Squamous Cell Carcinoma
n T Classification n Tumor Size

Tis Carcinoma in situ
T1 Tumor ≤2 cm in greatest dimension with <2 “high-risk” featuresa
T2 Tumor >2 cm in greatest dimension with or without one additional “high-risk” featurea or
any size with ≥2 “high-risk” featuresa
T3 Tumor with invasion of maxilla, mandible, orbit, or temporal bone
T4 Tumor with invasion of skeleton (axial or appendicular) or perineural invasion of skull base
n N Classification n Nodal Metastatic Burden
N0 No regional lymph node metastasis
N1 Metastasis in single ipsilateral lymph node, ≤3 cm in greatest dimension
N2a Metastasis in single ipsilateral lymph node, >3 but <= 6 cm in greatest dimension
N2b Metastasis in multiple ipsilateral lymph nodes, <= 6 cm in greatest dimension
N2c Metastasis in bilateral or contralateral lymph nodes, <= 6 cm in greatest dimension
N3 Metastasis in lymph node, >6 cm in greatest dimension
n M Classification n Site
M0 No distant metastasis
M1 Distant metastasis present
a
“High-risk” features include horizontal size >2 cm, depth ≥2 mm, perineural invasion, location on the ear, lip, or within a chronic wound or scar,
poorly differentiated cell types, rapid growth, or recurrence.
Edge SB, Byrd DR, Compton CC, et al., eds. AJCC Cancer Staging Manual. 7th edn. New York, NY: Springer; 2010.
achieving histologically negative margins, the recommended There is currently no role for adjuvant therapy in patients who
surgical margin for low-risk lesions is 4 mm, and for high-risk are at risk for recurrence. Patients with distant metastasis or
lesions it is 6 to 10 mm. An increasing number of high-risk advanced local disease not amenable to surgery or other treat-
features of the primary tumor may require a larger margin of ment modalities require systemic chemotherapy.
resection. In anatomically complex areas of the face or in par-
ticularly high-risk cSCC tumors, Mohs’ micrographic surgery
is the treatment of choice. Since cSCC tends to metastasize Malignant Melanoma
to the lymph nodes preferentially, there is some interest and
initial success in using sentinel lymph node biopsy to diag- Epidemiology and Risk Factors
nose subclinical lymph node metastasis and stage high-risk Malignant melanoma is the most deadly form of skin can-
tumors. However, more controlled prospective randomized cer, diagnosed in 114,900 patients (46,770 noninvasive and
trials are required to determine whether detection of subclini- 68,130 invasive) and resulting in 8,700 deaths in the United
cal nodal metastasis will result in better clinical outcomes.20 States in 2010.1 The incidence has been steadily increasing
TABLE 1 4 . 3
Anatomic Stage/Prognostic Groups For Cutaneous Squamous Cell Carcinoma
n Stage n T n N n M
0 Tis N0 M0
I T1 N0 M0
II T2 N0 M0
III T3 N0 or N1 M0
T1 or T2 N1 M0
IV T1, T2, or T3 N2 M0
Any T N3 M0
T4 Any N M0
Any T Any N M1
Reproduced from Farasat S, Yu SS, Neel VA, et al. A new American Joint Committee on Cancer Staging system
for cutaneous squamous cell carcinoma: creation and rationale for inclusion of tumor (T) characteristics. J Am
Acad Dermatol. January 2011;64:1051-1059.

over the past 50 years (currently 20 in 100,000 people), with melanomas are detected by clinical examination. It is impor-
notable growth in young white women 15 to 39 years (3% tant to note, however, that a minority of lesions are atypical
annual increase over the past 15 years) and white men over and can be nonpigmented (5%), resemble other types of cuta-
65 years (5.1% annual increase since 1975). Overall, it is the neous malignancies (basal or squamous cell carcinoma), or be
fifth most common malignancy in men and the seventh in smaller than 6 mm in size.
women, and 1 in 52 people will be diagnosed with melanoma Melanoma can be classified into five clinical and histo-
in their lifetime. Although melanoma accounts for less than logic growth patterns, each of which has unique clinical char-
5% of all skin cancer cases, it results in greater than 75% of acteristics: superficial spreading, nodular, lentigo maligna,
skin cancer deaths—approximately one person dies of mela- acral lentiginous, and desmoplastic melanoma. With the
noma every hour. Indeed, melanoma is a significant public exception of nodular melanoma, the remaining subtypes orig-

healthcare problem—the incidence is increasing, there is a inate from an in situ radial growth phase that does not have
predominant modifiable risk factor (sun exposure), and it is metastatic capability. The prognostic significance of growth
curable in the very early stages but not in advanced disease. pattern remains controversial, although there are some
Assessment of risk factors for melanoma can be divided into genetic factors identified within the subtypes that may have
host factors and environmental factors. Host factors that con- prognostic value. Superficial spreading melanoma presents
fer a higher risk of developing melanoma include physical attri- as flat or slightly elevated lesion with variegate pigmenta-
butes such as fair features, Fitzpatrick I–II skin types, and blue/ tion, most commonly occurring on the trunk in men and the
green eyes. Additionally, numerous common congenital nevi, legs in women, in patients aged 30 to 50 years. As the name
atypical nevi, and giant nevi are all associated with increased would imply, the growth pattern is typically superficial and
risk. A personal history of melanoma is thought to confer a 5% radial with scattered atypical melanocytes in the epidermis.
lifetime risk of developing a second melanoma. Finally, familial It is the most common subtype in the Caucasian population
melanoma accounts for approximately 10% of all cases and is and likely contributes significantly to the increasing incidence
associated with mutations within the cyclin-dependent kinase of melanoma over the past 30 years. Nodular melanoma is
inhibitor 2A locus (CDKN2A), cyclin-dependent kinase 4 the second most common growth pattern, which often lacks
(CDK4), and melanocortin 1 receptor (MC1R). the classic features commonly identified by the ABCDE mela-
Perhaps the most significant and modifiable environmental noma screening tool. These lesions commonly present as a
risk factor for melanoma is sun exposure, particularly inter- smooth, single colored (black or brown) elevated nodule or
mittent and intense exposure. UVA and UVB exposure are an ulcerated mass on examination, frequently affecting the
both strongly associated with melanoma. One or more blis- legs or trunk. They are typically thicker and more advanced
tering sunburns early in life or greater than five sunburns at at the time of diagnosis, largely due to a relatively short or
any age increases the lifetime risk of developing melanoma lack of radial growth phase. Overall, nodular melanomas
twofold. Regular broad spectrum sunscreen use may reduce account for most thick melanomas; however, the survival
the risk of developing invasive melanoma.21 It is important to rate and prognosis is similar to that of the other clinical types
note that while intense sun damage is very strongly associ- when thickness and ulceration are taken into account. Both
ated with melanoma, it is not necessarily required for malig- nodular and superficial spreading melanomas are associ-
nant transformation, as a significant number of lesions arise in ated with increased sun exposure in fair-skinned individuals.
relatively sun-protected areas (soles of feet, anus, and vagina). Lentigo maligna melanoma (Figure 14.5) is a slow growing
This underscores the complex multifactorial role of host and lesion with radial spreading that typically arises in long-
environmental factors in melanoma pathogenesis. standing pigmented lesion on chronically sun-damaged ana-
tomic sites (head and arms) in older patients. Hypopigmented
lesions are also possible within this subtype. It occurs most
Diagnosis and Staging often in fair-skinned older individuals, with an average age
Since early detection of melanoma is critical to improve public of diagnosis at 65 years, and is associated with solar elas-
healthcare outcomes, the simple yet effective ABCDE diagnos- tosis of the surrounding skin. Acral lentiginous melanoma
tic tool was developed at the New York University Langone affects only 2% to 8% of Caucasians, but accounts for up
Medical Center to educate the public and general healthcare to 36% of melanoma diagnosed in African Americans, mak-
practitioners, simplifying the decision to biopsy a suspicious ing it the most common subtype within this demographic.23 It
lesion (Figure 14.4).22 This tool utilizes five simple criteria for commonly occurs on the palms of the hand, sole of the feet,
identifying pigmented lesions that are suspicious for mela- or beneath the nail plate (subungual) and presents at a more
noma: Asymmetry, Border Irregularity, Color Variegation, advanced stage with an aggressive course compared with the
Diameter > 6 mm, and Evolution or change in the appearance other subtypes. Subungual variants commonly present as a
of lesion over time. Using these criteria, the vast majority of longitudinal line of pigment extending the length of the nail
plate, with the hallmark spread of the pigment to the prox-
imal nail fold referred to as Hutchinson sign. Finally, des-
moplastic melanoma is a relatively uncommon subtype that
presents as an unremarkable plaque or nodule and can easily
be misdiagnosed at an early stage. It affects older patients
(although not as old as lentigo maligna melanoma) most com-
monly in the head and neck and occurs in men twice as often
as in women. Desmoplastic melanoma is frequently associ-
ated with nerve invasion and spread along fascial planes and
tends to be thicker at the time of diagnosis. They are locally
aggressive with a higher rate of local recurrence, but exhibit a
low incidence of lymph node involvement. These clinical fea-
tures more closely resemble a soft tissue sarcoma, suggesting
that the underlying biology of desmoplastic melanoma may
FIGURE 14.4. Malignant melanoma. Lesions suspicious for mela-
be unique compared with the other subtypes.
noma demonstrate asymmetry, border irregularity, color variegation, Definitive biopsy remains a critical factor in both establish-
diameter >6 mm, and evolution or change in the appearance. (Photos ing the diagnosis and providing valuable information about
courtesy of Richard L. Shapiro, MD.) staging and prognosis, as histologic characteristics of mela-
noma are powerful independent predictors of 5- and 10-year

using evidence-based data collected over the past decade.

Using a population of 38,918 melanoma patients, the 2009
AJCC Staging and Classification guidelines identified several
new findings. Tumor thickness, mitotic rate, and ulceration
were the most significant prognostic factors associated with
localized tumors. Furthermore, since mitotic rate is the second
most powerful predictor of survival after tumor thickness, it
was recommended that the mitotic rate replace Clark’s level as
a criterion for defining T1b lesions. Clark’s level is no longer
recommended for use in melanoma staging. The N component
(Regional Lymph Nodes) of the TNM classification system
was modified to include the number of metastatic nodes, over-
all tumor burden, and ulceration of the primary lesion. The
M component (Distant Metastasis) of the TNM classification
system continues to be defined by the site of distant metas-
tasis and elevation of serum LDH, which has been identified
as an independent predictor of survival outcome in stage IV
patients. Finally, all patients with microscopic nodal metasta-
sis diagnosed by sentinel lymph node biopsy (including those
identified by immunohistochemical staining) regardless of the
overall tumor burden are classified as stage III, which gives a
more accurate survival estimate for stage IIB–IIIA disease.
The observed 5- and 10-year survival rates by stage
of patients diagnosed with melanoma are summarized in
Table 14.6. However, prognostication in melanoma is a com-
plex process and continues to evolve based on observations
in clinical trials. Thus, factors not accounted for by the AJCC
staging system, which are known to have an impact on prog-
nosis (age, sex, anatomic location of the primary lesions, and
number of distant metastases), contribute to the individual
patient’s long-term outlook. In an effort to develop a statisti-
cal model to predict survival outcome in localized melanoma
using individual patient characteristics, the AJCC Melanoma
Task Force released an Internet-based prognosis tool based on
clinical data from >50,000 melanoma patients (http://www.
melanomaprognosis.org).24 This tool was successfully vali-
FIGURE 14.5. Lentigo maligna melanoma is a slowly progressive dated on an independent data set and represents a valuable
melanoma in situ that consists of malignant cells without invasive tool for clinicians to use to provide patients with real-time
growth. (Photo courtesy of Richard L. Shapiro, MD.) evidenced-based prognosis data based on their individual case
characteristics.
survival rates. A full thickness excisional biopsy with a 1 to Surgical Management

2 mm margin of normal tissue is the method of choice for Wide and Deep Excision. Surgical excision not only is
suspicious lesions. In larger lesions located in areas where a critical for establishing the diagnosis but is also the defini-
complete excision may be technically difficult or result in sig- tive management of malignant melanoma. Historically, 5 cm
nificant deformity (i.e., areas of the face), it may be necessary margins were advocated for local tumor excision based on
to perform an incisional biopsy or multiple punch biopsies. observations that melanoma had a propensity to recur adja-
This should include the most raised area of the lesion. Shave cent to the primary site. Over the past few decades, however,
biopsies should never be performed on lesions with a high the guidelines for surgical margins have been redefined by sev-
clinical suspicion of melanoma as there is an unacceptably eral randomized prospective clinical trials25-31 and are largely
high rate of positive deep margins, which precludes accurate based on the thickness of the primary lesion (Table 14.7). In
staging and treatment. All patients diagnosed with cutaneous many cases, the primary tumor can be managed with a full
melanoma undergo a thorough skin assessment and clinical thickness elliptical excision, down to the level of deep mus-
evaluation of the relevant nodal basins. Further screening cular fascia, with primary closure. Challenging anatomic
workup for newly diagnosed patients with invasive melanoma sites include the ear, face, hands, and feet. Melanoma of the
includes chest X-ray, complete blood count, liver function ear is generally treated by full thickness wedge excision and
tests, and serum lactate dehydrogenase (LDH). Abnormal primary closure due to the proximity of the underlying car-
findings in the review of systems or these screening modali- tilage to the thin overlying skin. Primary lesions of the face
ties should prompt further imaging studies such as computed can be particularly challenging, and every effort should be
tomography (CT) scanning or positron emission tomography made to excise the primary lesion with recommended mar-
(PET) scan. Patients with head and neck primary tumors are gins. However, narrower margins in anatomically complex
likely to benefit from CT or PET imaging to identify suspected areas for intermediate thickness lesions (1 to 4 mm) may be
nodal involvement. Further metastatic workup includes serum considered—there is a higher rate of local recurrence, but no
alkaline phosphatase, serum creatinine, body CT imaging, significant impact on long-term survival.25 Invasive melanoma
MRI of the brain, and bone scan. of the fingers and toes often requires amputation through the
The AJCC recently updated the staging system for mid-phalanx proximal to the primary lesion (Figure 14.6).
melanoma from the previous system described in 2001 In subungual melanoma of the index, middle, ring, or little
(Tables 14.4 and 14.5).18 The widespread use of sentinel lymph fingers, this requires amputation through the mid-portion
node biopsy as well as a large collaborative effort among clini- of the middle phalanx; for the thumb, through the proximal
cians has allowed the AJCC to update the staging guidelines phalanx. Likewise, for the great toe (most common site of

TABLE 1 4 . 4
TNM Staging Categories For Cutaneous Melanoma
n T Classification n Thickness (MM) n Ulceration Status
Tis NA NA
T1 ≤1.00 a: without ulceration and mitosis <1/mm2
b: with ulceration or mitosis >1/mm2

T2 1.01-2.00 a: without ulceration
b: with ulceration
T3 2.01-4.00 a: without ulceration
b: with ulceration
T4 >4.00 a: without ulceration
b: with ulceration
n N Classification n No. of Metastatic Nodes n Nodal Metastatic Burden
N0 0 NA
N1 1 a: Micrometastasisa
b: Macrometastasisb
N2 2-3 a: Micrometastasisa
b: Macrometastasisb
c: In transit metastases/satellites without
metastatic nodes
N3 4+ metastatic nodes, or matted nodes,
or in transit metastases/satellites with
metastatic nodes
n M Classification n Site n Serum LDH
M0 No distant metastases NA
M1a Distant skin, subcutaneous, or nodal Normal
metastases
M1b Lung metastases Normal
M1c All other visceral metastases Normal
Any distant metastasis Elevated
NA, not applicable; LDH, lactate dehydrogenase.
a
Micrometastases are diagnosed after sentinel lymph node biopsy or when nodal metastasis exhibits gross extracapsular extension.
b
Macrometastases are defined as clinically detectable nodal metastases.
Reproduced from Edge SB, Byrd DR, Compton CC, et al., eds. AJCC Cancer Staging Manual. 7th edn. New York, NY: Springer; 2010.
digital melanoma) and remaining toes, amputation through the growing experience and success of sentinel lymph node
the mid-proximal phalanx is recommended. Palmar or plantar biopsy, it is standard of care for patients at high risk for nodal
melanoma requires excision down to the palmar/plantar fas- metastases.
cia with primary closure or local tissue rearrangement. Dorsal Most practitioners advocate sentinel lymph node biopsy in
lesions on the hands/feet or web-space lesions require soft tis- clinical stage I/II melanoma with tumor thickness from 1.00
sue resection down to the tendon or bone with skin grafting or to 4.00 mm and clinically negative node basins (Table 14.7).
local flap coverage. Additionally, consideration can be given to patients with
tumors between 0.76 and 1.00 mm with features such as
Sentinel Lymph Node Biopsy. The sentinel lymph node ulceration, lymphovascular invasion, age <40 years, sig-
is the first lymph node in the drainage basin to receive affer- nificant vertical growth phase, and increased mitotic rate.
ent lymphatic communication from the primary tumor site, Finally, patients with >4.00 mm tumors and clinically nega-
prior to spread to the other nodes in this region. Based on tive nodes benefit from the prognostic information obtained
observations that this functionally defined node was nearly from sentinel node sampling. Technical limitations to sentinel
universally involved when lymph node spread of melanoma lymph node biopsy include a previous wide and deep exci-
was detected in lymphadenectomy specimens, it was postu- sion with extensive reconstruction and local tissue rearrange-
lated that selective sampling of this important “marker” could ment, anatomic sites where there are more than one drainage
serve as an accurate predictor of involvement of the rest of basin (i.e., scalp), or anatomic sites where the primary is very
the nodal basin. Supported by numerous prospective ran- close to the sentinel node (i.e., overlying the parotid) and
domized clinical trials, the feasibility and accuracy of sentinel γ-detection is difficult. In patients with a previous wide and
lymph node biopsy has been definitively established. Due to deep excision who underwent simple closure, sentinel lymph

TABLE 1 4 . 5
Anatomic Stage/Prognostic Groups For Cutaneous Melanoma
n Clinical Staging n Pathologic Staging

Stage 0 Tis N0 M0 Stage 0 Tis N0 M0
Stage IA T1a N0 M0 Stage IA T1a N0 M0
Stage IB T1b N0 M0 Stage IB T1b N0 M0
T2a N0 M0 T2a N0 M0
Stage IIA T2b N0 M0 Stage IIA T2b N0 M0
T3a N0 M0 T3a N0 M0
Stage IIB T3b N0 M0 Stage IIB T3b N0 M0
T4a N0 M0 T4a N0 M0
Stage IIC T4b N0 M0 Stage IIC T4b N0 M0
Stage III Any T ≥N1 M0 Stage IIIA T1-4a N1a M0
T1-4a N2a M0
Stage IIIB T1-4b N1a M0
T1-4b N2a M0
T1-4a N1b M0
T1-4a N2b M0
T1-4a N2c M0
Stage IIIC T1-4b N1b M0
T1-4b N2b M0
T1-4b N2c M0
Any T N3 M0
Stage IV Any T Any N M1 Stage IV Any T Any N M1
Reproduced from Edge SB, Byrd DR, Compton CC, et al., eds. AJCC Cancer Staging Manual. 7th edn. New York, NY: Springer; 2010.
node biopsy is a viable option and should be performed technetium-99m) around the primary tumor site, followed by
where indicated. serial images of the γ-emission pattern. As the colloid enters
The process of sentinel lymph node biopsy involves the lymphatic channels surrounding the lesion, it travels to the
mapping the sentinel lymph node by two complementary first lymph node where it collects, forming a “hot spot” on the
techniques: preoperative lymphoscintigraphy and direct intra- emission imaging (Figure 14.7). This identifies the anatomic
operative visualization of draining lymphatic patterns using a location of the sentinel node, but gives no information as to
blue dye. Typically on the morning of surgery, patients receive whether it contains metastatic melanoma. This area is marked
an injection of γ-emitting radioactive colloid (commonly and the patient is sent to the operating suite with the images
TABLE 1 4 . 6
Survival Rates For Cutaneous Melanoma By Stage Subungual
melanoma
n Stage n 5 Y (%) n 10 Y (%)
Stage IA 97 95
Stage IB 92 86
Stage IIA 81 67
Stage IIB 70 57
Stage IIC 53 40
Stage IIIA 78 59
Stage IIIB 59 43
Stage IIIC 40 24
Stage IV 15 10
Data extrapolated from Edge SB, Byrd DR, Compton CC, et al., eds.
AJCC Cancer Staging Manual. 7th edn. New York, NY: Springer; 2010. FIGURE 14.6. Typical level of amputation for a subungual melanoma.

TABLE 1 4 . 7
Surgical Treatment For Cutaneous Melanoma
n Tumor n Excision n Regional Lymph Node

Thickness Margin Treatment
In situ 0.5 cm None
Less than 1.0 mm 1 cm Nonea
1.0 to 4.0 mm 2 cm Sentinel lymph node biopsy

Greater than 4.0 mm 2 to 3 cm Sentinel lymph node biopsyb
a
Consideration for sentinel lymph node biopsy can be given for tumors between 0.76 and 1.00 mm with
f eatures such as ulceration, lymphovascular invasion, age <40 significant vertical growth phase, and
increased mitotic rate.
b
For patients with clinically negative nodes.
to guide the surgeon in identification of the sentinel node.

Following induction of general anesthesia, a second lymphatic
mapping technique is used for intraoperative identification
of the sentinel node. Blue dye (isosulfan blue or methylene
blue) is injected intradermally around the primary melanoma
and massaged for approximately 5 minutes to augment dye
flow in the lymphatic channels. Based on the post-emission
imaging and marking, a limited incision is made over the site
of the proposed sentinel node, and dissection into the lym-
phatic basin is guided by the use of a handheld γ-probe and
the presence of blue dye in lymphatic channels or nodes. The
ideal sentinel node identification would be a single blue lymph
node with significant γ-emission; however frequently, the blue
dye is absent and identification can be reliably made by radio-
activity alone. The sentinel node is then excised, taking care
not to disturb the channels of the surrounding lymph node
basin, and sent to pathology in formalin for permanent fixa-
tion, sectioning, and immunohistochemistry. Frozen sections
are generally discouraged, although advances in immunostain-
ing may make this technique more widely acceptable. Survey
of the remaining lymphatic tissue should reveal <10% of the
highest sentinel node emission. Greater than 10% suggests
the presence of additional “sentinel” nodes, which should be
excised and processed in a similar fashion. Following the sen-
tinel node biopsy, the primary lesion is excised and closure of
both sites proceeds.
Routine histologic examination with H&E staining
has traditionally been the gold standard for sentinel node
examination and identifies 15% to 20% of micrometa-
static disease in sentinel lymph node specimens. However,
it is vulnerable to miss up to 12% of true-positive nodes.
Immunohistochemical staining has enhanced the sensitiv-
ity of the micrometastasis detection by up to 40%.32 Due
to its utility, immunohistochemical identification of micro-
metastatic nodes has been incorporated into the 2009 AJCC
staging system. S-100 is the most sensitive marker for the
detection of melanoma (detected in >90% melanomas) but
is also expressed in a broad range of different cell types and
neoplasms, limiting its specificity as a marker. HMB-45 and
MART-1 are more specific cellular markers detected in mela-
noma, but each lacks sensitivity. Therefore, a combination of
these tumor markers is used in the pathologic examination.
Recently, reverse transcriptase polymerase chain reaction has
been used as a molecular staging tool, and ongoing trials are
evaluating its utility.
Lymphadenectomy. Complete surgical lymphadenectomy
is indicated in patients with clinically involved nodes diagnosed
by examination, fine needle aspiration, and/or sentinel lymph
FIGURE 14.7. Lymphoscintigraphy demonstrates localization of node biopsy. Nodal status is the most important prognostic
radioactive colloid to the sentinel lymph node. (Photo courtesy of factor in staging malignant melanoma. The revised AJCC stag-
Russell S. Berman, MD.) ing system for melanoma accounts for the number of positive
nodes as well as the overall tumor burden. Patients with only

one positive node have a better prognosis than patient with carcinoma resembles melanoma in its aggressive behavior and
multiple nodes. Some controversy exists, however, on the lymphatic spread. Diagnosis is established by biopsy, which
overall benefit of elective lymph node dissection in patients features dense nodules of small basophilic cells in the dermal
with clinically uninvolved nodes. While multiple clinical trials space often with lymphovascular invasion that must be dif-
have failed to show any benefit overall of non-selective elective ferentiated from other small cell neoplasms, particularly small
lymph node dissection, there may be some data to suggest that cell carcinoma of the lung. Further workup should include
it may offer a survival benefit in select cases. chest imaging to help exclude this possibility.
While potentially therapeutic, a complete lymphadenec- Surgical management of the primary tumor is wide exci-
tomy carries a significant risk for substantial morbidity. sional biopsy, often with 2 to 3 cm margins. There is a high
Postoperative lymphedema is a major source of physical rate of local recurrence, which ranges from 40% to 45%.34 In
and psychological distress in patients already coping with a anatomically complex areas, Mohs’ surgery should be consid-
diagnosis of melanoma. The rate of lymphedema following ered. Due to the propensity of Merkel cell carcinoma to spread
axillary and inguinal lymphadenectomy can be as high as to the lymph node basin first prior to metastasizing to distant
30% and 60%, respectively, compared with the incidence of sites, sentinel lymph node biopsy or elective lymph node dis-
lymphedema in patients who have only had a sentinel node section is recommended. The most powerful prognostic factor
biopsy, which ranges from 3% to 7%. It is important to coun- in determining survival is the presence of lymph node metas-
sel patients that while the use of sentinel node biopsy signifi- tasis. Radiation is considered an adjuvant therapy for tumors
cantly reduces the risk of lymphedema, it does not eliminate >2 cm and can be used following surgical management of both
it completely. the primary site and lymph node basin. Chemotherapy cur-
rently has a very limited role in treatment.
Advanced Melanoma. The prognosis for stage IV mela- Several different staging systems of Merkel cell carci-
noma is poor, with only 10% to 15% of patients living past noma exist, making prognostication difficult when compar-
5 years. A number of modalities have been studied in clini- ing outcomes data from disparate studies. Five-year survival
cal trials including immunotherapy (high-dose interleukin 2, rates for localized disease range from 44% to 68% and for
interferon alpha, combination therapy, adoptive immunother- regional or metastatic spread 23% to 42%.35,36 Recently, the
apy, and vaccines), systemic chemotherapy (dacarbazine and AJCC developed a more standardized evidence-based stag-
fotemustine), isolated limb perfusion, and radiotherapy, each ing system exclusively for Merkel cell carcinoma, no lon-
with limited success in highly selected cases. However, there ger including it with all other non-melanoma skin cancers
are no provocative data indicating that any of these treat- (Tables 14.8 and 14.9).18
ments reliably prolongs survival in stage IV melanoma. In the
absence of effective medical therapy, surgical management of
metastatic melanoma may offer a survival benefit to selected Dermatofibrosarcoma
patients with isolated or limited metastatic burden.33 Protuberans
Dermatofibrosarcoma protuberans (DFSP) is a soft tissue
Merkel Cell Carcinoma sarcoma of dermal fibroblastic origin, the pathogenesis of
Merkel cell carcinoma is a relatively rare (approximately 1,500 which is poorly understood. It occurs rarely, with an annual
cases annually) but aggressive cutaneous malignancy, typically incidence of only 4.2 per million. DFSP often presents on the
affecting fair-skinned patients with a history of sun exposure trunk and extremities of adults as a slowly growing, painless,
who are over 50 years of age. It has been associated with UV violaceous or erythematous nodular plaque. However, its clin-
exposure, a history of non-melanoma skin cancer, radiation ical appearance can vary, and development of the tumor has
exposure, immunosuppression, organ transplantation, B-cell been associated with trauma or scar formation (Figure 14.9).
neoplasia, and ectodermal dysplasia. Merkel cell carcinoma Lesions suspicious for DFSP should undergo needle, inci-
typically presents as a solitary, painless, erythematous nod- sional, or excisional biopsy to confirm a diagnosis. Most of
ule on sun-exposed skin, with about half of cases arising in these tumors are histologically classified as “low grade” and
the head and neck and approximately 10% in the periocu- are associated with a favorable prognosis following surgical
lar region (Figure 14.8). The most common site of metasta- resection. However, the fibrosarcomatous “high-grade” vari-
sis is the lymph nodes and 25% to 30% of patients initially ant (approximately 10% of cases) represents a much more
present with lymph node involvement. Clinically, Merkel cell aggressive tumor with metastatic potential. If signs and symp-
toms of metastatic spread are present, further evaluation with
CT or PET imaging may be warranted. Despite a high recur-
rence rate, metastatic disease only occurs in 1% to 2% of
cases. Most patients with DFSP have an excellent outcome,
and mortality is rare.
Wide local excision with 3 cm margins is recommended,
although subclinical extensions of tumors that appear as nor-
mal collagen may frequently lead to inadequate resection.
This failure to achieve negative margins despite wide local
excision is thought to be responsible for the high rates of
local recurrence found with DFSP. In a study of 159 patients
from Memorial Sloan Kettering Cancer Center, only 53%
were found to have negative margins despite wide local exci-
sion, and 21% developed a local recurrence.37 Some authors
advocate Mohs’ micrographic surgery for DFSP, particularly
in cosmetically sensitive areas, but larger studies have not
been published. Adjuvant radiation therapy has traditionally
been used to reduce the risk of local recurrence when residual
disease remains after surgery. In addition, the advent of tar-
FIGURE 14.8. Merkel cell carcinoma of the scalp. (Photo courtesy of geted molecular therapies, such as the selective tyrosine kinase
Joseph F. Merola, MD.) inhibitor imatinib mesylate, has provided new effective and
safe options for adjuvant treatment of DFSP.38

TABLE 1 4 . 8
TNM Staging Categories For Merkel Cell Carcinoma
n T Classification n Tumor Size

T0 No evidence of primary tumor (e.g., nodal/metastatic presentation without
associated primary)
Tis Carcinoma in situ
T1 ≤2 cm maximum tumor dimension

T2 >2 cm but ≤5 cm maximum tumor dimension
T3 >5 cm maximum tumor dimension
T4 Primary tumor invades bone, muscle, fascia, or cartilage
n N Classification n Nodal Metastatic Burden
cN0 Nodes negative by clinical examinationa (no pathologic node examination performed)
pN0 Nodes negative by pathologic examination
N1 Metastases in regional lymph node(s)
N1a Micrometastasisb
N1b Macrometastasisc
N2 In transit metastasisd
n M Classification n Site
M1 Metastases beyond regional lymph nodes
M1a Metastases to skin, subcutaneous tissues, or distant lymph nodes
M1b Metastasis to lung
M1c Metastases to all other visceral sites
a
Clinical detection of nodal disease may be via inspection, palpation, and/or imaging.
b
Micrometastases are diagnosed after sentinel or elective lymphadenectomy.
c
Macrometastases are defined as clinically detectable nodal metastases confirmed by therapeutic lymphadenectomy or needle biopsy.
d
In transit metastasis: a tumor distinct from the primary lesion and located either (1) between the primary lesion and the draining regional lymph
nodes or (2) distal to the primary lesion.
Reproduced from Merkel cell carcinoma, Chapter 30, AJCC Cancer Staging Manual. New York, NY: Springer; 2009.
Sebaceous Carcinoma
Sebaceous carcinoma (also referred to as sebaceous gland car-
cinoma, sebaceous cell carcinoma, or meibomian gland carci-
noma) is a rare, aggressive neoplasm that originates from cells
within the sebaceous glands. A majority of sebaceous carcino-
mas occur in the periocular region, commonly in the eyelid,
and usually arise from the meibomian glands of the tarsus.
These tumors may arise de novo, but some have been shown to
originate from preexisting sebaceous lesions such as sebaceous
nevus. Muir-Torre syndrome is an autosomal dominant skin
condition characterized by sebaceous skin tumors (including
sebaceous carcinoma) associated with internal malignancies
such as gastrointestinal, gynecologic, or urologic tumors. The
most common clinical presentation of sebaceous carcinoma is
a painless, round, subcutaneous nodule. However, due to their
varied clinical and histologic appearance, sebaceous carcino-
mas commonly mimic benign or less aggressive lesions, which
may lead to a delay in diagnosis or inappropriate treatment.
Patients presenting with atypical or recurrent chalazion, eyelid
thickening, or persistent blepharitis should prompt evaluation
for sebaceous carcinoma. Older age and female sex are impor-
tant risk factors for developing these tumors.
FIGURE 14.9. Dermatofibrosarcoma protuberans arising from a Orbital imaging may be performed if there is extensive
prior scar. (Photo courtesy of Richard L. Shapiro, MD.) periocular involvement. Histologic diagnosis is confirmed by
either incisional or excisional biopsy, which should include

TABLE 1 4 . 9
Anatomic Stage/Prognostic Groups For Merkel Cell Carcinoma
n Stage n T n N n M
0 Tis N0 M0
IA T1 pN0 M0
IB T1 cN0 M0
IIA T2 or T3 pN0 M0
IIB T2 or T3 cN0 M0
IIC T4 N0 M0
IIIA Any T N1a M0
IIIB Any T N1b or N2 M0
IV Any T Any N M1
Reproduced from Merkel cell carcinoma, Chapter 30 AJCC Cancer Staging Manual. New York, NY:
Springer; 2009.
18. Edge SB, Byrd DR, Compton CC, et al., eds. AJCC Cancer Staging Manual.
full thickness skin, tarsus, and palpebral conjunctiva. The New York, NY: Springer; 2010.
mainstay of treatment is surgical, using wide local excision 19. Brantsch KD, Meisner C, Schönfisch B, et al. Analysis of risk factors deter-
with 5 to 6 mm margins or by Mohs’ micrographic surgery. mining prognosis of cutaneous squamous-cell carcinoma: a prospective
Tumor extension posteriorly may require orbital exenteration. study. Lancet Oncol. 2008;9:713-720.
20. Ross AS, Schmults CD. Sentinel lymph node biopsy in cutaneous squamous
Recurrence occurs in up to a third of cases and metastases cell carcinoma: a systematic review of the English literature. Dermatol Surg.
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Chapter 15 n Thermal, Chemical, and
Electrical Injuries
Matthew B. Klein

Few areas of medicine are as challenging medically and sur-
gically as burn care. Burn injuries affect the very young and
Organization of Burn Care
the very old, both men and women. Burn injuries can vary The essence of successful burn care is the team. No indi-
from small wounds that can be easily managed in the outpa- vidual is capable of meeting the many acute and long-term
tient clinic to extensive injuries resulting in multiorgan system needs of the burn patient. Therefore, burn care is best
failure, a prolonged hospital course, and long-term functional delivered in a specialized burn center where experienced
and psychosocial sequelae. physicians, nurses, physical and occupational therapists,
According to the National Institutes of General Medical nutritionists, psychologists, and social workers can all
Sciences, an estimated 1.1 million burn injuries require medi- participate in the care of the individual. With the excep-
cal attention annually in the United States. Of those injured, tion of small burns, patients with burn injuries should be
about 50,000 require hospitalization and about 4,500 die referred to a burn center. The American Burn Association
annually from burn injuries. Survival following burn injury has established formal criteria for transfer to a burn center
has significantly improved over the course of the 20th cen- (Table 15.2). It is important to consider these as only guide-
tury. Improvements in resuscitation, the introduction of topi- lines. Patients who do not have a local physician comfort-
cal antimicrobial agents, and, most importantly, the practice able caring for even a minor burn should be transferred to
of early burn wound excision have all contributed to the the nearest burn center.
improved outcome. However, extensive burn injuries remain
potentially fatal. Evaluation of the Burn Patient
Once a patient arrives at the burn center, a thorough evalu-
Burn Management: Overview ation is performed so that an effective treatment plan can be
initiated. It is important to remember that burn patients are
Etiology trauma patients, and they require evaluation in accordance
Burn injuries can result from a variety of causes. Scald burns with the Advanced Trauma Life Support (ATLS) protocol.
are the most common cause of burn injury in the civilian Airway, breathing, and circulation must be assessed immedi-
population. The depth of scald burn is determined by the ately following a burn injury. In addition to ensuring a patent
temperature of the liquid, the duration of exposure to the airway, adequate breathing, and circulation, the presence of
liquid (Table 15.1), and the viscosity of the liquid (there is additional injuries—particularly life-threatening injuries—
usually prolonged contact with more viscous liquids). Scald requires exclusion.
burns with hot liquids will typically heal without the need A thorough history of the burn injury is critical as it may
for skin grafting. Grease burns, however, tend to result in provide some important information that will ultimately
deeper dermal burns and will occasionally require surgical affect management. Details related to the location of the
management. Flame burns, the next most common cause injury (indoors vs. outdoors), type of liquid involved in a
of burn injury, typically result from house fires, campfires, scald, duration of extraction from fire, as well as details of
and the burning of leaves or trash. If the patient’s clothing the patient’s other medical problems are all elements of an
catches fire, burns will usually be full thickness. Flash burns adequate history. Any child who has an injury that is suspi-
are quite common as well and typically result from igni- cious for abuse should be admitted to the hospital regardless
tion of propane or gasoline. Flash burns will typically injure of burn severity so that social services can be contacted and
exposed skin (most commonly face and extremities) and usu- the circumstances surrounding the injury investigated. Adults
ally result in partial thickness burns. Contact burns occur with burn injuries greater than 15% to 20% are admitted to
from contact with woodstoves, hot metals, plastics, or coals. an intensive care unit for adequate monitoring and infectious
Contact burns are usually deep but limited in extent of body control. Smaller children or elderly patients with less exten-
surface area injured. In addition, burn injury can result from sive burn injuries are monitored in an intensive care setting.
electrical and chemical agents as well. In addition, patients requiring close airway monitoring (i.e.,
suspected inhalation injury) or frequent neurovascular checks
are placed in an intensive care unit setting.
Table 15.1
Determination of Burn Extent. The extent and depth of
Immersion Time To Produce Full Thickness Burns burn wounds are established shortly following admission. The
total body surface area (TBSA) burned is calculated using one
n Time n Temperature (°F) of several techniques. When calculating TBSA, one includes
1s 158 those areas of partial and full thickness burns. Superficial
burns are not included in the calculation. The rule of nines
2s 150 (Figure 15.1) is perhaps the best known method of estimating
10 s 140 burn extent. However, it is important to note that the propor-
tions of infants and children are different than those of adults.
30 s 130 The head of children tends to be proportionately greater than
1 min 127 9% TBSA, and the lower extremities are less than 18%. In
addition, it is important to explain to the inexperienced person
10 min 120
that the percentage assigned to a body part represents a total
127
Table 15.2
9%
Burn Center Referral Criteria
The American Burn Association has identified the following

injuries as those usually requiring a referral to a burn center.
Patients with these burns should be treated in a specialized Anterior
burn facility after initial assessment and treatment at an emer- 18%
gency department.
Posterior
Questions about specific patients can be resolved by confirma- 18%
9% 18% 9%
tion with the burn center.
Second- and third-degree burns >10% body surface area (BSA)
in patients <10 or >50 years old. Anterior
1% 1% 18%
Second- and third-degree burns >20% BSA in other groups. 1%
9% Posterior 9%
Second- and third-degree burns with serious threat of functional
or cosmetic impairment that involve the face, hands, feet, geni- 18%
18% 18%
talia, perineum, and major joints. 1% 1%
Third-degree burns >5% BSA in any age group. 14% 14%
Electrical burns, including lightening injury.
Chemical burns with serious threat of functional or cosmetic
impairment.
Inhalation injury with burn injury.
Circumferential burns with burn injury.
Burn injury in patients with preexisting medical disorders that could Adult Child
complicate management, prolong recovery, or affect mortality. FIGURE 15.1. The Rule of 9’s provides a facile method of estimat-
ing total body surface area burned. Due to differences in body pro-
Any burn patient with concomitant trauma (for example, frac- portions, the percentage for each body area is different in adults and
tures) in which the burn injury poses the greatest risk of morbidity children.
or mortality. However, if the trauma poses the greater immediate
risk, the patient may be treated in a trauma center initially until
stable, before being transferred to a burn center. Physician judg-
ment will be necessary in such situations and should be in concert Depth of Burn Injury. Thermal injury can injure the
with the regional medical control plan and triage protocols. epidermis, a portion of or the entirety of the dermis, as
Hospitals without qualified personnel or equipment for the well as subcutaneous tissue. The depth of the burn affects
care of children should transfer burned children to a burn the healing of the wound, and therefore, assessment of
center with these capabilities. burn depth is important for appropriate wound manage-
ment and, ultimately, the decision for operative interven-
tion. The characteristics of superficial, partial, and full
area, so that a portion of an arm burn is only a portion of 9%. thickness burns are described below and summarized in
A second technique of estimating TBSA is using the patient’s Table 15.3.
hand. The patient’s hand represents about 1% TBSA and the Superficial burns involve the epidermis only and are ery-
total burn size can be estimated by determining how much of thematous and painful. These burns typically heal within 3 to
the patient’s (not the examiner’s) hand areas are burned. Lund 5 days and are best treated with a topical agent such as aloe
and Browder charts are a more accurate method of assessing lotion that will accelerate healing and soothe the patient. In
burn extent. They provide an age-based diagram to assist in addition, oral analgesics can be helpful. Sunburns are the pro-
more precisely calculating the burn size (Figure 15.2). totypical superficial burns.
Table 15.3
Burn Depth Categories
n Burn degree n Cause n Surface appearance n Color n Pain level
First (superficial) Flash flame, ultraviolet Dry, no blisters, no or Erythematous Painful

(sunburn) minimal edema
Second (partial Contact with hot liquids Moist blebs, blisters Mottled white to pink, Very painful
thickness) or solids, flash flame to cherry red
clothing, direct flame,
chemical, ultraviolet
Third (full Contact with hot liquids Dry with leathery eschar Mixed white, waxy, Little or no pain;
thickness) or solids, flame, chemi- until debridement; charred pearly; dark, khaki, hair pulls out easily
cal, electrical vessels visible under eschar mahogany; charred
Fourth (involves Prolonged contact with Same as third degree, pos- Same as third degree Same as third degree
underlying flame, electrical sibly with exposed bone,
structure) muscle, or tendon

Chapter 15: Thermal, Chemical, and Electrical Injuries 129

FIGURE 15.2. The Lund and Browder chart provides a more precise estimate of burn TBSA for each body part based on
the individual’s age.
Partial thickness burns involve the entirety of the epider- Deep partial thickness burns involve the entirety of the
mis and a portion of the dermis. Partial thickness burns are epidermis and extend into the reticular portion of the der-
further divided into superficial and deep partial thickness mis. These burns are typically dry and mottled pink and
based on the depth of dermal injury. Superficial and deep white in appearance and have variable sensation. If protected
partial thickness burns differ in appearance, ability to heal, from infection, deep partial thickness burns will heal within
and potential need for excision and skin grafting. Superficial 3 to 8 weeks, depending on the number of viable adnexal
partial thickness burns are typically pink, moist, and painful structures in the burn wound. However, they will typically
to the touch (Figure 15.3). Water scald burns are the proto- heal with scarring and possible contractures. Therefore, if
typical superficial partial thickness wound. These burns will it appears that the wound will not be completely reepithe-
typically heal within 2 weeks and will generally not result in lialized in 3 weeks time, operative excision and grafting is
scarring, but could result in alteration of pigmentation. These recommended.
wounds are usually best treated with greasy gauze with anti- Full thickness burns involve the epidermis and the entirety
biotic ointment. of the dermis. These wounds are brown-black, leathery, and

Initial Management
Intravenous Access. Intravenous access is important for
patients who will require fluid resuscitation as well as for
those patients who will require intravenous analgesia. Two
peripheral IV lines are usually sufficient for patients with
less than 30% burns. However, patients with larger burns or
significant inhalation injury may require central line place-
ment. Both peripheral and central lines can be placed through
burned tissue when required. The burned area is prepared
with topical antimicrobial solution as is done when preparing
uninjured skin. Lines should be securely sutured in place, par-
ticularly over burned areas where the use of tape dressings is
difficult. Typically, a triple lumen catheter is adequate access
since large volume fluid boluses are not a standard component
of burn resuscitation. Furthermore, there is usually no need
for a pulmonary artery catheter introducer since these cath-
eters are of little benefit, and carry certain complication risks,
in the resuscitation of the burned patients. Arterial line place-
FIGURE 15.3. A superficial partial thickness scald burn is typically ment is usually necessary in the patient who is intubated and is
moist, pink, and tender. These burns will usually heal within 1 to 2 weeks. likely to remain intubated for several days.
Escharotomy. The leathery eschar of a full thickness burn

can form a constricting band that compromises limb perfu-
insensate (Figure 15.4). Occasionally, full thickness burn sion. It is important to determine if escharotomy is necessary.
wounds will have a cherry red color from fixed carboxyhe- During fluid resuscitation the problem worsens because of
moglobin in the wound. These wounds can be differentiated swelling. In general, escharotomies are indicated for full thick-
from more superficial burns because they are usually insen- ness circumferential burns of the extremity or for full thick-
sate and do not blanch. Full thickness burns are best treated ness burns of the chest wall when the eschar compromises
by excision and grafting, unless they are quite small (size of a thoracic cage excursion and, thus, ventilation of the patient.
quarter). Escharotomy can be performed at the bedside using a scalpel
Determination of burn depth is usually easy for superficial or electrocautery. Adequate release occurs when the eschar
and very deep wounds. However, determining the depth of separates, perfusion improves, and, on occasion, a popping
deep dermal burns and their healing potential can be more sound is heard. The ideal location of escharotomy incisions is
challenging. It often takes several days to determine whether shown in Figure 15.5. It is important to avoid major superfi-
these are wounds that will heal within 3 weeks or would be cial nerves when performing escharotomy. The incision should
better managed with excision and grafting. A variety of tech- go through only eschar, not fascia. Incisions that are too deep
niques have been described for precise determination of burn can unnecessarily expose vital underlying structures such as
depth including fluorescein dyes, ultrasound, laser Doppler, tendons and also increase the chance of desiccation and death
and magnetic resonance imaging. However, none of these of otherwise healthy tissue.
methods have proven to be more reliable than the judgment of
an experienced burn surgeon. Topical Wound Agents. Following admission to the burn
center, the patient’s wounds are cleansed with soap and water.
Loose tissue and blisters are debrided. Body and facial hair
are shaved if involved in the area of a burn. Daily wound care
is performed on a shower table with soap and tap water or,
if the burn wound is small, at the patient’s bedside following
a shower. The use of tanks for wound care has fallen out of
favor because of the risks of cross-contamination.
Burn injury destroys the body’s protective layer from the
environment and dressings are needed to protect the body from
infection and minimize evaporative heat loss from the body.
The ideal dressing if it existed would be inexpensive, easy to
use, require infrequent changes, and be comfortable. While a
number of topical agents are available for burn wound care, it
is best to have a simple, well-reasoned wound care plan.
The choice of topical burn wound treatment is contingent
on the depth of burn injury and the goals of management.
Superficial burn wounds (such as sunburns) require soothing
lotions that will expedite epithelial repair such as aloe vera.
Partial thickness burn wounds need coverage with agents that
will keep the wound moist and provide antimicrobial protec-
tion. Deeper partial thickness burn wounds should be covered
with agents that will protect the eschar from microbial coloniza-
tion. Once the eschar has lifted and the wound has begun to epi-
thelialize, a dressing that optimizes epithelialization (i.e., greasy
gauze and antibiotic ointment) is utilized. Full thickness burns
FIGURE 15.4. Full thickness burn wounds have a dry, leathery are also covered with a topical agent that protects the burn
appearance and can vary in color from brown to black to white. Full wound from getting infected until the time of burn excision.
thickness burns are insensate and will not blanch. Prophylactic systemic antibiotics have no role in the man-
agement of burn wounds. In fact, the use of prophylactic


A B
FIGURE 15.5. The location of escharotomy incisions on the (A)

upper extremity; (B) hand; and (C) lower extremity.
C
antibiotics has been shown to increase the risk of opportunis- treating burn wound infections. Mafenide is commonly used
tic infection.1 Since burn eschar has no microcirculation, there on the ears and the nose because of its ability to protect
is no mechanism for the delivery of systemically administered against suppurative chondritis; however, silver sulfadiazine
antibiotics. Therefore, topical agents need to provide broad- appears to be equally effective in this setting. Since mafenide
spectrum antimicrobial coverage at the site of colonization— penetrates eschar well, twice-daily administration is typically
the eschar. necessary. Mafenide-soaked gauze can also be used as a dress-
In the early postburn period, the dominant colonizing ing for skin grafts that have been placed over an infected or
organisms are staphylococci and streptococci—typical skin heavily colonized wound bed. There are two well-recognized
flora. Over time, however, the burn wound becomes colonized drawbacks of mafenide. Mafenide is a potent carbonic anhy-
with gram-negative organisms. Thus, topical antimicrobial drase inhibitor and, therefore, can cause a metabolic acidosis.
agents used in early burn care should have broad-spectrum This problem can confound ventilator management. In addi-
coverage to minimize colonization of the wound, but they tion, the application of mafenide can be painful and therefore
need not penetrate the burn eschar deeply. its use may be limited in partial thickness burn wounds.
Silver sulfadiazine is the most commonly used topical Silver nitrate is another commonly used topical antimi-
antimicrobial agent. Silver sulfadiazine has broad-spectrum crobial agent. Silver nitrate provides broad-spectrum cover-
antimicrobial coverage, with excellent Staphylococcus and age against gram-positive and gram-negative organisms. It is
Streptococcus coverage. However, silver sulfadiazine is inca- relatively painless on administration and needs to be applied
pable of eschar penetration, so it is less useful in the man- every 4 hours to keep the dressings moist. Silver nitrate has
agement of the infected burn wound. Wounds treated with two principal drawbacks. First, it stains everything it touches
silver sulfadiazine will develop a yellowish-gray pseudoe- black, including linen, floors, walls, and staff’s clothing.
schar that requires removal by cleansing during daily wound Second, since silver nitrate is prepared in water at a relatively
care. Traditionally, the principal drawback of silver sulfadia- hypotonic solution (0.5%), osmolar dilution can occur result-
zine was thought to be leukopenia. However, it is not clear ing in hyponatremia and hypochloremia. Therefore, frequent
whether the leukopenia that occurs results from silver sul- electrolyte monitoring is needed. Rarely, silver nitrate can
fadiazine toxicity or from the margination of leukocytes as cause methemoglobinemia. If this occurs silver nitrate should
part of the body’s systemic inflammatory response to the burn be discontinued.
injury. Regardless, the leukopenia is typically self-limited, and Bacitracin, neomycin, and polymyxin B ointments are all
therefore, the silver sulfadiazine should not be discontinued. commonly used for coverage of superficial wounds either
Patients with a documented sulfa allergy may or may not alone or with petrolatum gauze to accelerate epithelialization.
have a reaction to the silver sulfadiazine. If there is concern These ointments are also used routinely in the care of superfi-
about an allergy, a small test patch of silver sulfadiazine can cial face burns. Mupirocin (Bactroban) is another topical agent
be applied. Typically, if there is an allergy, the silver sulfadia- that is effective in treating methicillin-resistant Staphylococcus
zine will be irritating rather than soothing. In addition, a rash aureus (MRSA). Mupirocin should be used only when there is
could signal a silver sulfadiazine allergy. a culture-proven MRSA infection to avoid the development of
Mafenide (Sulfamylon) is another commonly used anti- resistant infections.
microbial agent. Mafenide is available as a cream and, more
recently, as a 5% solution. Mafenide, like silver sulfadiazine,
has a broad antimicrobial spectrum, including gram-positive Fluid Resuscitation
and gram-negative organisms. In addition, mafenide read- Significant burn injury not only results in local tissue injury
ily penetrates burn eschar, making it an excellent agent for but also initiates a systemic response that impacts nearly

every organ system. The release of inflammatory mediators the first 8 hours and the second half administered over the
(including histamine, prostaglandins, and cytokines) can lead next 16 hours. Children who weigh less than 15 kg should
to decreased cardiac output, increased vascular permeability, also receive a maintenance IV rate with dextrose-containing
and alteration of cell membrane potential. The purpose of solution since young children do not have adequate glycogen
fluid resuscitation is to provide adequate replacement for fluid stores.
lost through the skin and fluid lost into the interstitium from It is important to remember that the formula provides
the systemic capillary leak that occurs as part of the body’s merely an estimate of fluid requirements. Fluid should be
inflammatory response. Therefore, significant volumes of titrated to achieve a urine output of 30 cc/h in adults and
intravenous fluid may be required to maintain adequate organ 1 cc/kg/h in children. Therefore, a Foley catheter should be
perfusion. used to accurately track urine output. If urine output is inad-
An understanding of burn shock physiology is essen- equate, the fluid rate should be increased; conversely, if the
tial to understanding the rationale for the various formulas urine output is greater than 30 cc/h, the fluid rate should be
that have been described for fluid resuscitation. Burn injury decreased. Fluid boluses should only be used to treat hypoten-
destroys the body’s barrier to evaporative fluid losses and sion and should not be used to improve urine output. Patients
leads to increased cellular permeability in the area of the with deeper, full thickness burns and patients with inhalation
burn. In addition, in cases of larger burns (>20%), there injury tend to require higher volumes of resuscitation.
is systemic response to injury that leads to capillary leak-
age throughout the body. Arturson2 in 1979 demonstrated Colloid. Protein solutions have long been used in burn
that increased capillary permeability occurs both locally and resuscitation and have been the subject of debate for decades.
systemically in burns greater than 25%, and Demling3 dem- The use of colloid has the advantage of increasing intravascu-
onstrated that half of the fluid administered following 50% lar oncotic pressure, which could theoretically minimize capil-
TBSA burns ends up in uninjured tissue. Therefore, burn lary leak and potentially draw fluid back intravascularly from
resuscitation must account not only for the loss of fluid at the interstitial space. The Brooke and Evans formulas devel-
the site of injury but also to the leak of fluid throughout the oped during the 1950s and 1960s both included the use of
body. These losses are even greater if an inhalation injury is colloid in the first hours of resuscitation. However, the use
present since there will be increased fluid leak into the lungs of colloid in the early postburn period can lead to the leak-
as well as an increased release of systemic inflammatory age of colloid into the interstitial space, which can aggravate
mediators. Capillary leak usually persists through the first 8 tissue edema. Therefore, colloid is typically not used until
to 12 hours following injury. 12 to 24 hours following burn injury when the capillary leak
The use of formal fluid resuscitation is reserved for patients has started to seal.
with burns involving more than 15% to 20%. Awake and Several different colloid formulations have been used.
alert patients with burns less than 20% should be allowed to Albumin is the most oncotically active solution and does
resuscitate themselves orally as best as possible. A number of not carry a risk of disease transmission. Fresh frozen plasma
approaches using a number of different solutions have been has also been used, but since this is a blood product, there
proposed for intravenous fluid resuscitation. is a risk, albeit small, of disease transmission. Dextran is a
nonprotein colloid that has also been used in burn resuscita-
Crystalloid. The Parkland formula, as described by tion. Dextran is available in both a low and high molecular
Baxter, is still the most commonly used method for esti- weight form. Low molecular weight dextran (dextran 40) is
mation of fluid requirements (Table 15.4]). The formula more commonly used. Dextran increases urine output with
(4 cc × weight in kilograms × %TBSA) provides an esti- its osmotic effect, and therefore, urine output may not be an
mate of fluid required for 24 hours. The fluid adminis- accurate indicator of volume status. In addition, dextran has
tered should be Lactated Ringer’s (LR). LR is relatively the disadvantage of relatively and potentially catastrophic
hypotonic and contains sodium, potassium, calcium, chlo- allergic reactions.
ride, and lactate. Sodium chloride is not used because of
the risk of inducing a hyperchloremic acidosis. Half the Hypertonic Saline. Hypertonic saline solutions have
calculated fluid resuscitation should be administered over been used for many years for burn resuscitation. Advocates
of hypertonic saline argue that hypertonic solutions increase
serum osmolarity and minimize the shift of water into the
interstitial space. This should theoretically maintain intravas-
Table 15.4 cular volume and minimize edema. However, this theory has
The Parkland Formula For FLUID Resuscitation not been well substantiated in the literature.4
Regardless of the type of resuscitation fluid used, urine
Formula: 4 cc/kg/%TBSA = total fluid to be administered in output is the best indicator of resuscitation. Tachycardia is
the first 24 h often present as a result of the body’s systemic inflammatory
response, pain, or agitation and, therefore, is not as accurate
½ of fluid should be given in the first 8 h a barometer of volume status. The use of pulmonary artery
½ of fluid should be given in the next 16 h catheter parameters to guide fluid resuscitation has been
found to lead to overresuscitation. Serial lactate and hemato-
Fluid should be Ringer’s lactate crit measurements serve as secondary indicators of resuscita-
Sample calculation: 70 kg person with a 50% TBSA burn tion. Poor urine output is likely the result of hypovolemia and
is therefore appropriately treated with increased fluid admin-
4 × 70 × 50 = 14 L of fluid
istration, not diuretics or pressors.
7 L in the first 8 hours (875 cc/h) The risks of underresuscitation are well understood: hypo-
7 L in the next 16 hours (437 cc/h)
volemia and worsening organ dysfunction. More recently, the
risks of overresuscitation are becoming clear as well. The need
• The formula is only a guideline. Fluid administration for intubation, prolonged ventilation, and increased extremity
should be titrated to urine output of 30 cc/h for adults and edema that can extend the zone of burn injury and the poten-
1 cc/kg/h for children. tial for extremity and abdominal compartment syndrome can
Pediatric patients less than 15 kg should also receive mainte- all result from excessive fluid resuscitation.5,6
nance fluid based on their weight. While there are several formulas to guide fluid resuscita-
tion in the first 24 hours following burn injury, it is important

to remember that patients may continue to have large fluid resuscitation. In addition, if a patient with a suspected
requirements for several days following injury. At the conclu- inhalation injury has a worsening respiratory status, intu-
sion of the first 24 hours, fluids should not be discontinued, bation should be promptly performed. Aggressive pulmo-
but rather titrated for a goal urine output of 30 cc/h. Patients nary toilet, bronchodilators, and clearing of secretions are
with large burns will have large volumes of insensible losses all essential components of patient management. Steroids
that will require replacement with intravenous fluids. have not been shown to be beneficial in the treatment of
inhalation injury, and the use of prophylactic antibiotics
Decision Not to Resuscitate should be avoided. Radiographs may be useful following
admission to evaluate possible pneumonia. Repeat bron-
Despite the significant advances in burn care, some injuries choscopy can be useful in obtaining sputum samples for

are not survivable. In cases of extensive burn injury, a deci- culture and for assistance in suctioning sloughed mucosa
sion is made regarding the potential futility of resuscitation that the patient is unable to clear. Patents who sustain
and subsequent surgical management. This is clearly a dif- inhalation injury are at increased risk for respiratory fail-
ficult decision that needs to be based on several factors: an ure and subsequent infection.
accurate assessment of the patient’s injury, location of burns, Patients who develop signs of adult respiratory distress syn-
depth of burns, presence of inhalation injury, the patient’s age drome should be placed on low (protective) tidal volumes on
and comorbidities, and the typical mortality level based on the ventilator in order to protect the pulmonary parenchyma
these factors. from additional damage. Typically, these lower tidal volumes
There have been several formulas described for estimating will result in hypercapnia, which should be permitted in order
mortality, but none is perfect. Baux suggested that adding age to protect the lungs.
and TBSA gives an estimate of mortality. Zawacki’s descrip- The utility of hyperbaric oxygen for patients with ele-
tion of the Z score is another formula that has been described vated carboxyhemoglobin levels has long been debated.
to estimate mortality. The score is based on several factors The potential benefit of hyperbaric oxygen is the rapid
including extent of burn injury, extent of full thickness burn reduction of carbon monoxide levels, with the potential
injury, presence of inhalation, and age.7 to minimize potential neurologic sequelae of carbon mon-
Part of the difficulty in determining survivability is that oxide poisoning. Hyperbaric oxygen can reduce the half-
each burn is quite different. In addition, each patient is quite life of carbon oxide from 40 minutes on 100% FiO2 to 20
different. This is particularly true in older patients, since there
minutes. However, hyperbaric oxygen is not without risk.
is great heterogeneity in patients of the same age. Prior to mak-
Hyperbaric oxygen can cause pneumothorax and perfo-
ing a decision regarding resuscitation, frank discussion with
ration of the tympanic membranes. If the patient must be
the patient’s family, if possible, should occur. Members of the
transported to another medical center for hyperbaric oxy-
burn team—particularly the nurses caring for the patient—
gen, it may be possible to effectively treat an elevated car-
should be included in the discussion and comfortable with the
boxyhemoglobin with 100% oxygen in the time it takes
very difficult decision to not resuscitate.
to transport the patient to the hyperbaric chamber. One
Patients who are awake and alert who are not candidates
must also carefully weigh the risks of placing a critically
for resuscitation should also be involved in the process. These
ill patient in a chamber where access might be limited. Any
patients should be informed of the decision not to resuscitate
patient who is hemodynamically unstable, requires aggres-
and given the opportunity to talk with family members. Often
sive resuscitation, and is hypothermic should probably not
patients with extensive full thickness burns can be extubated
be transported for hyperbaric oxygen.
and be awake and alert enough to have an opportunity to say
good-bye to family members.
Nutrition
Nutritional support is a cornerstone of burn patient man-
Inhalation Injury agement. Hypermetabolism and hypercatabolism both occur
The inhalation of the products of combustion can lead to dev- following burn injury. This increased metabolic rate begins
astating pulmonary injury. Direct thermal injury occurs rarely immediately following injury and persists until complete
and usually only in the case of steam burns. Inhalation injury wound coverage is achieved. In addition, the nutritional
significantly increases burn mortality for a given percent skin requirements to heal burn wounds, skin grafts, and donor
burn. Carbon monoxide inhalation is potentially devastating sites all increase the nutritional needs of the burn patient.
since carbon monoxide will bind to hemoglobin and interfere Feedings, whether oral or enteral, should be initiated
with the delivery of oxygen. as soon following admission as possible. Most patients
Diagnosis of inhalation injury is best made by consid- with burns of under 20% TBSA can obtain enough calo-
eration of the circumstances surrounding the burn injury ries on their own. However, patients with larger burns or
and findings on physical examination. However, the gold patients who will be intubated for several days should have
standard for diagnosis is bronchoscopy. Evaluation of an enteral feeding tube placed on admission. Ileus follow-
inhalation injury should include an arterial blood gas and ing burn injury commonly occurs, and it may take days for
carboxyhemoglobin level. An elevated carboxyhemoglo- the return of gastrointestinal function. However, ileus can
bin is consistent with inhalation injury; however, patients be prevented by starting feeds in the immediate post-injury
who smoke will have an elevated baseline carboxyhemo- period. The burn team’s dietician should be consulted to
globin, sometimes as high as 10. In addition, the carboxy- assist in determining nutritional needs, to provide monitor-
hemoglobin level should be interpreted in light of the time ing of caloric intake, and to make appropriate adjustments
since injury and the level of oxygen support the patient has to the patient’s nutrition plan. Due to the high levels of nar-
received since the injury. The half-life of carboxyhemoglo- cotics patients receive, routine use of stool softeners should
bin on 100% oxygen is 40 minutes, so a patient with a car- also begin on admission to prevent constipation and intoler-
boxyhemoglobin level of 10 forty minutes following injury ance of feedings.
may have had an initial level of 20. Parenteral nutrition is associated with higher rates of
Management of inhalation injury is usually support- infection, attributable, in part, to the prolonged need for cen-
ive. Patients with signs and symptoms of inhalation injury tral venous access. Parenteral nutrition should only be used
may require intubation. In general, it is better to secure a in cases when the patient has a prolonged paralytic ileus,
patient’s airway early in the postburn period, particularly pancreatitis, bowel obstruction, or other contraindication to
if the patient is going to require large volumes of fluid enteral feeding.

There are several equations for the estimation of caloric

requirements. The two most commonly used formulas for cal- Deep Venous Thrombosis
culating caloric requirements are the Curreri formula and the Patients who sustain burn injuries often have multiple risk fac-
Harris-Benedict formula. The Curreri formula differs for chil- tors for deep venous thrombosis. Injuries to the extremity as
dren and adults: well as the occasional need for prolonged bed rest (particularly
in the intubated patient) and indwelling catheters increase the
Adults: 25 kcal × weight (kg) + 40 kcal × %TBSA risk of venous thrombosis. Therefore, deep venous thrombosis
Children: 60 kcal × weight (kg) + 35 kcal × % TBSA prophylaxis is required in burn patients who are hospitalized
and are unable to regularly ambulate.
The Harris-Benedict formula provides an estimate of basal
energy expenditure (BEE):
Infection
Men: 66.5 + 13.8 × wt (kg) + 5 × height (cm) - 6.76 Infection remains a significant risk following burn injury.
× age (years) Prolonged intensive care unit stay, prolonged periods of intu-
Women: 655 + 9.6 × wt (kg) + 1.85 × height (cm) bation and mechanical ventilation, and potential colonization
- 4.68 age (years)8 of burn eschar contribute to the risk of infection. In addition,
indwelling vascular and bladder catheters provide another
The calculated BEE is multiplied by an injury factor (typi- source of invasive infection. In fact, nearly all patients with
cally 2.1 for patients with large burns) in order to provide an major burns have bouts of infection.
estimate of caloric requirements. The Curreri formula generally Burn patients are also functionally immunocompromised
overestimates caloric requirements, particularly in the elderly, for a number of reasons. First, the skin that serves as the
and the Harris-Benedict formula can underestimate caloric principal barrier between an individual and the environment
requirements, so an average of the two is often used. Indirect is lost. Similarly, the mucosal barrier of the respiratory tract
calorimetry using a metabolic cart can be used for patients on may also be injured. In addition, the cellular and humoral
a ventilator. However, the formula is less reliable at FiO2 lev- portions of the immune response are compromised following
els above 50%. The metabolic cart will provide an estimate burn injury. Decreased production of antibodies and impaired
of energy expenditure by measuring oxygen consumption and chemotaxis and phogocytosis all increase the risk of infection
carbon dioxide production. In addition, a respiratory quotient and decrease the body’s ability to fight infection.
can be calculated from these data, which will provide informa- The diagnosis and management of infection in the burn
tion about whether the patient is being overfed or underfed. patient can be challenging. Fevers and leukocytosis can result
Protein requirements should also be calculated. Burn from the systemic inflammatory response to burn injury and not
patients catabolize significant amounts of skeletal muscle and necessarily infection. Thrombocytosis is also frequently observed
require protein replacement not only to maintain muscle mass in stable burn patients. Nearly all patients with greater than
and function but also to provide building blocks for wound 15% TBSA burns will be febrile within the first 72 hours fol-
healing. Patients with normal renal function should receive lowing burn injury. Therefore, routine culture of these patients
2 g of protein per kilogram per day. Supplemental vitamins in this early time period is likely unnecessary. However, follow-
and minerals should also be provided to optimize wound healing the initial 72 to 96 hours, periodic cultures are important
ing. Vitamins A and C, as well as zinc have known benefits in in making a diagnosis of infection. Temperature spikes warrant
wound healing and the use of vitamin E, selenium, and iron culturing of urine, sputum, blood, and central lines. In addition,
supplements has also been described. any change in the patient’s status including hypotension, altered
Regular nutrition monitoring, particularly for intensive mental status, intolerance of tube feeds, hyperglycemia, and
care unit patients, should be performed. Our practice is to hypoglycemia should raise the suspicion of infection.
obtain weekly C-reactive protein, albumin, prealbumin, and Management of infections in burn patients must be culture
vitamin C levels as well as a 24-hour total urea nitrogen. driven. Presumptive broad-spectrum antimicrobial coverage is
Calorie counts should be used to monitor the patient’s oral fraught with potential complications including breeding resis-
intake and help determine when enteral feeds can be safely tant organisms and increasing the risk of fungal infections.
weaned and ultimately discontinued. Selection of antibiotics should be based on culture results. In the
Blood glucose levels should be closely monitored on case of suspected pneumonia, bronchoscopic samples may be
patients, particularly those in the intensive care unit. Enteral helpful in differentiating pneumonia from airway colonization.
feeding, along with the body’s systemic inflammatory
response, can increase blood glucose levels. The benefits of Pain Control
tight glucose control in critically ill patients have been well
documented. Sliding scale insulin coverage should be initiated Pain management is an important factor in caring for the burn
on all patients in the intensive care unit and there should be patient. Burn patients typically have two types of pain: back-
a low threshold for initiating an insulin drip, since this will ground and procedural. Background pain is present on a daily
allow for tighter blood sugar control. basis with little variation. Procedural pain occurs during daily
wound care and therapy. The best approach to pain manage-
ment is to keep it simple. Polypharmacy can easily occur on
Gastrointestinal Prophylaxis a patient who is hospitalized for a long time and will make
Stress ulcers (Curling’s ulcers) were once a common com- weaning the patient from the medications very difficult.
plication following severe burn injury. The development of Background pain is best treated with longer acting agents.
prophylactic agents, including histamine receptor blockers, Methadone can be used for patients who are going to have a
sucralfate, and protein pump inhibitors, has nearly eliminated long hospital course. Methadone has a half-life of 6 hours and
the occurrence of stress ulcers. Perhaps the best protection can reduce the need for high doses of other agents. However,
against stress ulcers is feeding the patient. Feeding the stom- patients on methadone require a taper prior to discontinua-
ach early in the hospital course will minimize posttraumatic tion of the medication. Oxycodone or morphine can then be
gastric atony, will provide continuous coating of the stomach, used for breakthrough pain. Nonsteroidal agents should be
and is easier to place at the bedside than a duodenal tube. avoided in patients likely to undergo surgical excision and
Stress ulcer prophylaxis is therefore only necessary in those grafting. For procedural pain, shorter acting agents are prob-
patients who are not taking oral or enteral feeds or those with ably best since wound care is usually a short-duration activity.
a previous history of peptic ulcer disease. Many patients—particularly children—may also benefit from

low-dose benzodiazepines since wound care can be anxiety assess the viability of the excised wound bed. This can par-
provoking for many patients. Again, the use of short-acting ticularly be a problem when excision is carried down to fat.
benzodiazepines is favorable. Fascial excision involves excision of the burned tissue
and subcutaneous tissue down to the layer of the muscle fas-
cia. Fascial excision can be carried out using electrocautery,
Surgical Management which makes for a more hemostatic excision (Figure 15.7).
Early burn excision and skin grafting has become the standard In addition, by carrying out excision through a well-defined
of care for full thickness burn wounds. The concept of early anatomic plane, it is easier to control bleeding by identify-
excision was popularized in the early 1970s by Janezovic.9 ing and ligating larger vessels. However, in performing fascial
Traditionally, burn eschar was left on the wound and pro- excision, it is possible that viable subcutaneous tissue is being

teolytic enzymes produced by neutrophils and bacteria would excised. Fascial excision can also result in a cosmetically unac-
lead to the separation and sloughing of the eschar. The under- ceptable contour deformity and lymphedema of the excised
lying granulating wound would then be skin grafted. It has extremities.
become clear, however, that in cases of extensive burn injury, A newer device for burn excision is the water jet–powered
this delay in management results in more extensive bacterial VersaJet (Hydrosurgery System; HydroCision, Andover, MA).
colonization and increased likelihood of burn wound sepsis, This device provides a relatively facile and precise tool for the
multiple organ failure, and, ultimately, death. excision of eschar and is particularly useful for excision of
The benefits of early burn excision are clear and have concave surfaces of the hand and feet as well as for excision of
been well documented.9-12 Early excision and grafting results the eyelids, ear, and nose (Figure 15.8).13
in increased survival, decreased infection rates, and decreased Regardless of which technique is used, extremity exci-
length of hospital stay. In addition, early removal of burn eschar sions should be performed under tourniquet control to
also appears to decrease the risk of hypertrophic scarring. minimize blood loss. In addition, suspension of the upper
If feasible, early staged excision should begin on post- and lower extremity from overhead hooks can facilitate
burn day 3 for major burns that are clearly full thickness. excision and graft placement, particularly on the posterior
Operations can be spaced 2 to 3 days apart until all eschar aspect of the lower extremities. The risks of blood loss and
is removed and the burn wound covered. The interval days probable need for transfusion should be clearly commu-
are to allow for stabilization and resuscitation of the patient. nicated to the anesthesia team prior to the start of exci-
Excised wounds can be temporarily covered with biologic sion. In addition, the operating room should be warmed
dressings or cadaveric allograft until autogenous donor sites and bear huggers should be used when possible to minimize
are available. hypothermia.
Adequate hemostasis is critical to minimizing hematoma
Techniques of Excision formation and ultimately graft loss. Telfa pads (Kendall,
Mansfield, MA) soaked in an epinephrine solution (1:10,000)
There are two techniques of burn wound excision: tangen- are a mainstay of hemostasis, combined with topical pressure
tial excision and fascial excision. Tangential excision is the and cauterization when necessary. More recently, the use of
sequential removal of layers of eschar and necrotic tissue until fibrin glue has gained popularity in assisting with hemostasis
a layer of viable, bleeding tissue that can support a skin graft as well as with graft fixation.
is reached. Tangential excision is carried out using Watson
or Goulian (Weck) blades (Figure 15.6). The Watson blade
has a dial to set the depth of excision and the Goulian blades Skin Grafting
come with guards of varying opening to allow adjustment of The process of engraftment is essentially that of revasculariza-
excision depth. These settings and guards are only guides, tion of the graft. Initially, the graft has no vascular connec-
and ultimate depth of excision is influenced by the operator. tion with the recipient bed and survives through the process of
There are two principal disadvantages of tangential excision. diffusion of nutrients from the wound bed, a process known
First, when excising a large surface area, there can be substan- as plasma imbibition. Typically, the process of revasculariza-
tial blood loss and, second, it may be difficult to accurately tion will begin 48 hours after graft placement. The process of
FIGURE 15.7. This elderly patient had full thickness burns to the
FIGURE 15.6. Tangential excision is performed using a Watson chest that were excised using a fascial excision. The edges of the wound
(shown above) or Goulian knife. Tissue is serially excised until viable, were sutured to the pectoral fascia to minimize the ledge at the perim-
bleeding tissue that can accept a graft is reached. eter of the excision.

A number of dressings can be used for meshed skin

grafts. Wet dressings, consisting of antimicrobial solution
(Sulfamylon), provide a moist environment to accelerate epi-
thelialization of the interstices. Greasy gauze and Acticoat
(Smith and Nephew) have also been used as dressings over
meshed grafts. Acticoat is a relatively new antimicrobial dress-
ing that consists of a polyethylene mesh impregnated with
elemental silver. Silver provides antimicrobial activity by dis-
rupting bacterial cellular respiration. Both greasy gauze and
Acticoat are capable of providing a moist environment that
will accelerate closure of graft interstices. Bolsters of cotton or
greasy gauze are needed when grafts are placed over areas of
convexity or concavity.
Sheet grafts can be left open to the air to allow for moni-
toring or can be dressed with a nonadherent gauze. Typically,
dressings over sheet grafts are removed on the day following
skin grafting to allow for evacuation of seroma or hematoma
that can occur. Facial skin grafts should similarly be covered
with a nonadherent or greasy gauze and we will commonly use
FIGURE 15.8. The VersaJet water dissector is a new technology that
can be very useful for the excision of the eyelids (shown above), ears,
a Jobst skin featureless facemask garment (Beiersdorf-Jobst,
and web spaces. Inc., Rutherford College, NC) to minimize graft sheering.
The Vacuum Assisted Closure (VAC; Kinetic Concepts
Inc., San Antonio, TX) device is another option for skin graft
coverage. The VAC is a negative pressure device that is able
revascularization occurs by a combination of neovasculariza- to prevent graft sheering and is particularly useful over areas
tion (ingrowth of host vessels into the graft) and inosculation, of convexity or concavity. The VAC can be left in place over
the direct biologic anastomosis of cut ends of recipient vessels a skin graft for 5 days and then can be easily removed at the
in the graft bed with those of the graft itself. Concomitant bedside. Alternatively, an Unna boot can be applied over
with revascularization of the graft is the organization phase, grafts of the arm and leg. The Unna boot will provide vas-
which describes the process by which the graft integrates with cular support and prevent graft sheering while allowing early
the wound bed. mobilization.
Skin grafts are typically classified according to their thick-
ness as either split (partial) thickness or full thickness depend- Donor Site Selection and Care
ing on whether they include the full thickness of the dermis or
just a portion of it. Split thickness grafts are further classified Selection of donor sites is often dependent on the availability
into thin, intermediate, or thick depending on the amount of of unburned skin. For children, the buttock and scalp provide
dermis. The thinner a skin graft, the more contraction that the most inconspicuous donor sites. Plasmalyte can be infused
occurs at the recipient site following transplantation. Thicker subcutaneously to facilitate graft harvest in these areas. When
grafts contract less at the recipient site, but leave a greater der- larger amounts of skin are needed, then the thighs and back
mal deficit at the donor site, which will therefore take longer can be used.
to heal and have an increased risk of hypertrophy. The ideal donor site dressing would minimize pain and
Skin grafts can also be meshed or unmeshed (sheet grafts). infection, accelerate epithelialization, and be cost-effective.
From an aesthetic standpoint, sheet grafts will always be There are a number of donor site dressings available, which
superior to meshed grafts. It is best to perform sheet graft- may suggest that no perfect dressing exists.
ing over the face, hands, and forearms since these are exposed
areas. In larger burns, there is inadequate skin available to Management of Specific Areas
perform sheet grafting over all burned areas and the skin Face. Plastic surgeons who do not routinely care for burn
grafts need to be meshed. Skin grafts can be meshed 1:1, 2:1, patients may be called upon to manage facial burns—both
3:1, 4:1, and even 6:1. However, for practical and cosmetic acute and reconstructive. Few areas of burn care can be more
purposes, mesh of 2:1 is the most commonly used. Meshing challenging than the management of facial burns. The aes-
of skin grafts allows for the egress of fluid from the wound thetic and functional outcomes are critical to the daily life of
bed, which minimizes seroma and hematoma formation and the patient and intimately related to feelings of self-esteem.
therefore decreases the risk of graft loss. In addition, meshing Management of facial burns begins at the time of admis-
a graft allows for expansion, which provides greater wound sion. Many patients with facial burns sustain inhalation
coverage. injuries and are intubated. The endotracheal tube should be
Skin grafts can be affixed to the wound bed using a vari- secured in such a way so as to minimize pressure necrosis
ety of techniques. Staples are the most commonly used and of the lip. Patients who are going to be intubated for a long
are probably the most expeditious way to secure grafts when period of time may benefit from the wiring of the endotra-
a large area of the body is being covered. Suturing of grafts cheal tube to the teeth or to a segment of an arch bar that
is particularly useful in children because absorbable sutures can be wired to the upper teeth. This provides a reliable and
need not be removed. We have had a great deal of success sturdy method for tube fixation and will minimize pressure on
using Hypafix (Smith and Nephew, London, England), par- the lip. This will also allow for facile and secure positioning
ticularly for fixation of sheet grafts. Hypafix is an elastic of the tube in the operating room (Figure 15.9). In addition,
adhesive dressing that can be easily applied using mastisol consideration for tracheostomy should be made if a prolonged
as an adhesive. The Hypafix remains in place and can only period of intubation is required. While the benefits of early
be removed by using Medisol. Fibrin glue and other tis- tracheostomy are not well established in burn patients, tra-
sue sealants have also been used to affix skin grafts to the cheostomy will allow improved pulmonary toilet to reduce
wound bed. pneumonia risk. If the neck is burned as well as the face, the
There are numerous options for skin graft dressings. neck can be excised and tracheostomy performed in the same
Typically, the decision is guided again on the type of graft— setting. If a feeding tube is placed, care must be taken to mini-
meshed or unmeshed—and on the location of the graft. mize alar or columellar pressure necrosis.

Facial excision is typically carried out using Goulian
blades. Traction sutures are frequently used on the upper and
lower eyelids to aid in excision. More recently, the availability
of the VersaJet water dissector has helped in excising areas
with difficult contour such as the eyelids and ears. Small areas
of exposed cartilage of the ear should be excised and the skin
closed primarily over the defect.
Sheet autograft is always used for coverage of the face. The
appearance of meshed grafts to the face is cosmetically unac-
ceptable. The scalp is an excellent source of autograft, given

the color match with the face. However, in the case of full
facial burns, scalp skin is usually inadequate and a different
donor site is needed so there is uniformity in the coloring of
the skin grafts. A facemask (such as a Jobst skin featureless
facemask) should be placed in the operating room to help
immobilize the skin grafts. Skin grafts should be inspected on
the first postoperative day so any blebs or fluid collections
that may impair graft take can be drained.
Neck. Excision and grafting of the neck can also be chal-

lenging. The key to management of the neck is to make every
effort to minimize wound and graft contraction. Whenever
possible, it is best to cover the neck with sheet grafts. The
grafts should be placed with the neck in maximal hyperex-
tension. For the first several days following graft placement,
the neck should be immobilized in a splint. Once the grafts
have taken, the patient should be started on aggressive range
of motion exercises. Aggressive range of motion exercises are
critical both for patients who heal without grafting and for
patients who undergo grafting. These exercises should con-
tinue for the several months it takes for the grafts to mature.
FIGURE 15.9. The endotracheal tube can be secured to a segment of Hands. Hand burns occur from a variety of mechanisms.
an arch bar and then suspended from the ceiling using a rope. This
provides both stable fixation of the tube and complete access to the
In the pediatric population, hand burns frequently occur as a
face for excision. result of contact with a fireplace or wood stove or from grab-
bing a hot object. The palm has excellent healing capacity and
these pediatric palm burns rarely require grafting. However, it
is critical to emphasize to the patient’s parents the importance
All patients with periorbital burns should undergo an of range of motion exercises. Stretching should be performed
intraocular exam with a Wood’s lamp. If this exam is positive, on a routine basis—either during diaper changes or feeding
then an ophthalmologic consult is required. In addition, if the times—to minimize contractures of the palm and digits. In the
patient has lagophthalmos, it is important to keep the eyes cases of deeper palm burns, nocturnal extension splints may
well moisturized with ophthalmic ointment to prevent expo- be necessary. It is also important to emphasize to parents to
sure keratitis. Despite optimal periorbital burn and ocular let the child use his or her hands as soon following injury as
management, patients may still develop conjunctivitis and/or possible and bulky dressings that inhibit mobility should be
exposure keratitis. In these cases, consideration for reversible minimized.
lateral marginal tarsorrhaphy should be made.14-18 Similarly, adult hand burns often heal without the need
The practice of excising facial burns has long been debated for skin grafting. Patients are encouraged to begin range of
in the literature.15-18 The traditional method of facial burn motion exercises as soon following burn injury as possible.
management was to perform daily wound care until the face Range of motion exercises will reduce extremity edema and
either healed or the underlying eschar lifted, leaving a gran- also optimize the return of function once the skin wounds
ulating wound bed that could accept a skin graft. It is now have healed. Static splinting is not recommended, unless the
clear that better outcomes are achieved if non-healing areas patient is intubated and unable to participate in therapy.
are excised and then subsequently skin grafted. As in other If splinting is necessary, the wrist should be placed in mild
parts of the body, it is generally easy to determine the healing extension, the metacarpophalangeal joints in 70° to 90° of
capacity of shallow burns and deep burns. The burns of inde- flexion, and the interphalangeal joints in extension. Even in
terminate depth pose a greater challenge. those instances, however, therapists should regularly range
Over the past 30 years, it has been our practice at the the extremities.
University of Washington to excise facial burns. Our protocol If it is clear that a burn wound will not be healed within
and results can be found in recent publications.19,20 Patients 3 weeks, is best treated by excision and grafting. With few
who are admitted with facial burns undergo debridement of exceptions, burns of the hand should be grafted with sheet
loose blisters and debris and then daily wound care. It has grafts. Hand excision, particularly of the web spaces and
become our practice to assess patients with facial burns at digits, can be challenging. Great care should be taken to not
day 10, at which time it is usually clear which burns will expose tendons. In addition, excision should occur under
heal within 3 weeks and which will not. Patients with burns tourniquet control. If a burn is so deep that adequate excision
that are thought to not be able to heal within 3 weeks are would surely expose tendons, then flap coverage should be
scheduled for excision and grafting. It is important to note considered.
that patients with full thickness burns with clearly no healing Following excision and grafting of the hand, splint immo-
potential should be operated on in the first week to 10 days if bilization should occur for at least 5 days postoperatively.
the patient is stable and there are no other more urgent areas The wrist should be positioned in slight extension, the
of excision. metacarpophalangeal joints should be placed in flexion, the

interphalangeal joints in extension, and the thumb in abduc- reconstitute. Blisters should be decompressed with a sterile
tion. Graft take should be assessed at postoperative day 5 and pin, the epithelial layer can be left in place, and the area should
the decision for initiation of range of motion exercises should be covered with a band-aid. Patients should be instructed to
be made. Once graft healing is complete, compression gloves soak the band-aid prior to removal to protect against further
that will minimize hand edema and possibly scar hypertrophy injury from the adhesive.
should be worn.
Perineum. Scald burns remain the most common burns Chemical Injuries
of the perineum and they typically result from the spilling Traditionally, chemical injuries have been classified as either
of hot beverages that are held between the legs while driv- acid burns or alkali (base) burns. The severity of chemical
ing. These scald burns tend to heal within 1 to 2 weeks injuries depends on the composition of the agent, concentra-
time, and wound care and pain control are the mainstay tion of the agent, and duration of contact with the agent. In
of treatment. Full thickness burns can occur as part of a general, alkaline burns cause more severe injury than acid
larger flame burn and the healing potential of these injuries burns since alkaline agents cause a liquefaction necrosis,
can be more varied. It is not necessary to insert a Foley in which allows the alkali to penetrate deeper, extending the
all patients who sustain perineal burns. In fact, all patients area of injury. Chemical injuries have also been classified
should be given the option to void spontaneously and a according to their mechanism of tissue destruction: reduc-
catheter should be placed only if they have difficulty void- tion, oxidation, corrosive agents, protoplasmic poisons, vesi-
ing. An external genital burn is not likely to lead to urethral cants, and desiccants.
(internal) stenosis. Deep burns to the penis and scrotum The first step in managing a chemical injury is removal
should be given ample time to heal. In fact, the scrotum is of the inciting agent. Clothes, including shoes, that have
rarely grafted since it can usually heal by contraction and been contaminated are removed. Areas of affected skin are
not leave a noticeable scar. Patients who sustain full thick- copiously irrigated with water. Adequate irrigation can
ness, charred burns of the genitals and cannot have a Foley be verified by checking the skin pH. Burns from chemical
placed should be evaluated by the urologists for placement powders are the one exception to the rule of water irriga-
of a suprapubic tube. tion since the water can activate the chemical. The pow-
der should first be dusted off, and then irrigation can take
Lower Extremities. Of all the burns treated in the out- place. Neutralization of the inciting agent should never
patient setting, patients with feet and leg burns tend to be attempted since this will produce an exothermic reac-
have the most difficulty. Edema can delay wound healing tion that will superimpose a thermal injury on top of the
and increase patient discomfort. The key to treating lower chemical injury. Occasionally, the burned individual may
extremity burn wounds is to encourage the patient to ambu- not know specifically with which agent they were working
late, with the appropriate support of an ace bandage or and therefore it may be necessary to contact a plant man-
Tubigrip (ConvaTec, Princeton, NJ). Ambulating minimizes ager or the manufacturer of the suspected inciting agent.
the pooling of blood in the distal aspect of the extremity and If ocular injury has occurred, the eyes should also be copi-
thereby decreases edema. In addition, the sooner the patient ously irrigated. Eye wash stations should be located in most
is able to ambulate, the sooner they will be able to resume workplaces where chemicals are used. It is important that
normal level of activities once their wounds heal. While the eye be forced open to allow for adequate irrigation. An
not ambulating, leg elevation can be helpful in minimizing ophthalmologist should be consulted to assist in the man-
edema as well. agement of these patients.
If leg or foot burns require excision and grafting, consid- Certain chemical agents have specific treatments.
eration needs to be made of the postoperative physical ther- Hydrofluoric acid (HF) requires specific mention. HF is com-
apy plan. Small burns of the leg and foot can be grafted and monly used in the glass and silicon chip industries as well
dressed with greasy gauze and then covered with an Unna as in a number of industrial cleaning solutions. HF read-
boot. The Unna boot provides support and immobilization of ily penetrates the skin and continues to injure tissue until it
the graft and allows for early mobilization. This is an excel- contacts a calcium source, likely bone. Given the ability of
lent dressing for both adults and children. Patients with insen- the fluoride ion to chelate calcium, patients with even small
sate feet are poor candidates for Unna boot dressings. Patients HF burns are at risk for the development of hypocalcemia,
who require grafting both above and below the knee should which can be severe enough to have cardiac effects. In fact,
be fitted with knee immobilizers postoperatively to maintain HF burns in excess of 10% can be fatal. The use of calcium is
knee extension. the most effective treatment agent. Calcium gluconate gel can
be applied topically if the patient is treated rapidly enough,
Outpatient Burn Management that is, before the HF has penetrated the skin. Direct injec-
Most burn patients will have some aspect of their care in the tion of calcium gluconate into the burned area has long been
outpatient burn clinic. Again, a multidisciplinary approach in advocated; however, this may not effectively neutralize the
this setting is crucial to the success of outpatient burn wound HF and may cause skin necrosis. Therefore, if following copi-
management. Experienced nurses, physical and occupational ous irrigation and topical treatment with calcium has been
therapists, and psychologists all play an important role in ineffective, the patient should be treated with an intra-arterial
patient management, even in the outpatient setting. Issues of infusion of calcium gluconate. Diminished pain is the hall-
range of motion, optimization of function, and the psychoso- mark of effective treatment. Patients with extensive HF burns
cial aspects of reintegration into society all must be dealt with and certainly patients with intra-arterial infusions require
in the outpatient clinic. In addition, addressing work-related close monitoring and should have frequent serum calcium
issues including determining appropriate time to return to checks.
work and the potential needs for work accommodations also Ingestion of chemically toxic agents can occur by children
needs to occur. or by adults as part of a suicide gesture or attempt. Again,
There are several other issues particularly relevant to out- the principle of lavage to dilute the inciting agent is practiced.
patient care. Newly healed burn wounds and donor sites are These injuries are typically managed by, or in conjunction
highly susceptible to blistering and to breakdown. The new with, gastroenterologists, pulmonary specialists, or general
epithelium lacks the connections to the underlying wound surgeons. Laryngoscopy and endoscopy should be performed
bed, which will prevent shearing. It often takes up to 6 months to help define the extent of injury. Enteral feeding beyond the
to a year for these critical basement membrane structures to zone of injury is often necessary.

Electrical Injuries
Electrical injuries are potentially devastating injuries that
result in injury to the skin as well as other tissues including
nerve, tendons, and bone. Electrical burns can take several
forms including injury from the electrical current itself, flash
burns, flame burns, contact burns, or a combination thereof.
Traditionally, electrical injuries have been divided into low
voltage (less than 1,000 V) and high voltage (greater than
1,000 V). The considerations and management issues between

the two are often different. Following electrical injury,
it is important to follow the ATLS protocol and assess the
patient’s airway, breathing, and circulation. Once stabilized,
it is important to ascertain the circumstances surrounding the
injury, the voltage of the injuring current, whether there was
loss of consciousness at the scene, other associated injuries
(i.e., fall from a cherry picker basket), and whether there was
a cardiac or respiratory arrest at the scene.
Evaluation in the emergency room includes a thorough FIGURE 15.10. This patient sustained a high-voltage electrical injury
physical examination where the %TBSA is calculated (if there and presented with a contracted wrist and tight forearm compart-
was a flame burn), and the neurovascular status of injured ment. He was taken emergently to the operating room for forearm
extremities is determined. In addition, all patients who sustain fasciotomy and carpal tunnel release.
electrical injuries should have an ECG in the emergency room.
Patients with a low-voltage injury who had no loss of
consciousness and no dysrhythmia present can be discharged
home. The notable exception is a child who has an oral burn issue of routine immediate decompression of high-voltage
from biting an electrical cord. These patients require admis- injuries. They concluded that a select group of patients require
sion and monitoring for labial artery bleeding. immediate decompression of the arm or hand or both to pre-
Management of patients with high-voltage injuries is dic- vent additive injury from pressure. Clinical indications for
tated by the extent of injury, the presence of cutaneous burns, this group of patients include progressive motor and sensory
and the presence of myoglobinuria. There is no formula for exam, severe pain, and loss of arterial Doppler signal and
fluid management of electrical burn patients per se. If there patients who do not adequately resuscitate because of sus-
are extensive cutaneous burns, then the Parkland formula is pected ongoing myonecrosis. Patients with a fixed neurologic
applied and fluid administration is titrated to achieve a urine deficit typically do not benefit from decompression.
output of 30 cc/h. If myoglobinuria is present, intravenous flu- The ideal timing for tissue debridement has similarly been
ids should be titrated to a goal urine output of 100 cc/h until controversial. The ideal time to determine the presence of myo-
the urine clears. Serial urine myoglobin checks are usually necrosis is typically 3 to 5 days following injury. Therefore,
unnecessary, since treatment is initiated based on the presence early debridement might not be sufficient since irreversibly
of tea-colored urine and should be continued until the urine injured tissue may not have demarcated. At 3 to 5 days, all
clears. If myoglobinuria persists despite fluid resuscitation, unhealthy tissue can be debrided and definitive wound closure
then mannitol can be administered. Alkalinization of urine can be achieved at this time. In cases of extensive limb injury,
has also been advocated following electrical injury in order free tissue transfer might be necessary to provide wound cov-
to prevent precipitation of myoglobin in the kidney tubules. erage or to preserve limb length for optimal prosthesis fitting.
Patients who sustain high-voltage injuries should be placed In these cases, definitive wound closure can be performed at a
on a cardiac monitor for the first 24 hours following admission. second operation following wound debridement to allow for
This has been the traditional practice regardless of whether a appropriate planning and patient counseling.
dysrhythmia is present at the time of admission. There are no There are several long-term sequelae of electrical burns of
data substantiating routine monitoring of high-voltage inju- which the patient and physician should be aware. Neurologic
ries, and this is a practice that may change over time. deficits including peripheral and central nervous system disor-
Early management of electrical injuries should focus on ders can develop weeks to months following electrical injury.
the need for fasciotomy or compartment release. Peripheral Therefore, all patients who sustain high-voltage electrical inju-
neurovascular exams are performed to monitor for signs of ries should undergo a thorough neurologic evaluation at the
compartment syndrome. Some patients will present with a time of admission and prior to hospital discharge. Cataracts
contracted upper limb and tight forearm compartments, and can also occur following electrical injury. The exact mecha-
these patients undergo immediate fasciotomy and carpal tun- nism is not known, but all patients should undergo a baseline
nel release (Figure 15.10). Otherwise, progressive sensory and ophthalmologic examination following high-voltage electrical
motor loss and increased compartment pressures are indica- injury. A number of complications can also arise in the injured
tors of the need for fasciotomy. Many surgeons have argued extremity, including heterotopic ossification (HO), neuromas,
that all patients should undergo immediate surgery for nerve phantom limb pain, and stump breakdown if the patient has
decompression and debridement of necrotic tissue. On the undergone amputation.
one hand, carpal tunnel release and fasciotomy are relatively
straightforward operations to perform and if the patient
derives even a small amount of benefit then the procedures are
Cold Injury
worthwhile. However, the risks of the procedures, particularly Exposure to extremes of cold (and wet) conditions can lead
if not necessary, can be significant. Exposure of the median to cellular injury and death. Cell death and tissue necrosis
nerve and forearm musculature increases the risk of tissue des- occur from the formation of ice crystals within the cells and
iccation and necrosis. extracellular space as well as from microvascular thrombosis.
It is often difficult to determine preoperatively who will Cellular injury from ice crystal formation occurs during the
benefit from the decompression procedures. Decreased sensa- period of cold exposure, whereas microvascular thrombosis is
tion and motor function may represent a neuropraxia from thought to occur during reperfusion when the affected limb is
direct current injury to the nerve. Mann et al.21 explored the rewarmed. Similar to burn injury, frost bite injury is classified

according to the depth of injury. Mild frost bite, also known most commonly used product is Integra (Integra Life Sciences,
as frost nip, is similar to a superficial burn injury, with tis- Plainsboro, NJ). Integra is a bilayer construct; the deeper layer
sue erythema, pain, and edema. Second-degree frost bite is consists of bovine collagen and chondroitin-6-sulfate, and the
marked by blistering and partial thickness skin injury. Third- outer layer is a silastic membrane that serves as a temporary
degree frost bite occurs when there is full thickness necrosis of epidermal replacement. Integra is placed on a newly excised
the skin, and fourth-degree frost bite occurs when there is full wound bed and fixed into place. The silastic layer remains
thickness skin necrosis as well as necrosis of the underlying in place until the dermal component vascularizes, which is
muscle and/or bone. Again, it is important to note that deter- typically 2 to 3 weeks. Then the patient is taken back to the
mination of the full depth of tissue injury is not possible until operating room, the silastic is removed, and a thin (0.006″)
several weeks following the injury. autograft is placed on top. The Integra neodermis serves as a
The first step in the management of frost bite is removal of scaffold for the ingrowth of tissue from the patient’s wound
all wet clothes, gloves, socks, and shoes. Patients should then bed (Figure 15.11). Integra has been used successfully in
be wrapped in warm blankets. Frost bite can also be associ- the management of extensive burns—including burns of the
ated with hypothermia. In these cases, care must be taken to face—as well as for pediatric burns.
rewarm the entire body. In cases of extreme hypothermia (less
than 32°C), warming can be achieved with the use of warm
intravenous fluids, bladder irrigation with warm solutions, Late Effects of Burn Injury
placement of peritoneal catheters and chest tubes through
which warm fluids can be administered, and even, if available, Hypertrophic Scarring
cardiopulmonary bypass. Frost-bitten extremities should be Hypertrophic scarring is one of the most distressing outcomes
rapidly rewarmed in water that is 40°C. Typically, rewarming of burn injury (Chapter 16). Hypertrophic scars can be not
can be completed in 20 to 30 minutes. Adjunctive use of non- only unsightly but painful and pruritic as well. Hypertrophic
steroidal anti-inflammatory medications and calcium channel scarring can occur in grafted wounds and unexcised wounds
blockers has also been described. that took longer than 2 to 3 weeks to heal. Patients with pig-
Patience is required in determining which areas require mented skin tend to be at a higher risk for the development
debridement. There is an old adage that states “frostbite in of hypertrophic scarring. The biologic and molecular basis of
January, amputate in July.”18 While this might be hyperbole, the hypertrophic scarring is not well understood, and therefore,
concept of allowing tissue to fully demarcate is essential since it is our ability to prevent hypertrophic scarring is limited (Chapter
difficult to determine which tissue may survive in the immediate 2). However, several strategies exist to prevent or minimize
post-injury period. Early debridement and amputation are neces- hypertrophic scarring. Pressure garments are commonly used
sary if soft tissue infection occurs during the waiting period. over areas that have been grafted or have taken longer than
3 weeks to heal. No study has clearly demonstrated that gar-
Skin Replacement ments prevent hypertrophic scarring, but the elastic support
of the garments can help symptoms of throbbing and pruritis.
Early excision and skin grafting has become the standard of Silicone has similarly been advocated for the treatment and
care for surgical management of the burn wound. However, in prevention of hypertrophic scarring. There are several theories
cases of extensive burn wounds, the surface area burned may as to how and why silicone works, but again, there is no well-
exceed the available donor sites. In these cases, burn wounds accepted explanation. Steroid injection has also been used to
are excised and covered with biologic dressings until complete minimize the symptoms associated with hypertrophic scarring.
coverage with autografts can occur. These cases of extensive
burn injury have demonstrated the need for a replacement for
human skin. Efforts over the past two decades have focused Marjolin’s Ulcer
on the development of a temporary and, ideally, permanent Marjolin’s ulcer is one of the most dreaded long-term com-
replacement to native human skin. While there is no perma- plications of a burn wound. Marjolin’s ulcer is the malig-
nent product available to replace both the epidermis and der- nant degeneration of a healed burn wound, which can occur
mis, there have been a number of products introduced over the decades following injury. These tumors typically occur in
past decade that address a portion of the skin. Currently, the areas that were not skin grafted and are typically aggressive.
A B
FIGURE 15.11. The use of Integra for burn wound coverage. A. Full
thickness burn wound prior to excision. B. Fascial excision of burn
wound leaving a viable, well-vascularized wound bed. C. Application
of Integra with silastic left in place. Two weeks later, the silastic was
removed and a split thickness skin graft was placed over the Integra.
C

The presence of an ulceration in a previously healed burn will help determining which reconstructive procedure is best.
wound should raise the suspicion of malignancy and warrants Again, it is important to emphasize to the patient that recon-
biopsy and appropriate evaluation. structive surgery can improve the appearance of scars but does
not erase all scars. Tissue expanders have been quite useful in
Heterotopic Ossification various aspects of soft tissue reconstruction including treat-
ment of burn alopecia. Consideration of the patient’s ability
Heterotopic ossification (HO) results from the deposition of
to comply with tissue expansion, particularly the need for fre-
calcium in the soft tissue around joints. These calcium depos-
quent clinic visits, is essential
its block normal joint functioning. HO most commonly affects
the elbow and shoulder joints and occurs 1 to 3 months fol-
lowing injury. Patients who develop HO will have increased Conclusion

pain and decreased range of motion of the affected joint.
Radiographs demonstrate calcium in the soft tissue. There Despite all the advances in burn care over the past century and
have been several medical treatments described; however, few the exciting prospects on the horizon, the core of burn care
have proven to be effective. Surgical management involves remains the burn team. As each aspect of burn care becomes
direct excision of the heterotopic bone and is usually best car- increasingly complex, with increasingly specialized fields of
ried out once complete wound coverage has been achieved. knowledge, the importance of a team of experts will become
even more integral to successful care. Most assuredly, plastic
Burn Reconstruction surgeons will always be an integral member of that team.
Secondary reconstruction of the burn wound poses one of the

greatest challenges to reconstructive surgeons (Chapter 16). References
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considered. The reconstructive patient usually wants to mini- 20. Klein MB, Moore ML, Costa B, et al. Primer on the management of face
burns at the University of Washington. J Burn Care Rehabil. 2005;26:2-6.
mize the number of operating room trips and hospital stays as 21. Mann R, Gibran N, Engrav L, et al. Is immediate decompression of
these tend to interfere with his or her established daily routine. high voltage electrical injuries to the upper extremity always necessary?
However, conflicting procedures should not be performed. In J Trauma. 1996;40:584.
addition, donor sites need to be rationed thoughtfully.22 22. Engrav LH. Primary and secondary reconstruction of the burned face. In:
Grotting J, ed. Reoperative Aesthetic and Reconstructive Surgery. St. Louis,
Adequate patient education is of paramount importance. MO: Quality Medical Publishing; 1995.
The patient must have a realistic expectation of what can be
achieved in reconstruction, including an understanding of lim-
itations. Decisions regarding procedures should be made over
Suggested Readings
a series of detailed discussions, not a single brief clinic visit.22 1. Luce EA. Burn care and management. Clin Plast Surg. 2000;27:1.
2. Heimbach DM, Engrav LH. Surgical Management of the Burn Wound.
The first critical step in formulating a surgical plan is the New York, NY: Raven Press; 1984.
diagnosis of the problem. The determination of tissue defi- 3. Herndon D. Total Burn Care. London: W.B. Saunders; 2002.
ciency, shortened scar, and contour problems, for example, 4. Practice guidelines for burn care. J Burn Care Rehabil. 2001.

Chapter 16 n
Principles of Burn
Reconstruction
Matthias B. Donelan and Eric C. Liao
Reconstructive surgery following burn injury involves at 1 year because of hypertrophy, contracture, and erythema
almost every aspect of plastic surgery. The patient popula- can become inconspicuous with further maturation. Healed
tion includes children and adults. All areas of the body can second-degree burn deformities under tension with resulting
be involved. Deep structures can be injured either acutely or hypertrophy are unsightly. With time and relief of tension,
secondarily. Satisfactory outcomes require correction of both they will greatly improve. Premature early excision of such
functional and aesthetic deformities. Yet, at the same time, the scars with primary closure frequently results in a wide iatro-
reconstruction of burn deformities requires a unique perspec- genic scar, which then becomes a more obvious permanent
tive and an emphasis on certain fundamentals and techniques deformity. Lacking camouflage, the surgical scar may be more
that make it a specialized area of reconstructive surgery. The noticeable than the burn scar, and increased tension from the
surgeon must thoroughly understand the processes of wound excision can create contour deformities. Excision and primary
healing and contraction. The effect of time on the maturation closure of burn scars should be reserved for small scars in con-
of scars is of pivotal importance and requires patience and spicuous locations that will allow a favorably oriented closure.
judgment on the part of the surgeon and the patient. Correct Although counterintuitive, it is helpful to learn to love
timing of surgery is essential. Multiple operations are the rule burn scars. After all, without scarring, healing cannot occur,
and frequently take place over a period of many years. Donor so scars are our friends. For successful burn reconstruction,
sites are frequently limited or compromised. Successful sur- one must learn to appreciate scars and understand their
gical outcomes require a well-functioning support system, behavior. Scar rehabilitation is usually a better alternative for
including nurses, therapists, psychosocial practitioners, and, the patient than scar excision. Scars under tension are angry
hopefully, a supportive family. All of these factors affect the and respond with erythema, hypertrophy, pruritus, pain, and
outcome of surgery.
Burn injuries vary greatly in severity and extent, yet vir-
tually all postburn deformities have similar components that
must be addressed. This chapter provides a strategic approach
to burn reconstruction based on surgical principles particu-
larly relevant to this field that will help in the analysis, man-
agement, and surgical treatment of this large and challenging
group of patients.
General Concepts
Over the past 50 years, primary excision and grafting of
deep second-degree and full-thickness burns has become the
standard of care in the United States and in most developed
countries (Chapter 16).1,2 Early excision and grafting has
decreased the mortality and morbidity of acute burn inju-
ries.3 The duration of acute hospitalization has been greatly
reduced. Early excision and grafting has also decreased the
frequency and severity of contractures and hypertrophic scar-
ring. Occasionally, however, one still encounters patients who
were treated “expectantly” with late grafting and disastrous
results (Figure 16.1).
All burns of the second and third degree result in open
wounds. Open wounds heal by contraction and epitheliali-
zation. Contraction may be decreased by early excision and
grafting, but is always present to some degree. Contraction
leads to tension, and tension is one of the principal causes of
hypertrophic scarring and unfavorable scarring in general.
Understanding the role of tension in the evolution of postburn
deformities is essential.
Burn reconstruction is fundamentally about the release of
contractures and the correction of contour abnormalities. It
should not be focused on the excision of burn scars. Scar exci-
sion is an oxymoron. A scar can only be traded for another
scar of a different variety. When the fundamental problem
is that of inadequate skin and soft tissue, further excision of
“scars” can add to the clinical problem. Well-healed burn
scars, if given enough time to mature, are often an excel- Figure 16.1. Contracture due to late grafting. A 4-year-old boy
lent example of nature’s camouflage. The subtle and gradual from Central America treated with months of dressings and late graft-
transition from unburned skin to scar helps the deformity ing, resulting in severe contractures.
blend into its surroundings. A burn scar that is conspicuous
142
Chapter 16: Principles of Burn Reconstruction 143
tenderness. Relaxed scars are happy scars. They respond by
flattening, softening, and becoming pale and asymptomatic. Timing of Reconstructive
Directing reconstructive surgery toward relieving tension is Surgery
practical and achievable and often results in great improve-
ment. Advances in laser therapy have greatly facilitated scar Patients with postburn deformities present to the plastic sur-
rehabilitation, further decreasing the indications for scar exci- geon in one of three ways. In the ideal circumstance, the plas-
sion. Ill-advised attempts to excise scars can be simplistic and tic surgeon is involved in the patient’s care from the time of
are potentially harmful. Burn reconstruction strives to make the acute injury. The involvement may be as the treating phy-
the patient clearly better, not just different from normal in a sician or as a consultant with occasional participation in the
different way. patient’s acute care. It is a truism that the reconstruction of

Contracture releases can be accomplished with local tis- burn deformities begins with the acute care. Plastic surgical
sue rearrangement such as Z-plasties or transposition flaps or consultation can help prevent secondary deformities by ini-
by releases and skin grafting of the resulting defects. Releases tiating appropriate acute intervention and can also enhance
can be performed by either incising or excising scars. Release outcomes by assisting with aesthetic decisions such as skin
by incision takes advantage of the healing that has already graft donor site conservation. The second group of patients
occurred and because of the relief of tension, it will usu- are those with recent burns who received their acute burn
ally improve the appearance and quality of the tissue that is care at another facility and come to the plastic surgeon for
retained. Mature scars and grafts are a known commodity and another opinion. They have immature scars. The third group
will not contract significantly after release. New grafts are less of patients are those who present with mature scars and grafts
predictable. Incisional releases also create a smaller defect and, and established burn deformities.
therefore, conserve donor sites. When the contracted tissue is The timing of burn reconstruction falls into three distinct
of unacceptable quality, or too irregular, excision of scars is phases: acute, intermediate, and late. As a general rule, burn
required for the best result (Figure 16.2). In most cases, how- reconstruction is best delayed until all wounds are closed,
ever, it is better to work with the grafts and scars that are inflammation has subsided, and scars and grafts are mature
already present than to excise them. Grafts can be either split and soft. Acute reconstructive intervention is required during
thickness or full thickness. Defects resulting from scar release the early months following burn injury when urgent proce-
can also be closed with flaps transferred with either traditional dures are necessary to facilitate patient care, to close complex
or microsurgical techniques. The choice of the appropriate wounds such as open joints, or to prevent acute contractures
intervention and the timing of intervention are both essen- from causing irreversible secondary damage. Examples of
tial ingredients that determine success or failure after burn indications for acute surgical intervention are eyelid contrac-
reconstruction. tures with exposure keratitis, cervical contractures causing
A C
Figure 16.2. Excisional release in the developing breast. A. A 15-year-old girl with bilateral lower-pole breast contractures. B. Excisional
release of the lower half of the breasts with split-thickness skin grafting allowed the compressed breast tissue to expand and assume its normal
shape. C. Breast augmentation and nipple areola complex reconstruction.

airway issues, and “fourth-degree burns,” such as in electrical Steroids are effective in diminishing and softening hyper-
injuries, where acute flap coverage is required. trophic scars. Topical steroids are helpful. Steroid injections
The intermediate phase of burn reconstruction is best are powerful. The latter must be used carefully because of
described as scar manipulation designed to favorably influ- potential problems with atrophy of the scar and the underly-
ence the healing process. After a patient’s wounds have closed, ing subcutaneous tissue.6 Their use should be limited to situ-
physical and occupational therapy must continue to correct ations where time, pressure, silicone therapy, and massage
or prevent contractures, as well as enhance scar maturation are ineffective and surgery is not an option. For example,
with the use of pressure garments, silicone gels, and massage. isolated hypertrophy without tension such as on the face or
The efficacy of such treatments has been demonstrated over shoulders is a good indication. A solution of triamcinolone
many years.4,5 Enthusiastic support of these ancillary mea- (10 mg/mL mixed half and half with 1% Xylocaine with
sures by the plastic surgeon and the entire burn team can be epinephrine) administered by intralesional injection with a
very helpful in maximizing patient compliance. The length glass tuberculin syringe, never more frequently than once a
of time required to reach the end point of burn scar matura- month, is efficacious in decreasing hypertrophy and prevent-
tion is considerably longer than is generally appreciated. Scars ing undesirable side effects. Ablative fractional laser therapy
that are thick, raised, and erythematous after 1 year or lon- provides a new, and potentially more efficacious, way of
ger will often improve dramatically if given more time, often delivering corticosteroids into the dense collagen of hyper-
several years. When tension is present, scars never heal well. trophic scars.
Judicious surgical intervention to relieve tension during this Intermediate-phase scar manipulation is of particular ben-
intermediate period can positively influence scar maturation. efit in the management of facial burn deformities. This is an
A longitudinal scar across the antecubital space subjected to area where treatment is evolving and there is considerable
constant tension and relaxation will remain contracted and potential for improvement. Computer-generated clear face
hypertrophic despite pressure, silicone, massage, and splint- masks with silicone lining are expensive but efficacious and
ing and may result in ulceration or “spontaneous release.” well tolerated by patients. Relief of tension on facial scars by
Relieving tension by either carrying out Z-plasties within the eliminating extrinsic contractures from the neck, as well as
scarred tissue or performing a release and graft can help the from the inconspicuous periphery of the face by release and
entire scar to improve after the tension has been eliminated grafting or Z-plasties, can be exceedingly beneficial to the
(Figure 16.3). Hypertrophic scars are common in healed sec- healing of facial burns. The pulsed dye laser (PDL) is effec-
ond-degree burns under tension. When the tension is relieved, tive in decreasing facial erythema when used in this interme-
the subsequent improvement in appearance and elasticity is diate phase and seems to result in more favorable long-term
often remarkable. scar maturation. Z-plasties within the hypertrophic scar to
A B
Figure 16.3. Multimodal scar manipulation without scar excision. A. An 8-year-old boy 6 months following flame burn injury with diffuse
facial hypertrophic scarring and contractures. B. Ten years later following pressure, massage, steroid injections, and multiple Z-plasties within the
scar tissue, the hypertrophy has resolved. The depth of the burn is indicated by the absence of beard growth. No scars were excised.

decrease tension and more favorably align scars can achieve patients’ families desire expeditious reconstructive surgery.
dramatic results over time (Figure 16.4).7 Patients would like their scars to be “removed” and they want
Late-phase reconstructive surgery includes all post- to “get on with their lives.” Most of the time, this is not in
burn deformities that are stable and consist of mature scars the patient’s best interest. As mentioned above, the amount
and grafts. It is not uncommon in this group of patients for of time that is required for burn scars to reach their final state
hypertrophic scars to present with areas of open ulceration. of maturation is not generally appreciated. If the prolonged
This is almost always caused by chronic tension. The result- process of scar maturation is allowed to occur, particularly
ing ischemia in the scar causes unstable epidermal coverage. when aided by appropriate help from the surgeon and thera-
Operations directed at relief of the tension will usually cure pists, hypertrophic, contracted, and conspicuous scars that
the chronic open wounds. are problematic at 1 year or longer can improve greatly with

The transition from acute burn injury to the late phase more time. Because of the gradual and subtle transition from
of reconstructive surgery can be prolonged and is unique for unburned skin to burn scar, mature scars are usually less con-
each patient. The experience, judgment, and expertise of the spicuous than would be surgical scars resulting from exci-
plastic surgeon are extremely important during this period. sion and primary closure. Education of the patient and the
After the acute phase of a burn injury, the patients and the patient’s family is essential in order to help guide them to the
A C
Figure 16.4. Pulsed dye laser and tension relief with Z-plasties.
A. An 11-year-old girl, 2 years after burns with hypertrophic scarring
of right cheek and lower lip ectropion. B. Z-plasties relieve tension
and separate broad areas of scarring. After softening of scars, the
lower lip was elevated with Z-plasties. C. Six years after burn and
12 laser procedures. The scars are flat, soft, and pale. The lower lip
ectropion is corrected. No scars were excised.
B

best possible outcome. The desire for “excision” can lead Enthusiasm and optimism on the part of the surgeon and the
to iatrogenic deformities such as shown in Figure 16.5. This entire reconstructive team is essential. Including the patient’s
unfortunate result could have been avoided with more time family in these discussions is important. A strong support sys-
and Z-plasties performed within the maturing hypertrophic tem is necessary for what is often a long and arduous process.
scar tissue.
Fundamentals
Reconstructive Plan
Several basic concepts and techniques are worth reviewing in
A prospective plan for reconstructive surgery is developed the context of burn reconstruction.
with the patient and the patient’s family during the intermedi-
ate phase or at the time of consultation with a patient who has Contractures. Burns cause tissue loss, wounds heal with
established postburn deformities. Planning the reconstructive contraction, and contractures result. Contractures can be either
sequence is helpful to the patient, the family, and the surgeon. intrinsic or extrinsic. Intrinsic contractures result from injury
Because the patient’s priorities may be different from the sur- or loss of tissue in the affected area, causing distortion and
geon’s, education, careful consultation, and mutual agreement deformity of the part. Extrinsic contractures occur when tis-
are of extreme importance. Operations to improve essential sue loss at a distance from an affected area creates tension that
function are the initial priority, but appearance, particularly distorts the structure. Eyelid ectropion, for example, can result
of the face and hands, is always a consideration. The goal of from either intrinsic or extrinsic contractures. Although this
reconstructive surgery is to return patients as much as possible concept is obvious and well known, the frequency with which
to their pre-burn condition. Therefore, all reconstructive pro- it is ignored in burn reconstruction is astounding. Contracture
cedures aim to improve both the function and the appearance deformities must be carefully evaluated and an accurate diagno-
of the operated area. The planning process gives the patients sis made. Corrective measures can then be directed at the cause.
perspective and helps them develop a positive attitude as There is rarely any indication for release and graft or Z-plasty
they look forward to significant improvement in the future. in unburned skin because of a deformity resulting from an
extrinsic contracture.
Tension. For scars to mature as well as possible, tension

must be eliminated. Tension deforms normal body con-
tours, and the resulting abnormal shape draws attention to
the injured area. Relief of tension and restoration of normal
contour by either release and grafting or Z-plasties is perhaps
the most basic fundamental of all burn reconstruction. The
amount of tension in the skin following a burn injury is often
not obvious, particularly to inexperienced surgeons. When
releases are carried out and defects are created, the amount
of tissue required to close the open defects can be surprising.
Donor Sites. Donor site availability is often problematic in

burn reconstruction. Severe burns are usually extensive, and
successful reconstruction requires careful allocation of donor
site material. Split-thickness grafts from the buttocks, thighs,
and postaxial trunk are best used for contracture releases of
the trunk and extremities. Full-thickness skin grafts from the
retroauricular area, cervicopectoral area, and the upper inner
A B arms are best reserved for head and neck reconstruction. The
lower abdomen and groin are excellent donor sites for full-
thickness grafts, usually allowing primary closure of the donor
site. Full-thickness skin grafts from these areas tend to have a
yellowish hue in fair-skinned patients, which is a disadvantage
for facial reconstruction.
Release and Grafting. Nothing could be simpler than the

concept of a surgical release and graft. Attention to detail is
important, however, to obtain the best result. Burn contrac-
tures are usually limited to the superficial scars or grafts and
a thin layer of fibrous connective tissue just beneath the skin
surface. The underlying structures, such as subcutaneous fat,
breast gland, and orbicularis muscle, are merely compressed
and displaced. Releasing incisions or excisions should be lim-
ited whenever possible to the superficial scarred tissues alone.
When this is done, normal contour is restored as the deep tissues
unfurl, expand, and return to their normal shape (Figure 16.2).
Failure to limit the release to the superficial scar causes iat-
rogenic contour deformities that are often impossible to cor-
C D
rect (Figure 16.6). Overcorrection of the contracture is always
Figure 16.5. Iatrogenic deformity of the lower extremity. A. attempted and grafts are sutured with a bolster dressing.
A 13-year-old girl with hypertrophic, contracted, medial popliteal Placing fishtail dart at the ends of the releasing incisions adds
scar 1 year following burn injury. B. Tissue expander in place prior to
scar excision and flap rotation. C and D. Postoperative result of scar
additional skin and helps to prevent recurrent contracture
excision shows a conspicuous surgical scar, and abnormal leg contour by creating W-plasties at the ends of the graft. Postoperative
with compression of the calf. The flap fills and deforms the medial management of grafts with pressure and c onformers is
popliteal concavity. essential to minimize graft contracture and wrinkling. The
raised edges of the grafts that result from overcorrection and


A B
Figure 16.6. Failure to limit release to superficial tissue. A. Incisional release in the antecubital space violated the subcutaneous fat creating a
severe contour abnormality. B. With elbow flexion, the depression and skin prolapse is a conspicuous iatrogenic deformity.
pressure from the tie-over dressing will virtually always flat- beyond the margins of the scar. After a successful Z-plasty,
ten. If not, they can easily be excised or revised. the hypertrophic scar resolves and becomes more elastic, and
it also has been narrowed by the procedure. The physiology
Z-plasty. The Z-plasty operation is an essential and power- of this phenomenon is related to the immediate and ongoing
ful tool in the surgeon’s armamentarium for burn reconstruc- remodeling of collagen that occurs in hypertrophic scars fol-
tion. For more than 150 years, the Z-plasty has been used for lowing the relief of tension.8 Hypertrophic scar remodeling
its ability to lengthen linear scars by recruiting relatively lax also takes place when tension is relieved by release and graft,
adjacent lateral tissue. The Z-plasty, however, is much more but the use of the Z-plasty is simple, elegant, and powerful. As
than a simple geometrical exercise in lengthening a linear scar. John Stage Davis said, “It is difficult to realize how much per-
When executed properly, it causes a profound beneficial effect manent relaxation can be secured by the use of scar infiltrated
on the physiology of scar tissue. Burn scar contractures are tissue in this type of incision until one is familiar with the pro-
frequently diffuse, and excision is neither practical nor desir- cedure and its possibilities. In addition, the improvements in
able. When a Z-plasty is performed properly, recruiting lat- the appearance of scars following Z-plasty revision is often
eral tissue, two goals are accomplished. The central limb is dramatic”.9 Z-plasties can also be used to flatten hypertrophic
lengthened, decreasing longitudinal tension on the scar, and scars and elevate depressed scars. This occurs because the
the width of the scarred area is decreased by the medial trans- lateral limbs of the Z-plasty are extended into normal tis-
position of the lateral flaps (Figure 16.7). The narrowing of sue. When the flaps are transposed, the transverse limb goes
scars by Z-plasty revision can be very effective. A 60° Z-plasty straight across from normal to normal with a resulting level-
lengthens a scar by 75% while narrowing it by approximately ing effect. This benefit is obtained immediately in the operat-
30%. The Z-plasty also adds to scar camouflage by making room. When the Z-plasty flaps are incised, the tips should
ing the borders more irregular. For a Z-plasty to lengthen a be cut perpendicular to the central limb for a short distance as
burn scar and restore elasticity, the lateral limbs must extend shown in Figure 16.7. This adds additional tissue to the flap
tips and improves blood supply.
Wherever burn scar crosses a concave surface, there is a
tendency for the scar to contract, hypertrophy, and “bow-
string.” Z-plasty helps alleviate this common problem. The
Z-plasty can also be used at the same time to enhance con-
tour by appropriately designing the flaps. A Z-plasty release
is designed such that, following transposition of flaps, the
B
tight transverse limb is located where a normal concavity
would occur. For example, the Z-plasties shown in Figure 16.8
D release contractures and are used to emphasize jawline defini-
BD
AC
tion. The axilla, antecubital space, and popliteal space are fre-
A
quent sites of hypertrophic scar contracture with bowstringing
and are often suitable for treatment with Z-plasty. The medial
popliteal scar in Figure 16.5 could easily have been corrected
C with one or two Z-plasties within the scar, releasing the con-
tracture, improving the appearance, and restoring the normal
concave contour. Linear hypertrophic scar contractures are
seen less frequently across extensor surfaces. The two excep-
tions are the wrist and anterior ankle because of their ability
to dorsiflex.
Figure 16.7. Z-plasty. Transposing the flaps of a Z-plasty length- Laser Therapy. Hypertrophic scarring is a frequent com-
ens the central limb and also narrows the involved scar by the medial
transposition of the flaps. The flap tips should be incised perpendicu-
plication after partial-thickness burn injuries that take longer
lar to the central limb for a short distance to supply more tissue and than 3 weeks to completely epithelialize. Despite conserva-
enhance the blood supply. Following transposition, the more irregular tive management and close monitoring, hypertrophic scars can
borders help to camouflage the scar. become severe during the first 2 years after the burn and per-
sist for years afterward. The PDL has emerged as a successful

A C
Figure 16.8. Z-plasty to increase jawline definition.

A. Hypertrophic contracted neck scars create an extrinsic con-
tracture deforming the lower eyelid, oral commissure, and the
jawline. B. Z-plasty design incorporates the scarred tissues in the
flaps. C. Four years following Z-plasties, the facial deformities
are corrected and the scar is flat, soft, and asymptomatic.
B
treatment modality during this period of scar proliferation ation and improvement in texture and pigmentation have been
and is an effective alternative to scar excision, particularly in reported following fractional laser therapy.11-13 These promising
patients with hypertrophic facial burn scars.10 Multiple stud- interventions are further enhancing our ability to rehabilitate
ies have demonstrated its beneficial effect on scar erythema burn scars.
and hypertrophy. The PDL also rapidly decreases pruritis and
pain and provides an additional, low-morbidity, therapeu- Grafts. Skin grafts are pivotal in burn reconstruction.
tic intervention for patients and their families during the often A few generalizations about their characteristics may be
prolonged period of scar maturation. When combined with helpful. Split-thickness skin grafts contract more than full-
tension-relieving Z-plasties, the improvement can be profound thickness skin grafts, have more propensity to wrinkle, and
(Figure 16.4). Restoration of hypertrophic facial scars to their always remain shiny with a “glossy finish.” Thick split-thick-
previous state of a flat, epithelialized surface is a superior out- ness skin grafts contract less and provide a more durable skin
come compared with surgical excision with its concomitant coverage, but do not possess elastic properties. Meshed split-
increase in facial tension. Similar benefits can be obtained thickness grafts are rarely indicated in burn reconstruction
in other anatomic areas as well. The development of frac- surgery. The meshed pattern is permanently retained and has
tional ablative and non-ablative laser therapy using various an unattractive “reptilian” appearance. Hyperpigmentation of
types of lasers including CO2 and erbium offers new options grafts is a frequent problem in dark-skinned patients, particu-
for the management of burn scars in the future. Scar relax- larly those of African descent.

Full-thickness skin grafts are reliable workhorses in facial in the literature regarding complications, in general the scalp
burn reconstruction. The use of full-thickness grafts in other is a privileged site for tissue expansion.14,15 The use of tis-
areas should be carefully considered. Full-thickness grafts are sue expansion in other areas of burn reconstruction is more
elastic, contract less, have a “matte finish” like normal skin, problematic. Because the underlying theme of burn deformi-
and create a durable, resilient, skin surface. Full-thickness ties is tension and tissue deficiency, stretching adjacent tis-
grafts, however, require a well-vascularized bed and primary sue in order to carry out scar excision can result in increased
closure or grafting of the donor site and are best reserved for tension and iatrogenic contour abnormalities (Figure 16.5).
reconstruction of the head and neck or the hand. Composite The complication rate of tissue expansion in burn patients
grafts from the ear are useful for complex facial burn recon- can be high in the extremities, reaching 25% to 50% in some
struction, but should only be used when there is adequate reports.16 In contrast, tissue expansion of the scalp is well tol-

blood supply in the recipient bed. erated and very successful. After alopecia, the most common
use of tissue expansion is probably in the reconstruction of
Flaps. Flaps, with or without tissue expansion, are useful for facial burn deformities. Care must be taken when advancing
burn reconstruction. They are mandatory for complex defects or transposing expanded flaps from the cervicopectoral area
such as open joints or exposed vessels or to provide tissue to the face. It is easy to create extrinsic contractures with a
coverage that allows for later complex reconstruction, such as downward vector resulting in a “sad” facial appearance that
tendon or nerve grafting in the hand. Large flaps involve a con- is distressing to patients. Contour deformities can also be cre-
siderable trade-off because of their donor site morbidity. Their ated in the neck with loss of jaw line definition.
elasticity and minimal contracture, as well as excellent color
and texture match, make them an excellent option when avail- Evaluation and Treatment
able for the correction of cervical contractures (Figure 16.9).
Flaps are frequently recommended in the literature for axil- Successful burn reconstruction requires perspective, patience,
lary contractures. The normal axilla is concave and lined with a thorough understanding of the problem, and judicious appli-
thin skin. This allows the arm to rest comfortably at the side. cation of the fundamentals of burn reconstruction. As noted
Transposition of flaps into the axilla can effectively release previously, burn reconstruction is primarily about the release
contractures, but can also create terrible contour deformi- of contractures and the correction of contour abnormalities.
ties. When potential flap tissue is available, either posterior When contractures have a predominantly linear component
or anterior to the axilla, multiple Z-plasty flaps in series can and there is a relative excess of vascular, elastic tissue lateral
usually release axillary contractures and preserve or restore to the contracture, the Z-plasty is simple, is reliable, and has
normal contour (Figure 16.10). When diffuse axillary scarring the least morbidity. Z-plasty minimizes the need for most
is present, release and graft is the best option, even though postoperative therapy, including pressure garments, and the
it requires postoperative splinting and often more than one benefit of the procedure is prolonged. The relaxed scar tissue
intervention. will continue to soften, flatten, and loosen for many months
to years after the operation is performed.
Tissue Expansion. Tissue expanders have transformed Z-plasties can also be used on the narrower, linear, com-
the treatment of postburn alopecia. Bald areas of 50% of ponents of diffuse areas of hypertrophic scarring to separate
the scalp or more can be successfully reconstructed, fre- islands of scar and restore elasticity. Contour abnormali-
quently requiring more than one expansion. The scalp is ties can be corrected at the same time. The relief of tension
an ideal site for tissue expansion because of its blood sup- leads to improved maturation. When erythema is present,
ply, convex shape, and the unyielding skull against which to the PDL is an effective adjunctive therapy. Following the
expand (Figure 16.11). Although there are conflicting data benefit of initial scar revision, repeat surgery can be carried
A B C
Figure 16.9. Correction of cervical contracture using regional flap. A. Recurrent anterior cervical contracture in a 17-year-old boy following
split-thickness skin grafting. B and C. Transposition flap from the unburned right cervicopectoral area restores normal function and appearance.

B D
Figure 16.10. Multiple Z-plasties for axillary contracture. A. Extensive posterior axillary contracture with hypertrophic scarring. B and C.
Multiple Z-plasties and local flaps in series easily release the contracture and flatten the hypertrophic scars. D. Eight years later complete release
has been maintained, the scars are flat and soft, and the contours are normal.
out 1 or 2 years later. Typically, this secondary surgery When contracted scars or grafts are diffuse and Z-plasty
is directed toward scars that previously were not conspicu- or other local flap rearrangement is not possible, then release
ous or symptomatic but have become so after the treated and split-thickness skin grafting is usually the best option
scars flatten, soften, and become less noticeable. It is to correct contractures. Care must be taken to preserve and
often remarkable how much improvement in appearance, restore normal tissue contours when releases are carried
contour, and softness can be accomplished by such “sep- out to prevent unsightly iatrogenic contour abnormalities
arating” Z-plasties. Patients are almost always pleased (Figure 16.6).
with the outcome and frequently ask for subsequent Flaps are excellent for cervical contractures when they
similar procedures, a true indication of successful surgery are available (Figure 16.9). Otherwise, release and split-
(Figure 16.12). thickness skin grafting is a reasonable option, although this


A B
Figure 16.11. Tissue expansion for burn alopecia. A. A 7-year-old girl with extensive alopecia involving the vertex, parietal, and occipital
areas of the scalp. B. Ten years later following two tissue expansions, alopecia has been eliminated and a normal temporal hairline and sideburn
restored.
requires meticulous postoperative management and often categories as described in Table 16.1. Type I deformities
more than one release and graft.17 Microvascular free tis- consist of essentially normal faces that have focal tissue loss
sue transfer has been advocated for anterior neck contrac- or diffuse burn scarring with or without associated contrac-
tures, but its use has been limited because of complexity and tures. Type II deformities make up a much smaller number of
morbidity. patients who have “panfacial” burn deformities consisting of
Tissue expansion is the ideal treatment for postburn alo- what can be referred to as facial burn stigmata. Table 16.2
pecia. Even when the area of alopecia is relatively small, lists the stigmata of facial burns, which include lower eye-
scalp expansion should be considered. Excision and direct lid ectropion, shortening of the nose with ala flaring, a short
closure of scalp alopecia usually results in a straight line scar retruded upper lip, lower lip eversion, inferior displace-
under tension that tends to widen and become conspicuous ment of the lower lip, flattening of facial features, and loss
over time. Tissue expansion allows the closure to be carried of jawline definition. The surgical goals when treating type I
out without tension, incorporating interdigitating local flaps deformities should be different from those appropriate for
and Z-plasties that obscure the scar and prevent widening. treating type II deformities.
Whenever possible, the use of a single large expander is desir- Type I patients have essentially normal faces and surgical
able, even if that requires expansion of some areas of alope- intervention should not adversely affect overall facial appear-
cia. The larger the expander, the lesser the separation of hair ance. The surgeon must not fall into the trap of compromis-
follicles. When expansion is accomplished with a single large ing normal features and contours to “excise scars.” Iatrogenic
expander placed through a single small incision, manipula- deformities create an abnormal look and can easily become
tion of the scalp at the time of alopecia excision is facilitated grotesque. A normal looking face with scars is more attrac-
because the flaps have not been compromised. tive than an even slightly grotesque face with fewer scars.
Facial burn reconstruction is complicated and can seem Surgery should only be performed when it is reasonably cer-
overwhelming in severe cases. The importance of time and tain that it will make the patient better, not just deformed in
allowing for maximal scar maturation to occur, along with a different way. Scar revision with Z-plasties and local flaps
the use of ancillary techniques such as pressure, silicone gel, is usually the best option for type I patients (Figure 16.13).18
steroids, judicious surgical intervention, and the use of the Full-thickness skin grafts from the most appropriate available
laser for erythema cannot be overemphasized. donor sites are excellent for focal contractures. All human
It can be helpful to think of patients with facial burn appearance is a mosaic to some degree and mosaic faces with
deformities as falling into two fundamentally different normal movement and expression look much better in real

Table 16.1
Facial Burn Categories
n Type n Description
I ssentially normal faces with focal or diffuse
E
burn scarring with or without contractures
II anfacial burn deformities with some or all of
P
the stigmata of facial burns (see Table 16.2)
Table 16.2
Stigmata of Facial Burns
A Lower eyelid ectropion

Short nose with ala flaring
Short retruded upper lip
Lower lip eversion
Lower lip inferior displacement
Flat facial features
Loss of jawline definition
have been returned to their normal location and shape with-

out tension, it is remarkable how much improvement in
appearance can be accomplished in even severe facial burns
(Figure 16.14).
Cosmetics are effective in covering or minimizing abnor-
B malities of color and texture in all body areas, but their appli-
cation requires skill and commitment, and their use is usually
limited to the face. Many female patients become exceed-
ingly adept at cosmetic camouflage. Male patients are less
likely to take advantage of this opportunity to minimize their
deformity.
Conclusion
Advances in the care of acutely burned patients have cre-
ated a challenge and an opportunity. More patients survive
today with extensive areas of healed burn scar and graft. But
this increased challenge provides great opportunity for plas-
tic surgery. Although much gloom and doom surrounds the
acute care of burn patients, the injuries are usually superficial.
Other than the burn scars and contractures, these patients
are usually completely healthy, and successful reconstructive
surgery can often restore them to a happy and productive
C life. Large series have shown excellent long-term outcomes in
Figure 16.12. Effect of Z-plasties on hypertrophic scars. A. Diffuse even extensively injured patients when compared with nor-
hypertrophic scarring of the anterior chest and axilla in a 6-year-old mal controls.19 Patience, persistence, and determination are
boy with contracture and deformity of the normal contours. B. Broad essential to accomplish successful reconstruction. The skill-
areas of scar were separated with multiple Z-plasties on two separate ful application of basic surgical techniques to the reconstruc-
occasions as noted in the text. C. Seven years later, after two Z-plasty tion of postburn deformities can be gratifying to patients
procedures and treatments with the pulsed dye laser, the scars are flat,
and surgeons alike. Ancillary techniques of scar rehabilita-
soft, and elastic. The normal chest and axillary contours have been
restored. tion and photomedicine are providing less morbid and more
effective ways to reconstruct burn deformities. The future is
bright for further progress. The ultimate principle of burn
reconstruction is learning to understand, appreciate, and
life than they do in images. The PDL is helpful in decreasing favorably influence the processes of wound healing and scar
erythema. maturation.
Type II patients present a completely different clinical
situation. The surgical goals for these patients should be the
restoration of normal facial proportion and the return to nor-
Acknowledgments
mal of the position and shape of facial features. When nor- The authors thank Ms. Aisling Fitzpatrick for assistance with
mal facial proportion has been restored and facial features preparation of this manuscript.


A B
Figure 16.13. Type I patient. A. A 24-year-old woman following extensive acid burns to the face. B. Nasal reconstruction was performed with
turn-down flaps and split-thickness skin grafting. Four facial scar revisions with Z-plasties and local flaps were carried out over a 3-year period.
A B
Figure 16.14. Type II patient. A. A 30-year-old male firefighter following a severe facial burn with facial burn stigmata. B. Eight years later
following extensive reconstructive surgery with full-thickness grafts, composite grafts, and multiple scar revisions.

10. Parrett BM, Donelan MB. Pulsed dye laser in burn scars: current concepts
References and future directions. Burns. 2010;36:443-449.
1. Cope O, Langohr JL, Moore FD, Webster RC Jr. Expeditious care of 11. Waibel J, Beer K. Fractional laser resurfacing for thermal burns. J Drugs
full-thickness burn wounds by surgical excision and grafting. Ann Surg. Dermatol. 2008;7(1):12-14.
1947;125:1-22. 12. Haedersdal M, Moreau K, Beyer D, Nymann P, Alsbjorn B. Fractional
2. Janzekovic Z. A new concept in the early excision and immediate grafting of nonablative 1540 nm laser resurfacing for thermal burn scars: a randomized
burns. J Trauma. 1970;10:1103-1108. controlled trial. Lasers Surg Med. 2009;41:189-195.
3. Burke JF, Bondoc CC, Quinby WC. Primary burn excision and immediate 13. Lee SJ, Kim JH, Lee SE, Chung WS, Oh SH, Cho SB. Hypertrophic scarring
grafting: a method shortening illness. J Trauma. 1974;14:389-395. after burn scar treatment with a 10,600-nm carbon dioxide fractional laser.
4. Larson DL, Abston S, Evans EB, Dobrkovsky M, Linares HA. Techniques Dermatol Surg. 2011;37:1168-1172.
for decreasing scar formation and contractures in the burned patient. J 14. Neale HW, High RM, Billmire DA, et al. Complications of controlled tissue
Trauma. 1971;11:17. expansion in the pediatric burn patient. Plast Reconstr Surg. 1988;82:840-848.
5. Ahn ST, Monafo WW, Mustoe TA. Topical silicone gel: a new treatment for 15. Pisarski GP, Mertens D, Warden GD, Neale HW. Tissue expander com-
hypertrophic scars. Surgery. 1989;106:7. plications in the pediatric burn patient. Plast Reconstr Surg. 1998;102:
6. Ketchum LD, Robinson DW, Masters FW. Follow-up on treatment of 1008-1012.
hypertrophic scars and keloids with triamcinolone. Plast Reconstr Surg. 16. Friedman RM, Ingram AE Jr, Rohrich RJ, et al. Risk factors for com-
1971;48:256-259. plications in pediatric tissue expansion. Plast Reconstr Surg. 1996;98:
7. Donelan MB, Parrett BM, Sheridan RL. Pulsed dye laser therapy and 1242-1246.
Z-plasty for facial burn scars: the alternative to excision. Ann Plast Surg. 17. Cronin TD. The use of a molded splint to prevent contracture after split skin
2008;60:480-486. grafting on the neck. Plast Reconstr Surg Transplant Bull. 1961;27:7-18.
8. Longacre JJ, Berry HK, Basom CR, Townsend SF. The effects of Z plasty on 18. Taylor HO, Carty M, Driscoll D, Lewis M, Donelan MB. Nasal reconstruc-
hypertrophic scars. Scand J Plast Reconstr Surg. 1976;10:113-128. tion after severe facial burns using a local turn-down flap. Ann Plast Surg.
9. Davis JS. The relaxation of scar contractures by means of the Z-, or reversed 2009;62(2):175-179.
Z-type incision: stressing the use of scar infiltrated tissues. Ann Surg. 19. Sheridan RL, Hinson MI, Liang MH, et al. Long-term outcome of children
1931;94:871-884. surviving massive burns. JAMA. 2000;283:69-73.

Chapter 17 n Radiation and Radiation
Injuries
James Knoetgen III And Salvatore C. Lettieri

of disease with preservation of surrounding uninvolved struc-
Introduction tures. Disadvantages include the length of treatment, the need
Roentgen’s discovery of X-rays in 1895 was closely followed for access to appropriate facilities and equipment, and the
by the introduction of radiation therapy for the treatment of a potential additive and chronic effects of radiation therapy.
variety of cancers and other disease processes. Radiation pro-
vides both diagnostic and therapeutic benefits, but the result-
ing changes to exposed tissues pose wound healing problems
Delivery of Radiation
and reconstructive dilemmas for which the plastic surgeon is There is a distinction between diagnostic and therapeutic
often consulted. This chapter explains the basics of radiation radiation. The most common application of diagnostic radia-
therapy, discusses the radiation wound issues that are fre- tion is a simple radiograph (X-ray). The amount of radiation
quently faced by plastic surgeons, and emphasizes the unique delivered for a standard radiograph typically ranges from 20
problems posed by specific anatomic locations. to 150 kV, whereas a therapeutic treatment range is typically
Radiation refers to the high-energy particles (alpha parti- from 200 kV to 25 MV. Radiation therapy can be delivered
cles, beta particles, and neutrons) and electromagnetic waves via external or internal routes. The delivery technique most
(X-rays and gamma rays) that are emitted by radioactive sub- commonly used is external beam radiotherapy, which origi-
stances (uranium, radon, etc.). Alpha particles are large, posi- nates from a source external to the patient, a linear accelera-
tively charged, helium nuclei. Radium and radioactive isotopes tor (LINAC). A variety of radiation beams can be delivered
can be consumed orally or intravenously to emit alpha par- in this manner, such as low-energy radiation beams from a
ticles into surrounding tissues. Beta particles are small, nega- cobalt source in a cobalt machine. Other atomic particles,
tively charged electrons and are used in electron beam therapy such as neutrons, are also delivered via this mechanism. This
(e.g., treatment of mycosis fungoides), and can penetrate up to technique allows daily fractionated delivery of radiation over
1 cm of tissue. Gamma rays are uncharged photons produced a several week course. External beam therapy can be delivered
by the natural decay of radioactive materials (radium, cobalt as an independent treatment preoperatively, intraoperatively,
60, etc.) and can penetrate deeply into tissues. Roentgen rays or postoperatively.
(X-rays) are similar to gamma rays, except that they are artifi- Delivery of radiation from within the patient’s body is
cially emitted from tungsten when bombarded with electrons. termed brachytherapy. Radioactive sources are inserted into
Radiation doses are measured in a variety of units. These the patient for temporary or permanent irradiation. This
units measure the energy absorbed from a radiation source technique allows for continual treatment of the tumor with
per unit mass of tissue. The current unit of measure for thera- radiation over a course that usually lasts several days. Its
peutic radiation is the Gray (Gy). The Gray is defined as the advantages include decreased treatment time and greater abil-
absorption of 1 J of ionizing radiation by 1 kg of tissue. The ity to spare uninvolved local tissues. Brachytherapy may also
older term for this is the “rad,” and 1 rad is equal to 0.01 Gy. be indicated in patients who have been previously irradiated
A typical curative treatment could be in the range of 60 to and are no longer candidates for external beam therapy hav-
80 Gy. Generally, adjuvant treatments tend to be within the ing already received the maximum recommended dose for a
40 to 60 Gy range. The type of tumor, area of treatment, specific anatomic area. Brachytherapy is commonly used for
and goal of treatment determine the precise dosing. The total the treatment of pelvic cancers such as cervix or prostate, and
treatment is usually divided (fractionated) over the course of this can also be used as an adjunctive therapy for soft tissue
several sessions. This generally allows the normal, or non-dis- tumors. For example, a patient may undergo external beam
eased, tissue that surrounds the tumor, to recover better than radiation for the treatment of a sarcoma with subsequent
if it were treated with one large dose. resection and placement of brachytherapy catheters for local-
The two main forms of radiation exposure are irradiation ized, direct radiation treatments. Plastic surgeons may be con-
and contamination. Irradiation refers to radiation waves that sulted because brachytherapy catheters can be covered with
pass directly through the human body, whereas contamina- a soft tissue flap where primary closure is not possible. The
tion is contact with and retention of radioactive material. catheters are then “loaded” with various radioisotopes. The
Contamination is usually the result of an industrial acci- “loaded” catheters then create a controlled, localized irradia-
dent. The plastic surgeon is most concerned with irradiation tion until the catheters are removed.
as opposed to contamination since current regulations have Radiation may also be delivered via robotic methods
made industrial accidents and exposures quite rare. allowing for the controlled delivery of low dosages of radia-
Irradiation is a local therapy applied to a specific body site tion to specific anatomic locations. This technique is used for
containing a tumor or disease process, or to draining lymph intracranial tumors, for example.
node beds thought to contain or potentially contain micro-
scopic or gross disease. Large tumors may be treated preoper-
atively with radiation therapy (induction therapy) to decrease
Radiation Damage
the tumor burden prior to surgical extirpation. Adjuvant Regardless of the delivery technique, radiation therapy works
radiation therapy is performed in addition to the surgical by damaging the targeted cells through complicated intracel-
extirpation with the goal of treating the tumor’s resection bed lular processes whose mechanisms continue to be studied to
and regional lymph nodes in specific clinical scenarios, such this day. The interaction of radiation with water molecules
as large tumors, recurrent tumors, extracapsular lymph node within the cell creates free radicals that cause direct cellular
involvement, and positive resection margins. The potential damage. A range of biochemical lesions occur within DNA
advantage of radiation therapy over surgery is local treatment following exposure to radiation, and this can result in two
155
different modes of cell death: mitotic (clonogenic) cell death When confronted with a wound that has late radiation
and apoptosis. The biochemical lesion most often associated changes, the first step is to rule out the presence of a recur-
with cell death is a double-stranded break of nuclear DNA.2 rent or new tumor (possibly radiation induced). It is impera-
Irradiated tissues suffer both early and late effects. Early tive that the plastic surgeon does not assume this has been
effects occur during the first few weeks following therapy and ruled out by the referring physician or surgeon. Diagnosis is
are usually self-limited. They result from damage to rapidly often assisted by standard radiographs, computed tomogra-
proliferating tissues, such as the mucosa and skin. Erythema phy (CT) scans, and magnetic resonance imaging (MRI) and
and skin hyperpigmentation are the most common problems is confirmed with a tissue biopsy. If tumor is present, a full
and these are treated expectantly with moisturizers, local workup and evaluation by the appropriate extirpative surgeon
wound care, and observation. Dry desquamation occurs after are required. After tumor extirpation is complete, reconstruc-
low to moderate doses of radiation, while higher doses result in tive efforts of the resulting defect are then initiated.
moist desquamation. At the tissue level, stasis and occlusion of If tumor is not present, the next step in management is
small vessels occur, with a resulting decrease in wound tensile complete resection and debridement of all nonviable irradi-
strength. Fibroblast proliferation is inhibited and may result in ated tissues and foreign bodies (sternal wires, previous sutures,
permanent damage to fibroblasts. This creates irreversible injury etc.).5 Primary closure or skin grafting of the irradiated wound
to the skin which may be progressive. While the plastic surgeon will fail because of the poor vascularity and fibrosis of the
is often not required to treat early radiation injuries, chronic wound bed. Likewise, muscle flaps transposed into an irra-
injuries frequently require the plastic surgeon’s attention. diated, poorly vascularized wound bed may not heal well. It
Late, or chronic, radiation effects can manifest anytime after is imperative that the plastic surgeon first establishes a clean
therapy, from weeks to years to decades after treatment. While wound with well-vascularized edges before proceeding with
acute effects are uncomfortable and bothersome to the patient, reconstruction. This frequently requires multiple debridements
they are generally self-limited and resolve with minimal treat- rather than a single operative endeavor, as the extent of radia-
ment and local wound care. Chronic effects, however, can be tion injury often exceeds what appears to be the boundary of
progressive, disabling, cumulative, permanent, and even life damaged tissue. A common cause of recurrent infections, sinus
threatening. Late injuries include but are not limited to tissue tracts, and non-healing wounds is retention of nonviable mate-
fibrosis, telangiectasias, delayed wound healing, lymphedema rials such as foreign bodies, bone, and cartilage secondary to
(as the result of cutaneous lymphatic obstruction), ulceration, inadequate debridement.
infection, alopecia, malignant transformation, mammary When incising severely irradiated tissue, a defect much
hypoplasia, xerostomia, osteoradionecrosis, and endarteritis. larger than anticipated is often created. Irradiated tissue is often
Long-term effects of radiation therapy also include constrictive tight and creates a constricted skin envelope. When incised, the
microangiopathic changes to small- and medium-sized vessels,3 wound edges will retract and create a larger defect than expected
which are significant when performing reconstructive proce- (Figure 17.1). This is an important concept to understand when
dures with either pedicled flaps or free tissue transfers. planning the reconstruction, as one may need more nonirradi-
ated tissue for reconstruction than originally estimated.
Once debridement is complete, stable wound closure is
General Principles of Treating obtained. Thorough preoperative planning and a systematic
approach to reconstruction of irradiated defects are needed.
Irradiated Wounds Reconstruction usually includes transposition of a well-
In most circumstances, a radiated wound will not heal as well vascularized nonirradiated soft tissue flap. Reconstruction of
as a nonirradiated wound. The plastic surgeon will generally be these defects is often challenging and is associated with relatively
called upon to care for three different populations of irradiated high complication rates. While planning the reconstruction, the
patients. The first population is those who have not yet received plastic surgeon chooses the flap that will best provide a healed
irradiation but will be receiving radiation therapy intraopera- wound and maximize preservation of function. It is generally
tively or postoperatively. This is often seen in the immediate accepted that irradiated muscles should not be transferred as this
breast reconstruction patient who is undergoing mastectomy may result in partial or complete muscle necrosis.6 The transfer
and potential postoperative radiation therapy or the sarcoma of a muscle whose pedicle has been irradiated may also be asso-
patient undergoing extirpation with intraoperative radiation ciated with a higher than normal complication rate.7 If a nonir-
therapy. Also, bronchial stumps can be reinforced when a com- radiated muscle flap or the greater omentum is not available, a
pletion pneumonectomy is anticipated, usually with intratho- free tissue transfer will be required. Since the tissue surrounding
racic transposition of a serratus muscle flap.4 an irradiated wound is fibrotic with endothelial damage in the
The second patient population includes those who have local vessels, the plastic surgeon must frequently ride the “recon-
already received radiation therapy and now have a recurrent structive elevator” (rather than the ladder) and proceed directly
or new tumor, or a radiated wound not amenable to primary with a free tissue transfer.
closure, frequently with the exposure of vital or significant An important concept is that the poorly vascularized
structures such as the bone, viscera, and neurovascular bun- peripheral tissue surrounding the open wound requires recon-
dles. These patients will require tumor extirpation or wound struction in addition to the wound itself. It is equally important
debridement(s) followed by reconstruction. to evaluate the tissue surrounding the defect. The flap must be
The third group of patients includes those who require approximated with well-vascularized tissue rather than irradi-
reconstruction for intraoperative radiation therapy. ated, fibrotic tissue. The redundant flap may also be buried
Intraoperative radiation therapy is occasionally used in the beneath the surrounding injured skin, reconstructing the miss-
treatment of sarcomas, pelvic tumors, and other malignancies. ing or fibrotic subcutaneous tissue layer. This delivers addi-
In this situation, the reconstructive ladder is applicable and tional blood supply to the skin and increases “mobility” as
if reasonably healthy soft tissue is present, a primary layered well. Flap coverage may also provide some pain relief for these
closure can be attempted. Many of these wounds will heal patients. The remainder of this chapter addresses the pertinent
well even though they have received intraoperative radiation issues of irradiated wound treatment by anatomic area.
therapy. However, if the bone, prosthetic material, or neuro-
vascular bundles are exposed or if a significantly sized soft
tissue defect is present, flap coverage is indicated to protect Skin
these structures and fill the defect. A subset of this patient cat- Non-melanoma skin malignancies can be treated
egory includes those who are receiving brachytherapy cath- with approximately a 90% cure rate with irradiation
eters intraoperatively, which require coverage. (Chapter 14). Since surgical extirpation and radiation

Chapter 17: Radiation and Radiation Injuries 157

A B
C D
Figure 17.1. A 60-year-old man with laryngeal cancer treated with

radiation resulting in an anterior neck wound. A. Pre-op appearance.
B. Treated with resection of all radiated tissues with completion lar-
yngectomy and partial esophagectomy. C–E. Reconstruction with free
anterolateral thigh flap. The de-epithelialized central portion of the flap
was folded for internal esophageal reconstruction, and skin paddles
provided external skin coverage.
E
treatment provide similar results for skin cancers, the pros

and cons of each are considered before a recommendation is Extremities
made. Surgical extirpation has an immediate result, whereas Soft tissue sarcomas of the extremities can be aggressive tumors
radiation therapy requires prolonged therapy as well as involving multiple structures and tissue planes. Surgical extir-
access to radiation therapy facilities. Long-term complica- pation is often combined with intraoperative or postoperative
tions such as fibrosis, ulceration, ectropion, osteitis, and radiation therapy, either external beam or brachytherapy.
chondritis are possible complications of radiation therapy. Therefore, treatment of these patients requires a multidisci-
It is therefore generally reserved for patients who are not plinary approach often involving surgical oncologists, vascular
surgical candidates. There is another subgroup of patients, surgeons, orthopedic surgeons, radiation oncologists, plastic
such as those with positive cutaneous margins or perineu- surgeons, and others (Chapter 94). The goal is to obtain loco-
ral invasion, who may require treatment with postoperative regional tumor control while simultaneously attempting limb
radiation. salvage and maximal preservation of limb function. Patients
Low-dose radiation therapy is also used postoperatively in may have received irradiation before extirpation, which is
the treatment of benign disease, such as keloids and hypertro- important in the planning of the radiation therapy (i.e., the
phic scars. This technique takes advantage of fibroblast inhi- patient may require brachytherapy as opposed to external
bition caused by ionizing radiation. The radiation is generally beam therapy or a modification of the external beam dose).
administered on the same day the keloid is excised and for The sequence is especially important to the plastic surgeon and
several days thereafter. the planning of wound closure and reconstruction.

Wide local tumor resections of the extremity often result opinion and not widely accepted. An alternative technique
in large soft tissue defects, as well as osseous defects. Osseous employs placement of a tissue expander at the time of mas-
defects will require orthopedic reconstruction with prosthetic tectomy and before radiation therapy to create and maintain
materials, total arthroplasties, or bone grafts. All bone, ten- a soft tissue envelope for a later reconstruction that includes
dons, prosthetic materials, and neurovascular bundles must be autologous tissue, with or without an implant.
covered with well-vascularized viable tissue in order to obtain A critical issue that requires consideration when performing
stable soft tissue reconstruction and a healed wound. The autologous breast reconstruction is the quality of irradiated
addition of radiation therapy to the tumor bed after recon- vessels of pedicled flaps (internal mammary vessels in TRAM
struction, as well as all previous irradiation, must be consid- flaps and the thoracodorsal vessels in latissimus dorsi muscle
ered when planning reconstruction. flaps) and the quality of irradiated recipient vessels in autolo-
The goal of soft tissue reconstruction is to obtain stable gous reconstruction with free flaps (TRAM, Deep Inferior
coverage of all vital structures. While the “reconstructive lad- Epigastric Artery Perforator Flap (DIEP), Superior Gluteal
der” generally proceeds from the simplest to the most com- Artery Perforator Flap (SGAP), etc.). Pedicled TRAM flaps
plex method of closure, it may be prudent to bypass one or have been demonstrated to have a higher incidence of both
more of the standard rungs to arrive at a more stable closure. skin and flap necrosis when the pedicle has been exposed to
For example, a defect in the medial thigh created by resection radiation preoperatively,7 and are associated with an increased
of a liposarcoma and irradiation that may seem amenable to incidence of total TRAM flap failure.12 When performing a
primary closure may benefit from coverage with a pedicled pedicled TRAM flap with irradiated vessels, decreased com-
musculocutaneous flap, especially if the femoral vessels are plications in this group may be achieved with a flap delay, a
exposed. Likewise, a soft tissue defect of the knee may not be bipedicled TRAM flap, or turbocharging the flap (although
amenable to coverage with a gastrocnemius muscle flap if this turbocharging pedicled flaps is a controversial subject).
muscle was within the field of previous irradiation and may be The alternative is a free tissue reconstruction using a flap
better treated with a free muscle flap. that has not been irradiated (Chapter 62). When performing
Closure of a defect is not the only goal when reconstructing a free tissue transfer for breast reconstruction, the surgeon
these wounds. Preserving and maintaining maximal function must inspect the quality of the irradiated recipient vessels.
is of importance as well. When critical muscles or large muscle Significant scarring and fibrosis surrounding the vessels and
masses are resected and/or irradiated, it is often advantageous radiation damage to the lumen of the recipient vessels will
to perform a neurotized muscle reconstruction. This can often increase the chance of free flap failure. Radiation therapy
give patients at least partial function of a joint or limb. results in constrictive microangiopathic changes to small- and
medium-sized vessels as well as inhibition of fibroblast func-
tion, which increases the risk of anastomotic failure.3
Breast Occasionally, the potential need for postoperative irradia-
The breast is an anatomic structure that is frequently irradiated tion is uncertain at the time of mastectomy. In this setting,
and cared for by the plastic surgeon. Breast reconstructions the plastic surgeon must decide whether to perform immediate
using autologous or prosthetic materials are more complicated reconstruction or delay reconstruction until after the potential
when the treatment plan includes radiation therapy. There are radiation therapy is completed. This is a frequent clinical sce-
basically two breast patient populations the plastic surgeon nario faced by plastic surgeons. Most plastic surgeons agree
will encounter: 1) the patient who has already received radia- that superior outcomes are achieved with a delayed autolo-
tion therapy to the breast(s) for the treatment of a previous gous reconstruction, rather than an immediate reconstruc-
malignancy and is now in need of further extirpation and/or tion and postoperative radiation of the flap.13,14 It is therefore
reconstruction and 2) the patient who is undergoing mastec- prudent to delay reconstruction until the final decision about
tomy and may receive postoperative radiation therapy, usually postoperative irradiation is made.
because of tumor size or nodal involvement.
The first clinical scenario requires the plastic surgeon to
perform a breast reconstruction in an irradiated field. The sur- Head and Neck
geon must first evaluate the breasts and chest and assess the Head and neck malignancies provide unique and complicated
degree of radiation damage. The patient should be examined treatment challenges. These tumors are frequently aggressive
for erythema, hyperpigmentation, and the degree of fibrosis with high recurrence rates. Treatment usually requires surgical
of the breast and surrounding tissues and skin. A basic tenet extirpation and radiation therapy. Surgical extirpation often
of reconstructing the irradiated breast is that delivery of well- results in large defects with exposure of vital structures that
vascularized tissue via autogenous reconstruction will require complicated soft tissue and/or osseous reconstruction.
yield a far superior result than prosthetic implants alone. Extirpation may result in full thickness defects that involve
Reconstruction with tissue expansion and implants has been a fistulous communication between the oral cavity and the
demonstrated to yield a higher rate of wound healing prob- blood vessels of the neck. Reconstruction of these defects is
lems and implant exposure, as well as a higher incidence of challenging and is made more difficult if the irradiated tissues
Baker III and IV capsular contracture.8,9 Nava et al. recently are fibrotic and if the local vessels are damaged.
reported 257 consecutive patients reconstructed with tempo- Osteoradionecrosis of the mandible or maxilla is a com-
rary breast tissue expanders followed by permanent prosthe- plication occasionally seen after radiation therapy and is
sis. Forty percent of patients who received radiation during another clinical scenario that requires resection/debridement
the tissue expansion phase had an unsuccessful reconstruction, of affected tissue followed by osseous reconstruction.
whereas only 6.4% of those who received radiation therapy to The affected regions may be categorized into thirds. The
their permanent implants had an unsuccessful reconstruction lower third includes the mandible and neck region. The mid-
(vs. 2.3% in the control group)10 (Chapter 59). dle third includes the maxilla and the orbit, and the upper
Reconstruction with autogenous tissue, usually via a ped- third corresponds to the skull base and cranium. Each region
icled or free Transverse Rectus Abdominis Myocutaneous is unique and has its own issues and challenges.
(TRAM) flap or a latissimus dorsi muscle flap with an The patient with a head and neck malignancy may present in
expander/implant, will often yield a superior result. If autol- one of several different scenarios. The patient may present with-
ogous breast reconstruction is not an option, some surgeons out any preoperative radiation and be treated with surgical resec-
advocate immediate insertion of a breast tissue expander/ tion and reconstruction followed by postoperative radiation.
implant at the time of mastectomy with completion of expan- Alternatively, the patient may have had preoperative radiation
sion prior to irradiation,11 although this is a controversial and be scheduled to undergo extirpation and reconstruction.

Other possible presentations include patients who have failed therapy, used to downstage (shrink) tumors preoperatively,
radiation therapy with persistent cancer or a recurrent cancer. tends to create more bleeding and inflammation in the treated
These patients may require a “salvage” procedure with recon- area. Although the irradiated vessels may be adequate for use,
struction. Finally, there are patients who have undergone suc- the dissection may be tedious because of the inflammation.
cessful radiation therapy for malignancy and are “cured” but Chronic radiation injury, however, will tend to have more
then suffer from the functional sequelae of the radiation therapy. fibrosis in the affected area as well as thickening of the tissue
While head and neck defects were traditionally recon- planes and absence of standard anatomic landmarks, which
structed with local and regional flaps, free tissue transfer has makes dissection even more slow and difficult.
become the standard reconstruction technique. The pectoralis Patients who will be having postoperative irradiation do
major muscle flap was used for soft tissue coverage of neck not have these issues and will have unoperated tissues and

defects before free tissue transfer was introduced. This flap virgin surgical planes. In fact, the neck dissection leaves the
is limited by its bulk, difficult arc of rotation, and limited vessels exposed and ready for use. It is often prudent to rec-
reach into the oral region. Other local muscle flaps such as ommend to the extirpative surgeon that an adequate length be
the sternocleidomastoid or platysma may not be useable or left on vessels that are ligated and resected, in order to have a
predictable in the irradiated neck. Free tissue transfer allows stump for anastomosis, rather than ligating the branch flush
well-vascularized, nonradiated tissues from a distant site to be with the larger vessel from which it arises.
used for reconstruction of the radiated defect. Osseous reconstructions of the head and neck offer addi-
Because of the vital structures located in the head and neck tional challenges. Mandible resections are usually recon-
region, it is imperative to obtain a stable closure. Success is structed with a fibula flap to deliver well-vascularized
measured not only by the cure or control of the tumor but also nonirradiated tissue to the wound bed (Chapter 37). A non-
by wound healing and preservation of function. The primary vascularized bone graft will not fare well if the surrounding
goals are complete healing without infection, dehiscence, or soft tissue envelope has been irradiated. This may lead to a
intraoral breakdown that may result in fistula formation. The chronic non-healing wound with possible draining sinus tracts.
secondary goal is maintenance/restoration of function. The Generally, a complex full thickness defect that involves bone
tertiary goal is a cosmetically acceptable appearance. and intraoral lining is best served by a vascularized bone flap.
Full thickness defects of the head and neck region may In the absence of any viable alternatives for vascularized bone
require reconstruction of multiple layers, including the intra- graft, a free tissue transfer with a nonvascularized bone graft
oral lining, osseous reconstruction of the mandible or max- could then be used. This is not an ideal option considering the
illa, esophageal or laryngeal reconstruction, and soft tissue/ possibility of adjunctive radiation that is often administered
skin coverage (Figure 17.1). Partial thickness defects may only postoperatively. While some authors have reported successes
require intraoral lining or soft tissue coverage. Usually, local with bone grafting or a cancellous “tray,” these reconstruc-
flaps are not useable, except for perhaps a temporalis muscle tions need to be performed within a well-vascularized bed and
flap to obliterate the maxillary sinus or the palate region. Free are therefore not indicated in irradiated wounds.
tissue transfer is preferred, especially in irradiated head and An uncommon yet potentially lethal complication of radia-
neck defects. The types of free tissue transfers utilized include tion therapy to the head and neck is infection leading to
a thin fasciocutaneous flap (radial forearm flap), an intermedi- wound dehiscence and exposure of the vessels. This can result
ate thickness flap (scapula or parascapular flap), or a variable in vessel rupture or anastomotic leak that can result in life-
thickness flap (anterolateral thigh flap). Muscle flaps (rectus threatening hemorrhage.
abdominis or latissimus dorsi) can also be used. The greater Middle third defects often require maxillary reconstruc-
omentum is excellent as a “carrier” for bone and skin grafts tion. There are few local tissue options and therefore these
but offers no structural strength. often require primary vascularized bone graft reconstructions
Generally, vessels in the neck are readily available and of (Chapter 39). The midface area generally has a high risk of
adequate caliber. However, even if the vessel caliber is ade- exposure to the oronasal cavity and therefore will benefit
quate, irradiated vessels are more difficult to dissect and use from reconstruction with vascularized bone grafts.
for microanastomosis because of local fibrosis and radiation Reconstructions of the upper third of the head and neck
injury to the vessels. Preoperative evaluation of the vessels is offer unique challenges. The skull base must be separated
recommended. Venous outflow is difficult to assess preopera- from the oronasal cavity to prevent infection and cerebrospi-
tively and the possibility that adequate venous outflow will nal fluid leaks. Composite resections of upper third lesions
not be found intraoperatively is anticipated. Thoughtful pre- generally require vascularized reconstructions, usually in the
operative planning with a “plan A” and at least one “plan B” form of a free tissue transfer (Chapter 39). Local vessels in
is necessary before undertaking these procedures. If the radi- the upper third region are limited and may require vein graft-
ated vessels are deemed unsatisfactory for anastomosis, the ing. Postoperative radiation therapy may be required if the
surgeon should be prepared to find vessels in other areas of resected tumor has positive margins. Unfortunately, too often
the neck, such as the contralateral side and the supraclavicular it leads to post-radiation damage that may necessitate free tis-
region, or even outside of the neck region. If distant vessels sue transfer for coverage. This scenario needs to be thoroughly
are utilized, then vein grafts are required, so it is imperative discussed with the patient in advance (Figure 17.2).
to warn patients preoperatively about the potential need for
surgery to other parts of their body. Although vein grafting
generally increases microanastomotic failure rates, vein graft- Chest
ing into an area that is easily dissected with a technically eas- Radiation therapy to the chest wall is used in the treatment of
ier anastomosis is better than a difficult anastomosis to poor lymphomas, large chest wall or pulmonary tumors, and for
quality vessels without a vein graft. recurrent malignancies after previous resections (Chapter 92).
Vein grafts are often necessary for coverage of irradiated Post-radiation complications in this patient population include
scalp defects. Many surgeons prefer to utilize the larger arteries radiation ulcers, infected wounds, persistent or recurrent
and veins in the neck in lieu of smaller vessels near the scalp, tumors, and cardiac and pulmonary disorders. As the thoracic
such as the superficial temporal arteries. While several authors cavity houses a variety of vital organs, radiation damage to
have reported success with the superficial temporal artery, it is the chest wall can create a potentially lethal clinical scenario
generally accepted that the neck vessels are easier to work with requiring immediate attention from the cardiothoracic sur-
and have less chance of causing anastomotic problems. geon as well as the plastic surgeon. These patients are often
The timing of reconstruction relative to the delivery of quite ill, requiring prolonged stays in the intensive care unit
radiation also needs to be considered. Induction radiation and a multidisciplinary team approach.

D
Figure 17.2. A 28-year-old female who received radiation therapy as
a child for treatment of a blood dyscrasia developed basal cell carcinoma
of scalp as an adult. A. Pre-op appearance. B. Tumor was resected and
reconstructed with a free anterolateral thigh flap. Subsequently treated
with local radiation to treat positive margins of sagittal sinus, resulting
in marginal flap necrosis and wound breakdown. C and D. Salvage pro-
cedure performed with parascapular free flap.
C
The first step in evaluating a patient with one of these intrathoracic negative pressure for respiration. The prosthetic
problems is to rule out the presence of new or recurrent material is then covered with a viable soft tissue flap, usually a
tumor. This workup includes standard imaging studies such musculocutaneous flap or a muscle flap with a skin graft. Flaps
as chest radiograph, CT, or MRI, and possibly bronchos- frequently used for chest wall reconstruction include one or
copy. After the extent of tumor involvement is determined, both of the pectoralis major muscles, latissimus dorsi muscles,
it must be completely resected with negative margins before and rectus abdominis muscles, as well as the greater omentum5.
reconstructive options are considered. If tumor is not present, Advantages of the pedicled greater omental flap are its
then the radiation ulcer or infected wound must be thoroughly large surface area and excellent vascularity. Complete debride-
debrided, and all fibrotic radiated tissue and foreign bodies ment of irradiated chest wounds often results in large irregu-
resected. Chronic sinus tracts in the chest wall can often be lar defects, and the omentum tends to cover these defects
traced to a sternal wire, retained suture, or persistent infected nicely since it can be molded into irregular defects quite easily
cartilage. Debridements are often performed serially, as it is (Figure 17.3). In many cases, the omentum with a skin graft
often difficult to judge the extent of remaining nonviable tis- is adequate and underlying foreign bodies in the form of mesh
sue after a single procedure. As often seen in other anatomic can be avoided taking advantage of the chest wall stiffness
areas, the extent of radiation injury exceeds what initially caused by post-radiation fibrosis.
appears to be the boundaries of damaged tissue. The omentum is procured through an upper midline lap-
After resection and debridement is complete, the wound is arotomy incision, mobilized, and usually based on the right
evaluated to determine if it is partial or full thickness. Since gastroepiploic vessels. Skin grafting is generally performed in
the chest wall is a relatively thin structure, most chest wall a delayed fashion after a few days of dressing changes and one
defects following thorough debridement are full thickness and is sure that all of the transposed omentum is viable. This gives
will require chest wall reconstruction prior to soft tissue cov- the plastic surgeon time to observe the omental flap, debride
erage. Chest wall reconstruction is performed by either the any nonviable portions, and re-advance or redistribute the pli-
thoracic surgeon or plastic surgeon experienced in chest wall able omentum as necessary. Disadvantages of the omentum
reconstructions. Prosthetic material, such as Gortex (W.F. are the lack of structural strength. It is simply a vascularized
Gore, Inc., Phoenix, AZ) sheeting or Prolene (Ethicon, Inc., “carrier” for skin graft in this case. There is also the addi-
Sommerville, NJ) mesh, is usually employed for this recon- tion of an upper midline laparotomy and violation of a sec-
struction if the wound permits. The goal is to obtain an air- ond body cavity, but its large size, malleability, vascularity,
tight seal at the time of closure in order to maintain appropriate and acceptable donor defect make it an attractive option. The


A B
Figure 17.3. A 45-year-old woman with bilateral breast cancer and

multiple local recurrences, treated with extensive chest wall radiation,
resulting in left chest wall osteoradionecrosis. A. Pre-op appearance.
B. Osteoradionecrosis resected and reconstructed with pedicled greater
omental flap and skin grafting. C. Note the well-healed flap and skin
graft, surrounded by poor quality tissue with extensive radiation fibrosis.
C
omentum can also be used for lower back closures by tunnel- The aforementioned muscle flaps can also be used to
ing it through the retroperitoneum and paraspinous muscles. reconstruct the vagina, in addition to filling the dependent
Radiated wounds of the chest may involve, in rare circum- pelvic defect. In the male, a musculocutaneous flap can serve
stances, disruption of the aerodigestive tract or the heart with the purpose of obtaining a healed perineal wound and filling
the great vessels. These have been dealt with on some occa- the most dependent portion of the pelvic defect to promote
sions with intrathoracic muscle flaps4. wound healing, prevent evisceration, and attempt to prevent
Because of the abundance of local muscles and the greater adhesions deep in the pelvis.
omentum, free tissue transfer is often not needed for most
chest wall reconstructions. However, the radiated patient may
not have adequate local muscles, and transposition of irra-
Fat Grafting for Treatment
diated muscles can result in partial or total necrosis.6 If the of Radiation Damage
greater omentum is not available, a free tissue transfer may be A fascinating recent development in the treatment of radia-
required in these extreme situations.15 tion damaged tissues is the use of autologous fat grafting
As in the treatment of all radiation wounds, obtaining a (Chapter 44). Plastic surgeons have a long history of using
well-healed chest wall relies on adequate debridement of vascularized fat in one form or another (TRAM flap, omental
nonviable tissue. Only then should chest wall and soft tissue flap, dermal fat graft, etc.) for reconstructive purposes. Several
reconstruction be attempted. authors have reported clinical improvement in radiation dam-
aged tissue following fat grafting. For example, Sultan et al.18
Perineum studied the effects of fat grafting in radiation damaged skin
Gynecologic malignancies occasionally require extensive peri- and concluded that fat grafting attenuated inflammation in
neal resections and/or pelvic exenterations followed by radia- acute radiodermatitis and slowed the progression of fibro-
tion therapy resulting in perineal wounds not amenable to sis in chronic radiodermatitis in a murine model. It has been
primary closure (Chapter 96). Similar perineal defects are cre- hypothesized that clinical improvements seen in radiation-
ated after abdominoperineal resections for anal or low rectal damaged skin treated with autologous fat grafting is related
tumors. A pedicled rectus abdominis musculocutaneous flap is to the adipose-derived stem cells present within the stromal
often the flap of choice. If this is not available, other options vascular fraction of the fat graft. This is a new and exciting
include the use of thigh muscles (rectus femoris and gracilis) area of reconstructive surgery and certainly warrants further
and fasciocutaneous flaps (anterolateral thigh flap). investigation and exploration.
The greater omentum has been used for decades to treat the
chronic vesicovaginal fistula and to fill the severely irradiated
pelvis.16,17 It can also be employed to support a primary closure,
Summary
or if no other options are available it can be used alone with While radiation therapy has many benefits, late changes fol-
a skin graft (although the omentum is sometimes resected by lowing irradiation have been well described and offer the plas-
the extirpative surgeon in cases of gynecologic malignancies). tic surgeon many reconstructive challenges. Each anatomic

location offers unique problems to the plastic surgeon. But 4. Arnold PG, Pairolero PC. Intrathoracic muscle flaps. An account of their use in
the management of 100 consecutive patients. Ann Surg. 1990;211(6):656-660.
the basic tenets of treating irradiated wounds are the same, 5. Arnold PG, Pairolero PC. Chest wall reconstruction: an account of 500 con-
regardless of anatomic location: secutive patients. Plast Reconstr Surg. 1996;98:5.
6. Arnold PG, Lovich SF, Pairolero PC. Muscle flaps in irradiated wounds: an
1. Establish a diagnosis (rule out malignancy and determine account of 100 consecutive cases. Plast Reconstr Surg. 1994;93:324.
the extent of tissue damage). 7. Jones G, Nahai F. Management of complex wounds. Curr Probl Surg.
2. If tumor is present, perform the appropriate workup and 1998;35:194.
treatment. 8. Evans RD, Schusterman MA, Kroll SS, et al. Reconstruction and the radiated
breast: is there a role for implants? Plast Reconstr Surg. 1995;96(5):1111-1115.
3. Thoroughly debride the radiated wound of all nonviable 9. Forman DC, Chiu J, Restifo RJ, et al. Breast reconstruction in previously
tissue and foreign bodies and transfer as much tissue as irradiated patients using tissue expanders and implants: a potentially unfa-
possible to permit resection of even more of the periphery vorable result. Ann Plast Surg. 1998;40:360.
in questionable wounds. 10. Nava MB, Pennati AE, Lozza L, et al. Outcomes of different timings of
radiotherapy in implant-based reconstructions. Plast Reconstr Surg.
4. After adequate debridement has been obtained, usually in 2011;128(2):353-359.
stages, reconstruct osseous defects with vascularized bone 11. McCarthy CM, Pusic AL, Disa J, et al. Unilateral postoperative chest wall
and soft tissue defects with well-vascularized, nonirradiated radiotherapy in bilateral tissue expander/implant reconstruction patients: a
soft tissue. All neurovascular bundles, bone, tendon, and prospective outcomes analysis. Plast Reconstr Surg. 2005;116(6):1642-1647.
12. Hartrampf CR Jr, Bennett GK. Autogenous tissue reconstruction in the mas-
prosthetic material must be covered with healthy soft tissue. tectomy patient: a critical review of 300 patients. Ann Surg. 1987;205:508.
5. In the case of pedicled flaps, it is better to base a flap 13. Tran NV, Evans GR, Kroll SS, et al. Postoperative adjuvant irradiation:
on a nonirradiated pedicle, and in the case of free tissue effects on transverse rectus abdominis muscle flap breast reconstruction.
transfer, it is best to use nonirradiated recipient vessels. Plast Reconstr Surg. 2000;106:313.
14. Spear SL, Ducic I, Low M, Cuoco F. The effect of radiation on pedicled
Consider preoperative evaluation of vessels and anticipate TRAM flap breast reconstruction: outcomes and implications. Plast
the need for vein grafts. Reconstr Surg. 2005;115(1):84-95.
6. Reconstruction of these defects is challenging and fraught 15. Cordeiro PG, Santamaria E, Hidalgo D. The role of microsurgery in
with high complication rates, so always have a “plan B” in reconstruction of oncologic chest wall defects. Plast Reconstr Surg.
2001;108(7):1924-1930.
mind and anticipate complications. 16. Turner-Warwick RT, Wynne EJ, Handley-Ashken M. The use of the omen-
tal pedicle graft in the repair and reconstruction of the urinary tract. Br J
References Surg. 1967;54(10):849-853.
17. Turner-Warwick RT, Chapple C, ed. The value and principles of omen-
1. Evans RD. Radiation effects. In: Achauer B, Eriksson E, Guyuron B, toplasty and omental inter-position. In: Functional Reconstruction of
Coleman J, Russell R, Vander Kolk C., eds. Plastic Surgery: Indications, the Urinary Tract and Gynaeco-Urology: An Exposition of Functional
Operations, and Outcomes. St. Louis, MO: Mosby; 2000:409-423. Principles and Surgical Procedures. Oxford, UK: Blackwell Publishing
2. Ross GM. Induction of cell death by radiotherapy. Endocr Relat Cancer. Company; 2001:155-185.
1999;6:41-44. 18. Sultan SM, Stern CS, Allen RJ Jr, et al. Human fat grafting alleviates radia-
3. Fajardo LF, Berthrong M. Vascular lesions following radiation. Pathol Ann. tion skin damage in a murine model. Plast Reconstr Surg. 2011;128(2):
1988;23:297. 363-372.

Chapter 18 n
Lasers In Plastic
Surgery
David W. Low and Ivona Percec

photons hit other excited electrons, more photons are released
Introduction and the light energy increases (Figure 18.1).
Plastic surgeons recognized the potential benefit of treat- A laser tube has a mirror at each end and contains a solid,
ing vascular lesions with lasers in the 1980s, but it was not liquid, or gas medium within it whose electrons are in a rest-
until the widespread popularity of laser skin resurfacing in ing state. As energy is added to the system, the majority of
the following decade that most plastic surgeons jumped on the electrons become excited (population inversion) and begin
laser surgery bandwagon. Taking advantage of the public’s to release photons. Only those photons that hit the mirrors
fascination with high-technology, laser therapy has been par- directly are reflected back into the lasing medium, creating
tially misrepresented as the “state-of-the-art” treatment for a more and more photons that travel back and forth between
variety of conditions. Often described as painless, and exag- the mirrors, parallel to the tube. Since the photons are in
gerated as producing perfect results, lasers have been misused phase, the intensity of the light increases in the tube. This
as a marketing tool to lure patients away from conventional, phenomenon has been described as light amplification by the
low-tech techniques that can often produce equivalent results stimulated emission of radiation, or the more familiar term
at significantly lower cost. On the other hand, there are some LASER. (In contrast, TASER is an acronym for Thomas A.
conditions such as port wine stains that are best treated by Swift’s Electric Rifle and has nothing to do with light energy.)
laser, and the standard of care demands familiarity with this To allow light to escape from the tube, one of the mirrors is
treatment modality. only partially reflecting. The emitted light is coherent; it is in
The modern plastic surgeon is therefore faced with the phase, parallel, and in most cases monochromatic. In contrast,
dilemma of trying to sort out which lasers are best for which incandescent light is noncoherent, meaning it has many wave-
conditions, which manufacturers’ claims are credible, and, lengths and is not parallel.
ultimately, which lasers are the safest investment in a rapidly Light energy can be visible or invisible depending upon its
changing world of high-tech solutions to a variety of recon- wavelength. The spectrum of electromagnetic radiation ranges
structive and cosmetic problems. from long radio waves (wavelength > 10 cm) to extremely
This chapter provides a basic introduction to laser technol- short gamma rays (<10–11 m). The entire spectrum includes
ogy, laser tissue interactions, and examples of what conditions radio, microwaves, infrared, visible (400 to 700 nm), ultravio-
are appropriate for laser treatment with currently available let, X-ray, and gamma rays.
laser technology. Laser safety is an important consideration
for both the patient and the treating physician, and safety Types of Lasers
issues are discussed at the end of the chapter. The laser tube may contain either a gas, liquid, or solid las-
ing medium (Table 18.1), and new lasers are constantly being
invented and promoted to the medical community. The first
Laser Physics laser, invented in 1960, used a synthetic ruby rod, and other
solid crystal lasers include yttrium aluminum garnet (YAG).
How Laser Light Is Produced The YAG crystal contains neodymium, erbium, or holmium
Criminal masterminds Auric Goldfinger and Dr. Evil were fas-
cinated by amplified light, “a sophisticated heat beam which
we called a ‘laser,’” but fortunately in the 21st century, most
lasers are used instead for therapeutic purposes. Although the
vast array of available lasers can be confusing, laser physics
are straightforward, and only a basic understanding of light
energy is necessary to understand how lasers work. Light
energy can be described as either a series of particles (photons)
or as a wave phenomenon. The color of light is determined by
the distance between two successive waves (the wavelength,
usually measured in nanometers). The human eye can see only
a narrow range of the electromagnetic spectrum (visible light),
and many lasers produce invisible light in the infrared range.
A molecule or atom in its resting state is composed of a
nucleus and circulating electrons. If energy is added to the sys-
tem, the electrons become excited and circulate at a higher
orbit. Eventually, an excited electron will fall back to its rest-
ing orbit, releasing a specific packet of energy—a photon.
That photon has a wavelength specific to that molecule. Some
molecules have more than one excited orbit, and therefore, Stimulated Emission
the light emitted may have more than one wavelength. If a Figure 18.1. Laser physics. A photon is released when an excited
photon collides with an excited electron, that electron falls electron fall returns to its resting orbit. If the photon strikes another
back to its resting orbit, thereby releasing another photon. excited electron, a second photon is released. The stimulated emission
The two photons are in phase, meaning their wave patterns of multiple photons produces light of increasing intensity.
are synchronized and therefore reinforce each other. As these
163
TA B L E 1 8 . 1
Lasers With Plastic Surgery Applications
n Name n Wavelength (NM) n Target Chromophore

Solid Ruby 694 Melanin, tattoo pigment
Neodymium:YAG 1,064 Pigment
KTP 532 Oxyhemoglobin, melanin
Erbium:YAG 2,940 Water
Diode 800 Melanin (oxyhemoglobin)
Alexandrite 755 Melanin, tattoo pigment
Liquid Yellow dye 595 Oxyhemoglobin
Green dye 510 Melanin
Gas Argon 488,514 Oxyhemoglobin, melanin
Helium:neon 633
Carbon dioxide 10,600 Water
Excimer Ultraviolet Breaks chemical bonds
ions, each with its own specific wavelength and tissue interac- Ablative Lasers. Lasers that nonspecifically destroy the tis-
tions. In a dye laser, the medium is a solution of a fluorescent sue can be used to remove skin lesions or remove layers of
dye in a solvent such as methanol. Organic rhodamine dye skin, usually with minimal blood loss because the dermal ves-
is used in the yellow dye laser, and although the earlier dye sels are coagulated as the tissue is vaporized. CO2 laser light is
lasers had adjustable (tunable) wavelengths ranging from yel- absorbed by intracellular water, which vaporizes the tissue as
low to red, currently available dye lasers offer single wave- the water turns to steam.
length light energy. In a helium–neon laser, it is a mixture of
the gases helium and neon. In a diode laser, it is a thin layer Vascular Lesion Lasers. The fact that oxyhemoglobin
of semiconductor material sandwiched between other semi- absorbs green and yellow light has spawned a variety of lasers
conductor layers. Excimer lasers (the name is derived from the appropriate for treating dermal vessels. Historically, the argon
terms excited and dimers) use reactive gases, such as chlorine (blue/green) laser was the first clinically useful laser, but yel-
and fluorine, mixed with inert gases such as argon, krypton, low light has become the preferred color (oxyhemoglobin
and xenon. When electrically stimulated, a pseudomolecule absorption peak at 577 nm yellow light), with the pulsed yel-
(dimer) produces light in the ultraviolet range. low dye laser (intentionally adjusted to 585 and 595 nm for
greater dermal penetration) as the most popular type. The
Laser Tissue Interactions high-energy/short-duration pulse causes vascular disruption as
the blood rapidly heats up and expands. The potassium titanyl
When the laser strikes an object, a variety of desirable and phosphate (KTP) laser (532 nm—green light) also targets oxy-
undesirable effects may result as the light is reflected, scat- hemoglobin, but the pulses are much longer in duration and
tered, transmitted, or absorbed. A series of reflecting mirrors tend to coagulate rather than disrupt vessels. The diode laser
directs CO2 laser light to the handpiece, but reflected CO 2 (800 nm) can also be used for vascular lesions, as the light is
light off of a shiny surgical instrument is hazardous. The risk absorbed by both oxyhemoglobin and melanin.
of inadvertent light reflection can be reduced by using ebon-
ized instruments. The dull finish scatters laser light, diffusing Pigmented Lesion Lasers. Pigmented lesion lasers target
the concentrated energy beam. Glass and clear liquids will melanin. Benign pigmented lesions such as lentigines, café au
transmit some types of laser light, allowing photocoagulation lait spots, melasma, and Nevus of Ota or Ito may improve with
through glass slides, the vitreous of the eye, and water. Some a series of laser treatments. Although congenital nevi will also
lasers will also pass through the epidermis, allowing the energy lighten with laser therapy, this remains controversial; although
to reach dermal vessels and pigment without disrupting the it is unlikely that laser will increase the risk of malignant trans-
epidermal layer. It is the absorbed light that causes desirable formation, it may delay the diagnosis of a changing nevus by
or undesirable biologic effects. Except for the excimer lasers masking the color change associated with a melanoma.
that break chemical bonds, most laser energy is converted
into thermal (heat) energy. Depending upon the rate of tissue Photodynamic Therapy. The use of light-activated drugs
heating, surgical effects include welding, coagulation, protein to treat acne and other skin conditions currently is best rep-
denaturation, dessication, and vaporization. Some lasers will resented by Levulan (topical 5-aminolevulinic acid, DUSA
indiscriminantly target living tissue, while other lasers will pharmaceuticals). The compound is metabolized by sebaceous
semiselectively target a specific chromophore such as oxyhe- glands into porphyrins. The acne bacteria itself also produces
moglobin, melanin, and tattoo pigmentation. Selective pho- porphyrin, and the use of blue, green, or red light stimulates
tothermolysis describes the ability of lasers to target blood the production of oxygen free radicals that destroy the bacteria
vessels or pigment without harming the surrounding epider- and suppress the sebaceous gland activity. Photodynamic ther-
mis or dermis. It is generally safer to deliver cutaneous laser apy has also been used for actinic keratoses, non-melanotic
light in pulses rather than as a continuous beam, as the inter- skin cancer, T-cell lymphoma, and photorejuvenation.1
val between pulses allows the tissue to cool before the heat is
transferred to the surrounding dermis. Pulsed lasers respect Nonlaser Phototherapy. Intense pulsed light (IPL) is
the thermal relaxation time of dermal vessels (the time to dis- not actually laser light. Xenon flashlamps generate multi-
sipate the heat absorbed during a laser pulse). wavelength noncoherent light that is partially modulated

Chapter 18: Lasers in Plastic Surgery 165
by a series of filters. IPL is used for sun-related pigmentary A B
changes, telangiectasias, and hair removal. In radiofrequency
treatment, radio waves are used to heat the collagen of the
dermis and subdermis. It is thought to cause collagen contrac-
tion and stimulation of new collagen production. It has been
promoted as a noninvasive, nonablative treatment for skin
laxity in many areas of the body, including the face. Although
some publicized results are impressive, the ability to consis-
tently achieve such results is far less predictable than surgi-
cal skin tightening. Proper patient selection remains a clinical

challenge.
Figure 18.2. A and B. Ulcerated perineal hemangioma. Pulsed

Specific Laser Treatments dye laser may significantly reduce the pain and facilitate healing of
(Table 18.2) the wound, possibly by coagulation of the nerves and suppression
of the proliferating vessels.
Vascular Lesions
Hemangiomas. Hemangiomas are the most common benign
tumor of infancy, and at least 60% occur in the head and neck iscomfort. Laser treatments are not effective for already bulky
d
region. Although an estimated 70% of hemangiomas regress or subcutaneous hemangiomas, as the light will not penetrate
satisfactorily, 30% of patients still have cosmetically signifi- deeply enough to produce a noticeable improvement.
cant deformities. Parents are eager to seek treatment options Ulcerated hemangiomas can be excruciatingly painful,
on a proactive basis, and the laser is a potentially useful option especially when located in the perineal region. There has
in several settings.2 The pulsed yellow dye laser may be use- been some success with pulsed yellow dye laser treatment of
ful for very early hemangiomas, ulcerated hemangiomas, and these hemangiomas, with some babies showing significant
regressed hemangiomas that still contain vascular pigmentation pain relief within 24 to 48 hours, probably due to coagula-
or visible ectatic vessels. The laser only penetrates about a mil- tion of the sensitive nerve endings within the wound. Faster
limeter into the skin, and therefore, it is most effective for small healing has also been reported, although the mechanism for
flat hemangiomas. Parents should be advised that multiple laser this observation is unclear. Perhaps, the laser induces some
treatments may be necessary every 2 to 4 weeks during the pro- regression of the hemangioma, or wound care is facilitated
liferative phase, as hemangiomas will often exhibit temporary once the area becomes less sensitive, allowing for more rapid
regression followed by rebound growth. Laser therapy can be re-epithelialization (Figure 18.2A, B).
discontinued when the hemangioma finally enters a permanent Lastly, hemangiomas that have regressed well enough to
state of regression. Topical application of anesthetic cream avoid the need for surgical excision may have residual ectatic
may be desirable to reduce both the patient and the parent vessels that will improve with pulsed dye laser therapy. Larger
telangiectasias may also respond to simultaneous sclerother-
apy and laser treatment. Endothelial injury from the scle-
rosant followed by laser photocoagulation of the vessels may
T a bl e 1 8 . 2 have a synergistic benefit in removing these residual vessels.
Clinically Useful Lasers and Other
Phototherapy Devices Capillary Vascular Malformations. Port wine stains
tend to darken with age as the dilated dermal capillaries and
Vascular lesions Yellow dye venules enlarge with time. The involved area may also show
textural changes and soft tissue hypertrophy, and hyperplastic
KTP vascular nodules (pyogenic granulomas) may develop, with
Neodymium:YAG problematic bleeding. The pulsed dye laser (595 nm) is the
treatment of choice.2-4 Children respond better than teenagers
Intense pulsed light
and adults, possibly because the immature vessels are more
Skin resurfacing Carbon dioxide photosensitive, and treatment can be offered beginning in
Erbium:YAG
infancy (Figure 18.3). Parents should be advised that multiple
(at least six to eight) treatments are recommended for cumu-
Radiofrequency lative benefit, and that it is extremely rare for any capillary
Benign lesions, pigmented Intense pulsed light vascular malformation to completely disappear. Associated
bruising from the laser lasts for about 2 weeks, and gradual
Diode lightening of the vascular pigmentation may continue for at
Ruby least 2 months. Patients can be treated every 2 to 3 months.
Although topical anesthetic cream can be very useful on the
Benign lesions, cutaneous Carbon dioxide trunk and extremities and for small areas of the face, most
Hair removal Alexandrite children with large facial port wine stains will be better treated
under a general anesthetic. Metal eye shields are available for
Diode periorbital laser therapy, and placement of the shield directly
Neodymium:YAG on the globe permits laser treatment of the eyelid skin. The
eyelashes can be shielded by strategic placement of the wrap-
Ruby
per of an alcohol wipe, to avoid undesirable singeing of the
Intense pulsed light hairs. Eyebrows will also singe if lased, but the light does not
penetrate deeply enough to cause permanent suppression of
Tattoo removal Ruby
hair growth.
Alexandrite
Neodymium:YAG Venous Malformations. Venous malformations consist
of dilated clusters of varicose veins, and treatment options

absorbed laser energy may cause a desirable fibrosis of the der-

mis at the site of leaking lymphatic cisterns, in a sense “capping
the well.” The treatment is palliative rather than curative, but
can be easily repeated for unresectable lesions.
Venolymphatic Malformations. Similar to lymphatic

malformations, but associated with an additional venous com-
ponent, the cutaneous component may present as tiny purple
vesicles or crusting scabs (angiokeratomas). This is commonly
seen in Klippel–Trenaunay syndrome (patchy capillary mal-
formation with an underlying venolymphatic malformation
and hypertrophy of the involved extremity). The vesicles tend
to be more responsive to coagulation by a continuous laser
rather than a pulsed laser; therefore, the KTP laser is more
effective than the pulsed yellow dye laser. Crusting lesions
can be tangentially shaved, then compressed with a glass slide
to control bleeding while being lased. Long-standing large
crusted lesions may be more efficiently excised and oversewn.
Since the cutaneous lesions overlie a much more extensive
subcutaneous component, treatment is purely palliative, and
Figure 18.3. Port wine stain. The pulsed yellow dye laser remains reoccurrence is to be expected.
the laser of choice for pediatric capillary vascular malformations
(port wine stains). Multiple treatments are necessary to progressively Telangiectasias/Rosacea. Commonly called “broken
lighten the vascular pigmentation, and the laser is unlikely to com- blood vessels” by the lay public, telangiectasias represent undu-
pletely remove the stain. lating dilated dermal vessels that course through the dermal
layer. They appear discontinuous because they are visible near
the surface, and then disappear as they dive into the deeper der-
include laser photocoagulation, sclerotherapy, and surgical mis. Associated with accumulated UV damage or rosacea, they
debulking. Small superficial veins may improve with pulsed respond to a variety of vascular lesion lasers. Smaller telangiec-
dye laser therapy, but usually the energy pulse is too brief tasias also respond to IPL therapy. Multiple treatment sessions
and the vessels are too large to show significant benefit. are necessary for optimal results, and adult patients should be
Longer energy delivery with a continuous wave laser such as aware of the significant prolonged bruising (2 to 3 weeks) that
the KTP or neodymium:YAG laser can result in significant can be associated with certain lasers and laser settings.
heat absorption and vascular destruction, with a significant
shrinkage in the size of the malformation.5,6 In this setting,
Pyogenic Granulomas. Pyogenic granulomas are shiny
nodules of proliferative vascular tissue covered by a fragile
although the target chromophore is still oxyhemoglobin, the
epidermal layer (lobular capillary hemangioma) that have
prolonged energy delivery probably achieves its effect by non-
an annoying propensity to bleed when ulcerated. Commonly
specific heat delivery to all tissues in the area, and the risk
occurring in children and in pregnant women, they can occur
of post-laser scarring is higher. For this reason, the lips and
at any age and may be the result of minor trauma. Although
oral mucosa are more forgiving areas when one uses continu-
surgical excision is curative, tangential shave excision fol-
ous laser energy. For other areas of the body, or if the physi-
lowed by laser photocoagulation of the dermal base will often
cian wants to avoid excessive energy delivery to the surface
leave an imperceptible scar. A glass slide can be used to com-
layer, the fiberoptic tip can be passed intralesionally for deep
press the bleeding base, and a continuous laser such as the
coagulation. With the KTP laser, the glass tip can be placed
KTP laser will pass through the glass and coagulate the resid-
directly on the mucosa, and a brief pulse will create a small
ual proliferative lesion (Figure 18.4A, B). Although the pulsed
hole through which the laser can be passed transmucosally to
dye laser alone has been reported as a treatment option, mul-
the heart of the malformation. In other areas, a large gauge
tiple laser sessions may be necessary for large lesions, and no
hypodermic needle can be used to penetrate and protect the
specimen is available for pathologic confirmation.
skin while passing the laser fiber. The physician must under-
stand that this technique is highly operator dependent and Spider Angiomas These superficial vascular lesions are char-
somewhat blind. A high level of concentration is necessary acterized by a central feeding arteriole and radiating branches.
with constant verification of the location of the tip of the fiber Compression of the skin will blanch the lesion, which will then
by palpation or transillumination of the light, to decrease the readily reappear at the center and expand outward after the pres-
risk of thermal injury to the dermis or perforation of the over- sure is released. Although small angiomas can be successfully
lying intact skin. treated by destroying the central feeding vessel by electric cau-
Large venous malformations can be debulked by stan- tery, long-standing angiomas often will have a persistent periph-
dard surgical techniques or by using the fiber of a KTP or eral blush. The pulsed yellow dye laser is an excellent way to
neodymium:YAG laser as a contact tip laser scalpel. coagulate the entire lesion. The central feeding vessel may require
Endovenous laser photocoagulation with the assistance of a series of stacked pulses to destroy it, and it should appear black
ultrasonic guidance is now a therapeutic option for cosmetic at the end of the treatment session. Patients should be aware that
varicose veins as well as congenital venous malformations, reoccurrence may require more than one treatment.
usually performed by interventional radiologists and vascular
surgeons.7 Cherry Angiomas. Also known as senile angiomas, these
superficial macular or papular cherry-colored nodules are
Lymphatic Malformations. Cutaneous vesicles resembling commonly seen on adult skin. They may range in size from
tiny water blisters represent the dermal component of a lym- punctuate lesions to several millimeters. Any of the vascular
phatic malformation, which is usually associated with a more lesion lasers can be used to destroy them.
extensive subcutaneous component. Problematic lymphatic
oozing from ulcerated vesicles can be palliatively treated with Spider Veins/Vricose Veins. Dilated leg spider veins may
the CO2 laser, which is absorbed by water. The heat of the respond to a variety of lasers, but it is usually most efficient


A B
Figure 18.4. A and B. Pyogenic granuloma. A biopsy is taken prior to laser photocoagulation of the residual dermal proliferating vessels. The
KTP laser light will pass through the glass slide, which is used to compress the bleeding vessels. Note the protective laser eyeshield.
to remove the larger varicose veins first. Traditionally, a vari- and effective in improving the skin surface contour. The heat
cose greater saphenous vein is best treated by stripping and of the laser coagulates the exposed dermis, making the proce-
ligation, while other varicose veins and large spider veins will dure virtually bloodless, in contrast to dermabrasion or shave
respond to sclerotherapy. Endovenous laser therapy using excision. Retreatment for recurrent nodules is common and
a 810 nm diode laser with a bare fiber has become a viable easily repeated (Figure 18.5A, B).
treatment alternative.7
Pulsed dye laser (595 nm) or diode laser (800 nm) light will Pigmented Lesions. Melanin absorbs light in the ultraviolet
penetrate into the deep dermis to treat residual spider veins as to near infrared range; therefore, a wide variety of lasers have
well as the peripheral blush that is often seen after sclerosis of been used to target benign melanocytic lesions. Blue, green, red,
the larger vessels. Laser treatment requires photocoagulation and infrared wavelengths have been used. Although histori-
along the entire course of the vessel for best results, which is cally continuous wave lasers such as argon were initially useful,
why patients with extensive spider veins may be more effi- pulsed lasers are safer and less likely to cause scarring. Shorter
ciently treated initially by sclerotherapy. wavelengths will treat epidermal pigmentation, while lon-
ger wavelengths are more effective for dermal pigmentation.7
Adenoma Sebaceum/Tuberous Sclerosis. Patients with Epidermal lesions such as freckles (ephelides), solar lentigines,
tuberous sclerosis will develop firm pink nodules in a butterfly and labial melanocytic macules may respond to green pulsed
pattern across their cheeks and nose, with additional involve- dye (510 nm), KTP, also known as a frequency-doubled YAG
ment of their chins and foreheads. Neither adenomatous nor laser (532 nm), while deeper dermal pigmented lesions such as
sebaceous, these lesions are more a ccurately angiofibromas. café au lait spots, nevus of Ota (melanocytic pigmentation in the
Although theoretically photocoagulation with a vascular V1 and V2 distribution), and nevus of Ito (shoulder or upper
lesion laser should improve these dermal lesions, vaporization arm distribution) may respond to longer wavelength ruby (694
with a defocused CO2 laser appears to be much more efficient nm), alexandrite (755 nm), and diode (800 nm) lasers.
A B
Figure 18.5. A and B. Tuberous sclerosis. The CO2 laser readily vaporizes the raised angiofibromas and coagulates the dermal vessels.
Treatment is purely palliative, but results tend to be better than pulsed dye laser therapy.

A
Skin Lesions
Neurofibromatosis. Large plexiform neurofibromas
should be excised or debulked by standard surgical tech-
niques, but patients who request removal of hundreds of small
neurofibromas may be well served by CO2 laser destruction or
excision. The laser in a slightly defocused mode can vaporize B
and coagulate small neurofibromas. Large sessile or pedun-
culated neurofibromas can be readily excised with minimal
bleeding by vaporizing a ring of skin around the base of the
lesions with a focused beam, then amputating the subcutane-
ous tumor with a defocused beam to achieve better coagu-
lation. Small excision sites can be left to heal spontaneously,
while larger wounds can be loosely closed with a couple of
monofilament sutures. Patients should be reminded that the
treatment is palliative.
Syringomas/Cylindromas. Syringomas are benign tumors

of eccrine origin, most commonly found in the periorbital Figure 18.6. A and B. Rhinophyma. The ultrapulse CO2 laser with
area. CO2 laser vaporization results in rapid obliteration of a 3 mm handpiece vaporizes hypertrophic sebaceous glands and thick
these lesions, often without recurrence. Cylindromas are nod- dermis in a hemostatic and controlled fashion to achieve significant
ular dermal benign tumors thought to be of primitive sweat contour improvement. Re-epithelialization takes place over several
gland origin, an autosomal dominant inheritance pattern asso- weeks.
ciated with multiple cylindromas. Large disfiguring nodules
involving the face and scalp (so-called turban tumor) can be
excised or vaporized with the CO2 laser to reduce associated
operative blood loss. The procedure is only palliative. CO2 laser with minimal bleeding. The end result is superior to
shave excision and skin grafting (Figure 18.6A, B).
Actinic Keratosis. Patients with extensive actinic changes of
their facial skin or lower lip are candidates for laser skin resur- Epidermal Nevi. Epidermal nevi, while possessing no sig-
facing. This may be better tolerated than topical 5-fluorouracil nificant malignant risk, can cause severe disfigurement as the
therapy or a surgical lower lip vermilion shave. The CO2 nevi thicken and create a verrucous surface texture. Palliative
laser can readily vaporize the epidermis and papillary dermis, options include tangential shave excision, dermabrasion, and
allowing the regeneration of healthier skin. The laser will also full thickness excision, but CO2 laser vaporization may pro-
readily vaporize the vermilion of the lower lip, which heals vide a fast and clean way to improve the surface texture with
remarkably well in 2 to 3 weeks. Although painful until the minimal bleeding. For relatively thin but raised epidermal
vermilion mucosa regenerates, it avoids the need for a muco- nevi, the laser appears to vaporize the nevus along a clean and
sal advancement flap. consistent dermal plane. Thicker nevi may require multiple
laser passes, and extensively verrucous lesions seem to lack
Verruca Vulgaris. Wart removal is associated with a long list a clear cleavage plane with less satisfying surface uniformity.
of treatment modalities with variable rates of success, and most Wounds are covered with topical antibiotic ointment and are
surgical strategies involve reduction of the viral burden by exci- left to re-epithelialize. Patients must understand that this treat-
sion or destruction of the affected skin. The CO2 laser has been ment is usually not curative and future treatment sessions may
most commonly used to vaporize the involved area, particularly be desirable for recurrent skin thickening.
when there are multiple lesions that may make surgical exci-
sion difficult or undesirable. To reduce the risk of viral trans- Lentigines. Benign pigmented lesions associated with
mission to medical personnel, it is advisable to sharply excise sun exposure and freckles will respond to a wide range of
the bulk of the lesion, and then vaporize the base. A viral (N95) wavelengths. Green light lasers (510 nm pulsed dye, 532 KTP
mask for all participants (including the patient) and the use of laser), diode lasers (800 nm), and nonlaser IPL will lighten
a plume evacuator are mandatory to minimize the possibility of melanocytic pigmentation. These lasers will also lighten mela-
inoculation of the bronchial tree. For small warts, some success nocytic nevi, and clinical discretion must always be exercised
has also been associated with the pulsed dye laser. Presumably, when deciding which lesions can be safely treated and which
energy delivery to the dermis layer either sterilizes it or makes deserve biopsy prior to laser treatment.
the local environment inhospitable for the wart virus.
Hair Removal. The basic principle of laser hair removal is
Sebaceous Nevi (Nevus Sebaceus of Jadassohn) and to use light energy to destroy the hair root for permanent hair
Rhinophyma. This congenital nevus is most commonly reduction.8 This requires a deeply penetrating wavelength that
excised when it is located in the hair-bearing scalp because must reach the dermal papilla without adversely destroying
of the 15% risk of basal cell transformation in adulthood. the surrounding dermis. Most hair removal lasers target mela-
Additionally, the nevus is characteristically non-hairbearing, nin, and deeply penetrating lasers such as the diode (800 nm),
and it may become more cosmetically annoying during puberty alexandrite (755 nm), and YAG (1,064 nm) lasers are most
with stimulation of the sebaceous glands. However, sebaceous effective on patients with dark hair and fair skin. Patients
nevi on the face may leave a cosmetically disfiguring scar if with light or grey hair are poor candidates for these lasers,
excised. Superficial laser vaporization with the CO2 laser may even with efforts to darken the hairs with carbon particles.
offer surface textural improvement. More recently, the use of IPL with its range of wavelengths (510 to 1,200 nm) has been
photodynamic therapy with Levulan (topical 5-aminolevulinic promoted as a useful method of hair reduction for patients
acid) and laser activation has been shown to suppress sebaceous with fair hair.
gland activity in acne and may have applicability in suppression Patients should be advised that multiple treatment sessions
of sebaceous nevi. Rhinophyma, characterized by hypertrophic are the routine and that hair removal is not necessarily per-
sebaceous glands and marked thickening and distortion of the manent. Hair reduction and delayed hair regrowth are more
dermis layer of the nose, can be effectively vaporized with the realistic goals than complete hair removal.

Tattoo Removal. Tattoos are created by pigment or foreign omenclature and company branding efforts, it is best to cate-
n
matter that is imbedded in the dermis layer of the skin, inten- gorize these lasers by their differential effects on tissue, specifi-
tionally in the case of decorative tattoos, therapeutically in cally as ablative versus nonablative and fractional versus non-
the case of radiation marking or nipple/areola reconstruction, fractional. Ablative lasers (CO2 and erbium:YAG), which until
and traumatically in the case of road rash. Historically, the recently were the standard of care, are those that vaporize the
tattoos have been removed by abrasion of the skin, until the epidermis during treatment, when compared with nonabla-
deepest pigment has been removed. This routinely leaves tive lasers that do not vaporize the skin and require epidermal
shiny, atrophic scars at best, and hypertrophic or keloid cooling. Nonablative lasers (e.g., Nd:YAG) are generally safer
scars in unfavorable areas. The CO2 laser is simply a high- but less efficacious that ablative lasers, requiring multiple
tech method of dermabrasion and offers little advantage over treatments to achieve a less robust result than ablative lasers.

mechanical dermabrasion. The advent of Q-switched ruby, Fractional lasers treat the tissue with numerous microscopic
YAG, and Alexandrite lasers offers the possibility of tattoo patterned beams leaving a cuff of untreated tissue between the
removal without clinically apparent scarring.9,10 Pigment gran- treated sites, permitting faster re-epithelialization from islands
ules are fragmented into smaller particles that are then phago- of undamaged tissue. This is in contrast to non-fractional
cytized by macrophages. lasers that treat the entire targeted tissue with a continuous
Black ink is the most common color in tattoos, followed beam. The fractional beam technology can be applied to lasers
by blue, green, red, yellow, and orange. Additional colors of different wavelengths and therefore fractional lasers can
such as pink, brown, purple, and fluorescent colors make be ablative or nonablative in nature. The rapid evolution of
tattoo removal by a single laser more difficult, as a particu- new lasers over the past decade, especially the nonablative and
lar color may reflect rather than absorb the laser light. For fractional classes, is largely in response to an effort to decrease
example, red tattoos will reflect ruby laser light (694 nm) but the recovery time and complications from traditional lasers
will absorb wavelengths below 575 nm. The Q-switched YAG (ablative non-fractional).11
laser (1,064 nm) has a frequency-doubling KTP crystal, which
emits green light at 532 nm, thereby making it effective for Ablative Non-fractional Thermolysis. The ablative
red tattoos. CO2 and erbium:YAG lasers were the first to be used for cos-
Black and blue ink is well absorbed at all wavelengths and metic laser skin resurfacing for the signs of photoaging and
is effectively treated by the ruby, the YAG, and the Alexandrite remain the main players in classic laser resurfacing. Both
laser. The Alexandrite laser is also good for green pigment. lasers are used in multiple passes, with each pass removing
The 510 nm flashlamp-pulsed dye laser was originally devel- a controlled depth of skin, namely, the epidermis, followed
oped to treat melanocytic lesions, but the short pulse width by the papillary dermis and in certain situations, a portion of
(300 ns) has the capability to fragment pigment granules and the reticular dermis. The treatment stimulates the formation
is effective for red, purple, orange, and yellow pigments. of new and rejuvenated skin layers, as well as new collagen
Patients should be advised that multiple treatment ses- formation and collagen contraction resulting in improvement
sions are necessary, scarring may occur, colors may not of rhytids, skin laxity, and irregularity and hyperpigmenta-
lighten sufficiently, and some colors that contain iron oxide tion. In the appropriate patient, this treatment is extremely
pigments (such as flesh tones) may paradoxically darken to effective; however, it is not a substitute for rhytidectomy. One
black as a result of the extreme temperatures generated by advantage to laser skin resurfacing over dermabrasion or
the Q-switched lasers. Additionally, gunpowder tattoos may deep chemical peels is that the treatment is almost blood-free,
ignite when subjected to the extremely high temperatures of because the heat of the laser coagulates the dermal vessels.
the Q-switched lasers, resulting in thermal burns. This permits accurate visualization of the depth of penetra-
Recently, topical application of imiquimod cream, FDA tion from the pink papillary dermis to the yellow “chamois”
(Food and Drug Administration) approved in 1997 to treat reticular dermis, which is the typical endpoint of therapy.
premalignant and malignant skin cancers such as actinic kera- Furthermore, the laser hand piece may offer more uniform
tosis, Bowen’s disease, and basal cell skin cancer, as well as skin ablation compared with a dermabrasion burr or topically
genital warts, has been shown to lighten tattoos. A combina- applied acid.
tion of imiquimod and laser treatments has shown a synergis- In preparation for ablative non-fractional thermoly-
tic benefit in the removal of tattoo pigmentation. sis, pre-treatment with 1 month of topical retinoic acid and
hydroquinone is commonly prescribed to promote faster re-
Cosmetic Indications. Though the laser was initially epithelialization and to avoid post-laser hyperpigmentation,
embraced by plastic surgeons for reconstructive purposes, the respectively. When treating the perioral area, antiviral medica-
use of laser technology for cosmetic indications has become tions are recommended as prophylaxis against the herpes infec-
increasingly frequent over the last two decades. The ideal tions that can cause significant scarring. Patients should be
nonsurgical treatment method for aesthetic indications is advised that complete wrinkle removal is not possible and that
dependent on each patient’s skin type, goals, recovery time laser skin resurfacing is not a substitute for surgery. Moderate
priorities, threshold for complications, and aesthetic expecta- wrinkle effacement with improvement in hyperpigmentation
tions. Equally important is the consideration of the surgeon’s is a realistic goal with this treatment. The erbium:YAG laser
experience and familiarity with a particular laser modality. light has a greater affinity for water than CO2, and therefore,
The ideal treatment modality induces an improvement in the the depth of penetration is more shallow than the CO2 laser.
appearance of the skin with minimal skin injury. The most Despite faster healing and a decreased risk of prolonged ery-
common indication for aesthetic laser application is the treat- thema, the results with the erbium:YAG laser are generally
ment of the signs of photoaging, such as wrinkles, dyspig- less robust because of the reduced tissue penetration. More
mentation, elastosis, increased vascularity, and precancerous aggressive use of the erbium:YAG laser with longer pulses can
lesions such as actinic keratoses. Less frequent are the requests achieve results comparable to the CO2 laser. Potential com-
for the treatment of acne and surgical scars, contour abnor- plications include infection, scarring, hypopigmentation, pro-
malities, and striae. Although dermabrasion and chemical longed erythema, ectropion, and unpredictable alterations in
peels can achieve similar results at significantly lower cost, skin tone and texture. Ablative non-fractional thermolysis is
the public’s fascination with high-tech therapy has created contraindicated in actively infected skin, recent (<12 months)
a high demand for lasers and equally high expectations of history of isotretinoin/acitretin use, darker Fitzpatrick skin
wrinkle ablation, pigment correction, and skin tightening. types, and history of keloids. Finally, this treatment should be
Currently, there is a plethora of laser technologies available limited to the facial skin and not be used on the thinner skin of
for aesthetic applications. Due to the confusing nature of laser the neck, chest, or hands.12

A B C
Figure 18.7. Laser skin resurfacing. Treatment of perioral wrinkles and dyspigmentation with fractional CO2 laser. A. Pretreatment.
B. Immediately after treatment with punctate bleeding from MTZs. C. Two weeks post treatment.
Fractional Ablative Photothermolysis. Fractional ther- on the treatment parameters, up to 95% of the treated area
molysis was introduced in 2003 as a new technology that may remain undamaged. Because each MTZ is surrounded by
attempts to maintain the efficacy of non-fractional lasers undamaged tissue, there is rapid repopulation and collagen
while decreasing recovery time and risk profile. Though frac- remodeling of the treated area resulting in markedly faster
tional technology was initially applied to nonablative lasers, healing. Fractional ablative lasers have been used successfully
its most successful application to date has been in ablative for aesthetic indications, including the treatment of photoag-
lasers (CO2 and erbium:YAG). In fractional ablative lasers, ing (fine and moderate rhytids, skin irregularity, and laxity),
the laser beam is divided into thousands of microscopic col- melasma, dyschromias, and acne-induced and other types of
umns that deliver energy to the treated area as thousands of scars (Figure 18.8). The safety profile of fractional ablative
ablative microthermal treatment zones (MTZs), avoiding con- lasers is much improved over traditional ablative lasers, with
fluent ablative epidermal damage (Figure 18.7). Depending lower risks of scarring, hypopigmentation, and infections.
A B C
Figure 18.8. Laser skin resurfacing.

Treatment of facial rhytids and dyspigmen-
tation with fractional CO2 laser. A and C.
Pretreatment. D. Immediately after treat-
ment. B and E. Six weeks post treatment.
Note the improvement of solar lentigines and
softening of periorbital wrinkles.
D E

Consequently, fractional ablative lasers can be used in (585 and 595 nm), IPL devices (515 to 1,200 nm), Nd:YAG
patients with higher Fitzpatrick skin types and applied to lasers (1,064 nm Q-switched, 1,064 nm long-pulse, 1,319, and
areas such as the neck, chest, back, and extremities, cases in 1,320 nm), diode lasers (980 and 1,450 nm), and Er:glass laser
which traditional ablative lasers were not recommended. One (1,540 nm). The mid-infrared devices, including 1,320, 1,450,
should not presume fractional laser technologies are risk-free. and 1,540 nm lasers, seem to be the most effective for wrinkle
Though much less common, there are reports of complica- and acne scar reduction. Red color and vascular lesions are
tions, including prolonged erythema, dermatitis, purpura, best treated by hemoglobin-selective devices, such as the KTP,
infection, pigment alterations, and scarring after fractional pulsed dye, and long-pulsed Nd:YAG lasers. Though the KTP
treatments.13 Most fractional ablative laser treatments can has efficacy for pigmentation as does the Q-switched Nd:YAG
now be conducted in the office setting with topical anesthetic laser, the IPL devices, by virtue of their broad emission spec-

creams in combination with oral sedatives. Depending on the trum, appear to be the most effective for simultaneous treat-
treatment parameters, patients should expect a downtime of ment of both red and brown lesions.
1 to 7 days with erythema and swelling typically lasting 1
to 4 days and crusting up to 7 days on non-facial skin. As Fractional Nonablative Photothermolysis. Fractional
with traditional ablative treatments of the perioral area, pro- nonablative lasers first became available in 2003. As discussed
phylaxis against herpes infection with perioperative antiviral above, the fractional technology separates the laser beams
medication is recommended to prevent potentially significant into thousands of columns producing an array of MTZs,
scarring.14 permitting faster healing at the cost of a less vigorous effect.
A large number of branded fractional ablative lasers (CO2 There are an ever increasing number of fractional nonablative
and erbium:YAG) have become available in recent years. devices on the market based on the Nd:YAG, Er:glass, infra-
Though a thorough discussion on the specifics of each type of red, erbium fiber, and radiofrequency wavelengths. The public
laser is beyond the scope of this chapter, it will suffice to say quickly embraced this class of lasers mostly due to decreased
that patient selection remains key. Additionally, because of the downtime. Fractional nonablative lasers have the same indica-
multiple subtleties in fractional technology, a thorough under- tions as non-fractional nonablative lasers. These devices have
standing of the nuances of laser settings, including pulse energy, been used successfully to treat mild photoaging (dyschromias,
density, number of passes, and number of treatments for each elastosis, and fine rhytids) on the face, neck, chest, back and
clinical and anatomical application, as well as appropriate extremities, melasma, acne and other scarring, telangiectasias,
device selection, is critical for safe and efficacious treatment. As and other superficial vascular lesions. Multiple treatments
with non-fractional CO2 and erbium:YAG lasers, the fractional are typically required to achieve a significant result. Because
CO2 lasers have been found to produce more robust effects newer fractional ablative lasers have been shown to be more
and higher patient satisfaction than the fractional erbium:YAG effective in treating photoaging and scarring than fractional
lasers, albeit with a slightly longer recovery time.15 nonablative lasers, the latter are best suited to the treatment
of chromophore-specific targets such as dyschromias and
Nonablative Non-fractional Photothermolysis. In vascular lesions.
contrast to ablative laser rejuvenation procedures, nonabla-
tive non-fractional laser rejuvenation procedures induce a der-
mal healing response via delivery of heat without ablation, or
Laser Safety
injury to the epidermis. Consequently, the nonablative non- All surgical lasers are considered to be class IV devices: high-
fractional category of lasers is considered safer than ablative power lasers that are hazardous to view under any conditions
lasers, though also less efficacious. The exact mechanisms (directly or diffusely scattered) and are a potential fire and
of nonablative dermal remodeling have yet to be completely skin hazard.17 The American National Standards Institute
understood. It is hypothesized that nonablative lasers exert requires the laser key to be stored separately from the laser to
their effect via injury to the dermis and/or the dermal vascu- prevent unauthorized use.
lature resulting in a wound repair response, fibroblast stimu- Patients and all personnel present must wear wavelength-
lation, and collagen reformation. Nonablative treatments, specific safety goggles. There should be a limited number of
while desirable due to higher safety profile and easier patient entrances to the laser suite, each marked clearly with a laser
recovery, have yet to replace classic ablative resurfacing tech- warning sign. An extra pair of safety goggles should be left
niques or standard surgical procedures for facial rejuvenation. outside the door in areas of high traffic such as an operating
Nonablative resurfacing techniques are best suited for patients room. If one is treating around the eyes, corneal eye shields
who only require modest rejuvenation of the aging face, as the are necessary. The patient should be further protected with
improvements in fine lines, wrinkles, and dyschromias pro- wet drapes or crumpled aluminum foil (to reduce the risk of
duced by nonablative lasers are subtle and gradual. Because reflected laser light) when using the carbon dioxide laser. A
the epidermis remains grossly intact with nonablative laser laser-safe endotracheal tube should be used when using a laser
treatments, these lasers can be used for more delicate proce- in or around the oral cavity. The lowest possible FiO2 should
dures such as periorbital, neck and chest rejuvenation, as well be administered to decrease the risk of an inhalation or flash
as for the treatment of superficial acne scars and other types of burn. Exhaled oxygen can ignite singed nasal or lip hairs when
scarring. Nonablative lasers can also be quite effective for the using the carbon dioxide, pulsed yellow dye, or hair removal
treatment of solar lentigines, rosacea, telangiectasias, or spider lasers in the setting of enriched oxygen delivery.
angiomata. Most patients require two to three treatments Lasers that create significant laser plume, such as the car-
for sufficient improvement. Patients with moderate-to-severe bon dioxide laser, should be used with a plume evacuator to
rhytids or photodamage are poor candidates for nonab- prevent potential transmission of live virus particles into the
lative resurfacing and will benefit most from surgical or airway of treating personnel. When treating warts, an N95
ablative skin resurfacing procedures. Nevertheless, nonabla- mask or respirator is also highly recommended in addition to
tive non-fractional lasers may provide a reasonable compro- the plume evacuator, and the potential viral contamination
mise for the patients who cannot tolerate the downtime of can be reduced by shaving the bulk of the wart prior to laser
more aggressive procedures and are not satisfied with the min- vaporization of the base. Lastly, the use of an expensive laser
imal improvements achieved via superficial chemical peels or to treat conditions outside its capabilities or exaggeration or
microdermabrasion.16 falsification of the treatment outcome for monetary gain is
There are numerous nonablative non-fractional lasers unethical and medicolegally dangerous. Patients should have a
on the market. Some of the more commonly used lasers in realistic understanding of the expected results and the risk of
this category are the KTP laser (532 nm), pulsed dye laser treatment, as well as other treatment options.

8. Gold MH. Lasers and light sources for the removal of unwanted hair. Clin
References Dermatol. 2007;25(5):443-453.
9. Burris K, Kim K. Tattoo removal. Clin Dermatol. 2007;25(4):388-392.
1. MacCormack MA. Photodynamic therapy in dermatology: an update on
10. Bernstein EF, Bhawalkar J, Clifford J, Hsia J. Treatment of tattoos with
applications and outcomes. Semin Cutan Med Surg. 2008;27(1):52-62.
a 755-nm Q-switched alexandrite laser and novel 1064 nm and 532 nm
2. Burns AJ, Navarro JA. Role of laser therapy in pediatric patients. Plast Nd:YAG laser handpieces pumped by the alexandrite treatment beam.
Reconstr Surg. 2009;124(1 Suppl):82e-92e. J Drugs Dermatol. 2010;9(11):1333-1339.
3. Hennidige AA, Quaba AA, Al-Nakib K. Sturge-Weber and dermato- 11. Alexiades-Armenakas MR, Dover JS, Arndt KA. The spectrum of laser skin
mal facial port-wine stains: incidence, association with glaucoma, and resurfacing: nonablative, fractional, and ablative laser resurfacing. J Am
pulsed tunable dye laser treatment effectiveness. Plast Reconstr Surg. Acad Dermatol. 2008;58(5):719-737.
2008;121(4):1173-1180. 12. Brightman LA, Brauer JA, Anolik R, et al. Abative and fractional ablative
4. McGill DJ, MacLarren W, Mackay IR. A direct comparison of pulsed dye, lasers. Dermatol Clin. 2009;27:479-489.
alexandrite, KTP and Nd:YAG lasers and IPL in patients with previously 13. Metelitsa AI, Alster TS. Fractionated laser skin resurfacing treatment com-
treated capillary malformations. Lasers Surg Med. 2008;40(6):390-398. plications: a review. Dermatol Surg. 2010;36:299-306.
5. Low DW. Management of adult facial vascular anomalies. Facial Plast Surg. 14. Tierney EP, Kouba DJ, Hanke CW. Review of fractional thermolysis: treat-
2003;19(1):113-130. ment indications and efficacy. Dermatol Surg. 2009;35:1445-1461.
6. Miyazaki H, Kato J, Watanabe H, et al. Intralesional laser treatment of 15. Cohen SR, Henssler C, Johnston J. Fractional thermolysis for skin rejuvena-
voluminous vascular lesions in the oral cavity. Oral Surg Oral Med Oral tion. Plast Reconstr Surg. 2009;124(1):281-290.
Pathol Oral Radiol Endod. 2009;107(2):164-172. 16. Tierney EP, Hanke CW.: Recent advances in combination treatments for
7. Sharif MA, Lau LL, Lee B, Hannon RJ, Soong CV. Role of endovenous laser photoaging: review of the literature. Dermatol Surg. 2010;36:829-840.
treatment in the management of chronic venous insufficiency. Ann Vasc 17. Houck PM. Comparison of operating room lasers: uses, hazards, guidelines.
Surg. 2007;21(5):551-555. Nurs Clin North Am. 2006;41(2):193-218, vi.

part III
n Congenital Anomalies and Pediatric Plastic Surgery
Chapter 19 n Cleft Lip and Palate:

Embryology, Principles,
and Treatment
Congenital Anomalies and

Pediatric Plastic Surgery
Richard A. Hopper
Cleft lip and palate are the most common congenital cranio- pharyngeal constrictors have similar innervation. The tensor
facial anomalies. Successful treatment requires technical skill, veli palatini alone, as a derivative of the first arch, is inner-
knowledge of the abnormal anatomy, and appreciation of vated by the trigeminal nerve (cranial nerve V).
three-dimensional facial aesthetics. Cleft care requires a col- The first branchial arch and the mesenchyme ventral to
laborative multidisciplinary team. Through self-scrutiny, hon- the developing forebrain are responsible for the three named
est evaluation of the results, and a great deal of imagination, prominences that give rise to the face, mouth, neck, larynx,
plastic surgeons continue to advance cleft care. pharynx, and nasal cavities (Figure 19.1). The first bran-
chial arch contributes the paired maxillary and mandibular
prominences, which fuse to form the lateral and caudal com-
Embryology ponents of the primitive stomodeum or mouth. A central pro-
cess formed by the proliferation of mesenchyme ventral to the
Developmental Biology forebrain creates the frontonasal prominence (FNP), which
An understanding of head and neck embryology is helpful forms the cranial portion of the stomodeum. It is important to
in the appreciation of the wide spectrum of the cleft lip and note that the FNP and its derivatives are not formed by bran-
palate phenotype. The cranial portion of the human embryo chial arches, but rather originate from distinct mesenchyme
develops early, with the three germ layers (ectoderm, meso- ventral to the branchial arches. These five facial prominences
derm, and endoderm) forming in the beginning to middle of (two paired and one unpaired) are separated by external
the third week of gestation. The ectoderm layer gives rise to grooves, but the mesenchyme of all five is continuous, such
the cutaneous and neural systems, with differentiation starting that unobstructed migration of mesenchymal cells can occur
at 20 days. The interaction between ectoderm-derived com- around the stomodeum. Coordinated fusion and communica-
ponents at the crest of the neural fold gives rise to a unique tion between these five prominences are essential for normal
cell population of neural crest cells (NCCs). NCCs have the lip and palate development.
unique ability to remain pluripotent despite their single germ Development of the human face occurs between the 4th and
layer origin. NCCs migrate along cleavage planes between 10th weeks (Figure 19.1B–H). The nasal placodes develop as
germ layers and within the mesoderm to differentiate at their bilateral thickenings on the surface ectoderm of the infero-lateral
final destination into connective, muscle, nervous, or endo- aspect of the FNP by the end of the fourth week (Figure 19.1C).
crine tissue, as well as pigment cells. As the placodes elevate, medial and lateral nasal prominences
NCCs that migrate ventro-caudal from the crest come into develop around the depressed central nasal pit. Medial migra-
contact with the pharyngeal endoderm and mesoderm core tion of the maxillary prominence from the first arch effects
that surrounds the six aortic arches. This results in a series of medial migration of the nasal prominences, such that when they
mesenchymal swellings termed branchial arches in the fourth fuse together, the stomodeum is no longer in continuity with
week. The six paired branchial arches decrease in size from the nasal pit, creating the nasal–oral separation (Figure 19.1G).
cranial to caudal. Although the first and largest arch, the man- The medial nasal prominences form the philtrum and
dibular arch, is primarily responsible for development of the Cupid’s bow region of the upper lip, the nasal tip and septum,
anatomy that includes the lip and palate, the fourth arch is and the premaxilla back to the incisive foramen. The lateral
responsible for the pharyngeal constrictor, the levator veli nasal prominences form the nasal alae. The maxillary promi-
palatini, and the palatoglossus muscles, which play a role in nences form the lateral lip elements that normally fuse with the
the problems and treatments associated with cleft palate. Each philtrum derived from the medial nasal prominence. A failure
branchial arch gives rise to a nerve along with the associated of fusion of a lateral lip element (maxillary prominence) with
muscles. This muscle–nerve relationship is maintained regard- the philtrum (medial nasal prominence from the FNP) results
less of the functional interaction of the differentiated struc- in a unilateral cleft lip. If both maxillary prominences fail to
tures. Although the tensor veli palatini and levator veli palatini fuse, a bilateral cleft lip will result. With a failure of fusion to
work in close coordination in the mature normal palate and are the maxillary prominence, the growth of the medial placode
pathologically tethered through the aponeurosis of the tensor elements (prolabium, premaxilla, and septum) is unbalanced,
tendon in patients with cleft palate, they retain their distinct resulting in the central protrusion seen in a cleft patient.
innervation based on their embryologic origin. The levator The formation of the palate is also a result of interaction
veli palatini, as a fourth arch derived muscle, is innervated by between the FNP and maxillary prominences. The two medial
the fourth arch derived superior laryngeal branch of the vagus nasal prominences of the FNP merge to form the median pala-
(cranial nerve X). The fourth arch derived palatoglossus and tine process, which develops the primary palate, whereas the
173
174 Part III: Congenital Anomalies and Pediatric Plastic Surgery
Frontonasal prominence Maxillary prominence Mandibular prominence
Lens placode Eyelid

Nasal placode
Stomodeum Nostril
A Lower jaw
28th day
E
40th day
Eye
Nasal pit
Eyelid
Stomodeum
B
31st day Medial nasal
prominences merging
with each other and the
F
48th day maxillary prominences
Nasal pit
Nasal prominences
C Stomodeum
Eyelid
33rd day
Intermaxillary
Medial nasal segment
prominences G
Lateral nasal 10 weeks
prominences
D External ear
35th day
FIGURE 19.1. Illustrations of the progressive stages of the development of the human face. From gestational age of 28 days (A) through 10 weeks
(G) there is staged and progressive fusion of the frontonasal (purple), maxillary (orange) and mandibular (blue) prominences.
lateral palatine processes derived from the maxillary promi- cleft palate (33%) and isolated cleft lip (21%). The majority
nences form the secondary palate (Figure 19.2). During the of bilateral cleft lips (86%) and unilateral cleft lips (68%) are
eighth week, the lateral palatine processes change from their associated with a cleft palate. Unilateral clefts are nine times
initial vertical orientation to horizontal, within a period of as common as bilateral clefts and occur twice as frequently
hours. The developing mandible protrudes in synchrony to on the left side than on the right. Males are predominant
allow the tongue to descend and leave room for palate fusion. in the cleft lip and palate population, whereas isolated cleft
Fusion occurs in both the axial and sagittal planes, with the palate occurs more commonly in females. In the Caucasian
median palatine process and two lateral palatine processes population, cleft lip with or without cleft palate occurs in
fusing to form the palate, and the nasal septum descending approximately 1 in 1,000 live births. These entities are twice
from the FNP to join the fusion and separate the two nasal as common in the Asian population, and approximately half
cavities (Figure 19.2C–F). Fusion involves focal degeneration as common in African Americans. This racial heterogeneity
of the leading epithelial edges in a process felt to represent is not observed for isolated cleft palate, which has an overall
“programmed cell death.” Once fused, the mesenchyme of incidence of 0.5 per 1,000 live births.
the primary palate and anterior secondary palate ossify into Both environmental teratogens and genetic factors are impli-
the hard palate, whereas the posterior secondary palate forms cated in the genesis of cleft lip and palate. Intrauterine exposure
muscle to create the dynamic soft palate. to the anticonvulsant phenytoin is associated with a 10-fold
When there is normal fusion between the FNP and maxil- increase in the incidence of cleft lip. Maternal smoking during
lary prominences creating a normal lip and alveolus, but there pregnancy doubles the incidence of cleft lip. Other teratogens,
is lack of fusion between the lateral palatine processes of the such as alcohol, anticonvulsants, and retinoic acid, are associ-
opposing maxillary prominences, an isolated cleft of the second- ated with malformation patterns that include cleft lip and pal-
ary palate occurs. If, however, the maxillary prominences fuse ate, but have not been directly related to isolated clefts.
appropriately, creating a normal secondary palate, but the FNP Genetic abnormalities can result in syndromes that include
and maxillary prominences do not fuse, then a cleft lip and cleft clefts of the primary or secondary palates among the devel-
of the primary palate will occur. The variety of fusion patterns opmental fields affected. More than 40% of isolated cleft
between these two pathologic scenarios results in the plethora of palates are part of malformation syndromes, compared with
cleft lip and palate combinations described later in the chapter. less than 15% of cleft lip and palate cases. The most com-
mon syndrome associated with cleft lip and palate is van der
Woude syndrome with or without lower lip pits or blind
Epidemiology and Etiopathogenesis sinuses. Microdeletions of chromosome 22q resulting in velo-
Among the cleft lip and palate population, the most common cardiofacial, DiGeorge, or conotruncal anomaly syndromes
diagnosis is cleft lip and palate (46%), followed by isolated are the most common diagnoses associated with isolated cleft

Chapter 19: Cleft Lip and Palate 175
Median Parents of a child with a nonsyndromic cleft, or a family
palatine history of clefting, always ask about the risk of clefts in subse-
process quent pregnancies. The risk depends on whether the proband
has a cleft lip alone (CL), cleft lip with cleft palate (CLP), or a
Nasal cleft palate alone (CP). If the family has one affected child or
septum parent with CLP, the risk of the child of the next pregnancy
Lateral having CLP is 4%. If two previous children have CLP, the
palatine risk increases to 9%, and if one parent and one child were
process previously affected, the risk to children of subsequent preg-
A B nancies is 17%. For families with a child having CP, the risk
of CP to children of subsequent pregnancies is 2%, 6% if one
parent has CP, and 15% if one parent and one previous child
have CP.
principles

Median

palatine
process
Surgical Evaluation and Classification
The newborn infant with a cleft is ideally evaluated by the
Eye
cleft team in the first weeks of life. The increasing number
Nasal of clefts detected by prenatal imaging allows early prepara-
septum tion of the family and introduction to the treatment plan.
Patients with cleft lip and/or palate are not a homogenous
Lateral
group. As mentioned above, they can be divided into CL,
palatine
CP, and CLP; however, the surgical treatment plan requires
C process D
a more complex classification scheme. The cleft lip deformity
is typically divided into unilateral or bilateral, and then sub-
divided into complete, incomplete, or microform based on the
pattern of embryonic fusion described earlier. The width of
Nasal the cleft deformity and the degree of alveolar arch collapse
septum also play a part in surgical planning, as these directly relate
Primary to the degree of associated nasal deformity and the tension
palate and difficulty of the repair. The associated nasal deformity is
Sceondary similarly categorized as mild, moderate, or severe. Mild nasal
palate deformity is characterized by a lateral displacement of the alar
Lateral base with normal alar contour, minimal columella shortening,
palatine and normal dome projection. Moderate nasal deformity has
process lateral and posterior displacement of the alar base, columella
E F deficiency, and a depressed dome with mild separation of the
interdomal space. Severe nasal deformity has an underpro-
jecting alar dome with complete collapse of the lower lateral
cartilage and a severe deficiency of columella height with a
dramatic interdomal separation. Severe nasal deformities often
have a reversed curvature to the alar rim. The nasal deformity
Nasal is secondary to a three-dimensional distortion of the lower lat-
septum eral cartilage, described by some as the “tilted tripod.” It is
Hard not caused by hypoplasia or deficiency of the cartilage itself.
palate If a cleft palate is present, it is surgically classified as uni-
lateral, bilateral, or submucous. A submucous cleft results
Soft from epithelial fusion of the soft palate, but lack of the
palate
programmed mesenchymal fusion described in the embryol-
ogy section. The width of the cleft is noted as it affects the
Fused lateral difficulty of closure.
G palatine H Although most surgeons use the descriptive classification
process of cleft deformities during the initial assessment of a patient,
FIGURE 19.2. A. Sketch of a sagittal section of the embryonic head other classification systems are often used for outcome research
at the end of the sixth week showing the median palatine process, or and record keeping. Kernahan and Stark’s “stripped Y” diagrammatic
primary palate. B, D, F, and H. Drawings of the roof of the mouth classification scheme and its modifications continue to be used
from the 6th to 12th weeks illustrating development of the palate. The in many cleft centers. It recognizes the embryologic division
broken lines in (D) and (F) indicate sites of fusion of the palatine proof the primary (lip and alveolus) and secondary palates at the
cesses. The arrows indicate medial and posterior growth of the lateral incisive foramen. Kriens presented a palindromic acronym
palatine processes. C, E, and G. Drawings of the frontal sections of the organization of cleft deformities. The acronym LAHSHAL
head illustrating fusion of the lateral palatine processes with each other
denotes the bilateral anatomy of lip (L), alveolus (A), hard
and the nasal septum, and separation of the nasal and oral cavities.
(H), and soft (S) palates, by convention from right to left.
Lowercase letters represent incomplete clefts of the structure;
a period denotes no cleft. A bilateral cleft lip with a complete
palate. Although there is a recognized genetic component to unilateral cleft of the secondary palate, with incomplete cleft-
nonsyndromic cleft lip and/or palate, it appears to be multi- ing of the lip and alveolus on one side would be represented as
factorial. Among other recent studies, a meta-analysis of 13 LAHSal. This system is currently used for the outcomes regis-
genome scans by Marazita et al.1 revealed multiple cleft lip/ try of the American Cleft Palate and Craniofacial Association
palate genes on 16 chromosomal regions. (ACPA).

Microform Cleft Lip. The microform cleft (Figure 19.3A) by an alveolus position lateral to the desired alar base position
is characterized by a furrow or scar transgressing the vertical (i.e., with lip closure the alar base is medial to the alveolus
length of the lip, a vermilion notch, imperfections in the white and thereby sitting in the cleft). “Collapse” refers to a palatal
roll, and varying degrees of vertical lip shortness. Nasal defor- displacement of the lateral maxillary segment as predicated by
mity may be present and is sometimes more extensive than the the arch configuration of the medial, non-cleft dental ridge.
associated deformity of the lip. Surgery is generally indicated Clefts characterized as “narrow–no collapse” with mini-
but is approached cautiously to avoid a surgical deformity mal nasal deformity may be treated with presurgical taping
worse than the congenital defect. If there is isolated disruption to prevent widening of the cleft with growth and feeding,
of the orbicularis oris sphincter, it can be repaired through an prior to a primary cleft lip repair with primary tip rhinoplasty.
intraoral approach. Clefts characterized as “narrow–collapse” or “wide–collapse”
may benefit from presurgical molding to create the desired
Unilateral Incomplete Cleft Lip. Unilateral incomplete arch form, alveolar contact, and nasal anatomy at the time of
clefts (Figure 19.3B) are characterized by varying degrees of surgery. Clefts characterized as “wide–collapse” or “wide–no
vertical separation of the lip, but they all have in common collapse” must be assessed closely by the dental members of
an intact nasal sill. They typically require the same surgical the cleft team. If they feel that these cases are deficient in arch
technique as a complete cleft lip in order to repair the underly- mesenchyme, presurgical orthopedics is used to align the arch
ing muscle malposition, with the associated distortion of the segments by correcting the collapse, but not to close the alveo-
septum, alar base, and lip. If the nasal sill skin is normal, and lar cleft since this will result in a constricted or perhaps locked
the nasal lining intact, one of the challenges of the incomplete in arch. External taping can be used to correct the alar base
cleft is to elevate the nasal lining from the underlying alveolar position over the maintained arch form. The use of presurgi-
cleft to allow repositioning of the alar base while preventing cal orthopedics or aggressive presurgical taping has eliminated
a nasolabial fistula. As with complete clefts, the best time to the need for preliminary lip adhesion surgery. The primary
address the associated nasal and septal deformity is at the time benefit of a balanced arch configuration at the time of primary
of the primary lip repair. lip repair is decreased tension on the lip repair. A secondary
benefit is the reduction of alar discrepancy.
Unilateral Complete Cleft Lip. Unilateral complete clefts
(Figure 19.3C) are characterized by disruption of the lip, nos- Complete Bilateral Cleft Lip. The most obvious aspect
tril sill, and alveolus (complete primary palate). Since there is of a complete bilateral cleft is the protruding premaxilla
no skin bridge connecting the alar base to the footplates of (Figure 19.3D). Because of the lack of connection of the pre-
the lower lateral cartilages of the nose, unopposed pull of the maxilla with the lateral palatal shelves, the premaxilla has not
orbicularis oris muscle results in a more severe nasal deformity been “reined back” into alignment with the lateral arch seg-
than seen in an incomplete cleft lip. The alar base is displaced ments during fetal development. At the time of birth, the pre-
inferior and posterior, the ipsilateral lower lateral cartilage of maxilla protrudes on a vomerine stem. Uncontrolled growth
the nose is stretched and the natural contour deformed, and at the premaxillary suture results in over-projection of the
the floor of the nasal septum is displaced into the non-cleft premaxilla, with or without rotation and angulation of the
nostril, collapsing the nasal tip support. The critical factors segment. Just as the premaxilla is not reined back by the lat-
for evaluating unilateral complete clefts are the position of eral palatal shelves, the lateral palatal shelves are not pulled
the lesser and greater alveolar segments, the vertical height forward by their attachment to the premaxilla. Without the
of the lateral lip element, and the degree of associated nasal intervening premaxilla to maintain arch width, the lateral
deformity. The alveolar (maxillary) segments assume one of palatal shelves collapse toward the midline. The severity of
four positions: (a) narrow–no collapse; (b) narrow–collapse; this disruption of arch morphology varies, and will dictate the
(c) wide–no collapse; (d) wide–collapse. “Wide” is determined tension on the repair, the degree of dissection required, and,
A B
FIGURE 19.3. The clinical spectrum of cleft lip deformities. A. Microform cleft lip. B. Unilateral incomplete cleft lip. C. Unilateral complete cleft
lip. D. Bilateral complete cleft lip. E. Bilateral incomplete cleft lip. F. Hybrid incomplete and complete bilateral cleft lip.


C D
E F
FIGURE 19.3. (Continued)
ultimately, the final aesthetic result unless it is corrected prior is used to create the central lip element at the cost of inad-
to lip repair. Presurgical orthopedics is employed to achieve equate columella length and tip projection. A major benefit of
this correction prior to surgery. nasoalveolar molding (NAM) is the ability to lengthen both
The anterior nasal spine is poorly formed or absent in the columella skin and the prolabium prior to surgery, creat-
the bilateral cleft lip deformity, resulting in a retruded area ing enough skin to reconstruct the central lip length without
under the base of the septal cartilage and recession of the compromising nasal tip projection.
footplates of the medial crura. The footplates of the lower
lateral cartilages are displaced posterior and laterally, which Incomplete Bilateral Cleft Lip. Occasionally, bilateral
in turn pulls the normal junction (genu) of the medial and clefts are incomplete with a near-normal nose, a normally
lateral crura apart resulting in a broad, flat nasal tip. The positioned premaxilla, a skin bridge across one or both nasal
recession of the medial crural footplates along with lateral- floors, and clefts involving only the lip (Figure 19.3E). In such
ization of the domes and deficient skin produces the typical circumstances, a rotation-advancement approach, or a trian-
“absent columella” deformity. The most anterior and inferior gular flap approach similar to that used in unilateral repairs,
extent of the frontonasal process, which normally contributes can be used either in a single-stage or a two-stage opera-
to the skin between the philtral columns of the lip, forms a tion. In two-stage repairs one side is closed first, allowed to
wide, short disk, called a prolabium, that appears to hang heal, and then the other side is repaired a short time later.
directly from the nasal tip skin. In conventional techniques, Symmetry is difficult to achieve with a staged approach, and
the linear distance from the inferior tip of the prolabium to we prefer a single-stage procedure with a bilateral straight-
the nasal tip is inadequate to reconstruct both the central line technique as described later in the chapter. Patients with a
upper lip and columella length. This vertically limited tissue complete cleft on one side and an incomplete cleft on the other

present a surgical challenge (Figure 19.3F). These cases have

the asymmetric nasal deformity of a unilateral complete cleft Treatment
lip and the paucity of lip tissue of a bilateral cleft. If there is a
discrepancy in columella height between the two sides, we will
Multidisciplinary Cleft Care
consider a rotation-advancement repair on the complete side Individuals born with cleft lip and or palate require coordi-
to increase columellar length and a straight-line closure on the nated care from multiple specialties to optimize treatment
incomplete side. outcome. The national standard is in a center with a multi-
disciplinary cleft team, dedicated to treating cleft-related
Cleft Lip and Palate issues from birth to adulthood. Typical members of a cleft
team include an audiologist, dentist, geneticist, nurse, nutri-
The primary palate consists of the lip, alveolus, and anterior tionist/dietitian, oral surgeon, orthodontist, otolaryngologist,
palate back to the incisive foramen. The secondary palate con- pediatrician, plastic surgeon, psychologist, social worker, and
sists of the hard and soft palates from the incisive foramen speech pathologist (Table 19.1). Attentive team care in the
back to the uvula. The presence of a cleft palate introduces first few months of life will increase the success of primary
feeding difficulties, concerns regarding speech development, surgeries by preparing the infant and family medically, physi-
and the possibility of impaired facial growth. The width of cally, and psychologically.
a primary palate cleft and the degree of collapse are typically The emphasis is on coordination of subspecialized experts
increased in the presence of a cleft of the secondary palate. to minimize the number of surgeries performed while maxi-
The family is counseled about the increased number of surgi- mizing the benefit.
cal operations that will be required if a cleft palate is present:
primary cleft palate repair with intravelar veloplasty; possible
secondary surgery on the palatopharyngeal muscle sling, such Presurgical Orthopedics
as a sphincteroplasty or pharyngeal flap; and possible orthog- The goal of presurgical orthopedics is to adjust the cleft
nathic surgery at skeletal maturity. The abnormal attachment anatomy such that the surgery is minimized, and the result is
of the muscles of the soft palate in a cleft palate alters the optimized. One of the most common and time-tested forms of
tension on the pharyngeal drainage of the Eustachian canal, presurgical orthopedics is early and persistent lip taping in the
increasing the incidence of ear infections. Myringotomy and first month of life up to the time of the primary cleft lip repair.
grommet tube placement is performed in the majority of Due to the deformability of infant soft tissue, this gradual
infants at the time of either the lip repair or the palate repair force can cause a progressive decrease in cleft width.
to prevent the development of hearing abnormalities. More elaborate orthopedic devices involve appliances,
which are either active or passive. Generally, active appliances
Isolated Cleft Palate use an acrylic plate and controlled forces, sometimes from
The infant with isolated cleft palate is examined carefully for extra-oral traction (bonnet with straps), to move the maxil-
manifestations of the Pierre Robin sequence (micrognathia lary alveolar segments into approximation. One of the best
and glossoptosis leading to airway obstruction). The cause known active appliances is the pin-retained variety used by
of the cleft palate in the Pierre Robin sequence is thought to Latham2, which is designed to exert a forward force to the
be mechanical obstruction of the lateral palatine processes as lesser posterior segment of the unilateral cleft maxilla. It con-
they swing from a vertical to horizontal orientation during sists of a two-piece maxillary splint that overlies the palatal
palate fusion, and not because of failure of the fusion process shelves and is retained by short medial pins. An expansion
secondary to “programmed cell death.” The micrognathia and screw connecting the two pieces can be moved to adjust the
associated glossoptosis causes this obstruction, resulting in the width of the lateral palatal segments. An orthodontic elastic
characteristic wide “horseshoe” cleft palate. Since the associ- chain is used to retract the premaxilla. By adjustment of these
ated findings are caused by a “domino effect” starting with independent controls, the premaxilla is brought back into its
the micrognathia, and not a shared etiology, the condition is proper position in the arch before the primary repair. The
considered a sequence and not a syndrome. If the Pierre Robin Latham device requires a surgical procedure to introduce and
sequence is present, the majority of cases can be treated with remove it.
positioning and anti-reflux medications. In more severe cases, Passive appliances generally consist of an alveolar mold-
treatment may include nasopharyngeal airway protection, ing plate made of a hard outer shell and a soft acrylic lin-
gavage feedings, and apnea monitoring. A small percentage ing. By gradual alteration of the tissue surface of the
of Pierre Robin patients require surgical intervention such as acrylic plate, the alveolar segments are gently molded into
tongue–lip adhesion, distraction lengthening of the mandible, the desired shape and position by the direction of alveolar
or tracheostomy. Because of airway concerns, palatoplasty growth. The devices allow continued growth by a passive
may be delayed for several months in Pierre Robin patients molding action without permitting medial movement of the
compared with other cleft palate closures. buccal segments. Once the segments are in proper position,
early lip repair and bone grafting can be performed. This
Submucous Cleft Palate passive molding approach has evolved into the contempo-
rary technique of NAM.
The submucous cleft palate is traditionally defined by a triad
of deformities: a bifid uvula, absence of the posterior nasal Nasoalveolar Molding. The goal of NAM is not only
spine resulting in a notched posterior hard palate, and mus- to minimize the alveolar cleft width through passive acrylic
cular diastasis of the velum resulting in a zona pellucidum. plate molding but also to minimize the associated nasal defor-
Submucous clefts vary considerably, however, and muscular mity. The principle is that the high degree of plasticity and
diastasis can occur in the absence of a bifid uvula. The major- lack of elasticity in neonatal cartilage is caused by high levels
ity of patients with submucous cleft palate are asymptomatic. of hyaluronic acid, a component of the proteoglycan intercel-
Approximately 15% of patients will develop velopharyngeal lular matrix, as a result of high estrogen levels from expo-
insufficiency (VPI). VPI correlates with short palatal length, sure to maternal estrogen. During the first 2 to 3 months after
limited mobility, and easy fatigability of the palate. Because birth, active soft tissue and cartilage molding can take place
the majority of patients with submucous cleft palate remain through the application of persistent gentle external forces.
asymptomatic, a non-operative approach is recommended This phenomenon was used by Matsuo and Hirose for treat-
until speech can be adequately evaluated, which is typically ing the nasal deformity associated with a unilateral cleft lip
after 3 years of age. with intact nasal floor, and then later developed by Grayson

TABLE 1 9 . 1
Surgical Treatment of A Cleft Lip And Palate By Age
n Age n Treatment n Cleft Team Members

Prenatal Prenatal imaging, diagnosis, and counseling Multidisciplinary
Newborn a
Feeding assessment, medical assessment, Multidisciplinary
genetic counseling, treatment information
0–3 mo Presurgical orthopedics Orthodontist, plastic surgeon
3 mo (or after presurgical Primary cleft lip repair and tip rhinoplasty Plastic surgeon
orthopedics)a ± gingivoperiosteoplasty
12 mo (delayed if airway or Primary cleft palate repair with intravelar Plastic surgeon, otolaryngologist
medical concerns)a veloplasty ± bilateral myringotomy and tubes

Diagnosis of velopharyngeal Secondary palate lengthening or pharyngoplasty, Speech pathologist, plastic surgeon,
insufficiency (3–4 y) speech obturator otolaryngologist, orthodontist
School-age years Treatment of secondary lip and nasal Plastic surgeon
deformities
7–9 y (mixed dentition)b Secondary alveolar bone graft Orthodontist, plastic surgeon, oral surgeon
Puberty a
Presurgical orthodontics Orthodontist
Puberty Definitive open rhinoplasty Plastic surgeon
Skeletal maturity Le Fort I ± mandible orthognathic surgery Plastic surgeon, oral surgeon
Essential treatments of cleft lip and palate deformity.

a
Required if gingivoperiosteoplasty is not done or is unsuccessful.

b
and Cutting3 into the powerful current clinical tool applicable upper lip and create a columella at the time of primary bilat-
to all forms of clefting. eral cleft lip repair.
The technique of NAM starts shortly after birth, with an Iatrogenic deformities can be inadvertently created by the
impression of the intraoral cleft defect using an elastomeric NAM practitioner. Close communication with the surgeon
material in an acrylic tray. A conventional molding plate is during the course of molding is important in order to mini-
constructed on the maxillary study model from clear orth- mize this risk. The more common NAM deformities include
odontic resin. The molding plate is applied to the palate effacement of the Cupid’s bow anatomy due to over-stretching
and alveolar processes and secured through the use of surgi- of this region during taping, over-lengthening of the lateral lip
cal adhesive tapes applied externally to the cheeks and to an element from an inferior vector of taping on this skin, and a
extension from the oral plate that exits the horizontal labial “mega-nostril” deformity from over-elevation of the alar rim
fissure (Figure 19.4). The molding plate is modified at weekly before the gap between the alar base and columella base has
intervals to gradually approximate the alveolar segments. This been appropriately narrowed.
is achieved through the selective removal of acrylic from the
region into which one desires the alveolar bone to grow (“neg- Effect of Presurgical Orthopedics on Facial Growth.
ative sculpting”). At the same time, soft denture liner is added One of the most controversial issues surrounding presurgical
to line the appliance in the region from which one desires orthopedics in infants is a possible negative effect on maxil-
the bone to be moved. The ultimate goal of this sequential lary growth. Ross4 showed in a multicenter study that there
addition and selective removal of material from the inner is no difference in facial growth between cleft patients treated
walls of the molding plate is to align the alveolar segments with or without presurgical orthopedics. On the other hand,
and achieve closure of the alveolar gap. The effectiveness of Robertson5, in a 10-year follow-up study by a single surgeon,
the molding plate is enhanced by adequately supporting the demonstrated that better facial growth was achieved in patients
appliance against the palatal tissues and by taping the left and treated with this technique than in control subjects. In another
right lip segments together between clinical visits. Once the long-term single-surgeon study, Lee et al.6 showed that maxil-
alveolar cleft is 5 mm or less, the nasal changes of NAM can lary growth was not inhibited in patients aged 9 to 13 years
be achieved by the use of a nasal stent rising from the labial who had previously undergone presurgical NAM and primary
vestibular flange of the acrylic intraoral molding plate. The gingivoperiosteoplasty (GPP). In contrast, Berkowitz7 has
shape of the nostrils and alar rims is carefully molded through been openly critical of the Latham and Millard technique of
gradual modifications to the shape and position of the nasal presurgical Latham-type orthopedics, periosteoplasty, and lip
stents. A successful NAM result will result in the affected alar adhesion. He reports a higher incidence of anterior and buc-
rim curving upward into a normal position with a presurgical cal crossbite at 3, 6, 9, and 12 years of age after the procedure
“pinch test” (Figure 19.4). This result will greatly minimize when compared with no presurgical orthopedics without GPP.
the dissection required to create alar rim symmetry at the time Millard8 reviewed this same clinical database and also reported
of surgery. For bilateral cleft lip deformities, the nasal stents a higher incidence of anterior crossbite in the POPLA group,
are bilateral, with a joining bridge that creates a fulcrum at but a lower incidence of buccal crossbite. He noted that the two
the columella–labial angle. The prolabium is lengthened over groups had different orthodontic treatment protocols by differ-
this fulcrum using a vertical tape from the prolabial skin to ent orthodontists and that this could have a confounding effect
the molding plate, while the columella is lengthened by the on the results. The variability in the orthopedic and surgical
opposing upward pull of the nasal stents. This vertical stretch techniques used in all these studies precludes a global conclu-
is critical to create enough skin length to both reconstruct the sion on how to settle this controversy.

FIGURE 19.4. Nasoalveolar molding (NAM) of the unilateral cleft

deformity. A. Unilateral left complete cleft lip and palate in a newborn.
B. Infant wearing nasoalveolar molding plate with nasal extension.
The projecting button seen in the mouth is used to secure the plate to
the patient’s cheeks with tape and elastics. The nasal extension is not
added to the molding plate until the alveolar cleft is less than 5 mm
wide so as to avoid overstretching the nostril. C. Presurgical result of
the same patient after a course of NAM. The alveolar segments and
premaxilla are aligned, the cleft-side columella is lengthened, the alar
bases are in a more symmetrical position, and the cleft alar rim is
C
curved. D. Immediate post-surgery result of primary lip repair with
nasal dissection. E. Nasal appearance at 3 years. Although there is a
slight drop in alar rim elevation on the cleft side, acceptable symmetry
has been maintained.
Primary Unilateral Cleft Lip Repair

Numerous methods have been described for repair of the
cleft lip deformity. A variety of techniques are still practiced whereas the Trauner and Millard techniques introduce the
in different parts of the world and can usually be identi- lateral flap in the upper half. Most current techniques in
fied by the scar pattern. All repairs have in common the use North American focus on variations of the triangular flap
of a lateral lip flap to fill a medial deficit, focusing on cor- technique of Randall-Tennison,9,10 or the rotation flap tech-
recting the relative shortness of the medial lip element. For nique of Millard11–13.
example, the LeMesurier repair involves a lateral, quadrilat- There is no agreement on the ideal timing and the tech-
eral flap, whereas the Tennison repair and Rose-Thompson nique of repair among established and experienced cleft sur-
repair employ a lateral triangular flap. These two techniques geons. This underscores the fact that more than one treatment
introduce the flap into the lower half of the medial lip, plan is acceptable and that comparable outcomes can be

alteration of landmarks. The eyes are protected with occlu-
sive patches, and a throat pack is inserted. After marking
of landmarks and incisions, an equal mixture of 0.5% lido-
caine and 0.25% bupivacaine with 1:200,000 epinephrine
is injected in the planned dissection planes of the lip, in the
supraperiosteal plane of the cleft-side maxilla, and between
the skin and cartilage of the planned nasal dissection.
Accurate injection with a minimal volume of fluid maximizes
hemostasis and facilitates dissection. An infraorbital nerve
block with bupivicaine is used to minimize the early need for
analgesics post-surgery.
Surgical Technique. The markings for the modified

Mohler rotation-advancement repair used by the author are
applied as shown in Figure 19.5. The points in red are tat-

tooed with a 25G needle dipped in gentian violet ink such that

they are preserved during the course of the operation. The
depth of the Cupid’s bow on the medial lip segment is marked
as point 1, with point 2 being the white roll at the height of
the Cupid’s bow on the non-cleft side, and point 3 being equi-
distant on the cleft side. Ideally, the distance between each
point should be approximately 2.5 mm, for a final Cupid’s
bow width of 5 mm; however, this can be adjusted based
on the patient’s anatomy. Point 4 is selected by a number of
considerations, the least important of which is the traditional
E technique of matching the distance from the commissure to
Cupid’s bow on the non-cleft side. Instead, it is selected by
matching the vermilion and white roll thickness, or bulk of the
lateral lip segment with that of the medial site at the Cupid’s
bow peak. This point should coincide as closely as possible
achieved with different philosophies. Successful approaches with the point on the white roll that intersects the arc of a line
have in common a surgeon who is knowledgeable about the drawn from the alar base whose length equals the vertical lip
variation in abnormal anatomy among clefts, is comfortable height of the non-cleft side (the height from point 4 to point 5
with the details and limitations of the various technique, and equals that from point 6 to point 2 when the lateral lip is gen-
is able to combine these two qualities to achieve the optimum tly straightened without excessive traction). The vertical inci-
surgical result. sion of the lateral lip segment that will be approximated to the
The author employs a modification of the technique ini- medial segment to reconstruct the philtral ridge originates from
tially described by Mohler, which, in turn, is based on the point 4, crossing perpendicular to the white roll, then curves
technique of Millard.12 Compared with the traditional Millard sharply toward point 7 at the nasal sill. The triangle formed
by points 4, 5, and 7 is isosceles, with the height from point 4 to
technique, this technique minimizes the alar base skin inci-
point 7 equaling that from point 4 to point 5. It is important
sions and places the back-cut used to rotate the medial lip ele-
that the base of this isosceles triangle (line 5-7) does not vio-
ment at the base of the columella instead of the upper lip.
late the nasal sill. It is deceptive how much of the nostril base
With these modifications, the upper lip scar parallels the
is pulled onto the upper lip by the muscle deformity. As a con-
contralateral philtrum instead of curving across the philtral
sequence, if line 5-7 is placed in the visible crease that forms in
groove. The remainder of this section focuses on the modified
this region, once the muscles have been released and repaired,
Mohler technique used by the author.
the incision will fall up into the nostril floor, obliterating the
Timing and Treatment Planning. Whenever possible, natural fullness found in the part of the alar base. A good rule
all complete unilateral cleft lips undergo preoperative NAM of thumb is to make line 5-7 such that it is perpendicular to
at our institutions. Presurgical orthodontic treatment is ini- the vermilion border found between points 4 and 7. Although
tiated in the first or second week following birth, with the this inferior slope of the incision will appear non-intuitive,
maximum response occurring during the first 6 weeks. The once the lateral lip is brought into position, the line 5-7 will
primary lip repair is scheduled when the patient is approxi- become horizontal, and the fullness under the alar base will
mately 12 weeks of age, at which time closure of the ante- be preserved.
rior nasal floor and a primary tip rhinoplasty are also per- Point 4 can be chosen on most cleft lips using these two
formed. If the alveolar segments are appropriately aligned guidelines. In some cases, however, the lateral lip element is
and <2 mm apart, the family is offered a GPP at the time of vertically deficient, resulting in a point 4 that is too laterally
the surgery. Bone grafts are not employed with early closure displaced (too close to the commissure) to achieve a minimal
of the alveolus. If collapse is present or the gap is too wide, tension repair. In these cases, the arc of the lateral vertical
the GPP is deferred. incision from point 4 to point 7 can be increased to lengthen
Correction of the nasal deformity in unilateral clefts is the course between the two points. Another option, although
coupled with the rotation-advancement repair along with early rarely required, is to transpose a 2-mm triangular flap from
anterior septal repositioning. We believe that it is important the medial lip element under the C flap into a back-cut at
to minimize the number of secondary surgeries to the nose point 4 (not shown in Figure 19.5).
during the growth phase to minimize scarring and to optimize Care is taken during marking to mark the wet–dry red lip
the final result of a formal open rhinoplasty in adolescence or border as well as the white roll and vermilion border. The dry
thereafter. vermilion in the medial lip element often diminishes in height
as it approaches the cleft, being less than that on the oppos-
Anesthesia. General anesthesia is used for all stages of lip ing lateral lip element. A small triangle of dry red lip from the
repair. A straight, cuffed endotracheal tube is taped to the lateral lip element with a height that equals the deficiency is
chin by the surgeon to avoid distortion of the lower lip and created and inset into a back-cut at the wet–dry junction in

10
6 8
C
3 9 11
1 M 5
2
7 L 4
A B
FIGURE 19.5. Unilateral cleft lip repair. A. Markings for unilateral complete primary cleft lip repair. M, medial mucosal flap; L, lateral mucosal
flap; C, central cutaneous flap. The purple lines mark planned incisions. The dotted light blue line marks the intranasal lateral wall release if an
L-flap is to be used as shown in Figure 19.6. The dotted green line marks the posterior lateral nasal wall release to be used if an L-flap is not
needed. See text for details. B. Intracleft view of a patient with a unilateral cleft lip and palate, showing the wet–dry vermilion markings and the
intraoral markings to align the lip margin during closure of the oral mucosa.
the medial lip element. If the dry vermilion deficiency is not alar base has been achieved; and (3) points 12 and 13 (not
addressed in this fashion, the patient will have central lip dry- shown) that lie inside the lip on the wet mucosa, equidistant
ness and scabbing from the exposed wet red lip as they age. from the wet–dry junction, with point 12 being directly under
For the medial lip segment incisions, point 8 is chosen as point 3 on the undersurface of the lip, and point 13 being
the location of the back-cut of the C flap. Unlike the tradi- under point 4. These latter marks facilitate symmetric intra-
tional Millard repair, this point is located approximately oral closure of the mucosa when suturing and allow a sym-
1 mm up on the columella and three-fifths along the width metric full-thickness cut through the muscle of both red lips
of the columella, toward the non-cleft side. This allows the from points 3 and 4 to these two inside mucosa points.
back-cut scar to be hidden at the base of the columella, instead The lip is then infiltrated with lidocaine and epinephrine as
of on the upper lip. It also creates a vertical scar that mirrors described above (see Anesthesia). After the skin incisions are
the non-cleft philtral ridge and does not violate the philtral complete with a micro-knife, the red lip portions of the medial
groove. The incision from point 3 to point 8 is the vertical and lateral segments are everted to equal fullness, and a no. 11
philtral incision of the medial lip segment and defines the blade is used to transect the red lip mucosa and marginal com-
non-cleft border of the C flap. Unlike the traditional Millard ponent of the orbicularis oris between points 3 and 12 and 4
repair, this incision has only a slight medial curvature in order and 13, respectively. The superior labial arteries are identified
to create a vertical philtrum. The curvature can be adjusted and cauterized. The anterior border of the L-flap is marked
based on the curvature of the non-cleft philtral ridge. The by the incision from points 4 to 7. The posterior border of
cleft border of the C flap (from point 3 as it heads up into the L-flap starts at point 13 and parallels incision 4-7 until it
the nose) parallels the junction of the medial lip skin and the enters into the nose at the level of the palatal shelf, following
oral mucosa. It is important not to include any mucosa in the the natural demarcation between nasal and oral mucosa. This
C flap, as it will be rotated into the base of the columella to mucosal incision is extended as far posterior as possible. At
fill the skin deficiency after downward rotation of the medial this point, the decision is made whether the L-flap is required
lip segment. This inferior incision from point 3 extends into to expand the lateral nasal wall. In most clefts, the L-flap can
the nose, along the natural demarcation between the oral and be avoided to avoid any anterior intranasal incisions or flaps.
nasal mucosa, to create a small septal mucosal flap that will be The lateral nasal wall mucosa can be undermined as a sub-
used to repair the nasal floor back to the incisive foramen and periosteal superiorly based flap which is back-cut vertically
prevent a nasolabial fistula. as far posterior in the nose as possible (point 9, Figure 19.5),
Points 3 and 4 on the white roll are tattooed with needle behind the piriform rim (green dotted line in Figure 19.5). In
and ink to facilitate alignment at the end of the repair. The this fashion, the lateral nasal wall movement needed to elevate
author finds that when two marks are used to identify each the displaced alar base anterior and superior occurs through
of these points, there is less chance of error in alignment of opening of the back-cut inside the nose, leaving the exposed
the vermilion border. One mark is placed on the height of the lateral nasal wall bone to re-mucosalize. However, in severe
white roll and one at the top of the white roll. The other areas clefts and many bilateral clefts, the alar base–columella base
that are tattooed include the following: (1) the wet–dry red lip discrepancy is too great to leave a back-cut over the bone, in
junction on each side of the cleft, since this is effaced during which case the back-cut is made just behind the lateral crus of
surgical swelling; (2) points 10 and 11 inside the nostril that the lower lateral cartilage and the L-flap is inset and sutured
are marked equidistant from points 5 and 6, such that these into this more anterior defect (blue dotted line in Figure 19.5;
two points will be symmetric once appropriate rotation of the Figure 19.6). When the L-flap is elevated, it is a posterior


A
B
FIGURE 19.6. Nasal lining release and inset of L-flap. A. The con-
stricted lateral nasal lining is released with an incision behind the lateral
crus as marked by the dotted green line in Figure 19.5. The mucosal
L-flap is elevated from the lateral lip element. B. The L-flap is pedicled
off the lateral nasal wall and inset into the lining defect to support the
new position of the alar base. C. The inferior edge of the inset L-flap
can now be brought across the cleft and sutured to a minimal vomer
flap to close the nasolabial fistula and bring the alar base into a more
symmetric position.
C
based mucosal flap pedicled off the lateral nasal wall, poste- rotation, points 1, 2, and 3, the landmarks of the Cupid’s bow,
rior to the lateral crus of the lower lateral cartilage. The base should be aligned horizontally with minimal inferior traction
of the L-flap is left thick by dissecting in the subperiosteal and no distortion of the columella–labial angle.
plane on the piriform aperture. The L-flap is not inserted until Angled nasal tip scissors are used to dissect between the
the muscle release described below has been completed and footplates of the lower lateral cartilages by accessing them
the alar base is mobile. underneath the C flap. A vertical incision is made through the
With elevation of the L- and M-flaps in a submucosal plane, nasal mucosa in the area of the membranous septum between
the underlying orbicularis muscle can be judiciously separated the anterior edge of the cartilaginous septum and the posterior
from the overlying skin and underlying mucosa. With dis- edge of the ascending limb of the lower lateral cartilage within
section of the muscle of the medial lip segment, care must be the cleft-side nostril. This releases the cleft-side lower lateral
taken not to violate the midline of the philtrum to avoid dis- cartilage footplate, allowing differential elevation of this car-
torting the natural groove. The red lip mucosa and white roll tilage and associated nasal tip relative to the non-cleft side.
are not separated from the underlying marginal component of Scissor dissection then continues between the ascending limbs
the orbicularis oris muscle in order to permit normal anima- of the lower lateral cartilages, over the nasal tip, and along
tion of this area. The nasal and perioral components of the the alar component of the cleft-side lower lateral cartilage.
orbicularis oris muscle are separate at the exposed muscle edge The skin is carefully separated from the lower lateral cartilage
of the lateral lip segments. The separation of these two com- over the alar rim to allow the skin envelope to redrape when
ponents is a judgment call to decide how much muscle will be the cartilage is repositioned. This dissection pocket between
used to create the bulk under the alar base, and how much will the cartilage and overlying skin is extended up to the upper
be needed to create the transverse fibers of the upper lip. lateral cartilage (ULC) of the non-cleft side. This continuous
The medial lip segment is lengthened and rotated inferiorly dissection plane between the non-cleft upper lateral and cleft
by sequentially releasing the skin with a back-cut at the base lower lateral cartilages will later be used to place subcutane-
of the columella described above, then the muscle with a sepa- ous Tajima suspension sutures to adjust the alar rim contour.
ration of the nasal and perioral components of the orbicularis The final dissection involves releasing the abnormal attach-
oris, followed by the mucosa at the frenum. Care is taken not ments of the cleft alar base to allow tension-free approxima-
to fully release the frenum if possible to avoid creating a long- tion across the cleft. An upper gingivobuccal sulcus incision is
lip deformity. At the end of the medial lip segment release and performed on the cleft side and continued as a supra-periosteal

dissection over the face of the maxilla. Through this incision, To address the residual deformities of the nose, a retractor
the abnormal fibrous attachments of the cleft-side accessory is used to slightly overcorrect the cleft alar rim and underlying
nasal cartilages to the lateral piriform aperture are released. lower lateral cartilage in an advanced and superior position.
The dissection of the nasal component of the orbicularis oris This slides the released cleft lower lateral cartilage footplate
muscle from the oral component continues with this exposure toward the nasal dome in relation to the non-cleft side. A
directly under the skin of the alar crease. If these two mus- series of 4-0 PDS transfixion sutures are used to secure this
cle flaps are separated up to the overlying dermis, then when new relationship of the ascending limbs of the lower lateral
they are repaired to their partners across the cleft, the natural cartilages to the anterior septum. This elevation of the cleft-
appearing triangular depression forms at the height of the naso- side alar rim and lengthening of the columella leaves a defect
labial crease just under the alar base. Some surgeons advocate from the back-cut at the base of the columella. The C flap is
creating an incision directly along the alar crease to achieve this trimmed to fit and rotate into this defect. The rotation point
same effect, but the author believes that this additional scar can of the C flap creates a natural flare to the base of the colu-
be avoided through a careful subdermal dissection. All areas mella of the cleft nostril.
are checked carefully for hemostasis before the closure begins. The final sculpting of the nostril shape is achieved with a
Closure begins with the nasal floor. If used the L-flap is 4-0 PDS subcutaneous Tajima suspension suture. The needle
rotated, trimmed, and sutured into the defect created in the enters the nasal surface of the cleft lower lateral cartilage
lateral nasal lining when the cleft alar base is advanced into at the point of desired elevation, enters into the previously
the appropriate position (Figure 19.6). With execution of the described subcutaneous nasal tip dissection pocket, exits into
dissection described above, the alar base should be able to be the non-cleft nostril at the level of the ULC, and then returns
brought into symmetric position with the non-cleft alar base on its path, such that tightening of the suture will elevate
in all three dimensions, without undue tension. As the alar the cleft alar rim. Lateral alar cinch sutures of 4-0 PDS can
base is brought into position, the inferior edge of the lateral also be used to contour the lateral alar rim and nasal lining
nasal wall flap lining is sutured to the opposing septal mucosal in the new position, by exiting and entering the same percu-
flap created from the intranasal incision extending from point taneous hole in the alar groove. The number of suspension
3 to close the nasal floor from the nasal sill back to the inci- and cinch sutures required will depend on the degree of the
sive foramen. At the end of this nasal floor closure, the pos- deformity. With good NAM results, the degree of nasal dissec-
terior displacement of the cleft alar base should be corrected. tion and number of sutures required are minimized. With this
Closure of the nasal floor to the incisive foramen at the time of approach, the lip and nasal deformities can be addressed in a
primary lip repair will avoid any oronasal or nasolabial com- single surgery.
munication after the remaining nasal floor reconstruction dur-
ing the later cleft palate repair. If this detail is omitted from Unilateral Incomplete Cleft Lip Operative Technique.
the lip repair, the child will be forced to deal with an anterior The unilateral incomplete cleft lip deformity is treated with
nasolabial fistula until closure can be performed at the time of the same surgical technique and dissection that was described
secondary alveolar bone grafting. for the complete cleft lip, but with a few modifications. Failure
Lip construction is achieved by everting the red lip on either to address all the lip and nasal abnormalities in the incomplete
side of the cleft to even fullness and then advancing and clos- cleft lip with the same detail paid to the wide complete cleft
ing the lateral lip segment mucosa to the medial lip segment will result in a suboptimal result.
mucosa. The M-flap can be rotated into the defect from the Compared with the complete cleft lip repair, the incom-
releasing back-cut at the frenum if necessary, or it can be used plete cleft repair does not involve intranasal incisions. If pos-
to augment the labial sulcus. After the lip mucosa is closed, sible, the nasal sill is not violated by the vertical incision. If the
the white roll should be aligned across the cleft, and the red nasal base is wide compared with the non-cleft side, a small
lip should have equal fullness. If the lateral red lip is thin, the wedge can be removed from the nasal sill to create symmetry.
lateral lip flap had not been adequately advanced toward the If any nasal sill is resected, it is vital that the excision be min-
midline during the mucosa closure and the lip is inverted. imal, because over-resection with scarring will result in the
A sound muscle reconstruction forms the foundation of a recalcitrant micronostril deformity.
good cleft lip repair, creating a nasal component that supports The L-flap and M-flap are not required for the incomplete
the cleft alar base, a transverse oral component that gives nat- cleft lip repair because the nasal floor is intact. To correct the
ural animation and length, and a marginal component that alar base malposition, the abnormal attachments of the nasal
allows symmetry of the red lip. The nasal component of the cartilages to the piriform aperture must be released as in the
orbicularis oris is repaired first. A 4-0 polydioxanone suture complete cleft technique, but the nasal floor lining must also
(PDS) is used to secure the nasal component of the orbicu- be dissected free from the piriform rim. The thin nasal floor is
laris that had been dissected subdermal under the alar base firmly attached to the edge of the piriform opening and can eas-
as previously described to the muscle and periosteum in the ily be perforated if care is not taken. Failure to release the nasal
region of the anterior nasal spine. The point of suture on the lining from the underlying bone will make it impossible to mobi-
medial lip differs from patient to patient and requires differ- lize the alar base into the desired advanced and medial position.
ent rotations of the nasal muscle, and different vertical place- The nasal deformity is addressed with the same dissection
ment, to achieve symmetry with the non-cleft alar base. The as the complete cleft; however, the vertical nasal lining incision
perioral components of the medial and lateral lip segments are behind the ascending limb of the cleft lower lateral cartilage
approximated across the cleft using buried horizontal mattress is not available for improved access to the nasal tip. Angled
sutures of 5-0 vicryl to create a philtral ridge and construct nasal tip scissors are used to access the nasal tip between the
the oral sphincter. Once the oral and nasal components have footplates of the lower lateral cartilages; if necessary, the nasal
been differentially advanced into their desired positions, it tip can be approached laterally from the supraperiosteal max-
is important to then secure these two muscle flaps together illary dissection plane.
with a buried vicryl suture under the cleft nasal lining repair.
If this is not done, the lip muscles can separate from the nasal Microform Cleft Operative Technique. The critical fac-
repair, either lengthening the lip with time, or providing insuf- tor when evaluating the microform cleft is the vertical height
ficient support to the alar base. The vertical skin incision of of the lip. If the vertical height of the affected side approxi-
the lip is closed with buried 5-0 resorbable monofilament der- mates that of the normal side, imperfections in the vermilion
mal sutures, followed by sparse, non-strangulating, 6-0 inter- along the skin furrow can be eliminated with an elliptical exci-
rupted nylon sutures. Care is taken to ensure that the tattooed sion and a straight-line repair. Triangular flaps of the white
marks of the white roll on either side of the cleft are aligned. roll and vermilion can be used to balance the closure.

When the vertical difference exceeds 1 to 2 mm, the modi-
fied Mohler rotation-advancement repair described above Primary Bilateral Cleft Lip Repair
(see Unilateral Incomplete Cleft Lip Operative Technique) is Bilateral cleft lip repair presents different challenges from
used. The additional scar underneath the sill and columella unilateral cleft lip repair. Although the lip repair is made
is preferable to a loss of definition in the involved philtral more difficult by the deficiency of skin and muscle overly-
column, which invariably results with straight-line closure ing the premaxilla, it is the associated bilateral nasal defor-
when the elliptical excision is extended to provide the desired mity that has been a continuing challenge to correct. The
lengthening. treatment of the complete bilateral cleft and associated nasal
The correction of a very mild nasal deformity is deferred deformity remains in transition. Only recently, because of
in the microform cleft requiring a straight-line repair, as the NAM, have the results of one-stage primary bilateral cleft
repair does not necessitate a perialar incision. If the defor- lip and nose repair begun to approach those of unilateral
mity remains minimal, treatment is postponed until late ado- cleft lip and nose repair. Previous multistage techniques
lescence, when a definitive rhinoplasty is performed. With a often produced a lip and nose that were still quite abnor-
moderate nasal deformity and with mild deformities requir- mal, with a confluence of scars at the lip–columella junc-
ing a rotation-advancement lip repair, correction of the nasal tion, a broad nasal tip, an unstable premaxilla, and often

deformity is carried out with the lip repair. large nasolabial fistulas. Results fell short of ideal because

the condition was viewed as a purely cutaneous deformity.
Primary Septoplasty. The anterior cartilaginous deformity Over the past decade, techniques advocated by McComb,
associated with unilateral cleft lip involves displacement of Mulliken,15 Cutting, Trott, and others have recognized the
the inferior footplate away from the midline of the anterior importance of addressing the contribution of the nasal tip
nasal spine into the piriform floor of the non-cleft nostril. The cartilages and lip muscle to the cleft deformity. Previous
deformity is believed to be secondary to the unopposed pull techniques such as the banked forked flap procedure and
of the nasal component of the orbicularis oris on the non-cleft Cronin procedure focused on using the width of the prola-
side. The curvature of the cartilage associated with this dis- bium to repair the cleft lip with the least amount of tension,
placement causes a tilting of the septum and columella, result- and then at a second stage, after the lip has relaxed, use the
ing in decrease in tip support and nasal projection. lip tissue to treat the up-to-now ignored columella and nasal
A recent publication has reported on the benefit of cor- anatomy. Current techniques instead place the focus on how
rection of the septal deviation at the time of the primary to get the muscle and cartilage in appropriate anatomic posi-
cleft lip repair.14 We have been practicing this technique at tion, such that the growth and molding forces that occur
our institution for the past 5 years and have found the same in the years after lip and nose repair result in a progressive
benefits. Prior to muscle repair, the anterior septum can improvement, instead of deterioration of form and func-
be approached under the medial crura of the lower lateral tion. This shift from a skin-based to a cartilage- and muscle-
cartilages. It is important not to strip the mucoperiosteum based paradigm has produced a number of techniques with
from the vertical premaxillary suture located a few milli- improved outcomes.
meters behind the anterior septal edge. Sharp dissection is
performed on the inferior surface of the curved septal carti- Manchester- Versus Millard-Based Techniques. There
lage, releasing the fibrous bands that hold it to the non-cleft are two general methods for constructing the central lip ver-
piriform floor. Once released, the immature cartilage can be milion. One involves using the mucosa visible on the inferior
straightened and repositioned on the other side of the ante- aspect of the prolabial skin to form the central vermilion, such
rior nasal spine. Unlike adult cartilage, the cartilage does not as used in the Manchester repair. The original Manchester
need to be scored to change the memory of the curvature. repair did not create an orbicularis oris sling across the upper
In most cases, the repositioned septum is stable in its new lip, but instead sutured the muscle to the edges of the premax-
position, but a 5-0 PDS suture can be used to secure the base illa. As there was no muscle under the prolabium or within
to the periosteum. Successful repositioning of the caudal sep- the buccal mucosa, this approach did not provide sufficient
tum corrects the columella tilting and lifts the nasal dome. bulk to serve as the central lip vermilion and resulted in an
abnormal appearance with animation of the central upper lip.
Postoperative Care. Although we previously used soft arm A number of techniques have been described to address this
restraints for 2 weeks after lip repair, we no longer find them limitation, including bringing strips of muscle across this area
necessary and have had no problems with self-inflicted dehis- from the lateral lip, and de-epithelializing the buccal mucosa
cence. Care must be taken not to overuse morphine in these or subcutaneous tissue from the lateral sides of the prolabium
patients, since it is one of the most common root causes of and folding them behind the inferior prolabial mucosa. An
series of sentinel events in these patients. advantage of using the prolabial or buccal mucosa to create
We do not impose restrictions and allow return to the the central vermilion is that very little bulk of the lateral seg-
preoperative routine immediately. Diet is advanced to full- ment of the vermilion is required, thereby decreasing the ten-
strength formula or breast milk on the day of surgery to pac- sion required for closure across the cleft. The disadvantages of
ify the infant. Some surgeons have described a preference to this technique are that (a) there are two parallel scars across
feed with a catheter-tip syringe fitted with a small, red, rub- the red lip, (b) the central red lip does not have sufficient bulk,
ber catheter for the first 10 days postoperatively to minimize resulting in a whistle deformity, and (c) the central buccal
strain on the muscle and skin sutures and to avoid trauma to mucosa does not possess the same minor salivary gland distri-
the repaired velum. bution as the lateral vermilion tissues, often resulting in a dry,
Suture line care consists of regular cleansing with half- chapped, central vermilion segment. The author has needed to
strength hydrogen peroxide followed with a light coating of revise the lips of numerous older patients with Manchester-
antibiotic ointment. Sutures are removed on or after the third type repairs suffering from these problems, converting them to
postoperative day. After suture removal, taping and silicone a more functional Millard-type repair.
scar gel is encouraged. Parents are told to expect firmness in A second approach is to use the vermilion tissue from the
the lip scar and temporary shortening across the repair that lateral lip segments to create the central vermilion as a vari-
generally becomes maximum 4 to 6 weeks after surgery. Scars ation of the technique described by Millard. The muscle of
typically soften between 3 and 6 months postoperatively. If the lateral lip elements rotates down with the full-thickness
there is early evidence of aggressive hypertrophic scar forma- vermilion flaps and can create a satisfactory central vermilion
tion, intralesional injection of a dilute steroid can be consid- construction with a single vertical scar in the red lip under the
ered, but is rarely required. depth of the Cupid’s bow.

Surgical Technique. The author uses a modified Millard- rim, and the use of an upper gingivobuccal sulcus incision to
type repair for bilateral complete lip. The considerations when mobilize the lateral lip is also shared. Once the lateral lip ele-
making the lateral lip markings are similar to those described ments have been dissected and the alar bases and lateral nasal
for the unilateral cleft lip repair (Figure 19.7). The major linings mobilized, attention is shifted to the prolabial dissection.
difference is that point 4 is not located at the same level of the Bilateral cleft lip dissection places the prolabial skin at
cut through the red lip, but is instead located above the white risk for necrosis. Meticulous dissection and good judgment
roll, 2.5 mm lateral to the red lip transaction. This creates a is required to avoid this devastating potential complication.
2.5-mm wide flap on each lateral lip element consisting of red Once elevated, the superiorly based prolabial flap is perfused
lip and white roll. These two flaps are used to reconstruct the retrograde from the nasal blood supply through the ascend-
central white roll and red lip inferior to the prolabium. ing columella vessels. The columella vessels can be destroyed
For the prolabium skin markings, the prolabium is gently during the flap elevation, the nasal tip dissection and sutures
placed under traction to find the central vertical axis. Point can disrupt the retrograde flow from the nasal dorsum, and
1 is placed at this center axis directly above the mucosa–skin the lateral muscle dissection under the alar creases can cut the
junction. No mucosa from the prolabium is used for the ante- angular branch of the facial artery contribution to the overall
rior lip repair, but is instead used for the sulcus repair of the nasal perfusion.
anterior vestibule. Points 2 and 3 are at the same skin–mucosa After the skin incisions are made, the prolabial flap bordered
junction, 2.5 mm on each side of point 1. A small curvilinear by points 2, 3, 4, and 5 is elevated off the underlying mucosa.
incision is made between the three points to create a scar that The dissection is therefore submucosal and not subdermal. The
simulates the Cupid’s bow. Points 4 and 5 are located at the superiorly based mucosal flap, M, will later be used to recon-
desired columella–labial crease, just below the natural flare struct the anterior vestibule. From underneath the elevated
of the base of the columella. Placing these points too high to prolabial skin flap, scissor dissection is performed between the
try to gain more prolabial length will result in distortion of footplates of the lower lateral cartilages over the genu of the
the natural fullness at the base of the columella. The lateral lower lateral cartilages and up to the ULCs bilaterally. This
incisions from points 2 and 3 follow the mucosa–skin border, subcutaneous nasal dissection is the same as described in the
with care taken not to include any mucosa. They extend into unilateral technique, but is performed bilaterally.
the nose, under the footplates of the lower lateral cartilages, As with the unilateral repair, the first reconstruction is the
and along the demarcation of the nasal and palate mucosa. nasal floor. The L-flap or lateral nasal mucosal flap is swung
As described with the incision extending from point 3 into across the cleft and sutured to the septal flap using 5-0 vic-
the nose in the unilateral cleft lip repair, this extension of the ryl sutures. Care is taken to advance the alar bases during
incision into the nose creates a limited superiorly based nasal this nasal floor closure to avoid restricting their appropriate
septal flap that is later sutured to the lateral nasal wall flap to placement. For the intraoral repair, the thinned mucosal flap
repair the nasal floor. The medial incisions from points 2 and (M) elevated off the prolabium is draped over the premaxilla
3 stop below the columella at points 4 and 5. and quilted down to the periosteum of the exposed anterior
The lateral lip dissection, including the decision to use an surface. This creates a new sulcus edge at the level of the colu-
L-flap or a posterior nasal wall back-cut, is the same as previ- mella base, which is anatomic. The lateral oral mucosa flaps
ously described in the unilateral cleft lip repair. Attention to are then advanced across the clefts and secured at the midline
dissecting the oral and nasal components of the orbicularis oris, to this new sulcus in the region of what would be the anterior
releasing the accessory cartilages of the nose to the piriform nasal spine. If this creation of a neosulcus is not performed,
9 4 P5 8
7 6
3 1 2 L
L
14 M 10 11
13
A
B
FIGURE 19.7. Repair of unmolded bilateral cleft lip deformity. A. Markings and landmarks for bilateral cleft lip repair technique. P, prolabial
flap; L, lateral mucosal flap; M, medial mucosal flap. See text for details. B. Bilateral complete lip before surgical repair. C. Immediate postopera-
tive result in the same patient. D. Nine months after the operation. There is good symmetry with minimal labial scars. The width of the prolabium
and interdomal space have slightly increased at the expense of the columella height.


C
D
the central oral mucosa will prolapse over the central teeth readmission post-discharge. Although most primary cleft lip
and create a long-lip deformity with redundant mucosa. repairs are routine elective procedures, the rate of early seri-
Once the nasal lining, intraoral lining, and sulcus have been ous complications was associated with medical comorbidities
repaired, the alar bases are brought into their appropriate and a surgeon with lower clinical volumes.16
position by suturing the opposing dissected nasal muscle flaps
to the periosteum of the upper premaxilla. It is important to Lip Adhesion
suspend this subnasal muscle sling high, just above the recre-
Lip adhesion is still occasionally used for wide clefts by sur-
ated oral sulcus, in order to support the nose. With the alar
geons not working with a team or those patients with lat-
bases in position, the oral muscle flaps are brought over the
eral maxillary collapse that does not respond to presurgical
premaxilla and sutured to each other. Although this can be
maxillary orthopedics. We have not used it in our institution,
the most challenging part in repairing wide clefts, it is essen-
even with wide clefts that have elected not to undergo presur-
tial to get muscle continuity across the lip. The oral and nasal
gical molding. Some supporters of lip adhesion cling to the
muscle flaps are then secured to each other under the nose.
belief that it improves maxillary arch alignment and enables
It is even more important to do this in the bilateral repair to
a more predictable correction of the cleft nasal deformity in
prevent the tight transverse oral muscle sling from separat-
select patients. The improved nasal results are thought to be
ing from the secured nasal muscle sling. If separation occurs,
secondary to improved alar base arch support, which reduces
the lip muscles slip over and inferior to the premaxilla, cre-
the strain and relapse tendency for the mobilized lower lateral
ating a long-lip deformity. The marginal lip muscle is then
cartilage.
repaired and the opposing white roll flaps sutured under the
The adhesion is classified as a straight-line muscle
prolabium. A z-plasty can be placed at the wet–dry vermilion
repair and begins with the complete marking of a rotation-
junction of each lateral lip flap to create a tubercle. The pro-
advancement cheiloplasty. An L-flap is elevated from the lat-
labial flap is thinned as much as possible given the vascular-
eral segment beginning approximately 3 mm medial to the
ity, and when insetting, a deep suture is placed in the sagittal
Cupid’s bow peak. This flap length provides adequate tissue
plane, from the dermis to the nasal sling muscle. This creates
for nasal release. The flap is turned 90° into the nasal release
a columella–labial angle and prevents the obliteration of this
along the lateral floor of the nose, which follows the piri-
angle when the prolabial flap is inset. The forked flaps created
form rim and the lateral portion of the nasal bones. A con-
lateral to lines 2-5 and 3-4 are not banked, but are instead
tiguous, maxillary sulcus incision is made through this nasal
trimmed to fit the remaining defect under the nose at the base
mucosal incision, and the lateral lip and cheek muscle mass is
of the columella.
elevated in continuity from the maxilla and piriform aperture.
The postoperative care of the bilateral cleft patient is the
The L-flap is sutured into the nasal defect, and the lateral lip
same as for the unilateral cleft patient.
element is advanced medially for closure.
An M-flap is also raised 3 mm from the Cupid’s bow peak
Complications Following Cleft Lip Repair to maintain symmetry of repair. The mucosal flap is based
A retrospective review of 23 institutions in the Pediatric on the maxillary alveolus and is turned into the alveolar cleft
Health Information System database reported that 1.4% had a to augment closure. All dissection is maintained outside the
serious medical complication (primarily airway related) in the margins for primary lip repair. No medial muscle dissection is
first 24 hours after surgery and that 1.9% had an unscheduled done at this stage.
Closure is achieved with sutures placed in the undissected micrognathia of Pierre Robin sequence, the procedure can be
orbicularis layer along the paired margin and is reinforced delayed until age 14 to 18 months to allow further mandible
with a chromic catgut mucosal closure between the M-flap growth and to decrease the chance of postoperative airway
and the lateral lip mucosa. Skin is generally closed with inter- compromise.
rupted 5-0 chromic catgut, with sutures placed outside the
markings for definitive cheiloplasty. The adhesion effectively Cleft Palate Repair Technique. The two common
closes the nasal sill and upper two-thirds of the lip. The forces cleft palate repair techniques are a two-flap palatoplasty
from the overlying muscle closure have an immediate effect on with intravelar veloplasty as a modification of the tech-
the position of the alveolar segments. nique described by Veau, Wardill, and Kilner (the “Oxford”
palatoplasty), or a single-stage two-flap palatoplasty with
Primary Cleft Palate Repair Furlow double-opposing z-plasty to achieve the levator
Although cleft lip and cleft palate surgeries are linked by a repositioning and lengthening of the palate. Both techniques
shared patient population, and both require a complete under- share a common approach to the hard palate and the goal of
standing of the abnormal anatomy by the surgeon, they are creating transverse orientation of the reconstructed levator
surprisingly different. A cleft lip repair is an artistic, flexible sling.
technique tailored to the unique three-dimensional anatomy of The patient is placed in the supine position, with a shoul-
each child, whereas a cleft palate repair is a technical recipe, der roll to extend the neck. A number of mouth retractors
the success of which depends on precise and atraumatic execu- have been designed for the operation, but all retract the lips
tion. Following a cleft lip repair, the parents appreciate the and tongue, open the jaws, and keep the endotracheal tube
hours of work of the surgeon because of the visible incisions out of the operative site. Care must be taken not to hyperex-
and facial difference, whereas following a cleft palate repair, tend the neck, not to strangulate the tongue, and not to bruise
the key portions of the operation, namely the nasal closure the lips. The mouth and nasal cavities are cleaned with normal
and the intravelar veloplasty, are hidden in the mouth by the saline and a small throat pack is placed. The hard and soft
transposed oral flaps. The success of the cleft lip repair can be palates and the nasal septum are infiltrated with lidocaine and
predicted at the end of the operation; results of the cleft palate epinephrine, avoiding injection directly around the greater
repair take years to assess and cannot be evaluated definitively palatine vascular pedicle. With pressure, the mucoperiosteum
until the commencement of speech and completion of facial can be hydrodissected from the hard palate with the injection
growth. Despite the lack of surgical glamour associated with a to facilitate elevation of the flaps.
palatoplasty, the patient with a cleft palate requires multidis- The lateral aspect of the mucoperiosteal flaps are incised at
ciplinary evaluation and treatment, a technically sound opera- the junction between the hard palate mucosa and the attached
tion, and standardized postoperative care to achieve the desired gingiva, and then the anterior portions of the flap are elevated
results while minimizing the potentially severe complications. from the hard palate. With a curved elevator, through this lat-
eral incision, the nasal mucosa can be elevated from the lat-
Timing of Surgery. The optimum timing of cleft palate eral nasal wall on the cleft side and posterior nasal spine on
repair balances the benefit of normal velopharyngeal function the non-cleft side in continuity with the oral flaps. The medial
to optimize speech development against the potential disad- aspects of the flaps are released along the length of the cleft
vantage of impaired facial growth secondary to early surgical from alveolus to the tip of uvula, following the visible junction
trauma. Graber’s description in the late 1940s of restricted between the oral and nasal mucosa. Care must be taken not
maxillary growth following early palate closure was accompa- to leave the nasal flaps deficient. The oral flaps can always be
nied by a recommendation to delay surgery until 4 to 6 years mobilized to the midline, whereas the mobility of the nasal
of age. Because of the deleterious implications of this recom- flaps is limited if they are cut too short. For the Veau tech-
mendation on speech development, the conventional timing nique, the anterior tips of the mucoperiosteal flaps are released
for cleft palate repair was arbitrarily set at 18 to 24 months as to increase visualization of the greater palatine pedicle, which
a compromise between speech and facial growth. The current is carefully preserved and dissected circumferentially. For the
consensus, based on an increased understanding of speech Langenbeck technique, the anterior attachment is left intact,
development, is that cleft palate repair should be completed such that the flaps are bi-pedicled to improve vascularity and
before 18 months of age; however, there is no general agree- decrease dissection in the region of the premaxillary suture.
ment regarding the earliest that surgery can be performed. The disadvantage of the Langenbeck technique is that it may
Since Graber’s earlier work, there have been a number of stud- leave an anterior fistula behind the alveolus unless care is
ies indicating that impaired maxillary growth in cleft patients taken to raise a gingivolabial flap to close this portion. The
is independent of cleft palate repair and may result from the visibility of the pedicle is also decreased.
lip repair alone or may be an intrinsic phenomenon. Two structures tether the oral mucoperiosteal flaps and
Results from previous retrospective studies examining the limit their mobilization across the cleft at the level of the
effect of timing of cleft palate repair on speech development posterior nasal spine. The first is the greater palatine pedicle,
are inconsistent and are compromised by small study numbers and the second is the abnormal attachment of the levator veli
and potentially confounding variables. The one thing that the palatini and tensor palatini muscles to the posterior hard pal-
surgical community agrees on is that long-term, well-designed ate. A number of techniques have been described for length-
prospective studies are required before the optimum timing of ening of the pedicle, including osteotomies of the foramen to
cleft palate repair can be determined. release the pedicle from the bone, or circumferential release
There are currently two common approaches to the timing of the periosteal cuff around the pedicle. One or both of these
of cleft palate repair in North America: (a) two-stage repair, techniques may be required to achieve tension-free closure of
with the soft palate repair and veloplasty performed at the the oral lining. The pedicle dissection should be performed
time of lip adhesion or primary lip repair, and the hard palate before release of the muscle from the posterior hard palate. If
repaired before 18 months, or delayed further with the use the pedicle is compromised during the dissection, the muscle
of an obturator; and (b) single-stage repair around the age of attachments are required to perfuse the mucoperiosteal flaps.
11 to 12 months. Our center practices the latter approach, The nasal lining is then separated from the muscles of the
delaying the surgery until the time when the child starts to soft palate using sharp fine scissors. There is no reliable dis-
demonstrate the introduction of plosives (b, d, and g) in their section plane within the first 2 or 3 mm of the cleft edge,
speech. It is at this time that they require an intact velopha- and we prefer to leave this edge of the nasal lining flap thick
ryngeal sphincter to continue with normal speech mechanics. to help with suturing. Immediately beyond the cleft edge,
In children with airway issues, such as those associated with however, there is a defined, gray, smooth dissection plane.

The dissection continues laterally to the lingual surface of the will compromise function of the levator sling during speech.
medial pterygoid plate. The nasal lining is dissected off the We repair the muscle sling with approximately three buried
medial pterygoid plate in a subperiosteal plane down to the horizontal mattress sutures of 3-0 vicryl.
skull base so that the nasal flaps can be approximated across In the primary Furlow technique, the levator transposi-
the cleft with minimal tension. tion occurs through double-opposing z-plasties of the nasal
The final stage of the dissection is the intravelar velo- and oral flaps, with the levator muscle left attached to the
plasty, which is essential for normal speech development. As posterior-based flap on each surface, and the anterior-based
described by Sommerlad,17 the normal velum consists of the flaps being mucosa and submucosa only (Figure 19.8). The
levator muscle in the middle 40% and the tensor aponeurosis release on each flap extends toward the hamulus, such that
in the anterior 33%. In the cleft palate anomaly, the two mus- when transposed, the posteriorly based muscle–mucosa flaps
cles are closely related, with the tensor aponeurosis attach- become transversely oriented, and the long axis of the z-plasty
ing to the posterior border of the hard palate and the levator shifts from transverse to sagittal, thereby lengthening the soft
inserting at the margins of the cleft in the anterior half of the palate. An additional benefit of the Furlow technique is felt
velum. The abnormal attachment of the tensor can be directly to be the raising of the nasal lining superiorly during the flap
visualized at the posterior shelf of the hard palate as obliquely transposition, such that the soft palate is in a more functional

oriented fibers. The fibers are sharply released from the edge position relative to Passavant’s ridge on the pharynx.

of the hard palate, and the tensor tendon is divided medial to The palate is repaired sequentially: the nasal closure from
the hamulus. This allows mobilization of the levator muscle, anterior to posterior, followed by the oral closure from pos-
so that it can be retrotransposed across the cleft. terior to anterior. In a bilateral cleft of the secondary palate,
For an intervelar veloplasty, the levator is dissected bilateral mucosal flaps are elevated from the caudal edge of the
sharply from the overlying palatoglossus on its oral surface as vomer with a midline incision and sutured to the opposing lat-
described by Cutting, or the oral lining is dissected under the eral nasal flaps using buried interrupted 5-0 vicryl sutures. The
submucous glands as described by Sommerlad. In either tech- posterior extent of the vomerine flaps is at the posterior nasal
nique, care must be taken to leave a thick, well-perfused oral spine. At this point, the nasal closure continues with direct
mucosa flap that can be advanced medially across the cleft, approximation of the nasal lining of the soft palate across the
independent of the posterior-medial rotation of the levator cleft back to the uvula. With a unilateral cleft, only one vomer-
sling. The repositioning of the levator sling from an oblique ine flap is required. If there is an associated cleft of the primary
orientation to a transverse one not only serves to create an palate, the nasal lining is repaired as far anteriorly as possible.
intact circumferential levator–pharyngeal sphincter for naso- Ideally, the nasal floor should have been repaired by the earlier
pharyngeal closure and speech but also serves to lengthen the cleft lip repair back to the incisive foramen, such that oronasal
soft palate. After nasal closure, the mobilized levator sling is separation can be completed at the time of the palate repair.
transposed across the cleft. The tension of the muscle repair This saves the child the inconvenience of an anterior oronasal
is based on surgeon experience. A repair that is too tight can fistula during the years after the palate repair, and also makes
lead to a decreased nasopharyngeal aperture and potential a secondary alveolar bone graft easier and potentially more
postoperative airway compromise. A repair that is too loose successful as nasal closure has already been achieved.
x x
A C
FIGURE 19.8. Double-opposing z-plasty closure of a unilateral cleft of the primary and secondary palates. A. Design of the incisions. Dotted
black lines mark the oral surface incisions; dotted grey lines mark the nasal surface incisions. The location of the greater palatine pedicle is in the
region of the blue circle. Dotted blue lines mark the posterior aspect of the hard palate. The tensor tendon as it crosses over the hamulus to fuse
with the levator aponeurosis is marked with an “X.” B. The levator muscle is left attached to the mucosa of the posteriorly based flaps in both the
oral and nasal linings and the z-plasties are transposed. C. Transposition of the double z-plasty changes the orientation of the levator muscle from
oblique para-sagittal to transverse. This recreation of the levator sling creates a functional soft palate for velopharyngeal competence.

Various techniques have been described for uvuloplasty, be indicated. Symptomatic oronasal fistulas are treated early
including bilateral Y incisions and truncating the tip of the with local mucosal flaps. Asymptomatic oronasal fistulas may
uvula to create a broad raw surface. None are ideal. With be left unrepaired until the time of another surgical procedure
wide cleft repairs under increased tension, the uvula tends to such as alveolar bone grafting.
widen at the base and decrease in projection. All techniques
have in common accurate eversion of the mucosal lining of
the uvula and repair of the muscle bundle at the base of the Operative Treatment of
uvula to decrease postoperative widening and prevent fistula Velopharyngeal Insufficiency
formation. Speech and Language Development. All children born
Oral closure is achieved using either 4-0 chromic or 5-0 with a cleft palate require examination by a speech patholo-
vicryl vertical mattress sutures. Two 3-0 chromic sutures are gist at regular intervals to allow timely intervention if a sig-
used to grasp the underlying nasal lining closure as part of the nificant delay develops in receptive or expressive language.
mattress suture. These close the dead space between the oral The diagnosis and workup of language difficulties require the
and nasal lining. Horizontal mattress sutures of 3-0 chromic multidisciplinary involvement of the speech pathologist, audi-
are also used to secure the anterior tips of the mucoperiosteal ologist, otolaryngologist, psychologist, and pediatrician, as
flaps directly to the back of the alveolus. In a bilateral cleft, the delay is not always secondary to mechanical problems of
the flaps are also secured to the posterior aspect of the pre- the velopharynx. Other potential contributing factors include
maxilla, where a very limited mucoperiosteal dissection is per- hearing difficulties, abnormal speech habits, psychosocial
formed after an angled blade has created a transverse cut to delay, and tongue restriction. VPI is the inability to achieve
create an edge to receive a suture. The original description of closure of the velopharyngeal port during sustained speech.
the two-flap palatoplasty included a “pushback” to lengthen The most common cause of VPI is a cleft of the secondary pal-
the palate, which left the anterior hard palate exposed. This ate; however, other less common causes include submucous
pushback technique has been discontinued following evidence cleft palate, neuromuscular abnormalities, adenoidectomy,
of impaired facial growth and the resulting large anterior fis- and congenital VPI of unknown etiology. Once other causes
tula and is unnecessary for lengthening if a proper levator of language delay have been ruled out, a formal VPI workup
muscle transposition is performed. is performed to diagnose the underlying dynamics of the velo-
Meticulous hemostasis is essential during the cleft palate pharynx and to recommend appropriate treatment.
repair. If there is any sign of oozing from the flaps or lateral
defects, the bleeding is stopped prior to waking the patient.
Some surgeons suture absorbable hemostatic material in the Velopharyngeal Insufficiency. Intelligible speech pro-
lateral defects, but recognize that this does not replace surgical duction requires reliable and voluntary function of the velo-
hemostasis. Any blood that has collected in the oropharynx is pharyngeal valve that controls communication between the
suctioned. The patient is placed in soft arm restraints, and the oral and nasal cavities. The valve is closed by contraction of
endotracheal tube is not removed until spontaneous breath- the pharyngeal muscles that advance the lateral and posterior
ing and purposeful movement is established. We recommend pharyngeal walls, as well as the levator sling that pulls the soft
postoperative oxygen saturation monitoring and close obser- palate (velum) posteriorly. If this palatopharyngeal sling is
vation in the recovery room for 1 to 2 hours prior to discharge incompetent, abnormal coupling of the nasal and oral cavities
to the ward. Intensive care unit (ICU) level care may be indi- occurs, which results in hypernasality, nasal emission, impre-
cated in syndromic or other complex patients. cise consonant production, decreased vocal intensity (loud-
ness), and short phrases. These are the typical signs of VPI,
Complications Following Cleft Palate Repair. Compli- which may be caused by either a structural defect or a physi-
cations of cleft palate repair include bleeding, respiratory ologic dysfunction.
obstruction, infection, dehiscence, and oronasal fistula forma- Tissue deficiency, pharyngomegaly, and neurogenic paresis
tion. Significant postoperative bleeding is rare, but if it occurs, of the velopharynx can all cause VPI. Not all patients who
it requires re-intubation and exploration for hemostasis. exhibit glottal stops, pharyngeal fricatives, or nasal emission
Respiratory obstruction is also rare in the absence of excessive have, however, VPI. Learned articulatory compensations such
bleeding, but is life-threatening. The airway is monitored care- as glottal stops and pharyngeal fricatives may be confused with
fully in the recovery room and only after adequate assessment velopharyngeal dysfunction. Phoneme-specific nasal emission
should the baby be transferred to the floor. We recommend is often confused with VPI, even though no resonance disor-
oxygen saturation monitors to be employed on the floor or der exists. Other aspects of phonatory, articulatory, and pro-
the patient can be monitored in an ICU setting if the airway sodic breakdowns may be unrelated to the competency of the
is tenuous or the patient is syndromic. Monitors alone are not velopharyngeal valve. If opening of the velopharyngeal valve,
a fail-safe prophylaxis. They are only as good as the response instead of closing, is the problem, abnormal uncoupling of
of personnel to the alarm. Pain control should be handled by the nasal and oral cavities results in hyponasality. This can
experienced staff, as overmedication with narcotics can easily be found in individuals with hypertrophic adenoid tissue and
lead to respiratory arrest in these patients. Infants with Pierre must be recognized before considering surgical intervention.
Robin sequence or other congenital anomalies affecting the Nonsurgical treatments of VPI include speech therapy, pros-
airway are at highest risk for airway problems. thetic management with speech bulb or palatal lift appliances,
Palatal fistulas may present as asymptomatic holes or may and posterior pharyngeal injections or implants. The next sec-
cause such symptoms as speech problems, nasal regurgitation tion focuses on the surgical treatment of VPI.
of fluids, or difficulty with oral hygiene. The most common
locations are at the region of the incisive foramen, the pos- Preoperative Velopharyngeal Insufficiency Evalua-
terior nasal spine, and the uvula. Fistula rate has previously tion. The goal of surgical intervention in patients with VPI
been reported at 10% to 15%, but in experienced hands is is to provide a mechanism for functional speech. The design
now 5% or less. Meticulous surgical technique to create of the surgical procedure is based on the velopharyngeal
intact, well-perfused flaps that are carefully approximated anatomy and the function, which is determined by a series of
across the cleft with minimal tension is the best prophylaxis clinical and radiographic tests. Clinical examination includes
against fistula formation. The use of biomaterials, such as a formal recording of the child’s speech before, during, and
acellular cadaveric human dermis, has been described as a after therapeutic intervention. Typical speech samples include
reinforcing layer on top of the nasal closure for wide clefts. isolated phonemes, words, phrases, and non-nasal reading
With a well-executed technique this should rarely, if ever, passages with the nares occluded and unoccluded to detect

acoustic differences associated with cul-de-sac resonance. advocated preoperative computerized tomography or mag-
Dynamic study of the pharynx by multiview videofluoroscopy netic resonance imaging angiograms in these select patients.
and nasopharyngoscopy is usually indicated. This test pro- Complications following pharyngeal flap surgery are con-
vides information regarding the posterior and superior move- siderable compared with those of primary cleft lip and palate
ment of the velum as well as the degree of medial excursion repairs. The Hospital for Sick Children in Toronto published
of the lateral pharyngeal walls during speech. In patients who retrospective data from a 7-year period in 1992 and reported
have been referred from another center, intraoral examina- an 8.2% risk of bleeding, a 9.1% risk of airway obstruc-
tion and nasopharyngoscopy will determine if an intravelar tion, and a 4.1% risk of sleep apnea. Five percent of their
veloplasty was performed at the time of cleft palate repair and cohort required eventual surgical revision of the flap. With
if the levator sling is functioning appropriately. With these changes instituted by this group based on their review, includ-
tests, the VPI team can determine if the problem is of insuf- ing closer observation and monitoring, increased education,
ficient length and/or excursion of the velum, sagittal orienta- and decreased number of surgeons performing the procedure,
tion of the levators, or poor excursion of the pharynx, which the total rate of complications decreased from 11% to 3.2%.
will determine whether correction requires a secondary pal- Bleeding decreased to 1.4%, airway obstruction to 3.2%, and
ate lengthening procedure such as a Furlow palatoplasty or if hospital stay decreased from 5.8 to 3.8 days. These two valu-

pharyngeal surgery is indicated. able reports emphasize the potential complications associated

After pharyngeal flap surgery, patients are followed closely with pharyngeal surgery, and the benefit of constant vigilance
by both the surgeon and the speech pathologist. Clinical and quality improvement at all centers.
evaluations and tape recordings are obtained at least every As expected, sleep apnea or upper airway obstruction is a
3 months for the first year and then annually for 3 to 5 years. potential complication of an operation whose purpose is to
Periodic acoustical analyses with the sound spectrograph are decrease the velopharyngeal airway. Although studies report
used to monitor speech characteristics postoperatively and up to a 35% incidence of abnormal polysomnograms follow-
should validate more subjective, perceptual ratings in judging ing pharyngeal flap surgery, the vast majority of these patients
the success of surgery. resolve within 5 months. Lesavoy20 concluded that “the sur-
geon may sometimes need to accept some transient upper
Pharyngeal Surgery for airway obstruction to achieve correction of velopharyngeal
insufficiency.”
Velopharyngeal Insufficiency
The nonvelar surgical management of VPI usually consists of Sphincter Pharyngoplasty. The sphincter pharyngo-
pharyngeal flap or sphincter pharyngoplasty. Both have been plasties performed today are modifications of either the
shown to be efficacious. Hynes or the Orticochea techniques. In both techniques, the
sphincter is constructed from bilateral superiorly based flaps
Pharyngeal Flaps. Pharyngeal flaps may be superiorly or raised from the posterior tonsillar pillars, including mucosa
inferiorly based. Most studies in the literature have not found and the palatopharyngeus muscle. In the Hynes pharyngo-
a difference on speech outcome between the two dissections. plasty, the flaps are transposed to the midline and inset into
The mucosal flaps are raised from the posterior pharyngeal a defect created by a transverse incision at the level of the
wall and attached to the soft palate so as to create a mid- flap base. In the Jackson modification of the Orticochea
line obstruction of the oral and nasal cavities between two technique, the flaps are sutured together with a small, supe-
lateral openings (ports). The amount of lateral pharyngeal riorly based, posterior pharyngeal flap.21 Subsequent authors
wall motion will determine how wide the flap needs to be to and studies have emphasized that the level of the sphincter
achieve velopharyngeal competence. If the flap is too narrow, is the most important predictor of success in both of these
hypernasality will persist from the inability of the lateral pha- techniques. The pharyngeal constriction must be high, at the
ryngeal walls to close the ports on either side of the flap. If level of palatopharyngeal closure. The tightness of the pha-
the flap is too wide, passive occlusion of the lateral port can ryngoplasty can be controlled by the degree of overlap of the
occur, and the patient will develop mouth breathing, hypona- tonsillar flaps.
sality, and possibly obstructive sleep apnea. Hogan18 popular- The procedure achieves both static and dynamic reduction
ized the concept of lateral port control based on his appre- in the velopharyngeal port with no disruption of the velum.
ciation of the previous work by Warren et al. in the 1960s. It is ideal when there is poor medial excursion of the lateral
These pressure-flow studies demonstrated that oropharyngeal pharyngeal walls and a short anteroposterior component of
air pressure decreases markedly when the port cross section velar competency. It has the advantage of allowing revision if
exceeds 10 mm2, whereas nasal escape of air is audible above necessary by re-elevating the flaps and adjusting the tightness
20 mm2. Sprintzen et al. introduced the concept of “tailor- of the sphincter.
made” flaps based on preoperative evaluation of lateral pha- In both sphincteroplasties and pharyngeal flaps, the ade-
ryngeal excursion.19 noid pad can limit the superior dissection and placement
The technique of pharyngeal flap surgery involves longitu- of the obstruction. For these patients, the otolaryngologist
dinal incisions through the mucosa and muscle down to the on the cleft team is consulted to determine if an adenoid-
fascia on each side of the posterior pharyngeal wall. Dissection ectomy should be performed first in order to optimize the
is continued along the fascia. A superiorly based flap is trans- subsequent sphincter pharyngoplasty or pharyngeal flap
versely incised inferiorly and raised to a level above the palatal placement.
plane, which usually corresponds to 1 to 2 cm above the tuber-
cle of the atlas. An inferiorly based flap is incised just below Pharyngeal Flap Compared with Sphincter Pharyngo‑
the adenoid pad. The flap is usually inset with turn-back flaps plasty. Studies comparing the two pharyngeal surgeries have
on the nasal side of the uvula, with or without opening the not documented a significant difference in speech outcome.
midline palate repair. The turn-back flaps from the nasal Both techniques have advantages and disadvantages and
mucosa are used to line the raw surface of the pharyngeal flap potential complications and require an experienced surgeon
to minimize postoperative contraction. The pharyngeal donor for success. The results of a prospective international mul-
defect of the flap is closed primarily. In patients with velocar- ticenter randomized trial of 97 patients treated with either
diofacial syndrome, the internal carotid arteries can have an pharyngeal flap or pharyngoplasty were reported in 2005.22
anomalous course that approaches the midline. The pharynx Although early (3 months) elimination of hypernasality was
is observed and palpated carefully for any abnormal pulsa- achieved in twice as many patients treated with a flap, there
tions in the region of the proposed flap. Some authors have was no significant difference between the two techniques after

1 year in terms of resonance, nasalance, endoscopic outcomes, no detrimental effect on facial growth or dental eruption. To
and surgical complications. Sleep apnea rarely resulted from date, NAM with primary GPP comes closest to this goal. In
either procedure. this technique, after NAM treatment has decreased the alveo-
lar cleft size to less than 2 mm and the edges are parallel, a
Treatment of the Alveolar Cleft very limited subperiosteal dissection is performed inside the
The preconference symposium of the 2004 ACPA annual alveolar cleft as described by Millard. Small flaps are then
meeting focused on treatment of the alveolar cleft. Three raised to create a closed tunnel of periosteum joining the
approaches were presented and debated: (a) early alveolar exposed facing bone edges of the alveolar cleft. Bone forms in
bone grafting in the first year of life with autogenous rib corti- this tunnel to close the gap without the need of grafting. GPP
cal graft as a separate operation; (b) presurgical NAM with requires presurgical orthopedics by a trained team and has
primary GPP at the time of primary lip repair; and (c) sec- been reported to have a 60% chance of avoiding secondary
ondary alveolar bone grafting as a separate operation during bone grafting. However, GPP requires further evaluation to
mixed dentition with autogenous iliac crest cancellous graft. confirm that it has no detrimental effect on maxillary growth
No conclusions regarding the superiority of one technique or on the developing tooth buds.
over another could be drawn at the end of the symposium. Recombinant human bone morphogenic protein-2
Each approach has been studied by its proponents to provide (rhBMP2) is a mitogen that has been demonstrated to stim-
data justifying its use. Secondary bone grafting at the time of ulate osteoblastic activity and induce bone nodule forma-
mixed dentition remains the traditional and the most com- tion in animals. It has been approved by the U.S. Food and
mon technique for treatment of the alveolar cleft, and as such Drug Administration for clinical use in human spine fusion
remains the standard by which other techniques are compared procedures and has been shown to decrease non-union,
(Figure 19.9).23 The ideal treatment for the alveolar cleft donor-site morbidity, and operating time over autogenous
would be a minimal surgical intervention performed without grafting in this population. More recent clinical applications
an additional anesthetic, with no donor-site morbidity, and have been on patients undergoing alveolar augmentation
A B
C
FIGURE 19.9. Unilateral alveolar bone graft. A. Markings for the superiorly based mucoperiosteal flap. The inferior tip of the flap consists of
attached gingival to resurface the oral lining of the cleft. Stenson’s duct is marked with a blue dot. The dotted line marks a previous scar from the
primary lip surgery. B. The anterior flap has been elevated and the intracleft flaps have been used to close the oral lining as well as the nasal lining.
C. A bone tamp is used to gently pack autogenous cancellous bone chips from the iliac crest from the incisive foramen to the labial surface of the
cleft. D. Advancement and closure of the flap over the bone graft. The advancement is facilitated by a deep periosteal release.

and implant placement, and early trials are now underway elusive. The goals of early cleft lip and nose reconstruction
at individual centers for the treatment of alveolar clefts. are that the cleft be undetectable by peers at conversational
The risk–benefit profile of rhBMP2 in these patients will distance by school age to minimize psychosocial stigmata
remain unknown for the next decade. Concerns include an and that an optimal final surgical result using up-to-date
inflammatory response, heterotopic ossification, potential techniques be complete by skeletal maturity. This is rarely
long-term carcinogenesis, and a detrimental effect on nor- achieved by one surgery in wide, complete clefts, resulting in
mal dental ligament development. Patient selection should the need for secondary cleft lip and nose procedures.
therefore be based on enrollment in an institutional review Each secondary surgery is approached with the following
board approved trial with appropriate consent and evalu- guidelines in mind:
ation, including oversight by an independent data safety
• Identify the primary repair that has been performed to
monitoring board.
appreciate how it will affect the planned revisions.
• Recognize the optimum age to achieve the surgical goals.
Orthodontic and Orthognathic Treatment If the child is too young, small, temporizing procedures are
Following Cleft Palate Repair performed to minimize the deformity and scarring until the

definitive procedure can be performed.
Studies on unrepaired cleft palates in developing countries sug-

• Find the normal landmarks and return them to their nor-
gest that the surgical intervention of cleft palate repair impairs mal positions.
future maxillary growth. Some individuals with cleft palate • Do not remove any tissue until certain that it will not be
may also have an intrinsic limited growth potential. Decreased useful.
maxillary width and the resulting lingual crossbite are com- • Treat each case individually—there is no routine secondary
mon and are managed by orthodontic maxillary expansion procedure.
with a fixed appliance. Once expansion is completed, the opti- • Use the basic plastic surgery principle of transferring tissue
mum time for bone grafting is chosen according to the stage from areas of excess to areas in need.
of canine development. If the graft is performed too early, it • Replace the lost tissue with similar tissue when prior sur-
can result in bone resorption as a consequence of a lack of gery, growth, or the lack of growth is responsible for the
mechanical stimulation from a tooth. If the graft is performed deficiency.
too late and the erupting canine root does not have sufficient
bone support, the tooth may be lost.
Maxillary retrusion or midface hypoplasia resulting in an Indications for Surgery. The indication for a secondary
Angle class III occlusal relationship with anterior crossbite can surgical procedure is a correctable deformity given the age of
be managed in childhood with a distraction device such as a the patient, which if not repaired, will remain or will result in
Delaire mask to aid horizontal growth, but eventually requires psychosocial or functional problems. The surgeon must recog-
orthognathic advancement. A plan of treatment is formulated nize that there are four perspectives of anatomic abnormalities
on the basis of clinical examination, photographs, cephalo- to be considered: those of the surgeon, those of the patient,
metric studies, and dental models. If surgery is indicated, pre- those of the parent, and those of peers or other members of
surgical orthodontics is required to align dental arches and society. Which perspective is predominant affects both the
to eliminate crowding and dental compensations. Le Fort I indication for surgery and the chance of a successful outcome.
maxillary advancement is performed at the time of epiphyseal When addressing a patient with a secondary deformity,
closure at skeletal maturity, approximately age 16 years for a it is first necessary to recognize the cause of the deformity.
girl and 18 years for a boy. Large advances greater than 1 cm Steffensen24 outlined reasonable requirements for lip repair:
can be difficult as a result of restriction from palatal scarring (a) accurate skin, muscle, and mucous membrane union; (b)
related to palate repair or previous pharyngeal flaps and are proper rotation of the deflected medial and lateral orbicularis
prone to relapse. Adding distraction osteogenesis to the Le oris muscle into a horizontal position; (c) a symmetric nostril
Fort I osteotomy allows larger advancements and, in general, floor and nostril tip; (d) an even vermilion border with repro-
prevents relapse. duction of the Cupid’s bow; (e) slight eversion or pouting of
Polley and Figueroa have studied and popularized Le Fort I the central upper lip; and (f) a minimal scar.
maxillary distraction osteogenesis using an external cranial
halo-based device. Intraoral devices are now also available Timing of Secondary Repair. As mentioned above, the
that are attached across the osteotomy and are activated goals of secondary repair of cleft lip and nasal deformities are
through a trans-mucosal arm. Once the permanent teeth have that the cleft be undetectable by a peer at conversational dis-
descended below the osteotomy site, the traditional Le Fort I tance by school age and that an optimal final surgical result
osteotomy is performed and the distraction device is applied. is complete by skeletal maturity. To achieve this, we perform
The segment can then be advanced at a rate of 1 mm a day presurgical NAM in early infancy, followed by a primary
to the desired position of overcorrection. This is followed by lip repair with repositioning of the nasal cartilages when the
a period of wearing the device without advancement during patient is approximately 3 months old and defer any revisions
which ossification occurs within the osteotomy and consoli- until just prior to school age. At that time, any indicated lip
dates the new maxillary position. The original consolidation revisions are completed to facilitate the child’s interaction
period of 8 weeks for the external device has been decreased with peers in a school environment. In the case of an obvi-
to 2 to 3 weeks by the use of a removable, elastic-traction, ous residual nasal deformity, such as that following repair
traditional, orthodontic face mask that is attached to the oral of an unmolded wide bilateral cleft, a minor nasal tip rhino-
splint after removal of the halo. Polley and Figueroa’s studies plasty through limited intranasal incisions can be offered. The
demonstrated stability of large maxillary advancements with optimal time to complete the nasal reconstruction, however,
distraction osteogenesis. In addition there was minimal detri- is in adolescence, when a formal open rhinoplasty with car-
mental effect on speech. tilage grafting, septoplasty, and/or osteotomies can be done.
If orthognathic surgery is anticipated, the final rhinoplasty is
best deferred until after this is complete, as the appearance of
Secondary Cleft Lip and Nose Surgery the nose will change following repositioning of the bone that
Increased understanding of the primary cleft anatomy and an supports the nasal base.
improvement in the technique of primary repair have reduced
the severity of residual deformities and the need for secondary Muscle Secondary Deformities. As described earlier in
corrections. Perfection in a single surgery, however, remains the chapter, the key to a successful cleft lip repair requires full

release of the abnormal attachments of the orbicularis muscle rotation-advancement following a straight-line repair includes
and repositioning of the marginal, oral, and nasal components the following: (a) the philtral scar on the cleft side is short;
to create oral continuity and competence. When discontinuity (b) the Cupid’s bow is pulled up toward the nostril; (c) the
is present in a unilateral cleft repair, a subcutaneous groove nostril floor is wide; and (d) the ala is displaced laterally and
or trough appears and the scar contracture, which is nor- downward.
mally seen only in the first few months after a repair, persists. A short upper lip following a Millard-type rotation repair
The groove is more readily apparent on lip animation, with usually requires revision with recreation of the defect and
bulging of the lateral muscle segments caused by unbalanced repeat rotation-advancement. Simple re-rotation and advance-
contraction. In a bilateral repair, lack of muscle continuity ment of skin only, without complete takedown of the mus-
will result in a grossly widened prolabium, unrestricted pre- cular repair, should be reserved for minimal deficiencies.
maxillary growth, lack of upper lip animation, and widened Additional lengthening may be obtained by adding a z-plasty
interalar distance (Figure 19.10). Secondary deformities of the or triangular inset flap placed close to the sill of the nostril
muscle require recreation of the cleft defect, and appropriate or just above the white roll, so that it is not readily apparent.
repositioning of the different functional layers. For symmetrically short upper lips following a bilateral
repair, again the relative contribution of the muscle, skin, and
Vermilion Deficiency and Irregularities. The most com- mucosa must be determined. Lengthening of the skin of the
mon irregularity is a “whistle notch” deformity. Notching is central upper lip typically involves advancing the lateral lips
usually caused by inadequate approximation of the marginal toward the midline. The most frequent secondary deformity
component of the orbicularis oris muscle within the red lip. of the bilateral cleft lip is paucity of the central lip. The thin
Deficiency of the free edge of the lip can often be treated by central vermilion (whistle deformity) is more commonly seen
reopening of the inferior incision, symmetric eversion of the after a Manchester-type repair, where the central lip has been
medial and lateral lip elements, and accurate layered approxi- corrected with abnormal prolabial mucosa that is deficient in
mation of the muscle. A z-plasty in the wet vermilion can also bulk and often dry or flaking. The single-stage Millard-type
minimize recurrence of the deformity. The width of the dry ver- bilateral repair, in which the red lip component of the lat-
milion should also be measured. If there is deficiency of the lip eral segments creates the central vermilion, usually leads to
above the wet–dry junction, then a combination of triangular better symmetry and a fuller vermilion tubercle. If a whistle
inset flaps or z-plasty may be required to achieve and even thick- deformity is present following a Manchester-type repair, the
ness. If wet mucosa is left above the wet–dry junction, scabbing best treatment is often to convert the repair to a Millard-type
will result. The labial frenum should always be examined if pattern. Bilateral Burrow triangle excisions are made above
there is a red lip contracture to ensure that it is not contributing the white roll of the lateral lip; the width of the prolabium
to the problem. If the lip is excessively thick on the cleft side, a is decreased; and vermilion, marginal muscle, and white roll
transverse ellipse can be excised at the wet–dry junction. from the lateral lip elements are brought under the prolabial
skin (Figure 19.10).
Short Upper Lip. Deformities of the unilateral lip repair
are mainly asymmetries and disproportions. One of the most Long Upper Lip. The long lip is more commonly found
readily visible deformities is an asymmetry between the verti- in bilateral than unilateral clefts. It is usually secondary to a
cal heights of the peaks of the Cupid’s bow. If the Cupid’s failure to resuspend the nasal muscle sling and oral sphincter
bow is not level, the cause should be identified and a surgi- up to the anterior nasal spine at the time of the primary repair.
cal solution created. Vertical shortening of the cleft lip scar is This results in the transverse oral muscle descending below the
not uncommon in the first few months following surgery, but protruding premaxilla, similar to a low belt line over a pro-
should settle within a year postoperatively. tuberant abdomen. This not only causes a long-lip deformity
A short lip following unilateral repair refers to a dimin- but also flattens the columella–labial angle and removes the
ished vertical distance from the Cupid’s bow white roll to the molding force of the muscle below the premaxilla such that it
base of the columella, the alar base, or both. The most com- remains prominent. To correct this, the entire lip needs to be
mon cause of the short lip is inadequate lengthening at the opened and proper primary lip repair performed.
primary repair. Careful evaluation is required to determine In other cases of long upper lip in both unilateral and bilat-
if the vertical deficiency is primarily cutaneous, muscular, eral cleft lips, the problem is not an increase of vertical height,
mucosal, or all of them. The deficiency typically involves the but rather a prolapse of the intraoral vestibule. If the vestibule
medial lip element, but in some secondary cases the lateral lip sulcus had not been suspended in an anatomic position at the
is also short. If the alar base had not been adequately released time of the primary repair, then the wet mucosa falls down,
and repositioned at the primary surgery, the nasal deformity covering the maxillary teeth. This is often accentuated when
can also mask some of the vertical deficiency of the upper lip. the patient smiles and the mucosa is squeezed against the
The distance from the alar bases to the Cupid bow white roll labial surface of the teeth. Patients referred with this second-
should be compared with each other and then with the dis- ary deformity are often misdiagnosed with redundant mucosa
tance from the midpoint of the columella base. If the cleft-side and undergo transverse resection. If this is performed, the
alar base is still displaced inferiorly, and the upper lip is also patient will end up with an obliteration of the anterior sulcus
short, then a full revision is required with recreation of the and the lip tethered to the attached gingival of the premaxilla.
defect, release and repositioning of the alar bases and muscle, To distinguish a prolapsed sulcus from redundant mucosa, a
and lengthening of the lip either through a re-rotation of the cotton tip applicator is placed behind the lip and pushed up
medial lip and advancement of the lateral lip similar to the to simulate the appropriate sulcus height. If this corrects the
primary rotation repair, or with a combination of triangular deformity, then resuspension and recreation of the sulcus is
inset flaps from lateral to medial. If the alar bases are sym- required and not mucosal resection.
metric, however, and the deficiency is limited to the lip alone, In rare cases when there is isolated vertical excess of upper
the surgeon needs to determine if the oral component of the lip skin following unilateral or bilateral repair, a transverse
orbicularis is appropriate. If not, the lip must again be opened resection of skin under the nose can be performed followed
and reconstructed. If the muscle sphincter is correct, then a by resuspension of the oral muscle into an elevated position.
limited skin repair can be performed.
If a straight-line repair was performed primarily, it will Tight Upper Lip. A tight upper lip that cannot be cor-
not interfere with a subsequent rotation-advancement revi- rected sufficiently with local flaps requires a donation of tis-
sion, which will advance the alar base medially and lengthen sue from the lower lip via an Abbe flap. This is uncommon
the columella on the cleft side. The ideal indication for in unilateral repairs, but can be required following a bilateral


A B
D
FIGURE 19.10. Secondary bilateral cleft lip repair with functional muscle sphincter reconstruction. A. At the time of the primary repair, a
functional muscle reconstruction had not been achieved resulting in widened prolabium, scars, and interalar distance. Oral competence and ani-
mation was also limited. B. Surgical markings for reduction of the prolabial width. The white roll underneath the new prolabium will come from
the lateral lip elements. C. Dissection and release of the three components of the orbicularis oris muscle. The upper forceps is grasping the nasal
component and the lower forceps is grasping the oral component. The marginal component remains attached to the red lip mucosa. D. Surgical
result in the same patient 5 years later. With a functional muscle repair, the prolabial width is maintained and the scars are favorable.
repair that had complications. The Abbe flap improves the lip can be excised or alternatively it can be used to lengthen
balance between the upper and lower lips by bringing com- the columella, creating a central defect in the upper lip. A full-
paratively excessive tissue from the pouting lower lip to the thickness flap is designed centrally on the lower lip to recon-
tight upper lip that is deficient of tissue. The scar on the upper struct the aesthetic subunit of the upper lip philtrum. The

donor defect on the lower lip should not violate the mental the abnormal attachment of the nasal accessory cartilages
crease. The flap is rotated on a mucosal bridge containing an to the piriform rim is released in order for the alar base to
intact labial artery and vein that are found at the level of the be moved anterior, medial, and superior into the desired
vermilion border on the lingual (inner) side of the lip. The position. Because of the lack of skeletal support, the alar
pedicle is divided after 10 to 14 days, and the flap is inset. The base on the cleft side can, in some cases, become retroposi-
white roll of the flap segment must line up perfectly with that tioned with growth, even following an appropriate primary
of the lateral lip elements. Up to one-third of the lower lip can correction. If the patient is undergoing secondary alveolar
be harvested while still achieving primary closure of the donor bone grafting at the time of mixed dentition, this is the best
defect. If the muscle sphincter of the upper lip is in continuity, time to augment the deficient piriform rim with autogenous
the Abbe flap can be designed as a skin/mucosal flap to wrap cancellous onlay bone graft. The bone graft will elevate and
around the native orbicularis muscle. support the alar base to achieve symmetry and provide a
stable base for the remainder of the nasal reconstruction in
Premaxillary Setback. The complete bilateral deformity is the teenage years.
characterized by protrusion of the premaxilla and collapse of In the bilateral cleft deformity, the anterior nasal spine is
the lateral alveolar segments. Following repair of the orbicu- absent, and the footplates of the lower lateral cartilages rest
laris oris at the time of the primary repair, the segments are on the muscle repair over the premaxilla. Prior to the defini-
typically naturally molded by the muscle tension. In rare cases, tive secondary rhinoplasty, the position of the premaxilla must
persistent premaxillary protrusion may occur. With the help be assessed. If the patient has not yet undergone orthodontic
of the team orthodontist, the decision is made whether a pretreatment, the premaxilla can be retrusive or protrusive. Both
maxillary setback is required as an orthognathic procedure. deformities will affect the appearance of the nose and should
Premaxillary setback should only be performed by an experi- be corrected before a rhinoplasty is undertaken. In the unfor-
enced surgeon, as the vascular supply of the premaxilla is pre- tunate event that the premaxilla is absent, either because of
carious and loss of the entire premaxilla and central teeth can inappropriate resection or iatrogenic loss, prosthetic replace-
occur. In some cases, the lip repair has formed a constricting ment is needed to provide a base support for the nose and lip.
band superior to the premaxilla forcing the premaxilla inferi- A number of cleft patients will require orthognathic sur-
orly. Not only does the premaxilla continue to project, but its gery following orthodontics because of midface retrusion.
severe inferior malposition may result in the incisor teeth biting Ideally, the definitive rhinoplasty should be delayed until after
into the lower gingivobuccal sulcus. In this circumstance, resec- the maxillary advancement has been completed. The Le Fort
tion of a short section of vomer stem with repositioning of the segment contains the anterior nasal spine, which will affect
premaxilla, mucosal repair, and alveolar bone grafting may be the columella–labial angle and nasal tip projection.
required. Premaxillary setback and repositioning should only
be performed with the guidance of an orthodontist to plan for Nasal Dorsal Bone and Cartilage. The unilateral cleft
future dental rehabilitation and facial contour aesthetics. lip nasal deformity often includes a deviated bony and carti-
laginous nasal septum with or without deviation of the nasal
bones. If the nasal bony pyramid is symmetric, it can be mobi-
Secondary Cleft Lip Nasal Repair lized as a “monobloc” and centralized. If the pyramid is asym-
If the alar base position, the nasal component of the orbicu- metric, independent movements of the nasal bones will be
laris, and the nasal floor have been appropriately corrected required. We use a 3-mm osteotome percutaneously to control
and repaired at the time of the primary surgery, the majority the nasal osteotomies.
of the most challenging secondary deformities seen in adoles- The deviated nasal septum can be treated with a septo-
cence can be avoided. After an inadequate primary repair, the plasty, using sutures and scoring to straighten the nasal pas-
next most common cause of severe nasal deformities is mul- sage, or, alternatively, with a submucosal resection if cartilage
tiple, repeated open nasal procedures throughout childhood, graft is required for the nasal tip, leaving a 1-cm dorsal and
leading to heavy scarring, poor vascularity, and decreasing ventral L strut for support. In both cases, the base of the sep-
returns with each operation. The over-operated nose can be tum is mobilized and centralized using a permanent suture
a devastating deformity for a teenage cleft patient, with few through the periosteum of the nasal spine. If the septal carti-
options available to restore nasal form and function. lage is too weak to support the new position, onlay strut grafts
Any nasal surgery prior to adolescence should be limited are used to reinforce the nasal tip projection.
to repositioning of the muscle and cartilage such that natural As with any rhinoplasty, the preoperative evaluation
nasal growth will ameliorate the majority of the deformity. includes an intranasal examination. In the cleft deformity,
Resection of cartilage and cartilage grafting should be avoided the ULC is inferiorly displaced. This can clearly be seen on
in the growing nose, except in cases of severe iatrogenic sec- intranasal examination of an infant undergoing primary
ondary deformities. repair. An associated collapse of the internal nasal valve
The literature is replete with numerous approaches to sec- between the septum and ULC with nasal obstruction on
ondary repair of the cleft lip nasal deformity. Many older inspiration can be treated with spreader grafts using either a
techniques are still useful in certain circumstances, but should closed or open technique. This can also increase the width of
be used within the current paradigm of a systematic anatomic the middle third of the nose to improve symmetry in unilat-
evaluation of the deformity followed by an equally systematic eral cleft deformities. The spreader graft can also be extended
treatment plan. Just as techniques first used in the treatment to create increased support for the lower lateral cartilages of
of cleft patients formed the basis of the aesthetic rhinoplasty, the nasal tip.
many of the techniques that have recently evolved in aesthetic In severe bilateral cleft deformities that have undergone
plastic surgery have been adopted by cleft surgeons. Each numerous previous procedures, a cantilevered rib graft may be
component of the deformity must be addressed in an orderly required. This is often indicated in patients with saddle nose
manner: skeletal base, nasal dorsal bone and cartilage, nasal deformities from over-resection of the cartilaginous septum
tip cartilage, and, finally, the skin envelope.25 and an associated flattened nasal pyramid.
Skeletal Base. Like all facial structures, the nose is sup- Nasal Tip Cartilages. The medial and lateral crura of the
ported by the underlying skeleton. The cleft deformity is not alar cartilages in the secondary deformity are often displaced
restricted to skin and cartilage. In the unilateral deformity, posteriorly on the cleft side, with the lateral crus displaced lat-
the piriform rim under the ipsilateral alar base is deficient of erally. This causes collapse of the nasal tripod, alar rim hood-
bone and is retrusive. During the primary cleft lip surgery, ing, and lateralization of the genu of the nasal dome. Older

techniques transposed subsections of the displaced cartilages attempts to correct the deformed, deficient, and scarred skin
and are rarely indicated. The current consensus is to reposition envelope of a secondary or tertiary rhinoplasty. All cleft surgeons
the entire lower lateral cartilage structure using an open tip have experienced the satisfaction of constructing a formidable
rhinoplasty. Unlike a non-cleft rhinoplasty, simple reposition- cartilage framework, only to see it compromised under compres-
ing with nasal tip sutures is typically insufficient to correct the sion when the skin is re-draped. The delicate anatomy of the
cleft deformity. After the native cartilage framework is recon- natural soft triangle and nasal dome cannot be created with cur-
structed, autogenous cartilage grafting is required to strengthen rent secondary techniques, but should remain our goal.
the new position and to augment the nasal tip projection. Graft In teenage bilateral cleft patients if nasal growth has taken
augmentation is rarely indicated before adolescence. place without the genu of the lower lateral cartilages approxi-
In the unilateral deformity, a “springboard” non-anatomic mated, the columella skin will be either short or almost
alar batten graft is often required to maintain alar rim curva- absent, and the nasal tip will be wide and flat. Re-draping
ture. The graft is harvested from the septum and is anchored this deformed skin envelope over a cartilage reconstruction to
in a subcutaneous pocket at the alar base. The graft is then create a natural columella is difficult. In order to avoid this
bent under mild tension over the lower lateral cartilage and added challenge, performing a limited tip rhinoplasty just
secured to the nasal dome. The lateral crus is then secured to prior to the nasal growth spurt can close the interdomal space

the undersurface of the graft. The graft is non-anatomic and such that the subsequent growth lengthens the columella skin

should follow the alar rim from base to top, instead of head- and minimizes the cutaneous deformity faced in the definitive
ing posteriorly in the lateral nostril. The springboard effect of rhinoplasty in adolescence or thereafter. This surgery can be
the graft will create and maintain the desired alar rim curva- performed at age 4 to 5 but is limited to patients with palpable
ture when the skin is re-draped. divergence of the nasal domes (Figure 19.11).
In the bilateral cleft lip nasal deformity, the displaced In the unilateral deformity, the deformed skin envelope
lower lateral cartilages are addressed in a fashion similar to often overhangs the nostril apex. The Tajima “inverted U” nos-
that described above. Compared with the unilateral defor- tril apex incision can help to address this problem. The skin flap
mity, however, the nasal tip projection and support is more left attached to the inferior edge of the lower lateral cartilage
deficient. Columella cartilage strut grafts or septal extension turns over to form the inner lining of a constructed soft triangle.
grafts as described by Byrd26 are required to provide support A similar turnover flap approach can be used secondarily if the
to the nasal tip construct. After medialization of the genu of underlying cartilage is already in the correct position.
the lower lateral cartilages to the midline to create a nasal In the bilateral cleft lip nasal deformity, the skin envelope
dome, multiple onlay tip grafts are usually required to achieve is deficient vertically, from the nasal tip to the base of the
the desired shape and projection. columella. When closing the open rhinoplasty, the relatively
lax lateral tip skin is advanced toward the nasal tip when
Skin Envelope. A principal argument for an aggressive pri- the rim incisions are closed, in order to create sufficient skin
mary rhinoplasty in infancy is the frustration associated with for the nasal tip and columella closure. In severe deformities,
B
FIGURE 19.11. Early open nasal tip rhinoplasty for bilateral cleft lip deformity. A. At age 4, the patient’s nasal growth was following a pattern of
progressive relative columella shortening, increased nasal tip width, and decreased alar height. There was palpable divergence of the nasal domes.
Without early treatment, this deformity would pose a significant surgical challenge at the time of the definitive teen age rhinoplasty. B. Open nasal
dissection was performed limited to the lower lateral cartilages, leaving the intradomal fat attached to the skin envelope. The interdomal fat was
not removed. C. Using 5-0 PDS interdomal sutures (Ethicon, Somerville, NJ), the genu of the lower lateral cartilages we approximated and the skin
redraped. D. Five years later, the subsequent nasal growth and lengthened the c olumella and maintained alar height. The adaptation of the skin
envelope will be favorable for the definitive rhinoplasty at maturity.

C D
however, the skin envelope is too tight to drape over the car- deformities, especially those involving the nose, remains a chal-
tilage construct with tension-free closure at the columella inci- lenge and is still best treated by preventative surgery at the time
sion. Techniques that borrow skin from the upper lip, such as of the primary repair. Recent “inductive” techniques, such as
a V-Y advance, result in scarring at the lip–columella junction NAM and distraction osteogenesis, have improved care over
but may be required. Techniques that borrow from the hori- the past decade, and as comparable advances in plastic surgery
zontal laxity of the nasal tip skin, such as the McComb and occur in the future, a child born with a cleft can look forward
Brauer alar lift incisions, result in additional scars on the nasal to fewer operations with better aesthetic and functional results.
tip. Both approaches therefore have limitations and no ideal
alternative currently exists. References
Nostril Stenosis. Nostril stenosis, or a “micronostril defor- 1. Marazita ML, Murray JC, Lidral AC, et al. Meta-analysis of 13 genome
scans reveals multiple cleft lip/palate genes with novel loci on 9q21 and
mity,” can be one of the most difficult late complications asso- 2q32-35. Am J Hum Genet. 2004;75:161-173.
ciated with cleft lip repair. It is considerably easier to narrow a 2. Latham RA. Orthopedic advancement of the cleft maxillary segment: a pre-
nostril than to enlarge it. In general, any circumferential nasal liminary report. Cleft Palate J. 1980;17:227-233.
lining incision is associated with a high incidence of nostril 3. Grayson B, Cutting C, Wood R. Preoperative columella lengthening in
bilateral cleft lip and palate. Plast Reconstr Surg. 1993;92:1422.
stenosis. Intranasal z-plasties or composite grafts can be used 4. Ross RB. Treatment variables affecting facial growth in complete unilateral
if there is a localized constriction. If the patient has a micro- cleft lip and palate. Cleft Palate J. 1987;24:5-77.
nostril with constricted nasal floor and a medial displacement 5. Robertson NR. Facial form of patients with cleft lip and palate. The long-
of the alar base, a small inferiorly based nasolabial flap can term influence of presurgical oral orthopaedics. Br Dent J. 1983;155:59-61.
6. Lee CT, Grayson BH, Cutting CB, Brecht LE, Lin WY. Prepubertal midface
be used to correct both deformities. Long-term postoperative growth in unilateral cleft lip and palate following alveolar molding and gin-
use of nasal stents is required to minimize the chance of recur- givoperiosteoplasty. Cleft Palate Craniofac J. 2004;41:375-380.
rence, but, unfortunately, is limited by patient compliance. 7. Berkowitz S, Mejia M, Bystrik A. A comparison of the effects of the Latham-
An active nostril expander using a small jackscrew has been Millard procedure with those of a conservative treatment approach for den-
tal occlusion and facial aesthetics in unilateral and bilateral complete cleft
described by the group in Miami. In a compliant patient, this lip and palate: part I. Dental occlusion. Plast Reconstr Surg. 2004;113:1-18.
may be the best option available. 8. Millard DR, Latham R, Huifen X, Spiro S, Morovic C. Cleft lip and palate
treated by presurgical orthopedics, gingivoperiosteoplasty, and lip adhesion
(POPLA) compared with previous lip adhesion method: a preliminary study
Conclusion of serial dental casts. Plast Reconstr Surg. 1999;103:1630-1644.
9. Brauer RO, Cronin TD. The Tennison lip repair revisited. Plast Reconstr
Many plastic surgeons were drawn to their surgical specialty Surg. 1983;71:633.
after seeing a cleft lip repair. Cleft care stands out as a rare 10. Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation
opportunity to have a huge impact on an infant’s future psy- technique. Plast Reconstr Surg. 2005;116(1):61–71.
11. Millard DR. Refinements in rotation-advancement cleft lip technique. Plast
chosocial well-being and to follow these children over the Reconstr Surg. 1964;33:26.
formative years of their lives. Once in practice, the cleft sur- 12. Mohler LR. Unilateral cleft lip repair. Plast Reconstr Surg. 1987;80:511.
geon is reminded of the success, as well as of the failure, of 13. Stal S, Brown RH, Higuera S, et al. Fifty years of the Millard rotation-
his/her primary operations for years to come. Modern cleft advancement: looking back and moving forward. Plast Reconstr Surg.
2009;123(4):1364-1377.
surgical techniques, preoperative orthodontics, and specialized 14. Gosla-Reddy S, Nagy K, Mommaerts MY, et al. Primary septoplasty in
multidisciplinary team care enable us to achieve more consis- the repair of unilateral complete cleft lip and palate. Plast Reconstr Surg.
tent favorable primary surgical results. Repair of secondary 2011;127(2):761-767.

15. Mulliken JB. Primary repair of bilateral cleft lip and nasal deformity. Plast 21. Jackson IT, Silverton JS. The sphincter pharyngoplasty as a secondary
Reconstr Surg. 2001;108:181. procedure in cleft palates. Plast Reconstr Surg. 1977;59:518.
16. Hopper RA, Lewis C, Umbdenstock R, Garrison MM, Starr JR. Discharge 22. Abyholm F, D’Antonio L, Davidson Ward SL, et al. Pharyngeal flap and
practices, readmission, and serious medical complications following pri- sphincteroplasty for velopharyngeal insufficiency have equal outcome at
mary cleft lip repair in 23 U.S. children’s hospitals. Plast Reconstr Surg. 1 year postoperatively: results of a randomized trial. Cleft Palate Craniofac
2009;123(5):1553-1559. J. 2005;42(5):501-511.
17. Sommerlad BC. A technique for cleft palate repair. Plast Reconstr Surg. 23. Abyholm EE, Bergland O, Semb G. Secondary bone grafting of alveolar
2003;112:1542. clefts. Scand Reconstr Surg. 1981;15:127.
18. Hogan VM. A clarification of the surgical goals in cleft palate speech and 24. Steffensen WH. [Further experience with the rectangular flap operation for
the introduction of the lateral port control (l.p.c.) pharyngeal flap. Cleft cleft lip repair]. Plast Reconstr Surg. (1946) 1953;11:49-55.
Palate J. 1973;10:331-345. 25. Cutting CB. Secondary cleft lip nasal reconstruction: state of the art. Cleft
19. Shprintzen RJ, Lewin ML, Croft ML, et al. A comprehensive study of Palate Craniofac J. 37:538.
pharyngeal flap surgery: tailor-made flaps. Cleft Palate J. 1979;16:46. 26. Byrd HS, Andochick S, Copit S, Walton KG. Septal extension grafts:
20. Lesavoy MA, Borud LJ, Thorson T, Riegelhuth ME, Berkowitz CD. a method of controlling tip projection shape. Plast Reconstr Surg.
Upper airway obstruction after pharyngeal flap surgery. Ann Plast Surg. 1997;100:999-1010.
1996;36:26-30; Discussion 1-2.


Chapter 20 n Congenital Melanocytic Nevi
histologically from common acquired melanocytic nevi. In a

Overview giant CMN, the morphology of nevus cells can vary and is
Congenital melanocytic nevi (CMN) are rare pigmented usually more complex. Several histologic patterns have been
lesions that are believed to form between weeks 9 and 20 of identified, such as compound or dermal nevus, blue nevus,
gestation. Most are sporadic, but familial association is occa- neural nevus, and epithelioid cell nevus.
sionally observed. Color ranges from light to dark brown
and may appear blue in more darkly pigmented individuals.
Lesions have well-defined borders, but vary considerably in
Clinical Characteristics
size, pattern, and anatomic location. Although some lesions CMN may appear initially as a hairless, pale brown flat lesion
are flat, most cause some degree of skin surface distortion. at birth, which evolves with time to develop variegation and
Small nevi are defined as those <1.5 cm in largest dimension, hyperpigmentation. Dark, coarse hair may develop during the
while medium-sized nevi are those between 1.5 and 19.9 cm. first 1 to 2 years of life. By 10 years of age, the lesions often
Giant nevi have most commonly been defined as those that are develop a verrucous texture and become more elevated, with
>20 cm in greatest dimension in adulthood. Because congenital hypertrichosis and hyperkeratosis. Surface morphology var-
nevi enlarge with overall growth, this 20-cm figure corresponds ies widely and can be rugose, popular, pebbly, or even cere-
roughly to a 9-cm scalp or a 6-cm trunk lesion in an infant.1 briform appearance. Nodule formation typically represents
Other definitions relating the lesion’s size compared with body benign neurotization in the nevus. CMN may be associated
surface area define a giant nevus as one covering more than 1% with multiple smaller satellite lesions dispersed over the trunk,
total body surface area in the head and neck or 2% or more extremities, or head and neck, with satellite lesions present in
body surface area elsewhere. Giant nevi have also variously around 80% of giant CMN.
been defined as lesions larger than 100 cm2, covering more than The most common anatomic location for a giant CMN
5% total body surface area or a lesion that cannot be excised in is the posterior trunk, followed in frequency by the extremi-
a single surgery. As it is more difficult to determine the size of a ties and head and neck.3 Giant nevi may be found in specific
lesion relative to the body surface area, the majority of authors anatomic patterns, such as the “bathing trunk” and “glove-
report nevus size in terms of the greatest dimension of the lesion. stocking” distributions. Some interesting variants of CMN
include the “kissing nevus,” occurring on adjacent aspects of
the upper and lower eyelids, appearing as a single contiguous
Epidemiology lesion when the eyelids are closed. This pattern suggests CMN
Approximately 1% of the general population is thought to development between the 9th and 20th weeks of gestation,
have CMN, most of which are of the small variety. The inci- where the eyelids are still fused.
dence of giant CMN is estimated at 1 in 20,000 live births.2 The differential diagnosis for CMN includes other con-
The very large “bathing trunk” examples are rarer still, occur- genital pigmented lesions, such as epidermal nevus, nevus
ring in approximately 1 in 500,000 live births. sebaceous, café au lait spot, and Mongolian spot. Other
developmental anomalies may be associated with CMN,
particularly of the giant size, such as spina bifida, scoliosis,
Embryology, Genetics, and elephantiasis, clubfoot, and cranial osseous hypertrophy.
Histology Patients with multiple small CMN should be distinguished
from adults with multiple, acquired dysplastic nevi. This is an
Congenital nevi are theorized to represent a disruption of entirely different condition.
the normal growth, development, and migration of melano-
blasts. Melanoblasts migrate from the neural crest to vari-
ous sites in the body, including the skin, leptomeninges, eyes, Complications of Congenital
and ears between the 8th and 10th weeks of gestation. These
cells subsequently differentiate into dendritic melanocytes. Melanocytic Nevi
Abnormalities in neuroectodermal development and arrested
migration or differentiation of melanoblasts result in the for- Malignant Transformation
mation of a CMN. CMN contains nevus cells and is present at When melanoma is reported, it tends to occur in the trunk3
birth or, in some cases, may appear within the first year of life. and head and neck. It has never been reported in satellite
Nevus cells are distinguished from melanocytes by their lack lesions. Less than 0.5% of melanomas appear in preadoles-
of dendrites. The genetic etiology of CMN has been hypoth- cent children, but 33% of those that do are thought to arise
esized to involve hepatic growth factor/scatter factor, which is from CMN. Features that should prompt biopsy, if not com-
involved in the migration and development of neuroectoder- plete early excision, include those suggestive of dysplasia or
mal cells and found in large amounts in CMN. melanoma, such as ulceration, uneven pigmentation, bleeding,
Characteristic histologic features of CMN include the a change in shape, focal growth, or pain.
following: (1) nevus cells within the middle to deep reticu- When considering malignant transformation, it is essential
lar dermis and subcutaneous tissue or deeper structures; to distinguish between small and giant CMN. The lifetime
(2) nevus cells extending between collagen bundles in the risk of melanoma arising in small CMN has been reported
reticular dermis (“Indian” files) and around sebaceous glands, to range between 0% and 5%7; however, in clinical practice
sweat glands, and hair follicles; (3) infiltration of arrector pili malignant transformation is exceedingly rare in these small
muscles by nevus cells; and (4) perifollicular and perivascular lesions. The risk in giant CMN has been reported to range
distribution of nevus cells resembling an inflammatory reac- between 0% and 42%.8-11 Two prospective studies reported
tion. Small CMN may demonstrate dermal, junctional, or com- a cumulative 5-year life-table risk of developing melanoma in
pound nevus patterns, with some specimens indistinguishable giant CMN of 2.3%12 and 4.5%,1 respectively. The lifetime
200
Chapter 20: Congenital Melanocytic Nevi 201
risk was estimated to be at least 6.3%.13 Risk factors for the
development of melanoma in CMN include large size (diam-
eter > 20 cm), younger age (3 to 5 years), and multiple lesions
(three or more). If melanoma does develop, the pattern differs
between giant and small nevi. In giant CMN, melanoma usu-
ally develops deep to the dermal–epidermal junction or occurs
extracutaneously (e.g., the central nervous system [CNS] or
retroperitoneum) and is more difficult to detect. When malig-
nant transformation occurs in small CMN, this tends to origi-
nate in the epidermis and often demonstrates a morphology
similar to superficial spreading melanoma. Around 70% of
melanomas in giant CMN occur by age 13, with 50% arising
in the first 3 years of life, 10% later in childhood, and another
10% by puberty. Therefore surgical excision should be per-
formed in early childhood. Transformation may occur later in

life, and underscores the importance of long-term follow-up,

even after surgical intervention. Other tumors with reported
increased incidence in patients with large CMN include rhab-
domyosarcoma, malignant cellular blue nevus, differentiated
small round cell cancer, and spindle cell malignant tumor with
lamellar differentiation.
FIGURE 20.1. MRI scan of a patient with a giant congenital pigmented
nevus involving the torso and lower extremities who was found to have
Neurocutaneous Melanosis an asymptomatic focus of leptomeningeal melanosis within the cerebel-
lum (arrow). The plan to resurface the cutaneous congenital pigmented
Large CMN may occur in the setting of neurocutaneous mela- nevus was not altered given that the focus of leptomeningeal melanosis
nosis, in which collections of melanocytes are present in the was asymptomatic, and the patient was followed with regular neuro-
leptomeninges. Malignant transformation can occur in this con- logic examinations.
dition and result in primary CNS melanoma. Neurocutaneous
melanosis is a result of dysregulation in proliferation and
migration of melanoblasts in the CNS, resulting from an error
in embryonic development. Even without malignant transfor- even suggested starting intervention at 6 months of age, with
mation, neurocutaneous melanosis can carry significant mor- completion of staged surgeries before school age, so as to pre-
bidity and mortality from seizures, hydrocephalus, cranial vent stigmata associated with CMN and reconstruction.15 No
nerve palsies, developmental delay, and other signs of CNS clear consensus exists for management of small and medium
irritation. Patients tend to manifest symptoms at two peaks in CMN; however, it is apparent that the risk of developing mel-
age. In infancy, patients present with hydrocephalus, increased anoma is extremely low. Hence, recommendation would be
intracranial pressure, or developmental delay. In the second to for excision if performed, around puberty, with corresponding
third decades of life, patients may have increased intracranial decreased risk of anesthesia. As a caveat, often the presence
pressure or spinal cord compression. Neurocutaneous melano- and location of the anticipated scar may in fact make excision
sis may also be asymptomatic. Risk factors for association of of small CMN unwarranted.
neurocutaneous melanosis include (1) CMN in the midline of In general, a multidisciplinary approach should be followed,
the trunk or skull and (2) multiple satellite nevi (>20). with involvement of physicians from multiple specialities, such
Magnetic resonance imaging (MRI) screening of the CNS is as plastic surgery, dermatology, neurology, neurosurgery, radi-
recommended for those patients who are at high risk for neu- ology, and pediatrics. Regular skin examinations by the der-
rocutaneous melanosis. MRI should be performed early in life matologist before and after surgical intervention by the plastic
(between 4 and 6 months of age) prior to normal myelination of surgeon are essential to ensure early detection of possible fea-
the brain, which will obscure visualization of deposits of mela- tures of melanoma and subsequent detection of new lesions.
nin. Figure 20.1 shows a typical MRI of a patient with neuro- Parental education aids in dealing with patients and their fam-
cutaneous melanosis. Cerebrospinal fluid cytology may also be ilies. Involvement of a clinical psychologist will help a child
useful to analyze for the presence of atypical malignant cells. of school age get through peer pressure related to certain less
Treatment of symptomatic neurocutaneous melanosis may appealing procedures such as tissue expansion.
involve medical and surgical therapies such as placement of Treatment options for CMN include nonexcisional and
a ventriculoperitoneal shunt or radiation therapy. This con- excisional methods. Nonexcisional methods remain controver-
dition typically carries a bad prognosis with death expected sial, due to the lack of specimens for a histologic diagnosis and
within 2 to 3 years of diagnosis. Treatment of asymptomatic problems with postsurgical surveillance for malignant trans-
neurocutaneous melanosis identified on MRI is more contro- formation. Most of these techniques remove only the superfi-
versial and may best be done with serial MRI scans during cial layer of cells, leaving cells in the deep dermis. Lightening
childhood to follow progress and changes in lesions. In the the nevus while selectively leaving unaffected nevus cells in
absence of changing lesions, treatment may not be indicated. the deeper layer of the dermis and subcutaneous tissue makes
it more difficult to monitor the patient for clinical signs of
malignant transformation of the remaining nevus cells.
Management Chemical peels, lasers, curettage, and dermabrasion have
The fundamental guiding principle in the management of been reported as treatment for CMN.10 Phenol chemical peels
CMN relates to achieving a balance between treatment goals, have been used for CMN too large to be excised or where it
namely, elimination (or at least reduction) of the risk of malig- was felt that excision would lead to unacceptable scarring.16 In
nant transformation, preservation of function, and cosmetic this study, 75% of patients had an improved outcome. Lasers
appearance. At the same time, the risk of anesthesia and sur- have been used for the treatment of giant CMN, inclusive of
gery remains a consideration. The risk of melanoma in giant carbon dioxide, argon, ruby, and erbium:yttrium-aluminum
CMN is well established. Intervention, if performed, should garnet (Er:YAG). The 10,600 nm carbon dioxide laser works
be done early in life, as the risk of malignant transforma- by selective photothermolysis of melanocytic deposits and has
tion is greatest in the first decade of life.14 Some authors have been found to have acceptable aesthetic results. An undesirable

FIGURE 20.2. A 6-year-old boy who presented with a congenital pigmented nevus of the back measuring 10 cm × 9 cm (approximately 2%
body surface area) was treated with serial excision. The lesion was completely excised in two stages, with each excision spaced 6 months apart.
side effect, however, is hypertrophic scarring, found in 6 out

of 12 patients in one study.17 In fact, at least one report sug-
gests the possibility of a link between energy emitted by lasers
and increased risk of malignant transformation,18 as well as
increased metastatic potential in vitro.9
Curettage has also been used successfully in the neonatal
period for the treatment of giant CMN.19 The authors empha-
sized that this should be performed within the first 2 weeks
of life, where the cleavage plane between the upper and lower
dermis can still be easily found. This was performed as a one-
stage procedure under general anesthesia, with re-epithelial-
ization within 10 to 14 days. Good cosmetic and functional
results were achieved in all patients, with no malignant trans-
A B
formation detected over a decade of follow-up. Dermabrasion
has been reported similarly to be most effective when per-
formed during the neonatal period.20 As a caveat, in isolated
case reports, melanoma has been found to develop in giant
CMN 9 and 20 years after dermabrasion in childhood.21,22
Excisional methods include primary excision and closure,
serial excision, skin grafting, tissue expansion and skin sub- C D
stitutes. To address the malignant potential, only complete
excision of the nevus can be recommended as a solution.
However, in some cases the nevus cells extend deeply into the
subcutaneous tissue and the underlying muscle. Although it
is not always possible to clear the peripheral surgical margins
in all giant CMN, an effort should be made to clear the deep
margin of nevus. If the deep margin of resection remains posi-
tive, it is impossible to monitor the behavior of residual nevus
on a clinical basis following reconstruction.
When the lesion can be excised in three stages or less, serial
excision would be the recommended treatment of choice.23
This method is tolerated better by patients and has many fewer
complications compared with other techniques (Figure 20.2).
E F
In general, 6 months is allowed between successive excisions
to allow for scar maturation and relaxation of the tissue. If the FIGURE 20.3. A. A 7-month-old female is shown with a giant congeni-
lesion cannot be treated in three stages or less, tissue expansion tal pigmented nevus involving the torso and buttocks region and multiple
is the preferred option (Figure 20.3). Tissue expansion has the satellite nevi distributed through the entire body. B. Tissue expanders are
advantage of creating new tissue having the same qualities as placed above and below the nevus of the back. C. The back lesion is shown
after two stages of tissue expansion. D. The back is shown following three
the surrounding skin, such as color, texture, and presence of
stages of tissue expansion with complete removal of the giant nevus of the
hair. Expansion is performed over a period of 3 to 6 months back; only satellite nevi remain. E. Following three previous tissue expan-
and can often be done at home by educated parents at weekly sions, a fourth-stage expansion was initiated for resurfacing the remain-
intervals. A capsulotomy can be performed during surgery ing giant pigmented nevus of the left buttock. F. The buttock is shown 3
to maximize mobility of the expanded flap. We do not make months following expander removal and resurfacing of the buttock.
additional backcuts or incisions to promote advancement of

the expanded flap as this will introduce new scars. If more tis- can be used in conjunction with a thin split-thickness skin
sue is required, the expanders can be reinserted subsequently graft or cultured epithelial autograft (CEA) to achieve an opti-
for staged serial expansion. At least 3 months should elapse mal aesthetic result with minimal scar contracture. CEA has
between reinsertion of tissue expanders to allow adherence of also been reported to result in decreased scarring and accel-
the previously advanced skin flaps. In cases of extensive nevi erated healing when used in conjunction with curettage and
formation and limited normal donor skin for grafting, another Er:YAG laser ablation.25
option is to expand the donor skin prior to harvest. A sensible approach is to consider the lesion or lesions
Complications resulting from tissue expansion are reported within an anatomic context. Back lesions are ideal for tissue
to be between 13% and 20%.24 Major complications delay- expansion, as back tissue is sufficiently rigid to provide coun-
ing reconstruction include infection, hematoma, expander tertension for expansion, while lacking anatomical structures
exposure, extrusion, and failure. Minor complications that do that might be distorted by tissue expansion. For lesions in
not delay expansion include pain, seroma, and scar widening. the abdomen, a combined tissue expansion/abdominoplasty
Complication rates are highest in the lower extremity, during approach can be used, providing additional tissue for cover-
multistage expansion and in young children. Despite the sig- age. In the breast, care must be taken to avoid traumatizing
nificant incidence of major complications, in the majority of the developing breast bud. The family should be made aware

cases, patients go on to complete tissue expansion successfully. that reconstruction with tissue expanders can potentially lead

Issues such as infection and expander exposure can undergo a to distortion of the breast mound or nipple–areolar complex.
trial of conservative treatment and often do respond to anti- Breast asymmetry resulting from tissue expansion may require
biotics or dressing changes, respectively, permitting continued subsequent reconstruction with implants.
expansion after resolution. Tissue expansion is associated with more morbidity and a
An alternative to tissue expansion is the use of skin grafts higher failure rate in the extremities. In the proximal part of
and skin substitutes. These, however, have inferior aesthetic the arm and leg, expanded flaps originating in the back and
and functional outcomes compared with tissue expansion and groin may be transposed to reconstruct defects. For larger
should be reserved for cases where tissue expansion is not lesions distal to the knee or elbow, recruitment of tissue
possible in difficult anatomical regions or has failed. The cost through tissue expansion is more difficult and may require
of skin substitutes is another limiting factor. Dermal substi- other options such as skin grafting for lesions not amena-
tutes include Alloderm (LifeCell Corp., Branchburg, NJ) and ble to serial excision. Expanded abdominal flaps may also
Integra (Integra LifeSciences Corp., Plainsboro, NJ). These be used (Figure 20.4). Regional and free flaps, which may
A B
C D
E F
FIGURE 20.4. A 3-year-old boy who presented with a giant congenital pigmented nevus with circumferential involvement of the left forearm and
hand. A. The lower abdomen is expanded in preparation to resurface the extremity with an abdominal flap. B. The expander is removed and the
nevus excised circumferentially from the forearm and hand to the level of the distal metacarpals. C. The forearm is tunneled through the expanded
flap in the lower abdominal wall and bolsters applied to help contour the abdominal flap around the circumference of the forearm. The fingers
are left free distal to the metacarpal heads. D. An expanded full-thickness skin graft is harvested from the lower abdomen to resurface the palmar
aspect of the hand following a second-staged serial expansion. E. The upper extremity is shown 1 year following resurfacing with the expanded
abdominal flap. F. The donor site for the abdominal flap and full-thickness skin graft to the palm is shown 1 year postoperatively.

CMN involving the frontotemporal and parietal scalp. CMN

in the forehead may also be treated with tissue expanders if
less than two-thirds of the forehead is involved. Otherwise,
reconstruction of the entire forehead with a single full-thick-
ness skin graft is an option. CMN in the nasal area may be
reconstructed in continuity with forehead lesions using an
expanded forehead flap, part of which may be pedicled on the
supratrochlear or supraorbital artery and transposed to the
nose. Giant CMN in the cheek can be treated with expanded
cervical or postauricular flaps. Attention should be paid to
keeping incisions at the borders of aesthetic subunits.
In lesions around the eyelid, the ciliary margin should be
spared to minimize the risk of altered function. The goal of
surgery is primarily aesthetic in nature; hence, leaving some
A B nevus is not unacceptable.26 Part of the nevus may even be
left unexcised, to mimic a normal eyebrow. Options for
reconstruction include full-thickness skin grafts and local
advancement flaps. In this area, serial excision would cause
a deformity, and tissue expansion would result in recruitment
of tissue of different quality. Revisional procedures may be
required, such as scar revision and lateral canthopexy. CMN
in the ears present a reconstructive challenge, particularly
when situated in the lobule. Full-thickness skin grafts are the
modality of choice. Where these cannot be used, such as for
reconstruction of the lobule, local flaps such as postauricular
and helical rim advancement flaps are an option.27
Finally, clinical surveillance remains an important treat-
ment option, especially for lesions that are amenable to serial
observation, are minimally disfiguring, or are such that abla-
C D tive surgery would cause significant anatomic or functional
disruption. Because sun exposure is thought to increase the
risk of malignant transformation, strict sun avoidance should
be advised as a prophylactic measure in these patients.
Conclusion
In summary, congenital pigmented nevi can be thought of
as falling into two groups: giant CMN and all others. Giant
CMN represents the greater risk group for malignant trans-
formation. These require earlier, more aggressive intervention
and represent the most complex reconstructive challenges.
Should intervention be chosen, we recommend that the modal-
ity chosen not mask the clinician’s ability to monitor any
E F residual nevus for signs of malignant transformation. Caution
should be employed with nonexcisional strategies, such as
FIGURE 20.5. A. A 1½-year-old body is shown with a giant con- laser, chemical peel, and dermabrasion. A number of surgi-
genital pigmented nevus, involving the right frontotemporal and pari- cal techniques may be indicated and employed to reduce the
etal scalp. The nevus occupies approximately one-third of the total risk of malignant transformation and to minimize functional
scalp surface area, with a hyperpigmented region within the center. and cosmetic deformity. Particular effort should be made to
B. Tissue expanders are placed superior and posterior to the area achieve a clear, deep margin of resection so subsequent surgi-
of involvement in the frontoparietal scalp and in the occipital scalp. cal reconstruction will not mask residual nevi. There is evi-
C. The tissue expanders are shown following maximum inflation.
D. The nevus has been markedly reduced after first-stage expansion,
dence that prophylactic excision of giant CMN is effective
but recontouring of the expander bed deformities of the underly- in preventing malignant melanoma.28 For most areas of the
ing skull and advancement of the expanded scalp. E. A second set body, serial excision or tissue expansion should be considered
of expanders is placed in the frontoparietal and occipital scalps to the first line of surgical treatment.
address the residual nevus. F. The patient is shown 6 weeks following
second-stage scalp expansion, with complete excision of the giant con- References
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hair line. Redundant tissue of the scalp is allowed to contract over 1 nocytic nevi and the risk for the development of melanoma: a prospective
year before considering further excision so as to preserve hair follicles. study. Arch Dermatol. 1996;132:170-175.
2. Castilla EE, da Graca Dutra M, Orioli-Parreiras IM. Epidemiology of
congenital pigmented nevi: incidence rates and relative frequencies. Br J
Dermatol. 1981;104:307-315.
3. Egan CL, Oliveria SA, Elenitsas R, et al. Cutaneous melanoma risk and phe-
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Figure 20.5 illustrates management of a patient with a giant congenital nevi: a cohort study. J Am Acad Dermatol. 1995;32:595-599.

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Dermatol. 1980;116:1017. Multicentric malignant melanoma in a giant melanocytic congenital nevus
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Chapter 21 n Vascular Anomalies
Table 21.1
Definitions
Vascular anomalies come in all shapes and sizes. They may be flat International Society For The Study of Vascular
or raised and purple, red, or pink. They have been the subject of Anomalies Classification of Vascular Anomalies
superstition and folklore for eons. Early attempts at classification
of vascular lesions were hampered by the use of confusing, often n Vascular n Vascular
eponymous nomenclature, based variably on clinical, pathologic, Tumors Malformations
biological, embryological, or descriptive factors. An early patho- Infantile hemangioma Simple
logic classification by Virchow1 divided vascular anomalies into
Congenital hemangioma Capillary malformations
angiomas (simplex, cavernosum, and racemosum) and lymphan-
giomas (simplex, cavernosum, and cystoids). Conversely, a capil- Tufted angioma Venous malformations
lary malformation (CM) was variably described as a “port-wine Hemangiopericytoma Lymphatic malformations
stain,” “nevus flammus,” or “capillary hemangioma.”
Mulliken and Glowacki2 further defined the nature of vas- Pyogenic granuloma Arterial malformation
cular anomalies in a seminal work and classified these into Kaposiform hemangioendo- Combined
hemangiomas and vascular malformations, distinguishing thelioma
them based on clinical course, biologic behavior, and histo-
pathological features. This laid the groundwork for our cur- Spindle cell hemangioendo- Capillary–lymphatic–
rent understanding of these lesions. In 1993, Jackson et al.3 thelioma venous malformation
further divided vascular anomalies into hemangiomas, vascu- Rare hemangioendotheliomas Capillary–venous
lar malformations, and lymphatic malformations (LMs). (epithelioid, composite, reti- malformation
Most recently in 1996, the International Society for the form, polymorphous, Dabska
Study of Vascular Anomalies (ISSVA) proposed a classification tumor, etc.)
(Table 21.1) based on that originally published by Mulliken
and Glowacki, which divides vascular anomalies into vascu- Capillary–lymphatic
lar tumors and malformations.4 This is now the most widely malformation
accepted classification system and forms the basis for diagnos- Dermatologic acquired Lymphatic–venous
ing and treating vascular anomalies. Vascular tumors include vascular tumors (targetoid malformation
hemangiomas and other proliferative lesions. Vascular mal- hemangioma, glomeru-
formations are subdivided based on vascular components into loid hemangioma, micro-
simple and combined malformations. Integral variants of vas- venular hemangioma, etc.)
cular malformations include capillary, venous, arteriovenous,
and lymphatic malformations. Tumors and malformations are Arteriovenous
distinguished based on biological behavior, clinical appear- malformation
ance, and radiological and pathological features. Capillary–arteriovenous
Vascular tumors proliferate largely by endothelial cell malformation
hyperplasia. The prototypical lesion is the infantile heman-
Lymphatic–arteriovenous
gioma (IH), which demonstrates rapid postnatal growth and
malformation
slow regression during childhood. Vascular malformations, in
contrast, have a quiescent endothelium and are thought to be Arteriovenous fistula
caused by local defects of vascular morphogenesis and remod-
eling. Vascular malformations never regress and often persist
or enlarge throughout life. Vascular malformations have been
further categorized based on flow characteristics into fast- Pathogenesis
flow and slow-flow lesions. Fast-flow lesions include lesions
with an arterial component (AM [arterial malformation], The cellular origin of IH has been shown to be related to clonal
AVM [arteriovenous malformation], AVF [arteriovenous fis- expansion of a hemangioma-initiating multipotent stem cell,5
tula], C-AVM [capillary arteriovenous malformation], and which expresses the marker CD133 and has the capacity to
L-AVM [lymphatic arteriovenous malformation]). Slow-flow form human blood vessels expressing erythrocyte-type glucose
lesions would encompass all other lesions. transporter protein-1 (GLUT-1) and merosin. This vasculo-
genic activity appears to be confined to hemangioma-derived
stem cells only. Hemangioma endothelial cells also appear to
Infantile Hemangioma be fundamentally different from normal endothelial cells, with
constitutive low expression of vascular endothelial growth
Overview factor receptor (VEGFR)1 and missense mutations in genes
IH is a vascular tumor that affects from 5% to 10% of encoding VEGFR2 and TEM8 (tumor endothelial marker 8),
Caucasian infants by 1 year of age. It is more common in suggesting a germline mutation leading to variant downstream
females than in males (3 to 5:1) and in preterm infants (23%). signaling in the vascular endothelial growth factor (VEGF)
Around 80% of hemangiomas are solitary, while 20% are mul- pathway.6 The unique cellular nature of hemangioma cells
tifocal. IH is characterized by a three-stage life cycle, consist- suggests that the etiology of IH relates to a mutation of endo-
ing of the proliferating phase, involuting phase, and involuted thelial cells at the stem cell level instead of embolized placental
phase (Figure 21.1). cells, as previously postulated.
206
Chapter 21: Vascular Anomalies 207

A, B C

FIGURE 21.1. Hemangioma. This girl with a right facial hemangioma demonstrates the three-
stage life cycle of IH, consisting of the proliferating phase ((A) age 3 months), involuting phase
((B) age 18 months), and involuted phase ((C) age 7 years).
A characteristic marker of IH is GLUT-1. IH immunostains age. At this stage, the tumor is typically in its most florid
positively for GLUT-1 throughout its life cycle and is nega- presentation. The composition of the tumor becomes more
tive in most other vascular lesions. In the proliferative phase, apparent as it proliferates, demonstrating a superficial and/or
IH consists of plump, rapidly dividing endothelial cells, and deep component. The clinical presentation of the superficial
pericytes that form tightly packed sinusoidal channels. A char- component includes a bright red, well-demarcated, slightly
acteristic ultrastructural feature of this phase is the presence elevated noncompressible plaque. Hemangiomas deeper in
of multilaminated basement membranes. Increased angiogen- the dermis and subcutaneous tissue are usually soft, warm,
esis is seen in this phase as documented by the expression of ill-defined subcutaneous masses that have a slightly bluish
VEGF, matrix metalloproteinase (MMP)-2, proliferating cell hue. Often, hemangiomas have both superficial and deep
nuclear antigen, and basic fibroblast growth factor. These components.
markers of angiogenesis and cell proliferation are not seen in
vascular malformations. Involuting Phase. In the involuting phase, the florid crim-
In the involuting phase, there is gradually decreasing son color of IH fades to a dull purplish hue, with increased
endothelial activity and luminal enlargement. Apoptosis is pallor of the skin and decreased turgor of the tumor. This
seen in endothelial cells before 1 year and peaks in 2-year- phase marks the regression of the tumor, and typically lasts
old specimens. Increasing fibrosis, stromal cells (such as mast anywhere from 2 to 10 years. In many children the involuting
cells, fibroblasts, and macrophages), and expression of tissue phase results in virtually normal skin, but in a number of cases
inhibitor of metalloproteinase-1, a suppressor of new blood children with hemangiomas will exhibit residual telangiecta-
vessel formation, is seen.7 Finally, in the involuted phase, the sias, pallor, atrophy, textural changes, and sometimes residual
previously highly cellular lesion has been largely replaced by fibrofatty tissue.
loose fibrofatty tissue mixed with dense collagen and reticular
fibers. Involuted Phase. Regression is complete in 50% of chil-
dren by 5 years and in 70% of children by 7 years, with con-
tinued improvement up to 10 to 12 years of age. Bulky and
Clinical Features large lesions may regress completely, while a flat superficial
Hemangiomas typically appear at birth or within the first 2 hemangioma may lead to permanent alteration in the texture
weeks of life. Most of these are innocuous, with only about of the skin.
10% being locally invasive, disfiguring, or life-threatening.
The clinical appearance depends on depth, location, and stage Complications
of evolution. Around 30% to 40% are quiescent at birth,
appearing only as a cutaneous mark, such as a pale area, While most hemangiomas resolve without complication, a
macular stain, telangiectatic macule, or ecchymotic spot or considerable number result in functional impairment or per-
scratch. manent disfigurement. Ulceration is the most frequent com-
The current morphological classification system for hem- plication,8 occurring in 5% of all cutaneous hemangiomas,
angiomas separates them as localized, segmental, or multiple. and results in pain with the risk of infection, hemorrhage, and
Localized hemangiomas present as focal, tumor-like growths scarring. Those at greatest risk are large, segmental lesions of
that are contained to one defined cutaneous region and fail the lip, perineum, or intertriginous regions. Ulceration results
to demonstrate a linear or geometric pattern. Segmental hem- from necrosis and usually occurs during a period of rapid
angiomas are less common than the localized lesions and are growth. In addition to rapidly enlarging hemangiomas, ulcer-
generally more plaquelike in presentation. Segmental lesions ation has a high risk of occurrence in the anogenital region
also demonstrate a geographic distribution over a specific due to moisture and frictional stress, which results in extreme
cutaneous region and are more likely to be associated with pain on urination and defecation.
various complications, require more aggressive therapy, and Location also plays a major role in determining the likeli-
have a poorer overall outcome. hood of complications. Hemangiomas of the eyelid or in the
periocular region can cause astigmatism, strabismus, and, in
Proliferative Phase. In typical hemangiomas, the majority severe cases, amblyopia. Large hemangiomas on the pinna of
of proliferation occurs during a rapid growth phase in the the ear can cause deformation of the external ear or temporary
first 6 to 8 months with cessation of growth by 1 year of conductive hearing loss. Hemangiomas with a distribution

over the mandible, chin, and upper neck (“beard” distribu- It can result in sufficient shunting to cause high-output con-
tion) have a greater risk of association with airway heman- gestive cardiac failure. RICH’s defining feature is accelerated
giomas. Hemangiomas of the airway may be life-threatening regression, usually obvious within a few weeks after birth
because of their potential for proliferation and eventual air- and complete by 6 to 14 months of age. NICH presents as
way obstruction. Infants with subglottic hemangiomas often a well-circumscribed, plaquelike tumor with a pink, blue, or
present with hoarseness and stridor. These lesions in infants purple hue, central coarse telangiectasia, and a pale rim (21.2).
6 to 12 weeks old are of particular concern as they may prog- In contrast to RICH, NICH grows proportionately to the child
ress rapidly to respiratory failure. and remains unchanged, demonstrating a fast-flow signal by
In rare cases, multiple (usually greater than five) cutaneous Doppler examination. There are rare instances of coexistence
hemangiomas (diffuse hemangiomatosis) and large facial hem- of either RICH or NICH in a child with IH and also instances
angiomas are associated with visceral hemangiomas. These in which RICH ceases to regress and assumes the likeness
infants present from birth to 16 weeks of age with a triad con- of NICH.
sisting of congestive heart failure, hepatomegaly, and anemia,
resulting in higher morbidity and mortality rates. An associa- Differential Diagnoses
tion between hepatic hemangiomas and hypothyroidism has
While the clinical phases of proliferation and involution usu-
also been reported, due to the production of type 3 iodothy-
ally make the diagnosis clear, a deep lesion in the neck or trunk
ronine deiodinase by the tumor. Hence, thyroid-stimulating
may cause confusion with an LM. Similarly, a superficial hem-
hormone levels should be monitored in these infants. While
angioma in an extremity may resemble a CM. In these cases,
the liver is the most common internal organ involved, the gas-
ultrasonography or magnetic resonance imaging (MRI) may be
trointestinal tract, brain, and lung are also common sites.
useful to confirm a diagnosis. RICH and NICH can also be mis-
taken for AVMs due to a prominent fast-flow signal. Another
Congenital Hemangiomas differential is pyogenic granuloma, which unlike hemangiomas
These lesions are a unique subset of vascular tumors, distinct rarely appears before 6 months of age (mean age 6.7 years).
from IHs. Unlike IH, these rare lesions present fully grown These lesions grow rapidly and may form a stalk or pedicle with
at birth and do not demonstrate the rapid neonatal prolifera- epidermal breakdown. Other infantile tumors that may cause
tion characteristic of IH. These can be classified into rapidly confusion include kaposiform hemangioendothelioma, tufted
involuting congenital hemangioma (RICH) and noninvoluting angioma, (“angioblastoma of Nakagawa”), myofibromatosis
congenital hemangioma (NICH). (“infantile hemangiopericytoma”), and fibrosarcoma.
These lesions do not stain for GLUT-1, but have simi-
lar location, size, appearance, gender ratio, and histologi- Radiological Characteristics
cal and radiological features as IH.9 RICH manifests as a
solitary raised gray or violaceous tumor with ectasia, radial Ultrasonography of a proliferating-phase hemangioma demon-
veins, central telangiectasias, and a pale surrounding halo. strates a distinct shunting pattern, consisting of decreased arterial
FIGURE 21.2. Non-involuting congenital hemangioma. A. A 1 year-old boy with

noninvoluting congenital hemangioma (NICH) involving the right thigh diagnosed
at birth. B. Characteristic morphology is that of a well-circumscribed, plaquelike
tumor with a pink, blue, or purple hue, central coarse telangiectasia, and a pale rim.
C. MRI demonstrates lesion to involve the skin and subcutaneous tissues superficial
to the muscle fascia.

resistance and increased venous velocity. Even an experienced and intracranial hemangiomas associated with PHACE can
ultrasonographer can have difficulty distinguishing a young also be found in the literature.
hemangioma from an AVM because both are rheologically fast Hemangiomas located over the lumbosacral spine appear
flow. An MRI with contrast is the gold standard imaging modal- to also be a component of abnormal morphogenesis as they
ity, but it requires sedation or general anesthesia if the child is may be associated with occult spinal dysraphism or genito-
younger than 6 years old. MRI reveals parenchymatous (solid) urinary anomalies. Of greatest concern are those lumbosa-
tissue of intermediate intensity on T1-weighted spin-echo images cral hemangiomas that appear segmental, span the midline,
and moderate hyperintensity on T2-weighted spin-echo images. and are flat or telangiectatic. Early detection and therapeutic
Prominent flow-voids are located around and within the tumor, or surgical intervention are important to prevent permanent
indicating rapid flow in feeding arteries and dilated draining veins. neurologic sequelae.
At some time in the late involuting phase, hemangiomas become
slow-flow lesions, often with prominent fatty parenchyma.
Management
Association with Dysmorphic Features The management of hemangiomas remains controversial, with
a large and growing number of medical and surgical modali-

There are instances in which hemangiomas appear to be asso- ties. Due to the wide spectrum of clinical presentation and

ciated with certain dysmorphic conditions. Large facial hem- the potential for rapid change in early infancy, it can be chal-
angiomas of the neck and face, for instance, may be associated lenging to predict which hemangiomas will be innocuous and
with a syndrome referred to as PHACES: posterior fossa mal- which will be problematic. While the decision to treat hem-
formations, hemangiomas of the cervicofacial region, arterial angiomas that impair function or are life-threatening, such
anomalies, cardiac anomalies, eye abnormalities, and occa- as those occurring in the periocular region, airway, liver or
sionally sternal defects (Table 21.2). The large facial heman- gastrointestinal tract, is obvious, the decision to treat less-
gioma is usually plaquelike and segmental in nature. There is threatening hemangiomas often depends on the location of the
a marked female predominance (ratio of affected girls to boys, hemangioma, size, and growth phase as well as the age of the
9:1), which is significantly greater than the 3:1 ratio of girls patient at the time of evaluation.
to boys reported for typical hemangiomas. Figure 21.3 shows
a patient with PHACES who presents with the characteristic Observation. The majority of IH will involute with time,
facial hemangioma accompanied by significant abnormalities leaving normal or slightly blemished skin only. Reassurance
in the cerebrovascular circulation. of the parents and regular follow-up visits are essential to
Dandy-Walker malformation is the most common struc- monitor for local complications and progression of the hem-
tural brain abnormality associated with PHACES. However, angioma.
other central nervous system lesions have been shown.
Common arterial abnormalities of the head and neck include Local Wound Care. Management and treatment of ulcer-
agenesis, hypoplasia, stenosis, dysplasia, aneurysms, and ated hemangiomas should focus on healing the open wound,
anomalous branches of the major cerebral arteries. Incidence preventing secondary infections, and alleviating pain. Local
is unknown but potential neurologic defects such as develop- wound care may include compresses for gentle debridement
mental delay or seizure disorder, Horner syndrome, stroke, of thick crust and exudate reduction, barrier creams, such as
and progressive neurologic disease have been reported. zinc oxide or hydrophilic petroleum, applied to the surface of
Cardiac abnormalities include coarctation of the transverse the hemangioma, and occlusive dressings to serve as barriers
aorta, but congenital heart defects such as ventricular septal and prevent desiccation. Viscous lidocaine may help control
defects and patent ductus arteriosus may also be seen. Eye pain. Topical antibiotics may be efficacious for superficial
abnormalities include optic nerve hypoplasia, persistent reti- ulcerations, whereas oral antibiotics may be necessary if overt
nal vessels, and microphthalmia. Sporadic reports of endo- secondary infection is present and oral pain medicines may be
crinopathies, including hypothyroidism and hypopituitarism, required for pain.
Table 21.2
Anomalies Associated With Hemangiomas
n Category of Anomaly n Anomaly

Structural brain Posterior fossa
Dandy-Walker complex
Cerebellar hypoplasia/atrophy
Subependymal and arachnoid cysts
Hypoplasia or agenesis of
Cerebrum
Corpus callosum
Septum pellucidum
Vermis
Absent foramen lacerum
Polymicrogyria
Microcephaly
Heterotopia
Absent pituitary or partially empty sella turcica

n Category of Anomaly n Anomaly

Cerebrovascular Dysplasia of the large cerebral arteries
Stenosis, occlusion, absence, or moderate to severe hypoplasia of the large cerebral arteries
Aberrant origin or course of the large cerebral arteries
Saccular aneurysms
Persistent embryonic arteries (predominantly trigeminal)
Cerebral sinus malformations
Sinus pericranii
Dural arteriovenous malformations
Moyamoya vasculopathy
Acute arterial stroke
Cardiovascular Coarctation or interrupted aortic arch (most often transverse section)
Aneurysms of aortic arch
Right aortic arch
Double aortic arch
Congenital valvular aortic stenosis
Aberrant origin of a subclavian with or without a vascular ring
Stenosis, occlusion, absence, or moderate to severe hypoplasia of the vertebral arteries
Subclavian steal syndrome
Anomalous coronary arteries
Patent ductus arteriosus
Anomalous pulmonary veins
Patent foramen ovale
Cor triatriatum
Tricuspid atresia/stenosis
Dextrocardia
Persistent left superior vena cava
Ventral and atrial septal defects
Pulmonary stenosis
Tetralogy of Fallot
Ocular Posterior segment abnormalities
Retinal vascular abnormality
Persistent fetal retinal vessels
Iris vessel hypertrophy
“Morning-glory” disc
Peripapillary staphyloma
Optic nerve hypoplasia
Anterior segment abnormalities
Microphthalmos
Coloboma
Congenital cataracts
Sclerocornea
Iris hypoplasia
Exophthalmus
Congenital third nerve palsy
Horner syndrome


FIGURE 21.3. PHACES with facial hemangioma. Top row: A 6-month-old girl who presents with
left facial hemangiomas with secondary ptosis of the left upper eyelid. Bottom row: MRI demon-
strates an intracranial aneurysm involving the left internal carotid artery extending into the middle
cranial fossa (arrows).
Medical Management. Pharmacologic therapy is indicated Corticosteroids The role of steroids as a mainstay in treat-
for hemangiomas that threaten function or result in local comment of hemangiomas is well defined, with an overall response
plications. Around 10% of hemangiomas cause complications rate of approximately 85%.7 The mechanism of action has
such as major ulceration/destruction, distortion of tissues, and been found to be related to the inhibition of vasculogenic
obstruction of the visual axis or airway. Approximately 1% potential in hemangioma-derived stem cells, together with
of hemangiomas cause life-threatening complications, such as downregulation of expression of VEGF-A and other angio-
high-output cardiac failure from an intrahepatic hemangioma. genic proteins inclusive of urokinase plasminogen activator
There has been a recent trend toward early pharmacologic receptor, monocyte chemoattractant protein-1, interleukin-6,
treatment of hemangiomas in aesthetically prominent regions and MMP-1.11
that do not threaten function but result in cosmetic disfigure- Steroids can be administered intralesionally or topically
ment. The nasal tip is a representative area where patients for small, well-localized tumors or orally for large and/or
may be best served with early pharmacologic treatment and aggressive hemangiomas that may impair function, cause
possible laser therapy (Chapter 19) to speed involution and severe disfigurement, or are life-threatening. For intralesional
to prevent permanent skin changes, thereby providing the injections, usually three to five injections are administered at
optimal skin quality for subsequent surgical debulking of the 6- to 8-week intervals. Systemic corticosteroids remain first-
residual fibrofatty changes and correction of the splayed alar line therapy for large or life-threatening hemangiomas; how-
cartilages (Figure 21.4).10 ever, this may change with the recent advent of propranolol

FIGURE 21.4. Hemangioma. Top row: A 6-month-old boy presented with a bulbous heman-
gioma of the nasal tip during the proliferative phase. Middle row: The patient is seen at age 3
years following completion of treatment with intralesional steroids and pulsed dye laser ther-
apy. Cutaneous manifestations have resolved, but the nasal tip remains bulbous due to residual
fibrofatty changes secondary to the hemangioma. Bottom row: Surgical correction using an
open rhinoplasty approach was undertaken at 5 years of age to refine the nasal tip. The patient
is seen 1 year postoperatively. (From Arneja JS, Chim H, Drolet BA, Gosain AK. The Cyrano
nose: refinements in surgical technique and treatment approaches to hemangiomas of the nasal
tip. Plast Reconstr Surg. 2010;126:1291, with permission.)
in treating severe hemangiomas of infancy. A recommended Propranolol The remarkable effects of propranolol on regres-
dose of 2 to 3 mg/kg of oral prednisolone is given as a single sion of IH were discovered serendipitously and published in
morning dose for 4 to 6 weeks, and subsequently tapered over 2008.12 In many centers, propranolol has now become the first
several months and discontinued by 10 to 11 months of age. choice of therapy for complicated IH, even though we do not
A responsive hemangioma typically responds within several have a complete understanding of its mechanism of action.
days to 1 week. In an acute situation such as threatened upper The effective dosage used most commonly is 2 mg/kg daily in
airway or visual field compromise, intravenous corticosteroid three divided doses, with treatment continued until the end
at the same dose results in a more rapid response. of the proliferative phase, and weaning of propranolol over
Common adverse effects include Cushingoid facies, which a 2-month period. Propranolol has been found to be effective
occurs in virtually all treated infants, and temporary growth in the treatment of large facial hemangiomas following failure
retardation in around one-third of infants. However, most of oral corticosteroid therapy. It has also been found to be
patients tolerate treatment well and respond with either heman- highly effective in the treatment of hemangiomas in dangerous
gioma shrinkage or stabilization in size, with catch-up growth or life-threatening locations, such as in the airway, periocular,
occurring after treatments have stopped. Other potential side and even hepatic hemangiomas with diffuse neonatal heman-
effects include irritability, hypertension, immunosuppression, giomatosis,13 with dramatic results often seen within a week
hirsutism, myopathy, cardiomyopathy, and premature thelarche. of treatment.

Typically, the surface of the hemangioma exhibits whiten- necessary. In addition, there is evidence that the risk of scar-
ing, followed by rapid involution. Adverse effects reported ring when this is used to treat hemangiomas is greater than
in a number of studies include symptomatic hypoglycemia, that when treating port-wine stains. Other laser systems
bradycardia, and hypotension.14 Key to propranolol’s mecha- have also reportedly been used to treat hemangiomas, such
nism of action on hemangiomas is inhibition of the hypoxia- as the neodymium:yttrium-aluminum-garnet (Nd-YAG) and
inducible factor 1 alpha–VEGF signaling pathway, resulting in the potassium titanyl phosphate (KTP) laser, but these systems
downstream inhibition of angiogenesis mediators and a direct are more operator-dependent and tend to have a higher risk
cytotoxic effect, decreased tubulogenesis, and decreased endo- of scarring.
thelial cell migration with subsequent apoptosis.15.
Surgical Management. Surgical excision is typically used
Interferon Alpha Recombinant interferon (IFN)-α-2a or later in childhood to improve residual scarring or to remove
IFN-α-2b is a second-line agent for life-threatening heman- fibrofatty tissue. However, earlier removal may be considered
giomas or those that threaten a vital function (e.g., vision). for lesions that are localized or pedunculated, where resulting
Indications for its use include: (a) failure to respond to corti- abnormalities are virtually inevitable (Figure 21.5). Surgery
costeroid; (b) contraindications to prolonged parenteral corti- may also be performed if persistent bleeding or ulceration

costeroid; (c) complications of corticosteroid; and (d) paren- occurs, if function- or life-threatening lesions do not respond

tal refusal of corticosteroid. Corticosteroids and IFN should to pharmacologic therapy, or for school-age children in an
not be coadministered in therapeutic dosage; corticosteroids attempt to attain a more normal appearance.
should be tapered quickly on initiation of IFN. There is
no evidence for drug synergism. The empiric dose is 2 to 3 Infancy (Proliferating Phase) Indications for resection of a
mU/m2, injected subcutaneously daily. IFN dosage is titrated well-localized tumor in the first year are (a) obstruction, usu-
as the infant gains weight; otherwise regrowth can occur. The ally a tumor in the upper eyelid or subglottis; (b) deformation,
rate of response is >80% with 6 to 10 months of sustained for example, periorbital tumor causing amblyopia, retroau-
therapy usually required.16 ricular hemangioma causing a prominent ear; (c) bleeding;
IFN is effective therapy for tumors that cause Kasabach- (d) ulceration unresponsive to topical, intralesional, or systemic
Merritt phenomenon. Kasabach-Merritt phenomenon is a therapy; and (e) predictable scar or hair loss, particularly if the
rare, life-threatening condition, where a vascular tumor traps infant must undergo a general anesthetic for another reason.
and destroys platelets, resulting in thrombocytopenia. This
may lead to a consumptive coagulopathy, with loss of clot- Early Childhood (Involuting Phase) Indications for removal
ting factors such as fibrinogen, and subsequently dissemi- prior to entering school are: (a) resection is inevitable, for
nated intravascular coagulation and even death. Although it example, postulcerative scarring, unalterably expanded skin,
was initially thought that Kasabach-Merritt phenomenon was or high probability of residual fibrofatty tissue; (b) same scar
associated with IH, more recent literature associates this dis- length/appearance if excision were postponed; (c) scar eas-
order with specialized vascular tumors to include kaposiform ily hidden in relaxed cutaneous tension lines or a border of a
hemangioendothelioma and tufted angioma.17 Two caveats facial aesthetic unit; and (d) necessity for staged resection or
should be noted in managing this coagulopathy: (a) do not reconstruction.
transfuse platelets unless there is evidence of active bleeding
or unless a surgical procedure (such as placement of a long Late Childhood (Involuted Phase) Resection of an invo-
line) is indicated and (b) do not give heparin because it can luted hemangioma is usually undertaken (a) for damaged skin;
stimulate tumor growth and aggravate platelet trapping. 18 (b) for abnormal contour (fibrofatty residuum); (c) for distor-
The infant given IFN usually has a fever for the first 1 to 2 tion or destruction of an anatomic structure; or (d) because
weeks; pretreatment with acetaminophen 1 to 2 hours prior staged removal or reconstruction is necessary.
to injection dampens the febrile response. IFN causes revers-
ible toxicoses of up to fivefold induction in liver transaminase, Vascular Malformations
transient neutropenia, and anemia. Neutropenia is ascribed
to “margination,” not to suppression of bone marrow, and Clinical and Pathological Features
resolves on continued treatment. Infants on IFN grow and In contrast to hemangiomas, which have a defined natural
gain weight in a normal fashion. The worst long-term adverse history, vascular malformations might not present clinically
reaction is spastic diplegia, which usually improves following until early childhood and tend to grow proportionately
prompt cessation of therapy. Children receiving IFN require with the child, often becoming more prominent at puberty.
periodic neurologic and developmental assessment. They do not regress, and typically persist throughout life.
Vincristine Vincristine is a second-line therapy that has been They have been reported to occur in approximately 0.3%
used successfully in the treatment of infants with complicated to 0.5% of the population, with no gender predilection.
hemangiomas that do not respond to corticosteroids or cannot They are classified both by the predominant channel type
be weaned off corticosteroids. It has also been effective in the (Table 21.1) and by flow characteristics into fast-flow and
treatment of diffuse neonatal hemangiomatosis, kaposiform slow-flow lesions.
hemangioendothelioma, and tumors that cause Kasabach- Each of the four major categories of vascular malforma-
Merritt phenomenon. Vinca alkaloid must be administered tion has a unique histopathologic appearance and all are lined
through a central intravenous line. It has a response rate of by quiescent endothelium. CMs comprise regular, ectatic,
>80%. Side effects include peripheral neuropathy, consti- thin-walled capillary-to-venular–sized channels located in the
pation, minor hair loss, and sepsis and other complications papillary and upper reticular dermis (see Figure 21.6). There
related to the central line. is a deficiency of perivascular neural elements, which might
account for altered neural modulation of vascular tone and
Lasers. Lasers can be used to selectively treat hemangiomas progressive ectasia. Of note is that CMs may appear similar
depending on the specific indication (Chapter 19). Pulsed dye to tufted angioma on clinical examination (see Figure 21.7),
laser (PDL) can be effective in treating relatively flat, super- and an incisional biopsy is indicated if the diagnosis is in ques-
ficial hemangiomas but has limited depth of penetration and tion since the natural history and treatment for tufted angioma
is thus ineffective at treating deeper and thicker lesions. PDL differ markedly from those of CM. LMs have walls of vari-
seems to be most effective in treating residual telangiectases able thickness comprised of both striated and smooth muscle
after involution of the hemangioma. Careful consideration is and nodular collections of lymphocytes in the connective tis-
necessary before using PDL as several treatments are usually sue stroma. Venous malformations (VM) are characterized

FIGURE 21.5. Hemangioma. A. A 9-month-old girl presented with hemangioma of the upper lip. This was resected early due to aesthetic
concerns, as the prominent location and extent of skin disfigurement would have resulted in an inevitable residual deformity. B. Early postop-
erative image demonstrating restoration of the philtral architecture of the upper lip.
histologically by thin-walled vascular spaces surrounded by assessment of superficial lesions and assessment of blood flow
abnormally formed layers of smooth muscle, often in clumps. velocity, to distinguish fast-flow from slow-flow anomalies.
The dysplastic venous networks drain to adjacent veins, many However, Doppler ultrasound is very operator dependent and
of which are varicose and lack valves. Pale acidophilic fluid is may not delineate the anomaly well from adjacent structures.
typically seen within the channels and sacs of an LM, whereas Use of computed tomography (CT) is limited by lack of soft-
blood, fresh and organizing thrombi, and phleboliths charac- tissue detail and exposure to ionizing radiation. However, it
terize a VM. AVMs comprise thickened fibromuscular walls, has a place in the evaluation of intraosseous vascular malfor-
fragmented elastic lamina, and fibrotic stroma. The veins in an mations and secondary bony changes.
immature AVM are “arterialized” (reactive muscular hyper- MRI is probably the best imaging technique, being nonin-
plasia), whereas in a mature AVM, the veins evidence degen- vasive and nonionizing, and also providing superb detail of
erative fibrosis and muscular atrophy. soft tissues. It demonstrates flow characteristics, abnormal
channels, and extent of involvement in tissue planes. The use
of magnetic resonance angiography (MRA) and magnetic
Evaluation of Vascular Malformations resonance venography (MRV) allows differentiation between
Treatment by multidisciplinary teams remains key in the opti- slow-flow and fast-flow malformations.
mal management of patients.19 The development of vascular CM is not seen by MRI, except as minor cutaneous thick-
anomalies clinics and conferences allows evaluation by physi- ening. VM gives high-signal intensity on T2-weighted images,
cians in other specialties such as dermatology, radiology, and brighter than fatty tissue. Phleboliths are pathognomonic for
pathology to determine the best treatment for the patient. A a venous anomaly and seen as discrete round signal voids on
large number of imaging modalities are available for evalua- T1- and T2-weighted spin-echo and gradient images. It is dif-
tion of vascular malformations, with some more suited to each ficult to distinguish LM from VM or LVM. These are better
type of lesion. As first-line techniques, plain radiographs are delineated by the administration of intravenous gadolinium
useful in imaging skeletal growth disturbances and phleboliths and repetition of the T1-weighted sequences. VMs enhance
in VMs, while color Doppler ultrasound is useful for real-time inhomogeneously, whereas LM shows either rim enhancement
FIGURE 21.6. Venous malformation. Left: A 6-year-old boy presents with a superficial venulocapillary malformation involving the left side of
the face. Middle: Photomicrograph shows numerous small isolated branching vessels present in the superficial dermis (H&E, 4 ×). Right: Higher
power photomicrograph depicts a non-proliferative inactive endothelial layer (H&E, 20 ×).


FIGURE 21.7. Tufted angioma. Left: An 8-month-old boy presents with a tufted angioma involving the right side of the face. Middle: Small can-
non ball–like clusters of curvilinear capillaries are seen at multiple levels in the superficial and deeper dermis (H&E, 4 ×). Right: Higher power
photomicrograph shows clustering glomeruloid architecture within the clusters with focal spindle cell regions at the periphery corresponding to
focal lymphatic endothelial differentiation (H&E, 20 ×).
or no enhancement. AVM demonstrates a myriad of flow- with either maxillary (V2) or mandibular (V3) involvement are
voids in all sequences, high-flow vessels on gradient sequences, at low risk for having the disorder. The leptomeningeal vascu-
contrast enhancement with gadolinium sequences, and usually lar abnormalities can lead to seizures, contralateral hemiple-
no discrete parenchymatous signal abnormality. Other more gia, and variable developmental delay of motor and cognitive
invasive techniques that are less used nowadays include angi- skills. MRI with contrast (gadolinium) is more sensitive than
ography and venography. Angiography is used for therapeutic CT in revealing pial vascular abnormalities (CM, VM, AVF,
embolization, either preoperatively or in an elective setting. and AVM), cerebral atrophy, and prominent cortical sulci.
Children who have ipsilateral increased choroidal vascularity
Capillary Malformations are at risk for retinal detachment, glaucoma, and blindness,
particularly if the CM involves both V1 and V2 areas.
Overview. CMs are among the most common vascular
anomalies, with a frequency of approximately 3 in 1,000 live Treatment. The flashlamp-pumped PDL is the treatment
births, and an equal gender distribution. They usually pres- of choice for CMs. The PDL uses a wavelength (577, 585, or
ent at birth as pink or red intradermal discolorations that 595 nm) that selectively targets oxyhemoglobin and results in
may involve small areas or involve an entire limb or face intravascular thrombosis. Lightening of the lesion is usual,
(Figure 21.6). True CMs tend to be progressive, and thicken, occurring in 50% to 90% of patients. However, complete res-
darken, and become nodular with age. Conversely, a subset olution of the lesion is unusual. Better results are obtained for
of CMs (macular stains) often located on the central aspect younger patients treated in early childhood. For patients who
of the face and nape of the neck, variously termed “salmon do not respond to PDL, or those who no longer demonstrate
patch,” “nevus simplex,” or vascular stain,” lighten or disap- lightening of the lesion, typically after 6 to 10 treatments, alter-
pear within the first few years of life. native treatment options include newer laser devices such as a
long-pulsed tunable dye laser at 595 nm, alexandrite (755 nm),
Associated Conditions. Significantly, some CMs may be or Nd:YAG (1,064 nm) lasers and intense pulsed light (IPL).
associated with underlying abnormalities or syndromes. Facial
Soft-tissue and skeletal hypertrophy may require surgical
or extremity CMs may result in soft-tissue hypertrophy with
intervention, such as contour resection for macrocheilia and
underlying skeletal changes. Facial CMs tend to darken in
orthognathic procedures for asymmetric vertical maxillary
color and develop fibrovascular changes. Thickened purple
excess or for mandibular prognathism. Excision of localized
nodules may appear in adulthood and pyogenic granuloma
fibrovascular nodules is easily accomplished. In rare instances,
may manifest at any age. Overgrowth of CMs in the face may
it may be necessary to excise a thickened CM in an entire
manifest as lip or gingival enlargement, or maxillary or man-
facial aesthetic unit and resurface with a skin graft.
dibular overgrowth with subsequent skeletal asymmetry and
malocclusion. Overgrowth of extremity CMs is almost always
seen in the form of combined capillary–lymphatic malforma- Venous Malformations
tions or capillary–lymphatic–venous malformations (CLVM), Overview. VMs present clinically as soft, compressible, blue
manifesting as Klippel-Trenaunay syndrome (slow-flow subcutaneous masses (Figure 21.8), which enlarge with physi-
C-L-VM, axial elongation, and limb hemihypertrophy) or cal activity or in a dependent position. Dilated anomalous
Parkes Weber syndrome (AVM, cutaneous CM, and skeletal intradermal venous channels account for the blue coloration.
or soft-tissue hypertrophy of the limb). Lesions are typically painful in the morning, as a result of
CMs in the midline in the lumbar or even cervical area stasis and microthrombi. Like other vascular malformations,
may be associated with underlying spinal dysraphism. In the VMs grow proportionately with the child and often enlarge
occiput, one should be concerned for an underlying encepha- during puberty.
locele, while a CM in the upper back may indicate an AVM of
the spinal cord (Cobb’s syndrome). Associated Conditions. Head and neck VMs tend to be
Sturge-Weber syndrome consists of facial CM in the trigem- the most common and are often more extensive than apparent
inal nerve distribution, ipsilateral leptomeningeal, and ocular from the outside, extending to the underlying muscle or bone,
vascular anomalies and seizures. The capillary stain involves as well as into oral mucosa or salivary glands. As a result, these
the ophthalmic (V1) trigeminal dermatome, while patients lesions may be complicated by epistaxis or hemoptysis, airway

FIGURE 21.8. Venous malformation. Top row: A 15-year-old boy with extensive venous malformation of the buttock
and right thigh resulting in bleeding, pain, and severe distortion. Bottom row: Staged surgical reduction resulted in signifi-
cant improvement as seen in postoperative images 1 year later (From Arneja J, Gosain AK. Vascular malformations. Plast
Reconstr Surg. 2008;121:195e, with permission).
compromise, and abnormal speech and dentition. More often, patients with bleeding, or for painful or well-localized lesions.
patients may present with facial asymmetry or concerns about Orthognathic surgery may also be used to correct malocclu-
cosmesis. Extremity VMs may present with limb hypertrophy sion. Debulking of lesions may be useful for lesions in the
or asymmetry and may even have pathologic fractures with hands and feet, and resection of intramuscular VMs in the
osseous extension. thigh or calf may improve function.
An associated condition is Blue-rubber bleb nevus syn-
drome, which occurs in a sporadic fashion. Patients present Arteriovenous Malformations
with multiple lesions on the trunk, palms, and soles of feet, as
well as sessile or polypoid lesions in the gastrointestinal tract. Overview. AVMs are fast-flow lesions with a direct connec-
Intestinal bleeding may be severe, requiring transfusion. tion between the artery and vein, in the absence of an inter-
vening capillary bed. The majority of patients (40% to 60%)
Treatment. MRI is extremely useful for confirming the present at birth, with an equal gender distribution. The epi-
diagnosis of VM and mapping the extent of involvement, center of an AVM is called the nidus and consists of arterial
with venography serving as an adjunct for surgical plan- feeders, micro- and macroarteriovenous fistulas, and ectatic
ning. VMs exhibit a brighter signal than fat on T2-weighted veins. Intracranial AVM is more common than extracranial
sequences. A coagulation profile should be ordered to AVM, followed, in frequency of location, by limbs, trunk, and
exclude an underlying coagulopathy, as there is usually viscera. Schobinger’s staging system,20 accepted by the ISSVA,
localized intravascular coagulopathy and patients are at describes four stages.
risk for disseminated intravascular coagulopathy following Stage I lesions (quiescent phase), which usually last from
trauma or intervention. birth till adolescence, are asymptomatic, with the AVM hav-
Percutaneous sclerotherapy is the first-line treatment. ing the appearance of an involuting hemangioma or CM.
Agents that have been used include absolute ethanol, hyper- Stage II lesions (progressive phase) most often begin dur-
tonic saline, and 3% sodium tetradecyl sulfate. Local coming adolescence, where the AVM enlarges and darkens, with
plications include full-thickness skin necrosis, blistering, and increased warmth, palpable thrill or pulse, or murmur on aus-
neural deficits, while systemic complications reported include cultation. Trauma, pregnancy, or puberty may also cause pro-
renal toxicity and cardiac arrest. Adjuncts include the use of gression to this stage.
elastic compression garments for extremity VMs and daily Stage III lesions (destructive phase) are characterized by
prophylactic aspirin to reduce painful thrombotic events and destructive lesions with pain, bleeding, ulceration, or bone
formation of phleboliths. erosions, and typically occur after years of progression.
Surgery is useful for head and neck lesions where cos- Stage IV lesions (decompensation phase) are defined by
metic appearance is a concern, for severely symptomatic cardiac decompensation with congestive heart failure.

Treatment. Color Doppler evaluation and ultrasonogra- resection 24 to 48 hours after embolization (Figure 21.9).
phy are useful first-line tools to determine flow characteris- This serves to reduce intraoperative bleeding, but it does
tics. MRI defines the anatomy and extent of the lesion, while not diminish the boundaries of resection. Agents used for
angiography is useful in further characterizing the lesion and embolization include particles (gelfoam and acrylic), abso-
allows therapeutic embolization. lute ethanol, and sodium tetradecyl sulfate. Better outcomes
AVMs are usually treated when there are endangering are seen with stage I or localized stage II AVMs. Ligation
signs and symptoms, such as ischemic pain, recalcitrant or proximal embolization of arterial feeding vessels should
ulceration, bleeding, and increased cardiac output. Small never be done, as this results in rapid recruitment of nearby
localized AVMs may be primarily resected and reconstructed. arterial vessels to supply the nidus. Even after surgical resec-
Larger diffuse AVMs will require primary arterial embolization, patients need to be followed up for years with clinical
tion or superselective arterial embolization for temporary examination, ultrasonography, and/or MRI to monitor for
occlusion of the nidus (epicenter of the lesion), followed by recurrence.

FIGURE 21.9. Arteriovenous malformation. Progression of a high-flow arteriovenous malformation of the upper lip is seen over time.
A. At 2 years of age. B. The AVM has enlarged markedly by 4 years of age. C, D. Preoperative superselective embolization was performed fol-
lowed by surgical reduction of the AVM 48 hours later. E. Postoperative result. F. At age 10 years after further secondary surgery for revision of
the vermillion–cutaneous junction, percutaneous sclerotherapy, and laser treatments (From Arneja J, Gosain AK. Vascular malformations. Plast
Reconstr Surg. 2008;121:195e, with permission).

Surgical resection is the only way to potentially cure LMs.

Lymphatic Malformations However, multiple procedures may be required and complete
Overview. LMs consist of anomalous channels, vesicles, curative excision may not be possible due to the anatomical
or pouches filled with lymphatic fluid. Approximately 65% location of the LM, for example, in the head and neck region.
to 75% are present at birth with the rest evident by 2 years Postoperative complications include local wound infection,
of age. These are classified into microcystic, macrocystic, or hematoma, prolonged drainage, and nerve palsies. Localized
combined (microcystic–macrocystic). LMs never regress but and well-demarcated lesions generally have a better surgical
instead expand or contract depending on the ebb and flow outcome.
of lymphatic fluid and the occurrence of inflammation and Percutaneous sclerotherapy has gained recent popularity
intralesional bleeding. as an alternative treatment due to high morbidity associated
Macrocystic LMs are typically visible at birth and often with surgical resection in some areas of the body. Agents used
detected by prenatal ultrasonography. Most of these lesions include absolute ethanol, doxycycline, bleomycin, acetic acid,
are located on the head and neck or axilla, where they were sodium tetradecyl sulfate, or OK-432 (preparation of group A
referred to as cystic hygromas. They tend to present as isolated streptococcus treated with benzylpenicillin). Sclerotherapy has
poorly defined subcutaneous masses that expand over time, as been shown to be more effective in treating macrocystic LMs
anomalous channels become ecstatic. Cervicofacial LMs may compared with microcystic LMs.
inhibit normal vaginal delivery and subsequently lead to air-
way obstruction and problems with feeding and speech devel-
opment. Head and neck LMs are characterized by skeletal
Combined Vascular Malformations
hypertrophy (Figure 21.10). LM is the most common cause Slow-Flow Combined Malformations. Klippel-
for macrocheilia, macroglossia, macrotia, and macromala. Trenaunay syndrome refers to a combined CLVM associated
Lesions in the upper neck, floor of mouth, and tongue often with soft-tissue/skeletal hypertrophy in one or more limbs.
lead to progressive distortion and overgrowth of the mandi- The CMs are multiple, often in a patchy geographic pattern,
ble. Overgrowth in the body of the mandible manifests as mal- usually studded with hemolymphatic vesicles, and typically
occlusion, typically anterior open bite, and class III occlusion. located on the anterolateral aspect of the thigh, buttock, or
Theories formulated to explain skeletal hypertrophy include trunk. The anomalous veins are prominent laterally because
intraosseous LM or local mass and pressure effects. Intra- of insufficient to absent valves; deep venous anomalies also
abdominal LMs may present with abdominal pain, palpable occur. Lymphatic hypoplasia or localized lymphatic anomalies
mass, or symptoms of bowel obstruction. These can result in are primary defects. Limb hypertrophy can be minor to gro-
hypoalbuminemia secondary to protein-losing enteropathy. tesque; some patients with classic CLVM have a short limb.
Microcystic LMs are present at birth, but may not be Often there is lipomatous dorsal swelling and digital over-
obvious until complications such as infection or bleeding growth on the opposite foot. If significant (>2 cm) limb length
result. These are often located over proximal extremities, discrepancy exists, pediatric orthopedic evaluation should be
axillae, and chest regions and have been termed “lymphan- obtained. Surgical options include percutaneous epiphysiode-
gioma circumscriptum” due to their common presentation sis to induce growth arrest of the longer limb. Elastic support
as crops of thin-walled vesicles or hyperkeratotic papules garments protect the limb from trauma and decrease swelling
arranged irregularly in groups, typically localized to one associated with venous insufficiency. Resection or sclerother-
region (Figure 21.11). Further evaluation is indicated for apy of veins is reserved for patients with symptomatic super-
these lesions to define the extent of involvement, and MRI ficial varicose veins.
studies are extremely helpful as the lesions may involve Proteus syndrome is a sporadic disorder characterized by
deeper dermal or subcutaneous structures and are rarely well connective tissue nevi, lipomas, several unusual tumors, and
circumscribed. Microcystic LMs can also present as verru- disproportionate skeletal growth, in addition to ocular, pul-
cous lesions with black dots on the surface, with subsequent monary, and renal abnormalities. Asymmetrical growth and
misdiagnosis as genital warts when found in the perineum. soft-tissue changes are not present at birth; instead, they
In this form, the most common symptom is recurrent oozing evolve later, which serves to differentiate Proteus syndrome
of clear liquid. Long-standing microcystic LMs may result in from Klippel-Trenaunay syndrome. Vascular anomalies (CM,
squamous cell carcinoma. VM, LM, or combined forms) can occur, randomly distrib-
Combined LMs are frequently seen in the cheek, forehead, uted on the trunk and limbs. Proteus syndrome is thought to
and orbit. They cause facial asymmetry, ocular proptosis, and be caused by a dominant lethal gene that survives by somatic
distortion of features. Soft-tissue and bony hypertrophy are mosaicism. Management is largely supportive.
characteristics. A bulky tongue, covered with vesicles, impairs Maffucci syndrome denotes the coexistence of exophytic
speech and is complicated by recurrent infection, swelling, bleed- venous anomalies, with bony exostoses and enchondroma-
ing, poor dental hygiene, and caries. In the cervicofacial region, toses. These features usually do not manifest until early to
micro-macrocystic LM can cause airway obstruction, sometimes mid-childhood. Enchondromas are discovered first, typically
necessitating tracheostomy. Cervicoaxillary LM commonly located in the metaphysis and epiphysis of the long bones. The
involves the thorax and mediastinum, causing recurrent pleural venous lesions typically appear around 4 to 5 years of age as
and pericardial effusion. Extensive LM in an extremity is associ- firm, dome-like, bluish spots, usually on a finger or toe. Venous
ated with lymphedema. Pelvic LM manifests with perineal lym- anomalies also present in bones (particularly the limbs), lep-
phangiectasias. Generalized LM denotes skeletal involvement, tomeninges, or gastrointestinal tract. Malignant degeneration,
typically of the ribs, vertebrae, scapula, and long bones. usually chondrosarcoma and other nonskeletal neoplasms,
occurs in 20% to 40% of patients. Management is conserva-
Treatment. Radiographic studies are useful in confirming tive unless venous malformations become symptomatic.
and assessing the extent of disease. Ultrasonography can accu-
rately distinguish macrocystic from microcystic LMs. Doppler Fast-Flow Combined Malformations. Parkes-Weber
flow studies can also distinguish LMs (no flow) from VMs syndrome is defined by overgrowth of an extremity together
or AVMs, based on flow velocity. MRI remains the gold with the presence of an AVM with multiple AVFs. There is
standard for defining the extent of the lesion and is useful in usually a cutaneous CM. It usually affects the lower limb and
determining involvement of deeper structures in microcys- presents at birth with warmth, bruit, and thrill in a limb and
tic LMs. Untreated LMs may be complicated by infection or proximal trunk. There is a geographic pink, macular stain
intralesional bleeding. Antibiotics and observation, respec- and generalized enlargement. There may be lymphatic anom-
tively, are the treatment for these episodes. alies, either lymphedema or localized lesions.


FIGURE 21.10. Lymphatic malformation. Upper left: A 1-year-old male with lymphatic malformation of the head and neck; resection of sub-
mandibular soft-tissue involvement has been performed. Lower left: MRI demonstrates enlarged tongue and potential airway compromise. Upper
right: Significant mandibular prognathism is noted by age 5 years. Lower right: MRI demonstrates persistent tongue enlargement at age 11 years
despite previous surgical reduction and sclerotherapy (From Arneja J, Gosain AK. Vascular malformations. Plast Reconstr Surg. 2008;121:195e,
with permission).
MRI in young children often reveals only diffuse hypervas- deformity, papillomatosis, and recurrent infection, which in
cularity of enlarged muscles and bones. MRA and MRV show severe cases may require amputation.
generalized arterial and venous dilatation. Arteriography Bannayan-Riley-Ruvalcaba syndrome is characterized by
demonstrates microscopic AV fistulae throughout the delayed motor and speech development, proximal myopa-
affected limb, particularly near the joints. Significant limb thy, macrocephaly, pigmental penile macules, ileal and
length discrepancy may require percutaneous epiphysiodesis. colonic hamartomatous polyps, subcutaneous lipomas, and
Hypertrophied digits in the lower limb may result in severe Hashimoto thyroiditis. Vascular anomalies appear in wide

FIGURE 21.11. Lymphatic malformation. Left: A 16-year-old boy with a recurrent lymphangioma circumscriptum of the left posterior trunk.
Presenting symptoms consisted of daily episodes of pain and hemorrhage. Middle: CT scan revealed an extrafascial low-flow malformation.
Right: A 6-month follow-up after treatment with wide-local excision to the deep fascia and placement of a split thickness skin graft (From Arneja J,
Gosain AK. Vascular malformations. Plast Reconstr Surg. 2008;121:195e, with permission).
spectrum from small nodular cutaneous lesions, intramuscu- 9. Berenguer B, Mulliken JB, Enjolras O, et al. Rapidly involuting congeni-
tal hemangioma: clinical and histopathologic features. Pediatr Dev Pathol.
lar, intraosseous, and intracranial lesions to extensive AVM. 2003;6:495.
Bannayan-Riley-Ruvalcaba syndrome is an autosomal domi- 10. Arneja JS, Chim H, Drolet BA, Gosain AK. The cyrano nose: refinements in
nant disorder, allelic with Cowden syndrome, and caused by surgical technique and treatment approach to hemangiomas of the nasal tip.
mutations in PTEN, a tumor-suppressor gene. There is phe- Plast Reconstr Surg. 2010 126:1291.
11. Greenberger S, Boscolo E, Adini I, Mulliken JB, Bischoff J. Corticosteroid
notypic overlapping, and patients with either syndrome are at suppression of VEGF-A in infantile hemangioma-derived stem cells. N Engl
risk for developing benign and malignant neoplasms. J Med. 2010;362:1005.
12. Leaure-Labreze C, de la Roque ED, Hubiche T, et al. Propranolol for severe
References hemangiomas of infancy. N Engl J Med. 2008;358:2649.
13. Mazereeuw-Hautier J, Hoeger PH, Benlahrech S, et al. Efficacy of
1. Virchow R, ed. Die krankhaften Geschwu® lste. Berlin: A. Hirschwald; 1863. propranolol in hepatic infantile hemangiomas with diffuse neonatal hem-
2. Mulliken JB, Glowacki J. Hemangiomas and vascular malformations in angiomatosis. J Pediatr. 2010;157:340.
infants and children: a classification based on endothelial characteristics. 14. Holland KE, Frieden IJ, Frommelt PC, Mancini AJ, Wyatt D, Drolet BA.
Plast Reconstr Surg. 1982;69:412. Hypoglycemia in children taking propranolol for the treatment of infantile
3. Jackson IT, Carreno R, Potparic Z, et al. Hemangiomas, vascular malfor- hemangioma. Arch Dermatol. 2010;146:775.
mations, and lymphovenous malformations: classification and methods of 15. Chim H, Armijo BS, Miller E, Gliniak C, Serret MA, Gosain AK. Accepted
treatment. Plast Reconstr Surg. 1993;91:1216. for publication 2011, Ann Surg.
4. Enjolras O, Mulliken JB. Vascular tumors and vascular malformations (new 16. Boon LM, MacDonald DM, Mulliken JB. Complications of systemic cor-
issues). Adv Dermatol. 1997;13:375. ticosteroid therapy for problematic hemangiomas. Plast Reconstr Surg.
5. Khan ZA, Boscolo E, Picard A, et al. Multipotent stem cells recapitulate 1999;104:1616.
human infantile hemangioma in immunodeficient mice. J Clin Invest. 17. Garzon MC, Huang JT, Enjolras O, Frieden IJ. Vascular malformations:
2008;118:2592. part 1. J Am Acad Dermatol. 2007;56:353.
6. Jinnin M, Medici D, Park L, et al. Suppressed NFAT-dependent VEGFR1 18. Mulliken JB, Anupindi S, Ezekowitz RAB, et al. Case records of the
expression and constitutive VEGFR2 signaling in infantile hemangioma. Massachusetts General Hospital. Case 13-2004: a newborn girl with a
Nat Med. 2008;14:1236. large cutaneous lesion, thrombocytopenia, and anemia. N Engl J Med.
7. Mulliken JB, Fishman SJ, Burrows PE. Vascular anomalies. Curr Prob Surg. 2004;350:1764.
2000;37:517. 19. Mathes EFD, Haggstrom AN, Dowd C, et al. Clinical characteristics and
8. Haggstrom AN, Drolet BA, Baselga E, et al. Prospective study of infantile management of vascular anomalies. Arch Dermatol. 2004;140:979.
hemangiomas: Clinical characteristics predicting complications and treat- 20. van Aalst JA, Bhuller A, Sadove MA. Pediatric vascular lesions. J Craniofac
ment. Pediatrics. 2006;118:882. Surg. 2003;14:566.

Chapter 22 n
Single-Suture
Craniosynostosis and
Deformational Plagiocephaly
Gary F. Rogers and Stephen M. Warren
mesenchyme leads to premature fusion. Their theory was per-

Introduction vasive until Van der Klaauw (1946) and Moss (1959) sug-
Craniosynostosis is the premature fusion of one or more cra- gested that the dura mater acted as a conduit or “functional

nial sutures. This pathologic process occurs in 1 in 2,000 to matrix” for cranial base biomechanical forces. Accordingly,

2,500 live births and can occur in association with more than transmitted tension from an abnormal cranial base would pre-
130 different syndromes (multi-suture craniosynostosis is sumably alter normal cranial suture physiology. For example,
discussed in Chapter 23).1 Any cranial suture can ossify prema- in coronal synostosis, spatially malformed lesser sphenoidal
turely, but fusion is most common in the sagittal suture (40% wings were hypothesized to transmit aberrant tensile force
to 55%), followed by the coronal (20% to 25%), metopic (5% upward through dural fiber tracts leading to premature fusion
to 15%), and lambdoid (1% to 5%) sutures. Craniosynostosis of the overlying cranial suture. In sagittal synostosis, abnor-
results in characteristic changes to the cranial shape that indi- malities in the cribriform plate and crista galli could generate
cates which suture(s) is involved (Virchow’s law). Patients forces that, at the points of dural attachment, would promote
with craniosynostosis, especially syndromic forms, may also premature suture fusion.
have other physical findings such as midface hypoplasia, deaf- Contemporary research has fundamentally changed our
ness, blindness, speech impairments, learning disabilities, understanding of cranial suture fate. Based on a wealth of
nasopharyngeal airway obstruction, swallowing dysfunction, evidence, it appears that conserved signaling pathways medi-
heart and lung abnormalities, and extremity anomalies. ate cranial suture fate. Numerous in vitro and in vivo models
The diagnosis, management, and treatment of craniosyn- have demonstrated that the subjacent dura mater shapes the
ostosis can be complex and requires coordinated care. This is cranial suture complex by temporally and spatially supplying
best accomplished by an interdisciplinary team comprised of growth factors (e.g., fibroblast growth factor-2) and cellular
professionals from the following disciplines: anesthesiology, elements (e.g., osteoblastic cells) to the overlying osteogenic
craniofacial surgery, genetics, hand surgery, intensive care, fronts and suture mesenchyme. Genetic findings in human
neurosurgery, nursing, ophthalmology, orthodontics, pediat- syndromic and nonsyndromic craniosynostoses indirectly
rics, pediatric dentistry, prosthodontics, psychology, radiol- support this hypothesis. Using positional cloning, candidate
ogy, social work, and speech/language pathology.2 Implicit in gene approaches, and comparative genomic hybridization
the choice of a team is the understanding that the first pro- techniques, over 100 mutations have been identified in genes
cedure provides the best opportunity for an optimal surgical such as TWIST, NELL-1, MSX2, GLI3, AND FGFR1-3.1
outcome. A good or excellent surgical outcome is more chal- Exactly how these mutations cause craniosynostosis is still
lenging to achieve if critical tissues are surgically damaged, being elucidated. 3 The link between cranial suture fusion
malpositioned, or discarded. An experienced team is even and facial hypoplasia appears to occur through a secondary
more important when contemplating surgical revision. cascade of growth impairment that extends from the cranial
base through the facial skeleton. Findings by Mooney and
others suggest that the calvarial dysmorphology can drive
Pathogenesis the basicranial and midface changes. Further supporting
Historically, three etiopathogenic theories have dominated the evidence for the primacy of cranial vault pathology comes
field of craniosynostosis. In his 1851 paper on cretinism and from clinical observations by Marsh, Vannier, and others
pathologic brain malformation, Rudolph Virchow suggested that early cranial vault remodeling can sometimes lessen the
that cranial suture fate was independent of the neurocranial severity of cranial base and facial abnormalities.
environment. He presumed that the osteogenic fronts of the The sequelae of craniosynostosis include both physical
calvarial suture possessed the autonomous capacity (i.e., inde- deformity and insufficient cranial volume to permit normal
pendent of interactions with the dura mater or brain) to fuse or brain growth and development. While the effects of synostosis
remain patent. Virchow based his deductions on the work of on brain development are unclear, some studies demonstrate
Sommering (1800), who first described cranial suture anatomy neurocognitive deficiencies in children with synostosis; the
and proposed that premature suture fusion could alter the head etiopathogenesis of these neurocognitive impairments, how-
shape. Virchow’s etiopathogenic theory also benefitted from the ever, remains unknown and may be the result of, or simply
work of Otto, who used Sommering’s observations to develop associated with, the fusion of a cranial suture.
the hypothesis that suture fusion in one region on the cranium
leads to compensatory overgrowth in another. Virchow’s pri-
mary contribution was to expand and refine Otto’s proposal
History of Treatment
and provided more conclusive support for what is now known The work of Otto and Virchow on the role of the cranial
as Virchow’s law: premature suture fusion results in compensa- sutures in normal and abnormal calvarial growth provided the
tory skull growth parallel to the fused suture and a decreased basis for early operative treatment of craniosynostosis. The
growth perpendicular to the suture (Figure 22.1). first recorded operations removed the offending suture in an
Virchow’s hypothesis of skull maldevelopment remained attempt to release the constricted brain. In 1890, Lannelogue
unchanged for nearly 70 years until 1920, when Park and described bilateral strip craniectomies for the correction of
Powers postulated that craniosynostosis was caused by a craniosynostosis. Lane subsequently described a similar and
primary defect in the cranial suture mesenchymal blastema. successful procedure in a 9-month-old infant with microceph-
They alleged that an embryologic defect in the cranial suture aly. Two years later, Jacobi reported poor outcomes and high
221
Metopic suture
Anterolateral
(sphenoid) fontanel Anterior
Coronal suture (frontal)
Frontal
fontanel
Squamosal
suture
Frontal
Parietal
Lambdoid Parietal Parietal

suture
Temporal
Sagittal
Posterolateral suture
(mastoid) fontanel
Occipital bone
Posterior (occipital) fontanel
FIGURE 22.1. Schematic drawing of metopic, sagittal, coronal, and lambdoidal cranial sutures. The confluence points of the cranial sutures
form the anterior, posterior, anterolateral (sphenoid), and posterolateral (mastoid) fontanelles. The fontanelles close sequentially and the sutures
function as growth centers. The metopic suture fuses by 8 months of age in nearly all children. The remaining sutures fuse late in life. Virchow’s
law states that premature suture fusion results in compensatory skull growth parallel to the fused suture and a decreased growth perpendicular
to the suture.
morbidity and mortality in 33 patients with craniosynosto- hospital stay, and cost compared with larger cranial vault
sis treated with open strip craniectomy. He attributed these remodeling procedures. Other authors have noted similar
untoward consequences to major blood loss associated with results.4 The effectiveness of this procedure, however, is lim-
the extensive surgical exposure. Interestingly, some authorities ited to infants in the first several months of life and the out-
dispute whether many of these infants actually suffered from comes of certain types of craniosynostosis, such as metopic,
craniosynostosis and contend that some had microcephaly as can be variable.2 In 2003, Lauritzen introduced the use of
a consequence of poor brain development. Either way, these internal spring distractors to improve cranial shape.5 When
“brain-releasing” procedures were abandoned in infants until compared with a modified pi procedure for sagittal synostosis,
1927 when Faber and Town presented their successful experi- spring-mediated skull reshaping had comparable clinical out-
ence using open craniectomy to treat severe forms of cranio- comes with appreciably less morbidity. The application has
synostosis in young infants. The success of these surgeons led been expanded to most forms of craniosynostosis with good
to an acceptance of more extensive operative treatments that reported outcomes.6 Since this procedure does not rely on the
persist today. brain to expand the bone segments, it can be done success-
As anesthetic and blood management techniques improved, fully in older infants who would not be candidates for simple
many surgeons became dissatisfied with the unpredictable suturectomy.
results of simple suturectomy and began to use more extensive The addition of three-dimensional computed tomography
reshaping techniques. In 1967, Tessier presented his experi- (CT), computer-guided modeling, improved pediatric anesthe-
ence with cranial vault remodeling procedures that involved sia and blood conservation/salvage techniques, critical care,
segmental bone removal, remodeling, and stabilization. The and intraoperative monitoring have improved the safety and
operations he described were much more extensive than the effectiveness of craniofacial surgery and decreased the mor-
any previous methods; Tessier’s operations required more bidity and mortality. Fixation using resorbable plates and
operative time, more blood loss, and observation in an inten- screws has also greatly improved the stability and longevity
sive care unit. Nevertheless, because the bone segments were of the correction. The adaptation of distraction osteogenesis
directly contoured and stabilized to achieve the desired shape, to the craniofacial skeleton plays a small role in skull remod-
these operations generally had more predictable outcomes eling, but it has radically altered and expanded our surgical
than simple release procedures. Furthermore, they could be armamentarium for the treatment of midface hypoplasia in
done at any age since they did not rely on brain expansion to syndromic patients.
improve the cranial form or volume. These techniques remain
the gold standard in most large craniofacial centers.
Recently, several less invasive methods to treat craniosyn- Cranial Anatomy and The
ostosis have been introduced. In 1999, Jimenez and Barone
presented their experience with endoscopic strip craniectomy
Development of Anomalies
and postoperative orthotic helmet therapy. The suturectomy The morphogenetic path between craniofacial embryogenesis
was performed with the assistance of an endoscope through and pathogenesis is extremely narrow. Cephalic development
small incisions. The patients were fitted with a postoperative involves exceedingly complex mechanisms built on conserved
cranial orthosis to guide changes in cranial shape. The authors elements that have undergone enormous evolutionary change.
reported significant reductions in blood loss and transfusion, Cranial plates of the membranous neurocranium develop

Chapter 22: Single-Suture Craniosynostosis and Deformational Plagiocephaly 223
through the coalescence of ossification centers that arise from
the primitive mesenchyme overlying the brain (membranous Functional Aspects
ossification). The majority of the cranial base, or chondrocra-
nium, begins as a cartilaginous anlage that becomes ossified Increased Intracranial Pressure
gradually during embryologic development (endochondral It has long been observed that changes in calvarial shape can
ossification). Cranial sutures and fontanelles are the mesen- induce compensatory changes in the shape of the underlying
chyme that persists between the calvarial plates. The major brain. With premature fusion of the cranial sutures and con-
cranial sutures are the metopic, sagittal, coronal, and lambdoid tinued brain growth, surgeons have long speculated that such
(Figure 22.1). A list of minor sutures includes the temporosqua- a mismatch in shape and volume between the cranium and the
mosal, frontonasal, sphenoethmoidal, and frontosphenoidal. brain could lead to elevated ICP and neuropsychosocial retar-
The cranial sutures are important for two reasons. First, dation. Lannelongue (1890) suggested that craniosynostosis
they allow the head to deform during parturition so that the resulted in microcephaly with secondary mental retardation.
infant can pass through the pelvis. Second, the sutures cou- He thought that excision of the fused sutures could reverse
ple rapid brain expansion early in life to the growth of the or prevent intellectual impairment. Shillito and Matson also
cranium. Coordinated allometric growth of the cranium is advocated craniectomy in infancy to prevent elevated ICP

achieved through a series of tissue interactions between the and subsequent brain damage. Marchac and Renier measured

brain, dura mater, suture mesenchyme, and calvarial bones. the ICP in 121 craniosynostosis patients with an epidural
Growth of the cranium is passive and occurs in response to sensor.8 They detected elevated ICP in 42% of patients with
outward expansion of the brain. This creates tension across multiple-suture involvement and in 7% to 13% of patients
the sutures and stimulates formation of new bone along the with single-suture involvement.8 They noted a decrease in ICP
edge of the adjacent bony plates (osteogenic fronts of the cra- in patients who underwent cranial surgery.8 Gault et al. also
nial sutures). Thus, the cranial sutures permit the cranium to demonstrated that raised ICP was most frequent in those chil-
grow and expand as rapidly as the underlying brain. dren with more than one suture fused prematurely (complex,
Craniosynostosis can impair brain growth and develop- oxycephaly, Crouzon, brachycephaly, and Apert syndromes).
ment. Normally, the brain attains about 83% of its final vol- Craniocerebral disproportion, however, is not the only
ume by 2 years of age and the remaining 17% is acquired cause of elevated ICP in patients with craniosynostosis. Sleep
between 2 and 8 years of age.7 With the exception of the apnea resulting from midfacial retrusion can induce episodic
metopic suture, which normally closes by 8 months of age, the nocturnal elevations in ICP secondary to the dilating effects
other cranial sutures are patent during this period.3 If a single of hypercapnia on the cerebral vasculature. Another potential
suture fuses prematurely, compensatory growth in the remain- cause is venous hypertension resulting from stenosis or com-
ing patent sutures will lead to alterations in cranial shape (as plete closure of the sigmoid/jugular sinus complex.
predicted by Virchow’s law) but rarely leads to significant The gold standard for detecting elevated ICP is direct mon-
neurologic impairment. Single-suture fusions are occasionally itoring. Intraparenchymal and intraventricular monitoring is
associated with elevated intracranial pressures (ICPs) (~7.7%) more accurate than epidural measurements. The reliability
and subtle learning disabilities that go largely unrecognized.8 of lumbar puncture is questionable. One difficulty in inter-
The most common single suture to fuse prematurely is the sag- preting these numbers is that they fluctuate significantly with
ittal suture, followed by the coronal, metopic, and lambdoid. patient position, activity, blood pressure, and sleep. The most
Although most patients with single-suture synostosis have no meaningful results are obtained when patients are monitored
associated syndrome or identifiable genetic cause, approxi- for a period of time, usually overnight. Significant elevations
mately 25% of patients with unilateral coronal synostosis (>20 mm Hg) have been considered an absolute indication
will have a causative mutation (FGFR3 Pro250Arg, FGFR2, for intracranial expansion. Nevertheless, interpreting the sig-
TWIST, EFNB1, and NELL-1) and nearly 30% of patients nificance of borderline pressure elevations (15 to 20 mm Hg)
with metopic synostosis have an associated syndrome or a has been more problematic, and there is little consensus even
chromosome abnormality.1 Furthermore, familiar patterns of among neurosurgeons.
inheritance have been observed in sagittal synostosis. Thus, it Direct ICP monitoring is invasive and rarely used for rou-
is inaccurate to use the terms nonsyndromic and syndromic tine screening. Moreover, the measurement is only a snap-
craniosynostosis synonymously with single and multiple- shot in time: a normal pressure measurement early in life
suture craniosynostosis. does not imply that it will remain so as the brain continues to
Multiple-suture fusions significantly raise the possibility of grow. Consequently, many surgeons resort to less invasive,
cerebral compression and developmental effects (see section but less reliable, indicators of ICP. Conventional clinical
on Increased Intracranial Pressure). The most common mul- symptoms of acute ICP elevation, such as headache, somno-
tiple-suture fusion is bilateral coronal, but other unusual pat- lence, and dizziness, are often lacking even in affected chil-
terns have been described. Multiple-suture fusion that occurs dren. Papilledema and subsequent optic atrophy is strongly
early in utero can result in a cloverleaf, or Kleeblattschädel, suggestive of elevated ICP, but has limited sensitivity in chil-
deformity. In rare instances, all of the cranial sutures can be dren under 8 years of age. Findings can include blurring of
patent at birth and fuse later in infancy, a process termed pro- the disk margins and obliteration of the optic cup, elevation
gressive postnatal pansynostosis. These infants have small, of the nerve head (“champagne cork” appearance), capillary
but normally shaped heads and the only clinic sign may be congestion, hyperemia, venous engorgement, loss of venous
a relentless decline in head circumference percentile. Most pulse, peripapillary exudates, retinal wrinkling, and punctate
patients with multiple-suture fusions have an associated syn- nerve fiber layer hemorrhages. As optic atrophy progresses,
drome and a molecular basis for their craniosynostosis. The the disk becomes pale, the capillaries and hyperemia disap-
most common mutation associated with bilateral (and uni- pear, and significant secondary arteriolar narrowing occurs.
lateral) coronal synostosis is the FGFR3 Pro250Arg muta- Reducing ICP can reverse early changes, but more advanced
tion (Muenke syndrome), followed by mutations in TWIST degeneration may be permanent.
(Saethre-Chotzen syndrome), FGFR2 (Apert, Crouzon, and Radiographic evidence suggestive of elevated ICP includes
Pfeiffer syndromes), and EFNB1 (craniofrontonasal malfor- loss of subdural space, often with effacement of the basal
mation). The incidence of developmental and neurocognitive cisterns and vertex sulci, ventricular compression, and scal-
problems in this group is much higher than is seen in patients loping of the cranial endocortex. This latter finding has been
with single-suture fusion. It is unclear if this observation is a termed the “copper-beaten” skull and can be visualized on
result of the craniosynostosis, or the effect of the genetic aber- both conventional radiography and CT. It is a late finding
ration on brain development. caused by pressure remodeling of the inner table of the skull

by the gyral convolutions. The predictability of this finding coronal synostosis. This is secondary to decreased orbital
for ICP elevation has been questioned. While CT is the stan- depth and widening of the ethmoidal air cells and can lead
dard imaging technique, new imaging modalities are on the to corneal exposure and damage. Hypotelorism and stra-
horizon. For example, one day it may be possible to diagnose bismus can be associated with metopic synostosis. Patients
and monitor increased ICP using transcranial ultrasound and with unilateral coronal synostosis have elevation of the
resistive index calculations to assess the peak systolic and lesser and greater sphenoid wings (harlequin deformity)
diastolic velocities of the major cerebral vasculature (these that result in strabismus and ocular torticollis (head tilt to
velocities increase as ICP rises). Similarly, magnetic resonance unfused side) in nearly 80% of affected patients. In addi-
elastography may also be used in the future to measure ICP. tion, the contralateral orbital roof is depressed and 55% of
patients have astigmatism. Patients with Saethre-Chotzen syn-
Hydrocephalus drome (TWIST mutation) demonstrate upper eyelid ptosis.
Many of these manifestations are disfiguring and some can
Hydrocephalus is an infrequent finding in craniosynostosis.
threaten vision. Patients with strabismus or nonconjugate
It is more common in patients with Crouzon syndrome. CT
vision can develop decreased vision from amblyopia ex anop-
scans provide an accurate and noninvasive method of assess-
sia if the visual axis disturbance is not corrected. Strabismus
ing ventricular size; however, assessment of ventricular size
and amblyopia can occur in up to 40% of patients with
alone may not provide a true picture of hydrocephalus. For
syndromic craniosynostosis, but are less common in those
instance, ventriculomegaly is a common finding in patients
without an associated syndrome. Patching of one eye and oper-
with Apert syndrome, but is usually unrelated to increased
ative balancing of the extraocular muscles are the mainstays
ICP. More consistent findings include elevation of ICP on
of treatment.
direct monitoring, the presence of enlarged or enlarging ven-
tricles by serial CT scans, and periventricular lucency resulting
from transependymal flow of cerebrospinal fluid (CSF). Preoperative Considerations
Patients with craniosynostosis require interdisciplinary care
Mental Impairment and, therefore, should be managed at a craniofacial center.2
Children with craniosynostosis can have cognitive delay and Patients with syndromic craniosynostosis require the great-
learning disability. However, intellectual development and est scope and duration of care. Nevertheless, comprehensive
learning are affected by many variables, including the pres- assessment by an experienced craniofacial team is desirable
ence of an associated syndrome, concurrent ICP elevation even for patients with isolated single-suture fusion. Initial
or hydrocephalus, prematurity, or family history. Patients assessment involves a careful history and physical examina-
with single-suture fusion and without an associated syn- tion. Most surgeons can correctly identify which suture is
drome generally have near normal intelligence, but, as noted fused based on the cranial shape. Furthermore, obvious phe-
above, they may exhibit subtle learning disabilities. Patients notypic features, such as complex syndactyly, are usually not
with an associated syndrome have a significantly higher inci- challenging to link to an associated syndrome, such as Apert
dence of cognitive delay than the general population. This is syndrome. However, preoperative genetic testing and counsel-
loosely correlated with the type of syndromic diagnosis, but ing are highly recommended to help confirm less obvious diag-
there is typically wide variability within any given patient noses and provide the family (and the craniofacial team) with
population. important prognostic information. If possible, neuropsycho-
It is still unclear if the neurocognitive findings in patients logical evaluation should be performed to assess developmen-
with craniosynostosis are the result of the deleterious effects tal milestones. Syndromic patients with significant midfacial
of early growth restriction from the suture fusions, or if the retrusion may demonstrate obstructive sleep apnea and have
molecular process that lead to the suture fusion negatively difficult airways. Pulmonary and otolaryngologic evaluation
impacted central nervous system development. In support may include fiberoptic laryngoscopy and sleep studies. Early
of the former contention, Marchac and Renier found that intervention in such infants may include continuous positive
overall intelligence was better in patients who underwent an airway pressure. In selected patients, with severe midfacial
earlier cranial release compared with those who had a later deformities, tracheostomy may be required. Additionally, a
procedure.8 The findings are somewhat limited by the fact careful audiologic assessment should be performed on any
that the study was not controlled or randomized. Conversely, patient with an associated syndrome. Neurosensory abnor-
Starr and coworkers demonstrated that surgery did not malities are present in 95% of patients with Muenke syn-
favorably affect neurocognitve development in patients drome (FGFR3 Pro250Arg), and conductive hearing loss is
with single-suture synostosis.9 The parameter studied, how- common in Seathre-Chotzen syndrome, Apert syndrome, and
ever, was developmental quotient, not a sensitive indicator Pfeiffer syndrome.
of intellectual performance and of questionable validity in A psychologist may be helpful to provide support for the
younger age groups. Similarly, Camfield and Camfield con- patient and family. Additional evaluations by the orthodon-
cluded that mental impairment (IQ < 70) in children with tist, otolaryngologist, and ophthalmologist are critical in
single-suture craniosynostosis was usually the consequence patients with syndromic craniosynostosis. For patients under-
of a primary brain malformation rather than brain distor- going complex reconstructions, it is important to anticipate
tion from the craniosynostosis. A major limitation of most intraoperative and postoperative requirements. The role
prior neurocognitive studies in this patient population is that of the pediatric anesthesiologist and intensive care staff in
the instruments most commonly used (e.g., Bayley Scales and this regard cannot be overstated, and every patient should
IQ testing) lack sufficient sensitivity and specificity to detect undergo a preoperative evaluation by these specialists. Special
subtle cognitive differences, such as perceptual abnormali- attention should be focused on strategies to reduce blood loss
ties. More refined testing is needed to provide a more global and transfusion requirements, and the postoperative airway
and comprehensive understanding of cognitive function in management.
these patients.
Visual Abnormalities Radiographic Assessment

Ocular anomalies are not uncommon in patients with cranio- CT is the most accurate radiographic method to confirm
synostosis. Hypertelorism, exorbitism, strabismus, and pro- suspected craniosynostosis. Standard radiographs can be
ptosis are common with many syndromic forms of bilateral helpful in some instances (e.g., young infants), but they are

a distant second choice if CT is available. CT scans allow
the osseous anatomy, including the sutures, to be exam-
Timing of Surgery
ined with exceptional detail. In most situations, CT scans The optimal timing for surgical treatment of craniosynostosis
are not necessary to make the diagnosis of craniosynostosis is debatable. One philosophy is to operate as soon as possible
since the cranial shape is usually pathognomonic. However, to halt further progression of secondary craniofacial changes,
minor forms of craniosynostosis (e.g., frontosphenoidal) allow normal brain expansion, and capitalize on the amelio-
or certain multiple-suture fusion patterns may require CT rating effects of brain growth on overall skull shape. There
to define the pathology. The use of CT for diagnosis and is also a higher likelihood in a young infant that any bone
follow-up of craniosynostosis has been questioned because defects created during the operation will spontaneously ossify.
of the risks associated with even minor amounts of ion- However, there is a higher risk of anesthetic-related complica-
izing radiation in infants. In addition, infants and young tions in infants under a year of age, and some authors have
children may require sedation to obtain CT scan. While observed a greater need for revision in patients who are under-
the adverse health effects of CT are still being debated, it is going open remodeling procedures before 6 months of age.
recommended that these tests should only be ordered if the The compromise between these considerations generally yields
information provided is essential for care of the patient. an operative age between 3 and 12 months of age, although

Both authors use CT scans only in selective cases. this depends on many factors, including the operative tech-

Three-dimensional reconstruction of the cranium, orbits, nique employed, surgeon preference, and the risk of waiting.
and face is particularly useful to judge the Cartesian relation- A significant modifying factor for delaying surgery is the
ship between these structures (Figure 22.2). Computer-aided type of procedure, which will dictate the duration of surgery
design and virtual surgery provide additional benefit for and the anticipated blood loss. Techniques that require mini-
patients undergoing complex primary or secondary proce- mal operative dissection and have limited bleeding, such as the
dures. For example, computer-generated models can be manu- pi procedure (for sagittal synostosis), endoscopic suturectomy,
factured and milled from three-dimensional CT data and used and spring-mediated distraction, are usually performed before
preoperatively to assist in planning osteotomies. Virtual simu- 6 months of age. Suturectomy and, to a lesser degree, the pi
lations of preoperative osteotomies and bony movements are procedure depend on brain growth to improve cranial shape
now becoming available. and, therefore, are only effective if they are done at a very
Magnetic resonance imaging (MRI) is primarily used for early age (2 to 5 months of age). Spring-mediated distraction
soft tissue imaging and, therefore, is not routinely used for does not rely on brain growth for correction and can be used
nonsyndromic craniosynostosis. In syndromic cases, it can effectively in older infants (7 to 8 months of age). Large open
help diagnose associated brain abnormalities (e.g., agenesis cranial remodeling procedures have significant blood loss (300
of the corpus callosum) or the presence of an Arnold-Chiari to 400 cc) and relatively long operative times (3 to 5 hours)
malformation. The latter diagnosis is particularly important and are often deferred for safety reasons until the infant is
to identify prior to using the modified prone position for total 8 to 12 months of age. Even this generality has exceptions.
vault exposure during surgery. Cervical spine films should be For example, an infant with multiple-suture fusions and clear
taken in addition to the MRI to exclude the presence of cra- clinical evidence of elevated ICP will require cranial release
niovertebral anomalies or instability that might lead to spinal shortly after birth. Thus, the optimal time for operative inter-
cord or brainstem injury during such positioning. Although vention will depend on many variables and should be tailored
MRI does not expose the patient to ionizing radiation, the to the needs of the patient.
test requires the patients to be motionless, and infants and
young children often necessitate anesthesia. As with any test, Type of Surgery
the most important consideration when planning an imaging There is considerable variation from one center to the next
strategy is to have a clearly defined question and to select the in terms of management of craniosynostosis. These varia-
imaging modality with the highest likelihood of safely provid- tions include the use of endoscopic-assisted extended strip
ing the answer. craniectomies with postoperative cranial orthosis, springs,
distraction devices, and open partial or total cranial vault
remodeling procedures. The choice of treatment depends on
many factors, including, but not limited to, the patient’s age,
the location and number of sutures fused, the presence of an
associated syndrome, severity of pathology, and surgeon/cen-
ter experience.
Clinical Observations
and Management
Metopic Synostosis
The metopic suture is the first cranial suture to fuse and the
only one to fuse in childhood. It begins fusing as early as
3 months of age and is complete in nearly all patients by 6 to
8 months of age. Unlike the other cranial sutures, radio-
graphic evidence of a fused metopic suture in infancy or early
FIGURE 22.2. Axial (left) and three-dimensional (right) CT scan of a childhood is not per se abnormal. Instead, it is the phenotype
5-month-old patient with metopic craniosynostosis (trigonocephaly). (i.e., the extent of forehead and superior orbital narrowing)
The metopic suture fusion is more accurately detected on the axial that defines whether a radiographically closed metopic suture
images because the volume averaging of a three-dimensional surface is considered craniosynostosis (abnormally premature) or rep-
rendering can inadvertently make the suture appear fused. The three-
dimensional surface rendering provides excellent spatial relationship
resents normal physiologic closure. There is wide variation in
of affected and unaffected structures. Note: the coronal and lambdoi- the degree of forehead deformity, and the line between nor-
dal sutures are patent in the axial image. The coronal sutures can also mal and abnormal forehead contour is poorly defined. As a
be seen in the three-dimensional image. consequence, there can be significant diagnostic inconsistency
between centers and surgeons. On the more severe end of the

children. This is performed with the patient in the supine posi-

tion. The frontal bones and orbital bandeau are removed. A
stair-step osteotomy is performed at the midline. This step does
not correct the hypotelorism, but instead allows the bandeau
to be widened in the temporal areas. The V-shaped bandeau is
expanded and, if necessary, the flat lateral segments are con-
toured to increase the convexity. In severe cases, the expanded
bandeau may require a midline separation and leveling of each
half. If this creates a gap, it can be filled with a trapezoidal or
triangular bone graft. The nasal process of each frontal bone
is long and should be shortened. The bandeau is intentionally
overcorrected in the temporal areas and fixed with resorbable
plates. The coronal gap can be filled with a rectangular piece of
bone harvested from the vertex to stabilize the bandeau, pro-
vide bony continuity, and prevent any possibility of collapse.
While the frontal elements are off, particulate bone graft can be
FIGURE 22.3. Intraoperative superior view of a 9-month-old patient harvested from the inner table and stored in a blood-filled con-
with metopic craniosynostosis (trigonocephaly) lying supine on the tainer on the back table. This will provide bone graft to repair
table. Zigzag (or straight) markings are made at about the level of any defects created by the advancement or harvest of full-thick-
the coronal sutures (left). After elevating the coronal flap, the fron- ness bone graft. Each frontal bone is then remodeled with a
tal bones are small and flat (right). The coronal sutures are anteri-
orly displaced and there is compensatory enlargement of the parietal
shaping burr and/or radial osteotomies and then orthotopically
elements. The triangular cranial shape is exaggerated by the lack of or heterotopically affixed to the bandeau. The bifrontoparietal
lateral projection of the supraorbital rims and narrowing of the tem- segments can be affixed to the bandeau with resorbable plates,
poral regions. secured with wires or sutures. In order to create a smooth tran-
sition with the widened frontal segments, the parietal bones
laterally should be outfractured using horizontal barrel staves
and stabilized to the frontal elements with absorbable plates.
spectrum, premature closure of the metopic suture results in a Although the lateral bone gaps between the frontal and parietal
“keel”-shaped deformity termed trigonocephaly (Figure 22.3). segments could be left to heal spontaneously, repair with full-
Other findings include small, flat frontal bones, anterior thickness cortical bone harvested from the vertex provides bone
displacement of the coronal sutures, and compensatory continuity and reduces the likelihood of a depression (tempo-
enlargement of the parietal elements. The triangular cranial ral hollow) in this area. Any bony gaps on the vertex can be
shape is exaggerated by the lack of lateral projection of the filled with particulate graft stabilized with fibrin glue.10 As a
supraorbital rims and narrowing of the temporal regions last step, some surgeons (e.g., GFR) believe that the tempora-
(Figure 22.3). Patients often have hypotelorism, strabismus, lis muscle should be advanced anteriorly because the fronto-
and upslanting palpebral fissures (this is sometimes referred to orbital advancement procedure obligatorily moves the anterior
as the trigonocephalic “sequence”). boundary of the temporal fossa forward. Surgeons who per-
Metopic synostosis has long been thought of as a relatively form this procedure feel that failure to advance and re-suspend
uncommon form of craniosynostosis accounting for only the temporalis muscle to help fill this void can increase the like-
5% to 15% of single-suture, nonsyndromic craniosynostoses. lihood of temporal hollowing, a significant problem following
Recent publications and presentations suggest that the inci- these corrections. Whether the surgeon performs a temporalis
dence of metopic synostosis has increased and is as high as muscle advancement or not if the soft tissue closure is tight, the
25%. Because there are no clear objective criteria for defining galea can be scored to reduce tension on the repair. If this is
trigonocephaly, it is possible that the reported rise in this con- done carefully, this will not induce alopecia.
dition at some centers reflects a lower threshold for diagno- In older children, the bony remodeling techniques are
sis rather than a true increase in prevalence. Brain expansion altered to allow reshaping of the more mature cranial vault.
is not usually impaired by trigonocephaly, although Renier The bone may be more brittle and bending is difficult. The
et al.8 noted elevated ICP in 7.7% of patients. However, it is major difference in technique in this age group involves selec-
important to note that 33% of patients with metopic synosto- tive weakening of the bone by the placement of endocortical
sis have an associated syndromic diagnosis (e.g., Opitz C with channels or “kerfs” in the bone. Patients older than 1 year of
agenesis of the corpus callosum) or chromosome abnormality. age usually require bone grafting of osseous defects remaining
These patients may have inherent limitations to frontal lobe after correction. The harvest of autogenous bone graft from
development, and forehead correction after surgery may dete- the endocortical surface of the frontal bones simultaneously
riorate over time. weakens the bone and provides a plentiful source of autog-
enous bone graft. Since there is less opportunity for bony
remodeling in older patients, accurate contouring and posi-
Surgical Options tioning of all bone segments is critical.
For infants less than 3 months of age, endoscopic suturec-
tomy and postoperative cranial orthosis therapy are treat-
ment options. However, the outcomes using this technique for Unilateral Coronal Synostosis
metopic synostosis are the most unpredictable of all the single- Premature fusion of one of the coronal sutures, or synostotic
suture synostoses, and the possibility of incomplete correction frontal plagiocephaly (a Greek term meaning oblique skull),
and need for a subsequent open remodeling procedure should is the second most common type of craniosynostosis (20% to
be discussed with the family. Spring-mediated distraction is 25%) and occurs in approximately 1 in 10,000 live births.
another alternative in children up to 7 months of age.5,6 This Fusion of the coronal suture impairs ventral expansion of the
technique has also been shown to correct associated hypo- anterior cranial fossa and leads to shortening of the anterior
telorism, a benefit that seems unique to this method. cranial fossa ipsilateral to the fused suture. Growth superi-
In many centers, open fronto-orbital advancement is the orly results in elongation of the forehead, whereas inferiorly
preferred way of treating metopic synostosis. This method has directed growth produces deformity of the middle cranial
predictably good outcomes if done correctly and, unlike the fossa with ventral bowing of the greater wing of the sphe-
aforementioned techniques, can be used in older infants and noid. The deformity of the sphenoid results in effacement of

the temporal fossa, which, combined with shortening of the
lateral wall of the orbit, produces mild proptosis of the globe.
The “harlequin” orbit seen on anterior–posterior radiographs
is pathognomonic for unilateral coronal synostosis and is sec-
ondary to the lack of descent of the greater wing of the sphe-
noid during development. There is a compensatory bulge in
the ipsilateral squamous portion of the temporal bone, con-
tralateral frontal and parietal bones, and, to a much lesser
degree, the contralateral occipital bone. The fused coronal
suture may demonstrate prominent ridging, and the ipsilateral
frontal and parietal bones are flattened.
The facial features associated with unilateral coronal cra-
niosynostosis are quite predictable. There is shortening of the
ipsilateral palpebral fissure, superior and posterior displace-
ment of the ipsilateral orbital rim and eyebrow, and devia-

tion of the nasal root toward the flattened frontal bone. The

chin point deviates to the contralateral side, and the malar
eminence is displaced anteriorly on the fused side. As noted
above, the orbital changes cause ocular torticollis in approxi-
mately 80% of patients and nearly half have astigmatism on
the side opposite the fusion. Twenty-five percent of patients
have an associated molecular/syndromic diagnosis, the most
common being FGFR3 Pro250Arg (Muenke syndrome), fol-
lowed by FGFR2, TWIST (Saethre-Chotzen syndrome), and
EFNB1 (craniofrontonasal malformation).
Surgical Options FIGURE 22.4. Intraoperative superior view of a 10-month-old

patient with right coronal craniosynostosis (unilateral synostotic
Endoscopic suturectomy and postoperative helmet therapy plagiocephaly) lying supine on the table. After elevating the coronal
and spring-mediated distraction are options for early correc- flap, the right frontal bone appears smaller and flatter (upper left).
tion of unilateral coronal synostosis. One study found a lower The orbital bandeau and frontal bones are removed and reshaped on
incidence of ocular torticollis and astigmatism in patients the back table (upper right). Particulate bone can be harvested from
undergoing early endoscopic suturectomy compared with the endocranial side of the frontal bones (lower left). The bandeau is
those who had a later fronto-orbital advancement. In addition, orthotopically repositioned and secured with resorbable plates (lower
right). The frontal bones can be orthotopically or heterotopically (pic-
early intervention may lead to better overall facial symme- tured here) and the particulate bone graft can be used to fill the bone
try. The results of these techniques are promising but further defects.
validation of the long-term outcomes is still not available.
Most centers still treat coronal craniosynostosis using con-
ventional fronto-orbital advancement. The patient is placed
supine and a bifrontal craniotomy is performed (Figure 22.4).
The orbital bandeau is removed and recontoured, often with Sagittal Synostosis
an intentional anterior overcorrection on the ipsilateral side. The sagittal suture is the most likely to fuse prematurely and
The affected side must be overcorrected or reversion to the comprises 40% to 55% of all forms of craniosynostosis. The
pathologic asymmetry is assured. Some authors have recom- male-to-female incidence ratio is 4:1. As the sagittal suture
mended using an onlay bone graft over the orbital rim on fuses, the expanding brain drives the coronal and lambdoid
the ipsilateral side to help accentuate the sagittal projection. sutures to compensate by increasing bone deposition in the
The bandeau is orthotopically repositioned with an ipsilat- frontal and occipital bones, respectively. The metopic suture
eral advancement and affixed to the temporal fossa with a compensates with symmetric bone expansion along its bor-
resorbable plate. Some patients with associated syndromic ders. The compensatory growth process produces the char-
diagnoses can have relative retrusion on the unfused side as acteristic frontal and occipital prominence seen in sagittal
well and may require an asymmetric bilateral advancement synostosis. The resultant cranium has an increased anteropos-
to create adequate projection of the orbital rims and fore- terior length and decreased width, yielding a “boatlike” or
head. With large advancements, a full-thickness rectangular scaphocephalic shape. There is phenotypic variation depend-
bone graft behind the bandeau will help prevent postopera- ing on the timing and, for incomplete fusions, the extent and
tive collapse and ensure bony healing. Some surgeons choose location of the suture closure.
to perform dural plication with the bipolar cautery or with
sutures to correct the contralateral prominence of the dura.
The frontal bone is remodeled using radial osteotomies, and Surgical Options
selective fractures are performed to achieve the desired form. As with other types of single-suture synostosis, endoscopic
The convexity of the ipsilateral bone is increased while that suturectomy and postoperative cranial orthosis therapy, or
of the contralateral side is decreased. The frontal bone plates spring-mediated distraction can be used successfully in infants
are reattached to the orbital bandeau with sutures or wires. younger than 5 months of age. Correction of sagittal synosto-
The frontal bones should be attached to the parietal seg- sis with either of these methods has been demonstrated to be
ments to prevent collapse during redraping of the coronal highly effective and the likelihood of incomplete correction is
flaps. Full-thickness bone grafts harvested from the vertex remote. Endoscopic suturectomy is usually performed via one
can be used to fill the lateral coronal gap, especially on the or two small (<2 cm) incisions placed perpendicular on either
more advanced side. Particulate cranial bone graft harvested end of the sagittal suture. The fused sagittal suture is removed
from the endocortex of the frontal elements, or ectocortex in a 1-cm strip of bone (Figure 22.5); some surgeons add tem-
of the parietal bones, can easily cover all remaining bone poral and parietal barrel stave osteotomies. Most surgeons
defects. The asymmetry of the palpebral fissure can be cor- recommend a postoperative cranial orthosis to help limit
rected with a lateral canthopexy on the side of the fusion. anterior–posterior growth and encourage bitemporal/

FIGURE 22.5. Comparison of endoscopic suturectomy and open cranial vault reshaping. Intraoperative superior view of a 3-month-old patient
with sagittal craniosynostosis (scaphocephaly) lying in a modified prone position on the table (upper left). The endoscopic suturectomy is per-
formed via two small (<2 cm) incisions placed perpendicular to the anterior and posterior limits of the sagittal suture. The fused sagittal suture is
removed in a 1-cm strip of bone; some surgeons add temporal and parietal barrel stave osteotomies (upper right). Most surgeons recommend a
postoperative cranial orthosis to help limit anterior–posterior growth and encourage bitemporal/biparietal expansion (middle left). The duration
of wear is typically 6 to 10 months or until the desired shape is obtained. Alternatively, in older patients, sagittal craniosynostosis can be cor-
rected with an open approach using a pi or modified pi procedure (middle right). The patient is typically placed in a modified prone position. The
excised segments include bone on either side of the sagittal suture (which comprise the vertical limbs of the π) and a transverse segment of bone
parallel to the coronal suture (which comprises the horizontal limb of the π) from squamosal suture to squamosal suture. Barrel stave osteotomies
can be added as necessary to allow temporal/parietal outfracture. The “hung-span” modification of the pi procedure holds these barrel staves
in position with a spanning resorbable plate extending from the frontal bone to the occipital bone along the equator of the skull (lower left).
The anterior–posterior dimension of the cranium can be reduced by advancing the sagittal strip to the frontal bone and securing it with suture
or resorbable plates. The degree of shortening that can be safely achieved is variable and limited by the shape of the underlying brain. However,
aggressive shorting is not recommended.
biparietal expansion. There is little question that a prop- the cranial vault by increasing the parietal and temporal width
erly designed and rigorously worn orthotic can significantly while gently decreasing its anteroposterior dimension. In an
improve outcomes. The duration of wear is typically 6 to 10 older child, the degree of anterior–posterior shortening that
months or until the desired shape is obtained. If patient com- is safe is considerably less than in a young infant. Total vault
pliance is unlikely or impractical, this option should not be remodeling for sagittal synostosis requires exposure from the
used. glabella anteriorly to the posterior lip of the foramen magnum
Spring-mediated distraction does not rely on brain growth to posteriorly. This can be achieved using a modified prone posi-
expand and correct the cranial shape and can be used in infants tion. However, supine positioning on a cerebellar head holder
up to 7 to 8 months with very good results. Suturectomy can be can be just as effective and less risky. The supine position for
done through an open vertex incision or small incisions (similar correction of sagittal synostosis requires some head manipula-
to those described above) with endoscopic assistance. A sagittal tion to access the posterior cranium and it is wise to secure
strip of bone is removed and two properly tensioned springs the endotracheal tube to the mandible or dentition prior to
are positioned between the edges of the bone gap. This tech- prepping. An awl can be used to pass a 26-gauge wire around
nique requires a second minor operation to remove the springs, the mandible; for patients with mature dentition, the wire
although this can be done through small incisions and minor can be affixed to the teeth. The frontal and parietal segments
blood loss. A postoperative helmet is not required. are removed. Low temporal and parietal regions’ barrel stave
In addition to these options, some surgeons use a pi or osteotomies are performed and the segments are outfractured.
modified pi procedure (named after its semblance to the Greek This greatly expands the parietal width and provides a more
letter π) in affected infants who are less than 6 months of age. complete release. The cone-shaped occiput is remodeled with
This operation is midway between an open remodeling and radial osteotomies and bending to provide a more gradual
a suturectomy and has acceptable outcomes. It is simple to convex curvature. The bifrontal fragment is radial osteoto-
perform and is commonly used. The patient is typically placed mized and similarly reshaped. Shortening of the anteropos-
in the modified prone position. The excised segments include terior length is not always required. However, this can be
bone on either side of the sagittal suture (which comprise the accomplished by resecting a portion of the frontal and parietal
vertical limbs of the π) and a transverse segment of bone par- bones at the midline. The remaining parietal bone fragments
allel to the coronal suture (which comprises the horizontal are remodeled with the goal of increasing the lateral convex-
limb of the π) from squamosal suture to squamosal suture ity, particularly in the parietal regions.
(Figure 22.5). Barrel stave osteotomies can be added as neces- Once the bone fragments are remodeled satisfactorily, they
sary to allow temporal/parietal outfracture. The “hung-span” are secured with wire, suture, or plates. In an older child, one
modification of the pi procedure holds these barrel staves in of us (SMW) continues to use resorbable plates, while the
position with a spanning resorbable plate extending from the other (GFR) will, on occasion, choose titanium plates because
frontal bone to the occipital bone along the equator of the the risk of intracranial migration is minimal. The frontal seg-
skull. The anterior–posterior dimension of the cranium can ment is secured anteriorly to the superior orbital rims. If the
be reduced by advancing the sagittal strip to the frontal bone occipital segment was removed, it is reattached to the basal
and securing it with suture or resorbable plates. The degree of occiput posteriorly. One of us (SMW) secures the parietal seg-
shortening that can be safely done is variable and limited by ments using a spanning resorbable plate (hung-span technique)
the shape of the underlying brain. However, aggressive short- from the frontal to the occipital segments. The other (GFR)
ing is not recommended. secures the inferior aspect of each parietal bone is to the out-
For patients who present later (>6 months), the cranial fractured temporal bone with suture or wire. The parietal
bones are less malleable and more predictable outcomes can segments are then tilted laterally and affixed to the intact
be obtained with subtotal or total calvarial remodeling. The sagittal strip in an expanded position with resorbable plates.
primary operative goals are to release the stenosis and reshape Additional stability can be obtained by affixing the parietal

segments to the frontal and occipital bones with one long plate Operative Procedure. The patient is placed in the modi-
or several smaller segmental plates. Plate stabilization assures fied prone position and the occipital bone is fully visualized to
that the expansion and shape correction achieved intraopera- the level of the foramen magnum. A bilateral parieto-occipital
tively will not relapse or collapse postoperatively. bone segment is elevated or each parieto-occipital bone graft
In older children, the techniques of bone remodeling can be elevated leaving a strip of bone over the sagittal suture
require several modifications. Kerfs, or channels, placed on (Figure 22.6). Barrel stave osteotomies are performed bilater-
the internal surface of the bone oriented perpendicular to the ally in the flattened basal occipital bone to increase the con-
long axis of the bone segment, allow for selective weakening vex projection of the occipital bone locally. In patients with
of the bone and easier reshaping and molding. moderate unilateral deformity, the barrel staves are placed
primarily ipsilateral to the fused suture in the occipital bone.
Lambdoid Synostosis In more severe cases, bilateral barrel staves are performed to
Lambdoid synostosis is the least common form of craniosyn- infracture the contralateral and outfracture the ipsilateral infe-
ostosis (1% to 5%). It is characterized by ipsilateral occipital rior occipital bone. The bilateral parieto-occipital bone grafts
flattening, posterior/inferior displacement of the ispilateral are cut radially and remodeled to achieve a normally rounded,
symmetric posterior skull (Figure 22.6). The dura may be pli-

ear, bossing of the ipsilateral mastoid, and decreased height of
cated in areas of excess projection before bone remodeling.

the cranial vertex on the affected side. These features usually
allow the surgeon to readily distinguish lambdoid synosto- The bone grafts may be orthotopically or heterotopically
sis from the more common cause of posterior cranial flat- (switched) repositioned and secured with resorbable plates.
tening, deformational plagiocephaly, in which the ipsilateral
ear and forehead are anteriorly displaced (Figure 22.6). The Complications
physical features of deformational plagiocephaly will be dis-
Complications are relatively infrequent and may be divided
cussed in detail in the next section. In addition to differences
into those that are acute and those that are late.11 Acute com-
in physical presentation, CT scan demonstrates bony bridg-
plications include major blood loss, air embolus, dural tear
ing of the lambdoid suture and angulation of the posterior
with CSF leak, infection, and respiratory complications. Blood
cranial fossa toward the side of the fusion. These findings are
loss occurs nearly continuously intraoperatively and is the
not present in deformational plagiocephaly. The distinction
direct or indirect cause of most complications. Consequently,
between deformational plagiocephaly and lambdoid synos-
vigilant attention to accurate blood replacement is paramount
tosis is important since the former diagnosis rarely (if ever)
to avoid coagulopathy secondary to dilution of clotting agents.
warrants operative intervention, while the latter condition
Hemodynamically significant bleeding can occur with inadver-
has traditionally been managed with surgery. The decision to
tent tearing of a venous sinus or major cortical vein. Abnormal
recommend an operative repair for unilateral lambdoid syn-
transosseous veins, especially in the region of the torcula,
ostosis depends on the severity of the deformity. The treat-
can occur and are at risk during posterior bone dissection.
ment varies depending on whether the condition is unilateral
If a major vein is breached, blood loss can be rapid and life
or bilateral, but the operative exposure and craniotomy lines
threatening. It is critical to have sufficient intravenous access
are similar.
to allow rapid resuscitation if needed. Blood loss may continue
for 12 to 24 hours following cranial remodeling procedures,
and intensive care unit monitoring is essential. Air embolus has
been documented in children undergoing cranial procedures
and may occur in any operative position, including supine. It
is appropriate to consider the placement of precordial Doppler
monitors and end-tidal CO2 monitors to ascertain entrainment
of air into the venous system. Central venous lines are some-
times warranted to assess blood volume (and resuscitation)
and can be helpful to evacuate an air embolus if it occurs.
Dural tears are not uncommon and should be identified
and repaired acutely. An unrepaired or incompletely repaired
dural tear can result in a persistent CSF leak into the drain
(if one is used) or an unresolved fluid collection under the
closed coronal flaps. The first intervention to treat a postop-
erative CSF leak is to decrease the outflow using a lumbar
drain. If the output persists, surgical exploration and closure
are required. Persistent CSF leak can lead to infection, thin-
ning of the overlying bone, and a cranial defect. Infection is
an uncommon problem after cranial procedures but in the
rare instance it occurs; it can be potentially life threatening.
Infection can arise from a persistent CSF leak or a commu-
nication of the intracranial cavity with the nasal cavity or
frontal sinus. Because the frontal sinus develops quite late in
FIGURE 22.6. Intraoperative posterior view of a patient with left childhood, the latter is seen as a consequence of surgery in the
lambdoid craniosynostosis in the modified prone position (upper left). older child or adolescent.
Left and right parieto-occipital bone grafts are outlined leaving a strip Late complications are generally associated with the
of bone over the sagittal suture (upper right). Barrel stave osteoto- sequelae of abnormal bone healing and impaired bone growth.
mies are performed bilaterally in the flattened basal occipital bone to Children older than 1 year of age have a decreased ability to
increase the convex projection of the occipital bone locally. The bilat- ossify cranial defects compared with younger patients. The
eral parieto-occipital bone grafts are cut radially and remodeled to
rate of incomplete ossification has been estimated between
achieve a normally rounded, symmetric posterior skull (lower left).
The dura may be plicated in areas of excess projection before bone 5% and 20% and is positively correlated with age at repair.
remodeling. The bone grafts may be orthotopically or heterotopically Generally, defects greater than 2 cm at the end of a cranial
repositioned (pictured here) and secured with resorbable plates (lower procedure in children older than age 1 year should be repaired
right). with split calvarial bone grafts or particulate bone graft to pre-
vent postoperative cranial defects (see Chapter 31). Significant

bone loss requiring bone grafting may occur in the setting of the postnatal period in response to external resistance to the
infection and subsequent resorption. growing infant cranium. Many risk factors have been linked
From its inception, the use of miniplate and microplate to the development of deformational flattening: supine sleep
fixation has greatly improved the outcomes of craniofacial position, multiple births, developmental delay, small maternal
procedures. Early plating systems were made of titanium, but pelvis, breech position, oligohydramnios, male sex of fetus,
these plates and screws were noted to “migrate” intracrani- gestational diabetes, nulliparity of mother, high birth weight,
ally when used in infants. Although no harmful effects were large neonatal head size, vaginal delivery, prolonged length of
reported, most surgeons use resorbable plate fixation in the post delivery, hospital stay (>4 days), and prolonged duration
young child (<2 years of age) when it is feasible. of stage II labor.14 While the variables in this list appear oddly
Relapse and recrudescence of the original cranial defor- unrelated, most of them can be placed into one of three major
mity are uncommon if the correction is performed and sta- risk categories for cranial flattening: torticollis and cervical
bilized properly. However, numerous authors have reported imbalance, prematurity, or developmental delay. They all share
partial relapse with growth even in single-suture synostoses. a common pathogenic link: each can directly or indirectly have
This may be a result of several factors. Correction of the a negative impact on infant head mobility early in life. If the
neurocranium in infancy does not assure subsequent nor- infant is unable to alter his head position and redistribute the
mal growth of calvaria and cranial base. Furthermore, any area of resistance, cranial growth will occur around the point
molecular effects that lead to the initial fusion in utero could of contact (usually the flat bed). This is analogous to how an
still affect cranial growth until it is complete. Several studies unturned pumpkin flattens in a field—it cannot grow through
have reported a negative correlation between age at repair the ground so it grows along the ground. Over time, compensa-
and recurrence. The degree of relapse may also depend on tory and redirected growth will result in progressive flattening.
the severity of the initial phenotype as well as the continued It has been suggested that supine positioning is the cause
effect of cranial base restriction. More important factors may of flattening. However, it cannot be solely responsible since
be incomplete correction or inadequate bone stabilization. only 20% of supine infants develop flattening and these cra-
Often, no matter what technique is performed, patients may nial changes are also observed in prone-slept infants, albeit to a
appear slightly undercorrected in long-term follow-up. Some lesser extent. There are two primary reasons why supine posi-
surgeons prefer allowing the bone segments to “float” in tioning results in more cases of clinically apparent flattening.
anticipation that brain growth will help “normalize” cranial First, the occipital cortex grows at a faster rate than the frontal
shape. Unfortunately, this supposition has not been proven. cortex early in infancy. Thus, the degree of cranial deformity
Brain growth can be unpredictable in some patients and may that can develop over a fixed period of time will be greater in a
not be sufficient to alter shape. In addition, the soft tissue supine versus a prone-positioned infant and a greater percent-
envelope after a cranial expansion procedure is tight and can age of supine-positioned infants will reach the severity thresh-
cause collapse of inadequately stabilized bone segments. It old to be considered clinically flat. Second, supine infants reach
is much more predictable to achieve the desired correction early motor milestones slower than prone infants. Although the
before leaving the operating room. Cranial distraction has trend dissipates by a year of age, this means that supine infants
been advocated to reduce relapse by distracting the soft tis- will be slower to acquire independent head mobility (the anti-
sue and the bone simultaneously; however, these objectives dote for flattening) than their prone-positioned counterparts.
can be more easily achieved using judicious release of the Deformational plagiocephaly occurs primarily in infants
galea and particulate bone graft. with congenital muscular torticollis. This is not always easy
Overall, the morbidity and mortality from the treatment to detect in a newborn, but the presence of a “preferred” head
of craniosynostosis is quite low. Mortality has been variously position early in life is highly suggestive. The resultant cranial
reported to range between 1.5% and 2%. In 1979, Whitaker shape has been compared with a “parallelogram”; however,
and coworkers reported the experience of six craniofacial cen- the frontal bossing is usually never as significant as the occipi-
ters and found a mortality rate of 1.6%. Current advances in tal flattening. Asymmetric growth of the head is often accom-
monitoring and anesthetic techniques, as well as refinements panied by facial asymmetry, specifically an anterior shift of the
in surgical techniques, have driven this rate well below 1% at ipsilateral forehead, ear, and cheek. Asymmetric opening of the
most large centers. palpebral fissures can also be observed as a consequence of the
sagittal displacement of the ipsilateral zygoma. As asymmet-
ric occipital flattening progresses, forward movement of the
Deformational Plagiocephaly zygoma and attached lateral canthus on the affected side effec-
tively shortens the distance between the medial and lateral can-
and Brachycephaly thal tendons. As a result, tension is reduced on the tarsal plates,
In 1992, the American Academy of Pediatrics initiated the and the eye appears more open on the side of the flattening.
“Back to Sleep Campaign” to reduce the incidence of sudden The vertical palpebral asymmetry can be easily confused with
infant death syndrome. This policy has been widely imple- contralateral eyelid ptosis. As mentioned above, deformational
mented and resulted in a 40% reduction in the incidence of plagiocephaly is usually readily distinguishable from posterior
sudden infant death syndrome in the United States. One of synostotic plagiocephaly by its combination of occipital flat-
the unforeseen consequences of the campaign was a rise in ness, ipsilateral anterior ear shear, and forehead bossing.
asymmetric (plagiocephaly) and symmetric (brachycephaly) Deformational brachycephaly presents as relatively sym-
occipital flattening. Recent studies estimate the prevalence metrical occipital flattening and compensatory parietal wid-
of deformational posterior cranial flattening to be as high as ening. These infants have little or no occipital rounding and
20% in healthy infants; these estimates, of course, depend on appear to have a disproportionately wide or “big” head viewed
how abnormal flattening is defined. from the front. The posterior vertex may appear taller than the
Deformational flattening can be asymmetric or symmet- front, giving a sloped appearance to the head in profile.
ric.12,13 Asymmetric flattening is termed plagiocephaly, a word
derived from the Greek derivatives “plagios” (oblique) and
“kephale” (head). Symmetric flattening is termed brachyceph- Treatment
aly, or “short head,” to denote the loss of cranial length with Growth of the brain tends to improve symmetry of the cranio-
a compensatory increase in width. In reality, most patients facial skeleton once the external point of resistance is removed.
have a combination of asymmetry and cranial shortening, Since most patients develop good rotational control of the head
termed asymmetric brachycephaly. Unlike craniosynostosis, by 3 to 4 months, it is unusual for flattening to progress after
deformational changes are thought to arise predominantly in this time. The exceptions are infants with developmental delay

or those who were significantly premature. Recognizing that Referneces
supine positioning contributes to deformational plagiocephaly ,
primary care providers have educated parents about the impor- 1. Mendelian Inheritance in Man. http://www.ncbi.nlm.nih.gov/omim.
Accessed on February 26, 2012.
tance of supervised prone positioning and alternating head 2. McCarthy JG, Warren SM, Bernstein J, et al. Parameters of care for cranio-
position from left to right during supine sleep. In cases where synostosis. Cleft Palate Craniofac J. 2012;49(suppl):1S-24S.
muscular torticollis can be identified, physical therapy to stretch 3. Warren SM, Brunet LJ, Harland RM, Economides AN, Longaker MT.
the sternocleidomastoid and trapezius muscles is prescribed. The BMP antagonist noggin regulates cranial suture fusion. Nature.
2003;10:625-629.
Infants are monitored on a monthly basis for signs of improve- 4. Ridgway EB, Berry-Candelario J, Grondin RT, Rogers GF, Proctor MR.
ment. Those children who present early with mild or moder- The management of sagittal synostosis using endoscopic suturectomy and
ate deformity and signs of improvement can often be treated postoperative helmet therapy. J Neurosurg Pediatr. 2011;7:620-626.
with positional therapy alone. More severely affected children 5. Lauritzen CG, Davis C, Ivarsson A, Sanger C, Hewitt TD. The evolving role
of springs in craniofacial surgery: the first 100 clinical cases. Plast Reconstr
may benefit from a cranial orthosis. Although an association Surg. 2008;121:545-554.
between deformational flattening and developmental delay has 6. David LR, Plikatis CM, Couture D, Glazier SS, Argenta LC. Outcome anal-
been noted, it is the latter diagnosis that leads to the former, ysis of our first 75 spring-assisted surgeries for scaphocephaly. J Craniofac
not vice versa. There is no convincing evidence that deforma- Surg. 2010;21:3-9.

7. Fong KD, Warren SM, Loboa EG, et al. Mechanical strain affects dura
tional flattening causes impairment of cognitive development,

mater biological processes: implications for immature calvarial healing.
visual development, or temporomandibular joint function. Plast Reconstr Surg. 2003;112:1312-1327.
8. Renier D, Lajeunie E, Arnaud E, Marchac D. Management of craniosynos-
toses. Childs Nerv Syst. 2000;16:645-658.
Conclusion 9. Starr JR, Kapp-Simon KA, Cloonan YK, et al. Presurgical and postsurgical
assessment of the neurodevelopment of infants with single-suture craniosyn-
Deformational flattening is the most common cause of a cra- ostosis: comparison with controls. J Neurosurg. 2007;107:103-110.
nial shape abnormality in an infant. By comparison, craniosyn- 10. Greene AK, Mulliken JB, Proctor MR, Rogers GF. Primary grafting
with autologous cranial particulate bone prevents osseous defects
ostosis is relatively rare. There are no functional implications following fronto-orbital advancement. Plast Reconstr Surg. 2007;
from deformational flattening, and treatment is nonopera- 120:1603-1611.
tive. In contrast, patients with single-suture craniosynostosis 11. Czerwinski M, Hopper RA, Gruss J, Fearon JA. Major morbidity and mor-
can have low rates of elevated ICP, ocular abnormalities, and tality rates in craniofacial surgery: an analysis of 8101 major procedures.
Plast Reconstr Surg. 2010;126:181-186.
abnormalities in neurocognitive development. Therefore, it is 12. Rogers GF. Deformational plagiocephaly, brachycephaly, and scaphoceph-
imperative to properly distinguish these two entities in a timely aly. Part I: terminology, diagnosis, and etiopathogenesis. J Craniofac Surg.
fashion to ensure proper treatment. Early identification of cra- 2011;22:9-16.
niosynostosis permits treatment with newer minimally invasive 13. Rogers GF. Deformational plagiocephaly, brachycephaly, and scapho-
cephaly. Part II. Prevention and treatment. J Craniofac Surg. 2011;22:
techniques. Open cranial reconstruction remains the standard 17-23.
for older infants; the complication rate is very low when per- 14. Dec W, Warren SM. Current concepts in deformational plagiocephaly.
formed by an experienced team at a state-of-the-art facility. J Craniofac Surg. 2011;22:6-8.

Chapter 23 n
Craniosynostosis
Syndromes
Scott P. Bartlett and Christopher A. Derderian
Craniosynostosis, or premature closure of cranial vault and

cranial base suture, can involve any suture. Those most Crouzon Syndrome
commonly observed, in order of decreasing frequency, are (Acrocephalosyndactyly
sagittal, coronal, metopic, and lambdoidal (Chapter 22). In
simple craniosynostosis, one suture is prematurely fused. In
Type II)
multiple-suture synostosis, two or more sutures are prema- Crouzon syndrome is characterized by premature fusion of
turely fused. Craniosynostosis can occur as an isolated event calvarial sutures, midface hypoplasia, shallow orbits, ocular
resulting in non-syndromic craniosynostosis, or it can occur proptosis, and FGFR-2 receptor mutation (Figure 23.1). The
in conjunction with other anomalies in well-defined patterns clinical features were first described by Crouzon, a French
that make up clinically recognized syndromes. Syndromic neurologist, in 1912. The pattern of inheritance is autosomal
craniosynostosis is most often genetic in nature, and patterns dominant. The reported frequency is 1 in 25,000 live births.
of autosomal dominant, autosomal recessive, and X-linked The variability in expression of the dominant features that
inheritance have been observed. More than 90 reported make up Crouzon syndrome is widely recognized, and mild
syndromes are associated with craniosynostosis, with most deformities in a previously undiagnosed parent of a more
involving associated anomalies of the limbs, ears, and car- severely affected child is a common scenario.
diovascular system. Premature fusion of both coronal sutures, resulting in a
The Apert, Crouzon, Pfeiffer, Saethre-Chotzen, and brachycephalic head, is the most common calvarial defor-
Muenke syndromes represent the more commonly identified mity, but scaphocephaly and trigonocephaly, as well as the
craniosynostosis syndromes seen by plastic surgeons. These cloverleaf skull deformity, have been observed, as has “nor-
familial craniosynostosis syndromes share many common mocephalic” pancraniosynostosis. The craniosynostosis is
features, including midface hypoplasia, cranial base growth typically complete by 2 to 3 years of age, but often the sutures
abnormalities, abnormal facies, and limb abnormalities. In are fused at birth. The cranial base sutures are frequently
fact, the craniofacial features are clinically similar among involved, resulting in maxillary and midface hypoplasia.
the various syndromes so that the anomalies of the hands The maxillary hypoplasia is evidenced by a reduced dental
may be the differentiating clinical feature between the vari- arch width and a constricted, high palatal arch. Normal or
ous syndromes. Although it is clear that synostosis of the near-normal mandibular growth leads to a class III maloc-
cranial sutures is significantly involved in the development clusion. The midface hypoplasia is reflected in the shallow
of the abnormal craniofacial features in these syndromic orbits with exorbitism, which is a consistent finding and can
children, there probably exists a mesenchymal defect in result in exposure conjunctivitis or keratitis. Exorbitism can
the cranial base that also contributes to the craniofacial be so severe that herniation of the globe through the eyelids
deformity. may occur, requiring immediate reduction. Acuity problems,
The exact etiology of the craniosynostosis in these syn- strabismus, and hypertelorism have all been reported. A con-
dromic children remains unclear. Advances in molecular ductive hearing deficit is not uncommon. The defining char-
genetics provide insights into a possible link between muta- acteristic of Crouzon syndrome is that no commonly reported
tions identified in fibroblast growth factor receptor (FGFR) limb anomalies are present in this population of syndromic
genes and several autosomal dominant skeletal disorders. craniosynostosis patients.
Fibroblast growth factors participate in the regulation of Several reports have identified Crouzon syndrome as car-
cell proliferation, differentiation, and migration and play a rying a higher risk of elevated intracranial pressure (ICP)
role in controlling normal bone morphogenesis via complex than other forms of syndromic craniosynostosis, with one
cell-signaling pathways. The transduction of a fibroblast study demonstrating a 65% incidence of elevated ICP and
growth factor signal to the cytoplasm is mediated by a group the remainder borderline elevated. A retrospective review of
of transmembrane tyrosine kinase receptors known as the suture patency in patients with syndromic craniosynostosis
FGFRs. Mutations in three of the four known FGFR genes
located on chromosomes 8, 10q, and 4p have been identified
in the Pfeiffer, Apert, Crouzon, Muenke, and Jackson-Weiss
syndromes. Achondroplasia, a skeletal disorder that causes
the most common form of short-limb dwarfism, is also linked
to a mutation in the FGFR complex. The Pfeiffer syndrome
is linked to a mutation in both the FGFR1 and FGFR2 genes,
whereas the Crouzon and the Apert syndromes are linked
to mutations in the FGFR2 alone. The complexity of this
system is highlighted by the observation that two distinct
phenotypes of Apert syndrome are caused by missense sub- A B
stitutions in the base sequence for adjacent amino acids in FIGURE 23.1. Crouzon syndrome in a young female. Note the mid-
the FGFR2 gene resulting in a higher incidence of cleft palate face hypoplasia, shallow orbits, and ocular proptosis. A. Frontal view.
in one (S252W) and more severe syndactylism in the other B. Profile view.
(P253R).
232
Chapter 23: Craniosynostosis Syndromes 233
may offer some insight. The review demonstrated that patients
with Crouzon syndrome demonstrated earlier closure of the
lambdoid and sagittal sutures (median 6 and 21 months,
respectively) and a 72% incidence of type I Chiari malforma-
tion as compared with patients with Apert syndrome with
later suture closure (51 and 60 months, respectively) and a
2% incidence of type I Chiari malformation. We agree with
others that these clinically significant characteristics are likely A B
related and should be considered when planning the sequence FIGURE 23.3. A and B demonstrate the characteristic hand and foot
for surgical treatment of these patients. syndactyly, which are pathognomic for Apert syndrome. This com-
plex syndactyly most often involves fusion of the second, third, and
fourth fingers, resulting in mid-digital hand mass, but the first and
Apert Syndrome fifth fingers may also be joined to the mid-digital mass. In the feet,
(Acrocephalosyndactyly the syndactyly also usually involves the second, third, and fourth toes.
Type I)

Apert, in 1906, described a syndrome characterized by cra- Street Hospital data on the expectant management of their
niosynostosis, exorbitism, midface hypoplasia, and symmet- patients. Their protocol is to offer cranial vault expansion only
ric syndactyly of both hands and feet. Recently mutations in in the setting of confirmed elevation of ICP. Raised ICP devel-
genes coding for FGFR-2 have been identified in patients with oped in 83% (20/24) of patients, 50% in the first year of life,
Apert syndrome (Figure 23.2). The incidence is reported to be with the average age of onset at 18 months (range 1 month
between 1 in 100,000 and 160,000 live births. Most cases are to 4 years 5 months). Thirty-five percent of those who were
sporadic, although several cases with autosomal dominant treated successfully for their first episode of elevated ICP went
transmission have been reported. The cranial vault deformity on to develop a second episode on average 3 years 4 months
in these patients is variable, but most often presents as a short later.
anteroposterior dimension with craniosynostosis involving
the coronal sutures resulting in a turribrachycephalic skull,
with a large anterior fontanelle. The typical craniofacial Pfeiffer Syndrome
appearance includes a flat, elongated forehead with bitempo- (Acrocephalosyndactyly
ral widening and occipital flattening. The midface hypoplasia
is accompanied by orbital proptosis, downslanting palpe- Type V)
bral fissures, and hypertelorism. The nose is downturned at This syndrome was described by Pfeiffer in 1964 and con-
the tip, the bridge is depressed, and the septum is deviated sists of craniosynostosis, broad thumbs, broad great toes,
(parrot beak deformity). and, occasionally, a partial syndactyly involving the second
The maxillary hypoplasia results in a class III malocclusion and third digits. Pfeiffer syndrome is linked to mutations
with an anterior open bite, and commonly results in signifi- in both FGFR-1 and FGFR-2, which confer less and more
cant enough airway compromise to warrant tracheostomy. All severe craniofacial dysmorphism, respectively. Symptoms
patients have a high arched palate and 30% have an associate vary, ranging from very mild to severe. The mode of inheri-
cleft palate. The hand syndactyly, which is pathognomic for tance is autosomal dominant. The craniofacial features are
the condition, most often involves fusion of the index, middle, similar to those of Apert or Crouzon syndrome. The skull is
and ring fingers, resulting in mid-digital hand mass; the thumb turribrachycephalic secondary to the coronal and occasional
and little fingers may also be joined to the mid-digital mass sagittal synostosis (Figure 23.4). Maxillary hypoplasia with
(Figure 23.3). When the thumb is free, it is broad and deviates resulting midface deficiency leads to shallow orbits and exor-
radially due to an accompanying delta phalanx. In the feet, bitism. Hypertelorism and downslanting palpebral fissures
the syndactyly also usually involves the second, third, and are also common. The nose is often downturned with a low
fourth toes. These hand anomalies are so severe and function- nasal bridge. Intelligence is reported to be normal in the more
ally debilitating that referral to a hand surgeon with special common form of Pfeiffer syndrome. Broad thumbs and great
expertise in this area is essential. An extensive review of cen- toes are the hallmark of the syndrome, but the findings are
tral nervous system problems in patients with Apert syndrome frequently subtle. The partial syndactyly of the hands usually
shows an increased incidence of delayed mental development, involves the index and middle fingers. A partial syndactyly of
but many of these patients develop normal intelligence. Acne toes 2, 3, and 4 has also been noted. Cohen proposed a clas-
vulgaris is another characteristic feature seen during adoles- sification system that clusters patients into three types based
cence in over 70% of patients. upon their clinical findings and severity. Type I represents the
Perhaps our best understanding of the natural history of
raised ICP in Apert syndrome comes from the Great Ormond
A B
FIGURE 23.4. Pfeiffer syndrome in an infant female. A. Note the
severe midface hypoplasia, exorbitism, mild hypertelorism, and tur-
FIGURE 23.2. Apert syndrome in a 2-year-old female. Note the ribrachycephalic skull. B. The profile view clearly demonstrates the
severe midface hypoplasia, elongated forehead with temporal widen- abnormal brow-to-cornea relationships, concavity of the midface, and
ing, brachycephaly, and beaked nose. short nose.

“classic Pfeiffer” syndrome (features described above) which Intelligence is usually normal. A partial syndactyly involving
is milder than type II with a kleeblattschädel (cloverleaf) skull, the index and long fingers is often observed, and short stature
and type III Pfeiffer syndrome is the most severely affected. is also a frequent finding.
A recent review of 28 patients treated at a single insti- Patients with Saethre-Chotzen have a high incidence of
tution reported that the Cohen subtypes distribution was need for reoperation after cranial vault expansion, rang-
type 1 61%, type II 25%, and type III 14%(Fearon). These ing from 42% to 65%. Several reports have demonstrated
patients underwent an average of 2.5 cranial vault procedures, high reoperation rates for poor growth after fronto-orbital
1.6 neurosurgical procedures, and 3.5 other operations. In advancement (FOA); however, a recent report demonstrated
addition to the challenging reconstructive needs of the patient that this patient population also carries a greater than 40%
with Pfeiffer syndrome, this study highlighted several func- risk of developing elevated ICP after the initial cranial vault
tional considerations that should be aggressively treated or expansion. Clearly, such a high-risk population warrants
monitored in these patients including value in early placement strict monitoring and their families should be made aware that
of permanent tarsorrhaphies and supplementing these with the majority of these patients require more than one cranial
temporary tarsorrhaphies at the time of cranial vault proce- vault procedure in the course of their treatment.
dures, and high incidences of aural atresia (54%), conductive
hearing loss (86%), need for tracheostomy (61%), hydroceph-
alus (68%), and Chiari malformations (82%).
Muenke Syndrome
Unlike other eponymous craniosynostosis syndromes, Muenke
syndrome derives its name from the first report of the genetic
Saethre-Chotzen Syndrome mutation rather than the phenotype. The mutation is a pro-
(Acrocephalosyndactyly 250Arg mutation in FGFR-3 on chromosome 4p, which has
Type III) an incidence of 1 in 10,000 and demonstrates an autosomal
dominant inheritance pattern with variable expressivity. It is
This syndrome was first described by Saethre in 1931 and by estimated that Muenke syndrome may be present in 10% of
Chotzen in 1932. The predominant features include a brachy- unicoronal or bicoronal synostosis cases that were previously
cephalic skull, a low-set frontal hairline, prominent crus heli- believed to be non-syndromic in origin. The most consistent
cis extending through the conchal bowl, facial asymmetry, and features include craniosynostosis of the coronal sutures, hear-
ptosis of the eyelids (Figure 23.5). The mode of inheritance ing loss, developmental delay, and thimble-like middle pha-
is autosomal dominant, with wide variability in expression. langes. Midface hypoplasia is not a common finding. Muenke
The diagnosis is confirmed by identification of a mutation in syndrome exhibits significant variability in the presentation of
the TWIST-1 gene on chromosome 7p21, which is believed to craniosynostosis between genders, where 88% of females and
result in a dysregulation between bone deposition and mainte- 76% of males with the mutation have craniosynostosis. While
nance of suture patency. bicoronal synostosis is the most common presentation for both
The craniofacial features include unicoronal or bicoronal sexes, males demonstrate a much higher incidence of unicoro-
synostosis, which is often asymmetric giving a plagiocephalic nal craniosynostosis (37% bicoronal vs. 29% unicoronal) than
appearance and contributes to facial asymmetry. The low- females (58% bicoronal vs. 20% unicoronal). The pattern of
set hairline is also a constant feature of this syndrome. The sensorineural hearing loss found in these patients is character-
facial asymmetry is often accompanied by deviation of the istically a bilateral, symmetric, low- to mid-frequency pattern.
nasal septum and maxillary hypoplasia with a narrow palate. The clinical relevance of Muenke syndrome lies in the
course of these patients after their initial surgical treatment. In
a large retrospective review for patients with coronal cranio-
synostosis, the reoperation rate for elevated ICP in Muenke
syndrome was five times more common than in those with-
out the mutation. Others have also found rates of reopera-
tion to be much higher and aesthetic outcomes to be poorer
in Muenke syndrome. In a patient population that is already
A B C D at an increased risk for developmental delays, and lack signifi-
cant extracranial signs of their genetic diagnosis, a high level
of suspicion and low threshold for genetic testing must be had
when evaluating patients with unicoronal or bicoronal synos-
tosis, particularly those with a family history.
E F G H Functional Aspects
To fully appreciate the surgical treatment of children with
these craniosynostosis syndromes, it is necessary to under-
stand the craniofacial growth process and how it relates to cer-
tain functional aspects of development. Normal craniofacial
growth is directed by two general processes: displacement and
I J K L bone remodeling. During the first year of life, the brain triples
FIGURE 23.5. Saethre-Chotzen syndrome. Note the brachycephalic in size and continues to grow rapidly until about 6 or 7 years
and turricephalic skull, low-set frontal hairline, and ptosis of the of age. The growth of the brain causes displacement of the
eyelids (A–D). In this case, the patient had multiple-suture craniosyn- overlying frontal, parietal, and occipital bones in the presence
ostosis necessitating a strip craniectomy in early infancy. This was of open functioning sutures, and this stimulates bone growth
followed by fronto-orbital advancement at 10 months to improve and remodeling in the skull and cranial fossa. The growth and
brow position and frontal bone contour (E, F), followed by posterior maturation of the face follows a craniocaudal gradient, pro-
cranial vault distraction at age 24 months to remove occipital flatness
and the increased height of the posterior skull while further expanding
gressing from late childhood to adolescence, with maturation
the intracranial volume (G, H). With a decreased posterior vertical of the upper face followed by maturation of the midface and
height, the increased anterior vertical height and recurrent brow retru- finally the mandible. The functional aspects of development,
sion are addressed during a second FOA (I–L). which are directly or indirectly influenced by abnormal cra-
niofacial growth, are examined individually below.

Increased ICP leading to papilledema and optic atrophy
Intracranial Pressure can result in blindness. Whether the optic atrophy is secondary
The rapid growth of the brain in infancy demands rapid to increased ICP or is secondary to damage to the nerve from
accommodation of the cranial vault to maintain normal ICP. compression or a compromised vascular supply is not entirely
In the patient with craniosynostosis, there can be restricted clear. As in monitoring for increased ICP, transient pattern
growth of the cranial vault, resulting in a disparity between reversal VEP has emerged as a screening tool for possible visual
brain size and intracranial volume, which leads to increased dysfunction in children with syndromic craniosynostosis.
ICP.
Increased ICP can be recognized clinically by the finding
of papilledema on funduscopic examination and, in later
Hydrocephalus
stages, “thumb printing” or the beaten cooper appearance Although the incidence of hydrocephalus and craniosyn-
on plain radiographs from pressure of the gyri on the inner ostosis is rare, it appears that among children with cranio-
table of the calvarium. However, papilledema alone is not a synostosis syndromes, the incidence of hydrocephalus is
reliable marker for the potential for visual dysfunction nor significantly higher, with reports ranging from 4% to 10%.
increased ICP. Intraparenchymal monitoring remains the There is clearly a higher incidence of hydrocephalus among

gold standard in ICP monitoring. The placement of pres- children with Apert syndrome. The etiology of hydrocephalus

sure-sensitive filaments through a burr hole in the calvarium remains unclear, but it has been postulated that it is caused by
allows for continuous monitoring of ICP during normal increased venous pressure in the sagittal sinus secondary to
activities over a 24-hour period or longer; however, it carries obstruction of the venous outflow caused by the craniosynos-
the risks of bleeding and infection and requires admission to tosis. Both communicating and noncommunicating forms of
the hospital. hydrocephalus have been identified, but the communicating
Unfortunately, there does not yet exist an equally reliable form is more common. Hydrocephalus can present without
noninvasive indicator of increased ICP. In a study that evalu- either marked head enlargement (which may be difficult to
ated ICP by an epidural sensor in 358 children with various detect in the patient with syndromic craniosynostosis) or signs
types of craniosynostosis, it was found that children with of increased ICP. Preoperative CT scanning or ultrasonogra-
multiple-suture synostosis had higher rates of increased ICP phy helps define the population at risk. At the earliest sign
(26% to 54%), and in the syndromic population increased of progressive ventricular enlargement, a shunting procedure
ICP was noted in 66% of the patients with Crouzon syndrome should be performed to prevent cerebral injury.
and in 43% of those with Apert syndrome. Although it has
been documented by three-dimensional computerized tomog-
raphy (CT) studies that increases in intracranial and ventricu-
Surgical Management
lar volume occur following cranial vault reshaping, and that The surgical treatment of patients with craniosynostosis syn-
ICP pressure decreases, we cannot yet accurately determine by dromes dates from the late 19th century, when the first tech-
means of CT scan alone which group of patients with cranio- niques were aimed at correcting only the functional aspects
synostosis will develop increased ICP. Several new modalities of the deformity. The earliest techniques, linear craniectomy
have potential for noninvasive monitoring of ICP. and fragmentation of the cranial vault, still are useful in some
The first is transorbital ultrasound measurement of optic of the more severe deformities to provide temporary brain
nerve sheath diameter. Elevations in ICP affect the space and eye protection until a more definitive craniofacial pro-
around the optic nerve causing an increase in optic nerve cedure can be undertaken. Simple craniectomy or morcella-
diameter, and elevation above age-controlled diameters can tion performed in infancy, unfortunately, is accompanied
reliably predict elevated ICP. Another promising modality by a high rate of reossification and will give only modest
is visual evoked potentials (VEPs). This technique measures results when mobilization of the orbits and midface is not
the latency time of flash VEP–induced N2 wave response. performed concurrently. Additionally, the reossified bone is
Prolonged response time is predictive of elevated ICP. These of poor quality, making definitive correction more difficult.
techniques carry no inherent risks but limit monitoring to In 1967, Tessier first published his results following correc-
short observation periods. This may be misleading, because tion of the recessed forehead and supraorbital regions using
transient changes in ICP can occur based upon the patients’ an intracranial approach that allowed accurate osteotomy,
activity, position, or time of day. Therefore, confirmation with mobilization, and repositioning in adults. The current surgical
invasive monitoring is still required to correlate these findings. treatment approach is for children with syndromic craniosyn-
However, the combination of several signs and symptoms is ostosis and accompanying midface deficiency and involves an
frequently enough, when combined with the dysmorphic fea- initial posterior cranial vault distraction or FOA and cranial
tures, to warrant surgical intervention for both functional- vault remodeling, a midface advancement procedure with or
and appearance-related purposes. without distraction (Le Fort III or monobloc), and secondary
orthognathic surgery to correct any dentofacial deformities
(Le Fort I, mandibular osteotomies).
Visual Changes Surgical intervention for the correction of craniofacial
Craniosynostosis can result in abnormal growth of the skull deformities in patients with syndromic craniosynostosis can
and, in the syndromic population of patients, this is often be divided into those procedures that are performed early in
accompanied by midface hypoplasia. Underdeveloped shal- life (4 to 12 months) for suture release, cranial vault decom-
low orbits or abnormally shaped orbits can cause the eyes pression, and upper orbital reshaping/advancement and those
and periorbital structures to be displaced from their normal that are performed at a later age (4 to 12 years) for midface
position; this is termed exorbitism. Exorbitism can result in deformities and jaw surgery (14 to 18 years). The exact timing
corneal exposure and the development of keratitis, pain, infec- and sequence for each of the aforementioned surgical proce-
tion, corneal scarring, and, at worst, ulceration and blindness. dures is dependent on both the functional and the psycho-
Occasionally, the degree of exorbitism is so great that imme- logical needs of the patient (Table 23.1). The area of largest
diate surgical intervention is required to protect the globe. controversy centers around the timing of midface osteotomies.
Ocular motility problems frequently arise secondary to the Two approaches are currently practiced: (a) waiting until all
abnormal size and shape of the orbits. Strabismus with exo- midface and lower face growth is complete before performing
tropia is a common finding. Abnormal development and posi- a definitive osteotomy and advancement, or (b) performing a
tion of ocular muscles have also been frequently reported in midface advancement in childhood with the realization that
children with Crouzon or Apert syndrome. a second advancement will be necessary when mandibular

TA B L E 2 3 . 1
Syndromic Craniosynostosis Treatment Options
n Procedure n Timing (age) n Comments

Strip craniectomy for raised ICP only <6 mo
Posterior cranial vault distraction 6–12 mo Unless the patient requires ocular protection
Fronto-orbital advancement 6–12 mo Delayed as long as possible after posterior vault distraction
unless eye exposure issues, where it is first-stage procedure at
6–12 mo.
In some cases, it may be avoided and the anterior vault is
managed with a monobloc distraction. Otherwise between
2 and 5 y old, repeat cranial vault expansion procedures
may be indicated in childhood or adolescence for continued
growth restriction or abnormal growth of the skull
Le Fort III osteotomy and primarily 4–8 y If a conventional Le Fort III advancement is performed in
by distraction osteogenesis this age group, a secondary Le Fort III advancement may be
required in teenage years
9–12 y Delaying to this age in less severe cases may obviate the need
for a second major midface advancement.
Le Fort I ± mandibular osteotomy 14–18 y Required to establish neutral dental occlusion after facial
growth has ceased.
Monobloc frontofacial advancement 4–12 y Simultaneously improves forehead, orbital, and midface
aesthetics via distraction osteogenesis. Suitable for a patient
whose deformity allows simultaneous advancement
Contouring via reduction, onlay bone 15–19 y Performed as the final procedure to enhance aesthetics after all
grafts, bone substitutes, or alloplasts growth has ceased
growth is complete. Because midface advancement is usually these defects with particulate bone harvested from the endo-
performed using distraction techniques, the complications cortex of the cranial bone flaps as described by Greene et al.
of blood loss and infection have been dramatically reduced, (Chapter 22).
making the procedure more common in childhood.
Posterior Vault Expansion with
Fronto-orbital Advancement Distraction Osteogenesis
The surgical goals of FOA are threefold: (a) to release the Expansion of the posterior cranial vault provides a significantly
synostosed suture and decompress the cranial vault, (b) to greater gain in intracranial volume than FOA; however, expan-
reshape the cranial vault and advance the frontal bone, and (c) sion has historically been limited by soft tissue closure. With
to advance the retruded supraorbital bar, providing improved the advent of distraction osteogenesis (Chapter 24), the con-
globe protection and an improved aesthetic appearance. The comitant expansion of the soft tissue envelope in addition to
procedure is performed through a coronal incision. With the posterior cranial vault allows for significantly greater volu-
the assistance of a neurosurgical team, a frontal craniotomy metric expansion and relief of ICP. This procedure is particu-
is performed to release the involved sutures and elevate the larly beneficial to patients with raised ICP who are too young
frontal bone. In certain instances, the child may have under- for FOA or for those in whom greater functional and aesthetic
gone a prior frontal craniotomy to release the coronal sutures gains would be made from a posterior expansion rather than
when elevated ICP was suspected. Reossification usually has a second FOA. Posterior vault expansion has also been noted
occurred by 1 year of age. Once the frontal bone is removed, to have a positive affect on the appearance of the anterior
the brain is gently retracted, exposing the underlying retruded vault. While definitive remodeling procedures of the anterior
supraorbital bar, which is advanced, bolstered forward with vault and supraorbital bar are still necessary, the expansion
a cranial bone graft, and secured with resorbable plates or of the posterior vault provides protection to the rapidly grow-
sutures (Figure 23.6). Cranial vault remodeling technique is ing brain and allows for a single procedure to be performed
dependent on the preoperative head shape. For severe turri- for fronto-orbital reconstruction. The procedure, performed
cephaly, a total cranial vault reshaping is performed (often through a standard coronal incision, consists of a posterior
done in stages); this procedure allows for a significant reduc- craniotomy with limited dural dissection, barrel staving at the
tion in the vertical height of the skull. For the child with base of the occiput to limit step-off deformity, application of
mild turricephaly, only the anterior two-thirds of the vault is two collinear 1.5 mm mandibular distraction devices, and clo-
remodeled. The supraorbital bar and forehead are advanced sure. Activation is started at 3 to 7 days with advancement at
into an overcorrected position to allow room for further brain 1 mm/d. Advancements are typically between 20 and 30 mm,
growth. In patients aged 12 months or younger, the majority followed by a 6- to 8-week consolidation period. A second, lim-
of the cranial gaps created by FOA will ossify spontaneously. ited procedure is required for distraction device removal.
The ability to close large calvarial defects changes between Following these cranial vault remodeling and FOA
9 and 11 months of age, resulting in an increasingly lower procedures, the child is seen on a 6- to 12-month basis by the
probability of defect closure. Overall, roughly 20% of all craniofacial team. Continued growth of the cranial vault and
patients undergoing FOA will have persistent defects. We midface is monitored closely by means of three-dimensional
have therefore adopted the practice of primary grafting of CT scans, as well as clinical observation.

Sutures

A B
Resorbable plate
FIGURE 23.6. A. The typical lines of craniotomy for removal of the frontal bone flaps and lines of osteotomy for the frontal bandeau. The fron-
tal bone flaps are carried posteriorly, behind the position of the coronal sutures and anteriorly to leave sufficient height to the bandeau (≈2 cm).
B. Exposure of the temporal fossa and anterior cranial base is provided by the neurosurgeon. Bandeau cuts are carried inferiorly from the coronal
craniotomy to the level of the zygomaticofrontal (ZF) suture and anteriorly, parallel to the craniotomy cuts, through the ZF suture. Using mal-
leable retractors to protect the temporal and frontal lobes and orbital contents, osteotomies are made through the orbital roofs and transversely
just above the nasofrontal junction.
Although FOA and posterior vault distraction provide recurrent class III malocclusion in patients who undergo sur-
excellent decompression of the craniosynostosis and improve- gery earlier (4 to 9 years), often requiring a secondary Le Fort
ment in the shape of the cranial vault in the early postoperative III procedure in the teenage years. The authors believe that
period, continued growth restriction in both the cranial vault early correction of the midface deformity affords the patient
and the midface region often produces poor long-term aes- an overall aesthetic improvement that will have a significant
thetic results in these syndromic patients. If signs of increased positive psychological effect and improve self-esteem in these
ICP, severe exorbitism, or an abnormally shaped cranial vault children, and in our experience patients accept a secondary
recur, a second and, occasionally, a third cranial vault remod- Le Fort III or monobloc procedure as a standard step in their
eling procedure are indicated (Figure 23.7). treatment.
Regardless of the timing, distraction has evolved as the
Surgical Correction of the treatment modality of choice for the extensive midface
advancement these patients require. The efficacy and improved
Midface Deformity safety profile of both Le Fort III and monobloc distraction
The first attempt to correct the midface deformity in a syn- over single staged osteotomy advancement procedures have
dromic craniosynostosis patient was a Le Fort III proce- been well documented. Distraction allows for expansion of
dure performed by Sir Harold Gillies. He later abandoned the soft tissue envelope with the bony advancement, which
the operation because of its morbidity, but the proce- aids in preservation of the barrier between the nasopharynx
dure was later resurrected and popularized by Paul Tessier and anterior vault and decreased tendency to relapse from
(Figure 23.8). The Le Fort III can be performed alone or, if soft tissue contraction. A modified Le Fort III osteotomy is
all permanent teeth have erupted, in conjunction with a Le performed (Figures 23.8 and 23.9). Distraction is initiated
Fort I advancement. The monobloc frontofacial advancement at 5 to 7 days post-op (principles of distraction discussed in
procedure, which involves the advancement of the Le Fort III Chapter 24). The surgical technique and distraction protocol
fragment in coordination with the frontal bar, was developed is dictated by the patient’s bony deformity. In addition to Le
by Ortiz-Monasterio (Figure 23.9). The monobloc procedure, Fort III osteotomy, the techniques for midface improvement
while offering the advantage of simultaneously correcting may include facial bipartition to correct the hypertelorism,
the supraorbital and midface deformity, is associated with downslanting palpebral fissures, and midface concavity that
greater blood loss and a higher infection rate, which is most are characteristic of Apert and Pfeiffer syndromes.
likely a result of the direct communication between the cra- In our institution, the age of midface distraction is typi-
nial and nasal cavities. Patients with ventricular shunts have cally 5 years. While the goals of midface distraction in this
an exceedingly high rate of infection because the brain can- age group are tailored to the patient’s deformity, the univer-
not expand into the newly created dead space. This increased sal goals are maximal projection of the zygoma and resto-
risk makes the traditional monobloc procedure in the neo- ration of orbital volume. The result is typically a transition
natal period contraindicated. However, Polley has demon- from a severe Angle Class III to Class II occlusion. The final
strated that a monobloc distraction may be performed early occlusion is addressed with the definitive orthognathic proce-
in select patients with significant upper airway obstruction dure once the patient reaches skeletal maturity. Advantages
and craniosynostosis. of distraction include (a) less blood loss and shorter oper-
The exact timing of midface correction remains a contro- ative time at the initial p rocedure; (b) greater advance-
versy among craniofacial surgeons. Some craniofacial centers ment (up to 20 mm or more) as compared with standard
advocate early surgical correction between the ages of 4 and advancement techniques (6 to 10 mm maximum); (c) less
7 years; others prefer to wait until skeletal maturity is reached risk of infection with the monobloc procedures; and (d) less
at around puberty, unless airway obstruction or severe exor- relapse. Disadvantages include the (a) prolonged time (sev-
bitism dictates immediate early surgery. The advocates of eral months) needed for distraction and consolidation; (b)
delayed surgical correction cite evidence of a high incidence of need for a second procedure to remove buried devices; and

A B
C D
FIGURE 23.7. Posterior vault distraction. In addition to volume expansion of the cranial vault, a second goal of posterior vault distraction is to improve
the typically flat occiput of the turricephalic skull. This is accomplished with osteotomy design and vector selection that allows posteroinferior movement
of the distracted bone flap as seen in (A) and (B). The dura remains attached to the bone flap and barrel staves are made inferiorly to allow for a smooth
transition of the post-distraction bone flap and inferior occiput. To prevent displacement of the device, a minimum of five screws are used per footplate
of a 1.5 mm mandibular distraction device with a 30 to 35 mm barrel. The lateral X-rays in the pre- and post-activation states are seen in (C) and (D).
A B
FIGURE 23.8. A. Osteotomies for Le Fort III distraction. Note that the lateral orbital rim osteotomy is in a much lower position than in the traditional Le
Fort III procedure. B. This figure demonstrates the final position of the midface segment at the end of the activation phase. With internal devices, it is criti-
cal to have collinear positioning of the devices with the correct vector as these devices afford no ability to adjust the vector of distraction during activation.


A B
FIGURE 23.9. A. Osteotomies for monobloc distraction with an external distraction device in place. B. This postoperative view shows the
overcorrected position of the midface and depicts the location of generate deposition in the area of the pterygoid plates posterior to the advanced
midface segment. While as close an approximation to the desired vector is used in device application, the external device affords significant ability
to adjust the vector of distraction in multiple planes. This flexibility makes the external device superior to internal devices in our opinion.
(c) need for wearing an external halo device for a prolonged deformities. The class III malocclusion, secondary to midface
period. Overall, distraction osteogenesis has improved the retrusion, is the most commonly seen deformity and often
results obtainable for midface advancement while mini- develops despite appropriate midface surgical treatment. The
mizing the complications. Figure 23.10 is an example of a team approach to the management of these jaw abnormalities
patient who underwent a monobloc advancement utilizing involves an orthodontist, a dentist, and a craniofacial surgeon.
distraction osteogenesis. Following the completion of growth of both the maxilla and
the mandible and any needed presurgical orthodontic therapy,
surgical correction involving at least a Le Fort I osteotomy
Orthognathic Surgery with a sliding genioplasty is usually indicated. These surgical
The abnormal patterns of facial growth in children with cra- procedures are usually performed between the ages of 14 and
niosynostosis syndromes often result in significant dentofacial 18 years, when the facial skeleton is mature.
B
FIGURE 23.10. Fronto-orbital and midface advancement at age 6 years using monobloc distraction in a child with Crouzon syndrome.
A. Preoperative and postoperative frontal view and 3D CT reconstructions. B. Preoperative and postoperative profile view and three-dimensional
computerized tomography (CT) reconstructions. Note the desired, overcorrected position of the midface and orbit-producing mild enophthalmos
and a significant Angle class II relationship.

4. Cohen MM Jr, ed. Craniosynostosis: Diagnosis, Evaluation, and
Final Facial Contouring Management. New York, NY: Raven Press; 1986.
5. Fearon JA. Halo distraction of the Le Fort III in syndromic craniosynostosis:
At the completion of facial growth and all major osteotomies, a long-term assessment. Plast Reconstr Surg. May 2005;115(6):1524-1536.
contour irregularities of the facial skeleton may still remain. 6. Fearon JA, Rhodes J. Pfeiffer syndrome: a treatment evaluation. Plast
Final contouring procedures are often performed at this time. Reconstr Surg. May 2009;123(5):1560-1569.
They include smoothing irregularities, adding bone grafts or 7. Flores RL, Shetye PR, Zeitler D, et al. Airway changes following Le Fort
III distraction osteogenesis for syndromic craniosynostosis: a clinical and
bone substitutes to different areas (e.g., calcium carbonate cephalometric study. Plast Reconstr Surg. August 2009;124(2):590-601.
cements), and resuspending soft tissues such as the midface or 8. Foo R, Guo Y, McDonald-McGinn DM, Zackai EH, Whitaker LA,
lateral canthi. Bartlett SP. The natural history of patients treated for TWIST1-
confirmed Saethre-Chotzen syndrome. Plast Reconstr Surg. December
2009;124(6):2085-2095.
Conclusion 9. Gosain AK, Santoro TD, Havlik RJ, et al. Midface distraction following Le
Fort III and monobloc osteotomies: problems and solutions. Plast Reconstr
In the past, children with craniosynostosis syndromes were Surg. 2002;109:1797-1808.
10. Greene AK, Mulliken JB, Proctor MR, Rogers GF. Primary grafting
stigmatized as being mentally challenged because of their cra- with autologous cranial particulate bone prevents osseous defects fol-
niofacial features when, in fact, they were often of normal lowing fronto-orbital advancement. Plast Reconstr Surg. November
intelligence. The advent of craniofacial surgery techniques, 2007;120(6):1603-1611.
although far from perfect, offers these children a chance of 11. Honnebier MB, Cabiling DS, Hetlinger M, McDonald-McGinn DM,
Zackai EH, Bartlett SP. The natural history of patients treated for FGFR3-
obtaining a more normal facial appearance and the opportu- associated (Muenke-type) craniosynostosis. Plast Reconstr Surg. March
nity to grow, develop, and integrate socially with their peers. 2008;121(3):919-931.
The application of newer operative techniques to craniofacial 12. Liasis A, Nischal KK, Walters B, et al. Monitoring visual function in chil-
surgery, including endoscopic surgery and distraction osteo- dren with syndromic craniosynostosis: a comparison of 3 methods. Arch
Ophthalmol. August 2006;124(8):1119-1126.
genesis, is expected to offer improved results with fewer com- 13. Paige KT, Vega SJ, Kelly CP, et al. Age-dependent closure of bony
plications. Distraction osteogenesis has yielded promising defects after frontal orbital advancement. Plast Reconstr Surg. September
results in the cranium and midface. The real future of chil- 2006;118(4):977-984.
dren with craniosynostosis syndromes, however, lies in the 14. Shetye PR, Boutros S, Grayson BH, McCarthy JG. Midterm follow-up of
midface distraction for syndromic craniosynostosis: a clinical and cephalo-
hands of the molecular geneticists. The advances in this field metric study. Plast Reconstr Surg. November 2007;120(6):1621-1632.
have allowed for the identification of the gene and associated 15. Slaney SF, Oldridge M, Hurst JA, et al. Differential effects of FGFR2 muta-
mutation for several craniosynostosis syndromes. Ultimately, tions on syndactyly and cleft palate in Apert syndrome. Am J Hum Genet.
the ability to genetically screen for these DNA mutations will May 1996;58(5):923-932.
16. Steinbacher DM, Skirpan J, Puchała J, Bartlett SP. Expansion of the pos-
allow for appropriate family counseling and perhaps, in the terior cranial vault using distraction osteogenesis. Plast Reconstr Surg.
future, gene therapy for the correction of the mutation. February 2011;127(2):792-801.
17. Tessier P. The definitive plastic surgical treatment of the severe facial
Suggested Readings deformities of craniofacial dysotosis: Crouzon’s and Apert’s disease. Plast
Reconstr Surg. 1971;48:419.
1. Arnaud E, Marchac D, Renier D. Reduction of morbidity of the frontofacial 18. Thompson DN, Harkness W, Jones B, Gonsalez S, Andar U, Hayward R.
monobloc advancement in children by the use of internal distraction. Plast Subdural intracranial pressure monitoring in craniosynostosis: its role in
Reconstr Surg. September 2007;120(4):1009-1026. surgical management. Childs Nerv Syst. May 1995;11(5):269-275.
2. Bartlett SP, Losee JE, Baker SB. Reconstruction: craniofacial syndromes. In: 19. Whitaker LA, Bartlett SP, Shut L, et al. Craniosynostosis: an analysis of
Mathes SJ, ed. Plastic Surgery. Vol IV. 2nd ed. Philadelphia, PA: Saunders the timing, treatment, and complications in 164 consecutive patients. Plast
Elsevier; 2006:495-520. Reconstr Surg. 1985;80:195.
3. Bradley JP, Gabbay JS, Taub PJ, et al. Monobloc advancement by distrac- 20. White N, Evans M, Dover MS, Noons P, Solanki G, Nishikawa H. Posterior
tion osteogenesis decreases morbidity and relapse. Plast Reconstr Surg. calvarial vault expansion using distraction osteogenesis. Childs Nerv Syst.
December 2006;118(7):1585-1597. February 2009;25(2):231-236.

Chapter 24 n Craniofacial Microsomia and
Principles of Craniofacial
Distraction
Joseph G. Mccarthy
Craniofaciall Microsomia Table 24.1
Craniofacial microsomia, a variable hypoplasia of the skel- Structures Derived From The First and Second

eton and soft tissue, is the second most common congenital Branchial Arches and The Otic Capsule

deformity of the head and neck region, with an incidence as
high as 1 in 3,500 live births. First branchial arch
The deformity has been known by a variety of terms. In Maxillary process Maxilla
Europe, the term dysostosis otomandibularis has been used.
Gorlin and Pindborg preferred hemifacial microsomia, but Palatine bone
this term implies that the syndrome is unilateral and that the Zygoma
deformity is confined to the face. I prefer the term unilateral
Mandibular process Trigeminal nerve
craniofacial microsomia or, when there is bilateral involve-
ment, bilateral craniofacial microsomia. Anterior part of auricle
Bilateral craniofacial microsomia can be confused with Mandible
Treacher Collins syndrome (Chapter 28), but the latter shows
a well-defined pattern of inheritance and the pathology is rela- Head of malleus
tively symmetrical. Treacher Collins syndrome has other distin- Body of incus
guishing features (absence of the medial lower eyelashes, lower
eyelid hypoplasia, and antegonial notching of the mandible), Tympanic bone
findings that are absent in craniofacial microsomia. Likewise, Sphenomandibular ligament
craniofacial microsomia should be distinguished from micro-
gnathia of the development or posttraumatic type where the First branchial groove External auditory meatus
underdevelopment is restricted to the mandible and there is no Tympanic membrane
evidence of facial paralysis, ear anomalies, or hypoplasia of the
soft tissue. First pharyngeal pouch Eustachian tube
Middle ear cavity
Etiology Second branchial arch Facial nerve
The hypoplasia is variable and can be manifested in any Posterior part of auricle
structure(s) derived from the first and second branchial arches Manubrium of malleus, long
(Table 24.1), accounting for the wide spectrum of the deformity. process of incus, stapedial super-
The genetics of the syndrome are poorly understood. In a structure, tympanic surface
series of 102 affected patients, only 4 had a sibling or parent with
evidence of craniofacial microsomia; indeed, only a few pedigrees Stapedial artery, styloid process,
of the syndrome have been reported. Despite the possibility of an stylohyoid ligament
occasional autosomal dominant transmission, only a 2% to 3% Lesser cornu of hyoid
recurrence rate was found in a study of first-degree relatives.
Several theories have been proposed in an attempt to Otic capsule Vestibular surface of stapes,
understand the etiopathogenesis. Stark and Saunders invoked internal acoustic meatus
the concept of mesodermal deficiency, the current theory for Inner ear
cleft lip/palate formation. Tessier, in a classification system of
orbitofacial clefts, invoked a clefting mechanism. He described Modified from Pearson AA, Jacobson AD. The development of
the ear. In: Manual of the American Academy of Ophthalmology
three clefts involving the orbitozygomatic complex in patients & Otolaryngology. Portland, OR: University of Oregon Printing
with craniofacial microsomia (see Chapter 26). Department; 1967 and Converse JM. Reconstructive Plastic Surgery.
The most commonly accepted is one of vascular insult, Philadelphia, PA: Saunders; 1977.
with hemorrhage formation in the developing first and second
branchial arches. The stapedial artery is a temporary embry-
onic collateral of the hyoid artery. Defects of this temporary side of the mouse model. Moreover, the laboratory findings were
vessel may result in hemorrhage, accounting for injury to the supported by the clinical documentation in Germany of approxi-
developing first and second branchial arches. mately 1,000 severe cases and an additional 2,000 less severe
Laboratory phenocopies of craniofacial microsomia have cases of craniofacial microsomia following the widespread use of
been created following the administration of triazine to the devel- thalidomide as a tranquilizer in pregnant women.
oping mouse and thalidomide to the monkey. Histologic studies
demonstrated hematoma formation before formation of the sta-
pedial artery. The spectrum of the pathology varied depending
Epidemiology
on the volume of hemorrhage, ranging from involvement of only The incidence of the syndrome is not accurately known in the
the external ear and auditory ossicles to a larger defect involving United States but has been reported to be as high as 1 in 3,500
the zygomatic complex and the entire mandible on the affected live births. If all infants with preauricular skin tags and so-called
241
isolated microtia are included, the incidence of maldevelopment paralleled in the corresponding planes of the maxillary sinus
of the first and second branchial arches is much higher. floors and pyriform apertures. Similarly, the maxillary and
Similarly, the sex ratio is not accurately known; in a series mandibular dentoalveolar complexes are reduced in the verti-
of 102 patients, 63 were males and 39 were females. Another cal dimension on the affected side.
series reported an almost equal sex ratio (59 males and Pruzansky proposed a classification of the mandibular
62 females). Studies of “isolated” microtia patients, on the deficiency, which was later modified by Mulliken and Kaban
other hand, all report a clear male preponderance. (Figure 24.2):
The incidence of bilateral involvement is said to be 10% to
I. Mild hypoplasia of the ramus with minimally affected
15%. The true incidence is probably higher when one consid-
mandibular body.
ers the presence of preauricular skin tags and subtle radio-
II. The condyle and ramus are small; the head of the con-
graphic abnormalities of the mandible on the contralateral,
dyle is flattened; the glenoid fossa is absent; the condyle is
“unaffected” side.
hinged on a flat, often convex, infratemporal surface; the
coronoid may be absent.
Clinical Findings III. The ramus is reduced to a thin lamina of bone or is com-
pletely absent. There is no evidence of a temporomandib-
There is a wide variety of pathologic expression of craniofa-
ular joint.
cial microsomia in the following anatomic regions: jaws, other
craniofacial skeletal components, muscles of mastication, The above classification was subsequently modified by sub-
ears, soft tissue, and nervous system (Figure 24.1). dividing type II based on the pathology of the temporomandib-
ular joint region. In type IIA, although the ramus and condyle
Jaws are abnormal in size and shape, the glenoid fossa–condyle rela-
tionship is maintained. Temporomandibular joint function is
The most obvious deformity is the mandible, especially the
almost normal. In contrast, in type IIB, the condyle is hypoplas-
ascending ramus, which is reduced in the vertical dimension.
tic and malformed and displaced toward the midline relative to
The size of the condyle usually reflects the degree of hypopla-
the contralateral side. Patients open with restricted hinge-like
sia of the ramus. Involvement of the temporomandibular joint
functioning of the mandible on the ipsilateral side.
ranges from mild hypoplasia to a pseudoarticulation at the
cranial base to complete absence of the condyle. In addition to
being short, the ramus is usually displaced toward the midline. Other Skeletal Components
The chin is deviated toward the affected side and there is a The maxilla is reduced in the vertical dimension and, depend-
corresponding cant of the mandibular occlusal plane, which is ing on the degree of hypoplasia of the mandible, there is a
corresponding cant of the occlusal surface of the maxillary
dentition.
Type I A B
Type IIA
Type IIB C Type III D

Figure 24.2. Pruzansky’s proposed (1969) classification of the
mandibular deformity in craniofacial microsomia as modified by
Mulliken and Kaban (1987). A. Type I: The condyle and ramus are
reduced in size but the overall morphology is maintained. B. Type IIA:
The ramus and condyle demonstrate abnormal morphology but the
Figure 24.1. Patient with left-sided craniofacial microsomia dem- glenoid fossa has maintained a position in the temporal bone simi-
onstrating the characteristic occlusal cant upward on the affected side lar to that of the contralateral side. C. Type IIB: The ramus/condyle
with associated cheek hypoplasia and ear anomaly. The oral commis- is hypoplastic, malformed, and displaced toward the midline.
sure is also elevated on the affected side. The chin point is deviated to D. Type III: The ramus is essentially absent without any evidence of
the affected side. temporomandibular joint.

Chapter 24: Craniofacial Microsomia and Principles of Craniofacial Distraction 243
The zygomatic complex can be reduced in all dimensions;
the zygomatic arch can be decreased in length or absent. These Nervous System
findings, combined with soft-tissue deficiency, result in a Cerebral abnormalities, although rare, can occur and include
reduction in the distance between the oral commissure and ear hypoplasia of the cerebrum and corpus callosum, as well as
vestige on the affected side. hydrocephalus of the communicating and obstructive types.
The temporal bone can also be involved, although the The brain stem can be involved secondarily because of anoma-
petrous portion is spared. The mastoid process can be lies of the cervical vertebrae, resulting in disturbances such as
hypoplastic and there can be partial or complete lack of impression of the brain stem.
pneumatization of the mastoid air cells. The styloid process The most common cranial nerve anomaly is an incomplete
can be shortened or absent. The orbit is often reduced in facial palsy of varying degrees, attributed to the following
all dimensions, and occasional patients have microphthal- (alone or in combination): absence of the intracranial por-
mos. The frontal bone can be flattened, giving the illusion tion of the facial nerve and nucleus in the brain stem, aberrant
of a plagiocephaly although the ipsilateral coronal suture pathway of the nerve in the temporal bone, or agenesis of the
is patent. facial muscles. Absence of facial nerve function in the distri-
Malformations of the cervical vertebrae are not uncom- bution of the marginal mandibular branch is seen in approxi-

mon and include the presence of hemivertebrae, fused verte- mately 25% of patients, with weakness of other components,

brae, and even a basilar impression syndrome. Goldenhaar such as the buccal and zygomatic branches, occurring in a
described a variant of craniofacial microsomia characterized smaller percentage.
by epibulbar dermoids/lipodermoids, associated vertebral
abnormalities (usually cervical), and occasional rib anomalies.
Classification
Muscles of Mastication Several classifications have been described based on the clini-
cal findings of the patient with unilateral craniofacial microso-
The syndrome is not restricted to the skeleton; the associated mia. Harvold, Vargervik, and Chierici proposed the following
muscles of mastication are hypoplastic. The deficiency, how- classification:
ever, is not always proportional to the skeletal deficiency. A
three-dimensional computed tomography (CT) scan study I (A). The classic type characterized by unilateral facial
compared the volume of the mandibular deformity with that underdevelopment without microphthalmos or ocu-
of the adjacent muscles of mastication and noted that there lar dermoids but with or without abnormalities of
was not always a 1:1 relationship in the degree of pathologic the vertebrae, heart, or kidneys.
involvement. I (B). Similar to type I (A) except for the presence of
Muscle function is impaired, especially evident in lateral microphthalmos.
pterygoid muscle function on the affected side. The lateral I (C). Bilateral asymmetric type in which one side is more
pterygoid muscle is responsible for movement of the mandi- severely involved.
ble and chin point to the contralateral side. Consequently, I (D). Complex type that does not fit the above but does
in patients with unilateral craniofacial microsomia, who not display limb deficiency, frontonasal phenotype,
attempt a protrusive chin movement, the chin deviates to or ocular dermoids.
the affected side during opening and during forceful pro- II. Limb deficiency type (unilateral or bilateral) with or
trusion. The hypoplastic lateral pterygoid muscle on the without ocular abnormalities.
affected side is overpowered by its unaffected counterpart. III. Frontonasal type. Relative unilateral underdevelopment
Moreover, mouth opening is also adversely affected by the of the face in the presence of hypertelorism with or
hypoplastic ramus and malpositioned temporomandibular without ocular dermoids and vertebral, cardiac, or renal
joint. abnormalities.
IV. (A) Unilateral or (B) bilateral. Goldenhar type with facial
underdevelopment in association with other dermoids,
Ears with or without upper lid coloboma.
Involvement of the auricle occurs in most patients (Chapter 27).
Meurmann proposed a classification of the external ear defor- Munro and Lauritzen proposed a clinical classification
mities: Grade I, distinctly smaller malformed auricle but all system (Figure 24.3) that was designed as an aid in planning
components are present; Grade II, only a vertical remnant of surgical correction:
cartilage and skin with aural atresia (complete atresia of the Type IA: The craniofacial skeleton is only mildly hypo-
external auditory canal); Grade III, almost complete absence plastic and the occlusal plane is horizontal.
of the auricle except for a small remnant, usually a soft-tissue Type IB: The skeleton is similar to IA, but the occlusal
lobule. Nagata’s classification (Chapter 27) is more useful for plane is canted.
the surgeon. The great majority of patients with microtia also Type II: The condyle and part of the affected ramus are
have aural atresia. A small percentage do have a canal, but absent.
in many of these patients the canal is stenotic, atypical, or in Type III: In addition to the findings in type II, the zygo-
abnormal position. matic arch and glenoid fossa are absent.
Type IV: This is an uncommon type with hypoplasia of
Soft Tissue the zygoma and medial and posterior displace-
ment of the lateral orbital wall.
On the affected side, preauricular skin tags are common, and
Type V: The most extreme type has inferior displacement
the skin and subcutaneous tissue of the cheek show varying
of the orbit with a decrease in orbital volume.
degrees of hypoplasia. Hypoplasia or aplasia of the parotid
gland has been documented. The soft-tissue deficiency occurs Vento and colleagues proposed the nosologic OMENS
in all three dimensions. classification system in an effort to standardize reporting
Lateral facial clefts (macrostomia) are common associated between treatment centers. The acronym OMENS designates
findings and also contribute to the overall cheek hypoplasia. each of the five major areas of involvement in craniofacial
Overt clefts of the soft palate are said to occur in 25% of microsomia: O = orbital, M = mandibular, E = ear, N = facial
patients, and the soft palate may deviate to the affected side nerve, and S = soft tissue. The orbital gradations were based
on voluntary function. on size and position; the mandible was scored as noted above;

Mandibular distraction is indicated in the newborn or

infant with sleep apnea (with or without a tracheostomy).
Distraction can correct not only the sleep apnea but also the
associated alimentary or feeding problems (e.g., swallowing
and gastroesophageal reflux). The principles of distraction
and the applications in the mandible and other parts of the
craniofacial skeleton are addressed in a separate section later
in this chapter.
Two to Six Years of Age

In the child with mild deformity, such as Pruzansky type
I mandible and a horizontal occlusal plane (Munro and
Lauritzen type IA), no surgical treatment is recommended at
this early age.
In the child with severe reduction in the vertical height
of the mandibular ramus (Pruzansky types I and II), airway
problems, and obvious aesthetic deformity, the technique of
distraction osteogenesis (Figure 24.5) is considered. Sufficient
clinical experience with mandibular distraction has accumu-
lated to demonstrate that this technique improves the airway,
lengthens the affected ramus, and also augments the associated
soft tissue and muscles of mastication. The gradual nature of
Figure 24.3. Classification of unilateral craniofacial microsomia
proposed by Munro and Lauritzen in 1985. The circle in Figure IA the distraction process lowers relapse rates. Studies also dem-
designates the usual site of skeletal involvement. The midsagittal, onstrate that the distracted ramus/condyle remodel to assume
midincisor, occlusal, and orbital planes are designated. See text for a more anatomic size, shape, and position. Studies have dem-
details of each type. (From McCarthy JG, Grayson BH, Coccaro PJ, onstrated that the distracted mandible does not grow as much
et al. Craniofacial microsomia. In: McCarthy JG, ed. Plastic Surgery. as the contralateral side, necessitating secondary distraction or
Philadelphia, PA: WB Saunders; 1990, with permission.) definitive jaw surgery when craniofacial growth is completed
(approximately age 17 years), or both.
In the patient with a Pruzansky type III deformity without
evidence of a ramus, condyle, and glenoid fossa (or zygomatic
the ear anomaly was categorized essentially according to the
arch), a preliminary costochondral rib or iliac bone graft
Meurmann classification; the facial nerve was according to
reconstruction is performed at approximately age 4 years. In
which branches were involved, and the soft tissue was accord-
this technique, the glenoid fossa, zygomatic arch, and ascend-
ing to the degree of subcutaneous and muscular deficiency.
ing ramus are reconstructed in a single surgical procedure
(Figure 24.6). If there is a persistent mandibular deficiency,
Preoperative Assessment especially manifested by airway obstruction, distraction, as a
secondary procedure, is considered.
A complete clinical evaluation is mandatory, because other
In the child with bilateral craniofacial microsomia
organ systems, such as the kidneys and heart, can be involved.
(Pruzansky types I and II mandibular deformity) with asso-
The role of the pediatric otolaryngologist is critical in assess-
ciated sleep apnea (with or without tracheostomy), bilateral
ing the airway and auditory function. The patient with airway
mandibular distraction can be performed after sleep studies
problems will require endoscopy and sleep studies. Medical
have established the diagnosis and the latter has been con-
photographs are obtained, including frontal, lateral, oblique,
firmed by endoscopy. In these children, the treatment can
submental vertex, and occlusal views. Cephalograms (postero-
result in removal of the tracheostomy. If no mandibular rami
anterior, lateral, and basilar) and a panoramic roentgenogram
exist, bilateral costochondral graft reconstruction is required.
(Panorex) are likewise obtained. The optimal way to define
the various skeletal deformities is with a three-dimensional
CT scan (Figure 24.4), which can be reformatted to give a Six to Sixteen Years of Age
dentascan and document the location of tooth follicles in the This is the period of orthodontic treatment, including possible
younger patient in whom cephalograms and Panorex cannot functional appliance therapy to promote eruption and growth
be obtained. i-CAT scans have recently been added as a tool in of the dentoalveolus on the affected side. Distraction can be
planning skeletal surgery. considered in the patient with chronic low-grade sleep apnea
and in the patient with severe dysmorphism who has never
received treatment. Ear reconstruction is undertaken during
Treatment this period (Chapter 27). Serial autogenous fat injections or
No standardized treatment program exists for the child with insertion of a microvascular free flap to augment the facial
craniofacial microsomia. The pathology, as emphasized soft tissue and improve facial contour results in considerable
before, is variable, and other factors, such as growth and aesthetic improvement.
development and prior therapy, are considered before recom-
mending an individualized treatment program. Older Than Sixteen Years of Age
Surgery is often indicated in the period of skeletal maturity
Younger Than Two Years of Age because of residual deficiency resulting from inadequate
Excision of the preauricular skin tags and cartilage remnants growth and development on the affected side, severe maloc-
is often satisfying to the parents, because it removes some of clusion, or failure of the patient to seek treatment previously.
the stigmata of the syndrome. Likewise, macrostomia can be At this point in time, when craniofacial growth and devel-
corrected by a commissuroplasty on the affected side or on opment are complete, the following procedures are con-
both sides in bilateral cases. In the occasional patient with sidered: (a) limited autogenous bone grafting of deficient
involvement of the fronto-orbital region, characterized by portions of the craniofacial skeleton; (b) bilateral mandibular
severe retrusion of the supraorbital bar and frontal bone, a advancement in patients with mild to moderate mandibular
fronto-orbital advancement may be necessary. micrognathia; (c) combined Le Fort I osteotomy, bilateral


Figure 24.4. Three-dimensional CT scans of three unilateral microsomia cases demonstrating increasing severity from left to right. The affected
side of each case is on the top panel, with the corresponding normal contralateral side on the lower panel. The three cases correspond to the
modified Pruzansky classification of mandibular deformity: class I (left), class II (center), class III (right). (From Mathes SJ. Plastic Surgery.
Philadelphia, PA: WB Saunders; 2005, with permission.)
Figure 24.6. The technique of reconstruction of an absent ramus,

zygomatic arch, and the temporomandibular joint with costochon-
dral rib grafts. Note the cartilage graft simulating the disc and the
cartilaginous portion of the rib graft simulating the condyle. Rigid
Figure 24.5. Mandibular distraction. A semi-buried device, placed skeletal fixation (screws and plates) is also utilized. (Modified from
with an oblique vector, is depicted. The bony generate is seen in the Munro JR, Lauritzen CG. Classification and treatment of hemifa-
distraction gap. (From Nelligan P. Plastic Surgery. Philadelphia, PA; cial microsomia. In: Caronni EP, ed. Craniofacial Surgery. Boston,
WB Saunders; 2012, with permission.) MA: Little, Brown; 1985:391–400, with permission.)

mandibular osteotomy, and genioplasty (Figure 24.7); and was provided by Abbot in 1927. The biologic principles
(d) serial autogenous fat injection or insertion of a microvas- were insufficiently studied; the devices were poorly designed;
cular free flap to augment the soft tissue of the face on the infection, fibrous union, nerve palsy, and joint contractures
affected side. resulted; and the concept was abandoned.
Ilizarov1,2 conducted laboratory studies and popularized
the concept of distraction osteogenesis in the long (endo-
Principles of Craniofacial chondral) bones of the extremities for limb lengthening and
Distraction for the closure of bony defects. McCarthy and colleagues at
New York University3-5 applied the technique to the bones
Distraction osteogenesis is an established therapeutic tool, espe-
(membranous) of the craniofacial skeleton in a series of canine
cially in the craniofacial skeleton where it has the enormous
mandible studies and introduced clinical craniofacial distrac-
advantage of eliminating bone grafts and alloplastic materials,
tion in 1989.
almost completely eliminating infections after osteotomies, and
While distraction in the extremities has fallen out of favor,
decreasing the rate and extent of osteotomy relapse.
distraction in the craniofacial skeleton (for deficiencies of
The technique is unique in that it applies gradual and incre-
the mandible, maxilla, midface, zygomas, and cranium) has
mental traction force/tension to surgically separated bony
assumed a much larger role.
segments to produce additional bone. In essence, it releases
inherent biologic forces to generate tissues, that is, bone and
the associated neuromuscular/soft-tissue complex. The tech- Principles
nique could actually be called distraction histogenesis in that The biologic concept of targeted bone growth/deposition is
distraction of the skeleton also causes enlargement of the best demonstrated by cranial sutures. As the rapidly enlarg-
overlying or surrounding soft tissue. Distraction osteogenesis ing brain in the growing neonate separates the individual
represents one of the first examples of surgically induced tis- cranial bones, the sutures react by depositing new bone.
sue engineering. In this manner the cranial vault increases in surface area
to provide a skeleton of adequate volume for protection
History of the brain. Maxillary arch expansion by activation of a
device placed across the palatine suture, as routinely prac-
Skeletal molding has been practiced for centuries. In certain
ticed by orthodontists, is another example of distraction
African tribes, serial applications of metal necklaces at a
osteogenesis.
young age result in elongation of the neck. Mayan cultures
The concept is simple.
performed cranial molding with the application of helmets to
the skulls of infants. 1. The bone is separated into segments either by a full-
Early in the 20th century, Codivilla reported a technique thickness osteotomy or by a low-energy corticotomy (spar-
involving an osteotomy of the femur and application of exter- ing the endosteum or marrow space). The location of the
nal traction to lengthen the lower extremity. A similar report bony separation is termed the distraction zone.
Bone to be
removed
A B
Figure 24.7. The combined Le Fort I and bilateral sagittal split osteotomy and genioplasty, in a patient
with right-sided hemifacial microsomia. A. (left) Lines of osteotomy. The osteotomy and site of vertical
impaction are illustrated on the left maxilla. The solid circles designate the midpoints of the chin, maxilla,
and orbital region (midsagittal plane). The arrow shows the direction of the jaw movements. B. (right)
Following movement of the maxillary, mandibular, and chin segments and the establishment of rigid skeletal
fixation with plates and screws. Note the interpositional bone graft in the right maxilla. The solid circles
line up along the midsagittal plane. (Modified from Obwegeser HL. Correction of the skeletal anomalies of
otomandibular dysostosis. J Maxillofac Surg. 1974;2:73, with permission.)

2. Time is allowed (5 to 7 days) for reparative callus forma- patients, successful distraction can be performed across patent
tion in the distraction zone (the latency period). or open sutures (trans-sutural distraction). Palatal or maxil-
3. Gradual distraction forces are applied to separate the lary expansion with an orthodontic appliance is an example
edges and elongate the intersegmentary callus under ten- of the latter, and trans-sutural midface distraction has been
sion (the activation period). successfully achieved in an immature canine model.
a. Rigidity of the distraction device is critical to maintain Distraction ostoegenesis represents a unique form of frac-
the intersegmentary gap tissues in a direction or vector ture healing. In contrast to fracture healing that occurs via
parallel to the orientation of the device (the vector of a cartilaginous intermediate, distraction of both the mem-
distraction). branous bone of the craniofacial skeleton and the endochon-
b. A rhythm of 0.25 mm four times a day is preferable dral bone of the extremities occurs without a cartilaginous
(0.5 mm twice a day is generally acceptable in a clinical intermediate.
setting).
4. At the end of activation, the external fixation must be
Histologic Analysis
maintained in position to allow consolidation of the newly The histologic changes occurring in the distraction zone

formed bone (distraction generate). The consolidation have been elucidated in animal experiments. A circumferen-

period usually lasts approximately 8 weeks. tial corticotomy was performed in the region of the angle of
the mandible at a position posterior to the molars in a canine
The three types of distraction osteogenesis are as follows model.4 After the application of a distraction device, and a
(Figure 24.8): latency period of 7 days, the device was activated at the rate
1. Unifocal—a single osteotomy with distraction forces and rhythm of 0.5 mm twice a day for a total of 20 mm (acti-
applied by a device attached by screws on either side of the vation period). The distracted mandibles were harvested at
osteotomy; several time points during the activation and consolidation
2. Bifocal—a single osteotomy with one set of pins adjacent periods and subjected to histologic and microradiographic
to the osteotomy and the other set on the distal side of a examination.
skeletal defect, with a single distraction device spanning During the latency period (after osteotomy and before acti-
the transport segment; vation of the device), bone repair is similar to that observed
3. Trifocal—two osteotomies used to fill a skeletal defect in a after fracture healing—hematoma formation and the migra-
bidirectional manner with a spanning distraction device. tion of inflammatory cells into the osseous gap or distraction
zone.
The transport segment is delivered into the skeletal defect Microscopic examination after activation of the distraction
by forces applied by the distraction device. The leading edge device demonstrates the presence of tapered cells, similar to
of the segment has a fibrocartilage cap. Bone grafting is usu- fibroblasts, and new blood vessels, which form a fibrovascu-
ally required after the transport segment has been finally lar matrix aligned longitudinally in the direction of the dis-
“docked,” the fibrocartilage is resected, and the defect is traction vector. Osteoid synthesis and mineralization are not
replaced by a bone graft. However, after temporomandibu- apparent until almost 14 days after the initiation of activation.
lar ankylosis release with a gap arthroplasty, the cartilaginous At approximately 3 weeks after activation, calcification
leading edge of the transport segment simulates a neocondyle of the linear-oriented collagen bundles is noted, followed by
and no grafting is performed. the appearance of osteoblasts along the collagen bundles and
The most usual type of distraction is transosteotomy formation of bony spicules that extend from the edges of the
(or transcorticotomy) distraction. However, in very young osteotomy toward the central portion of the distraction zone.
With progressive calcification of the generate, there is bony
closure of the distraction defect. Continued remodeling of the
Unifocal New bone newly formed bone, as evidenced by the appearance of osteo-
clasts, results in lamellar bone with marrow elements of
adequate volume.
In summary, the following four temporal zones are
observed in the distraction gap (Figure 24.9):
1. Fibrous central zone (mesenchymal proliferation)—
longitudinally oriented fibrous bundles;
Transport 2. Transition zone—osteoid formation along the collagen
Bifocal segment bundles in the distraction gap;
3. Remodeling zone—the appearance of osteoclasts with
remodeling of the newly formed bone; and
4. Mature bone zone.
Biomolecular Analysis
Transport
segments The development of a laboratory rat model of mandibular dis-
Trifocal
traction has permitted the study of a relatively large number of
animals with the potential for detailed biomolecular analysis
of the distraction zone.6 At the end of the latency and in the
early activation periods, there is a metabolically active, het-
erogeneous cell population (endothelial cells, fibroblasts, and
Figure 24.8. The three types of distraction osteogenesis: uni- polymorphonuclear leukocytes) in the distraction zone, all
focal, bifocal, and trifocal. The solid gray zone represents the associated with the presence of type I collagen bundles. The
newly generated bone at the osteotomy/corticotomy site. The
arrows designate the direction of the distraction (strain) forces.
latter become organized and oriented as a fibrovascular bridge
The transport segments are white. (Adapted from Aro H. in a plane parallel to the distraction vector. The arrival of large
Biomechanics of distraction. In: McCarthy JG, ed. Distraction osteoblasts at the edges of the osteotomized bone is associated
of the Craniofacial Skeleton. New York, NY: Springer; 1999.) with osteoid deposition along the collagen bundles; this is fol-
lowed by mineralization of the generate in the distraction gap.

1 2 3 4 of immunolocalization of focal adhesion kinase and other

molecular mediators supports the hypothesis that bone for-
mation in mandibular distraction is regulated by mechanical
forces, signaling integrin-mediated single-transduction path-
ways at the molecular level.
Mandible Distraction
The mandible was the obvious first choice for craniofacial
distraction.5 It is an accessible, somewhat tubular bone in
which changes can be easily documented by measurement of
radiographic and occlusal changes. In addition, a clinical need
Figure 24.9. Schematic of the temporal stages of bone generation in existed for a therapeutic paradigm shift, especially in pediat-
unifocal distraction. See text for details. (From Karp NS, McCarthy JG, ric patients with deficiency of the mandibular ramus and life-
Schreiber JS, et al. Membranous bone lengthening: a serial histologic threatening respiratory problems.
study. Ann Plast Surg. 1992;29:2, with permission.) In contrast to classic mandibular osteotomies, distrac-
tion permits surgery at a younger age without the need for
bone grafts, blood transfusions, prolonged operations, and
extended hospital stays. There is also an associated expan-
A marked increase in transforming growth factor β1 sion or lengthening of the overlying soft tissues and muscles
(TGF-β1) is demonstrated as early as 3 days into the latency (distraction histiogenesis). The relapse rate is lower, as the
period. Expression of this cytokine peaks during the late bone is lengthened gradually at the rate of 1 mm/d, in con-
stages of the activation period.7 It returns to near-normal lev- trast to an acute intraoperative forceful skeletal advancement
els toward the end of the consolidation period. These find- against deficient and restrictive soft tissues.
ings imply a regulatory mechanism for TGF-β1 in inducing A variety of mandibular distraction devices are available
collagen deposition and noncollagen extracellular matrix and the surgeon must choose between an external (extraoral)
proteins involved in the mineralization and remodeling of and a buried (intraoral) device (Figure 24.10). In general, extra-
bones. TGF-β1 is also important in the activation of VEGF oral devices are associated with more successful and consistent
(vascular endothelial growth factor) and basic FGF (fibro- outcomes. They are especially indicated when the skeletal site
blast growth factor). TGF-β1 also plays a regulatory role in for the osteotomy and pin insertions is diminutive in area and
osteoblast migration, differentiation, and bone remodeling. volume. A distinct disadvantage is that it leaves an external
Neovascularization is critical to the success of distraction.8 scar, which can be obvious and hypertrophic in some patients.
Although osteocalcin (a noncollagenous matrix protein) Although intraoral or semi-buried devices are associated
expression is decreased during the latency period, an increased with better scar formation, it is usually also necessary to place
expression is observed early in the activation period, and it
is increased to normal levels by the end of the consolidation
period. Osteocalcin plays an important role in mineralization
and bone remodeling. The key quality of bone, that is, its
rigidity or hardness, is attributable to the mineralization of the
linear-oriented extracellular matrices.
A more complete understanding of the biomolecular reg- 4 mm
ulation of distraction osteogenesis offers the possibility of 12 mm
future clinical manipulation of the distraction zone, for exam-

ple, increasing the rate of activation and decreasing the length
of the consolidation period. If the latter goals can be achieved, A B
the length of the overall distraction treatment period would be
significantly reduced.
Biomechanics
In distraction osteogenesis, the tensile forces delivered to the
developing callus at the osteotomy site cause elongation of the
callus. The mechanical environment in the distraction zone is
determined by the following factors: the rigidity of the distrac-
tion device, the applied distraction forces, the inherent physi- C D
ologic loading (muscle action), and the properties of all of the
local soft tissues.9 Bone
Tensile strain is defined as the amount of elongation as a generate
fraction of the original bone length.9 At an activation rate of

1.0 mm/d and an osteotomy defect of 1.0 mm, the strain is 100%
during the first day of activation. By activation day 10, when
there is a 10-mm gap, the tensile strain has decreased to 10%.
Because bone can tolerate only 1% to 2% tensile strain (“ulti-
mate tensile strain”), bone tissue cannot survive for long a load E F
exceeding more than 1% to 2% tensile strain. Consequently,
bone formation is not observed in the distraction zone until Figure 24.10. Mandibular distraction. A. External technique: an
approximately 4 weeks of activation, that is, the period when intraoral incision along the oblique line of the mandibular remnant.
B. Sites of the pinholes and proposed osteotomy (dotted line). C. Pins
the tensile strength is at or below the ultimate tensile level. in place. D. Completing the osteotomy (cortices only). E. Distraction
The process by which mechanical forces are converted to device in place. F. Activation of the device with formation of the bony
cellular signals is termed mechanical transduction.10 A studied generate (shaded). (From Nelligan P. Plastic Surgery. Philadelphia,
pathway is the integrin-mediated signal transduction cascade. PA: WB Saunders; 2012, with permission.)
In the rat mandibular model of distraction, the demonstration

a transcutaneous (submandibular) incision for their inser- with autorotation of the mandible and anterior projection
tion. Consequently, there is always a resulting, albeit fine line, of the chin and tongue base. In bilateral mandibular distrac-
scar. The actual progress of the activation cannot be observed tion, vertical vectors again result in autorotation of the man-
externally, and in the infant in whom serial radiographs dible with more projection of the chin (e.g., Treacher Collins
are not possible, there can be an undetected mechanical syndrome, bilateral craniofacial microsomia). In contrast, in
problem. While molding of the generate is not possible, the bilateral mandibular distraction, horizontal vectors increase
semi-buried device (with the activation knob accessible trans- the anteroposterior dimensions of the body of the mandible
cutaneously) is ideal for patients requiring a vertical vector. but result in less chin projection (e.g., Pierre Robin sequence).
Intraoral devices are also more difficult to remove. The indications for mandibular distraction are both func-
tional and aesthetic. Distraction has revolutionized the treat-
Technique ment of the infant or young patient with sleep apnea and the
associated alimentary problems of eating and swallowing.
The mandible is approached by individual or combined trans-
The technique can be employed in the neonate and has obvi-
cutaneous (submandibular) or intraoral incisions.
ated the need for tracheostomy. Moreover, it has permitted
The first decision is the choice of a vector.11 The vertical
decannulation of tracheotomies in infants and young children.

vector is defined as one at 90° to the maxillary occlusal plane
Sleep apnea is also an unrecognized problem in older patients,

and is indicated when there is a vertical deficiency of the ramus
accounting for learning disabilities and behavioral problems.
(Figure 24.11). In patients with severe micrognathia associated
Mandibular distraction can have a positive impact on the
with deficiency of the mandibular body, the horizontal vec-
quality of life of such children.
tor (parallel to the maxillary occlusal plane) is selected. The
Mandibular distraction is also indicated for patients with
oblique vector is selected when there is a deficiency in both the
respiratory functional problems and facial dysmorphism in
vertical ramus and the horizontal body of the mandible.
such conditions as craniofacial microsomia, developmental
Clinical studies12,13 have demonstrated that in unilateral dis-
micrognathia, and Treacher Collins syndrome. Postablative
traction, a vertical vector results in lengthening of the ramus
mandibular defects and temporomandibular joint ankylosis
are other conditions that can be treated by transport distrac-
tion. Alveolar ridge distraction is indicated to increase alveo-
lar ridge bone volume for the insertion of dental implants or
for orthodontic tooth movements.
Treatment Goals
Even more than most surgical procedures, the surgeon is inti-
mately involved during the postoperative period. After the
completion of the latency period, the surgeon and orthodon-
tist oversee device manipulation (activation). In addition to
lengthening of the device and mandible, it may also be neces-
sary to “mold the generate” with orthodontic rubber bands or
manipulation of multiplanar distraction devices to correct or
ameliorate malocclusions.
In unilateral mandibular distraction, as in the patient with
A unilateral craniofacial microsomia, the treatment end points
are the movement of the chin to the contralateral side with
lowering of the ipsilateral oral commissure, the inferior bor-
Maxillary occlusal plane der of the mandible, and the occlusal plane to a level below
that of the contralateral side. Such “overcorrection” is espe-
cially indicated in the growing child. In bilateral mandibular
B distraction, the treatment end points include the achievement
of a slight anterior crossbite, especially in the growing child.
Maxillary Distraction
Maxillary Le Fort I distraction is indicated for the correction
of maxillary retrusion usually associated with cleft lip and
palate patients and the maxillary deformity in craniofacial
microsomia. The latter can be treated by combined maxillo-
mandibular distraction.
The advantages of maxillary distraction are that it can
be performed at a younger age, especially in the child with
respiratory obstruction or a severe malocclusion (anterior
crossbite) and midface retrusion that impact on psychosocial
functioning. During the period of mixed dentition, the surgeon
must be aware of unerupted maxillary teeth that lie along the
path of the Le Fort I corticotomy. Because activation is at the
C
rate of only 1 mm/d, and because the associated soft tissue is
also being distracted, the relapse problems associated with a
classic Le Fort I advancement in the patient with severe palatal
Figure 24.11. The vectors of mandibular distraction. A. Vertical
scarring are reduced. A corollary is that significantly greater
vector. B. Horizontal vector. C. Oblique vector. Note the vectors ref- maxillary advancement can be achieved (in excess of 15 mm).
erenced to the maxillary occlusal plane (red). (From Nelligan P. Plastic It should be emphasized, however, that a second maxillary
Surgery. Philadelphia, PA: WB Saunders; 2012, with permission.) advancement will most likely be required when the patient
achieves craniofacial maturity at the age of 17 or 18 years.

Several types of maxillary distraction devices are available.

An external head frame (RED) provides relative stability and
the ability to change the vector during activation (Figure 24.5),
but is somewhat cumbersome; a variety of buried or intraoral
devices are also available.
A maxillary degloving incision is made and the osteotomy
or corticotomy is carefully performed along the traditional
Le Fort I lines, with care being taken to avoid injury to
unerupted maxillary teeth. A vector is usually chosen in a for-
ward and downward direction.
The treatment’s end point is a class II malocclusion or
overjet in the growing child (“overcorrection”). The consoli-
dation period is approximately 2 months.
Midface Distraction A B
The clinical technique of midface or subcranial Le Fort III
distraction is based on laboratory studies.14 It has several
advantages in that it avoids the need for bone grafts and the
application of plates and screws. The length of the surgical
procedure and the volume of blood transfusion are reduced, as
is the length of hospitalization. Infection almost never occurs.
Moreover, the aesthetic results are superior to those of the tradi-
tional Le Fort III advancement with bone grafts because of more
zygomatic projection and a lower relapse rate. A greater degree
of midface distraction (up to 20 mm) can be achieved.15,16 Serial
CT studies have demonstrated bone deposition along the entire
Le Fort III osteotomy line as well as expansion of the nasopha-
ryngeal airway space with relief of obstructive sleep apnea.
Midface distraction is especially indicated in the syndromic C
craniofacial synostosis patient with exorbitism, malocclu- Figure 24.12. Midface distraction devices. A and B. External
sion, sleep apnea, midface retrusion, and severe dysmorphism. (red) device, C. Buried device with an activation arm that pen-
Patients with orbitofacial clefts are also candidates. When per- etrates the scalp. (From Mathes SJ. Plastic Surgery. Philadelphia, PA:
Elsevier; 2005, with permission.)
formed in a growing child, it must be emphasized to the fam-
ily that a second midface procedure will be required when the
child completes craniofacial skeletal growth in late adolescence.
There are two types of available distraction devices: head
frames and buried devices that can be directly applied to the osteotomized segment of cranial bone is moved into a cranial
craniofacial skeleton through a coronal incision (Figure 24.12). defect with bony generation in the donor defect.
The ideal vector of distraction is in an anterior direction
along a plane parallel to the maxillary occlusal surface. One
should guard against a vector that closes the anterior open
Future
bite and increases the vertical dimension of the face and orbit. The possibilities of craniofacial distraction are only beginning
Treatment end points in the growing child include overcorrec- to be realized. It has been demonstrated that all components
tion with an overjet or class II occlusion and maximal orbito- of the craniofacial skeleton—the mandible, maxilla, zygoma,
zygomatic advancement. orbits, and cranial bone—can be successfully distracted. As
the devices are miniaturized and automated, it is possible that
multiple bones could be individually distracted concurrently
Frontofacial (Monobloc) without the need for external devices. In the infant or young
Distraction patient, it may be possible to perform transutural distraction
without the need for osteotomies. As the molecular biology of
Frontofacial or monobloc distraction is similar to subcranial
the distraction zone is more fully understood, the rate of activa-
midface distraction except that the superior part of the orbits
tion may be increased beyond 1.0 mm/d and the consolidation
and frontal bones is distracted along with the midface frag-
period reduced far below the current requirement of 8 weeks,
ment. Collaboration with a neurosurgeon is required for the
thereby significantly reducing the overall length of treatment.
craniotomy and intracranial exposure. Severe exorbitism and
the need for expansion of orbital volume are ideal indications,
as well as patients who require expansion of the cranial vault
References
(anterior) for symptoms of increased intracranial pressure. Craniofacial Microsomia
Because the process is gradual, monobloc distraction
does not create the intracranial dead space that the standard 1. Gorlin RJ, Pindborg JJ. Syndromes of the Head and Neck. New York, NY:
McGraw-Hill; 1964.
osteotomy/advancement does. This almost eliminates the risk 2. Gosain AK, McCarthy JG, Pinto RS. Cervico-cerebral anomalies and basilar
of infection and cerebrospinal fluid leakage, common compli- impression in Goldenhar syndrome. Plast Reconstr Surg. 1994;93:489.
cations when monobloc osteotomies were performed with- 3. Grayson B, Boral S, Eisig S, et al. Unilateral craniofacial microsomia.
out distraction. Patients with functional ventriculoperitoneal Part I—mandibular analysis. Am J Orthod. 1983;84:225.
4. Longaker MT, Siebert JW. Microvascular free flap correction of hemifacial
shunts, however, remain at risk for these complications. atrophy. Plast Reconstr Surg. 1995;96:280.
5. McCarthy JG, Fuleihan NS. Commisuroplasty in lateral facial clefts. In:
Cranial Distraction Stark RB, ed. Plastic Surgery of the Head and Neck. Boston, MA: Little,
Brown; 1986.
6. McCarthy JG, Schreiber JS, Karp NS, et al. Lengthening of the human man-
Research studies17 and clinical reports demonstrate that dible by gradual distraction. Plastic Reconstr Surg. 1992;89:1.
cranial bone (i.e., cranial vault) distraction is clinically fea- 7. McCarthy JG, Grayson BH, Hopper R, Tepper O. Craniofacial microso-
sible. It is a form of bifocal or trifocal distraction in that an mia. In: Nelligan P, ed. Plastic Surgery. Philadelphia, PA: Elsevier; 2012.

8. Meurmann Y. Congenital microtia and meatal atresia. Arch Otolaryngol. 6. Rowe NM, Mehrara BJ, Dudziak MD, et al. Rat mandibular distraction
1957;66:443. osteogenesis: part I. Histologic and radiographic analysis. Plast Reconstr
9. Molina F, Ortiz-Monasterio F. Mandibular elongation and remodel- Surg. 1998;102:2022.
ing by distraction: a farewell to major osteotomies. Plast Reconstr Surg. 7. Mehrara BJ, Rowe NM, Steinbrech DS, et al. Rat mandibular distraction
1995;96:825. osteogenesis: part II. Molecular analysis of transforming growth factor beta
10. Mulliken JB, Kaban LB. Analysis and treatment of hemifacial microsomia in I and osteocalcin gene expression. Plast Reconstr Surg. 1999;103:536.
childhood. Clin Plast Surg. 1987;14:91. 8. Davidson EH, Sutton SM, Butala P, et al. Augmenting neovascularization
11. Munro IR, Lauritzen CG. Classification and treatment of hemifacial micro- accelerates distraction osteogenesis. Plast Reconstr Surg. 2011;128:406.
somia. In: Caronni EP, ed. Craniofacial Surgery. Boston, MA: Little, Brown; 9. Aro H. Biomechanics of distraction. In: McCarthy JG, ed. Distraction of the
1985:391-400. Craniofacial Skeleton. New York, NY: Springer; 1999.
12. Obwegeser HL. Correction of the skeletal anomalies of otomandibular dys- 10. Yu JC, Fearon J, Havlik RJ, et al. Distraction osteogenesis of the craniofa-
ostosis. J Maxillofac Surg. 1974;2:73. cial skeleton. Plast Reconstr Surg. 2004;114:1e.
13. Shetye PR, Grayson BH, Mackool RJ, McCarthy JG. Long-term stability 11. Grayson BH, McCormick S, Santiago PF, et al. Vector of device place-
and growth following unilateral mandibular distraction in growing children ment and trajectory of mandibular distraction. J Craniofac Surg. 1997;8:
with craniofacial microsomia. Plast Reconstr Surg. 2006;118:985. 473.
14. Vento AR, La Brie RA, Mulliken JB. The O.M.E.N.S. classification of hemi- 12. Dec W, Peltomaki T, Warren SM, Garfinkle JS, Grayson BH, McCarthy JG.
facial microsomia. Cleft Palate Craniofac J. 1991;28:68. Mandible response to unilateral distraction osteogenesis. Plast Reconstr Surg.
2008;121:2084.
Principles of Craniofacial Distraction 13. Vendittelli B, Dec W, Warren SM, Garfinkle JS, Grayson BH, McCarthy JG.

Mandible response to bilateral distraction osteogenesis. Plast Reconstr Surg.

1. Ilizarov G. The tension-stress effect on the genesis and growth of tissues: 2008;122:1144.
part I. The influence of stability of fixation and soft-tissue preservation. Clin 14. Staffenberg DA, Wood RJ, McCarthy JG, et al. Midface distraction
Orthop. 1989;238:249. advancement in the canine without osteotomies. Ann Plast Surg. 1995;34:
2. Ilizarov G. The tension-stress effect on the genesis and growth of tissues: 512.
part II. The influence of the rate and frequency of distraction. Clin Orthop. 15. Shetye PR, Boutros S, Grayson BH, et al. Midterm follow-up of midface dis-
1989;239:236. traction for syndromic craniosynostosis: a clinical and cephalometric study.
3. Karp NS, Thorne CH, McCarthy JG, et al. Bone lengthening in the cranio- Plast Reconstr Surg. 2007;120:1621.
facial skeleton. Ann Plast Surg. 1990;24:231. 16. McCarthy JG, Stelnicki EJ, Mehara B, et al. Craniofacial distraction. Plast
4. Karp NS, McCarthy JG, Schreiber JS, et al. Membranous bone lengthening: Reconstr Surg. 2001;107:1812.
a serial histologic study. Ann Plast Surg. 1992;29:2. 17. Bouletreau PJ, Warren SM, Pacione MF, et al. Transport distraction
5. McCarthy JG, Schreiber JS, Karp N, Thorne CH, Grayson BH. Lengthening osteogenesis: a new method to heal calvarial defects. Plast Reconstr Surg.
the human mandible by gradual distraction. Plast Reconstr Surg. 1992:89:1. 2002;109:1074.

Chapter 25 n Orthognathic Surgery
Stephen B. Baker
Retroclination—Posterior angulation of the anterior teeth.

Introduction Retrognathic—The condition of a mandible that is poste-
Orthognathic surgery is the term used to describe surgi- riorly positioned in relation to the cranial base.
cal movement of the tooth-bearing segments of the jaws.
Patients with dentofacial deformities that cannot be treated Establishing The Diagnosis
with orthodontics alone are candidates for jaw surgery. These
malocclusions are typically associated with skeletal discrep- History
ancies secondary to congenital anomalies, congenital syn-
An accurate understanding of the chief complaint is essential
dromes, nonsyndromic dentofacial abnormalities, or trauma.
in developing a treatment plan. Systemic diseases, such as
Approximately 2.5% of the American population has occlusal
juvenile rheumatoid arthritis, diabetes, and scleroderma, may
discrepancies severe enough to require surgical correction.1
affect treatment planning. With jaw asymmetries, a history of
Regardless of the etiology, patient examination and treatment
hyperplasia or hypoplasia secondary to a syndrome, traumatic
planning principles are the same. The goal of orthognathic
accident, or neoplasm will affect treatment considerations.
surgery is to establish ideal dental occlusion with the jaws in a
Each patient should be questioned regarding symptoms of
position that optimizes facial aesthetics.
temporomandibular joint (TMJ) disease or myofascial pain.
Motivation and realistic expectations are extremely important
Basic Dental Terminology to ensure an optimal outcome. It is important for the patient
to have a clear understanding of the procedure, the recovery,
Apertognathia—Vertical separation of the maxillary and
and the anticipated result prior to surgery. Orthognathic sur-
mandibular anterior teeth, frequently described as ante-
gery is a major undertaking, frequently lasting 2 to 3 years,
rior open bite.
and the patient must be appropriately motivated to undergo
Articulator—A mechanical device that simulates the tem-
all necessary perioperative orthodontic treatment and reha-
poromandibular joints and jaws to which the maxillary
bilitation to achieve the desired result. When it comes to jaw
and mandibular casts may be attached.
surgery, the patient is a particularly important member of the
Buccal—Pertaining to or adjacent to the cheek.
orthognathic surgery team.
Cast—A plaster replica of the teeth and surrounding
tissues.
Centric occlusion—The relation of opposing occlusal sur- Physical Examination
faces that provides the maximum planned contact or Good oral hygiene and periodontal health is necessary prior to
intercuspation. orthodontics and surgery. The occlusal classification is deter-
Centric relation—The relationship of the mandible to the mined, and the degree of incisor overlap and overjet is quanti-
maxilla when the condyles are in their most posterosu- fied. Often, the clinician can get a sense of the degree of dental
perior unstrained positions in the glenoid fossa. compensation (see below) on physical examination, but radio-
Cephalometric radiograph—A radiograph of the head graphic analysis is necessary to quantify dental compensation.
made with precise reproducible relationships between The surgeon should assess the transverse dimension of the
X-ray source, subject, and film. maxilla. If a crossbite is present, models are obtained to dif-
Class I occlusion—The mesiobuccal cusp of the first per- ferentiate a relative crossbite from a true crossbite. An abso-
manent maxillary molar occludes in the buccal groove lute crossbite is due to maxillary constriction and will require
of the permanent mandibular first molar. either orthopedic (orthodontic appliance) or surgical expan-
Class II malocclusion—The mesiobuccal cusp of the first sion to correct (see below). If the mandibular third molars are
permanent maxillary molar occludes mesial to the buc- present, they will require extraction 6 months before perform-
cal groove of the permanent mandibular first molar. ing a sagittal split osteotomy. Any missing teeth and periapical
Class III malocclusion—The mesiobuccal cusp of the first pathology are noted. Any signs or symptoms of TMJ dysfunc-
permanent maxillary molar occludes distal to the buccal tion are evaluated before proceeding with surgery.
groove of the permanent mandibular first molar. The frontal facial evaluation consists of assessing the verti-
Distal—Away from the median sagittal plane of the face cal facial thirds: trichion to glabella, glabella to subnasale,
and following the curvature of the arch and subnasale to menton. Each of these facial thirds should
Labial—Pertaining to the lip, especially in reference to the be about equal. If the lower two-thirds of the face are short,
surface of a tooth. they can be increased by inferiorly repositioning the maxilla,
Lingual—Pertaining to the tongue, especially in reference which will result in increasing the distance from the glabella
to the surface of a tooth. to pogonion. In contrast, a long lower face may benefit from
Mesial—Situated toward the midline of the dental arch. a maxillary impaction, which would have the opposite effect.
Overjet—Degree to which the upper incisors extend beyond The most important factor in determining the ideal vertical
the lower incisors labially. Normal overjet is 2 mm. height of the maxilla is the amount of incisor showing while
Overlap—The amount maxillary incisal edges vertically the patient’s lips are in repose. A man should show at least
overlap the mandibular incisor edges with the mouth 2 to 3 mm while as much as 4 to 5 mm is considered attractive
closed. Normal incisal overlap is 2 mm. in a woman. If the patient shows the correct degree of incisor
Palatal—Pertaining to the palate, especially in reference to in repose but shows excessive gingiva in full smile, the max-
the surface of a tooth. illa must not be impacted. It is more important to show the
Proclination—Anterior angulation of the anterior teeth. correct degree of incisor in repose than it is to be concerned
Prognathic—A forward position of the mandible in rela- about excess gingiva in full smile. The surgeon certainly
tion to the cranial base. would not want to bury the incisors in repose just to reduce
252
Chapter 25: Orthognathic Surgery 253
the degree of gingiva in a full smile. If lip incompetence or incisors will retrocline while the lower incisors will procline.
mentalis strain is present, it is usually an indicator of vertical The opposite will occur in a patient who has dental compen-
maxillary excess. sation for an underbite (class III malocclusion). Thus, dental
The sagittal facial fifths are also evaluated. The inter- compensation will mask the true degree of skeletal discrep-
canthal distance should be about the same as the distance ancy. Precise analysis of the dental compensation is done on
between the medial and lateral canthus of each eye. If the the lateral cephalometric radiograph.
lateral fifths are deficient, augmentation can be performed If the patient desires surgical correction of the defor-
with bone grafts or implants. The inferior orbital rims, mity, presurgical orthodontics will decompensate the occlu-
malar eminence, and piriform areas are evaluated for the sion, thereby reversing the compensation that has occurred.
degree of projection. If these regions appear deficient, maxil- Decompensation has the effect of exaggerating the malocclu-
lary advancement is indicated; if they are excessively promi- sion but allows the surgeon to maximize skeletal movements.
nent, the maxilla may benefit from posterior repositioning. If the patient is ambivalent or not interested in surgery, mild
The alar base width should also be assessed prior to surgery cases of malocclusion may be treated by further dental com-
since orthognathic surgery may alter the width (Chapter 48). pensation. Compensation will camouflage the deformity and
Asymmetries of the maxilla and mandible should be docu- restore proper overjet and overlap. The dental movements

mented on physical examination, and the degree of deviation for decompensation and compensation are in opposite direc-

from the facial midline noted. The soft tissue envelope of the tions, making a decision regarding surgery and communica-
upper face is evaluated for descent of the malar fat pads, the tion between surgeon, orthodontist, and patient extremely
severity of the nasolabial creases, and folds. Skeletal move- important.3
ments of the maxilla will affect these areas. It is important
for the surgeon to realize that skeletal expansion (anterior or
inferior repositioning of the jaws) will attenuate the creases Cephalometric Analysis and Dental Models
and folds, while skeletal contraction (posterior or superior A lateral cephalometric radiograph is performed under repro-
movements of the jaws) will accentuate these problems. 2 ducible conditions so that serial images can be compared. This
The surgeon certainly does not want to give the patient a film is usually taken in the orthodontist’s office utilizing a
prematurely aged appearance as a result of the procedure. cephalostat, an apparatus specifically designed for this pur-
However, as will be discussed later, the surgeon can take pose, and head frame to maintain consistent head position. It
advantage of skeletal expansion to reduce some of these soft is important to be certain that the surgeon can visualize bony
tissue creases giving the patient a youthful appearance and as well as soft tissue features on the image to facilitate trac-
reducing the signs of aging. In evaluating the chin, the clini- ing all the landmarks. A piece of transparent acetate tracing
cian assesses the labiomental angle (Chapter 51). An acute paper is secured with tape over the radiograph and the follow-
angle indicates a short or prominent chin, while effacement ing landmarks are traced: sella, inferior orbital rim, nasion,
of the crease suggests excessive vertical length or insufficient frontal bone, nasal bones, maxilla, maxillary first molar and
anterior projection. central incisor, external auditory meatus, the condylar head
The profile evaluation focuses on the projection of the fore- and mandible, and the mandibular first molar and incisor.
head, the malar region, the upper and lower jaws, the nose, The soft tissue of the forehead, nose, lips, and chin is also
the chin, and the neck. The assessment can be verified through traced. Once the normal structures are traced, several planes
cephalometric analysis, but an experienced clinician can usu- and angles are determined (Figure 25.1).
ally determine whether the deformity is due to the maxilla, The maxillary plane is represented by a line drawn between
mandible, or both. Frequently, the optimal aesthetic result is the anterior nasal spine (ANS) and posterior nasal spine (PNS).
achieved by ignoring the cephalometric norms and treatment The occlusal plane is drawn between the occlusal surfaces of
planning the jaw movements based on the patient’s facial the teeth. The mandibular plane is drawn between menton
form as determined by the surgeon’s physical examination. If and gonion, and the Frankfort horizontal plane is delineated
the jaws appear to be aligned but the chin projection is either between the superior portion of the external auditory meatus
pronounced or deficient, a genioplasty may be all that is nec- (porion) and the inferior orbital rim (orbitale). Analysis of
essary (Chapter 51). The proper position of the nose relates these planes aids in establishing an accurate diagnosis. A steep
to the upper lip, which is supported by the maxillary incisors, mandibular plane is usually associated with a class II maloc-
and the chin. Because both of these structures may be altered clusion, anterior open bite, and a short mandible. A shallow
by orthognathic surgery, it is important to predict how the mandibular plane is associated with a deep bite, class III mal-
dimensions of the nose will fit into the new facial proportions occlusion, and a long mandible.
(Chapter 48). A rhinoplasty may be necessary to maintain The SNA and SNB are the two most important angles in
proper facial proportions. The soft tissues of the neck should determining the positions of the maxilla and mandible rela-
also be assessed. The patient with submental laxity will not tive to each other as well as to the cranial base. These angles
benefit aesthetically from posterior positioning of the mandi- are determined by drawing lines from sella to nasion to point
ble. Mandibular advancement, however, will improve the lax- A or point B, respectively. By forming an angle with the sella
ity and the cervicomental angle. In a patient with prominent and nasion, this position is related to the cranial base. The
submental fat in whom mandibular advancement is contrain- maxilla will be considered first. Point “A” represents the
dicated, suction-assisted lipectomy is helpful in removing the anteroposterior position of the maxilla. If the SNA angle is
adipose deposits (Chapter 65). Redundant skin will require excessive, the maxilla exhibits abnormal anterior position
direct excision. relative to the cranium. If SNA is less than normal, the max-
The maxillary and mandibular dental midlines are assessed illa is posteriorly positioned relative to the cranial base. The
to determine if they are congruent with each other and the same principle applies to the mandible; the only difference is
true facial midline. Any deviations are noted and quantified. that point “B” is used to relate mandibular position to the
The presence of mandibular third molars is noted because if cranial base. The importance of the cranial base as a reference
a sagittal split osteotomy is planned, it is recommended that is that it allows the clinician to determine if one or both jaws
they be removed 6 months before surgery so the screw fixa- contribute to the deformity. For example, a patient’s class III
tion has adequate bone. The presence and degree of dental malocclusion (underbite) could develop from several differ-
compensation is also recorded. The term “dental compensa- ent etiologies: a retrognathic maxilla and normal mandible,
tion” is used to describe the tendency of teeth to tilt in a direc- a normal maxilla and a prognathic mandible, a retrogna-
tion that minimizes the dental malocclusion. For example, in thic mandible and a more severely retrognathic maxilla, or a
a patient with an overbite (class II malocclusion), the upper prognathic maxilla and a more severely prognathic mandible.

surrounding the facial skeleton is the most crucial factor in

determining the aesthetic success of orthognathic procedures,
and the jaws should be positioned so that they provide opti-
mal soft tissue support.
Historically, skeletal movements that expanded the soft
tissue of the face were less stable, so posterior and superior
movements were preferred. Although more stable, these
movements resulted in contraction of the facial skeleton with
the associated redundancy of soft tissue characteristic of pre-
mature aging. Since the introduction of rigid fixation, oste-
otomies that result in skeletal expansion have been achieved
with predictability. It is important that the surgeon develop a
treatment plan that will expand or maintain the preoperative
volume of the face.2 If a superior or posterior (contraction)
movement of one of the jaws is planned, an attempt should be
made to neutralize the skeletal contraction with an advance-
ment or inferior movement of the other jaw or the chin. It is
important to avoid a net contraction of the facial skeleton as
Figure 25.1. Standard lateral cephalometric tracing with land-
this may result in a prematurely aged appearance.
marks. S, sella—the center of the pituitary fossa; N, nasion—the most As skeletal expansion is increased, soft tissue laxity is
anterior point of the nasofrontal suture in the midsagittal plane; Ar, reduced and facial creases are softened. These effects increase
articulare—the intersection of basisphenoid and the posterior border the definition of the face, creating a more attractive appear-
of the condyle; A, subspinale—the deepest point of the anterior bor- ance. It has been shown that skeletal expansion is aesthetically
der of the maxilla between the anterior nasal spine and prosthion, pleasing even if facial disproportion is necessary to achieve
usually around the level of the apex of the maxillary central incisor; the expansion.4 Fashion models often exhibit slight degrees of
Pog, pogonion—the most anterior point of the contour of the chin; facial disproportion and are considered beautiful. The aesthetic
B, supramentale—the deepest point between infradentale and pogo- benefits the patient receives by expanding the facial envelope
nion at the level of apices of the mandibular incisors; ANS, anterior
nasal spine—the most anterior point of the nasal floor; Me, menton—
frequently justify the small degree of disproportion necessary
the lowest point of the contour of the mandibular symphysis; GN, to achieve them. Even in young adolescent patients that do not
gnathion—the midpoint between Pog and ME created by bisecting show signs of aging, one must not ignore these principles. A
the facial line (N-Pog) and the mandibular plane (Go-Me); PNS, successful surgeon will incorporate these principles into the
posterior nasal spine—the most posterior point on the contour of treatment plan of every patient so that as the patient ages, the
the hard palate; MP, mandibular plane—a plane constructed from signs of aging will be minimized and a youthful appearance
menton (Me) and gonion (Go); NF, nasal floor—a plane constructed will be maintained as long as possible (Figure 25.2).
from PNS to ANS; Go, gonion—located by bisecting the posterior An example demonstrating these principles is an adult
ramal plane and the mandibular plane angles: It is the midpoint of woman who presents for surgery with a slightly prognathic
the curvature connecting the ramus and the mandibular body. (From
Wolfe AA, Berkowitz S. Plastic Surgery of the Facial Skeleton. Boston,
mandible, submental laxity, jowl descent, and deep nasola-
MA: Little, Brown and Co.; 1989:57, with permission.) bial creases. If a treatment plan were developed based solely
on cephalometric values, a mandibular setback would be the
appropriate procedure. This procedure would do nothing for
the upper face and would accentuate the submental laxity
All of these conditions yield a class III malocclusion, yet each and jowl descent. In contrast, if one were to accept the slight
requires a different treatment approach. The surgeon can prognathism and advance the maxilla to a class I relationship,
delineate the true etiology of the deformity by relating the the nasolabial crease and jowl descent would be improved,
maxilla and mandible independently to a stable reference and the submental laxity would not be made worse. Thus,
point, the cranial base. moving the normal maxilla into a class I occlusion with a
Plaster dental casts are obtained during the treatment plan- prognathic mandible establishes a normal occlusion and
ning process. Casts are useful because they allow the surgeon achieves excellent aesthetics despite being slightly dispropor-
to evaluate the occlusion when the casts are articulated into tionate (Figure 25.3).
the proper position. Analysis of the new occlusion gives the A class I occlusion can be achieved with the jaws in a vari-
clinician an idea of how intensive the presurgical orthodon- ety of different positions. The goal in treatment planning is
tic treatment plan will be. Casts also allow the clinician to to use the data from the patient’s examination to predict the
distinguish between absolute and relative transverse maxillary location of the jaws that will optimize the soft tissue features
deficiencies. Absolute transverse maxillary deficiency presents of the face. Reducing the emphasis on normal values and
as a posterior crossbite with the jaws in a class I relationship. increasing the awareness of the soft tissue effects of skeletal
A relative maxillary transverse deficiency is commonly seen movements, a skeletal “disproportion” may be chosen inten-
in a patient with a class III malocclusion. As the maxilla is tionally, leading to a more favorable result. However, it is the
advanced or the mandible retruded, the crossbite is elimi- discretion of the surgeon to incorporate these principles into a
nated. Articulation of the casts into a class I occlusion allows treatment plan pleasing to the patient and understood by the
the surgeon to easily distinguish between relative and absolute patient.4
maxillary constriction.
Basic Approaches To
Developing A Treatment Plan Commonly Encountered
Once the data are obtained, the surgeon can determine which
abnormalities the patient exhibits and the extent to which
Problems
these features deviate from the norm. However, the treat- The basic treatment principles in commonly encountered den-
ment plan is the application of this data to give the patient the tofacial deformities will be presented. The surgeon must rec-
best aesthetic result while establishing a class I occlusion. The ognize there are multiple solutions to a single problem; this is
goal is not to “treat the numbers” in an attempt to “normal- where the proper application of the previously discussed prin-
ize” every patient. The appearance of the soft tissue envelope ciples is crucial to achieving the best aesthetic result.


A B D
C E
Figure 25.2. Sagittal split osteotomy and alloplastic mid-

face augmentation. This patient exhibited a left unilateral
crossbite, a prominent chin, and malar deficiency (she is miss-
ing a central incisor). She did not desire two-jaw surgery and
her malocclusion was treated with bilateral sagittal split oste-
otomy. Her midface deficiency was corrected with prosthetic
malar and piriform augmentation. A. Frontal examination
preoperation. B. Profile preoperation. C. Occlusion preopera-
tion. D. Frontal postoperation. Note the attenuated nasolabial
creases from malar implants. E. Profile postoperation. Noted
improved malar projection achieved and alloplastic augmenta-
tion. F. Postoperation occlusion.
F

A B C
D E F
Figure 25.3. Ignoring cephalometric norms and expanding soft tissue. This is a patient whose cephalometric analysis demonstrated a normal
SNA and a high SNB (A–C). Correcting to cephalometric norms would indicate a mandibular setback procedure. In order to optimize the facial
soft tissue envelope while restoring a class I occlusion, a decision was made to perform a Le Fort I maxillary advancement. Additionally, her
incisal show was deficient so the maxilla was moved inferiorly to restore normal incisal show. The inferior positioning of the maxilla resulted in
a clockwise rotation of the mandible reducing the patient’s chin projection as well (D–F).
different treatments to achieve aesthetic goals. If some poste-

Skeletal Class II Occlusion rior positioning of the mandible is necessary, one may advance
A skeletal class II malocclusion is almost always due to man- the maxilla to counteract the skeletal contraction produced
dibular retrognathia and is almost always best treated by man- from the mandible. Additionally, the patient may benefit from
dibular advancement (Figure 25.4). The mandible is small, and a genioplasty that can counteract any skeletal contraction that
forward positioning is an expansile movement that enhances occurs from a mandibular setback. As in the class II patient,
the facial form. If the maxilla is also slightly deficient or in a a minor malocclusion with minimal dental compensation may
normal position, one may consider a bimaxillary advancement be corrected with orthodontic treatment alone. In contrast, a
to further enhance facial soft tissue definition. If the malocclu- minor malocclusion with dental compensation may become a
sion is minimal and there is little pre-existing dental compen- significant malocclusion after dental decompensation, making
sation, one may choose to have the orthodontist intentionally the patient a good surgical candidate.
compensate the dentition to correct the occlusion and avoid
surgery. In contrast, if the malocclusion appears minimal but Maxillary Constriction
there is dental compensation, from previous orthodontic treat-
Many patients can exhibit a maxilla that is narrow. Maxillary
ment, the skeletal discrepancy will be more significant after
constriction may occur as an isolated finding or as one of
the orthodontist decompensates the dentition, allowing surgi-
multiple abnormalities. Up to about 15 years of age, the
cal correction.
orthodontist can expand the maxilla nonsurgically with a
palatal expander. If orthopedic expansion cannot be done,
Skeletal Class III Malocclusion a surgically assisted rapid palatal expansion (SARPE) can be
A prominent lower jaw may be treated by advancing the max- performed.5 If the maxilla requires movement in other dimen-
illa, posteriorly positioning the mandible, or by combining sions, a two-piece Le Fort I osteotomy can be performed to
these procedures. It is important to consider the contributions widen the maxilla and simultaneously move the maxilla in the
of the mandible and the chin separately as each may require desired direction (Figure 25.5).

A B

C
Figure 25.4. Technique for sagittal split osteotomy. The sagittal

splitting procedure is the most versatile ramus osteotomy, as it can be
used for both mandibular advancement (A) and mandibular setback
(B). The procedure is performed through an intraoral approach and D
requires special instrumentation to be performed with ease. Three or
four screws are placed percutaneously to effect rigid fixation. It is vital
that the mandibular condyles be properly seated at the end of any
mandibular osteotomy. If they are not, when intermaxillary fixation is
removed they go back into the glenoid fossae with a resultant anterior
open bite.
E D
Apertognathia Figure 25.5. Versatility of the Le Fort I osteotomy. The Le Fort I
An anterior open bite is caused by a premature contact osteotomy sections the maxilla transversely at a level between the
of the posterior molars. The recommended treatment is a roots of the teeth (note that the root of the cuspid may extend as
posterior impaction of the maxilla with or without coun- high as the piriform rim) and the infraorbital foramen. After the lower
portion of the maxilla is mobilized, movement in a number of direc-
terclockwise rotation of the occlusal plane. (By convention,
tions is possible. A. Lengthening of the maxilla with an interpositional
clockwise and counterclockwise movements are defined by bone graft (note the use of miniplates for fixation). B. Shortening
the direction the jaw on jaws move when viewed from the of the maxilla after resection of bone above the osteotomy line.
right lateral view.) By reducing the vertical height of the C. Advancement of the maxilla. D. Segmentalization of the maxilla
posterior maxilla, the mandible can come into occlusion after downfracture and extraction of teeth. E. Setback of maxilla.
with the remaining mandibular teeth. Posterior maxillary
impaction does not necessarily result in incisor impaction;
the posterior maxilla is simply rotated upward using the
incisal tip as the axis of rotation. Therefore, incisor show
should not be affected. If a change in incisor show is also Short Lower Face
desired, the posterior impaction is done and then the whole A short lower face is marked by insufficient incisor show and/or
maxilla can be inferiorly positioned or impacted to its new a short distance between subnasale and pogonion. Treatment
position (Figure 25.6). is aimed at establishing a proper degree of incisor show. The
facial skeleton should be expanded to the degree that provides
Vertical Maxillary Excess optimal soft tissue aesthetics. As the maxilla is inferiorly posi-
tioned, clockwise mandibular rotation will occur, leading to
Vertical maxillary excess is typically associated with lip incom-
posterior positioning of the chin. The surgeon needs to assess
petence, mentalis strain (chin dimpling), and an excessive
the new chin position on the cephalometric tracing to deter-
degree of gingival show. This condition is also known as long
mine if an advancement genioplasty is now necessary to coun-
face syndrome. The treatment approach is to impact the max-
ter the effects of mandibular clockwise rotation.
illa to achieve the proper incisal show with the lips in repose.
Impaction results in skeletal contraction, so the surgeon must
consider if anterior positioning of the jaws could be tolerated Facial Asymmetry
to neutralize the associated adverse soft tissue effects. As the Facial asymmetry may occur from asymmetric growth of
maxilla is impacted, the mandible rotates counterclockwise to the mandible due to hemifacial microsomia (Chapter 24),
maintain occlusion. This rotation results in anterior positioning pediatric trauma, radiation, neoplasms, or other etiologies.
of the chin and is called mandibular autorotation (Figures 25.3 Correcting facial asymmetry typically requires a maxillary
and 25.7). The opposite occurs if the maxilla is moved in an osteotomy to level the occlusal plane of the maxilla and center
inferior direction. In this case, the chin point rotates in a clock- the maxillary dental midline so that it is congruent with the
wise direction, which results in posterior positioning of the chin facial midline. A mandibular osteotomy is then performed to
point. It is important to note these effects on the cephalometric bring the mandibular dentition into a class I occlusion with
tracing during treatment planning because a genioplasty may the maxillary dentition. The chin is assessed to determine if
be required to reestablish proper chin position. it will be in the midline after the mandibular osteotomy. If
A B
Figure 25.6. Cephalometric tracing. A. This patient exhibits an

anterior open bite, but has good incisal show on repose. The normal
landmarks on the cephalogram are recorded. B. The maxilla is then
traced and is put into ideal position. Because incisal show is good,
the anterior maxilla is not lowered and the occlusion is achieved with
a posterior impaction. C. The mandible is then rotated into its new
position using another piece of acetate that includes the mandible.
The condyle is the center of rotation when moving the mandible.
Because the mandible cannot be advanced without creating a maloc-
clusion, the chin is moved forward to advance pogonion.
C
the chin is asymmetric or deficient, a genioplasty is performed tissue profile. They also allow the surgeon to determine the
to move it into a normal position based on the new maxil- distances the bones will be moved. Different tracing methods
lomandibular relationship. Occasionally, a mandibular angle are used for isolated maxillary, isolated mandibular, or two-
bone graft and/or autologous fat grafting may be necessary to jaw surgeries. All cephalometric tracings begin by securing
optimize skeletal and soft tissue facial symmetry (Figure 25.8) a clear piece of acetate tracing paper over the cephalometric
radiograph. The anatomy and aforementioned cephalometric
points are then marked on the tracing paper (Figure 25.6A).
Preparing For Surgery
Mandibular Surgery. When isolated mandibular surgery
Pre-Op Cephalometric Tracing is indicated, a second piece of acetate is used to trace only the
Cephalometric tracings give the surgeon an idea of how skel- mandible and the soft tissue of the chin and lower lip. This
etal movements will affect one another as well as the soft second tracing of only the mandible is then placed into the

desired occlusion against the maxilla on the first tracing. The
differences in distance between the point B and the first molar
cusps when comparing the new and original positions of the
mandible denote the distance that the mandible will be anteri-
orly or posteriorly positioned. The new soft tissue profile can
also be estimated from the tracing.
Maxillary Surgery. In isolated maxillary surgery, a second

piece of acetate with only the maxilla, first molar, upper inci-
sors, and lip is placed into the desired position. The incisal edges
of the incisors should be placed at least 3 to 4 mm below the
lower margin of the upper lip. The anterior positioning of the
maxilla will be determined by placing the maxillary teeth against
the mandibular teeth in a class I occlusion (Figure 25.6B).
An anterior open bite will require posterior maxillary

impaction until the mandibular teeth contact the maxillary

teeth in normal occlusion. The appropriate degree of poste-
rior maxillary impaction is verified by using a tracing of the
mandible and rotating it counterclockwise with the condyle
remaining in the original position (Figure 25.6C). The proper
position of the maxilla is determined by establishing a class I
occlusion with the incisal edges 3 to 4 mm below the upper
Figure 25.7. Autorotation of mandible. A counterclockwise mandibu- lip. The movement required in each portion of the maxilla can
lar rotation will produce an increase in the anterior position of the chin. be determined by measuring the distance between landmarks
Clockwise rotation will posteriorly position the chin. The final anticipated of the new maxillary position and the original position. Useful
projection of the chin needs to be cephalometrically assessed to determine landmarks for the maxilla are the incisal edge, the mesial cusp
if it will require surgery to move it into a more aesthetic position. of the first molar, ANS, and PNS. The anteroposterior posi-
tion of the maxilla will be determined by soft tissue aesthetics
A B C
D E F
Figure 25.8. Facial asymmetry after subcondylar fracture as a child. Preoperative images demonstrate facial asymmetry (A), microgenia
(B), and an occlusal cant (C). To restore facial symmetry, the patient had a leveling Le Fort I osteotomy, bilateral sagittal split osteotomy, center-
ing and advancement genioplasty, left mandibular angle bone graft, and autogenous fat grafting to the left cheek (D–F). These procedures restore
facial symmetry and correct the occlusal cant.
and the occlusion. If soft tissue aesthetics require moving the

maxilla into a position that precludes a class I occlusion, the
mandible will have to be moved with the maxilla.
Two-Jaw Surgery. In two-jaw surgery, the maxilla is posi-

tioned on the cephalometric radiograph as above, and then
the new position of the mandible is placed using separate
pieces of acetate overlying the original cephalometric tracing.
By measuring the difference between the new landmarks and
the original landmarks, the surgeon determines the distance
he/she is moving the maxilla and/or mandible in each dimen-
sion.6 Predictive computer imaging may be useful at this point.
The patient should be informed that the computer-generated
image is not a guaranteed result, only a guide to the surgeon’s
goals. It is useful to make sure the patient and the surgeon are
in agreement about the goals prior to surgery. The next step is
to simulate these movements on plaster casts of the jaws.
Traditional Model Surgery

Model surgery starts by obtaining accurate casts of the patient’s
occlusion. If the surgeon does not have a dental laboratory,
the orthodontist is usually helpful in obtaining the casts. It is
important to obtain accurate casts as the success of the techni-
cal portion of orthognathic surgery correlates directly to the
accuracy of the model surgery and splint fabrication.
Isolated Mandibular Surgery. It should be noted that

if isolated mandibular surgery is being performed, the casts
can be hand articulated into the desired occlusion. The Galetti
articulator is a useful tool that allows securing of the casts
with a screw mount. A universal joint allows the casts to be set
to the desired relationship. Surgical splints can then be made
from the articulator. If the maximum intercuspal position is
the desired postoperative occlusion, a splint is not necessary.
The surgeon can osteotomize the mandible and secure it into
its new position using the maximum intercuspal position as
the guide to the new position. The surgeon should always ver-
ify the desired postoperative occlusion with the orthodontist Figure 25.9. Articulated dental casts. A semiadjustable articulator
with mounted casts enables assessment of occlusal cants, malocclu-
prior to surgery. sion, and skeletal relationships.
Isolated Maxillary and Two-Jaw Surgery. A face bow
is a device that is used to accurately relate the maxillary model
to the cranium on an articulator. If a maxillary osteotomy is maxilla is in its new position, the cast is secured with sticky
being performed, one set of models should be mounted on an wax or plaster to the mounting ring (Figure 25.11). Now it
articulator using the face bow (Figure 25.9). Two other sets can be placed on the articulator. At this point, the surgeon has
of models are used in treatment planning. Next, an Erickson a mounting of the postoperative maxilla related to the pre-
model block is used to measure the current position of the operative position of the mandible. An acrylic splint is made
maxillary central incisors, cuspids, and the mesiobuccal cusp at this point. This splint is called the intermediate splint and
of the first molar.7 The face bow–mounted maxillary cast is will be used in the operating room to index the new position
placed on the model block. The maxillary model is then mea- of the maxilla to the preoperative position of the mandible. A
sured to the tenth of a millimeter vertically, anteroposteriorly, second mounting with the casts in the occlusion desired by the
and end-on (Figure 25.10). By having numerical records in orthodontist is used to make a final splint that will represent
three dimensions, the surgeon can reproduce the maxillary the new position of the mandible to the maxilla. This is fabri-
cast’s exact location as well as determine a new location. cated in a manner similar to the splint for isolated mandibular
Reference lines are circumferentially inscribed every 5 mm surgery (Figure 25.12). If the occlusion is good, intercuspal
around the maxillary cast mounting. The distances the max- position can be used to position the mandible without a splint.
illa will move in an anteroposterior, lateral, and vertical direc-
tion have been determined from the previous cephalometric Computer-Assisted Surgical
examination and the resulting proposed changes in the maxil-
lary position. These numbers are added or subtracted from the
Simulation
current values in the x-, y-, and z-axes measured on the model Recent advances in 3D computer-aided topography as well
block to determine the new three-dimensional (3D) position as computer-aided design/manufacturing (CAD/CAM) have
of the maxillary cast. The occlusal portion of the maxillary led to an emergence of several computer-assisted surgical
cast is removed from its base using a saw. As much plaster simulation (CASS) software programs with a wide range of
is removed from the cast as is necessary to accommodate the applications. Recently, CASS technology has been adapted for
new position of the maxilla. Soft wax is inserted in the gap orthognathic surgery to assist in cephalometric analysis, vir-
between the base of the cast and the occlusal portion. The wax tual model surgery, and splint fabrication.
allows slight manipulations of the occlusal portion of the cast CASS incorporates 3D computed tomography (CT) imag-
while providing some stability. The tooth cusps are measured ing and virtual surgery with CAD/CAM splint fabrication
in three dimensions until they match the desired postoperative for patients undergoing orthognathic surgery. The patients
position of the maxilla. Once the model block verifies that the have their treatment plan developed by clinical examination

surgical splints. The splints, as well as 3D treatment planning
images, are mailed to the surgeon overnight.8
Overview of Pre-Op Treatment

The patient has multiple visits at the surgeon’s office and
has undergone a thorough discussion of the surgical options.
Good oral health has been achieved. Any TMJ problems
have been addressed and appropriate clearance has been
obtained. The patient has had preoperative orthodontics to
level, align, and decompensate the occlusion. Based on the
physical and radiographic examinations, a treatment plan
has been developed that will achieve a class I occlusion and
optimize the facial soft tissue aesthetics. The preoperative
examination will determine the distances the jaws will have

to move to achieve the desired result, and model surgery or

CASS has been performed to develop surgical splints that will
intraoperatively position the jaws into the position deter-
mined by the cephalometric tracing. If a segmental osteot-
omy is planned, the orthodontist will have diverged the root
apices on either side of the proposed osteotomy to minimize
the chance of damage to tooth roots. The surgeon verifies
that the splints fit and that good surgical lugs have been
applied to the arch wire. Soldered lugs work the best. If the
lugs break in surgery, the proper application of the splint can
be compromised, making an ideal result much more difficult
to obtain. In two-jaw surgery, autodonation of packed red
blood cells is useful.
Surgical Procedures
Pertinent Anatomy
Figure 25.10. Erickson model block. The preoperative maxillary
position is recorded in three dimensions shown with the Erickson The important structures in the mandible that may be injured
model block. The landmarks are the incisal edge, the canine cusp, and in the mandibular osteotomy are the inferior alveolar nerve,
the mesiobuccal first molar cusp. The movements in an anteroposte- its terminal branch called the mental nerve, and the teeth api-
rior, transverse, and vertical direction were determined by the physical ces. The third division of the trigeminal nerve enters the man-
and radiographic examinations. These measurements are added to or dibular foramen to become the inferior alveolar nerve. It runs
subtracted from the preoperative measurements. within the mandible below the tooth roots and exits at the
level of the first to the second premolar through the mental
foramen to become the mental nerve. The nerve is most medial
to the outer cortex in the region of external oblique ridge. This
and evaluation of dental casts received from the orthodontist.
is where the vertical portion of the sagittal split osteotomy is
After the plan is established, the patient has a bite registra-
made because it affords the largest margin of error.
tion performed that is attached to a bite jig with radiopaque
The maxilla is associated with the descending palatine
markers. Before the CT is performed, natural head position is
artery, the infraorbital nerve, the tooth roots, and the inter-
recorded by entering Euler angles that record the pitch, yaw,
nal maxillary artery. The internal maxillary artery runs about
and roll, and thus, give a reference for natural head position
25 mm above the pterygomaxillary junction, and the descend-
once the 3D CT has been obtained. The CT scan and a set of
ing palatal artery descends in the posteromedial maxillary
dental casts marked with the desired occlusal relationship are
sinus. The infraorbital nerve exits the infraorbital foramen
then sent to the CASS company (Figure 25.13).
below the infraorbital rim along the midpupillary line. The
Once the materials have been received, the surgeon com-
maxillary tooth roots extend within the maxilla in a superior
municates with the CASS company by phone, and both parties
direction. The canine has the longest root and is usually visible
access the 3D CT scan using gotomeeting.com. The surgeon
through the maxillary cortical bone.
discusses the planned osteotomies with the consultant and
can visualize the skeletal movements on the computer while
the consultant moves the jaws into their desired position. General Principles
Once the surgeon has confirmed the planned osteotomies, the Several principles have broad application to jaw surgery. Blood
new data can be used to fabricate the intermediate and final loss can be substantial in maxillofacial surgery. Standard
Figure 25.11. Establishing the desired postsurgical maxillary position. The cast is divided with enough plaster removed to allow the desired
manipulation. The maxilla is moved into its new position and secured with sticky wax. This cast is then reattached to the articulator and the
intermediate splint is made. The final splint can be made on a Galetti articulator as shown in Figure 27.10.

A B
Figure 25.12. Galetti articulator. The articulator enables articulation of models for mandibular surgery. A. This photograph demonstrates the
preoperative occlusion. B. This photograph shows the desired occlusion by the orthodontist. The anterior occlusion has no open bite and the mid-
lines are congruent. The posterior open bite is easily closed with postoperative orthodontics; in this case, a splint was used to preserve the posterior
open bite intra- and postoperatively. The splint minimizes the risk of the posterior bite closing, which would compromise the anterior occlusion.
A B
ANS right ANS left

A right A left
U6R U6L
C
Figure 25.13. Computer-assisted surgical simulation. This is a new L6R L6L
technique that obviates the need for traditional model surgery and
splint fabrication. A bite registration is taken (A) and then attached to
a gyroscope connected to a computer (B) that allows the computer to UK9R UK9L
record the head position in three dimensions (C). The CT scan and the ISU1
3D bite registration data are sent to the CASS company. The 3D CT
ISL1 B
data are then used to simulate the postoperative result and record the
anatomic landmarks of the new jaw position (D). The surgical plan is D
determined by the surgeon on a conference call with the CASS team.
Once the postoperative result is confirmed, the splints are fabricated
with CAD/CAM technology and mailed to the surgeon the next day.

techniques of head elevation, hypotensive anesthesia, blood just posterior to the last maxillary molar and drops through
donation, and administration of erythropoietin are useful the maxillary tuberosity. The cut should be made at least 5
adjuncts. Before the incisions are made, an antimicrobial rinse mm above the apices of the teeth. This distance is determined
is helpful to minimize the intraoral bacterial count. A topical from the panorex radiograph. If cuts are complete, the max-
steroid is applied to the lips to reduce pain and swelling asso- illa should be able to be downfractured with manual pressure.
ciated with prolonged retraction. Intravenous steroids may An alternative is to use the Rowe disimpaction forceps. These
also be useful to reduce postoperative edema. fit into the piriform aperture and on the palate to provide
The occlusion desired postoperatively may not be the same increased leverage for the downfracture. Pressure should be
as maximum intercuspal position. The splint is useful in main- applied in a slow, steady controlled fashion, not in a series of
taining the occlusion in the desired location when it does not quick random movements. If the maxilla is not mobilized with
correspond to the maximal intercuspal position. It is easy relative ease, the cuts are likely not complete and should be
for the orthodontist to close a posterior open bite, but it is reevaluated. Once the downfracture is complete, a bone hook
very difficult to close an anterior open bite with orthodontics can be used by the assistant to hold maxilla down while any
alone. At the end of the case, it is important to have the ante- remaining bony interferences are removed. The descending
rior teeth and the canines in a class I relationship without an palatine arteries will be seen near the posteromedial maxillary

open bite. sinus. These can be clipped prophylactically without compro-

After surgery, it is useful to use guiding elastics to control mising the blood supply to the maxilla. The splint is then used
the bite. Class II elastics are placed in a vector to correct a to place the maxilla in its proper position. Intermaxillary fixa-
class II relationship (maxillary lug is anterior to the mandib- tion is then applied with 26 gauge wires around the surgical
ular lug). Class III elastics are applied to correct a class III lugs. The amount the maxilla will be impacted or elongated
discrepancy. With rigid fixation, the elastics will not correct has been determined in the treatment plan. This distance
malpositioned jaws. They serve only to help the patient adapt is added or subtracted from the medial canthal–incisor dis-
to their new occlusion. Minor malocclusions can be corrected tance to determine the new vertical position of the maxilla.
with postoperative orthodontics or occlusal equilibration. Four 2 mm plates, usually L-shaped, can be used to secure the
Certain skeletal movements are inherently more stable than maxilla. The maxillomandibular fixation (MMF) is released
others. Stable movements include mandibular advancement and occlusion verified prior to closure. If the alar base is wide,
and superior positioning of the maxilla. Movements with an alar cinch can be performed to normalize the width. This
intermediate stability include maxillary impaction combined is performed by placing a suture around the transverse nasalis
with mandibular advancement, maxillary advancement com- muscle and setting the alar base to the desired width. Lip
bined with mandibular setback, and correction of mandibular shortening may also result from closure. A V-Y closure at the
asymmetry. The unstable movements include posterior posi- central incisor can help alleviate this effect.
tioning of the mandible and inferior positioning of the max- In patients that require increased cheek projection, a high
illa. The least stable movement is transverse expansion of the Le Fort I osteotomy can be performed. This differs in that
maxilla. Long-term relapse with rigid fixation has not been the transverse osteotomy is made as high as the infraorbital
demonstrated to be clearly superior to nonrigid fixation in nerve will allow. If further cheek projection is necessary, bone
single-jaw surgery. However, in two-jaw surgery, rigid fixa- grafts can be added. In the case of inferior or anterior posi-
tion results in less relapse.9 The judgment of the surgeon will tioning, gaps between the segments greater than 3 mm should
dictate the extent to which the facial skeleton can be expanded be grafted with either autogenous bone, cadaveric bone, or
without resulting in unacceptable relapse. block hydroxyapatite. Finally, if simultaneous expansion of
the maxilla is necessary, the maxilla can be split into two or
more pieces to allow simultaneous expansion (see Figures
Le Fort I Osteotomy 25.5 and 25.13).
The first step in any facial osteotomy is satisfactorily securing
the nasal endotracheal tube; the author’s preference is a nasal Surgically Assisted Rapid Palatal Expansion
RAE tube. The vertical position of the maxilla is recorded by
Correction of transverse maxillary constriction can be made
measuring the distance between the medial canthus and the
in adolescence with nonsurgical orthodontic appliances. As
incisal edge of the maxillary incisor. The maxillary vestibule
the sutures begin to close during late adolescence, relapse
is injected with epinephrine prior to patient preparation. An
increases. A multi-piece Le Fort osteotomy can be performed
incision is made with electrocautery 5 mm above the mucogin-
to provide simultaneous maxillary expansion, but the degree
gival junction from first molar to first molar. A periosteal ele-
of relapse is high. In the young adult, the preferred procedure
vator is then used to expose the maxilla around the piriform
is the SARPE. The orthodontist places a palatal expander
rim and infraorbital nerve. Rapid exposure of the maxilla is
prior to the procedure. A Le Fort I osteotomy is performed to
achieved by elevating in the “hot lanes” of facial dissection:
completely mobilize the maxilla from the upper face. A small
just lateral to the piriform aperture and along the zygomatic
osteotome is used to make a thin cut between the roots of the
buttress. These areas allow rapid subperiosteal elevation but
central incisors. The midline split is completed to the PNS.
avoid the infraorbital nerve. Once the “hot lanes” have been
Separation is verified by activating the device. The maxilla is
elevated, the nerve is easily identified and the remainder of the
widened until the gingiva blanches and is then relaxed sev-
maxilla can be safely exposed. Obwegeser toe-in retractors are
eral turns to avoid ischemia.5 The SARPE offers the best sta-
held by the assistant at the head of the operating table. The tis-
bility for maxillary expansion in the young adult and older
sue is released from the ANS. As the dissection extends later-
patient.10,11 Transverse deficiencies of the mandible can be cor-
ally, it is important to remain subperiosteal to avoid exposure
rected with a similar technique, which will be discussed in the
of the buccal fat pad. A Woodson elevator is used to initi-
chapter on distraction osteogenesis (Chapter 24).
ate reflection of the nasal mucosa, and a periosteal elevator is
used to complete the dissection of the nasal floor and lateral
nasal wall. A double-balled osteotome is used to separate the Bilateral Sagittal Split Osteotomy
septum from the maxilla and a uniballed osteotome is used to The endotracheal tube placement and epinephrine injection
release the lateral nasal wall. The surgeon can insert a finger are the same as for the Le Fort osteotomy. The cut is made
on the posterior palate to help feel when the cut is complete. with electrocautery about 1 cm from the lateral aspect of the
A periosteal elevator is used to protect the nasal mucosa and molars and extends from midramus to the region of the second
then a reciprocating saw is used to make a transverse osteot- molar. If insufficient tissue is left on the dental side of the inci-
omy from the piriform aperture laterally until the cut descends sion, closure is more difficult. A periosteal elevator is used to

expose the lateral mandible and the anterior coronoid process must be made posterior to the mandibular foramen. The anti-
in a subperiosteal plane. As the coronoid process is exposed, lingula is an elevation on the lateral mandible that serves as a
placement of a notched coronoid retractor may facilitate the landmark because it indicates the location of the mandibular
dissection. After the top of the coronoid process is exposed, a foramen. After both sides are complete, the distal segment is
curved Kocher with a chain can be snapped in place and the moved into occlusion making sure that the proximal segments
chain secured to the drapes. To optimize blood supply, sub- remain lateral to the distal segments posteriorly. Because
periosteal dissection is limited to those areas required to com- rigid fixation is difficult to apply, a single wire or no fixa-
plete the osteotomy. A J-stripper is used to release the inferior tion is used, and the patient remains in intermaxillary fixation
border of the mandible from the attachments of the pterygo- for 6 weeks. This osteotomy can be done from an extraoral
masseteric sling. The external oblique ridge and inferior bor- approach, but this incision results in a scar on the neck.
der of the mandible should be exposed. The medial aspect of
the ramus is also dissected subperiosteally. The mandibular Two-Jaw Surgery
nerve should be identified. A Seldin elevator is then inserted
Moving the maxilla and the mandible in one procedure
medial to the ramus and above the nerve. The superior edge
requires osteotomizing both jaws and precisely securing them
of the elevator is then rotated medially exposing the medial
into the position determined by the treatment plan. If proper
ramus and protecting the nerve. A reciprocating saw is used to
treatment planning, model surgery, and splint fabrication
make a cut on the medial ramus that is parallel to the occlusal
are performed, each jaw should be able to be placed into its
plane and extends through about two-thirds to the posterior
desired position with precision. The mandibular bony cuts are
ramus. The cut extends from medial to lateral until the saw
made first, but the actual splitting of the bones is not per-
is in the cancellous portion of the ramus, which is about half
formed. The maxillary osteotomy is made and the maxilla is
the width of the ramus. Mandibular body retractors are then
mobilized and placed into its new position using the interme-
placed and the osteotomy is continued from the midramus
diate splint. The splint is used to wire the teeth into tempo-
down along the external oblique ridge gently curving to the
rary intermaxillary fixation. The intermediate splint indexes
inferior border of the mandible. The cuts are verified with an
the new position of the maxilla to the preoperative position
osteotome, and then large osteotomes are inserted and rotated
of the mandible. With the condyles gently seated, the maxil-
to gently separate the segments. The tooth-bearing segment
lomandibular complex is rotated so that the maxillary inci-
is referred to as the distal segment and the condylar portion
sal edge is at the correct vertical height. The maxilla is plated
as the proximal segment. The inferior alveolar nerve should
into position, and the intermaxillary fixation is released. The
be identified and found in the distal segment. If part of the
mandibular osteotomies are completed and the distal segment
nerve is located within the proximal segment, it should gen-
of the mandible is placed into the desired ultimate occlusion
tly be released with a small curette or tapped out by placing
using the final splint. If the teeth are in good occlusion with-
an osteotome against the inner aspect of the cortical bone of
out the splint, the final splint may not be necessary to estab-
the proximal segment so that the nerve is released as a unit
lish the desired occlusal relationship. Wire loops secure the
with the enveloping cancellous bone. After both osteotomies
occlusal relationship and the rigid fixation of the mandible is
are complete, the distal segment is placed into occlusion and
completed as previously described.
secured by tightening 26 gauge wire loops around the surgical
lugs. If a surgical splint is necessary to establish the required
occlusion, it is placed between the teeth prior to intermaxil- Complications
lary wiring. The proximal segment is then gently rotated to
Improper positioning of the jaws is manifested by poor
ensure it is seated within the glenoid fossa. When the condyle
occlusion or an obvious unaesthetic result. If the complica-
is comfortably seated within the fossa, it is rotated to align
tion results from improper condyle position during fixation
the inferior borders of the two segments and then secured into
or improper indexing of the splint, fixation must be removed
position with a clamp. Three lag screws will be placed at the
and reapplied. It is wise to verify splint fit prior to surgery.
superior border of the overlapping segments. To ensure that
Meticulous treatment planning prior to surgery minimizes
the transbuccal trocar will be in the proper place, a hemo-
splint-related problems.
stat is placed at the proposed screw location and pointed out
Measures to reduce the chance of a bad sagittal split should
toward the cheek. A small stab incision is made in the skin,
always be employed. Removal of mandibular third molars
and the trocar is placed through the tissue bluntly until the
6 months prior to the osteotomy allows time for the sockets to
tip enters the oral incision. The trocar is then exchanged for a
heal, which decreases the chance of a bad split. If the segments
drill guide, and the 2.0 and 1.5 mm drills are used in the lag
do not appear to be easily separating, the surgeon should
sequence to make three holes through the overlapping por-
verify that the osteotomies are complete. Excessive force
tion of the proximal and distal segments. The screw lengths
increases the chance of an uncontrolled mandibular split. If
are measured and the screws inserted. The contralateral side is
a bad split occurs, the segments can be plated to reestablish
then done in a similar fashion. The intermaxillary fixation is
normal anatomy, and the proximal and distal segments can
then released, and the mandible is gently opened and closed.
then be secured into the desired position with rigid fixation.
The teeth should meet in a class I occlusion. If a malocclu-
Bleeding may occur from any area but most commonly
sion is noted, the most likely etiology is that one or both con-
from the descending palatine artery in the maxilla. This can be
dyles were not seated properly during application of fixation.
stopped with packing or by placing a hemoclip on the artery.
The screws should be removed and replaced until the correct
Bone wax is useful for bleeding bony edges.
occlusion is established. The wounds are irrigated and closed
Nerve damage is rare but may occur. The nerves associ-
with interrupted 3-0 chromic sutures.
ated with these procedures are the infraorbital, the inferior
alveolar, and the mental nerves. If a transection is witnessed,
Intraoral Vertical Ramus Osteotomy coaptation with 7-0 suture is recommended if possible. The
A second technique for correcting mandibular prognathism or patient should be informed that there is about a 25% chance
asymmetry is the intraoral vertical ramus osteotomy. The inci- of some paresthesia immediately after surgery but permanent
sion is the same as the sagittal split osteotomy. A subperiosteal changes are seen only in 1% to 2% of patients.
dissection is performed from the lateral ramus and a Merrill- Nonunion or malunion is rare after surgery. If a mal-
LeVasseur retractor is used to hold this tissue laterally. An union occurs, re-ostomy may be necessary. A nonunion
oscillating saw is then used to make a vertical cut from the would require secondary bone grafting to establish osseous
sigmoid notch to the inferior border of the mandible. The cut continuity.

Treatment of Dentofacial Deformity. St. Louis, MO: Mosby; 2003:
References 213-223.
1. Morris AL. Ackerman JL, Flesch R, et al. Handicapping Orthodontic 7. Erickson K. An Instructional Manual for the Model Platform and Model
Conditions. Washington, DC: National Academy of Sciences; 1975. Block. Tonawanda, NY: Great Lakes Orthodontics, Ltd.; 1990.
2. Rosen HM. Facial skeletal expansion: treatment strategies and rationale. 8. Goldstein J, Baker SB. Outcomes in computer-assisted surgical simulation
Plast Reconstr Surg. 1992;89:798. for orthognathic surgery. J Craniofac Surg. 2012;23:133.
3. Tompach PC, Wheeler JJ, Fridrich KL. Orthodontic considerations in 9. Proffit WR, Turvey TA, Phillips C. Orthognathic surgery: a hierarchy of
orthognathic surgery. Int J Orthod Orthognath Surg. 1995;10:97. stability. Int J Adult Orthod Orthogn Surg. 1996;11:191-204.
4. Rosen HM. Aesthetics in facial skeletal surgery. Perspect Plast Surg. 1993;6:1. 10. Stromberg C, Holm J. Surgically assisted rapid maxillary expansion in
5. Betts NJ, Vanarsdall RL, Barber HD, Higgins-Barber K, Fonseca RJ. adults: a retrospective long-term follow-up study. J Craniomaxillofac Surg.
Diagnosis and treatment of transverse maxillary deficiency. Int J Orthod 1995;23:222.
Orthognath Surg. 1995;10:75. 11. Silverstein K, Quinn PD. Surgically assisted rapid palatal expansion for
6. Proffit WR, Sarver DM. Treatment planning: optimizing benefit to the management of transverse maxillary deficiency. J Oral Maxillofac Surg.
patient. In: Proffit, WR, White RP, Sarver DM, eds. Contemporary 1997;55:725.


Chapter 26 n Craniofacial Clefts
and Hypertelorbitism
James P. Bradley And Henry K. Kawamoto
Congenital craniofacial clefts are malformations of the cra-

nium and face with deficiencies or excesses of tissue along Defining Features Of
an anatomic line based on embryologic maldevelopment.1 Craniofacial Clefts
They are among the most disfiguring of all facial anomalies.
Craniofacial clefts exist in a multitude of patterns and varying
degrees of severity.2 They are expressed either unilaterally or Number 0 Cleft
bilaterally. In addition, one cleft type may manifest on one The number 0 cleft has been called median craniofacial dys-
side of the face, while a different cleft type is present on the raphia, centrofacial microsomia, frontonasal dysplasia, or
other side.3 median cleft face syndrome—but for accuracy it is the facial
manifestation or lower half of “median craniofacial dyspla-
Tessier Classification sia.” Patients with this midline facial cleft may have a cra-
nial extension or a number 14 cleft. The number 0 Tessier
The Tessier classification for rare craniofacial clefts is the craniofacial clefts are unique in that there may be deficient,
most complete and has withstood the test of time.1 This clas- normal, or excess tissue. Tissue agenesis and holoprosenceph-
sification links clinical observations with underlying skeletal aly (the hypoplasias) are one end of the spectrum, and fron-
deformities seen with preoperative 3D computed tomogra- tonasal hyperplasia and excessive tissue (the hyperplasias) are
phy (CT) scan imaging and confirmed during surgery. Newer the other end. Median anomalies with normal tissue volume
neuroembryologic theories that allow for mapping of devel- occupy the middle portion of the spectrum (Table 26.1).5
opmental zones of the face have confirmed the value of the Median craniofacial hypoplasia (deficiency of midline
Tessier classification to embryologists and geneticists, not just structures): A deficiency may manifest as hypoplasia or agen-
surgeons (Figure 26.1).4 esis in which portions of midline facial structures are missing.
In the Tessier classification, clefts are numbered from 0 to This developmental arrest may range from the mildest form
14 (Figure 26.2). The eyelids and orbits are designated as the of hypoplasia of the nasomaxillary region and hypotelorism
horizontal axis of this functional system dividing the face into to a severe form of cyclopia, ethmocephaly, or cebocephaly.
upper and lower hemispheres. The orbit separates the facial The subcategories in Table 26.1 demonstrate that the severity
clefts (0 through 7; going from medial to lateral) from the of the facial anomalies generally correlate with the severity of
cranial clefts (8 through 14; going from lateral to medial). In brain abnormality and mental retardation. Clinically, it may
many cases, the facial clefts extend into the cranium in pre- be important to distinguish among patients with poor brain
dictable lines to form combination cranial and facial clefts,
including 0 and 14, 1 and 13, 2 and 12, 3 and 11, 4 and 10,
5 and 9, and 6 and 8. The soft tissue and skeletal compo-
nents are seldom affected to the same extent. The skeletal
landmarks tend to be more constant and reliable than the soft
tissue landmarks.
FIGURE 26.2. Tessier’s classification of craniofacial clefts: The left

half (right side of the face) depicts the skeletal locations of numeric
clefts and the right half (left side of the face) outlines the clinical loca-
FIGURE 26.1. Embryological correlation to Tessier craniofacial tions of clefts based on soft tissue landmarks. Facial clefts, number
clefts: Tessier-numbered craniofacial clefts are depicted as growth 0 through number 7; cranial clefts, number 8 through number 14.
center junctions in this 45-day-old fetus. Mandibular midline facial cleft number 30 is also seen.
266
Chapter 26: Craniofacial Clefts and Hypertelorbitism 267
Table 26.1
Number 0 Cleft: Median Craniofacial Dysplasia
I. Median Craniofacial Hypoplasia (tissue deficiency or

agenesis)
A. Holoprosencephalic spectrum (Alobar Brain)
1. Cyclopia: Single eye in a single orbit. Arhinia with
proboscis often located above the single orbit and
microcephaly.
2. Ethmocephaly: Severe hypotelorism but separate
orbits. Arhinia with proboscis located in between the
orbits.

3. Cebocephaly: Severe hypotelorism. Proboscis-like

rudimentary nose.
4.
A genesis of the primary palate and associated
midline structures with severe hypotelorism.
B. Median cerebrofacial hypoplasia (lobar brain): With
midline facial hypoplasia and midline cerebral malfor-
mations. Unilateral or bilateral cleft lip and palate can
be present.
C.
M edian facial hypoplasia (lobar brain): Midline
facial hypoplasia without gross cerebral involvement.
Unilateral or bilateral cleft lip and palate can be present.
1. Median facial hypoplasia full form
2. Microform median facial hypoplasia
a. Binder syndrome
b. Central maxillary incisor anomaly A
c. Absent upper lip frenulum
II. Median Craniofacial Dysraphia (normal tissue volume but
clefted)
A. True Median Cleft:
It can be presented as isolated cleft of the upper lip
“0 cleft” or with tissue deficiency or agenesis, “e.g.,
absent nasal septum.”
B. Anterior Encephaloceles: An encephalocele is a cystic
congenital malformation in which central nervous sys-
tem structures herniated through.
III.
M edian Craniofacial Hyperplasia (tissue excess or
duplication)
This spectrum of anomalies include all forms of excess tis-
sue starting from just thickened or duplicated nasal septum
to the more severe forms of frontonasal dysplasia.
differentiation (alobar holoprosencephaly) who may die in

infancy from those with a better prognosis (lobar brain).
Soft tissue deficiencies with Tessier 0 clefts include the
upper lip and nose. Agenesis or hypoplasia may result in a
false median cleft lip and absence of philtral columns. When
a wide central cleft exists, it typically extends the length of the
upper lip and into the nasal floor (Figure 26.3A). With nasal
anomalies the columella may be narrowed or totally absent.
The nasal tip may be depressed from lack of septal support.
The septum may often be vestigial with no caudal attachment
to the palate. Dental abnormalities may include a single maxil- B
lary central incisor or even absent central maxillary incisors.
FIGURE 26.3. Number 0 cleft: Median craniofacial hypoplasia.
Skeletal deficiencies range from separation between the A. Patient with midline facial hypoplasia. B. Illustration shows
upper central canines to absence of the premaxilla and a cleft skeletal involvement with separation between the central incisors and
of the secondary palate (Figure 26.3B). Nasal deficiency may widening of the nasal region and orbital hypertelorism.
include partial or total absence of the septal cartilage and

even nasal bones. The bone defect may extend cephalad into
the area of the ethmoid sinuses and result in hypotelorism or
cyclopia.
Median craniofacial dysraphia (normal tissue volume but
clefted): These Tessier 0 clefts have normal tissue volume
but are abnormally split (true median cleft lip) or displaced
(encephalocele).
Soft tissue involvement: When an isolated cleft of the upper
lip is not associated with tissue deficiency (e.g., absent nasal
septum) or tissue excess (e.g., duplicated septum), it is con-
sidered a “true” median cleft lip (Figure 26.4). With a true
median cleft lip there is a split between the median globular
processes; whereas, with a false median cleft lip an agenesis of
the globular processes may occur.
Skeletal involvement: When the true median cleft passes
between the central incisors, the cleft can continue posteriorly
as a midline cleft palate. When the cleft encroaches into the
interorbital region, hypertelorbitism may occur.
Median craniofacial hyperplasia (excess of midline tis-
sue): This spectrum of midline anomalies includes all forms of
excess tissue from a thickened or duplicated nasal septum to
the more severe forms of frontonasal dysplasia (Figure 26.5).
Soft tissue midline excess may be manifested in the lip with
broad philtral columns or a duplication of the labial frenulum.
The nose may be bifid with a broad columella and mid-dorsal
furrow. The alar and upper lateral cartilages may be displaced
laterally.
Skeletal excess in a wide 0 facial cleft can be seen as a dia-
stema between the upper central incisors. A duplicate nasal
spine may exist. A keel-shaped maxillary alveolus with ante-
rior teeth angled toward the midline creating an anterior open
bite is characteristic. Central midface height is shortened. The
A
B
FIGURE 26.5. Number 0 cleft: Median craniofacial hyperplasia.
FIGURE 26.4. Number 0 cleft: Median craniofacial dysplasia. Patient A–C. Patients with excessive midline tissue manifested by bifid nose
with a “true” median cleft lip deformity. and an accessory band of skin on the nasal dorsum.

2 cleft the ala is hypoplastic, whereas in the number 1 cleft,
the ala is merely notched at the dome. The lateral aspect of
the nose is flattened and the dorsum is broad. The eyelid is
not involved; the cleft passes medially to the palpebral fissure.
Although the medial canthus is displaced, the lacrimal duct is
usually not involved. If the cleft continues in a cephalad direc-
tion as a cranial number 12 cleft, then distortion of the medial
brow is noted.
Skeletal involvement: The number 2 cleft begins between
the lateral incisor and the canine. It extends into the pyriform
aperture, lateral to the septum and medial to the maxillary
sinus (Figure 26.7B). A hard and soft palate cleft may occur.
The nasal septum may be deviated away from the cleft. The
cleft distorts the nasal bones as it passes between the nasal
bones and the frontal process of the maxilla. Asymmetry of

the greater and lesser sphenoid wings and anterior cranial

base is present.5
Number 3 Cleft
The number 3 cleft or the oronasoocular cleft is the most com-
mon of the Tessier craniofacial clefts.
Soft tissue involvement: The number 3 cleft begins similar
to number 1 and number 2 clefts passing through the philtral
column and floor of the nose (Figure 26.8A). Deficiency of
tissue between the alar base and lower eyelid results in a short-
ened nose on the affected side. The cleft passes between the
medial canthus and the inferior lacrimal punctum. The lac-
rimal system, particularly the lower canaliculus, is disrupted.
Blockage of the nasolacrimal duct and recurrent infections
of the lacrimal sac are common. The inferior punctum is dis-
placed downward and drainage may occur directly onto the
cheek instead of into the nasal cavity.
C The medial canthus is inferiorly displaced and may be
hypoplastic. Colobomas of the lower eyelid are medial to
FIGURE 26.5. (Continued) the inferior punctum. Involvement of the globe is rare but
microphthalmia may occur. Typically, the eye is malposi-
tioned inferiorly and laterally. Injury to the eye, including
corneal erosions, ocular perforation, and loss of vision, may
cartilaginous and bony nasal septum is thickened or dupli- result from desiccation unless the globe is protected.
cated. The nasal bones and nasal process of the maxilla are Skeletal involvement: Osseous characteristics of this facial
broad, flattened, and displaced laterally from the midline. cleft include involvement of the orbit and direct communica-
Ethmoidal and sphenoidal sinuses may be enlarged, contribut- tion of the oral, nasal, and orbital cavities (Figure 26.8B). The
ing to symmetrical widening of the anterior cranial fossa and cleft begins between the lateral incisor and the canine. In con-
hypertelorism. trast to the number 1 and number 2 facial clefts, the anterior
maxillary arch is flat in the number 3 cleft. The number 3 cleft
disrupts the frontal process of the maxilla and then terminates
Number 1 Cleft in the lacrimal groove. Both the orbital floor and anterior cra-
Soft tissue involvement: The number 1 cleft, similar to the nial base are displaced inferiorly.
common cleft lip, passes through the cupid’s bow and then the
alar cartilage dome. Notching in the area of the soft triangle Number 4 Cleft
of the nose is a distinct feature (Figure 26.6A). The columella
may be short and broad. The nasal tip and nasal septum devi- The number 4 cleft occurs lateral to the nose and other median
ate away from the cleft. When the cleft is evident medially to facial structures.
a malpositioned medial canthus, telecanthus may result. With Soft tissue involvement: As opposed to numbers 1, 2, and
accompanying cranial extension as a number 13 cleft, vertical 3 facial clefts, the number 4 cleft begins lateral to cupid’s bow
dystopia may be present. and the philtral column, medial to the oral commissure, and
Skeletal involvement: An alveolar cleft would pass between goes lateral to the nose (Figure 26.9A). The orbicularis oris
the central and lateral incisors (Figure 26.6B). This parame- muscle is located in the lateral lip element with no muscle cen-
dian cleft separates the nasal floor at the pyriform aperture trally. The cleft passes lateral to the nasal ala. Although the
just lateral to the nasal spine. The cleft may extend posteriorly ala is not involved and the nose is intact, the ala is displaced
as a complete cleft of the hard and soft palate. Extension of superiorly.6 Bilateral involvement pulls the nose upward. The
the cleft in a cephalad direction is through the junction of the cleft extends through the cheek and into the lower eyelid lat-
nasal bone and the frontal process of the maxilla. eral to the inferior punctum. The lower eyelid and lashes may
extend directly into the lateral aspect of the cleft. The medial
canthus and nasolacrimal system are normal. The globe is
Number 2 Cleft typically normal but microphthalmia and anophthalmos may
Soft tissue involvement: This other paramedian facial cleft may be seen.
also begin in the region of the common cleft lip. However, the Skeletal involvement is usually less extensive than the
nasal deformity is in the middle third of the alar rim and dis- number 3 cleft. The alveolar cleft begins between the lat-
tinguishes the number 2 cleft (Figure 26.7A). In the number eral incisor and the canine (Figure 26.9B). The cleft extends

FIGURE 26.7. Number 2 cleft. A. Patient with hypoplasia of the mid-

B dle third of the right nostril rim causing the appearance of alar base
retraction. The lateral nose is flattened. The medial border of the eye-
FIGURE 26.6. Number 1 cleft. A. Patient with notched left alar dome brow is also distorted as evidence of a number 12 cranial cleft. There
and orbital dystopia. B. Skeletal involvement is through the pyriform is also orbital dystopia and displacement of the right medial canthus.
aperture just lateral to the nasal spine and septum. The orbit is dis- B. Skeletal involvement shows deformity of the pyriform aperture and
placed laterally. nasal bone.


A
B
FIGURE 26.9. Number 4 cleft. A. Bilateral clefting of the upper lip
lateral to cupid’s bow with malar extension to the lower eyelids ter-
minating in the lower eyelid medial to the punctum with asymmetric
involvement. B. Skeletal involvement begins between the lateral incisor
and canine and extends through the maxilla between the infraorbital
B foramen and the pyriform aperture. The orbit, maxillary sinus, and oral
cavities communicate.
FIGURE 26.8. Number 3 cleft. A. Patient with complete form has a
right cleft lip and palate and severe shortening of tissues between the
right alar base and medial canthus. The right nasal ala is displaced
superiorly, the medial canthus is displaced inferiorly, and the nasolac-
rimal system is disrupted. B. Skeletal involvement is between the lat-
eral incisor and the canine extending up through the lacrimal groove. orbital cavity but not the nasal cavity. The cleft then passes
The cleft creates a direct communication among the orbital, maxillary medial to the infraorbital foramen. This landmark defines
sinus, and nasal and oral cavities. the boundary between the medial number 4 facial cleft and
lateral number 5 facial cleft. The number 4 cleft terminates at
the medial aspect of the inferior orbital rim. With an absent
lateral to the pyriform aperture to involve the maxillary medial orbital floor and rim, the globe may prolapse inferi-
sinus. The medial wall of the maxillary sinus is intact. A con- orly. In bilateral cases, the medial midface and premaxilla are
fluence exists between the oral cavity, maxillary sinus, and protrusive.

Number 5 Cleft Number 6 Cleft

This facial cleft is the rarest of the oblique facial clefts. This zygomaticomaxillary cleft represents an incomplete form
Soft tissue involvement: (Figure 26.10A, B) The number of Treacher-Collins syndrome. Similar and often more severe
5 facial cleft begins just medial to the oral commissure and cleft facial features are seen in Nager syndrome. Patients with
courses along the cheek lateral to the nasal ala. The cleft ter- Nager syndrome may also have radial club deformities of the
minates in the lateral half of the lower eyelid. Although the upper extremities.
globe is typically normal, microphthalmia may occur. Soft tissue involvement: The cleft is often identified as a
Skeletal involvement: The alveolar cleft begins lateral to the vertical furrow due to hypoplastic soft tissue from the oral
canine in the region of the premolars. In contrast to the number commissure to the lateral lower eyelid (Figure 26.11A). This
4 cleft, the number 5 cleft then courses lateral to the infraor- line of hypoplasia runs through the zygomatic eminence along
bital foramen and terminates in the lateral aspect of the orbital an imaginary line from the angle of the mandible to the lateral
rim and floor (Figure 26.10C). The cleft is separated from the palpebral fissure. The lateral palpebral fissure is pulled down-
inferior orbital fissure. The maxillary sinus may be hypoplas- ward. The lateral canthus is displaced inferiorly. This may
tic. Prolapse of orbital contents through the lateral orbital floor create an appearance of a severe lower lid ectropion and an
defect into the maxillary sinus causes vertical orbital dystopia. antimongoloid slant. Colobomas appear in the lateral lower
The lateral orbital wall may be thickened and the greater sphe- eyelid and mark the cephalic end of the cleft.
noid wing abnormal. The cranial base is normal. Skeletal involvement: The number 6 facial cleft is along
the zygomaticomaxillary suture separating the maxilla and
zygoma (Figure 26.11B). There is no alveolar cleft but a short
posterior maxilla may result in an occlusal tilt. Choanal atre-
sia is common. The cleft enters the orbit at the lateral third of
the orbital rim and floor and connects to the inferior orbital
fissure. The zygoma is hypoplastic.
C
FIGURE 26.10. Number 5 cleft (left) and number 4 cleft (right).
A. This patient demonstrates bilateral facial clefts with a left-sided
number 5 cleft beginning just medial to the oral commissure and
extends up the lateral cheek to the middle of the eyelid while the right-
sided number 4 cleft begins lateral to cupid’s bow and extends up to
the medial third of the lower eyelid. B. Postoperative view of same
patient after repair of bilateral clefts. C. Skeletal involvement in the
left-sided number 5 cleft begins at the premolars and extends lateral to
the infraorbital foramen, while the right-sided number 4 cleft begins
between the lateral incisor and canine and passes medial to the infra-
orbital foramen.
B

Number 7 Cleft
This temporozygomatic facial cleft is the most common cra-
niofacial cleft. It is seen in some cases of craniofacial microso-
mia (oculo-auriculo-vertebral spectrum).7 The number 7 cleft
is also seen in Treacher-Collins syndrome (Figure 26.12).
Soft tissue involvement: The cleft begins at the oral com-
missure and varies from a mild broadening of the oral com-
missure with a preauricular skin tag to a complete fissure
extending toward a microtic ear. Typically, the cleft does not
extend beyond the anterior border of the masseter. However,
the ipsilateral tongue, soft palate, and muscles of mastication
(cranial nerve V) may be underdeveloped. The parotid gland
and parotid duct may be absent. Facial nerve weakness (cra-
nial nerve VII) may be present. External ear deformities range

from preauricular skin tags to complete absence of the ear.

Preauricular hair is usually absent in patients with craniofacial
microsomia. Patients with Treacher-Collins often have pre-
auricular hair from the temporal region pointing to the oral
commissure. The ipsilateral soft palate and tongue are often
hypoplastic.
Skeletal involvement: A wide range of osseous anomalies
are associated with a number 7 cleft. The skeletal cleft passes
through the pterygomaxillary junction. Tessier believed that
the cleft is centered in the region of the zygomaticotemporal
suture. The posterior maxilla and mandibular ramus are hypo-
plastic in the vertical dimension, creating an occlusal plane
B
FIGURE 26.11. Number 6 cleft. A. Patient with an incomplete form
of Treacher-Collins syndrome shows bilateral linear malar hypopla- FIGURE 26.12. Number 7 cleft: Patient with a complete fissure of
sia. B. Skeletal involvement occurs in the region of the zygomatico- the right oral commissure, which extends toward the external ear
maxillary suture. The zygoma is hypoplastic. resulting in macrostomia.

that is canted cephalad on the affected side. The coronoid and displaced. In the most severe form, the zygomatic arch is
process and condyle are also often hypoplastic and asymmet- disrupted and is represented by a small stump. The malposi-
ric, which contributes to a posterior open bite on the affected tioned lateral canthus is caused by a hypoplastic zygoma that
side. The zygomatic body is severely malformed, hypoplastic, results in the inferiorly displaced superolateral angle of the
orbit. Occasionally, severely deforming number 7 clefts can
cause true orbital dystopia. The abnormal anterior zygomatic
arch continues posteriorly as a normal zygomatic process of
the temporal bone. The cranial base is asymmetric and tilts
causing an abnormally positioned glenoid fossa. The anatomy
of the sphenoid is abnormal and there can be a rudimentary
medial and lateral pterygoid plate.
Number 8 Cleft
This frontozygomatic cleft divides the facial clefts from the cranial
clefts. The number 8 cleft rarely occurs alone but usually asso-
ciated with other craniofacial clefts, like Treacher-Collins syn-
drome (Figure 26.13A, B). Tessier believed that Treacher-Collins
syndrome was a combination of the 6, 7, and 8 facial clefts.
Soft tissue involvement: The number 8 cleft extends from
the lateral canthus to the temporal region. A dermatocele may
occupy the coloboma with absence of the lateral canthus.
Abnormalities of the globe, in the form of epibulbar der-
moids and lipodermoids, are also often present, especially in
Goldenhar’s syndrome.
Skeletal involvement: The bony component of the cleft
occurs at the frontozygomatic suture. Tessier noted a notch
in this region in patients with Goldenhar syndrome. In the
complete form of Treacher-Collins syndrome, the zygoma
may be hypoplastic or absent and the lateral orbital wall miss-
ing (Figure 26.13C). Thus, the lateral palpebral fissure’s only
support is the greater wing of the sphenoid and downward
FIGURE 26.13. Combination number 6, 7, and 8 cleft. A. Patient

with Treacher-Collins syndrome demonstrates malar hypopla-
sia, antimongoloid slant to palpebral fissure, and a retruded chin.
B. Postoperative image after malar reconstruction with cranial bone
grafts, eyelid reconstruction with lid switch flaps, and mandibular dis-
traction to remove the tracheostomy. Subsequently, the patient under-
went bilateral total ear reconstruction. C. Skeletal involvement in the
complete form includes absence of the zygoma, lateral orbital wall
(greater wing of sphenoid provides remaining portion of the lateral
wall), and lateral orbital floor.
B

slanting occurs. With this bony defect, there is soft tissue con-
tinuity of the orbit and temporal fossa.
Number 9 Cleft
This upper lateral orbit cleft is the rarest of the craniofacial
clefts. The number 9 cleft begins the march from lateral to
medial of cranial clefts 9 through 14.
Soft tissue involvement: The number 9 cleft is manifested
by abnormalities of the lateral third of the upper eyelid and
eyebrow (Figure 26.14). The lateral canthus is also distorted.
In the severe form, microphthalmia is present. The superolat-
eral bony deficiency of the orbits allows for a lateral displace-
ment of the globes. The cleft then extends cephalad into the
temporoparietal hair-bearing scalp. The temporal hairline is

anteriorly displaced and an abnormal projection of temporal

hair is often seen in the number 9 cleft.
Skeletal involvement: The bony defect of the number 9
cranial cleft extends through the superolateral aspect of the
orbit. Distortion of the upper part of the greater wing of the
sphenoid, the squamosal portion of the temporal bone, and
surrounding parietal bones may be present. Hypoplasia of the
greater wing of the sphenoid results in a posterolateral rota-
tion of the lateral orbital wall.
Number 10 Cleft
Soft tissue involvement: The number 10 cleft begins at the
middle third of the upper eyelid and eyebrow (Figure 26.15A).
The lateral eyebrow may angulate temporally. The palpebral
fissure may be elongated with an amblyopic eye displaced
inferolaterally. The entire upper eyelid may be absent in severe
forms (ablepharia). Colobomas and other ocular anomalies
A
FIGURE 26.15. Number 10 cleft. A. Patient with fronto-orbital

encephalocele in the mid-right forehead. This fills the void from the
cleft defect in the center of the left superior orbital rim. The right
globe is displaced downward. B. Skeletal defect and asymmetric
hypertelorism are demonstrated on the right.
may be present. Frontal hair projection may connect the tem-

FIGURE 26.14. Number 9 cleft: Patient with left side rare number poroparietal region to the lateral brow.
9 cleft through the superiolateral orbital roof with microphthalmia. Skeletal involvement: The bony component of the number
10 cranial cleft occurs in the middle of the supraorbital rim

just lateral to the superior orbital foramen (Figure 26.15B).

Often an encephalocele occupies the defect through the fron-
tal bone, and a prominent bulge is observed in the forehead.
The orbit may be deformed with a lateroinferior rotation.
Severe cases may result in orbital hypertelorism. The anterior
cranial base may also be distorted.
Number 11 Cleft
Soft tissue involvement: The medial third of the upper eyelid
may show involvement with a coloboma (Figure 26.16). There
may be disruption of the upper eyebrow, which extends up
to the frontal hairline. A tongue-like projection at the medial
third of the frontal hairline may also be identified.
A
C
B D
FIGURE 26.16. Number 11 cleft. A. Left lateral view of patient with large right frontoencephalocele, a left side number 3, 11 and right side
3, 10 craniofacial cleft. B. Computed tomographic scan revealed significant bony defect of the right fronto-orbital region. C. Frontal view after
encephalocele repair and right fronto-orbital reconstruction; the patient showed improvement but still had orbital and facial cleft deformities.
D. Patient seen after premaxillary repositioning and bilateral cleft lip adhesion.

Skeletal involvement: The number 11 cleft may be seen as
a cleft in the medial third of the supraorbital rim if it passes
lateral to the ethmoid bone. If the cleft passes through the
ethmoid air cells to produce extensive pneumatization, then
orbital hypertelorism results. The cranial base and sphenoid
architecture, including the pterygoid processes, are symmetric
and normal.
Number 12 Cleft
Soft tissue involvement: The soft tissue cleft lies medial to
the medial canthus and colobomas extend to the root of the
eyebrow (Figure 26.17A). There is lateral displacement of the
medial canthus with aplasia of the medial end of the eyebrow.
There are no eyelid clefts. The forehead skin is normal with a

short downward projection of the paramedian frontal hairline.

Skeletal involvement: The number 12 cleft passes through
the flattened, frontal process of the maxilla (Figure 26.17B).
It then travels superiorly, increasing the transverse dimension
of the ethmoid air cells, producing orbital hypertelorism and
telecanthus. The frontal and sphenoid sinuses are also pneu-
matized and enlarged. The frontonasal angle is obtuse. The
cleft is located lateral to the olfactory groove; thus, the cribri-
form plate is normal in width. Encephaloceles have not been
observed with this cleft.
Number 13 Cleft
Soft tissue involvement: The soft tissue cleft is medial to intact
eyelids and eyebrows; however, the eyebrow may be displaced
(Figure 26.18). The cleft is located between the nasal bone and
the frontal process of the maxilla and may have a paramedian
frontal encephalocele. A V-shaped frontal hair projection can
also be seen.
Skeletal involvement: Changes in the cribriform plate
are the hallmark of a number 13 cleft. The paramedian B
FIGURE 26.17. Number 12 cleft. A. Patient with left-sided cleft

has hypertelorbitism and a disturbance of the left medial eyebrow.
B. Postoperative image of patient after facial bipartition, medial can-
thopexy, but prior to nasal correction. C. Skeletal involvement of left
side clefting through the frontal process of the maxilla displacing the
orbit laterally.
A

bony cleft traverses the frontal bone, and then courses

along the olfactory groove. There is widening of the olfac-
tory groove, the cribriform plate, and the ethmoid sinus,
which results in hypertelorism. A paramedian frontal
encephalocele can cause the cribriform plate to be dis-
placed inferiorly, leading to orbital dystopia. When the
cleft is bilateral, some of the most extreme cases of hyper-
telorism can be seen.2
Number 14 Cleft
Soft tissue involvement: Similar to its facial counter-
part, the number 0 cleft, the number 14 cleft may pro-
duce agenesis, normal (cleft) or overabundance of tissue
(Figure 26.19). With agenesis, orbital hypotelorism results;
more severe holoprosencephalic malformations include
cyclopia, ethmocephaly, and cebocephaly. Malformations
of the forebrain are usually proportional to the degree of
facial abnormality.
At the other end of the spectrum, orbital hypertelorism is
associated with the number 14 cleft. Lateral displacement of
the orbits can be produced by midline masses such as a fron-
A tonasal encephalocele and a midline frontal encephalocele.
Flattening of the glabella and extreme lateral displacement of
the inner canthi are also seen. A long midline projection of
the frontal hairline marks the superior extent of the soft tissue
features of this midline cranial cleft.
B FIGURE 26.19. Number 14 cleft. A. Patient with number 0 to 14

cleft with hypertelorbitism, a form of median craniofacial hyperplasia
FIGURE 26.18. Number 13 cleft. A. Newborn with a right cleft, (tissue excess). B. Postoperative image after corrective encephalocele
which begins cleft through the right alar dome (number 1 cleft) and repair, medial orbit repositioning, and nasal bone grafting. C. Skeletal
extends to the frontal bone to cause right-sided hypertelorbitism. involvement shows displacement of the frontal process of the maxilla,
B. Postoperative image after corrective facial bipartition and nasal the nasal bones, and medial orbital walls laterally. This large defect is
reconstruction with forehead flap. often occupied by an encephalocele.

Skeletal involvement: The frontal encephalocele herniates
through a medial frontal defect (Figure 26.19B). The caudal
aspect of the frontal bone is flattened giving the glabellar
region a flattened and indistinct position. No pneumatization
of the frontal sinus is evident; however, the sphenoid sinus
is extensively pneumatized. The crista galli and the perpen-
dicular plate of the ethmoid are bifid or widened and caudally
displaced. Consequently, the cribriform plate, which is nor-
mally located 5 to 10 mm below the level of the orbital roof,
can be caudally displaced up to 20 mm. The anterior cranial
fossa is upslanting, causing a harlequin eye deformity on plain
radiographs.
Number 30 Cleft

The median cleft of the lower jaw is caudal extension of the

number 14 cranial cleft and number 0 facial cleft.
Soft tissue involvement of this midline cleft may be as
mild as a notch in the lower lip. However, often the entire
lower lip and chin may be involved (Figure 26.20). The ante-
rior tongue may be bifid and attached to the split mandible
by a dense fibrous band. Ankyloglossia and total absence
of the tongue have been reported with midline mandibular
clefts.
Skeletal involvement is typically a cleft between the cen-
tral incisors extending into the mandibular symphysis. This
anomaly is thought to be caused by failure of fusion of the
first branchial arch. As an example, the hyoid bone may
be absent and the thyroid cartilages may fail to form com-
pletely. The anterior neck strap muscles are often atrophic
and replaced by dense fibrous bands that may restrict chin
flexion.
B
Hypertelorbitism
With cranial clefts 10 through 14, the distance between the
medial canthi may be increased (telecanthus) and the bony
interorbital distance may be increased (orbital hypertelorism
or hypertelorbitism). The bony interorbital distance is typi-
cally measured with a CT scan as the interdacyron (the most
medial region of the orbit) distance. Excessive interdacyron
distance or hypertelorbitism may be mild (30 to 34 mm),
moderate (35 to 39 mm), or severe (>40 mm). In the grow-
ing child, excessive distance may be considered anything over
25 mm (Figure 26.21).8 More specific information on bony
interorbital distance by age and sex in growing children can
be found in normative data tables such as that provided by
Waitzman et al.9
Orbital dystopia may be either vertical or horizontal. The
midline number 14 cleft may have horizontal or transverse
dystopia with the bony orbits displaced laterally (orbital
hypertelorism) or medially (hypotelorism); whereas, the lat-
eral number 10 through 13 clefts may have a component of
vertical dystopia or asymmetric orbital hypertelorism with the
orbits on different horizontal planes.
Correction of hypertelorbitism may be achieved with a
facial bipartition or orbital box osteotomy. A facial bipar-
tition involves a coronal and gingivobuccal sulcus incision,
a craniotomy for exposure, orbital and midface osteoto-
mies, central wedge ostectomy (between the orbits), trans-
position of the orbits to an intradacyron distance less than
17 mm, and rigid fixation (Figure 26.22).10 Medial canthi
bolsters and correction of excessive glabellar soft tissue is
necessary. In addition to narrowing the orbital distance, a
facial bipartition procedure will also widen a constricted
palatal arch. Alternatively, an orbital box osteotomy may
be used to narrow orbital distance or correct vertical dys-
topia. The latter technique may be more appropriate in
C circumstances where palatal arch width is not narrowed,
FIGURE 26.19. (Continued) and widening of the arch width would result in lateral
crossbite.

A
FIGURE 26.20. Number 30 cleft. A. Preoperative view of patient
with number 30 cleft with a deep tongue groove and fusion to the
clefted mandible. (Also presented are number 0 to number 14 clefts).
B. Postoperative view of same patient with number 30 midline man-
dibular cleft after skeletal and soft tissue repair. (Courtesy of Cassio
Raposo.)
B
A B
FIGURE 26.21. Number 0, 14 cleft correction. A–B. Frontal views of patient with Tessier number 0 to number 14 craniofacial cleft.
A. Preoperative image demonstrating large midline frontonasal encephalocele. B. Postoperative image after gradual orbital contraction procedure
and median cleft lip and nose repair. C and D. Lateral views of patient with Tessier number 0 to number 14 craniofacial cleft. C. Preoperative
image demonstrating the anterior displacement of the encephalocele with functional problems of independent ocular movement and drooling.
D. Postoperative image after corrective procedures. Functional improvements in ocular, oral competence, and speech were noted. E. Preoperative
3D CT scan with large central osseous defect and 81 mm interdacryon distance. F. Postoperative 3D CT scan image after orbital distraction with
midline device in place.


C D
E

A B
FIGURE 26.22. Facial bipartition technique: Illustration. A. Frontal view of osteotomy lines, including craniotomy, midline asymmetric V-wedge
excision of frontonasoethmoidal bone, and midface buttresses (zygomatic arch, circumferential orbital walls, and pterygomaxillary). B. Frontal
view of fixation with midline “keystone” box fixation plate.
5. Allam KA, Wan DC, Kawamoto HK, Bradley JP, Sedano HO, Saied
Summary S. The spectrum of median craniofacial dysplasia. Plast Reconstr Surg.
2011;127(2):812-821.
Craniofacial clefts are variable defects of the hard and soft 6. Longaker MT, Lipshutz GS, Kawamoto HK Jr. Reconstruction of Tessier
tissue. They range from mild, barely visible (forme fruste) to no. 4 clefts revisited. Plast Reconstr Surg. 1997;99(6):1501-1507.
severe, largely disfiguring. 7. Gorlin R, Jue K, Jacobsen U, Goldschmidt E. Oculoauriculovertebral syn-
drome. J Pediatr. 1963;63:991.
8. Converse JM, Ransohoff J, Mathews ES, Smith B, Molenaar A. Ocular
References hypertelorism and pseudohypertelorism. Advances in surgical treatment.
Plast Reconstr Surg. 1970;45(1):1-13.
1. Tessier P. Anatomical classification facial, cranio-facial and latero-facial
9. Waitzman AA, Posnick JC, Armstrong DC, Pron GE. Craniofacial skeletal
clefts. J Maxillofac Surg. 1976;4(2):69-92.
measurements based on computed tomography: Part II. Normal values and
2. Kawamoto HK. Rare craniofacial clefts. In: McCarthy JG, ed. Plastic
growth trends. Cleft Palate Craniofac J. 1992;29(2):118-128.
Surgery. Philadelphia, PA: Saunders; 1990:2922-2973.
10. Bradley JP, Levitt A, Nguyen J, et al. Roman arch, keystone fixation
3. Kawamoto HK Jr. The kaleidoscopic world of rare craniofacial clefts: order
for facial bipartition with monobloc distraction. Plast Reconstr Surg.
out of chaos (Tessier classification). Clin Plast Surg. 1976;3(4):529-572.
2008;122(5):1514-1523.
4. Carstens MH. Development of the facial midline. J Craniofac Surg.
2002;13(1):129-187; discussion 188-190.

Chapter 27 n Ear Reconstruction
Charles H. Thorne
is hanging as a chondrocutaneous flap on the posterior skin.

Partial Acquired Defects Extra length can be gained by a V-Y advancement of the heli-
Most acquired, partial auricular defects have a good surgical cal crus, as described in the correction of the constricted ear.
solution. The more superior on the ear the defect is located, Defects up to 1.5 cm can be closed without tension. Defects
the more choices there are for reconstruction. Reconstruction larger than 2 cm are too large for this technique. In order to
of the lobule is the most difficult and is aesthetically the most facilitate closure, it is necessary to “cheat” by removing some
important. of the scaphal cartilage, taking tension off the reapproximated
helical rim. Reducing the scapha reduces the size of the ear and

Although some defects can be closed by soft tissue alone,

cartilage is usually required for support. For smaller defects, the patient should be alerted to this fact in advance. Although
a conchal cartilage graft may suffice. However, for larger originally described for upper-third auricular defects, this tech-
defects the rules of Firmin (Firmin, Personal communication, nique is also effective for middle-third defects, as well as for
2013) are extremely helpful: Defects that consist of 25% or defects at the junction of the middle and lower thirds.
more of the helical rim or involve more than two planes (i.e., If the helical rim alone is missing, as may occur in burn
involve antihelix as well as helix and scapha) will require rib injuries, a thin tube of retroauricular skin can be applied to
cartilage for support. Conchal cartilage will not provide suf- the residual scapha with acceptable results (Figure 27.2). This
ficient support in these cases. is one example where cartilage may not be necessary. The dis-
advantage of this technique is that it requires three stages to
“waltz” the tube into place: (a) formation of the tube in the
Specific Regional Defects sulcus, (b) transfer and insetting of one end of the tube, and
External Auditory Canal. Stenosis is best treated by (c) transfer and insetting of the other end of the tube.
a full-thickness graft applied over an acrylic mold, pro-
Upper-Third Defects. Techniques available for upper-
vided a reasonable recipient vascular bed can be prepared.
third defects in increasing order of size and complexity are as
Occasionally, multiple Z-plasties are used to relieve webbing
follows (Figure 27.3):
of the orifice, or a local flap is employed to line the canal and
break up the contracture. An acrylic stent is recommended for 1. Local skin flaps (Figure 27.3 A and B)
several months to counteract the inexorable tendency toward 2. Helical advancement (Figure 27.3 C and D).
contracture. 3. Contralateral conchal cartilage graft covered with a retro-
auricular flap (Figure 27.3 E and F).
Helical Rim. Acquired losses of the helical rim vary from 4. Chondrocutaneous composite flap (Figure 27.3 G and H).
small defects to major portions of the helix. The former defects, 5. Rib cartilage graft covered with retroauricular skin or tem-
which usually result from tumor excisions or minor traumatic poroparietal flap/skin graft (see Figure 27.5).
injuries, are best closed by advancing the helix in both direc-
tions, as described by Antia and Buch1 (Figure 27.1). The suc-
cess of this excellent technique depends first on freeing the helix
Middle-Third Defects. Techniques available for middle-
third defects are as follows:
from the scapha via an incision in the helical sulcus that extends
through the cartilage but not through the posterior skin. The 1. Primary closure with excision of accessory triangles
posterior auricular skin is undermined, until the entire helix (Figure 27.4).
FIGURE 27.1. Antia-Buch helical advancement. A. An incision is designed inside the helical rim and around the crus of the helix. B. The incision is
made through the skin and the cartilage, but not through the posterior skin. The helical rim is advanced to allow closure and a dog-ear of skin (dotted
line) is removed on the back of the ear. C. Closure showing the crus of the helix advanced into the helical rim. (Copyright Charles H. Thorne, MD.)
283
A B C D
FIGURE 27.2. Helical reconstruction with a thin caliber tube flap. A. Burn deformity of the helix. B. Construction of the tube flap in the
retroauricular sulcus. C. Transfer of one end of the tube. D. Final result. (Courtesy of Burt Brent, MD.)
2. Helical advancement. Cartilage grafts can be inserted via the Converse tunnel
3. Conchal cartilage graft and retroauricular flap. procedure in which the skin is not detached at the junction
4. Rib cartilage graft and retroauricular flap and/or temporo- of the residual ear and the retroauricular skin. The problem
parietal flap (Figure 27.5). is that precise placement of the graft with exact coaptation
A B C D
E F G H
FIGURE 27.3. Four techniques for repairing upper-third auricular defects. A and B. Preauricular flap. The flap is transposed to repair a minor
rim defect. C and D. Antia-Buch helical advancement. E and F. The combination of a retroauricular flap and conchal cartilage graft. G and H.
Chondrocutaneous conchal flap to reconstruct the helical rim. Of the upper-third techniques, the only one not shown is a rib cartilage graft,
which is shown in Figure 30.11. (Courtesy of Burt Brent, MD.)

Chapter 27: Ear Reconstruction 285
History
Gillies is credited with the first use of rib cartilage for con-
struction of an auricular framework in 1920. The impor-
tance of his contribution was temporarily obfuscated by
several reports using allogeneic cartilage. The allogeneic
cartilage, whether from a living donor such as the patient’s
parent or preserved cadaver cartilage, always underwent
gradual resorption.
The modern era of auricular reconstruction began with
Tanzer3 who reintroduced the technique of autogenous cos-
tal cartilage grafts as a method of auricular reconstruction.
Tanzer’s results inspired Brent who modified, improved,
A B and standardized a four-stage technique of auricular recon-
struction.4 Nagata developed a more complex technique that

FIGURE 27.4. Wedge resection and primary closure with excision of
condensed microtia repair into two stages.5 The Nagata tech-

accessory triangles. A. Wedge excision performed and accessory triangles
designed. B. Closure of the defect. The accessory triangles help prevent nique requires more cartilage and the construction of a higher
the auricle from cupping forward. (Copyright Charles H. Thorne, MD.) profile, more detailed framework than the Brent technique.
Firmin analyzed those characteristics of a “Brent ear” that fall
short of a normal ear and reported a large series using her
modification of the Nagata technique.6
While the technique of autogenous auricular reconstruc-
to remaining cartilage is difficult using this approach, and
tion was evolving, silastic was also used, instead of rib car-
a detached retroauricular flap (Figure 27.5) is preferable.
tilage, as the auricular framework. This material, as well as
Middle-third auricular tumors are excised and closed by either
other artificial materials, led to a high incidence of extru-
a wedge resection with accessory triangles (Figure 27.4) or a
sion. More recently, the use of porous polyethylene frame-
helical advancement, as previously described.
works has been explored and has become the standard
Lower-Third Auricular Defects. Various techniques treatment offered by some surgeons. The largest series was
have been described to reconstruct earlobe defects using soft- reported by Reinisch.7 Early attempts were associated with
tissue flaps. These techniques are not as effective as those that a 42% incidence of framework extrusion leading to modifi-
employ cartilaginous support. Like the alar rim, the normal cations of the original technique and coverage of the frame-
earlobe does not contain cartilage. A reconstructed earlobe, work using a temporoparietal fascial flap. This drastically
however, will only maintain its contour if cartilage is included, reduced the complication rate and is the technique of choice
analogous to nonanatomic alar rim grafts. The author prefers in his opinion.
to use thin, flat cartilage obtained from the nasal septum.2 The Finally, an auricular prosthesis is another option. The intro-
cartilage is placed beneath the cheek/retroauricular skin in the duction of titanium osseointegrated fixtures by Branemark
first stage. A hole can be made in the cartilage at this initial has made prosthetic reconstruction of the auricle a more sta-
stage for later ear piercing. In the second stage, an incision ble and user-friendly alternative.8 The role of prosthetic recon-
is made around the cartilage graft and the flap is advanced struction in microtia will also be discussed later.
beneath the earlobe as in a facelift (Figure 27.6).
Anatomy and Surgical Challenge
Microtia The ear is composed of a delicate and complex-shaped carti-
lage framework covered on its visible surface with thin, tightly
Microtia literally means small ear. The simplicity of the term adherent, hairless skin. A reconstructed auricular framework
belies the vast complexity of this entity, in terms of both the must be more rigid than the cartilage framework of a nor-
variable clinical presentation and the difficulty of surgical mal ear. When the auricular framework is placed beneath the
reconstruction. skin in the temporal region, a combination of the tight skin
envelope and the progressive scar contracture will gradually
obliterate the fine details if the framework is built to mimic
the delicate framework of the normal ear. As such, any recon-
structed ear that maintains its projection and definition in the
long term will be more bulky and will lack the flexibility of
the normal ear.
Consequently, even the best result using current tech-
niques for auricular reconstruction is imperfect. The deficien-
cies of current techniques make it even more important that
the reconstructed auricle be the correct size, be located in the
proper position such that one earlobe is not higher than the
other, and be properly angulated relative to the other facial
structures.
Embryology
The middle and external ears are derived from the first (man-
dibular) and second (hyoid) branchial arches. Most patients
A B with microtia have atresia (absence) of the external audi-
FIGURE 27.5. Reconstruction of a partial defect using rib cartilage
tory canal and tympanic membrane with variable deformi-
framework and retroauricular flap. The technique is a workhorse for ties of the middle ear ossicles. Rarely, a patient will present
partial defects. A. The incision is designed. B. The cartilage has been with microtia and a patent, stenotic canal. Least common but
placed and the flap closed over it. (Copyright Charles H. Thorne, MD.) most difficult to repair are patients with an auricular vestige
and canal that are markedly abnormal in position. Because

A B
FIGURE 27.6. Earlobe reconstruction using nasal septal cartilage. A. Original defect secondary to discoid lupus erythematosus.
B. Final result after two-stage reconstruction using thin cartilage from the nasal septum. (Copyright of Charles H. Thorne, MD).
the meatus can only be moved a limited distance, the surgeon

must consider complete excision of the canal. Canaloplasty and Middle Ear Reconstruction
The inner ear is derived from totally separate embryologic Patients with unilateral microtia/atresia usually have nor-
tissues from the middle/external ear and is, therefore, almost mal hearing in the contralateral ear. This should be veri-
always normal in patients with microtia. In other words, the fied by an otologist as early as possible after birth. The
hearing loss in microtia/atresia patients is conductive in nature. main goal then becomes protection of the better hearing ear
throughout development. It is important that otitis media
Incidence/Genetics in the ear with normal hearing be treated completely and
that a hearing test be repeated after completion of treat-
The incidence of microtia varies widely among ethnic groups.
ment. Residual middle ear fluid in the normal ear may
Textbooks cling to the figure of 1 in every 6,000 births. The
result in hearing impairment and consequently interference
incidence is higher in patients of Asian ethnicity. In addition,
with speech development.
microtia is almost twice as common among males as females
Patients with unilateral microtia reasonably do well from
and almost twice as common on the right side compared with
a hearing/speech point of view. They have difficulty localiz-
the left. Bilateral microtia occurs somewhere between 10%
ing sounds and discriminating sounds in noisy environments.
and 20% of patients with microtia.
Patients with unilateral atresia can frequently function in a
Most cases of microtia occur in an isolated fashion. Only
classroom and traditionally have survived without amplifica-
rarely does microtia appear to run in families. One exception is
tion. School performance, however, is improved if the child/
Treacher Collins syndrome, which frequently presents with bilat-
teacher employ an FM unit or, even better, if the child has
eral microtia and is inherited in an autosomal dominant fashion.
a bone-conduction or bone-anchored hearing aid to provide
binaural hearing.
Microtia in Hemifacial Microsomia Patients with bilateral microtia/atresia are in an entirely
Older publications suggest that isolated microtia and hemifa- different situation. These patients are functionally deaf with
cial microsomia are distinct entities. In fact, microtia is part complete conductive hearing loss bilaterally. These patients
of the spectrum of hemifacial microsomia deformities, all of are fitted with a bone-conduction hearing aid as early as pos-
which owe their origin to maldevelopment in the first and sec- sible in life and benefit from a bone-anchored hearing aid
ond branchial arches. At one end of the spectrum is the patient retained with a titanium abutment when they get older.
with microtia who appears to have an otherwise symmetrical Approximately one-half of the patients with microtia/aural
face. At the other end of the spectrum is a patient who mani- atresia have middle ear anatomy that can be reconstructed
fests underdevelopment of all tissues on one side of the face, surgically. In bilateral cases, this is extremely important and
including microtia, aural atresia, underdevelopment of the may eliminate the need for a hearing aid or at least decrease
mandible, underdevelopment of the soft tissues of the cheek, total dependence on such a device.
and underdevelopment of the facial nerve. Microtia and hemi- The issue in the unilateral case is not as clear because, as
facial microsomia should not be considered as separate enti- stated above, these patients function reasonably well. Most
ties (Chapter 24). otologists around the world do not recommend canaloplasty

in patients with unilateral microtia. The surgical results are • Atypical microtia. These patients present with deformities
prone to stenosis of the external auditory canal meatus as that do not fit into any of the above categories.
well as scar contracture of the reconstructed tympanic mem-
brane. While the immediate postoperative audiograms show
excellent results, the hearing in the reconstructed ear tends Surgical Reconstruction
to deteriorate with time. There are otologists, however, who The following are the three options for reconstruction of
believe that the results of canaloplasty are more than suffi- microtia:
cient to warrant the procedure in unilateral cases. The timing
1. Autogenous reconstruction.
of the auricular reconstruction relative to the canaloplasty is
2. Composite autogenous/alloplastic reconstruction using an
important. The auricular reconstruction is best performed
alloplastic ear framework.
before the canaloplasty. Auricular reconstruction is possible
3. Prosthetic reconstruction.
after canal surgery but the result is compromised by the scar-
ring in the region.
Autogenous Reconstruction. The two main techniques
described for autogenous reconstruction of the auricle using
Classification

a rib cartilage framework are the Brent technique and the

The microtia deformity itself is enormously variable. At one Nagata technique.
end of the spectrum is an auricle that is slightly small but oth- The Brent technique involves four stages:
erwise normal in appearance. At the other end of the spectrum
is the patient with complete anotia. Various classifications 1. Creation and placement of a rib cartilage auricular frame-
have been proposed to deal with the vast variability in clini- work (Figures 27.7 and 27.8).
cal presentation. The Nagata classification is useful because it 2. Rotation of the malpositioned ear lobule into the correct
correlates with the surgical approach. position (Figure 27.9).
3. Elevation of the reconstructed auricle and creation of a
• Lobule type. These patients have an ear remnant and mal- retroauricular sulcus (Figure 27.10).
positioned lobule but have no concha, acoustic meatus, or 4. Deepening of the concha and creation of the tragus
tragus. (Figure 27.11).
• Concha type. These patients present with an ear remnant,
malpositioned earlobe, concha (with or without acoustic The Nagata technique is performed in two stages:
meatus), tragus, and antitragus with an incisura intertragica. 1. Creation of an auricular framework including the tragus
• Small concha type. These patients present with an ear rem- and rotation of the lobule into the correct position (in
nant, malpositioned lobule, and a small indentation instead other words, combining stages 1, 2, and 4 from the Brent
of a concha. technique) (Figures 27.12 and 27.13).
• Anotia. These patients present with no, or only a minute, 2. Elevation of the reconstructed ear and creation of the ret-
ear remnant. roauricular sulcus (Figure 27.14).
FIGURE 27.7. Fabrication of ear framework from rib cartilage. Brent technique, stage 1. A. The base block is obtained from the synchondrosis
of two rib cartilages. The helical rim is obtained from a “floating” rib cartilage. B. Carving the details into the base using a gouge. C. Thinning of
the rib cartilage to produce the helical rim. D. Attaching the rim to the base block using nylon sutures. E. Completed framework.

A B C
FIGURE 27.8. Insertion of the ear framework. Brent technique, stage 1. A. Preoperative markings indicating the desired loca-
tion of the framework (solid line) and the extent of the dissection necessary (dotted line). B. Insertion of cartilage framework.
C. Appearance after the first stage. A suction catheter is used to suck the skin into the interstices of the framework. (Courtesy
of Burt Brent, MD.)
Technical Details of the Two Techniques. The patient beyond the outline of the eventual auricle. In the Nagata tech-
is examined standing and the location of the earlobe on the nique, a pedicle is maintained to the dissected flap to improve
normal side is transferred to the affected side. This is the single blood supply.
most important marking because symmetrical earlobes is one Attention is turned to the chest. Although a transverse inci-
of the primary goals of the procedure. If the reconstructed ear sion will heal more favorably than an oblique incision, the
is too low, it will not be aesthetically pleasing, no matter how latter provides better exposure. The rectus abdominis muscle
beautiful it is in isolation. The normal ear is traced on clear is divided. In the Brent technique, two pieces of cartilages are
x-ray film and sterilized. Using this tracing, additional tem- harvested. In the Nagata technique, five pieces are required. In
plates are made. A template of the desired framework is made, addition to the synchondrosis of two cartilages and a free rib
approximately 3 to 4 mm shorter and narrower than the even- for the helical rim, the Nagata technique requires removal of a
tual ear. If the Nagata technique is performed, additional tem- piece for the antihelix/triangular fossa, a piece for the tragus/
plates are constructed of the antihelix/triangular fossa piece antitragus, and a piece to be banked in the chest for the second
and the tragus/antitragus piece. stage. This piece is wedged into the sulcus at the second stage
The exact location and orientation of the desired auricle to provide projection of the auricle. Nagata harvests the car-
are drawn on the patient. Decisions are made about the loca- tilages in a subperichondrial plane, leaving the perichondrium
tion of the incisions. In the Brent technique, an incision is in the chest when the cartilages are removed. The author tends
designed that can be used again at the time of lobule rotation to take the cartilages with the perichondrium and has not
and at the time of tragus construction. If the Nagata technique noticed a significant difference in the chest wall deformity. If a
is used, the incision is designed as shown in Figure 27.13, to pneumothorax is created, a catheter is placed into the pleural
allow rotation of the lobule. The incision is made and the cavity. After the incision is closed the catheter is withdrawn
cartilage remnant is removed, carefully preserving the skin while the anesthesiologist applies positive pressure ventilation.
and avoiding buttonholes if possible. The pocket is dissected An additional catheter is left in the wound for the administra-
tion of Marcaine postoperatively.
Details are applied to the base using gouges. In the Nagata
technique, the antihelix/triangular fossa piece is attached. The
helical rim is attached in a similar fashion in both techniques.
The difference is that Nagata recommends waiting until the
child is 10 years old, which yields cartilages that are long
enough to reconstruct the crus of the helix. Finally, the tragus/
antitragus piece is attached in the Nagata technique. Nagata
uses wire sutures. The author has used nylon sutures, rather
than wire, for both the Brent and Nagata techniques, with
adequate fixation and a low incidence of suture extrusion.
The framework is inserted into the pocket along with
two suction drains. Once the closure has been accomplished
and the dressing has been applied, the drains are attached to
Vacutainer tubes. The tubes are changed every half hour for
2 hours, then every hour for 2 hours, and then every 4 hours
overnight. The dressing is removed on the second postopera-
A B tive day and the patient is discharged.
Firmin has made significant modifications in the Nagata
technique and has now accumulated the largest experience
FIGURE 27.9. Rotation of lobule. Brent technique, stage 2. The ear-
lobe is rotated from its vertical malposition into the correct position at
with experience with ear reconstruction in the world—
the caudal aspect of the framework. A. Design of lobe rotation is made over 3,500 cases. The modifications will not be discussed
such that the same incision can be used in stage 4, tragus construction. in detail because she has not yet published them but they
B. After rotation of the lobule. (Copyright Charles H. Thorne, MD.) must be recognized as her contributions. 9 In most cases,
she employs a simpler incision than Nagata that preserves


A B C

FIGURE 27.10. Elevation of framework and skin graft to sulcus. Brent technique, stage 3. A. Incision is designed behind the ear. B. The retroau-
ricular scalp is advanced into the sulcus so that the eventual graft will not be visible. C. Full-thickness graft to the exposed medial surface of the
auricle. (Copyright Charles H. Thorne, MD.)
the retrolobular skin and increases the likelihood that the of the framework. Exposed areas of more than 1 cm in great-
patient can have the ear pierced in the future. In addition, est dimension require urgent coverage, usually with a tempo-
she has added additional pieces of cartilage on the deep roparietal flap and skin graft. In some cases, a flap of skin
surface of the framework to increase the projection of and from the retroauricular region may be used to cover a small
stabilize the tragus and to increase the height of the pos- area of exposed helix. For areas of exposure over the anti-
terior conchal wall. She has also developed classifications helix, a flap of conchal skin can be rotated, leaving the con-
and algorithms for the management of the skin, the type of cha to be skin grafted. In fact, if there is the slightest question
framework necessary, and the technique used for the eleva- about whether an exposed area will heal, then flap coverage
tion at the second stage. is indicated. One never regrets performing flap coverage of an
An example of framework construction is shown in exposed area of cartilage framework, but one may certainly
Figure 27.15. The appearance after insertion in the skin regret not performing such a procedure.
pocket is shown in Figure 27.16. An example of a postopera-
tive result is shown in Figure 27.17. Elevation of Framework. In the third stage of the Brent
technique and the second stage of the Nagata technique, the
Complications. Complications of the Brent technique are previously placed framework is elevated and the retroauricu-
rare in experienced hands. Complications of the Nagata tech- lar sulcus is resurfaced. Nagata adds a piece of rib cartilage
nique, at least in the author’s hands, are relatively common. covered with a temporoparietal flap. The cartilage is banked
The most common complication is exposure of the carti- under the skin at the time of the first stage and is wedged into
lage framework. Management requires experience, but these the sulcus to provide projection to the reconstructed auricle in
wounds may heal by secondary intention if they are less than the second stage. The fascial flap covers the graft and provides
1 cm in maximum dimension and not over a prominent part a bed for skin grafting (Figure 27.14). In both the techniques
A B C
FIGURE 27.11. Construction of tragus. Brent technique, stage 4. A. The conchal graft is taken from the posterior conchal wall of the contralateral ear.
B. An L-shaped incision is made and the graft is inserted with the skin surface down. C. The graft healed nicely. (Copyright Charles H. Thorne, MD.)

FIGURE 27.12. Fabrication of ear framework from rib cartilage. Nagata technique, stage 1. A. In a manner similar to Brent, the base and its
details are carved from the synchondrosis of two adjacent ribs. B. The four pieces of cartilage that make up the cartilage framework are seen and
numbered. The base and helical rim are present as they are for the Brent technique. There is an additional antihelix-triangular fossa piece and an
additional tragus-antitragus piece that are unique to the Nagata procedure. (Copyright Charles H. Thorne, MD.)
A B
FIGURE 27.13. Insertion of the cartilage framework. Nagata technique, stage 1. A. The incision is designed, robbing most of the skin on the medial
surface of the lobule that will be necessary to line the concha. B. The pocket is dissected, leaving an intact “pedicle” at the caudal end of the flap.
C. The framework is inserted. D. Appearance of the framework after stage 1. Suction drains are in place to coapt the skin to the underlying cartilage.
(Copyright Charles H. Thorne, MD.)


A B C
FIGURE 27.14. Elevation of framework. Nagata technique, stage 2. A. The auricle is elevated, the scalp is advanced into the sulcus (arrows), the
cartilage graft is wedged into the sulcus, and the graft is covered with a temporoparietal flap and skin graft. B. The skin graft is in place. Nagata
described the use of split-thickness skin but this author has noted tremendous shrinkage of the thin grafts and recommends full-thickness graft. C.
Cross section showing the cartilage graft in place providing projection as well as the temporoparietal flap covering the cartilage graft. (Copyright
Charles H. Thorne, MD.)
the scalp is advanced into the depth of the sulcus, and the some cases obliterating the reconstructed sulcus. For this rea-
medial surface of the elevated framework is resurfaced with son, the author prefers a full-thickness graft from the groin.
a skin graft. The disadvantage is a visible scar but the full-thickness graft
Both Nagata and Brent recommend a split-thickness graft resists contracture and is more likely to result in maintenance
for this stage. The grafts contract significantly, however, in of the reconstructed sulcus.
A B
Figure 27.15. Construction of the cartilage framework. A. This

author uses Nylon sutures to attach the cartilage pieces to construct
the framework. Firmin and Nagata employ stainless steel wire. B. The
completed framework. C. The deep surface of the completed frame-
work showing the extra pieces described by Firmin to stabilize the tra-
gus and to increase the projection of the posterior wall of the concha.
(Copyright Charles H. Thorne, MD).
C

A B
Figure 27.16. The framework immediately after insertion. A. Appearance of the framework after insertion and application of suction to the
drains. B. Close-up view. The abnormal contour near the lobule is one of the drains. (Copyright Charles H. Thorne, MD.)
Composite Autogenous/Alloplastic Reconstruction. In also tire of the maintenance required of the abutments and
these patients, an auricular framework composed of porous the surrounding soft tissue. If adequate hygiene is not main-
polyethylene (Medpor) is used instead of costal cartilage. tained, the skin/abutment interface becomes inflamed and
Reinisch originally reported a 42% incidence of implant expo- use of the prosthesis must be discontinued awaiting resolu-
sure. He modified the technique, adding temporoparietal flap tion of the inflammation. Additionally, the daily removal and
coverage of the framework, and reported a vastly decreased replacement of the prosthesis serves as a constant reminder
complication rate. of the deformity. In contrast, children with an autogenous
reconstruction incorporate the new ear into their sense of self.
Prosthetic Reconstruction. Prior to the introduction Finally, prostheses lack the warmth and texture of autogenous
of implant retention of prostheses, prosthetic reconstruc- reconstructions and, despite the superior details, are not more
tion depended on adhesive retention and was impractical. “lifelike.”
Branemark osseointegrated titanium implants have made It is important to note that prostheses require replacement
prosthetic reconstruction somewhat more practical but this every five years for the life of the patient and, therefore, pros-
technique remains, in the author’s opinion, a second choice to thetic reconstruction is more expensive in the long term than
autogenous reconstruction. autogenous reconstruction.
Children are poor candidates for prostheses, often refusing To this author’s thinking, the only absolute indication for
to wear them regardless of the retention mechanism. Children prosthetic reconstruction in a child with microtia is failed
Figure 27.17. Example of a patient with microtia and the postoperative result. (Copyright Charles H. Thorne, MD.)

autogenous reconstruction with inadequate soft tissue for used, the ear would be placed far too posteriorly and would
either a second autogenous reconstruction or a Medpor recon- appear strikingly abnormal. Of equal importance, however,
struction. In such a patient, a prosthesis may represent the the ear must not be placed too low or too anterior. The
only salvage procedure available. author attempts to place the ear in the correct craniocau-
Relative indications for the use of prosthetic reconstruc- dal position so that the earlobes are at the same level and
tion include a very low hairline where a temporoparietal flap then determines the anteroposterior positioning based on
would be required to allow autogenous reconstruction or the relationship to the sideburn. No ear will look normal
extreme hypoplasia of the tissues with a concavity where the unless there is a sideburn in front of it.
auricle will eventually be located.
Acquired Deformity versus Microtia
Personal Thoughts on Surgical Reconstruction. The
author has extensive experience with both the Brent and the Total auricular reconstruction of the acquired deformity
Nagata techniques of auricular reconstruction and it is on the differs from congenital microtia. There is always less skin
basis of that experience that the following comparative state- available. In microtia, removal of the cartilaginous remnant
ments are made. provides some supple, unscarred skin to supplement the

The Nagata procedure was designed to address the per- retroauricular skin. In the acquired situation, there may be

ceived weaknesses of the Tanzer/Brent technique, particularly no residual ear skin, and the presence of scarring from the
the region of the concha, crus of the helix, tragus, and incisura traumatic or surgical removal of the ear restricts the skin
intertragica. As such, the best possible Nagata-type result may pocket. In many cases, a temporoparietal flap with skin
have superior details to the best possible Brent-type result. graft is required in addition to the native skin. The flap
The problem is that the “best possible results” do not occur provides an unlimited amount of vascularized tissue, but
most of the time. the combination of the flap and the skin graft never has the
The Nagata procedure, at least in the hands of this author, definition or color match of the native skin. In addition, the
is definitely associated with a higher complication rate. The presence of an external auditory meatus limits the access
framework is of much higher profile, is much more complex incisions, the extent of the skin pocket, and the risk of
in its details, and contains many more sutures. As such, the infection. The canal is colonized with bacteria, frequently
chance of cutaneous necrosis with framework exposure is sig- Pseudomonas species, which adds additional problems not
nificantly greater using the Nagata technique. On the other encountered in microtia cases.
hand, these areas of exposure are generally small and heal
without further surgical intervention and do not necessarily Special Situations
compromise the result.
The individual surgeon must decide, factoring in his/her Acute Auricular Trauma and Cauliflower Ear
experience, whether the possibility of a superior result is worth A hematoma may result from trauma and frequently occurs in
the increased risk of the Nagata procedure. In his own prac- wrestlers. Unless evacuated, the blood tends to become carti-
tice, this author currently uses the Nagata/Firmin technique laginous, resulting in the so-called cauliflower ear. Once fully
in most patients. In patients with extremely tight skin, or the developed, the cauliflower ear is extremely difficult to correct.
presence of other scars, the Brent technique is used because of Hematomas may require repeated aspirations or an incision to
its safety and reliability. fully evacuate. Suturing gauze bolsters to the auricle to com-
The other issue involves the chest donor site. The Nagata press the skin against the cartilage usually prevents reoccur-
technique requires harvesting twice as much cartilage as the rence (Figure 27.18).
Brent technique. While Nagata harvests all cartilage subperi-
chondrially, no detailed study has been performed comparing
the chest wall deformity created by the Nagata technique at
Amputated Ear
age 10 years with the deformity created by the Brent technique Most attempts to replace an amputated ear will fail, resulting
at age 6 years. Although the donor site is an issue not to be in additional incisions/scars and “burning bridges” that may
ignored, it tends not to be an issue regardless of which tech- be useful for secondary reconstruction. The patient, however,
nique is used. Patients simply do not complain about the chest will not easily accept the decision to discard the amputated
unless they are extremely thin. part without an attempt at replacement. There is no easy
Proponents of the composite alloplastic/autogenous recon- answer.
struction using Medpor cite the lack of chest donor-site scars/ Replantation of amputated ears has been reported and
deformity as an advantage. Although that is true, these same some excellent results have been obtained. The vessels are
reports fail to mention the scars/deformity that replaces the small, however, and failure is common. Any attempt at replan-
chest deformity. For example, the composite technique robs tation must consider that success is unlikely and may result in
the contralateral normal ear of all the skin behind it, result- scars that limit later reconstructive attempts. Incisions for the
ing in obliteration of the sulcus or a skin graft donor-site scar exposure of recipient vessels are kept to a minimum.
if the retroauricular defect is replaced with partial-thickness Reattaching large pieces of auricular tissue as composite
skin. Additionally, this technique requires a scalp scar to grafts is doomed to failure. The good news is that such an
harvest the temporoparietal flap. These scars are frequently attempt does not disrupt the surrounding tissues, does no harm,
hypertrophic and/or associated with thin strips of alopecia, and makes the patient feel that “something” is being done.
which may be more troublesome to the patient than a chest Removing the skin from the cartilage and burying it beneath
wall scar. the retroauricular skin is a poor choice. The thin, delicate car-
tilage will not maintain its shape sufficiently against the forces
of scar contracture. An alternative is to cover the de-skinned
Severe Facial Asymmetry cartilage with a temporoparietal flap. The esthetic result will
Placing the reconstructed ear in the best location is straight- be poor for the reasons mentioned above and this useful tissue
forward if the face is symmetrical or near symmetrical. will not be available for secondary reconstruction.
In cases of significant asymmetry, however, compromises Several successful cases have been reported in which
must be made. The surgeon cannot rely on measurements the posteromedial skin was removed from the amputated
from landmarks such as the lateral canthus and oral compart, the cartilage was “fenestrated,” retroauricular skin
missure, because the entire side of the face is so much was excised, and the part was placed on the healthy bed.
smaller than the other side. If such measurements were The anterolateral auricular skin is vascularized through the

A B C
FIGURE 27.18. Management of an acute othematoma. A. Recurrent conchal hematoma. B. Through-and-through bolster sutures, after evacuation
of the hematoma. C. Appearance of ear after the compression dressing has been removed at 10 days. (Courtesy of Burt Brent, MD.)
cartilage fenestrations by direct contact with this healthy,

vascularized bed. Earring Complications
In the opinion of the author, the ideal scenario for an While ingenious techniques have been described to reconstruct
amputated ear is an attempt at microvascular replantation traumatic clefts in the lobe caused by earrings, the most reli-
through the available wound, without additional incisions. able method is to excise and close the defect in one stage and
If unsuccessful, secondary reconstruction with rib cartilage re-pierce the ears 6 weeks later, or whenever the induration
grafts is performed, with or without a temporoparietal flap. subsides.
If replantation is not an available option, the part should be Another complication of earrings is keloid formation.
replaced as a composite graft (knowing it will fail), or the part Small keloids can be excised and closed primarily and may
should be discarded. not recur. If the patient is truly prone to keloids, then excision,
triamcinolone injection, and pressure earrings are warranted.
Acute Auricular Burns If the keloid recurs, excision with immediate irradiation offers
the best chance of avoiding recurrence.
Acute burns may result in chondritis. Characterized by ten-
Finally, piercing through the cartilage in the upper portion
derness, erythema, warmth, and induration, chondritis usually
of the ear can result in severe infections. While not common,
occurs several weeks after the initial injury. Once chondritis is
chondritis can lead to severe, permanent disfigurement of
diagnosed, aggressive steps are taken to eradicate the infection
the auricle. Infections, therefore, are treated aggressively. If
and prevent subsequent deformity. Drainage and placement of
cartilage requires debridement, it is performed early to limit
an irrigation system is an appropriate first step. If this therapy
the deformity and incisions are planned carefully to minimize
fails, the involved cartilage must be debrided. When the latter
these deformities.
becomes necessary, incisions are planned judiciously to mini-
mize the effect on secondary reconstruction.
References
Skin Cancer/Malignant Melanoma 1. Antia NH, Buch MS. Chondrocutaneous advancement flap for the marginal
defect of the ear. Plast Reconstr Surg. 1967;39:472
Cutaneous malignancies of the helical rim can be excised and 2. Bastidas N, Jacobs JM, Thorne CH. Ear lobule reconstruction using nasal
closed with helical advancement as described above. Lesions septal cartilage. Plast Recon Surg. 2013;131(4):760.
in the concha or over the antihelix can usually be excised 3. Tanzer R C. Total reconstruction of the auricle: a 10-year report. Plast
and skin grafted. If the cartilage is involved, it can be excised 4. Brent BD. Technical advances in ear reconstruction with autogenous rib
and the graft placed directly on the posterior skin. Malignant cartilage grafts—personal experience with 1,200 cases. Plast Reconstr Surg.
melanomas should be excised with the same margins as mel- 1999;104:319.
anomas of the equivalent depth in other parts of the body. 5. Nagata S. A new method of total reconstruction of the auricle for microtia.
Plast Reconstr Surg. 1993;92:187.
Melanoma in situ does not require a full-thickness excision. 6. Firmin R. Ear reconstruction in cases of typical microtia. Personal experi-
These lesions are excised with a 5-mm margin, preserving the ence based on 352 microtic ear corrections. Scand J Plast Surg. 1998;32:35.
perichondrium, and the skin grafted. Invasive melanomas of 7. Reinisch JF, Lewin S. Ear reconstruction using a porous polyethylene frame-
the helical rim require wedge resection to achieve adequate work and temporoparietal fascia flap. Facial Plastic Surg. 2009;25(3):181.
8. Thorne CH, Brecht LE, Bradley JP, et al. Auricular reconstruction: indi-
margins, eliminating helical advancement as an alternative cations for autogenous and prosthetic techniques. Plast Reconstr Surg.
for closure. These defects may be large and require secondary 2001;107(5):1241.
reconstruction. 9. Firmin, Personal communication and unpublished data, 2013.

Chapter 28 n Miscellaneous Craniofacial
Conditions: Fibrous Dysplasia,
MOEBIUS Syndrome, Romberg
Syndrome, Treacher Collins
Syndrome, Dermoid Cyst, and
Neurofibromatosis
Robert J. Havlik

This chapter describes several disorders that do not “fit” in relatively easily diagnosed based on clinical and radiologic
with other conditions in plastic surgery, or for that matter, investigation, whereas establishing the diagnosis of the mono-
with other conditions in medicine. With the exception of neu- stotic form is more difficult because of the number of other
rofibromatosis, these conditions are distinctly uncommon. important lesions that are included in the differential diag-
With the rapid developments in molecular biology, two of nosis. In the axial skeleton the lesions frequently appear as
these disorders have been shown to be caused by disorders in well-circumscribed radiolucent lesions with a thin sclerotic
intracellular second messenger systems—fibrous dysplasia and periphery. In contrast, the lesions of the craniofacial skeleton
neurofibromatosis 1 (NF-1). are more poorly defined and more radiopaque. Bone biopsy in
many areas of the axial skeleton in fibrous dysplasia is gener-
ally avoided, especially where the risk of pathologic fracture
Fibrous Dysplasia is high. However, in the mandible, where monostotic involve-
Fibrous dysplasia is a benign disorder of the bone that affects ment is most frequent in the craniomaxillofacial skeleton and
both the axial and the craniomaxillofacial skeleton. Fibrous therefore there is the greatest difficulty differentiating this
dysplasia is not “classically” a congenital disorder, since it from other solitary bony lesions, bone biopsy has not been
is not usually evident at birth, but becomes clinically evident reported to cause a pathologic fracture in fibrous dysplasia.
during late childhood or adolescence. It occurs sporadically Malignant degeneration of fibrous dysplasia has been reported
and genetic transmission has not been documented. Fibrous to occur in 0.5% of cases with monostotic involvement, and
dysplasia has been traditionally divided into three main cat- up to 4% of cases with McCune-Albright syndrome. Notably,
egories: monostotic (or monocystic), polyostotic, and the the most frequent site for sarcomatous degeneration is the cra-
McCune-Albright syndrome. The majority of patients (∼70% niofacial skeleton.
to 80%) present with a single area of bony involvement
(monostotic or monocystic fibrous dysplasia).1 Of the patients Pathogenesis
with polyostotic fibrous dysplasia (20% to 30%), approxi- This disorder is centered around a structural and functional
mately 3% present with a triad of polyostotic fibrous dyspla- change in the cellular transduction mechanism involving
sia, precocious puberty, and skin pigmentation known as the G-proteins.1 The G-protein is a membrane-bound intracellu-
McCune-Albright syndrome.1 This skin pigmentation pres- lar signaling mechanism that carries the message of extracel-
ents as “café-au-lait” spots with irregular borders, described lular hormone binding into the cell to create an effect. The
as being similar to the coastline of Maine. In addition to G-proteins themselves have an intrinsic activity that causes
this classic triad, McCune-Albright syndrome is also associ- hydrolysis of GTP to GDP. In fibrous dysplasia, the G-protein
ated with several different endocrine disorders, all caused by has a decreased ability to hydrolyze GTP, resulting in the
autonomous hormonal overproduction, such as growth-hor- G-protein remaining in an activated state, leading to continued
mone producing pituitary adenomas, hyperthyroid goiters, stimulation of cAMP and multiple other effects.1 Significantly,
and adrenal hyperplasia. many of the adrenal, hypophyseal, thyroid, and gonadal cells
The craniomaxillofacial structures are involved in approxi- of patients with McCune-Albright syndrome show the same
mately 25% of cases with monostotic fibrous dysplasia and mutations, thereby leading to increased “on” activity, and
up to 50% of cases with polyostotic involvement. The most constitutively increased hormone production.
common presentation in the craniofacial skeleton is that of a It has been postulated that the timing at which this muta-
painless, enlarging mass of bone. The maxilla is the bone most tion occurs in embryologic development may determine the
often involved, followed in frequency by the frontal bone, clinical extent of the disease. In other words, a mutation that
but all bones of the craniomaxillofacial skeleton may show occurs late in embryologic development or even a postnatal
involvement. The clinical manifestations of fibrous dysplasia one will lead to a decreased cellular complement with the
include expansive growth leading to aesthetic and functional mutation and therefore lead to the development of monostotic
compromise. Maxillary lesions can lead to dental malocclu- bone involvement. In contrast, a somatic mutation that occurs
sions, tilting of the occlusal plane, or significant facial defor- in early embryologic development would lead to a larger por-
mity and asymmetry. In lesions with orbital involvement, tion of afflicted cells within the individual, and this leads to
visual disturbance, ocular proptosis, and orbital dystopia can multicentric involvement (polyostotic fibrous dysplasia). If the
occur. In lesions with sphenoid involvement, blindness may mutation occurs early enough in development, it may also lead
occur as a result of impingement on the optic nerve. to the involvement of additional tissues (endocrine disorders,
The difficulty in the diagnosis of fibrous dysplasia var- McCune-Albright syndrome, etc.). As noted above, there have
ies with the extent of presentation of the disease. The poly- been no documented cases of genetic transmission of fibrous
ostotic and McCune-Albright forms of fibrous dysplasia are dysplasia, it is believed to be a lethal mutation.
295
in fibrous dysplasia without a significant risk of fracture.

Treatment Depending on the severity of the involvement, either contour
Treatment of fibrous dysplasia in the craniofacial skeleton is reduction or resection can be performed. In lesions involving
determined by the functional or aesthetic problems created by the ramus in which the temporomandibular joint (TMJ) is
the disease process. The mere existence of fibrous dysplasia spared, every effort should be made to plan the resection and
does not mandate treatment. In bones of the axial skeleton, reconstruction maintaining the existing joint. In larger lesions,
the expansile process, coupled with cortical resorption, can resection of the tumor with free fibula reconstruction is a rea-
lead to decreased structural strength and pathologic fracture. sonable approach.
This is seldom the case in the craniomaxillofacial skeleton, Until recently, surgical treatment was the only option for the
and indications for treatment are more frequently related to treatment of fibrous dysplasia. Recently, several small series
aesthetic imbalance, facial disfigurement, distortion of the have been published using medical therapy with pamidronate,
functional occlusion, ocular proptosis, and impingement on an aminobisphosphonate.3 This treatment has resulted in an
neural foramina. Impingement on the optic nerve has led to increase in bone mineral density and radiologic signs of heal-
visual disturbance and blindness. ing with the thickening of the cortical bone in some cases. In
Treatment recommendations for fibrous dysplasia have many cases, there has also been a significant decrease in pain
occasionally been made based on the clinical observation that with pamidronate therapy. Bisphosphonate therapy can be
the disease will “burn out” in the post-pubertal adolescent complicated by the formation of bony sequestra. Figure 28.2
state as skeletal maturity is reached. Unfortunately, there are shows a bony sequestrum of the maxilla that eroded through
no data to support this contention. the palate. Radiation therapy is contraindicated because of an
Surgical treatment is often designed to counter the effects increased propensity for malignant transformation.
of mass expansion and the consequent deformity that occurs
in the facial skeleton. Therefore, in most cases, surgery of the MOEBIUS Syndrome
craniofacial skeleton will consist of either a contour reduc-
tion of the afflicted area, or resection and replacement of the Moebius syndrome is a rare disorder characterized by absence
affected bone. Contour reduction is a more limited operation, of certain cranial nerves. Classically, Moebius syndrome is
but the lesion always recurs. A decision is made between con- defined by the absence of the sixth and seventh cranial nerves
tour reduction versus resection and replacement based upon resulting in masklike facies, incapable of animation, and an
the rate of tumor growth, or the “aggressiveness” of this inability to laterally deviate the eyes (abducens palsy). The
benign process, and the location and potential complications inability to show a facial response to verbal and nonverbal
of continued growth and expansion. Resection is followed communication is a devastating deficiency. In the United
by reconstruction with either prosthetic materials or bone Kingdom, there were approximately 90 cases of Moebius
autograft. syndrome in a population of 50 million people, yielding a
In the cranial vault, bone involvement is frequently both prevalence of 1 in 550,000. By extrapolation, in the United
expansile and hyperostotic. The frontal bone is the most fre- States there would be expected to be approximately 500 cases.
quently involved bone, followed by the sphenoid bone. In In some publications, Moebius syndrome is defined more
the case illustrated in Figure 28.1 both resection and contour broadly, including patients with additional facial nerve pal-
reduction techniques were used for hyperostotic fibrous dys- sies. Involvement of nearly all of the facial nerves has been
plasia in the right frontoorbital region and the right parietal documented, but the third, ninth, tenth and twelfth nerves are
region. The resection and cranial bone autograft reconstruction most commonly involved.4 In addition to the characteristic
were performed in the right orbit and frontal bone, where the facies associated with the sixth and seventh nerve palsies, pto-
potential problems with recurrent tumor and repeat resection sis, nystagmus, or strabismus may be present, and epicanthal
would be more complicated. In contrast, the parietal bone was folds are frequent (Figure 28.3). The nose typically has a high,
completely removed, and contour reduction was performed broad nasal bridge, and this increased breadth extends down-
down to the level of the cortical plate. When fibrous dysplasia ward to the nasal tip. The mouth opening is typically small. In
involves the skull base, surgical resection is not possible. addition, there can be hypoplasia of the tongue, either unilat-
Fibrous dysplasia of the orbit raises several special con- erally or bilaterally. There frequently is poor palatal mobility,
siderations. First, the mass effect of bone growth can lead to poor suck, inefficient swallowing, and drooling. The mandible
dystopia and visual disturbances. The potential problems of tends to be hypoplastic. These factors can contribute to dif-
recurrence in this area, particularly with the potentially more ficulty feeding during the first year of life, frequently leading
difficult surgery in the recurrent field from scarring, often to poor growth. A coarse voice and speech impairment can
swing the balance toward resection of the afflicted bone and be present, although hearing is usually normal. As the child
replacement. Second, specific to the orbit is the concern that grows, the ability to open the mouth and feed improves slowly
growth of fibrous dysplasia can lead to optic nerve compres- and significantly. The facial paralysis and masklike facies may
sion, subsequently leading to visual change and blindness. tend to bias early estimates of psychomotor activity, which
Visual loss has been cited as the most common neurologic tend to be low. Despite the perception created by the lack of
complication of fibrous dysplasia involving the skull. facial expression, only 10% to 15% are mentally retarded.4
Although optic nerve decompression in patients with
fibrous dysplasia of the sphenoid surrounding the optic canal Etiology and Pathogenesis
and with documented changes in vision is widely accepted, The etiology of this disorder has not been clearly elucidated.
“prophylactic” decompression of the optic nerve is not rec- It occurs sporadically, and in cases of “classic Moebius syn-
ommended. Furthermore, decompression after visual decre- drome” involving only sixth and seventh cranial nerves,
ment or visual loss will not restore the visual deficit.2 The risks genetic transmission is rare. For Moebius syndrome, four
involved with surgical decompression of the nerve include separate and distinct, though not mutually exclusive, patho-
a lack of improvement in vision, which occurs in anywhere genetic mechanisms have been advanced: (1) aplasia/hypopla-
from 5% to 33% of cases, and blindness resulting from sia of the cranial nerve nuclei; (2) destruction of the cranial
the surgery.2 nerve nuclei; (3) peripheral nerve abnormalities; and, (4) pri-
Fibrous dysplasia of the mandible presents as a mass lesion mary myopathy. Operative findings and postmortem exami-
with cortical expansion. Because the presentation with man- nations have supported each of these four mechanisms.4,5 In
dibular disease is frequently monostotic, bone biopsy may be those patients with cranial nerve nuclei deficits, as with other
indicated to establish or confirm the diagnosis. As noted pre- central deficits, “downstream” changes in nerve and muscle
viously, biopsy of the mandible can be safely accomplished would be expected to occur.

Chapter 28: Miscellaneous Craniofacial Conditions 297

A B
C D
FIGURE 28.1. Fibrous dysplasia. A. Preoperative lateral view of

fibrous dysplasia involving right orbit, frontal bone, and parietal bone.
B. Preoperative “worm’s eye” view. C. Preoperative axial CT image.
D. Intraoperative view showing increased density of fibrous dyspla-
sia involving right frontal and right parietal bones. E. Planned split
graft donor site using metallic template fabricated in 1F (illustration
by Min Li MD). F. Intraoperative view following completed resection
of tumor and reconstruction of orbital roof and supraorbital bar using
split cranial bone grafts from left parietal bone and contour reduction
of right parietal bone. G. CT scan showing completed reconstruction.
H. Three-year postoperative frontal view. I. Three-year postoperative
“worm’s eye” view.
E

H
I


A
FIGURE 28.2. A. Axial and (B) coronal images of bony sequestrum

of maxilla in patient with fibrous dysplasia that eroded through palate. B
inability to show a facial response. Facial reanimation surgery,

Treatment which employs microvascular free muscle transfer innervated
Treatment has progressed more rapidly than our understanding through the use of a suitable motor nerve, is effective in restor-
of this rare disorder. This treatment is focused on alleviating one ing function in many different etiologies of facial nerve deficits,
of the most socially devastating problems of this disorder—the and this treatment has been extended to Moebius syndrome.
Zuker et al. report a series of 10 patients who had an average
movement of their oral commissures following bilateral micro-
vascular transfers of 1.37 cm, allowing for meaningful and
deliberate facial animation.5 In addition, the children showed
improvement with drooling and improved ability to drink. The
surgery also has a definite benefit on speech.5
Romberg Disease (Progressive

Hemifacial Atrophy)
Progressive hemifacial atrophy (PHA) is widely known by the
eponym Romberg disease. In an era of molecular and genetic
analysis, PHA remains the most enigmatic of the craniofacial
disorders. The etiology of this disorder remains unknown.
Clinical Findings
PHA may involve any or all of the facial tissues, typically
involving skin and subcutaneous tissue, but also potentially
muscle, cartilage, and bone. Although there is new evidence
that the trigeminal nerve (V) is involved, Pensler et al.6 have
reviewed the clinical course in 41 patients and report that the
initial presentation included the distribution of V1 in 35% of
cases, the distribution of V2 in 45% of cases, and the distri-
bution of V3 in the remaining 20% of cases. Facial involve-
ment is unilateral in 95% of all cases, and either side of the
face is equally likely to be involved. The initial presentation
typically involves the skin and may be quite subtle, sometimes
including pigment changes in which there may be either a
brownish or bluish color to the skin, or even hypopigmen-
tation. Alternatively, the disorder may present as a limited
area of atrophy of the subcutaneous fat. A striking arche-
typal presentation often includes a nearly vertical linear
FIGURE 28.3. Child with Moebius syndrome with typical masklike depression of the forehead extending into the eyebrow and
facies and downslanted oral commissures. frontal hairline, known as the coup de sabre, or “cut of the
saber” (Figure 28.4). This clinical sign was thought to be

C D
FIGURE 28.4. Progressive hemifacial. A. Frontal view of 14-year-old female with onset at 10 years. There is a large area of alopecia of scalp,
mild soft tissue depression, loss of medial eyebrow, and vertical deficiency of right alar rim consistent with a mild “coup de sabre” type deformity.
The nose not only shows vertical deficiency, but also thinning and collapse. Radiographic evaluation revealed no evidence of skeletal irregularity.
B. Intraoperative view showing dermal fat graft in position for grafting soft tissue deficiency of forehead. An ear cartilage conchal bowl com-
posite graft was used to reconstruct the alar deficiency after the rim was dissected free. C. Initial postoperative result of ala reconstruction.
D. Postoperative result. The dermal fat graft initially led to significant overcorrection of the deficiency, but now yields a favorable result. The alar
correction was diminished by the late presentation of a Pseudomonal infection of the cartilage.
pathognomonic for Romberg disease, but can also be noted lasts from 2 to 10 years. The subcutaneous tissue is the most
in linear scleroderma, a subtype of localized scleroderma, and severely involved, followed by substantial involvement of
this has led to a potential overlap of these diagnoses. the skin and muscle. The facial musculature undergoes thin-
PHA is not a congenital disorder, with the typical onset ning, but usually maintains sufficient power to animate the
being in the first or second decade of life. The hallmark of the face. The muscle involvement commonly includes atrophy of
disorder is a slowly progressive course, with an “active phase” the tongue and palatal tissues. Patients with an early age of
of disease characterized by involution, or “wasting away” of onset (during facial growth) are much more likely to have sig-
the skin, subcutaneous tissue, and muscle. This active phase nificant skeletal involvement. Pensler et al.6 report that 65%

of their patients had osseous involvement, and they found a the onset of tissue involution. The sympathetic hypothesis is
strong correlation between the age at onset and the degree based on an association of Horner syndrome, pilomotor reflex
of bone hypoplasia. However, in their review, they noted no changes, unilateral mydriasis, vasomotor disorders, unilateral
correlation between the other findings of severity of soft tis- migraine, and perspiration disorders. Based on current evi-
sue atrophy, the duration of the disease, the initial site of skin dence, no definitive etiology has been established.
changes, and the eventual location or magnitude of the skel- The insightful work of Pensler et al. has provided some
etal involvement. enhanced understanding.6 First, in their clinical review, they
In cases where the disease occurs during the first decade found no evidence of sensory, sympathetic, parasympathetic,
of life, profound skeletal hypoplasia is usually present. This or sudomotor dysfunction. Muscles of mastication and facial
stands in distinct contrast to those cases that present initially expression were found to be fully functional. Biopsies revealed
in the second decade of life. In these latter cases, there is typi- epidermal atrophy and a variable perivascular mononuclear
cally limited, if any, impact on the facial skeleton with the cell infiltrate, with morphologic characteristics of lymphocytes
gross morphologic changes being limited to the skin and sub- and monocytes, that were grouped around dermal neurovas-
cutaneous tissue. The patient in Figure 28.4 had disease onset cular bundles. Many of the venules were noted to have striking
at 10 years of age. There is clinical involvement of the skin, degenerative alteration in the lining epithelium with reduplica-

eyebrow, and periocular tissues. There is clearly hypoplasia or tion of the basal lamina. Significantly, they also noted that

atrophy of the right nasal sidewall and cartilaginous atrophy elastic fibers were present and morphologically intact (in con-
of the nasal ala. Her dental development and occlusal rela- trast to linear scleroderma). They interpret these findings as
tions show no signs of involvement. In view of this strong cor- being consistent with a lymphocytic neurovasculitis, and they
relation of the severity of this disorder with the age of onset, advance this theory as a pathogenetic mechanism.
it is unclear whether the facial skeleton actually undergoes Understanding the pathogenesis of this disease is compli-
atrophy. More likely, the bone fails to develop fully in the cated further by the apparent overlap between the disorder of
field of overlying atrophy of the skin and subcutaneous tis- linear scleroderma and PHA. It is very likely that many of the
sue. The skeletal “atrophy” in PHA is more accurately termed cases that have historically been termed Romberg disease may
hypoplasia. include cases of linear scleroderma, since differentiating the
In early onset cases, the skeletal involvement often includes two clinically is difficult, if not impossible. Linear scleroderma
the mandible and midface, with concomitant implications for may also show monocytic infiltrates. The only finding that has
the occlusal relationships and facial appearance. There can been reported as useful to differentiate these two disorders
be hypoplasia of the mandible, including significant verti- is the absence of elastic fibers in the scleroderma group, and
cal undergrowth of the ramus and a deficiency in posterior their preservation in the PHA group.6 The fact is that these
facial height. The mandible may also show significant sagit- two diagnoses may be describing the same entity.
tal undergrowth. The maxilla may also manifest both verti-
cal and sagittal undergrowth in the sagittal plane. Because
the involvement is unilateral, profound tilting of the occlusal Treatment
plane develops. When PHA involves periorbital tissues enoph- Many surgeons will defer treatment until the disease “burns
thalmos is a frequent finding. Pensler et al., based on radio- out,” or reaches a stable plateau phase. For milder asymmetry
graphic orbital measurements, suggest that the enophthalmos and atrophy of the skin and subcutaneous tissue, injection of
is not due to a skeletal change in the orbital volume, but that it collagen and hyaluronic acid derivatives or fat injection can
is related to atrophy of the periorbital soft tissues.6 provide some benefit.
PHA can be associated with many other findings, includ- For small areas of asymmetry, dermal grafts, fat grafts, or
ing areas of skin and subcutaneous atrophy elsewhere on the dermal-fascial-fat grafts can be considered. These can be tai-
body distinct from the face. The disorder is associated with lored to smaller defects and provide an acceptable improve-
nervous system dysfunction including Horner syndrome, tri- ment with a limited operative approach and limited operative
geminal neuralgia, and unilateral mydriasis. Central nervous time and risk (see Figure 28.4). However, because of the
system involvement has been reported in smaller series by sev- variability in graft survival, overcorrection is necessary. In
eral authors, ranging from MRI changes to seizure disorders. addition, there is typically a postoperative period that is char-
However, the relative paucity and inconsistency of data at this acterized by induration. The technique of serial mini-graft
point precludes any definitive correlation between these reports. “threading,” as described by Coleman, has enhanced the reli-
ability of autologous fat grafting.7 Overall, the experience in
the literature with larger nonvascularized transfer of fat tissue
Etiology has been inconsistent.
The etiology of PHA is unknown. PHA does not show any Microvascular free tissue transfer is the gold standard in
genetic predilection, is found in all races, and there is no evi- reconstruction for Romberg disease. Upton et al.8 reported
dence of a hereditary basis. It does occur more frequently in microvascular transfer of scapular and parascapular flaps in
females in most series. Patients will frequently remember an 30 patients, five of whom had Romberg disease. They utilized
“initiating event” in PHA and the onset of the disorder is long fat-fascial extensions with these transfers to fill isolated
often linked to an episode of trauma or infection. However, areas. They noted no postoperative atrophy in the 30 flaps,
it is unclear whether this is simply an event that calls atten- but they did note that in patients who gained weight, the flap
tion to a subtle area of initial clinical involvement, or whether volume increased. In addition, there were isolated areas, such
there are true pathogenetic associations. Traditionally, three as the upper lip, that tended to be undercorrected. They also
theories have been advocated for the etiology of Romberg dis- noted no evidence that free tissue transfer altered the natural
ease: the infection hypothesis, the trigeminal-peripheral neuri- history of the disease process in PHA.
tis hypothesis, and the sympathetic hypothesis. The infectious In children with the early onset of the disorder, there is
hypothesis was historically linked to an irritation of nerves. often distortion of the orbit and the zygomaticomaxillary
In the current era of a new understanding of infectious agents complex, leading to vertical orbital dystopia. Depending on
(viruses, prions, mad cow disease, chronic wasting disease of the severity, this can be corrected either through corrective
deer, etc.), the infectious hypothesis may be remain a tenable osteotomies and vertical repositioning of the orbit, or through
etiology until a definitive understanding of this disorder is bone grafting of the orbital floor. Involvement of the lower
truly established. The trigeminal-peripheral neuritis hypoth- face leads to severe maxillary and mandibular asymmetries,
esis suggests a neuritis involving the trigeminal nerve, and is with distortion of both the facial midline and occlusal plane.
supported by episodes of pain in the involved areas prior to Bimaxillary surgery is necessary to correct the occlusal plane.

entity is that it is bilateral and symmetrical. The periorbital

Treacher Collins Syndrome soft tissues show an antimongoloid slant of the palpebral fis-
Treacher Collins syndrome, or mandibulofacial dysostosis, is sures. The lower eyelid is hypoplastic with a coloboma located
a craniofacial disorder that has an incidence of between 1 in at the junction of the medial two-thirds and lateral third of
25,000 to 50,000 births and is characterized by a range of the lower lid. The deficiency involves both the skin of the
clinical presentations. The full clinical presentation is char- eyelid and the cartilage of the tarsal plate. The lower eyelid
acterized by hypoplasia/aplasia of the body and arch of the also lacks eyelashes typically over the medial third, and the
zygoma, a significantly increased facial convexity, mandibular lower eyelid is vertically deficient. These findings, along with
hypoplasia, a retrusive chin with increased vertical height, and the hypoplastic zygoma, lead to a striking clinical appearance
external ear anomalies. A key distinguishing feature of this (Figure 28.5). The nose is broadened in the midnasal dorsum,
FIGURE 28.5. Treacher Collins syndrome. A. Characteristic facies

with orbital findings including vertically deficient lower lid, lateral
eyelid coloboma, downslanting palpebral fissures (antimongoloid
slant), and hypoplastic malar eminences. B. Five-year-old male with
result of lid switch procedure with conjunctival grafting and cantho-
pexy performed at age 3 shows improvement in the orientation of
the palpebral fissure following resolution of edema and flap promi-
nence (with no further surgery or treatment) reveals favorable eyelid
and palpebral fissure position with deficiency over lateral malar emi-
nence. C. Approximately 1 year result after dermal fat grafting shows
improved contour in the malar eminence in 7-year-old.
C
and can have a slightly elongated appearance. The midface is of soft tissue coverage may also influence the problems with
hypoplastic, particularly at the level of the zygomatic body graft revascularization.
and arch, but also in the maxillae. The mandible is character- A component of the controversy regarding reconstruction
istically hypoplastic, with a chin that has the unusual combi- of the zygoma includes a consideration of the timing of recon-
nation of findings of being both increased in vertical height struction of the zygoma and the age of the patient. Posnick
but deficient in sagittal projection. An anterior open bite is et al.9 reported favorable results with reconstruction of the
often present. This combination exacerbates the overall clini- zygoma using full thickness bicortical grafts for reconstruction of
cal appearance of a facial profile that is much too convex. the zygoma at an age of 5-7 years. An alternative in the younger
Cephalometric analysis has revealed that this facial convex- child about to start school is the use of dermal fat grafts to help
ity is attributable to the mandibular hypoplasia and position, correct the soft tissue deficiency and effectively camouflage the
since the relationship between the midface and the anterior skeletal deficiency (Figure 28.5). Siebert has employed bilateral
cranial base is essentially within the normal range (SNA soft tissue free flaps to camouflage the skeletal deficiency with
angle). In addition, the occlusal plane tends to be quite steep, results that rival or exceed any skeletal reconstruction.
with a clockwise rotation of the plane (hypoplastic posteriorly The nasal deformity in Treacher Collins includes a broad
with decreased posterior facial height). There are characteris- midnasal dorsal hump, further accentuated by the retrusive

tically significant deformities of both the external and middle chin. The nasal dorsum is correctable through conventional

ear present, with a low lying hairline with tongue-shaped cau- rhinoplasty approaches and procedures, with the usual cave-
dal extensions of hair-bearing scalp in the preauricular areas. ats regarding avoiding airway obstruction.
Approximately one-third of Treacher Collins patients have
Pathogenesis a cleft of the palate. Strict attention is directed to ventilatory
Treacher Collins is an autosomal dominant disorder, with a status before considering repair of the cleft palate to avoid
markedly variable penetrance. While up to 60% of cases are ventilatory obstruction. In many cases, this requires correction
thought to arise de novo, the variability in penetrance occurs at of the hypoplastic mandible or tracheostomy prior to attempts
both the interfamilial and the intrafamilial level. All known cases at closure of the palatal cleft.
of Treacher Collins result from mutations in the TCOF 1 gene.
The TCOF 1 gene has been mapped to the 5q31.3-5q33.3 gene
Ears. The ears are characteristically involved in Treacher
Collins syndrome, and this includes the auricle, the external
locus. Identification of family-specific mutations and tracing
auditory canal, and the middle ear. Both left and right sides
these specific mutations through family pedigrees have shown
are afflicted, and the deficiencies tend to be symmetrical.
that the actual number of cases arising de novo may be less,
Middle ear malformations are common, and include aplasia,
and the familial transmission rate may actually be higher, since
hypoplasia, and/or ankylosis of the ossicles. Middle ear defor-
family members previously thought to be unaffected may in fact
mities accounted for the majority of the hearing loss in these
show the genetic mutation.
patients. Most patients (96%) have a moderate or greater
degree of hearing loss. This is critical to recognize and treat
Treatment appropriately since adequate hearing is essential for speech
Patients with Treacher Collins syndrome often require a life- development and speech production. External hearing assis-
saving tracheostomy at birth. The cranial vault may show a tance through hearing aids is often necessary.
mild deficiency in bitemporal diameter, but this is never of the The external ear deformities pose unique problems. First,
magnitude to merit surgical intervention. The orbital changes, the low-set hairline and “tongue” of hair-bearing scalp that
however, are striking and pathognomonic for this disorder. descends in the preauricular area often precludes reconstruc-
The orbital changes are consistent with the hypoplasia of tion with native mastoid skin and requires the alternative use
the zygoma that characterizes the disorder. Treatment goals of a temporoparietal fascial flap with skin graft for adequate
include the correction of both the lower eyelid and the cranio- reconstruction. Second, the external auricle reconstruction
facial skeleton. must be coordinated with the mandibular reconstruction
No perfect procedure exists for the lower eyelids. The and the reconstruction of the zygoma. If there is inadequate
cutaneous deficiency can be corrected through a lid switch non–hair-bearing mastoid skin for ear reconstruction, as
operation. The lid switch operation, with a laterally based is often the case, incisions in proximity to the ear must be
banner flap consisting of skin and orbicularis oculi muscle, carefully planned to preserve the superficial temporal artery,
has the advantage of providing vascularized tissue with an including incisions for any exposure at the level of the TMJ
excellent skin color match (Figure 28.5). The lid switch also and also coronal incision for reconstruction of the zygoma.
has a salutary benefit of vertical repositioning of the lateral If there is favorable mastoid skin for reconstruction, no inci-
canthus contributing to the correction of the antimongol- sions should be planned prior to placement of the cartilage
oid slant of the palpebral fissure. This flap, however, may framework, as these violate the blood supply and can con-
become edematous and remain “prominent” for a prolonged tribute to skin breakdown above the tension of a cartilage
period of time. framework reconstruction. Because the mandibular recon-
Several different techniques have been described for reconstruction must take into consideration obstructive airway con-
struction of the hypoplastic zygoma, including both split cerns and the timing of palatal closure, careful planning of
thickness and full thickness cranial bone grafts, vascular- each step in the child’s reconstruction is necessary. The man-
ized calvarial grafts based on a temporalis muscle pedicle, dibular deformity in Treacher Collins syndrome is extremely
and rib grafts. The cranial bone grafts are typically cut as variable and can include the entire spectrum of mandibular
one-piece T-shaped grafts that serve to reconstruct the body hypoplasia. The deformity can certainly be as complex as the
of the zygoma, the zygomatic arch, and the inferior orbital midfacial deformity. There is typically an exaggerated antego-
rim. Rib grafts are joined through the use of plates. Technical nial notch, clockwise rotation to an anterior open bite defor-
problems include the paucity of soft tissue in the malar emi- mity, and the appearance of excess facial convexity. There is
nence that is available for coverage of the skeletal reconstruc- a decreased posterior facial height and an increased height of
tion, a soft tissue problem exacerbated by the net volume the lower anterior face, partly due to the increased vertical
expansion required with the reconstruction of this area. Bone height of the chin. The mandibular body is also foreshortened
grafts in this area of craniofacial skeleton, however, even- in sagittal dimension. The Kaban/Mulliken modification of
tually undergo resorption. This may be partially due to the the Pruzansky classification of the mandibular deformity in
overlying soft tissue “matrix” in this disorder, and partially hemifacial microsomia is directly applicable and widely used
attributable to the inherent tendency of onlay bone grafts to to characterize the deficiency in Treacher Collins syndrome
undergo resorption with revascularization. The deficiency (Figure 28.6).10
Ultimately, these children will require secondary double jaw

surgery to correct the malpositioned midface, correct the
occlusal plane angle, and correct the facial height discrepan-
cies discussed above. A Le Fort I osteotomy and a sagittal split
osteotomy of the rib graft can be utilized, but obvious care
must be taken in the rib graft osteotomy.
Congenital Dermoid Tumors

Congenital dermoid inclusion cysts of the face are common
entities most commonly located in the upper lateral orbit and
the upper lateral orbital rim, although they also can be found
in the forehead and nasal areas.11 These lesions are benign,
and embryologically these cysts represent displacement or
retention of dermal and epidermal cells into embryonic lines
of development. These benign tumors are more common in
females than males.11 Surgical removal is the only effective
treatment, and complete resection is necessary for successful
management.
Clinical Findings
Congenital dermoid inclusion cysts can be subdivided into two
FIGURE 28.6. Kaban/Mulliken classification of hemifacial micro- groups, those involving the orbital/periorbital area (including
somia that can be extended to classify and discuss Treacher Collins the midline lower forehead) and those involving the nasal
patients. Hypoplasia of the mandible is broken into four groups: area. The lesions typically present as firm, but not hard, nodu-
type I – normal architecture but smaller dimensional size of mandible
and TMJ; type IIA – moderate hypoplasia of mandible with hypo-
lar lesions involving the upper lateral orbital rim or upper lat-
plasia of ramus and condyle but some TMJ development adequately eral orbit that slowly increase in size. They range in size from
positioned for symmetrical opening of the joint; type IIB – moderate a few millimeters to a few centimeters, but most are between
to severe hypoplasia of ramus, condyle, and TMJ joint that is mal- 1 and 2 cm in diameter. In lesions in the orbital and perior-
positioned inferiorly, medially, and anteriorly and is “operationally bital areas, the presence of an external ostium or punctum is
equivalent” to a type III child; type III – total absence of mandibular uncommon, whereas in the nasal dermoid lesions the pres-
ramus behind dentition not suitable for bone distraction. ence of a punctum occurs frequently. In a recent large series
of patients, 80% of the lesions in this series were located in
either the upper lateral orbit or the upper lateral orbital rim;12
10% of the lesions involved the upper medial orbit. The nasal
In general, patients with type I and IIA deformities have
lesions account for approximately 5% to 10% of all dermoid
normal TMJ function that should be preserved. Mandibular
lesions, and have a distinct clinical presentation and a distinct
deficiency in most of these patients can be corrected dur-
etiology. Nasal dermoid cyst/sinuses are typically located in
ing adolescence using conventional orthognathic procedures
the midline and they can have multiple presentations, includ-
including sagittal split osteotomy of the mandibular ramus
ing nasal pits, hair growth within a punctum, intermittent
and Le Fort I osteotomy of the midface to correct the angle of
drainage of sebaceous material, chronic draining sinus tracts,
the occlusal plane and close any anterior open bite. In addi-
abscess, and soft tissue infections including cellulitis. They
tion, an osseous genioplasty designed to decrease the vertical
can also present as recurrent lesions after failed incision and
height of the chin and improve the sagittal projection of the
drainage procedures (Figure 28.7A).
chin is routinely added.
In patients with type IIA mandibles with a significant loss
of posterior facial height and in patients with type IIB mandi- Etiology and Pathogenesis
bles, reconstruction can often best be obtained using the tech- The etiology of orbital and periorbital congenital dermoid
nique of mandibular distraction osteogenesis. The technique inclusion cysts is thought to be related to migrating tissue
uses a mandibular osteotomy, followed by application of an being “trapped” below the surface along lines of embryo-
external framework, and slow lengthening of the bone seg- logic fusion as embryologic development progresses. Dermoid
ments. It has the advantages of predictably lengthening bone inclusion cysts are distinguished from simple epidermoid
with a minimal degree of relapse, unlike conventional bone- inclusion cysts by the presence of dermis and skin adnexa in
grafting techniques. the wall of the lesion. Because the cysts have skin adnexa pres-
In type III mandibles, there is only a cortical shell of a manent, the cysts or sinuses can contain cellular debris, sebum,
dible behind the dentition. This anatomy precludes distraction and hair. The lesions subsequently enlarge over time. The eti-
osteogenesis. These children often require a tracheostomy in ology of nasal dermoid inclusion cysts and sinuses is distinct
the perinatal period for mandibular hypoplasia. These chil- from that of orbital or periorbital dermoids. Although three
dren require reconstruction of the mandibular ramus using a separate theories have been advocated to account for these
costochondral graft designed and positioned to abut against nasal dermoid sinus/cysts, the one that has been most often
the skull base, because there is hypoplasia of the glenoid fossa. acknowledged is the “nasocranial deep trilaminar” theory.
The costochondral rib grafts are harvested and positioned During normal embryogenesis the nasal and frontal bones
through Risdon (neck) incisions. Incisions in the preauricu- develop by intramembranous ossification, but remain sepa-
lar area are frequently necessary to assist in reconstruction of rated by a small fontanelle called the fonticulus nasofrontalis.
the zygomatic arch and glenoid fossa. This creates a posterior A prenasal space between the nasal bones and cartilaginous
“stop” for the costochondral graft and facilitates mandible nasal capsule extends from the skull base to the nasal tip.
function. This surgery can be performed at 6 to 10 years of Dura extends through the fonticulus nasofrontalis, into the
age, as the costochondral grafts are of adequate caliber to per- prenasal space, and comes into contact with skin. Normally,
form the surgery at that age. Significantly, these steps should the dura and skin separate as the nasal process of the frontal
be postponed until after ear reconstruction is completed, for bone grows. The dura recedes and the fonticulus nasofrontalis
the reasons of skin tension and vascularity previously noted. and foramen cecum fuse, forming the cribriform plates. Nasal


B
C
FIGURE 28.7. Dermoid sinus/cysts. A. Infected dorsal nasal dermoid
sinus after local attempt at excision – this lesion extended i ntra-cranially.
B. Patent foramen cecum in anterior skull base that transmitted der-
moid sinus intracranially. C. Bifid crista galli on coronal CT scan D.
Intra-operative photograph of intra-cranial extension of nasal dermoid
sinus cyst after “keystone” portion of supraorbital bar was removed.
D
dermoid cysts and sinuses are formed when the dura remains no further diagnostic evaluation is warranted. Surgical exci-
fused to the overlying skin, instead of separating. As the dura sion is performed in straightforward fashion. The lesions can
recedes intracranially, it pulls ectodermal tissue with it, most be approached through a supratarsal fold upper eyelid inci-
frequently along the tract through the foramen cecum. A sinus sion. Dissection is carried through the orbicularis muscle and
tract is formed when the misplaced dermal and epidermal directly down onto the cyst wall. The dissection then meticu-
lined tract maintains a connection with the skin, whereas a lously proceeds on the cyst wall around the lesion. For those
cyst is formed when ectoderm is trapped without egress to the in the periorbital area, the lesions are frequently below the
skin, trapping the sloughed contents below the surface. Nasal periosteum, so incision of this slightly tougher layer must
dermoids require a distinct evaluation and treatment that are occur as part of the complete excision of the cyst.
discussed separately below. For the 10% of these lesions that are nasal dermoids, the
critical issue in management is to establish whether or not there
is intracranial extension of the cyst/sinus. The midline location is
Treatment a harbinger of the potentially more complicated problem. If the
Complete surgical removal of these benign lesions is the lesion extends intracranially, then a formal craniotomy is often
only successful therapeutic strategy. For the 90% of these necessary. Preoperative imaging with fine cut CT scan through
lesions that are located in the orbital or periorbital areas, the anterior cranial base is essential and can differentiate whether

there is a patent foramen cecum and a bifid crista galli pres- Table 28.1
ent, two signs of intracranial extension (Figure 28.7B and C).
Although the presence of a bifid crista galli and an open cecum Clinical Diagnostic Criteria for Neurofibromatosis
does not confirm intracranial extension, it is agreed that a nor-
mal size and appearance of the crista galli and foramen cecum 1987 National Institutes of Health Consensus Conference
rules out intracranial extension. If the CT findings are positive, Neurofibromatosis-1
an MRI may provide additional insight. If the MRI is positive
with an obvious intracranial extension, then surgical planning Diagnostic criteria are met in an individual if two or more of
should include neurosurgical involvement and a formal craniot- the following are found:
omy. If a coronal incision and formal craniotomy are required, • Café-au-lait spots (Six or more over 5 mm in greatest
then the majority of the dissection and retrieval should be dimension in prepubertal individuals and over 15 mm in
accomplished from the coronal approach. This can be facilitated postpubertal individuals)
by outfracture of the “keystone” portion of the supraorbital
• Two or more neurofibromas of any type or one plexiform
bar12 (Figure 28.7D). If the MRI findings are equivocal or absent
neurofibroma
but the CT findings are positive, a frequent clinical scenario,
then planning should still include the possible need for a craniot- • Freckling in the axillary or inguinal region
omy and neurosurgical consultation and evaluation. In this case, • Optic glioma
the nasal lesion can be approached by an incision around the
lesion and dissection cephalad, or through an open rhinoplasty • Two or more Lisch nodules (hamartomas of the iris)
approach with a small incision around the base of the nasal • A distinctive osseous lesion such as sphenoid wing dysplasia or
punctum. The dissection then proceeds cephalad, meticulously thinning of long bone cortex with or without pseudoarthrosis
dissecting the stalk of the lesion up dorsal to the cartilage but
deep to the nasal bones. If the stalk can be completely removed, • A first-degree relative (parent, sibling, or offspring) with
there is no need for the craniotomy. Otherwise, the crani- NF1 by the above criteria
otomy is required to ensure complete removal (Figure 28.7D). Neurofibromatosis-2
Recurrence rates have been reported to be as high as 12%, and
incomplete removal can be associated with complications such Diagnostic criteria are met in an individual who has
as infection and osteomyelitis. • B ilateral eighth nerve masses seen with appropriate
imaging techniques
Neurofibromatosis • A first-degree relative with NF2 and either:
Neurofibromatosis is a common disorder, with an estimated 1. unilateral eighth nerve mass, or
100,000 cases in the United States alone. The disorder can
2. two or more of the following
involve both the central and peripheral nervous systems. The
clinical hallmark of the disorder is the development of multi- • neurofibroma
ple cutaneous and subcutaneous nodular tumors. The disease • meningioma
has protean manifestations, a variable age of onset, a variable
presentation, variability in clinical findings, and a variable but • glioma
progressive course. Over the past 25 years, our understand- • schwannoma
ing of neurofibromatosis has advanced significantly. Critical
to this advance was a National Institutes of Health Consensus • juvenile posterior subcapsular lenticular opacity
Statement in 1987 that established the diagnostic criteria for
“peripheral neurofibromatosis,” now known as neurofibroma-
tosis 1 (NF1), and “central neurofibromatosis,” now known as
neurofibromatosis 2 (NF2) (see Table 28.1). While refinements Diagnosis and Clinical Presentation
of these criteria have been proposed, the establishment of the Despite the localization of the gene for NF1, the diagnosis of
criteria in 1987 has effectively focused thought about neuro- NF1 remains based upon establishing the presence of clini-
fibromatosis throughout the world. Surgical resection remains cal features (Table 28.1). The clinical presentation of NF1 is
the mainstay of treatment for enlarging or symptomatic tumors. most commonly heralded by the appearance of café-au-lait
spots. These lesions are cutaneous hyperpigmented areas,
typically 20 to 30 mm in diameter, and are the most common
Etiology and Pathogenesis manifestation of NF1, with greater than six lesions found in
Plastic surgeons and craniofacial surgeons are primarily con- 90% to 99% of all cases.15 These lesions can sometimes be
cerned with the manifestations of NF113 which occurs over clinically difficult to differentiate from congenital nevi, but
10 times more frequently than NF2. The gene for NF1 has this can be readily accomplished by a simple dermal punch
been localized to band 11.2 of the long arm of chromosome biopsy. Most children present with café-au-lait spots as the
17, clearly distinct from that for NF2, which has been local- earliest and as the only manifestation of NF1, but greater
ized to the middle of the long arm of human chromosome 22. than 80% will develop additional signs of the disorder.
NF1 is a tumor suppressor gene that encodes the tumor sup- Axillary freckling generally appears before age 5 and is seen
pressor protein neurofibromin, which accelerates the conver- in approximately 80% of all cases of NF1.15 Lisch nodules are
sion of Ras-GTP to Ras-GDP in various cell types.14 In patients pigmented, dome-shaped nodules seen on the surface of the
with NF1, there is decreased production of neurofibromin iris that are best seen by ocular exam with slit lamp micros-
and therefore decreased inactivation of RAS-GTP to RAS- copy.15 They usually have an onset by 10 years of age and are
GDP. Therefore, at the molecular level, NF1 is grouped with present in nearly all NF1 cases by 20 years of age. As noted
the set of developmental disorders known as RASopathies.14 above, the NF1 gene is a tumor suppressor gene that regu-
Interestingly, NF1 also involves an alteration in intracellular lates cell proliferation, and intracranial tumors are frequent
messaging involving the GTP to GDP conversion, similar to occurrences in these NF1 patients. Optic pathway gliomas are
fibrous dysplasia. NF1 is transmitted as an autosomal domi- the most common central nervous system tumors in patients
nant disorder with a complete penetrance but variable expres- with NF1, occurring in approximately 15% of cases, and are
sivity. Families must be counseled that there is a 50% chance histologically identified as low-grade pilocytic astrocytomas.16
of an afflicted individual having an affected child. NF1 patients also have an increased incidence of brainstem

gliomas, as well as an apparent increase in the occurrence of Malignant degeneration of peripheral nerve sheath
benign and malignant astrocytomas, ependymomas, menin- tumors is more frequent than may be appreciated by con-
giomas, medulloblastomas, and malignant schwannomas. ventional wisdom, occurring in up to 13% of patients with
Skeletal abnormalities associated with NF1 include sphenoid NF1.15 Malignant peripheral nerve sheath tumors, formerly
wing dysplasia, macrocephaly, scoliosis, and thinning of long known as neurosarcomas or malignant schwannomas, arise
bone cortex—frequently manifest as anterior tibial bowing. from Schwann cells. Over 50% of patients with malignant
The sphenoid wing dysplasia is present in 5% to 7% of NF1 nerve sheath tumors have NF1. Only the plexiform neurofi-
cases and is characterized by unilateral agenesis of the greater bromas have a high propensity for malignant degeneration.
wing of the sphenoid (Figure 28.8A and B). This agenesis Medium and large nerves such as those involving the thigh,
creates a large communication between the middle temporal the buttock, the brachial plexus, and the paraspinal nerves
fossa of the brain and the orbit, and can lead to ocular pro- are most frequently involved. Pain is the most reliable indi-
ptosis, pulsatile exophthalmos, and exposure problems for the cator of malignant degeneration. Prompt medical attention
eye. It can be associated with neurofibromas within the cone is warranted and surgical biopsy is indicated. Once diag-
of periocular tissues. nosed, management consists of an aggressive attempt at
Neurofibromas, the hallmark of the NF1 disease, are total surgical resection. Metastases are common. Malignant

nerve sheath tumors that may arise anywhere along a soft tissue neoplasms occur approximately 34 times more

nerve sheath from the dorsal root ganglion to the termi- frequently than in a control group, and accounted for 9.4%
nal nerve branches.15 They are composed of Schwann cells, of the deaths of patients with NF1.15 Despite treatment, the
fibroblasts, mast cells, and perineural cells. Neurofibromas 5-year survival rate of malignant peripheral nerve sheath
occur in five main types: localized cutaneous neurofibro- tumors is estimated to be between 16% and 52%.
mas, diffuse cutaneous neurofibromas, localized intra-
neural neurofibromas, massive soft tissue neurofibroma
and plexiform neurofibromas. Plexiform neurofibromas
Treatment
are virtually unique to NF1 and are composed of nerve The craniofacial problems associated with NF1 typically are
sheath cells that proliferate along the length of a nerve. of two types—the orbitopalpebral neurofibromas associated
Plexiform neurofibromas are frequently associated with with sphenoid wing dysplasia (cranioorbital neurofibromato-
hypertrophy of the soft tissue and hyperpigmentation or sis) and the plexiform neurofibromas involving the soft tissue
hypertrichosis of the overlying skin. Their growth can of the face, largely in the distribution of the trigeminal nerve.
cause destruction or compression of local tissue, causing These two types may exist together in the same patient, but
significant morbidity. Plexiform lesions occur in between most frequently occur separately. Several core issues must be
16% and 40% of patients with NF1, and are found on the addressed in treatment planning. First, the surgery is treating
trunk in 43% to 44%, the extremities in 15% to 38%, and the deformity only. The underlying process of neurofibroma-
the head and neck in 18% to 42% of patients. Craniofacial tosis remains, and the recurrence of the neurofibromas is com-
plexiform neurofibromas most frequently involve the sec- mon. Second, both the timing of surgery and the extent of
ond and third divisions of the fifth cranial nerve and each surgery must be carefully considered. Third, neurofibromas
of these occur in approximately 5% of patients with NF1. of the face and cranioorbital region tend to bleed significantly
In contrast to the other types of neurofibromas, these plexi- during surgery, the bleeding is difficult to control with electro-
form neurofibromas are believed to be congenital in origin, cautery, and blood loss can be substantial. Jackson has even
and usually become evident by 2 years of age. Their growth reported the option of packing the facial wound open with
is unpredictable, but occurs frequently during early infancy compression, and returning in 48 hours to complete the opera-
and times of hormonal change such as preadolescence/ado- tion.16 Appropriate patient monitoring and intravenous access
lescence or pregnancy. Craniofacial neurofibromas cause must be a component of preoperative planning, and consider-
significant facial disfigurement. ation should be given to hypotensive anesthesia.16 Fourth, the
A B
FIGURE 28.8. Neurofibromatosis. A. Preoperative 3D CT Scan demonstrating large defect in sphenoid wing. B. Coronal CT scan of orbit reveal-
ing expanded orbit, vertical dystopia, and intraorbital neurofibromas. C. Postoperative 3D CT scan showing decrease in size of aperture between
orbit and middle fossa. This aperture allows passage of the ophthalmic nerve and contents of the superior orbital fissure. D. CT Scan of Orbit
Postoperative showing titanium and bone graft composite reconstruction of posterior sphenoid wing. E. Massive plexiform neurofibromatosis of
right face showing significant overgrowth with extensive distortion evident on frontal view. F. Postoperative result following staged resection and
suspension of soft tissue from zygomatic arch using sutures and fascia lata suspension demonstrates substantial improvement, but also continued
ptosis from laxity of soft tissues.


F
correction of the soft tissue structures is prone to recurrence of the involved tissues. It is likely that the optimal approach
of the initial deformity. The soft tissue of the face in neurofi- lies somewhere between these two ends of the spectrum, and
bromatosis, including the skin, ligaments, tendons and sub- should be decided by the surgeon based upon the degree of
cutaneous tissues appear to have a decreased tensile strength, the deformity and in consultation with the patient and family.
and there is a strong tendency toward stretch and “relax-
ation,” with recurrence of the original deformity. Finally, the Management of Cranioorbital Disorders. The
surgical management of this disorder must balance aesthetic orbital-palpebral neurofibromas associated with sphenoid
outcome with the preservation of function. While these con- wing dysplasia form a discrete subtype of neurofibromato-
siderations are acknowledged, surgery is the most powerful sis, frequently described as cranioorbital neurofibromatosis.
tool for helping these patients, and these patients are often The principal findings in this disorder are pulsatile exoph-
extremely grateful and appreciative of surgical intervention, thalmos, an enlarged bony orbit, orbital neurofibroma,
even though the aesthetic result may be less than what the sur- dysplasia or aplasia of the sphenoid wing with the pres-
gical team had desired. Surgical approaches vary from limited ence of a herniation of the temporal lobe of the brain into
surgery at intervals to massive “one-stage” surgical resections the orbit, and a bulging temporal fossa. In addition to the

e xophthalmos, there is also frequently vertical dystopia of aspects of management of neurofibromatosis, improvement
the globe. Overall, cranioorbital-temporal neurofibromato- can be significant, but correction is both difficult to achieve
sis has been found to exist in from 1% to 10% of patients and harder yet to maintain.
with NF1. While several etiologies have been advocated for
the sphenoid dysplasia, including a direct effect of the orbital Management of Plexiform Neurofibromas of the
neurofibroma on the bone versus a congenital mesodermal Face. Plexiform neurofibromas involving the face typically
maldevelopment with defective ossification of the sphenoid involve either the temporal fossa, or originate from one or
bone, the etiology of the sphenoid defect has not been clearly more divisions of the trigeminal nerve. Grabb et al. have elo-
demonstrated. quently described that neurofibromas “are woven into the
The management of the orbital structures is one of the normal fabric of the face and usually defy all but partial treat-
most complex issues in neurofibromatosis. In most cases, ment.” The plexiform neurofibromas that originate from one
when vision exists in the affected eye, although potentially or more divisions of the trigeminal nerve cause significant dis-
compromised, the eye should be preserved. 16 In patients tortion of the facial soft tissue and skeletal framework. The
with functional vision, Jackson approaches mild cases with characteristic overgrowth of the soft tissue leads to distor-
little change in orbital volume through the upper eyelid, tion of the eyebrow, thickening of the eyelids, ptosis, visual

whereas in cases with significant bony enlargement, he rec- obstruction, dysconjugate gaze, glaucoma, ectropion, and can

ommends use of a coronal flap, and a C-shaped osteotomy lead to visual loss. Epiphora is frequently present. The cheek is
through the lateral orbital wall, zygoma, and horizon- usually grossly involved and ptotic. There can be hypertrophy
tally through the maxilla below the inferior orbital nerve. of the nose and distortion of the nasal soft and cartilaginous
The neurofibroma is resected through either approach, tissue (Figure 28.8E and F). There can be significant dental
although he notes that it may be inadvisable to remove the involvement and distortion of the maxillary and mandibular
tumor completely in the plexiform variety where there is occlusal plane. Plexiform infiltration of the mandibular divi-
significant involvement of the neuromuscular structures, as sion of the trigeminal nerve can lead to compromise of buc-
this may cause a disturbance of eye movement and resul- cal, oropharyngeal, and retropharyngeal tissue causing speech
tant diplopia. The sphenoid wing can then be bone grafted, apraxia and oropharyngeal dysfunction. These patients have
using either split rib grafts or cranial bone graft. He also profound disfigurement and suffer from profound psychoso-
recommends identifying the greatly stretched levator apo- cial problems related to the deformity, and they are desperate
neurosis and repairing this directly to the tarsal plate, but for any improvement in appearance.
cautions against excess shortening of the levator aponeuro- Surgical management of neurofibromatosis of the tem-
sis and also against excess skin resection. In patients with poral fossa requires an assessment of risks and expected
a loss of vision, an orbital exenteration is performed. The outcomes. These are benign tumors that seldom cause
temporal lobe is reduced into the middle cranial fossa, and major problems. Certainly, the simple presence of a neu-
the entire defect in the sphenoid wing is bone grafted. The rofibroma in this location, as elsewhere, does not warrant
eyelid skin is then invaginated into the orbit and used as surgery. If pain and considerable enlargement supervene,
skin cover. Once healing is complete, the orbital defect is then surgery can be considered. Occasionally, these lesions
fitted with prosthesis. will cause deformity of the mandible and maxilla by a
An alternative way to approach these ocular problems mass effect. The temporalis muscle can be densely infil-
is through the use of a coronal incision and a frontal cra- trated by the neurofibromas. The caveat of blood loss
niotomy. The incision placement can be selected to allow during these procedures in NF1 patients must be acknowl-
for a forehead lift and direct excision of skin in those cases edged and planned for in these corrective skeletal proce-
with involvement of the forehead and eyebrow and resul- dures. Following resection, the most obvious problem is
tant ptosis of the eyebrow. The supraorbital bar and orbital frequently a soft tissue deficiency. Reconstruction can be
roof can be removed, allowing both direct exposure of the performed using microvascular free tissue transfer, dermal-
entire orbit and the opportunity to reposition the suprafascial-fat grafts, or onlay of the skull using bone substi-
orbital bar in cases of dystopia or orbital volume change. tutes. The exact method for reconstruction depends on the
The coronal approach allows for excellent visualization severity of the soft tissue deficit, with free tissue transfer
and separation of the dura from the periorbital structures. typically being reserved for larger deficiencies.
It also allows favorable visualization as dissection pro- Soft tissue plexiform neurofibromas of the forehead can be
ceeds medially and the ophthalmic nerve and vessels are approached through a coronal or “hairline” frontal incision.
approached. The cranial bone graft is cut precisely and These approaches allow excellent exposure, and can be used
placed to allow for separation of the middle cranial fossa to lift the redundant skin vertically as needed, thereby allow-
from the orbital contents, minimizing the area of defect ing correction of eyebrow ptosis. Separate incisions may be
which must remain to allow passage of the structure in the necessary to address orbital changes.
superior orbital fissure (Figure 28.8B and C). Many sur- Surgery to correct the hypertrophy of the cheek, the
geons have commented about the tendency for these grafts nose, and the lips should follow skeletal correction, if this is
to absorb over time, and the use of a “composite” graft of planned. Similar to the principles for reconstruction of con-
cranial bone and titanium mesh is often useful to tolerate genital defects, the skeletal framework correction should be
the pulsations of the brain and provide osseous healing and performed first if this is planned as a component of treatment.
stability (Figure 28.8D). In general, this consists of reduction of osseous structures
As difficult as the skeletal reconstruction may be, the soft with leveling of the occlusal plane through modifications of
tissue structures are more problematic as they have decreased standard orthognathic approaches and techniques. The cor-
tensile strength, tend to stretch and “relax,” and recreate the rection of the soft tissue of the cheek, nose, and lip can then
original deformity. The management of the medial and lateral be undertaken. The redundancy of the cheek skin can be
canthal structures is performed using standard techniques, but approached through a facelift incision/approach or through
it should be noted that these tissues always relapse. Similarly, a Weber-Ferguson approach. If the facelift incision is used,
this same problem can occur with ptosis correction, which fre- every attempt should be made to preserve the function of
quently must be repeated. One must avoid overcorrection of the facial nerve.15 Although many of the facial muscles may
the ptosis, as a foreshortened eyelid with ocular exposure is a have limited function due to involvement by a neurofibroma,
disastrous complication. It is much better to repeat the surgery the nerve should be preserved wherever possible. Direct full
and readvance the levator aponeurosis. As is true of many thickness excision of redundant tissue is frequently necessary.

The skin incisions usually heal favorably and do not tend References
to be either prominent or noticeable after surgery. The ten-
dency toward relapse should be counteracted by using per- 1. Marie PJ. Review. Cellular and molecular basis of fibrous dysplasia. Histol
Histopathol. 2001;16:981-988.
manent sutures to anchor the tissue to the bony skeleton at 2. Chen Y-R, Breidahl AMS, Chang C-N. Optic nerve decompression in
the zygomatic arch and wherever possible. In severe cases of fibrous dysplasia: Indications, efficacy, and safety. Plast Reconstr Surg.
redundancy, it may be worthwhile considering the use of ten- 1997;99(1):22-30.
sor fascia lata slings to suspend the soft tissue structures and 3. Matarazzo P, et al. Pamidronate treatment in bone fibrous dysplasia in
children and adolescents with McCune-Albright syndrome. J Pediatr
minimize the tendency toward relapse of the position of the Endocrinol Metab. 2002;15:929-937.
soft tissue. In cases with significant redundancy of the soft 4. Gorlin RJ, Cohen MM, Levin LS. Syndromes of the Head and Neck. 3rd ed.
tissue, facial animation may not occur to any appreciable Oxford, England: Oxford University Press; 1990:642-671.
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ate and yields a significant clinical improvement. The redun- with Moebius syndrome after segmental gracilis muscle transplant. Plast
Reconstr Surg. 2000;106:1-8.
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through direct excision. Both vertical and horizontal exci- Romberg’s hemifacial atrophy. Plast Reconstr Surg. 1990;85:669-674.
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part Iv
n Head and Neck
Chapter 29 n Soft-Tissue and Skeletal

Injuries of The Face
Larry H. Hollier JR., Patrick Kelley, and John C. Koshy
The treatment of the facial trauma patient continues to evolve injuries are more commonly penetrating in nature and initially
with progress in imaging, bone fixation technology, and the misleading as there may be minimal early signs of distress. The
application of microsurgical reconstructive techniques. Many of swelling that develops over the next 24 to 48 hours, however,
the principles of access, reduction, and fixation remain constant, may be sufficient to compromise the airway, which may result
but the application of these principles has been greatly facili- in a tracheotomy under less than favorable circumstances.
tated with improvements in instrumentation and osteosynthesis
technology. Facial trauma continues to be treated by a variety Hemorrhage
of specialists, including plastic surgeons, otolaryngologists, and
Head and Neck

oral surgeons. Plastic surgeons, however, are uniquely trained The dense vascularity of the head and neck can cause signifi-
to handle the full range of issues present in the trauma patient. cant blood loss from soft-tissue injuries. Fortunately, most of
these injuries allow sufficient access to apply direct pressure
and control bleeding. Pressure should be applied accurately
Initial Management and directly, as a number of critical structures can become
Facial injuries themselves are rarely life threatening, but are collateral victims by attempting to clamp sources of bleeding
indicators of the energy of injury. Initial care of all trauma with poor exposure and visualization. Bleeding that cannot
patients focuses on the algorithmic protocol of ATLS be controlled with direct pressure requires packing. Packing
(Advanced Trauma Life Support). Facial injuries should alert in the nasal cavity is usually effective and only rarely requires
the examiner to the possibility of airway compromise, cervical augmentation with a transnasal balloon catheter in the naso-
spine injuries, or central nervous system injuries. pharynx. These catheters only serve to impede blood from
entering the oropharynx where it can more easily enter the
Airway lungs. If massive hemorrhage is present, the airway should
be managed first by emergent intubation, followed by pack-
Airway compromise is the result of excessive bleeding from an ing and direct pressure. The source of bleeding is most com-
upper airway source, foreign bodies (including aspirated teeth monly a branch of the external carotid system, which is most
and bone fragments), or direct laryngeal injury. Often, upright appropriately controlled with angiographic embolization. The
positioning with cervical spine protection will improve airway radiologist frequently requires the assistance of the surgeon to
function compromised by excessive bleeding or foreign bod- remove the packing so that the bleeding source can be identi-
ies. Foreign bodies, when present, can also be mechanically fied. At this time, and with all cases of significant hemorrhage,
removed by the finger-sweep technique. Airway compromise type-specific blood should be readily available. Surgical liga-
can also occur when the floor of the mouth and tongue lose tion of the external carotid artery is not adequate and will
support from a comminuted mandible fracture and can be alle- not control bleeding from its injured branches because of the
viated by simple anterior traction on the mandibular symphysis. robust collateralization present and should not be attempted
The trauma team should have a low threshold for defini- (Figure 29.1).
tive airway protection via endotracheal intubation. The use of
blind nasal intubation should be carried out with caution, as
the procedure can exacerbate nasal and nasopharyngeal bleed- Central Nervous System
ing. Additionally, the tube may be inadvertently placed intra- Neurologic injury is commonly associated with severe facial
cranially in the obtunded patient with a skull base fracture. trauma. A retrospective study of the National Trauma Data
Endoscopic nasal or oral intubation improves safety by avoid- Bank found that the risk of head injury in the setting of iso-
ing cervical spine manipulation and further provides immedi- lated facial fractures ranged from 29% to 80%, with increas-
ate confirmation of tracheal intubation. ing rates as the fracture involved more cranial portions of the
Emergent tracheotomy is considered in the unusual cir- facial skeleton. In patients with multiple fractures, however,
cumstance of laryngeal fracture or inability to secure an upper the incidence of head injury becomes more uniform, affecting
airway route to intubation. Tracheotomy performed in the between 66% and 89% of all cases presenting at major trauma
controlled environment of the operating room is far superior to centers. Identifying these injuries is important, as patients with
either emergent tracheotomy or cricothyrotomy (also called cri- facial trauma rarely die from facial injuries, but can die from
cothyroidotomy); however, certain situations will require this associated injuries of the central nervous system. Most patients
emergent procedure, and there should be a low threshold for with facial trauma undergo computed tomography (CT) scan-
performing an emergent tracheotomy or cricothyrotomy. There ning. The most widely accepted method for expressing the
should also be a low threshold for a controlled, temporary tra- degree of neurologic injury is the Glasgow Coma Score. This
cheotomy procedure, in the patient with significant soft-tissue evaluates the motor, verbal, and eye-opening responses of the
trauma to the floor of the mouth and tongue, especially the patient on initial evaluation, rating the patient from a lowest
base of tongue, even if the airway appears stable initially. These score of 3 to a highest score of 15 (Table 29.1).
311
312 Part IV: Head and Neck
Facial fractures are also often complicated by cervical

spine injuries. In fact, a recent study of the National Trauma
Database found that 5% to 8% of isolated facial fractures and
7% to 11% of cases of multiple facial fractures will have an
associated c-spine injury.1 Suspicion for injury and vigilant
care of the cervical spine are key elements in the care of facial
trauma patients. Cervical spine precautions are mandatory
until the spine is cleared both clinically and radiographically.
For the obtunded patient, the cervical spine is best evaluated
with a CT scan, although a negative exam does not rule out
unstable ligamentous injury. These patients require additional
examination when the sensorium is clear and possibly flex-
ion/extension radiographs or magnetic resonance imaging to
definitively evaluate the cervical spine.
Facial Trauma Evaluation

History
Use of the AMPLE acronym (allergies, medications, past his-
tory, last meal, events surrounding the accident) facilitates a
complete trauma history.
Head and Neck Examination

A thorough head and neck examination is performed in a logi-
cal and consistent manner to avoid missed injuries. The exam-
Figure 29.1. Hemorrhage treated by embolization. Patient with ination includes the skin, soft tissue, neurovascular structures,
gunshot wound to mandible requiring embolization of lingual artery and bone. Initially, gross examination identifies skin and soft-
(note coil) to prevent exsanguination. Segmental defect is treated with tissue defects and any exposed bone. Next, ecchymoses and
a distraction device. soft-tissue swelling serve as red flags for potential underlying
injury and are used with information regarding the mechanism
of injury to develop a level of suspicion about the underly-
As a general rule, concomitant head injury is not a contra- ing injuries. Bony structures should be palpated in a system-
indication to facial fracture repair, assuming the neurologic atic fashion to identify tenderness, deformity, or step-offs. In
injury is stable and not in the process of evolution. In the the acutely injured patient with facial trauma, however, the
event of acute brain injury, the surgical repair of facial frac- physical exam is greatly impaired by facial swelling, and facial
tures generally is delayed to avoid the fluid overload associ- asymmetries secondary to fractures are usually concealed.
ated with surgery and, most importantly, to avoid undetected Additionally, it may be difficult to elicit tenderness because of
decline of neurologic function during the period of general simultaneous distracting injuries. The examiner must not be
anesthesia when clinical neurologic examination cannot be misled by more impressive injuries and overlook less obvious
performed. Once the central nervous system injury and con- but potentially significant problems.
comitant swelling have stabilized, facial fracture repair can The examiner then carefully assesses the patient for neu-
generally be undertaken safely. rologic deficits, including the trigeminal and facial nerves.
Sensory disturbances in the forehead, cheek, and lower lip
Table 29.1 should be well documented, as should any deficits in facial
nerve function. Nerve injuries that are not documented preop-
Glasgow Coma Scale eratively may be attributed postoperatively to surgical inter-
vention. Lacerations, contusions, and abrasions of the skin
Eye opening Spontaneous 4
may focus the exam by indicating which nerves are at risk.
To voice 3 Much of the long-term morbidity of facial trauma is asso-
ciated with ocular and orbital injury. Although there should
To pain 2
be a low threshold to involve the ophthalmologist, the physi-
None 1 cian treating facial trauma should be well versed in the ocular
Verbal response Oriented 5 examination. A complete ocular examination includes the eval-
uation of ocular history, acuity, light and red light perception,
Confused 4 ocular motility, pupillary exam, and examination of the con-
Inappropriate 3 junctiva and eyelids. Each eye requires assessment individually.
Examination of the oral cavity is essential, especially in the
Incomprehensible 2 obtunded patient who may have loose teeth, bone fragments,
None 1 or foreign bodies. Identification and removal of prosthetics
(e.g., dentures) is essential. The occlusion and intercuspation
Motor response Obeys commands 6 are carefully evaluated, as both mandibular and maxillary frac-
Localizes 5 tures can result in malocclusion. Patients are capable of sensing
the slightest change in their occlusion. Even in patients with
Withdraws (pain) 4 unusual bites, careful analysis of the wear facets may enable the
Flexion 3 surgeon to determine if an underlying malocclusion is present.
Proper record keeping of facial injuries includes rough
Extension (pain) 2
sketch drawings in the medical chart and photographs to doc-
None 1 ument injuries. These photographs may prove invaluable in
Glasgow Coma Score (Total) 3–16 the treatment of secondary deformities and can also be benefi-
cial in medicolegal disputes. As such, photographic consents

Chapter 29: Soft-Tissue and Skeletal Injuries of the Face 313
should routinely be obtained as part of the treatment consent Although facial wounds can usually tolerate up to a 24-hour
upon entrance to the emergency department. delay in repair, the longer the wound is open, the greater the
chance of infectious complications. Cleansing of wounds is
Imaging best performed with a mild surgical soap with the light use of
a scrub brush. More extensive wounds or those with a great
In almost all patients with facial trauma, CT scanning is per-
deal of contamination should be irrigated with a pulsed lavage
formed and is acceptable for the diagnosis of essentially all
system. All foreign debris are removed from the wound prior
facial fractures. The scan is performed with axial cuts no
to closure. Adequate cleansing usually requires total anesthe-
greater than 3 mm apart, from the top of the cranium through
sia of the region of concern and a cooperative patient. These
the bottom of the mandible. Additionally, in cases of complex
are the primary factors that dictate the method of anesthesia
facial trauma, it is helpful to have a three-dimensional recon-
necessary.
struction of the facial skeleton formatted so as to provide for
Although general anesthesia may be necessary for some
a better overall orientation.
wounds, many facial wounds can be repaired under a regional
The one area where the CT scan may not be entirely
nerve block. If regional blockade is impractical, a field block
sufficient is the mandible. Although the CT is essentially
may be necessary to avoid direct infiltration of excessive
100% sensitive and specific for the fractures, it does not give
amounts of local anesthetic. Excess local anesthetic may cause
detailed information about dental structures. This is most
distortion of anatomic landmarks that are useful in restoring
critical in the region of the mandibular angle with respect to
the tissues to their anatomic positions.
the condition of the second and third molars. Information
Only 1 to 2 mL of anesthetic at the site of the nerve trunk is
regarding root damage and tooth position relative to the
needed to provide complete anesthesia for the respective region.
fracture affects the planning and treatment of angle frac-
Often multiple regions require blockade. We recommend 1%
tures and is necessary to achieve optimal outcomes. For more
lidocaine with 1:100,000 epinephrine solution mixed at a 9:1
detailed information regarding these variables, a panoramic
ratio with 8.4% sodium bicarbonate solution (e.g., 9 mL lido-
radiograph is extremely beneficial. These radiographs evalu-
caine with epinephrine and 1 mL of bicarbonate solution). The
ate the entire mandible, from condyle to condyle, in a sin-
bicarbonate solution neutralizes the pH of the lidocaine, which
gle image and provide excellent detail of the condyles and
has two important benefits. First, it minimizes the pain of the
Head and Neck

dentition. Several downsides exist, though. First, the more
injection. Second, the lidocaine more effectively crosses the
commonly used panoramic devices require upright position-
neural membrane to affect its sodium ion channel in the neu-
ing and cervical spine clearance to be used, although certain
tral state and, therefore, has a quicker onset of action. Topical
less common devices allow the patient to be imaged while
cocaine (4%) is an excellent choice for anesthesia in the nasal
supine. Additionally, care must be taken when interpret-
cavity as it also stimulates vasoconstriction of the nasal mucosa
ing fractures based solely on a panoramic radiograph of the
providing for a painless and bloodless field.
mandible, especially the symphysis and parasymphysis, as
distortion of these regions can be misleading. In these cases,
a supplemental posteroanterior film of the mandible comple- Traumatic Wounds
ments the panoramic image by providing additional detail of Traumatic wounds can be variously described as lacerations,
the region. Lateral radiographs and/or CT scans can provide punctures, contusions, abrasions, and crush injuries. The
additional information about the regions posterior to the wound configuration, whether linear or stellate, is much less
parasymphysis (Figure 29.2). important to the final result than the degree of crush, contu-
sion, and vascular compromise of the tissues. The importance
Treatment of Soft-Tissue of wound cleansing prior to closure cannot be overemphasized.
Removal of all foreign bodies is essential as they are the source
Injuries of a prolonged inflammatory response and possibly infection.
Abrasions with residual foreign bodies will form a traumatic
Preparation and Anesthesia tattoo when not properly debrided. When tissue laxity allows
Facial injuries frequently involve contaminated wounds. The removal of crushed tissue margins, a judicious sharp debride-
most important initial responsibility of the surgeon is to con- ment of the wound margins is undertaken. Clearly devitalized
vert the contaminated wound to a clean one and then per- tissue is excised. Freshening the wound margins contributes to
form wound closure. Wounds are closed as soon as possible. rapid healing and improves the final result.
A B
Figure 29.2. Fracture missed by Panorex. A. The mandible appears normal on panoramic radiograph. B. Computed tomography scan of
same patient revealing complete fracture. Although panoramic radiographs provide valuable information about the mandible and dentition,
distortion in the image can conceal fractures.

Perhaps the most important step in the repair of skin lacer- the skin to the underlying cartilage framework of the ear ensures
ations is excellent approximation of the deep dermal layer. By that skin approximation accurately aligns the cartilage.
placing the tension of the closure deep to the skin, the result- The two most prominent concerns in ear injuries are
ing scar is improved. A good choice of the suture material hematoma and chondritis. Collections of blood in proximity
for this deep layer is poliglecaprone 25 (Monocryl; Ethicon, to the cartilage can result in cartilage resorption or a reac-
Somerville, NJ). Because of the monofilament nature of this tive chondrogenesis, which ultimately leads to cauliflower ear
suture, it may have a lower likelihood of suture contamination deformity. Hematomas are evacuated as quickly as possible to
and extrusion. It also maintains tensile strength for a sufficient avert this adverse sequela. Hematomas are drained through
period of time to allow for uncomplicated wound healing. incisions in the overlying skin, making an effort to conceal
The choice of suture for the skin depends on the patient. incisions if possible. Because of the robust perfusion to the
Assuming a good deep dermal layer has been placed, the auricular skin, a bolster is often required to prevent reaccumu-
skin suture serves only to more accurately approximate and lation of the hematoma. Alternatively, a small suction drain
evert the skin edges. In children, it is beneficial to avoid a or Penrose-type drain may be used. A compression dress-
permanent suture to obviate the need for suture removal. An ing is employed regardless of the type of drainage technique
excellent choice in this case is 5-0 or 6-0 fast-absorbing gut employed. Following treatment of significant lacerations, the
suture. This suture type dissolves so rapidly that suture marks convolutions of the ear are lined with antibiotic-impregnated
are not left on the face. It provides very little tensile strength, gauze and the ear bandaged in a light head wrap, providing
however, requiring the use of adhesive strips. If a skin adhe- gentle compression of the ear.
sive is chosen in the pediatric population, one must take care As a general rule, ear trauma is not terribly painful. The
not to place any within the wound itself, which may cause a development of pain in the posttreatment period may indi-
profound inflammatory response, resulting in breakdown of cate hematoma or infection. Delayed onset of pain, there-
the closure. fore, warrants immediate inspection. Infection involving the
A subcuticular skin suture is also an option in the face. cartilage (chondritis) is a serious complication. Cartilage has
Monocryl is again a good choice. Should one desire to remove poor blood supply, making it difficult to treat chondritis with
the suture, polypropylene may be the best choice as it slides oral antibiotics. These patients typically require admission for
out of the skin easily. Skin edges under a greater degree of intravenous antibiotics and possibly debridement. It is rare to
tension are usually best closed using interrupted nylon or develop a significant chondritis without concomitant pain.
Prolene. In heavily contaminated wounds, interrupted sutures Chondritis that is overlooked or not treated promptly may
or running sutures in short segments can be used. This allows result in loss of a significant portion of the auricular cartilage.
for removal of focal areas of suture in the case of infection,
avoiding a complete wound dehiscence. As a general rule, Nose. Soft-tissue injuries of the nose are somewhat dif-
sutures in the face can be removed by 5 to 7 days when they ferent from auricular trauma. When lacerations involve the
are load bearing. When a layer of reliable deep dermal sutures underlying cartilaginous support system of the nose, all lay-
is in place, superficial skin sutures can be removed as soon as ers should be repaired after appropriate anatomic reduction.
3 days to avoid suture marks. Simple reapproximation of the overlying skin does not neces-
sarily align the underlying cartilage. As such, any lacerations
Injuries to Special Facial Regions or transections of the upper or lower lateral cartilages should
be separately addressed. Because of the difficulty in achiev-
Eyelids. The most important aspect of evaluating trauma to ing adequate anesthesia and control of bleeding with the use
the eyelids is ensuring that injury to the globe has not occurred. of local anesthetic alone, general anesthesia is warranted to
A thorough ocular examination is an essential element. It is maximize patient comfort and control.
important to remember that the Bell phenomenon results in
an upward and lateral rotation of the globe. As such, one may Lips. The most important consideration in repairing soft-
find penetrating injuries to the globe in locations that do not tissue injuries involving the lips involves accurate reapproxi-
intuitively correspond to the eyelid injury. mation of the injured structures, especially the vermilion. A
Often a general anesthetic is required to provide sufficient discrepancy in alignment of the vermilion border as little as
anesthesia to explore eyelid injuries and allow for adequate 1 mm is noticeable at conversational distance. As such, prior
exploration of the globe. General anesthesia is particularly to infiltration of any local anesthetic, the location of the ver-
recommended in the pediatric population where additional milion border on either side of a laceration should be tattooed
damage can be caused by working with sharp needles and using a needle with methylene blue. The vermillion should be
instruments around the orbit in an uncooperative child. accurately reapproximated using a 6-0 nylon or similar suture.
Direct injuries to the globe warrant urgent ophthalmologic Great care must be taken to separately reapproximate the
consultation. underlying orbicularis oris muscle. Failure to do so will result
The most critical step in eyelid repair is placement of an in bunching of the muscle on either side of the laceration with
everting suture along the lid margin. This facilitates proper attempted animation and typically results in a shortened scar
alignment and makes notching of the lid margin less likely. with an exaggerated notching of the lip. Mucosal lacerations
The suture in the lid margin can be left long and taped down to are repaired using a resorbable suture such as chromic or
the cheek to prevent the suture ends from irritating the eye. In Vicryl (Ethicon, Somerville, NJ).
general, all layers of the eyelid (inner, middle, and outer lamel- A careful examination is performed to rule out underly-
las) should be repaired. Although the conjunctiva will heal well ing damage to the dentition. Any loose or damaged teeth are
without sutures, injuries associated with significant deformity documented. Particularly unstable teeth may benefit from a
should be sutured with plain gut suture, burying the knots bridle wire securing them to adjacent stable teeth. Panoramic
to avoid irritation of the globe. The middle lamella, includ- radiographs or periapical images may help to better delineate
ing the tarsus, is repaired with resorbable suture. The skin of the underlying dental trauma.
the eyelid is then repaired. Sutures are removed within 5 days.
Depending on the magnitude of the injury, it may be helpful to Facial Nerve. Soft-tissue injuries to the face involving the
place a Frost suture to support the lid position during healing, facial nerve are particularly devastating. In examining the
especially in injuries to the lower lids (Chapter 32). patient with facial soft-tissue injury, particularly penetrat-
ing wounds, facial motion is examined carefully. One should
Ears. Ear lacerations can usually be sutured in one layer, specifically test elevation of brow, forced closure of the eyes,
addressing the skin only. It is typically unnecessary to place a sep- voluntary smile, and eversion of the lower lip. Eversion of the
arate layer of sutures within the cartilage. The firm adherence of lower lip is not very well tested by asking a patient to purse

the lips; rather, it is best seen in attempted full-denture smile. if the restriction is caused by mechanical entrapment or by
Deficits in the presence of a penetrating injury likely repre- injury to the nerves or muscles. These emergency department
sent transection of a facial nerve branch. As a general rule, all maneuvers, although potentially quite informative, are no
such injuries should be explored operatively. The exception substitute for a thorough dilated exam by an ophthalmologist.
may be suspected injuries to the buccal branches medial to Ophthalmologic consultation should be considered in every
the lateral canthus of the eye, as a consequence of the exten- case of orbital trauma.
sive arborization of the nerve at this level. Most such injuries
will undergo spontaneous reinnervation over a 3- to 6-month Indications for Surgery: Orbital Floor. Indications
period. Injuries lateral to this and any deficit in brow eleva- for the repair of orbital fractures are an area of controversy.
tion, eye closure, or lower lip depression should be explored. Mechanical entrapment of an extraocular muscle may be
Timing is of importance in these situations. The ability to demonstrated on forced duction testing or on imaging stud-
identify the distal transected nerve end is facilitated by stimu- ies and is an indication for surgical repair. A second surgical
lating with a facial nerve stimulator and detecting the facial indication is evidence of enophthalmos. With the initial swell-
motion. After approximately 48 to 72 hours, the distal nerve ing present secondary to the trauma, any enophthalmos that
end can no longer be stimulated, greatly complicating accu- is manifest indicates a significant deformity as it would be
rate identification because of the small size of the nerve and expected to worsen with the resolution of swelling. Deferring
the inflammatory response in the surrounding tissues. These surgery will complicate the eventual repair that is required.
injuries should be repaired using microscopic magnification Defect size is the most controversial parameter in deter-
and 9-0 or 10-0 nylon epineural sutures. The time to recov- mining the indication for surgery. Various authors have used
ery for a repaired nerve can be approximated by measuring different guidelines.2 Many believe that any defect greater than
the distance between the site of injury and the target muscle. 1 cm2 benefits from surgical repair because of the likelihood of
Nerve regeneration typically occurs at a rate of 1 mm/d after a subsequent enophthalmos. Other authors have tried to quan-
1-month lag (Chapter 9). titate, via CT imaging, the actual increase in orbital volume
compared with the uninjured side. This volume is then used
Parotid Gland/Duct Injuries. The most significant con- to assess the risk of postinjury enophthalmos. Currently, there
cern in parotid injuries is the possibility of facial nerve injury. are no firm data confirming the usefulness of this approach.
Head and Neck

The facial nerve separates the parotid into a superficial and There is some benefit, regardless of the indications for
deep lobe, and lacerations in this region frequently injure both surgery, in delaying surgery until there is a modest improve-
the parotid gland and facial nerve. A parotid gland injury does ment in swelling. As a successful outcome in these injuries is
not require intervention unless the underlying parotid duct dependent on reestablishing the proper anteroposterior projec-
is involved. Involvement of the Stensen duct may result in a tion of the globe, it is helpful to have most swelling largely
parotid fistula unless corrected. These injuries may be difficult resolved. Because the surgical exploration of the floor evokes
to identify and may only be seen following repair of skin lacer- some degree of swelling, the cumulative effect can make it dif-
ations with subsequent accumulation of saliva. Identification ficult to gauge the degree of correction necessary. However,
and access to the distal segment of the Stensen duct can also whether the surgery is performed early or late, the operated eye
be facilitated by cannulating the papilla opposite the maxil- is overcorrected so that it projects a little farther than the unin-
lary second molar with a blunt parotid or lacrimal probe. jured eye immediately following surgery. Delays in care greater
The ends of the duct are freshened and repaired over a stent. than 3 weeks may result in greater difficulty with the surgery as
We often employ a 5 French pediatric feeding tube brought the periorbita becomes increasingly scarred within the defect.
through the papilla and secured intraorally to prevent inad-
vertent displacement during the healing period. Incisions/Technique. The most common complication
from incisions used to access the orbital floor is eyelid mal-
position. The subciliary approach, according to the literature,
Facial Fractures has the highest risk of associated lid retraction. The transcon-
junctival approach decreases the risk of lid malposition by
Orbital Fractures avoiding incisions through the skin and orbicularis muscle.
Orbital Examination. In patients with trauma involving Although some authors believe that a lateral canthotomy is
the orbit, a thorough examination of the globe and associ- unnecessary, there is no question that detaching the lateral
ated structures is performed. If the patient has had previous canthus improves exposure. If a lateral canthotomy is per-
iatrogenic globe penetration, such as cataract surgery or radial formed, a canthopexy must be performed at the conclusion
keratotomy, the risk of globe rupture following trauma is sub- of the case in order to reestablish the appropriate position of
stantially increased. A visual examination is then performed, the lateral canthal ligament. The subtarsal incision can also be
including an exam of the visual fields. Any damage to the employed, especially in older patients with prominent lower-
optic nerve may manifest first as a limitation in the visual field lid rhytids within which the incision is concealed. This inci-
rather than a significant change in gross acuity. sion provides the most direct access to the orbital floor and is
Additionally, one should test for color desaturation. The unlikely to cause lower-lid retraction. If a lateral canthotomy
first indication of optic nerve compression may be red color is not performed, the surgeon should be careful that the assis-
desaturation. The easiest way to test this in the emergency tant does not retract with excessive force on the lower eyelid,
department is to dim the lights and hold a penlight up to the which can result in inadvertent tears in the eyelid and may
finger. The light through the skin appears red. The patient also predispose to entropion.
should be asked with alternate eyes closed whether there is any Dissection of the lower lid is directed toward the perios-
difference in the intensity of the red color between the two eyes. teum of the infraorbital rim, which is incised on the outer
Direct and consensual pupillary responses are elicited to margin of the rim. A periosteal elevator is used to dissect pos-
determine the function of the second and third cranial nerves. teriorly. When the infraorbital nerve is encountered within the
Anisocoria may be an indication of second or third nerve orbital floor, it is protected and kept down with the bone. The
damage, or direct trauma to the iris. An afferent pupillary goal of the dissection is to identify the portion of the floor that
defect is indicative of optic nerve injury and can be elicited is still intact and contiguous with the orbital apex. Whatever
by a swinging flashlight test. Range-of-motion testing of each material is used to reconstruct the floor must be suspended on
eye will determine the function of the third, fourth, and sixth this posterior ledge to ensure accurate anatomic reconstruc-
cranial nerves. Restrictions in the range of motion of the globe tion. At times, the posterior ledge can be difficult to identify.
should be confirmed with a forced duction test to determine In these cases, it can be safely identified by placing the elevator

straight posteriorly into the maxillary sinus and gently moving

the elevator superiorly (Figure 29.3). The posterior floor is
then encountered. Once the margins of the defect are defined,
reconstruction can proceed.
Floor Implants. Tessier recommended bone for reconstruc-

tion of the orbital floor. Although reliable, the use of bone
does entail a longer operative time, potential donor site mor-
bidity, and some degree of resorption of the graft postopera-
tively. Alloplastic materials enjoy several advantages over bone
grafts, including immediate availability and no risk of resorp-
tion. The disadvantages are the potential risks of implant infec-
tion and extrusion, but these complications are rare. Among
the implants available are titanium mesh, high-density porous
polyethylene, combination polyethylene–titanium implants
(Figure 29.4), and resorbable materials. Very large orbital
defects, particularly those involving the medial wall, are best Figure 29.4. Combination polyethylene–titanium implants can be
reconstructed using implants containing titanium mesh because used to provide both support and ease of contouring. These function
of the support provided and the ease of contouring. Resorbable well in managing large orbital defects.
implants may be useful in smaller defects, particularly in chil-
dren, where there is some reluctance to use permanent implants
because of growth concerns. Silastic, although used commonly
Enophthalmos is particularly resistant to secondary correc-
in the past, is best avoided as a floor implant because of a rela-
tion and is most frequently caused by inaccurate reconstruction
tively higher risk of late extrusion and infection.
of the orbital floor and excessive orbital volume. As a result
Complications. The most common complications follow- of the incline of the floor, placement of the floor implant must
ing surgery for orbital fractures are lower-eyelid retraction be directed superiorly to anatomically reconstruct the defect.
and enophthalmos. As previously discussed, lower-eyelid Dissecting straight back rather than cephalically results in the
retraction is minimized by appropriate choice of incision. It implant being placed within the maxillary sinus (Figure 29.5),
may also be helpful postoperatively to place a Frost suture maintaining the expansion in the orbital volume and resulting
maintaining the lower eyelid in an elevated position for in enophthalmos. One must also remember that appropriate
24 hours following the procedure. If retraction is noted in the reconstruction of the orbital floor results in the operated eye
early postoperative period, the patient should begin aggressive being slightly proptotic in the early postoperative period when
lower-eyelid massage and forced eye-closure exercises. This compared with the uninjured side. Failure to achieve this at the
resolves the problem in the majority of cases. Early operative time of surgery is an almost certain guarantee of enophthal-
intervention for lid retractions should be avoided unless the mos when the swelling resolves. Although fat atrophy may also
patient is experiencing problems with corneal exposure and increase orbital volume somewhat postoperatively, the contri-
constant irritation of the eye. In the absence of symptoms, bution of this mechanism to enophthalmos is likely not signifi-
operative intervention for lid retraction should be delayed and cant. The most direct approach for correction of enophthalmos
then considered after 4 to 6 months if conservative measures is accurate and anatomic reconstruction of the orbital floor.
fail. Regardless of the initial incision, patients with postopera- Secondary reconstruction is more difficult than repair at the
tive lid retraction should be approached through a transcon- initial procedure. However, established postoperative enoph-
junctival incision. Scarring of the middle lamella is released thalmos never improves and, if bothersome to the patient, will
and a spacer such as hard palate mucosa placed. require reoperation.
Persistent diplopia may also be seen following repair of
orbital fractures. This is most troublesome if it is in the pri-
mary field of gaze or in downgaze, as walking may become
problematic. Performing a forced duction test intraoperatively
to ensure that implant placement has not resulted in a mechan-
ical interference with globe movement makes postoperative
Maxillary sinus
Figure 29.3. Identification of posterior ledge in orbital floor frac-

tures. Technique of safely identifying the posterior limit of an orbital Figure 29.5. Incorrectly placed orbital floor prosthesis. Orbital
floor defect. The elevator is placed into maxillary sinus and used to floor implant misplaced directly posteriorly into the maxillary sinus.
identify the posterior ledge by sweeping upward and forward. Note the flat lie of the implant, which should incline superiorly.

diplopia less common. In the event that the patient complains subtarsal incision is best. If a coronal incision has not been
of new-onset diplopia in the immediate postoperative period, used, the zygomaticofrontal suture requires exposure through
a CT scan is performed. If no mechanical impedance is appre- the lateral extent of the supratarsal fold. Although eyebrow
ciated, the patient is followed conservatively with ophthalmo- incisions have been used in the past, these may leave promi-
logic consultation to assist with care. Although this problem nent scars and provide less direct access to the suture.
is usually a result of low-grade neurapraxia, muscle contu- Once all of the articulations of the zygoma have been
sion, or swelling, which resolves spontaneously within several visualized, the fracture segments should be reduced and then
weeks, rebalancing of the extraocular muscles may be required stabilized. It is very useful to first align the zygomaticofrontal
and is not uncommon. Permanent diplopia is more likely after suture using either a wire or a 1.0-mm plate. This sets the
secondary reconstruction than after skeletal reconstruction at vertical height of the zygoma while still allowing rotation
the time of the injury. and further alignment at the level of the rim and the zygo-
maticomaxillary buttress. Once this suture is stabilized, the
surgeon should anatomically reduce the other two buttresses.
Orbitozygomatic Fractures Reduction may be facilitated by using a Carol-Gerard screw
Diagnosis/Examination. The physical examination in placed through the lower-eyelid incision into the body of the
orbitozygomatic fractures is important, but often misleading. zygoma (Figure 29.6). It acts like a joystick and allows easy
Swelling from the injury frequently conceals the malar recession control of the fracture fragment in three dimensions.
and any evidence of enophthalmos. Anesthesia in the distribu- A 1.5-mm plate is typically placed along the superior aspect
tion of the infraorbital nerve is common and should be docu- of the infraorbital rim rather than anteriorly to avoid either
mented on initial examination. Additionally, severely displaced visibility or palpability by the patient postoperatively. The
fractures may cause trismus secondary to impingement of the buttress that provides the most stability to the reduced fracture
coronoid process by the medial displacement of the zygomatic is the zygomaticomaxillary. A 2.0- or 1.5-mm L-plate is most
arch. The orbital aspect of these injuries necessitates careful commonly used at this location. In the most severe fractures,
ophthalmologic examination and is perhaps the most impor- when the arch has to be exposed to align the zygoma, this is
tant aspect of the preoperative workup. best plated first with a 2.0-mm plate to reestablish the width
The decision to operatively reduce an orbitozygomatic and projection of the zygoma.
Head and Neck

fracture is largely dependent on the CT scan data, as swelling It is not necessary to provide three or four points of fixa-
often precludes accurate determination of the degree of defor- tion for every zygoma fracture. Although multiple plates are
mity. When evaluating the CT scan, it is most useful to look at commonly used, it is usually a result of the sequence of steps
the lateral orbital wall on the axial cuts, which represents the used in aligning the fracture. Although three or four plates
articulation of the zygoma with the greater wing of the sphe- may be necessary in high-energy injuries, many fractures can
noid. This broad articulation will manifest any displacement be adequately fixated using a single 2.0-mm L-plate along the
present and determine the degree of deformity. One must also zygomaticomaxillary buttress.
assess four other articulations for displacement, including the When the zygomatic arch is significantly displaced and
infraorbital rim, the zygomaticomaxillary buttress, the zygo- comminuted, it requires full exposure and reconstruction.
maticofrontal suture, and the zygomatic arch. There is a tendency for surgeons to view the arch as an arch
Nondisplaced fractures may be safely managed with a soft when in reality it is much more of a straight anteroposterior
diet and close clinical follow-up. A nonchew diet will prevent structure. If reconstructed as an arch, it will result in exces-
the activation of the masseter from displacing the fracture seg- sive facial width and prominence to the region relative to the
ment. Displacement of the fracture is a definitive indication for contralateral side. In addition, the malar eminence will not
operative reduction and fixation, as the results of early opera- be projected as far forward as it should. This is an especially
tive repair far exceed those of delayed repair. Repositioning of important factor when there is significant destruction to the
a displaced fracture in a delayed setting requires osteotomy of malar and arch complexes bilaterally and the surgeon must
all buttresses and extensive craniofacial exposure. It is best to reestablish facial width in proportion to facial height without
reduce and fixate fractures anatomically in the acute setting. the benefit of other reference points (Figure 29.7).
Operative Techniques. The operative treatment of orbi- Arch Fractures. Unlike true orbitozygomatic injuries, iso-
tozygomatic fractures depends largely on the degree of dis- lated arch fractures frequently do not require operative reduc-
placement and comminution. The majority of patients can be tion. Operative treatment is indicated for severe depression of
accurately reduced and fixated using incisions in the upper the arch causing either a cosmetically significant contour depres-
gingivobuccal sulcus, the lower eyelid (transconjunctival), and sion or impingement on the coronoid process and trismus.
the lateral extent of the supratarsal fold of the upper eyelid. The fracture may be approached intraorally through an
The coronal incision is necessary only when the zygomatic upper buccal sulcus incision or an incision in the temporal
arch must be exposed and reduced as a guide to appropri- scalp. The intraoral approach, although more difficult, avoids
ate alignment of the zygoma. This is typically only necessary
when there is extensive comminution of the infraorbital rim
and zygomaticomaxillary buttress, so that these cannot be
used as an accurate guide to reduction. In practice, only three
of the four buttresses require reduction as long as the zygoma
is a single, large fracture segment.
As a general rule, the intraoral incision is typically per-
formed first. In lower-energy fractures, it is occasionally pos-
sible to elevate the displaced zygoma using an instrument
placed behind the zygomatic arch. If the fracture reduces with
this maneuver, a plate may be placed across the zygomatico-
maxillary buttress and the operation terminated. Even if this
does not allow anatomic reduction of the fracture, it is still
beneficial in that it moves the zygoma to a more anatomic Figure 29.6. Carol-Gerard screw. This instrument can be used to
location, facilitating the lower-eyelid dissection of the orbital gain control of the zygoma in orbitozygomatic fractures. It can be
rim. As with orbital fractures, the subciliary incision is typi- placed either through an intraoral incision or percutaneously.
cally best avoided. Generally, either the transconjunctival or

evidence of a deviated nose have an underlying nasal fracture.

Radiographs, although frequently obtained, are superfluous.
When examining a patient with a suspected nasal frac-
ture, an intranasal inspection is mandatory to identify a septal
hematoma. Untreated septal hematomas may lead to resorp-
tion of the cartilaginous septum and result in a saddle nasal
deformity. Septal hematomas should be expeditiously evacu-
ated. Reaccumulation can be prevented with the use of either
septal quilting sutures or intranasal splints.
Treatment. Treatment of nasal fractures can be divided into

early and late phases. If one sees a patient with nasal fracture
immediately following the injury, it is beneficial to perform
a closed reduction. This may be performed in the emergency
department using local anesthesia and an intranasal vasocon-
strictor. Although closed reduction can be performed any time
in the first 2 to 3 weeks, in the first few days following the
injury, the swelling may be so severe as to camouflage the
magnitude of the deformity and complicate accurate reduc-
tion. Swelling usually improves significantly 5 to 10 days after
Figure 29.7. Incorrect reduction of the zygomatic arch. Computed injury facilitating closed reduction.
tomography scan of a zygomatic arch that was inappropriately recon- The late phase is defined as a period where sufficient
structed as an arch. The normal arch lies in an almost straight antero- bony union has taken place such that osteotomy is required
posterior direction, as can be seen on the normal side. to correct the deformity. Correction in the late phase should
be viewed as a complete rhinoplasty. The contribution of the
septum to the deviation should be appreciated and addressed.
Simply performing osteotomies is unlikely to correct the defor-
an external scar. The scalp incision, commonly referred to as mity in the face of septal involvement, particularly in high
the Gillies approach, allows more direct access to the fracture dorsal deviations. Extensive septal mobilization, resection,
site. The incision is placed horizontally within the temporal and scoring may be necessary. Airway compromise should
hairline. This better camouflages the scar as hair can drape also be a focus of the rhinoplasty.
over the area, as opposed to a vertical incision, which allows
the hair to part on either side. Dissection is carried directly Maxillary Fractures
through the temporoparietal fascia and deep temporal fascia
into the muscle. The elevator is then placed in plane between Diagnosis. Fractures of the maxilla have been classically
the deep temporal fascia and the temporalis muscle and described as Le Fort I, II, and III patterns. These patterns, by
advanced to a position deep to the arch. Any resistance to slid- definition, are fractures that detach the maxilla from the skull
ing the arch inferiorly usually indicates that the plane of dis- base. The maxilla is mobile and may result in malocclusion.
section is too superficial. Outward pressure on the arch forces Although it is not uncommon that the anterior wall of the
the fracture into an anatomically reduced position. maxillary sinus, and even the zygomaticomaxillary and naso-
Occasionally, arch fractures essentially snap back into maxillary buttresses, are fractured in facial trauma, injury to
position and are stable. In the majority of cases, however, the these structures alone do not constitute a true Le Fort injury.
fracture is unstable in the reduced position. In such situations, The fracture must extend through the pterygoid plates to cre-
it is helpful to splint the reduced arch using permanent sutures ate a complete Le Fort fracture (Figure 29.8).
placed transcutaneously and encircling the arch. The suture is The Le Fort I injury classically passes through the maxilla
tied over a metal eye shield to provide constant upward and transversely, somewhere between the tooth roots and the infra-
outward traction. Typically two sutures are required to hold orbital rims, with preservation of the integrity of the infraorbital
the arch in position. Excessive tension on the sutures may lead rims. The Le Fort II fracture extends through the infraorbital
to skin necrosis at the margins of the eye shield. rim and nose and is sometimes referred to as a pyramidal frac-
ture. The Le Fort III fracture involves the zygomatic arch, lat-
Complications. After lower-lid malposition, the most com- eral orbital wall, and the nasofrontal region. Le Fort fractures
mon complication following repair of orbitozygomatic fractures rarely exist in pure form. More commonly, patients will present
is enophthalmos resulting from malreduction of the fracture. with a combination of injuries such as a Le Fort I on one side
As in orbital floor injuries, displaced orbitozygomatic fractures and a Le Fort III on the contralateral side.
almost always expand orbital volume, as the zygoma consti- Preoperative evaluation should be focused on the occlusal
tutes a large portion of the orbital floor and lateral wall. Both relationship. Any sign of malocclusion is evaluated carefully.
the increased orbital volume and the malar recession must Correction of the occlusion to the preinjury state will guide
be addressed in the treatment of the malreduced fracture. To the appropriate anatomic reduction.
address this, the zygoma is best osteotomized, repositioned
in its appropriate anatomic location, and secured with plates.
Operative Technique. Le Fort I injuries can be adequately
exposed through an upper gingivobuccal sulcus incision
Occasionally, the malar recession is not significant and treat-
and maxillary degloving. Le Fort II injuries often require a
ment can be directed at correction of the orbital volume alone.
lower-lid incision. As in orbital fractures, a transconjuncti-
As in an orbital floor fracture, additional alloplastic material
val incision is preferred over a subciliary incision. In older
may be placed in the floor or along the wall of the orbit to dimin-
patients, a subtarsal incision can be concealed in a lower-
ish volume and correct the enophthalmos. Maxillary sinusitis
lid crease. Le Fort III injuries may be approached through a
and persistent numbness in the infraorbital nerve distribution
combination of buccal sulcus and lower-lid incisions in low-
may complicate orbitozygomatic fractures less frequently.
to moderate-impact injuries. More severe injuries require a
coronal approach for exposure of the nasofrontal and medial
Nasal Fractures orbital regions and the zygomatic arch. Following mobiliza-
Diagnosis/Examination. The diagnosis of a nasal fracture is tion of all of these fractures, the patient should be placed in
clinical. Patients presenting with a history of acute trauma with maxillomandibular fixation, the fractures reduced, and the

A B
Figure 29.8. Incomplete Le Fort I fracture. A. Three-dimensional computed tomography demonstrating a midface fracture that appears to
be present at the Le Fort I level. B. Axial CT scan of the same fracture revealing intact pterygoid plates. This fracture was completely stable on
examination under anesthesia and thus does not require stabilization.
z ygomaticomaxillary and nasomaxillary buttresses stabilized tially by fixation of the bone fragment to adjacent surrounding
Head and Neck

with plates. bone. Type 2 fractures involve more extensive comminution;
however, the medial canthal tendon is still attached to a bone
Nasoorbitoethmoid Fractures fragment that can be stabilized directly. When the fragment is
Diagnosis and Examination. Fractures of the nasoorbito- too small for fixation, transnasal wiring can be used to posi-
ethmoid (NOE) region involve the medial orbit, nasal bones, tion the fragment and medial canthal tendon appropriately.
septum, and nasofrontal junction. On examination, patients Additional bone grafting may be required. Type 3 injuries
with NOE injuries may exhibit substantial loss of dorsal nasal involve avulsion of the medial canthal tendon from its skel-
support. Frontal sinus fractures (discussed later) and cerebro- etal insertion. In addition to appropriate reduction of bone
spinal fluid leaks also commonly accompany NOE fractures. fragments and bone grafting, these patients require transnasal
Additionally, telecanthus may be present secondary to lat- fixation of the medial canthal tendon.
eral displacement of the bone fragments bearing the medial When transnasal medial canthoplasty is necessary, it must
canthal tendon. These patients demonstrate an increased dis- be performed so that the direction of pull on the canthal ten-
tance between the medial canthi and rounding of the medial don is posterior and superior. A common mistake is to reat-
canthal angle. tach the canthal tendon too anteriorly, resulting in persistent
The CT scan is the most helpful radiologic tool in determin- telecanthus. The procedure is performed by drilling from the
ing the location of the injury and the degree of comminution— contralateral side through the ethmoid bones, with the exit
the two factors critical to determining the appropriate treatment. point planned at approximately the level of the superior
Analysis of the axial cuts should focus on the lacrimal fossa and aspect of the lacrimal fossa. This is an appropriate vector
the origin of the nasolacrimal duct. This region identifies the for pull on the tendon. The medial canthal tendon is either
level of insertion of the medial canthal tendon. Comminution grasped from the underside of the coronal incision or looped
at this level may necessitate transnasal fixation of the bone frag- from an anterior incision medial to the medial canthal angle.
ments bearing the medial canthal ligaments. Bilaterally mobile The wire or permanent suture is then placed through the drill
medial canthal tendons represent a significant challenge to hole using a wire-passing drill bit toward the contralateral
reconstruction as there is no normal frame of reference with side. The suture or wire can be affixed to a screw placed on
which to judge preoperative location of the medial canthi. the contralateral side.
On occasion, it is difficult to determine if the bone bearing Many of these injuries involve substantial loss of nasal
the medial canthal insertion is truly mobile. Definitive diagno- support that cannot be restored by direct plating. In these
sis can be made under anesthesia by placing a hemostat in the situations, onlay bone grafting of the nasal dorsum will rees-
nose to the level of the medial canthus. With a finger palpat- tablish the appropriate projection and width of the nasal
ing externally over the medial canthus and outward pressure radix. Multiple techniques have been described to stabilize
on the internally positioned hemostat, one can determine the bone grafts in this region including miniplates, lag screws, and
degree of mobility and lateral displacement, and consequently K-wires.
the need for operative reduction and stabilization. A soft-tissue bolster over the medial canthal valley is also
often necessary to restore the normal contour to this region.
Operative Technique. The majority of NOE injuries The medial canthal valley is a unique region of the face where
should be exposed through both coronal and lower-eyelid the skin is intimately adherent to the underlying skeleton. The
incisions. To improve visualization, it may be helpful to score soft-tissue bolster prevents the subcutaneous accumulation of
the periosteum in the glabellar region to allow expansion of blood and fluid that interferes with the healing of the skin
the soft-tissue envelope. As the fracture is dissected, one must directly to the underlying bone. These bolsters are usually
take great care not to strip the insertion of the medial can- left in place for 7 to 10 days. The skin underlying the bol-
thal tendon off the fracture fragments. Markowitz et al.3 have ster should be watched carefully for necrosis and the bolster
devised a classification scheme based on the relation of the should be tied in such a way to allow for adjustment of ten-
insertion of the medial canthal tendon to the fracture. Type sion postoperatively.
1 fractures involve a large bone fragment to which the medial The most common complication following NOE fractures
canthal tendon is inserted. These injuries may be treated essen- is telecanthus. This is difficult and sometimes impossible to

correct secondarily. Once it is established, the area must be

approached in a similar fashion, the scar contractures com-
pletely released, bone grafts placed to reestablish contour, and
transnasal canthoplasties performed. The results of secondary
repairs are always disappointing when compared with accu-
rate acute repair.
Frontal Sinus
Diagnosis and Examination. Patients with frontal sinus
fractures may present with obvious contour deformities of
the forehead, but often the swelling associated with the injury
blunts the degree of deformity. Injury to the frontal sinus
is commonly associated with injury to the central nervous
system, and early evaluation should focus on this possibil-
ity. Axial cuts of the CT scan are useful in determining the Figure 29.10. After removing the anterior table of the frontal
degree of injury and involvement of the anterior table, poste- sinus, one must delineate the limits of the sinus. This may not always
rior table, and the nasofrontal duct. These three structures are be visible directly, but it helps to turn down the operating room lights
used in the classification of frontal sinus fractures as well as and place a light source within the sinus.
subsequent treatment.
Isolated anterior table fractures may be treated simply by
reduction and plate fixation via a coronal incision or through Once the anterior table is removed, all mucosa is removed
existing cuts in the forehead. If extensive comminution exists, from the sinus. Because of small mucosal invaginations into
the anterior wall is replaced with split calvarial bone graft. the bone, termed the vascular crypts of Breschet, a burr
The function of the nasofrontal duct should be kept in mind at should be used to ensure complete mucosal obliteration. Once
all times. In many cases, involvement of the nasofrontal duct this has been accomplished, the nasofrontal drainage system
is obvious from the CT scan (Figure 29.9). This is particularly is plugged to prevent ingrowth of the mucosa from the eth-
true for fractures located inferior and medially in the sinus, moid sinus and nose below. This may be accomplished with
where the meatus typically originates. During operative explo- a graft of muscle, bone, fat, or a pericranial or galeal flap. At
ration, direct instillation of dye (fluorescein) into the region this point, many surgeons fill the sinus cavity with graft mate-
of the nasofrontal duct within the sinus cavity has been advo- rial, most frequently fat. The need to obliterate the sinus has
cated to test the function of the duct. The presence of dye on been challenged by some on the basis of the concept of osteo-
pledgets placed intranasally indicates a functional duct system. neogenesis. Rohrich and Mickel4 demonstrated spontaneous
Generally however, this should not be necessary. Based upon obliteration by bone in cat frontal sinuses that were surgically
the fracture pattern seen on the CT scan and intraoperatively, burred out and not filled with graft material. This technique
the surgeon should be able to make the decision regarding has been used by the authors for years without evidence of any
compromise of the nasofrontal duct. Any significant concern increase in complication rates over those published in the lit-
should prompt the surgeon to obliterate the sinus. erature. From a conceptual standpoint, one must question the
The first step in frontal sinus obliteration is removing the superiority of filling a bone cavity with nonvascularized mate-
anterior table entirely. The limits of the sinus may not be obvi- rial over simply not filling it at all. In reality, the pericranial or
ous based on direct examination, particularly in small frac- galeal flap used to obliterate the nasal communication may in
tures. Placing one arm of a bayonet forceps into the sinus until itself completely fill smaller sinus cavities (Figure 29.11).
the limits of the sinus are reached can help delineate the mar- Fractures of the posterior table of the frontal sinus place
gins of the sinus. Additionally, the operating room lights may the patient at risk for acute meningitis and late intracere-
be turned down and a light source placed within the sinus, bral mucocele formation. Fractured fragments of the poste-
defining the margins of the sinus (Figure 29.10). rior table may develop trapdoor-type phenomena leaving
small bits of mucosa within the cranial cavity. These areas
of trapped mucosa are at risk for mucocele formation.
Figure 29.9. Axial computed tomography scan of the frontoeth-

moidal region revealing complete obliteration of the nasofrontal duct Figure 29.11. Pericranial flap. This tissue is often used to interrupt
by bone fragments. The frontal sinus requires obliteration in the case the communication between the ethmoid sinuses and nose with an
of a nonfunctioning duct to avoid development of a mucocele. obliterated frontal sinus.

Evaluation of the axial cuts through the frontal sinus will Because the goal of treatment is to restore the mandibular arch
reveal displacement of the posterior table within the cranial to its preinjury occlusal state, as much information as possi-
cavity. Any significant posterior displacement or the presence ble is obtained regarding the preinjury occlusion, orthodontic
of a cerebrospinal leak is considered an indication to crani- treatment, and any history of dental extraction. The wear fac-
alize the sinus. Cranialization involves performing a frontal ets of the dentition are perhaps the most valuable indicators
craniotomy and removing the entire forehead as a bone flap. of the preinjury occlusion. Stable mandible fractures with no
The posterior table is then removed and the mucosa of the evidence of malocclusion can occasionally be treated with a
anterior table burred out. As in obliteration, the nasal com- nonchew diet for a period of 4 to 6 weeks, depending on the
munication is eliminated using a pericranial or galeal flap. The age, state of dentition, and compliance of the patient. For the
bone flap is then plated back into position and the brain is most part, this is the exception and not the rule, as patients suf-
allowed to expand into the space previously occupied by the fering from mandible fractures tend to be young, male patients
sinus. The extensive exposure provided by the approach also notorious for their noncompliant behavior.
allows repair of the dura, if necessary. Because of the constant motion of the lower jaw in nor-
mal daily function, mandible fractures tend to be painful until
Complications. The most significant complications related stabilized. Some of the immediate discomfort is relieved by
to frontal sinus fractures are infectious in nature. In cases in temporary immobilization of the fracture with a wire joining
which the frontal sinus has been preserved, one must give con- the teeth adjacent to the fracture site. This must be done care-
sideration to serial CT scans in the postoperative period to assess fully to avoid dislodging the teeth, which may be destabilized
adequate drainage of the sinus. Failure of the sinus to clear by the fracture. Documentation of mental nerve function is
radiographically may indicate impaired drainage that may lead performed. Mental nerve neurapraxia often indicates involve-
to infection. Evacuation of a poorly draining sinus should be ment of the body of the mandible between the mental fora-
achieved with aggressive medical therapy, including topical and men and the mandibular foramen. Because of the likelihood of
systemic decongestants and mucolytics, or via an endoscopic further neurapraxia related to surgical correction, it is wise to
or open surgical drainage procedure. Mucocele formation discuss the condition of the nerve and its clinical course prior
may be a late complication of these fractures (Figure 29.12). to operative repair.
Unfortunately, most mucoceles and infections present very late As mentioned earlier, an excellent single test for man-
Head and Neck

following these injuries. It is not uncommon for this to occur dibular fractures is the panoramic radiograph. This requires
years following the injury or surgery. Such delayed presentation that the patient be able to sit upright with a mobile neck, so
makes accurate data regarding the success of the various treat- cervical spine clearance is obligatory. The Panorex provides
ment options difficult to obtain. an excellent evaluation of the condyles and dental anatomy.
Because of the nature of the technique, however, there can be
Mandible Fractures significant distortion in the region of the symphysis, which
Diagnosis and Examination. A complaint of malocclu- may conceal fractures in this region (Figure 29.2). The sym-
sion after trauma is a reliable indication of a mandible fracture. physeal region is best evaluated with a plain, posteroanterior
radiograph of the mandible. A CT scan is frequently obtained
in the emergency center to evaluate facial trauma and, as men-
tioned previously, is quite sensitive and specific for detect-
ing mandibular fractures, but provides less information with
regard to dentition.
Fixation. Choice of fixation depends on the specifics of

each fracture. One must choose between rigid fixation (load
bearing) and what one might term functionally stable fixation
(load sharing).5 When internal fixation was first applied to
the mandible, it was generally felt that absolutely rigid sta-
bilization was required. Since then it has become appreciated
that many fractures may do just as well with lesser degrees of
stabilization or load-sharing fixation (Table 29.2).
Rigid fixation typically implies plates that accommodate
screws that are 2.4 or 2.7 mm in diameter. Functionally stable
fixation most often uses plates accommodating screws 2.0 mm
in diameter or smaller. The decision is determined largely by
the fracture pattern and its intrinsic stability. Patients with
severely displaced fractures or with multiple mandible frac-
tures have lost more of the intrinsic stability of the mandibu-
lar arch and may require fixation that is more rigid and bears
more of the functional mandibular load. Additionally, patients
at high risk for poor healing, such as those with atrophic man-
dibles or established infection, usually benefit from absolutely
rigid fixation. Uncomplicated, isolated mandible fractures heal
uneventfully using smaller plates and screws placed along the
lines of osteosynthesis as delineated by Champy (Figure 29.13).
Operative Technique
Symphysis/Parasymphysis Fractures. As with most man-
dible fractures, the operative procedure should begin by rees-
tablishing the patient’s occlusion using maxillomandibular
fixation. In severely displaced fractures, it may be beneficial
Figure 29.12. Frontal sinus mucocele. Axial computed tomography to expose the fracture first to achieve some degree of initial
scan of a mucocele several years following a frontal sinus obliteration reduction. If the arch bars are applied initially without pre-
with bone cement. liminary reduction, the arch bar itself may lock the arch into
a malocclusion.
TABLE 2 9 . 2
Stability of Fixation For Mandible Fractures 5
n Rigid Fixation n Functionally Stable Fixation (Nonrigid)
Reconstruction plate (and/or arch bar) One 4-hole 2.4 mm compression plate without arch bar
Two plates (miniplates, compression plates, or One 2.0 mm miniplate + arch bar
combinations of these) (and/or arch bar)
Two lag screws (and/or arch bar) One lag screw + arch bar
One plate plus one or more lag screws (and/or arch bar) One 2.0 mm miniplate without arch bar for angle fracture
One 4-hole 2.4 mm compression plate + arch bar
One 6-hole 2.4 mm compression plate (and/or arch bar)
Maxillomandibular fixation does not usually achieve suffi- molar is the cause of the majority of complications. These
cient immobilization and stabilization of symphyseal fractures teeth predispose the angle region to fractures by weakening
because of the lack of intercuspation of the anterior denti- the bone in the region. The fracture is considered open because
tion, and therefore displaced symphyseal fractures typically of communication with the third molar socket. Although the
require internal fixation. These fractures may be stabilized with decision to remove or retain the third molar is controversial, it
either large or small plates. Placement of a single, large plate is generally believed that any significantly damaged, loose or
(= 2.4 mm) along the inferior border using bicortical screws diseased third molar should be removed, as should any tooth
is sufficient. It should be noted, however, that contouring a that prevents reduction.
2.4-mm plate to the acute curvature of the symphyseal or para- Mandibular angle fractures have been treated with a variety
symphyseal region can be difficult and time consuming. Equally of fixation techniques. Ellis6 advocate using a single miniplate
rigid fixation can be achieved by placing a 2.0-mm plate with along the external oblique ridge of the mandible along the
bicortical screws at the inferior border and a 2.0-mm tension lines of Champy. When comparing this with all other forms
band (smaller plate at superior border) with monocortical of fixation, the authors found their complication rate to be the
screws just below the root apices. A well-placed arch bar can lowest. Additionally, the fracture may be stabilized along the
take the place of the tension band and be left in place until bone buccal cortex using a single 2.4-mm plate at the inferior bor-
union. We prefer a tension band as we use it to assist with reduc- der. Alternatively, one may use a strut plate (essentially two
tion prior to placing the inferior border plate. After the patient plates combined into one) (Figure 29.14). This is placed over
is placed into maxillomandibular fixation, two small holes are the inferior alveolar canal (midportion of the mandible) and
drilled into the inferior border on each side of the fracture to secured with monocortical screws. Intraoral exposure is pre-
accommodate a reduction clamp. With the bone aligned and ferred in the majority of patients with simple angle fractures.
the patient in occlusion, the monocortical tension band plate is A small incision in the cheek is required for placement of the
applied. With this in position, the bone reduction clamp may screws. However, in complicated or comminuted fractures
be removed without impacting the reduction and the inferior consideration should be given to an external incision. The
border plate placed onto a relatively stable platform. Most of external incision provides much greater exposure and control
these fractures may be treated via an intraoral incision. External over the fracture. The external scar and risk to the marginal
incisions are typically reserved for the most severe fractures in mandibular nerve are less important than proper stabilization
this region (multiple fractures and comminuted fractures). of a complex mandibular fracture.
Body Fractures. Mandibular body fractures are treated with Subcondylar Fractures. No fractures of the mandible are as
either maxillomandibular fixation alone (for 4 to 6 weeks) controversial as subcondylar fractures. In addition, the termi-
or internal fixation. Most practitioners prefer to perform an nology in the literature is confusing. Injury may occur at the
open reduction and internal fixation in these cases. As with level of the condylar head, the condylar neck, or the region
symphyseal and parasymphyseal fractures, a single 2.4-mm below the sigmoid notch, the subcondylar region. Condylar
inferior border plate or two 2.0-mm plates may be used. Care head injuries are intra-articular, are not amenable to internal
must be taken to avoid the mental nerve when placing the fixation techniques, and are associated with a high risk of
screws. As with symphyseal fractures, all but the most severe ankylosis. Condylar neck fractures are defined as those that
fractures are treated using an intraoral incision. occur between the head and the sigmoid notch.
Historically, most of these injuries have been treated using
Angle Fractures. Mandibular angle fractures are associated maxillomandibular fixation for a period of 2 to 6 weeks.
with the highest risk of infection and postoperative complica- Although this results in excellent functional occlusion, it rarely
tions. The presence of a partially erupted or impacted third reduces the fracture into anatomic alignment. Rather, the
patient develops a functional occlusal adaptation to the mal-
reduction. Patients frequently continue to deviate to the frac-
tured side with maximal opening and lose some of the contour
of the mandibular border on the fractured side.
Many authors advocate open reduction and internal fixa-
tion. Opponents are concerned with the risk to the facial nerve.
Although most published series report a low risk of permanent
injury to the facial nerve, even neurapraxia is a distressing com-
plication. In an effort to avoid this, endoscopic instrumentation
has been developed to fixate these fractures largely through an
intraoral incision with small trochar sites externally.7,8
Figure 29.13. Champy’s lines of osteosynthesis. Zide and Kent9 published a list of absolute and rela-
tive indications for open reduction and internal fixation of

Figure 29.14. A strut plate can be used for the treatment of mandibular angle fractures. The combination of two plates functions to provide
greater support to these fractures and are placed over the inferior alveolar canal and secured with monocortical screw.
subcondylar fractures. This list has been modified by the body of an infected fracture that had been previously repaired, the
of literature over the years. As a general rule, internal fixa- operative site is thoroughly irrigated and the stability of the
Head and Neck

tion is considered in cases where maxillomandibular fixation fixation assessed. In patients in whom the fixation has not
is contraindicated (e.g., poorly controlled seizure disorder), failed and continues to provide stabilization of the fracture,
when an acceptable occlusion cannot be reestablished, and the plates and screws are left in place and the wound cultured
with bilateral fractures in the setting of panfacial injury (to and closed over drains. Culture-specific antibiotic therapy is
reestablish appropriate posterior facial height). instituted after an appropriate operative culture is obtained.
When maxillomandibular fixation is chosen as the defini- If, on the other hand, the fixation is loose, it is removed and
tive treatment, the period of immobilization varies, depending a more rigid fixation applied to ensure stable fixation of the
on the age of the patient and the fracture pattern. Patients fracture site. The orthopedic adage is apt: “An infected union
in whom uncomplicated healing is expected are maintained is better than any nonunion.”
in maxillomandibular fixation for 2 to 3 weeks, followed
by an additional 2 to 3 weeks of nonchew diet. As a general
rule, the primary determinant of the period of treatment is Secondary Deformities in
the occlusion. Patients who present with no significant occlu-
sal change may not require maxillomandibular fixation at all.
Facial Trauma
Additionally, high condylar fractures may have a greater risk Enophthalmos
of ankylosis and should be immobilized for shorter periods
of time. The same can be said of children in whom maxil- Enophthalmos is defined as posterior displacement of the
lomandibular fixation is limited to 2 weeks. Many surgeons globe within the orbit. Clinically, it is noticeable when the
advocate the use of elastics rather than wire to allow some displacement is 2 mm or greater. Inferior displacement of
motion and guide the occlusion in the postoperative period. the globe is termed hypoglobus. Often there is some element
The hope is that the motion will prevent the stiffness associ- of both enophthalmos and hypoglobus in the presence of mal-
ated with long-term maxillomandibular fixation. The use of reduced or unreduced orbital injuries.
elastics should be restricted, however, to reliable patients. Failure to reestablish the correct orbital volume is the most
common mistake in the repair of these fractures, resulting in
Complications. The most common complication after man- late enophthalmos. This occurs if the orbital floor prosthe-
dibular fracture repair is malocclusion, usually secondary to sis is not appropriately angled superiorly toward the anterior
maladaptation of the plate used for fixation. Inappropriately edge of the remaining intact orbital floor but is placed straight
contouring the plate (especially a large plate such as the 2- to back into the maxillary sinus. Some suggest that correct place-
4-mm system) results in the mandible shifting to adapt to the ment of the implant or bone graft should be confirmed with
plate. It is less commonly seen when miniplates are used, as the an endoscope placed into the maxillary antrum.
plates tend to adapt to the bone instead of the reverse. This phe- Delayed enophthalmos is evaluated with a maxillofacial
nomenon is also less likely with locking plates. These are plates CT scan with 1.0-mm cuts through the orbits. Sagittal and
designed with threads within the screw hole. As the screw head coronal reconstructions are useful adjuncts to the orbital
approaches the plate, it locks into the plate. As such, the screw analysis and comparison with the normal contralateral side
does not continue to tighten and pull the bone up to the mal- is extremely helpful. Thorough examination of the eye is
adapted plate. The screw stops when it reaches the plate. performed by the ophthalmologist to assess abnormalities in
Once accurate reduction fixation has been applied to a vision or extraocular movement. The most common finding in
mandibular fracture, maxillomandibular fixation is released patients with enophthalmos is diplopia, more often in periph-
and the patient’s occlusion carefully assessed. Malocclusion at eral than central gaze. Diplopia is most frequently related to
this point mandates removal of the fixation and recontouring disorders of the nerves or scarring of muscles controlling ocu-
of the plate. It is a mistake to rely on postoperative maxillo- lar motility, but may be related to malposition of the globe.
mandibular fixation or elastics to correct a malocclusion sec- The central nervous system can accommodate some degree of
ondary to a malreduction. ocular displacement before diplopia becomes evident.
Infection is also a common complication of mandibular Correction of enophthalmos should be directed toward
fractures, most often as a consequence of mobility at the frac- correction of the orbital volume. In the case of fractures of
ture site or because of loose hardware. During the exploration the orbital floor or medial wall, placement of bone grafts or

an alloplastic implant in the deficient areas will help correct it is necessary to release the patient from maxillomandibular
the displacement. Titanium mesh is easier to mold and con- fixation. Maxillomandibular fixation can displace the condyles
tour to larger and more complex defects. Porous polyethyl- or bone fragments enough to give the appearance of a good
ene is useful in the reconstruction of isolated floor fractures. bite. When checking the occlusion at the conclusion of the pro-
The orbit is typically approached through a transconjuncti- cedure, the surgeon should use only gentle upward pressure on
val incision in much the same way as in primary repair. If the symphysis to check the occlusion. Because of the relatively
the problem with globe positioning is strictly one of poste- lax configuration of the mandibular articulation with the skull,
rior displacement (enophthalmos) with no vertical compo- it requires only a mild degree of force to dislocate the condyles
nent, and there is no well-defined defect to reconstruct, the and force the patient into an occlusal state that appears normal,
implant is typically placed posterolaterally in the orbital but is not centric. Centric occlusion is seen when the condyles
cone (Figure 29.15). This achieves forward displacement of are seated within the articular fossae. The challenge is to ensure
the globe without changing the vertical dimension. It is also that the occlusion at the end of the case is equal to centric
important to perform a thorough subperiosteal dissection occlusion.
of the orbital cone to prevent the globe from being tethered When malocclusion is discovered in the immediate post-
posteriorly by scar. A slight degree of overcorrection is war- operative period, Panorex and plain radiographs can often
ranted in these cases to compensate for swelling that occurs determine if the condition is amenable to operative correc-
during the dissection. tion. Minor tooth interferences can be addressed by burr-
Enophthalmos secondary to malunion of an orbitozygo- ing down teeth at the points of contact. Orthodontics is a
matic fracture requires careful evaluation. When the malar emi- powerful tool to address less-significant degrees of maloc-
nence is displaced in the presence of enophthalmos, corrective clusion. Orthodontics is often more useful in the malaligned
osteotomies of the entire zygomatic complex are performed at alveolar fracture or segmental fractures of this nature. The
the level of the zygomaticomaxillary buttress, infraorbital rim, majority of postoperative malocclusions, however, should be
arch, zygomaticofrontal buttress, and sphenoid articulation taken back to the operating room for exploration, removal
within the orbit. This is accomplished through the coronal, of hardware, appropriate reduction, and stabilization. If
lower lid, and buccal sulcus incision. Bone grafting is often internal fixation cannot be achieved for some reason, then
required to compensate for the inevitable loss of bone that the fail-safe maneuver is 4 to 6 weeks of maxillomandibular
occurs from the original injury. Orbitozygomatic osteotomies fixation.
for posttraumatic malunion with enophthalmos are challeng- In the case of malunion, where bone fragments are no lon-
ing, morbid and are associated with the need for revisionary ger mobile, osteotomies must be made. This approach requires
procedures even in the most experienced hands. the fabrication of models and mock surgery. The models are
cut to correct the malocclusion, and an occlusal or lingual
splint is fabricated to guide the repair. Although reproducing
Malocclusion the initial fracture often suffices, in late cases in which there
Malocclusion is a difficult problem to correct secondarily once has been some degree of dental compensation, sagittal split,
bone union has occurred. It is far easier to avoid it in the first and Le Fort I osteotomies may be required.
place. Although malocclusion can be related to malunion of
maxillary, palatal, or mandible fractures, it is most commonly
associated with poorly treated mandible fractures.
Temporal Hollowing
It cannot be overemphasized that the occlusion seen fol- Temporal hollowing is caused by injury and subsequent loss
lowing plating of the fractures must be meticulously evaluated. of volume within the temporal fat pad. The temporal fat pad
Any discrepancy seen in intercuspation and alignment of wear lies between the two layers of the deep temporal fascia (the
facets is corrected at that time. Removal and replacement of thick layer of fascia immediately superficial to the tempora-
hardware is a minor inconvenience when compared with the lis muscle) that encompass the fat pad and insert onto the
inconvenience to both the surgeon and the patient of a post- zygomatic arch. In dissection of the temporal region, some
operative malocclusion. To fully assess the corrected occlusion, surgeons believe it is important to dissect deep to the super-
ficial layer of the deep temporal fascia as one approaches the
zygomatic arch in an effort to protect the temporal branch
of the facial nerve. This results in some degree of trauma to
the fat pad, which may result in devascularization and some
loss of volume in this region. Nerve injuries are more likely
the result of excessive traction, which is not necessarily pre-
vented by this fascial layer. To minimize the risk of devas-
cularization and temporal hollowing, the authors prefer to
dissect just on top of the superficial layer of the deep tem-
poral fascia (or temporoparietal fascia) with a moist sponge
using a sweeping motion. The dissection should elevate the
superficial temporal fascia off the deep temporal fascia,
ensuring that the nerve is raised with the flap, and avoids the
fat pad altogether.
Once temporal hollowing has occurred, one effective treat-
ment is placement of a porous polyethylene implant in the
subperiosteal plane and secured to the temporal fossa. Because
of the deep placement of the implant below the temporalis
muscle, the size of the implant is frequently larger than one
would anticipate relative to the defect (Figure 29.16). Porous
Figure 29.15. If enophthalmos is strictly secondary to posterior
polyethylene offers several advantages, including availability,
displacement and there is no well-defined defect to reconstruct, bony permanency, and tissue ingrowth. It can also be stabilized
orbital volume can be reduced by placing a porous polyethylene with screws to the temporal region to prevent displacement.
implant wedge posterolaterally in the orbital cone. For smaller volume defects, autologous fat grafts are also an
option (Chapter 44).

for positioning of the medial canthus. The typical error is in
reinserting the canthus too far anteriorly. It should be remem-
bered that it is impossible to overcorrect the medial canthus in
this deformity.
Redraping the soft tissue of the medial canthal valley is a
significant challenge. Transnasal wiring or suturing can be
used to set the correct position of the medial canthus, but
does little to ensure that the overlying soft tissues adhere
down to the bone. It is useful in this regard to employ a
soft-tissue bolster to compress the skin to the bone. It is
best to use a technique that allows for adjustment of ten-
sion on the bolster postoperatively to avoid tissue necrosis.
The bolster helps eliminate dead space and evacuate blood
so that hematoma formation does not impede soft-tissue
adherence.
Gunshot Wounds and Panfacial Fractures

Gunshot wounds cause any combination of soft-tissue injury
Figure 29.16. Porous polyethylene implant used to treat temporal and fracture within the craniofacial skeleton. With most
hollowing. The implant is placed in the subperiosteal plane and larger handgun and rifle injuries to the face, the entrance wound
than the anticipated defect. tends to be inconspicuous relative to the degree of skeletal
injury. The exit wounds are more variable and depend to a
large degree on the caliber (energy) of the weapon. Shotgun
wounds, on the other hand, impart a great deal of soft-tissue
Telecanthus injury along with a significant degree of underlying skeletal
Head and Neck

Telecanthus is even more difficult to resolve secondarily than injury (Figure 29.17).
it is primarily. The most common findings are tenting of the The goal of skeletal reconstruction must first be the resto-
soft tissues of the medial canthus, lateral displacement of the ration of the anteroposterior projection and width of the face.
canthus, and rounding of the medial canthal angle. The goal Primary bone grafting has proven a reliable technique in the
of revisional surgery is to correct all of the above deformi- face of bone loss and severe comminution.10,11 Although the
ties and ensure that the skeletal contour in the region is cor- order in which the craniofacial skeleton is addressed is some-
rect. Because of the nature of soft tissue in the region, most what controversial, the zygomatic arch serves as a useful guide
deformities in bone contour are readily visible. Exposure is and should be reduced and fixed early in the sequence. Correct
obtained most frequently through coronal and lower-lid inci- positioning of the arch essentially establishes the proper facial
sions. The entire soft-tissue envelope is mobilized and scar width, framing the face. Failure to accurately reconstruct the
tissue resected or released. The correct position of the inser- arch results in the remainder of the reconstruction being set to
tion of the medial canthal tendon is at the posterosuperior the incorrect frame.
aspect of the lacrimal fossae. If this area has been distorted, it When a large soft-tissue component is also present, as
should be reconstructed to the appropriate contour, using the occurs with shotgun wounds, soft-tissue reconstruction
uninjured side to guide the reconstruction. The same is true becomes an early priority. Stable soft-tissue coverage is vital
A B
Figure 29.17. A and B. Shotgun wounds. Shotguns cause both extensive soft-tissue and skeletal destruction,
often resulting in severe comminution of the facial skeleton.

to restoration of the skeleton, especially when bone grafting preservation of critical structures, all efforts should be made
is required.12 Additionally, damaged and devitalized tissue can to achieve complete soft-tissue coverage and wound healing
lead to significant scar contracture that ultimately can limit within 1 to 2 weeks in an effort to avert scar contractures. At
facial form and function. Although debridement of soft tis- times, this goal can only be achieved with free tissue transfer
sues in the facial region should be tempered with the goal of (Figure 29.18).
A B
C D
Figure 29.18. Complete phases of treatment of

facial shotgun wound. A. Initial injury B. Three-
dimensional computed tomography scan revealing
degree of skeletal destruction. C. Reconstruction of
the zygomatic complex with extensive primary bone
grafts fixed with miniplates. D. Soft-tissue recon-
struction with a combination of local flap advance-
ment from cheek and radial forearm free flap for the
central region. Stable soft-tissue reconstruction is
critical to bone graft survival. E. Two-year follow-up.
E

Chapter 30 n Head and Neck Cancer and
Salivary Gland Tumors
David M. Otterburn and Pierre B. Saadeh
Head and neck cancers account for 3% to 5% of all cancers in cavity, nasopharynx, oropharynx, hypopharynx, and larynx
the United States, with an annual cancer mortality of around (Tables 30.2 to 30.7).
2%. They are most common in men and in people over the age Figures 30.2 to 30.10 present the relevant anatomy and
of 50 years and are more prevalent in the African American T staging of each region and the anatomy of the neck. The
population. Over the past few decades, survival has generally tumor, node, metastases (TNM) classification developed by
improved for head and neck cancers. The improved survival the American Joint Committee on Cancer (AJCC) in 2010
is due to early detection and early therapy. However, these is the standard system used to establish stage grouping and
survival curves have plateaued in recent years. Cancers in the to facilitate determination of both prognosis and treatment.2
oral cavity, which are easily detected by physical examination, Because T stage definitions vary depending on the primary site
have historically had the best outcomes. However, improved location, these definitions are included with the primary site
imaging using magnetic resonance imaging, positron emis- figures. Changes in the new edition of the AJCC for head and
sion tomography, and fiberoptic endoscopy has led to earlier neck cancer reflect the aggressive nature of surgical resection.
detection of previously difficult to evaluate areas such as the The monikers “unresectable and resectable” were changed
posterior pharynx. to “very advanced and moderately advanced.” This differen-
Ninety percent of all head and neck cancers are squamous tiation leads to stage IV disease being split into IVa “mod-
cell in origin. Common etiologic factors include tobacco and erately advanced local/regional disease,” IVb “very advanced
Head and Neck

alcohol, which seem to have a synergistic effect. Regional local/regional disease,” and IVc “distant metastatic disease.”
causative agents may include betel quid in Asia and mate, a Neither nonepithelial tumors (lymphoid tissue, soft tissue,
hot tea-like beverage, in South America. Over the past decade, bone, and cartilage) nor mucosal melanomas are included
the incidence of head and neck tumors in younger patients has in this classification system. Melanomas are discussed in
increased. This has been linked with human papilloma virus Chapter 14, and thyroid cancers, which rarely lead to recon-
(HPV) infections and is thought to be associated with exposure structive procedures, will not be discussed.
through oral sex. Fortunately, these tumors are more respon- The cervical lymph nodes are a primary site of metastasis
sive to therapies and generally portend a better prognosis. The for most head and neck cancers. As such, lymph node dis-
use of HPV vaccinations, which are effective in preventing cer- section, when appropriate, is important for tumor staging.
vical cancer, may also be effective against these tumors as they Table 30.83 defines the primary site locations of the neck.
are also caused by HPV serotypes 16, 18, and 31. Figure 30.8 demonstrates the anatomy and regional lymph
Cutting-edge advances in reconstruction following extirpa- node groups of the neck. To facilitate and standardize discus-
tive procedures include the use of robotics to inset microsurgi- sion of neck metastases and neck dissection, the neck has been
cal flaps and virtual planning. Although the indications and divided into nodal group levels.
operative techniques utilizing these advances are still evolving,
early reports are promising and have shown decreased opera-
tive morbidity and possibly improved outcomes. Epidemiology
Small tumors in most head and neck regions have a 90% Although head and neck cancers are a devastating group of
cure rate when treated by radiation or surgical resection. diseases, site- and stage-specific survival reveals that many
These survival figures decrease significantly with moderately invasive tumors exhibit a 5-year survival of over 60%
advanced tumors, resulting in average 5-year survival rates of (Table 30.9).4 In addition, the overall mortality for most sub-
approximately 50%. The use of neoadjuvant therapy has also sets has fallen from 1997 to 2002 in almost every subsite,
been an advance and has increased the potential for surgical and most dramatically in those locations that are not read-
resection of previously unresectable tumors. Overall survival ily palpable (Table 30.10).5 The incidence of squamous cell
based on stage is listed in Table 30.1. The distribution of these carcinoma of the head and neck has been decreasing in the
cancers based on anatomic subsite is displayed in Figure 30.1.1 United States, from 18 per 100,000 in 1974 to 14 per 100,000
Reconstruction of head and neck defects is critically depen- in 2007,6 possibly paralleling a decrease in smoking rates.
dent on a number of factors including anatomy, physiology, Cumulative DNA alterations caused by the synergistic effects
pathology of head and neck tumors, staging, and adjuvant of cigarette smoking and alcohol use are thought to underlie
therapy. This chapter will discuss the pertinent details of head a majority of mucosally derived head and neck squamous cell
and neck cancer and salivary gland cancer with the relevant carcinomas.
anatomy. Over the past decade, there has been a spike in the inci-
dence of head and neck tumors in younger patients. The eti-
Head And Neck Anatomy ology of these tumors is thought to be related to HPV virus
infection, with the majority of tumors demonstrating the same
and Staging serotypes (16, 18, and 31) associated with cervical cancer, a
A standardized approach to head and neck anatomy facili- finding that is thought to be due to increased rates of oral
tates discussion and treatment among medical profession- sex. This association is most prominent in women between
als. The primary site/subsite approach currently used for the ages of 15 and 34 years and occurs in the salivary glands
head and neck cancer reflects both unique regional tumor and tongue.7,8 Fortunately, the cure rate from these cancers is
behavior and specific treatment-related considerations. This higher than the typical squamous cell cancers, and recent evi-
section of the chapter focuses on sites with the greatest dence suggests that the use of the HPV vaccination for cervical
incidence of pathology and on subsites with specific recon- cancer may also be beneficial in preventing HPV-induced head
structive challenges. Primary tumor sites include the oral and neck cancers.
327
Table 30.1
Cancer of the Head and Neck: 5-Year Relative Survival Rates (%) By Ajcc Stage (5th Edition) and Site,
Ages 20+, 12 Seer Areas, 1988–2001
n Site/AJCC Stage n Stage I n Stage II n Stage III n Stage IV n Unstaged

Lip 96.3 82.7 75.6 48.1 88.3
Tongue 70.7 58.6 47.3 36.7 41.7
Floor of mouth 72.5 60.1 35.8 29.7 41.4
Gum and other mouth 80.9 62.2 45.1 40 49.3
Oropharynx and tonsil 56 58.3 55.4 43.4 43.8
Hypopharnyx 48.7 38.6 34.1 23.2 26.3
Salivary gland 95.7 76.7 72.6 37.2 74.1
Nasopharynx 78.4 63.7 59.5 46.7 57.8
Other oral cavity and pharynx 40.8 46.2 23.2 22.3 39.3
Larynx
Oral cavity
29%
33%
Oropharynx
20%
Hypopharynx
Salivary gland 7%
Nasopharynx
7%
4%
Figure 30.1. Distribution of head and neck cancer in the United States.1
Table 30.2
Primary Site Locations of The Oral Cavity
Lip Skin–vermilion junction to oral mucosa and including the commissures.

Buccal mucosa Mucosal lining extending from the pterygomandibular raphe forward. The Stensen (parotid) duct arises
next to second maxillary molar.
Alveolar ridge Gingival mucosa anterior to retromolar trigone.
Retromolar trigone Mucosa behind the last mandibular molar tooth extending superiorly to the maxillary tuberosity.
Hard palate Bounded by the superior alveolar ridge and the junction of the soft palate.
Floor of mouth Bounded by the inferior alveolar ridges and the tongue. Wharton (submandibular) ducts arise in the
midline.
Anterior (two-thirds) Extends anteriorly from the circumvallate papillae and bounded by the floor of mouth. Motor innerva-
tongue (oral tongue) tion of the tongue is via the hypoglossal nerve (cranial nerve [CN] XII), whereas sensory innervation is
via the lingual nerve (branch of CN V3).
Table 30.3
Primary Site Locations of The Nasopharynx
Hollow cavity delimited by oropharynx, hard palate, skull base, spine, and nasal cavity.

Chapter 30: Head and Neck Cancer and Salivary Gland Tumors 329
Table 30.4
Primary Site Locations of The Oropharynx
Soft palate Extends from the hard palate junction to the uvula posteriorly and anterior tonsillar pillars laterally.
Tonsil Bounded by the tonsillar pillars (faucial arch).
Lateral pharyngeal wall Extends from posterior tonsillar pillar to posterior pharyngeal wall. The internal carotid artery, inter-
nal jugular vein, vagus and sympathetic nerves, and cranial nerves IX to XII are located in the para-
pharyngeal space, which is immediately lateral to the lateral pharyngeal wall.
Posterior pharyngeal wall Bounded by lateral pharyngeal walls and extending from the level of the hard palate superiorly and
the hyoid bone inferiorly.
Posterior (one-third) From circumvallate papillae to epiglottis (vallecula).
tongue (base of tongue)
Table 30.5
Primary Site Locations of the Hypopharynx and Cervical Esophagus
Hypopharynx Arbitrarily divided into three anatomically contiguous regions.

Postcricoid region Extends from the arytenoids superiorly to the cricoid cartilage inferiorly.
Head and Neck

Posterior pharyngeal Anterior to retropharyngeal space and extends from the level of the epiglottis to the level of the
wall cricoid cartilage.
Pyriform sinus Pyramidal in shape with a base superiorly and an apex inferiorly. Extends from the oropharynx supe-
riorly to the laryngeal ventricles inferiorly. The medial border is the lateral cricoid cartilage while the
lateral border is the medial thyroid cartilage. The posterior border is bounded by both the lateral and
posterior pharyngeal walls.
Cervical esophagus Extends from the cricoid level to the sternal notch.
Table 30.6
Primary Site Locations of The Nasopharynx
Consists of the supraglottis, glottis, and subglottis.

Supraglottis Includes the epiglottis, arytenoids, aryepiglottic folds, and false cords.
Glottis Consists of the true vocal cords, the anterior commissure, and the posterior commissure.
Subglottis Region below the glottis extending to the inferior margin of the cricoid cartilage.
Table 30.7
Nasal Cavity and Paranasal Sinuses
Nasal cavity Extends superiorly from the walls of the ethmoid sinus anteriorly and the sphenoid sinus posteriorly
down to the hard palate anteriorly and nasopharynx posteriorly. Lateral margins are the medial walls of
the maxillary sinus and the nasal cavity is bisected sagittally by the septum.
Four paired sinuses
Maxillary sinus Bounded superiorly by the orbital floor, inferiorly by the hard palate, posteriorly by the pterygoid plates
and pterygopalatine fossa, and laterally by the pterygoid muscles and mandibular ramus.
Frontal sinus Above and along the anterior aspect of the ethmoid sinus.
Ethmoid sinus Between medial orbits, superior to nasal cavity.
Sphenoid sinus Skull base, posterior to ethmoid sinus.

Lip
Alveolar ridge
Hard palate
Retromolar T1 Tumor ≤2 cm in greatest dimension

trigone
T2 Tumor >2 cm but ≤4 cm in greatest dimension
Buccal
mucosa T3 Tumor >4 cm in greatest dimension
T4a Moderately advanced local disease
Oral tongue Lip: Tumor invades through cortical bone, inferior
alveolar nerve, floor of mouth, or skin of face (chin or
Floor of mouth nose)
Oral cavity: Tumor invades adjacent structures only
(e.g., through cortical bone, into deep extrinsic muscle
Alveolar ridge of tongue, maxillary sinus, or skin of face)
T4b Very advanced local disease
Lip Tumor invades masticator space, pterygoid plates, or
skull base and/or encases internal carotid artery
Figure 30.2. Anatomy and T staging of the oral cavity.2
Nasopharynx
Oropharynx
T1 Tumor confined to the nasopharynx or tumor extends
to oropharynx and/or nasal cavity without parapharyn-
geal extension (posterolateral infiltration)
T2 Tumor with parapharyngeal extension (posterolateral
Hypopharynx infiltration)
T3 Tumor involves bony structures of skull base and/or
paranasal sinuses
T4 Tumor with intracranial extension and/or involvement
of cranial nerves, hypopharynx, orbit, or with exten-
sion to the infratemporal fossa/masticator space
Figure 30.3. Anatomy and T staging of the nasopharynx.2

Soft palate
Tonsils
Pharyngeal
wall T1 Tumor ≤2 cm in greatest dimension
Base of T2 Tumor >2 cm but ≤4 cm in greatest dimension
tongue
T3 Tumor >4 cm in greatest dimension
Tumor involves the larynx, tongue musculature, or
surrounding bone (medial pterygoid, hard palate,
mandible)
Tumor involves the pterygoid plates and/or the skull
Head and Neck

base, lateral pterygoid muscle, and nasopharynx or
encases the carotid artery
Figure 30.4. Anatomy and T staging of the oropharynx.2
Primary tumor (T)

T1 Tumor limited to one subsite of the hypopharynx
and 2 cm or less in greatest dimension. Subsites
include postcricoid area, pyriform sinus, and
posterior pharyngeal wall
Pharyngeal T2 Tumor invades more than one subsite of the
wall hypopharynx or an adjacent site or measures more
than 2 cm but 4 cm or less in greatest diameter
Pyriform without fixation of hemilarynx
sinus
T3 Tumor measures more than 4 cm in greatest
dimension or with fixation of the hemilarynx
Pharyngoesophageal
(postcricoid area) Tumor invades thyroid/cricoid cartilage, hyoid
bone, thyroid gland, esophagus, or central compart-
ment soft tissue, which includes prelaryngeal strap
muscles and subcutaneous fat
Tumor invades prevertebral fascia, encases carotid
artery, or involves mediastinal structures
Figure 30.5. Anatomy and T staging of the hypopharynx and

cervical esophagus.2

Anterior commissure
Vocal cords
Supraglottis
Glottis
Subglottis
Supraglottis
T1 Tumor limited to one subsite of supraglottis, normal vocal cord mobility
T2 Tumor invades more than one adjacent subsite of supraglottis, glottis, or region outside the supraglottis (e.g., base of
tongue, vallecula, medial wall of pyriform sinus), normal vocal cord mobility
T3 Tumor confined to larynx with vocal cord fixation and/or invades any of the following: postcricoid area, pre-epiglottic
space, paraglottic space, and/or inner cortex of thyroid cartilage
Tumor invades through the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea, soft tissues of neck
including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
Tumor invades prevertebral space, encases carotid artery, or invades mediastinal structures
Glottis
T1 Tumor limited to the vocal cords or anterior/posterior commissure, with normal mobility
T1a One vocal cord
T1b Both vocal cords
T2 Tumor extends to supraglottis and/or subglottis and/or with impaired vocal cord mobility
T3 Tumor limited to the larynx with vocal cord fixation and/or invasion of paraglottic space and/or the inner thyroid
cartilage
Tumor invades through the outer cortex of the thyroid cartilage and/or invades tissues beyond the larynx (e.g., trachea,
soft tissues of neck including deep extrinsic muscle of the tongue, strap muscles, thyroid, or esophagus)
Subglottis
T1 Tumor contained in the subglottis
T2 Tumor extends to vocal cords with normal or impaired mobility
T3 Tumor limited to larynx with vocal cord fixation
Tumor invades cricoid or thyroid cartilage and/or invades tissues beyond the larynx (trachea, soft tissues of neck
including deep extrinsic muscles of the tongue, strap muscles, thyroid, or esophagus)
Figure 30.6. Anatomy and T staging of the larynx.2

Frontal sinus
Ethmoids
Sphenoid sinus
Nasal cavity
Ethmoids
Head and Neck

Nasal cavity
Maxillary
sinus
Maxillary sinus
T1 Tumor limited to maxillary sinus mucosa with no erosion or destruction of bone
T2 Tumor causes bone erosion or destruction including extension into the hard palate and/or the middle of the nasal meatus,
except extension to the posterior wall of maxillary sinus and pterygoid plates
T3 Tumor invades any of the following: bone of the posterior wall of maxillary sinus, subcutaneous tissues, floor or medial
wall of orbit, pterygoid fossa, ethmoid sinuses
Tumor invades anterior orbital contents, skin of cheek, pterygoid plates, infratemporal fossa, cribriform plate, sphenoid
or frontal sinuses
Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than maxillary
division of trigeminal nerve (V2), nasopharynx, or clivus
Nasal cavity and ethmoid sinus

T1 Tumor restricted to any one subsite, with or without bony invasion
T2 Tumor invading two subsites in a single region or extending to involve an adjacent region within the nasoethmoidal
c omplex, with or without bony invasion
T3 Tumor extends to invade the medial wall or floor of the orbit, maxillary sinus, palate, or cribriform plate
Tumor invades any of the following: anterior orbital contents, skin of nose or cheek, minimal extension to anterior
c ranial fossa, pterygoid plates, sphenoid or frontal sinuses
Tumor invades any of the following: orbital apex, dura, brain, middle cranial fossa, cranial nerves other than (V2),
asopharynx, or clivus
n
Figure 30.7. Anatomy and T staging of the nasal cavity and paranasal sinuses.2

1 2 3 4
0
Stage I Stage II Stage III Stage IVa
IIB
IA IB IIA N
1
Stage II Stage II Stage III Stage IVa
VI III VA
2
Stage III Stage III Stage III Stage IVa
VB
IV 3a
Stage IVb Stage IVb Stage IVb Stage IVb
3b Stage IVb Stage IVb Stage IVb Stage IVb

Figure 30.8. Nodal levels of the neck. 1A Submental, 1B
Submandibular, II Jugulodigastric, III Middle jugular IV Low jugular,
V Posterior triangle, VI pre-laryngeal/tracheal Stage IVc = M1
Figure 30.10. Staging for nasopharyngeal cancer.2
As a result of “field cancerization,”9 the entire upper

aerodigestive tract mucosa is at risk for both synchronous
(5%) and metachronous (5% to 15%) second primary malig- Oral Cavity
nancies. Lymph node dissections are generally performed Precancerous lesions of the oral cavity include leukopla-
when clinically positive nodes are noted. Consideration of tra- kia, which is common among smokers, and erythroplakia.
cheostomy and/or gastrointestinal feeding tube should be part Dysplastic leukoplakia and erythroplakia require, at a mini-
of the preoperative plan of any extensive resection/reconstruc- mum, close serial observation. Additionally, treatment options
tion of the head and neck. The surgical treatment of other oral include either chemoprevention (isotretinoin) or ablation with
malignancies is generally similar to squamous cell carcinoma cryotherapy, electrocautery, or surgery.
and is outlined below. Because of the accessibility of the oral cavity, and the mor-
bidity of radiation-induced xerostomia, early tumors of this
area (stages I and II) are generally treated surgically. Most
small tumors in the oral cavity and lip have cure rates greater
T
than 90%. However, lesions thicker than 0.5 cm, stage III or
IV or positive margins, typically require surgery and exter-
nal beam radiation or brachytherapy.10,11 Although there is
1 2 3 4a 4b
no consensus, many surgeons will perform a supraomohyoid
neck dissection (SOHND) (levels I–III) for N0 oral cavity can-
cers unless it is known preoperatively that adjuvant radiation
0
therapy will also be administered. In contrast, patients with
Stage I Stage II Stage III Stage IVa Stage IVb clinically palpable neck disease are usually treated with either
an extended (levels I–IV) or a complete (levels I–V) dissec-
tion and postoperative adjuvant radiation. Midline tongue
N and floor of the mouth masses are indications for bilateral
1
Stage III Stage III Stage III Stage IVa Stage IVb SOHNDs. The oral cavity has multiple subsites that are
described below.
Lip. Squamous cell carcinoma of the lip comprises approxi-

2
Stage IVa Stage IVa Stage IVa Stage IVa Stage IVb mately 30% of oral cavity malignancies, and the vast major-
ity of these occur on the lower lip (Chapter 14). In contrast,
the majority of tumors of the upper lip are basal cell carci-
nomas. Unlike squamous cell carcinomas of other regions of
3
Stage IVb Stage IVb Stage IVb Stage IVb Stage IVb
the head and neck, sun exposure is thought to play a major
role in the pathogenesis of upper lip squamous cell tumors.
The conspicuous appearance of these tumors often leads to
Stage IVc = M1 early diagnosis, with 90% to 100% cure rates of small lesions.
Figure 30.9. AJCC staging for paranasal and maxillary sinus Furthermore, occult metastatic spread is unusual for most lip
tumors, laryngeal tumors, hypopharyngeal tumors, oral cavity, and tumors except for those located in the commissures, which
oropharyngeal tumors.2 have a 20% risk. In situ lesions may be treated with shave
excision, topical 5-fluorouracil, or imiquimod (Aldara; 3M,

Table 30.8
Summary of The Regional Nodal Groups From The Most Recent Neck Dissection Classification System
n Level (nodal groups) n Anatomy n Likely primary site

Level I Submental: nodal tissue superior to the hyoid Floor of mouth, anterior oral
bone and between the anterior bellies of the cavity/alveolar ridge, lower lip
digastric muscles (sublevel 1A). Submandibular: Submandibular gland, oral/nasal
nodal tissue between the mandibular border and cavity, midfacial soft tissues
the digastric muscles, including the submandibular
gland (sublevel 1B).
Level II Nodal tissue along the upper aspect of the inter- Oral/nasal cavity, nasopharynx,
nal jugular vein extending from the skull base to oropharynx, hypopharynx, larynx,
the hyoid bone (clinical landmark) or the carotid parotid
bifurcation (radiologic landmark). Extends supe-
riorly to the border of the sternohyoid muscle and
inferiorly to the lateral border of the sternoclei-
domastoid muscle. Sublevel IIA represents tissue
anterior to the spinal accessory nerve whereas
sublevel IIB tissues are located posterior to the
spinal accessory nerve.
Level III Nodal tissue along the middle aspect of the inter- Oral cavity, nasopharynx,
nal jugular vein extending from the lower limit oropharynx, hypopharynx
of level II to the cricothyroid membrane (clinical
Head and Neck

landmark) or the omohyoid muscle (radiologic
landmark). Anterior and posterior borders are the
same as level II.
Level IV Nodal tissue along the lower aspect of the internal Hypopharynx, cervical esophagus,
jugular vein extending from the lower limit of larynx, thyroid
level III to the clavicle. Anterior and posterior bor-
ders are the same as level III.
Level V Nodal tissue along the posterior course of the Oropharynx, nasopharynx,
spinal accessory nerve. Triangle is defined by the posterior scalp and neck
lateral border of the sternocleidomastoid muscle,
the trapezius muscle, and the clavicle.
Level VI Nodal tissues delimited by the hyoid bone superi- Thyroid, glottic/subglottic larynx,
orly, sternal notch inferiorly, and common carotid piriform sinus apex, cervical
arteries laterally. esophagus
St. Paul, MN), whereas more advanced lesions require assess- to periparotid or neck lymph nodes. Preoperative mapping
ment of mandibular and/or mental nerve involvement prior may aid in surgical planning. Patients with more advanced
to excision with adequate margins. Because of the difficulty tumors and clinically negative lymph node examination are
reconstructing the commissure, less extensive malignancies of usually treated with sentinel lymph node biopsy followed by
this area may be treated with radiotherapy; however, large or superficial parotidectomy or neck dissection (depending on
ulcerated lesions are best treated with resection and recon- the drainage pattern) if the sentinel lymph node is positive. Lip
struction. Upper lip and commissure malignancies may drain reconstruction is discussed in Chapter 35.
Table 30.9
Stage- and Site-Specific 5-Year Survival Rates (%) For Invasive Cancers of The Head and Neck by
Surveillance, Epidemiology, and End Results (seer) Program of the National Cancer Institute
(1997–2002) 4
n Gum And
n Year Of n Salivary n Floor Of Other n Oropharynx
Diagnosis n Lip n Tongue Gland Mouth Mouth And Tonsil n Larynx
1997 91.4 59.1 73.3 49.5 56.6 52.4 65.9
1998 91.5 53.9 74.3 50.2 60.6 53.7 64.0
1999 90.8 56.1 72.9 54.3 62.9 61.0 64.6
2000 89.2 63.0 81.5 55.5 63.6 54.4 63.9
2001 90.4 59.8 69.9 54.6 61.2 59.8 63.6
2002 93.1 60.2 73.5 58.2 62.0 65.4 62.8

Table 30.10 segmental mandibulectomy, with bone cuts 1 cm away from

the soft-tissue portion of the malignancy and evaluation of
Decrease In Mortality In Head and Neck inferior alveolar nerve margins when possible. Larger tumors
Cancer From 1990 To 2001 Based On Anatomic that do not require segmental mandibulectomy may be
Location 5 resected in continuity with planned neck dissection through
a transcervical route. This subsite also has a propensity for
Bone 75% bilateral occult neck metastasis.
Oropharyngeal mucosa 70%
Retromolar Trigone. Tumors of this subsite are generally
Tonsil 54% difficult to treat because of challenging access and because of
their locally aggressive nature, which often requires segmen-
Parathyroid 50%
tal mandibular resection and inferior alveolar nerve sacrifice.
Lip 38% Resections of large or aggressive tumors in this area often
Soft tissue 33% result in complex defects involving the mandible, lateral phar-
ynx, and soft palate, making reconstruction particularly chal-
Hypopharynx 30% lenging.
Esophagus 26%
Alveolar Ridge. Malignancies occur in this subsite uncom-
Tongue 16% monly and are treated in a similar fashion as floor of mouth
Sinus 11% cancers. Small tumors can be excised with marginal man-
dibulectomy and adequate soft-tissue margins; large tumors
Larynx 6% usually require segmental mandibulectomy and reconstruc-
Salivary 6% tion. Lymph node evaluation is performed clinically and neck
dissection is indicated for clinically positive examinations as
Nasal 4.5% occult metastases are rare.
Thyroid 0%
Hard Palate. The hard palate is an uncommon subsite for
oral cavity tumors. Up to a third of tumors in this area are
of minor salivary gland origin. Principles of resection are
similar to those described for floor of the mouth and alveo-
Anterior (Oral) Tongue. The anterior tongue is the site lar ridge. Similarly, because occult neck metastases are rare,
of malignancy in 25% to 50% of oral cavity cancers, with the lymph node dissections are usually reserved for patients with
midlateral aspect most frequently affected. Because of the lack clinically palpable lymph nodes. Depending on the tumor size
of anatomic barriers to spread, tongue cancer has a propensity and location, resection may be performed perorally, through
for diffuse, infiltrative involvement, which is often difficult a transoral midface degloving approach, or through a Weber-
to gauge clinically. Curative resection, therefore, mandates Ferguson approach. The goals of hard palate reconstruction
an adequate margin (generally 1 cm) around the lesion. T1 are to maintain speech and feeding, to separate the oral and
or T2 lesions are usually amenable to transverse wedge exci- nasal cavities, and when possible to restore nasal lining. In
sion with a 70% to 85% cure rate. Larger T2 and posteriorly some cases, en bloc maxillary resections may include the infe-
situated lesions often require lip split and mandibulotomy to rior orbital rim necessitating reconstruction to restore orbital
obtain adequate exposure for tumor resection and, if indi- volume. Small defects may be addressed with local flap clo-
cated, incontinuity neck dissection. More recently, advances sure or prosthodontics, while large defects are often treated
in robotic surgery have enabled resection of these tumors with free tissue transfer and/or maxillofacial prosthodontics.
without mandibulotomy; however, this technique has yet to
gain widespread acceptance. Buccal Mucosa. Although also uncommon, buccal muco-
Small tongue resections (1 cm or less) are treated with sal malignancies are locally aggressive and have a propensity
primary closure or skin-grafting, whereas larger defects gen- to metastasize. Resection of these lesions may result in large,
erally require tissue transfer to maintain tongue mobility full-thickness soft-tissue deficits with significant cosmetic con-
and optimize oral function. T3 or larger lesions, or lesions sequences. Free tissue reconstruction is frequently required but
with aggressive histologic characteristics, may benefit from usually less than satisfactory since reconstruction often does
radiation therapy to decrease local recurrence rates of 30% not address facial nerve deficits resulting from full-thickness
to 40%. excision of facial musculature.
Floor of Mouth. Floor of mouth cancer accounts for 30%
of oral cavity malignancies and may extend locally into the Nasopharynx
tongue or the mandible, with the alveola being the usual entry Although tumors of the nasopharynx are rare in the United
site. Mandibular invasion may result in infiltration into the States, these tumors occur commonly in China due to dif-
cancellous bone and tumor tracking in a perineural fashion ferences in exposure to Epstein-Barr virus and alcohol con-
along the inferior alveolar nerve. Poor dentition is a risk fac- sumption. Unlike squamous cell cancers of other head and
tor for mandibular invasion as dentition maintains alveolar neck regions, there is no clear evidence that either cigarette
height, thereby serving as a barrier to tumor invasion. Further, smoking or moderate alcohol use increases the risk of these
loss of alveolar height in the edentulous patient places the cancers in the nasopharynx.12,13 Stage I tumors have a 5-year
alveolar canal in proximity to the mucosal surface and affords survival rate of 72%. Stage II and III tumors have survival
portal of entry via empty tooth sockets. rates between 62% and 64%. Stage IV disease drops to a
Because of the proximity of floor of mouth tumors to the 38% 5-year survival.14 Due to late development of symptoms,
mandible as well as their propensity for bony invasion, onco- locally advanced disease with invasion into local structures
logically sound management of this structure for complete and (bilateral) neck involvement is a common presentation.
tumor excision is an essential aspect of treatment. Surgical Skull base extension into the cavernous sinus may present with
guidelines include 1-cm margins, which include a marginal associated cranial nerve (CN) involvement most commonly in
mandibulectomy (rather than segmental mandibular resec- CNs III, IV, V, and VI. The primary treatment for this highly
tion) for tumors intimately adjacent to the mandible. In con- radiosensitive tumor is chemoradiation, with surgery reserved
trast, radiologic evidence of cortical invasion usually mandates for recurrent disease.15

evidence for which approach is superior is still being gathered;
Oropharynx however, it is clear that adjuvant and neoadjuvant therapy can
These tumors are uncommon, affect men three to five times lead to laryngeal preservation in select patients.
more than women, and usually occur in the fifth to sev- Small localized lesions of the pyriform sinus may be
enth decades. They are associated with betel nut and mate treated by partial laryngopharyngectomy, resulting in a
consumption, HPV virus infection, and tobacco/alcohol hemicircumferential defect of the hypopharynx as contrasted
use. Functional outcomes take on greater importance in with total laryngopharyngectomy, which results in complete
this subsite as a result of the proximity of the digestive and disruption of gastrointestinal continuity. Reconstructive
respiratory tracts to one another. Tumors in this region are options usually favor free tissue reconstruction with fas-
characterized by their relatively small size compared with ciocutaneous flaps for resurfacing of both hemicircumfer-
much larger neck metastases, the propensity of near midline ential and complete defects. The free jejunal flap was the
lesions for bilateral neck involvement, and the possibility of traditional method of reconstruction for complete defects;
retropharyngeal nodal metastasis. Although most tumors are however, fasciocutaneous flaps provide a better result for
squamous in origin, the higher concentration of lymphatic phonation, as they create a stiffer tube and do not secrete
tissue yields a proportionally higher incidence of lympho- mucus or have peristalsis. For partial defects, rotational
mas (mucosal-associated lymphoid tissue tumors), which are flap options include the pectoralis major flap and extended
exquisitely radiosensitive. supraclavicular flaps. Early neck metastases with a propen-
Sixty percent of patients present with a mass in the neck as sity for bilaterality warrant an aggressive approach to the
the primary tumor and are usually asymptomatic. However, neck for hypopharyngeal lesions.
CN IX or X involvement may present with referred otalgia
and/or ipsilateral soft palate paresis. CN XII invasion can Larynx
manifest as wasting and ipsilateral deviation of the tongue. In
light of functional considerations, early lesions (T1 and T2) In 2010, there were 12,700 new cases of laryngeal cancer
that cannot easily be resected are often best treated with radia- and 3,600 deaths.20 Not surprisingly, laryngeal cancers have
tion therapy. Advances in organ preservation chemoradia- a strong association with alcohol and tobacco use. Patients
tion protocols are increasingly relegating surgery to advanced who stop smoking decrease their risk of laryngeal cancer,
Head and Neck

lesions (T3 and T4) and to salvage for treatment failure or but remain at increased risk as compared with the general
recurrence.16 non-smoking population. Treatment considerations for car-
The base of the tongue, similar to other tongue tumors, cinoma of the larynx center on tumor ablation, local control,
is susceptible to infiltrative spread and is the most frequently and organ/voice preservation. There is also a high incidence
affected region of the oropharynx. While most base-of-tongue of second primary tumors (25%). Some clinicians believe that
tumors are presently treated with chemoradiation and/or treating all laryngeal cancers with isotretinoin may prevent
brachytherapy, there are multiple approaches to this area. secondary tumors; however, comparative studies have failed
Surgical access, depending on the lesion’s location and size, to show a survival benefit.21 The three parts of the larynx
includes transoral excision, lateral pharyngotomy, supra/ include the supraglottic, glottic, and subglottic regions.
transhyoid pharyngotomy, lip splitting, and paramedian Supraglottic Region. The supraglottic region is rich with
mandibulotomy. The latter approach implies a larger tumor, lymphatic vessels, and as a result, tumors of this region com-
which generally mandates advanced reconstruction. Similarly, monly present with lymph node involvement (25% to 50%).
locally advanced pharyngeal wall tumors require advanced They typically drain into the midjugular and jugulodigastric
access, laryngopharyngectomy, and reestablishment of diges- nodal groups. Stage I and II cancers can be treated with either
tive continuity. Tumors close to or involving the mandible surgery or radiation alone. Radiation avoids disrupting the
(ramus: tonsil, pharyngeal arches, and lateral pharyngeal larynx and therefore is the preferred modality. Stage III and
wall) require marginal or segmental mandibulectomy, usually IV cancers can be treated with either total laryngectomy or
with reconstruction, as outlined in the section on oral cavity post-op radiation, definitive radiation with surgery left for sal-
tumors. Except for early lesions of the soft palate and poste- vage or radiation failure or chemoradiation with surgery for
rior pharynx, the propensity for neck metastasis by tumors of salvage procedures.22,23
the oropharynx usually mandates neck dissection.
Glottic Region. The glottic region is devoid of lymphatics
Hypopharynx and Cervical Esophagus and usually presents early because of its symptomatic involve-
ment. Fortunately, this leads to earlier staging with better
Malignancies of the hypopharynx most frequently involve the tumor outcomes. Small stage I tumors may be laser excised
pyriform sinus, with dysphagia and palpable neck disease as and treated surgically or with definitive radiation. Stage II
frequent presenting complaints. Referred otalgia from tumor lesions are treated with surgery alone or radiation therapy
invasion of the tympanic branch of the CN IX is also a com- alone. Stage III and IV lesions are treated with surgery with
mon symptom and tumors spread locally by submucosal infil- possible postoperative radiation therapy, definitive radiation
tration. Locally advanced hypopharyngeal tumors have the therapy with surgery for salvage, or chemotherapy and radia-
highest rate of distant metastases (usually to the lungs), result- tion with surgery for salvage.
ing in the worst long-term survival among head and neck
tumors. Traditionally, hypopharyngeal tumors were resected Subglottic Region. Tumors in the subglottic region are
en bloc with the larynx (laryngopharyngectomy) due to the rare; however, due to the rich lymphatic network in this
proximity of the tumor to this structure and the limited ability region, these tumors are associated with earlier lymph node
to preserve laryngeal function. However, currently stage III involvement in the pretracheal and paratracheal nodes, the
and IV tumors are usually treated with neoadjuvant chemo- inferior jugular node, and the mediastinal nodes. Stage I and II
therapy and postoperative radiation therapy in an effort to tumors are treated with radiation therapy alone; stage III and
shrink the tumor to preserve laryngeal function.17-19 IV tumors are treated either with surgery or with radiation
There are no definitive studies to date to guide an evi- therapy in patients who are not surgical candidates. Radiation
dence-based protocol for hypopharyngeal cancer. Generally therapy may also be used in an adjuvant setting in addition to
T1 lesions are treated with radiation therapy alone, with all surgery in locally advanced or aggressive tumors.
higher stages receiving surgery followed by radiation therapy. Because the rate of neck involvement in the clinically nega-
Some groups rely on radiation therapy alone, with adjuvant tive neck exceeds 20% in stage I and II supraglottic tumors,
chemotherapy and surgery only for salvage procedures. The elective treatment of the neck (bilateral for midline or larger

lesions) is advocated either with surgery or with radiation and to options of management. The traditional radical neck
therapy. Management of the clinically lymph node–positive dissection involves unilateral removal of lymphatic groups
neck is variable and depends on the treatment modality I to V and sacrifice of the spinal accessory nerve, internal
selected for the primary lesion (i.e., either radiation or radia- jugular vein, and sternocleidomastoid muscle. Numerous
tion and surgery). modifications of this operation have been described in an
Free flap reconstruction (commonly radial forearm free effort to limit morbidity or to more specifically target occult
flap with palmaris longus tendon) of the vocal cord deficit in metastases (Table 30.11 and Figure 30.8). Neck dissections
vertical partial laryngectomy defects has increased the predict- are classified as comprehensive (radical, modified radical)
ability of the functional result in conservation laryngectomy or selective, based on the nodal levels dissected and non-
(less than total) procedures.24 Following total laryngectomy, lymphatic structures preserved.
speech may be reestablished through esophageal speech, tra- The proliferation of the various neck dissections is because
cheoesophageal puncture, or an electrolarynx. cervical metastases in untreated patients proceed in a predi-
cable fashion depending on the site of the primary tumor.
Nasal Cavity and Paranasal Sinuses In the N0 neck, treatment includes surgery or radiotherapy,
generally depending on the treatment modality selected for
Similar to the nasopharynx, sinonasal tract squamous cell
treatment of the primary tumor (“split-modality therapy”
carcinoma occurs infrequently and has a relatively low asso-
describes treating the primary tumor with surgery and the
ciation with cigarette smoking. The maxillary sinus is most
neck with radiation or vice versa). Elective treatment is further
frequently affected and tumors can grow considerably before
dependent on the location of the primary tumor.
becoming symptomatic. Tumors located below Ohngren’s
Occult metastases of oral cavity tumors increase with T3 or
line (a line extending from the medial canthus to the angle of
T4 lesions and tumors thicker than 3 mm, and such patients
the jaw) have a better prognosis than tumors located above
should undergo SOHND or radiotherapy. T2-4 tumors of the
it. Treatment of malignancies in this area is generally surgical
oropharynx, hypopharynx, and supraglottic larynx have a
and consideration must be given to possible involvement of
high incidence of occult cervical spread and should be treated
surrounding structures, including the remaining sinuses, the
with a lateral neck dissection or radiotherapy. However,
nose, the orbital floor and orbit, and the anterior and middle
because access to the oropharynx often necessitates a man-
cranial fossae. The functional and cosmetic deformities result-
dibulotomy, consideration should be given to an anterolateral
ing from tumor extirpation with uninvolved margins present
neck dissection. All N0 nasopharynx, pyriform sinus, and
significant reconstructive challenges, including restoration of
base-of-tongue lesions should be considered for elective neck
hard palate and orbital floor, dead space elimination, and pre-
treatment. T1-2 glottic tumors have such a small risk of occult
vention of cerebral spinal fluid leak. Postoperative radiation is
neck disease that elective radiotherapy should not be pursued.
usually indicated.
Elective surgical treatment of the neck is also indicated in
Because the rate of nodal metastasis in nasal cavity and para-
unreliable patients and if the approach of surgical treatment
nasal tumors is less than 20%, most surgeons do not operate on
of a primary tumor involves a neck approach (for either extir-
clinically negative patients (i.e., N0 neck) but reserve complete
pation or reconstruction).
neck dissections for patients with clinically evident disease.
Treatment of the clinically positive neck (N+) generally
Surgical therapy for stage I and II depends on the specific
involves comprehensive neck dissection with an effort to spare
sinus involved. Typically those that can be readily accessed
structures depending on tumor involvement. Selective neck
should be resected, otherwise they are radiated. Stage III and
dissection may be appropriate in many cases because of the
IV tumors generally undergo resection with postoperative
rarity of level V involvement (except in nasopharyngeal malig-
radiation therapy. Tumors of the nasal vestibule are often
nancies) in the absence of multilevel involvement or level IV
treated with radiation either prior to surgery to shrink the
adenopathy.
tumor or as the primary means of treatment as wide resections
Radiotherapy compares favorably to surgery in the elec-
in this area are severely deforming.
tive treatment of N0 necks with regard to locoregional recur-
rence, and the decision to use it varies from center to center.
Management of the Neck Although there is controversy regarding the timing of radia-
The prognostic and therapeutic implications of nodal metas- tion, radiotherapy is generally indicated in the treatment of
tases in the neck mandate a standardized approach both to N+ necks, particularly in the presence of multiple nodes or
the description of neck anatomy, as outlined previously, extracapsular extension.
Table 30.11
Description of Types of Neck Dissections
n Neck dissection type n Nodal levels dissected n Preserved structures

Radical neck dissection I–V None
Modified radical neck dissection (type I) I–V CN XI
Modified radical neck dissection (type II) I–V CN XI, SCM
Modified radical neck dissection (type III) I–V SCM, IJV
Supraomohyoid neck dissection I–III CN XI, SCM, IJV
Lateral neck dissection II–IV CN XI, SCM, IJV
Anterolateral neck dissection I–IV CN XI, SCM, IJV
Posterolateral neck dissection II–V CN XI, SCM, IJV
CN XI, spinal accessory nerve; IJV, internal jugular vein; SCM, sternocleidomastoid muscle.

Tumors are staged based on the same T, N, M classification
Salivary Gland Tumors as oral cavity cancer (Figures 30.2 and 30.12).25 Histologic
Neoplasms of the salivary glands are a unique and rare (3% to classification into low grade and high grade is important for
6% of all adults) subset of head and neck tumors. Their var- treatment options; however, tumor size may be a better indi-
ied histology and infrequent occurrence, as well as their rela- cator of long-term outcomes. For low-grade malignancies of
tionship to critical surrounding structures (facial nerve and the parotid, a superficial parotidectomy is required. All other
mandible), often present a diagnostic and therapeutic chal- malignant lesions require total parotidectomy. If there is
lenge. They typically occur in the sixth or seventh decade and facial nerve paralysis, the nerve is resected. In this setting with
present as a painless mass. More than half of salivary gland advanced disease, reconstruction is not usually indicated.
tumors are benign, but signs of neural involvement or pain do If tumor involves the facial nerve, but its function is pre-
point to malignant involvement. served, the nerve branches should be resected and recon-
There are three paired major salivary glands, the parotid, structed if reasonable. Large tumors, or those with close
submandibular, and sublingual glands (Figure 30.11), and 600 margins, or with evidence of lymph node involvement may
to 1,000 minor salivary glands distributed primarily through- benefit from radiation therapy.26,27 It is currently not clear if
out the oral cavity and upper aerodigestive tract. Their pur- chemotherapy is of any benefit in this pathology.
pose is to aid in digestion through the release of salivary
amylase and the lubrication of the food. Whereas the output
of the parotid gland is primarily serous, that of the subman-
Common Benign Salivary Gland Tumors
dibular and sublingual is mucous and that of the minor glands Pleomorphic adenoma is the most common deep lobe parotid
is mixed. In aggregate, the major and minor glands produce tumor. Because of their retromandibular position, it is com-
500 to 1,500 mL of saliva daily. mon for deep lobe parotid tumors to achieve a significant size
Seventy to eighty percent of all adult salivary gland tumors prior to diagnosis, as they are generally non-palpable. The
occur in the parotid gland, 8% to 15% in the submandibular, diagnosis is often made as an incidental finding on diagnos-
and 5% to 8% in the minor salivary glands. Sublingual neo- tic imaging studies obtained for other complaints. The opera-
plasms are extremely rare (<1%). Mucoepidermoid carcinoma tive approach is superficial parotidectomy and facial nerve
dissection followed by dissection of the nerve branches from
Head and Neck

is the most common malignant tumor of the parotid, while
adenoid cystic tumor is the most common in the submandibu- the tumor surface. The deep plane tumor is then delivered
lar and minor salivary glands. Adenoid cystic tumors have a beneath transposed branches. Pleomorphic adenomas have a
tendency for perineural invasion. recurrence rate of 2% to 7% and conversion to carcinoma ex
Histologically, there are over 40 types of salivary gland pleomorphic adenoma occurs in approximately 10% of cases.
tumors. They are the most diverse types of cancers in the Frey syndrome, also known as auriculotemporal nerve syn-
human body. Classification by cellular type includes epithe- drome, is a complication of superficial parotidectomy occur-
lial, nonepithelial, and malignant secondary neoplasms. Two ring as a result of abnormal reinnervation of sympathetic nerve
theories of histogenesis have been postulated to explain the fibers of the parotid by the transected branches of the auriculo-
broad variation (more than nine types) in histopathologic temporal nerve resulting in gustatory sweating. Although this
tumor types. In the multicellular theory, mature differentiated pattern of reinnervation occurs in as many as 80% of patients
cells of the glandular unit give rise to specific tumor histolo- who undergo superficial parotidectomy, only approximately
gies, although it requires dedifferentiation for some types. In 20% of patients notice the phenomenon or request treatment
the second and more popular theory, tumors arise from one of for it. Interposition of acellular dermal matrix may prevent the
two undifferentiated reserve cells. The only known predisposi- development of this phenomenon. Topical scopolamine cream
tion to salivary gland tumors is therapeutic external irradia- and injected Botox are also used for severe cases.
tion (acne and adenoid hypertrophy), with a latency, often, of Recurrent pleomorphic adenoma may be mono- or multi-
one to three decades. nodular and may occur up to several decades after treatment
of the index tumor. Tumor spill at the first procedure (capsu-
lar rupture) is not thought to predispose to this phenomenon.
These recurrent tumors may occur in extraglandular soft tis-
sues and may be aggressive and ultimately fatal (metastatic,
locally invasive, and skull base). More commonly, this is the
result of less-than-adequate surgery (i.e., nodulectomy, less-
than-superficial parotidectomy). Treatment is reoperation
with significant increase in the risk of permanent damage to
the facial nerve with each subsequent procedure. Adjuvant
external beam radiotherapy should be added in most cases of
multinodular recurrence.
Warthin tumor (benign cystadenoma lymphomato-
sum) exhibits a 5:1 male-to-female preponderance, typically
appearing in the fifth to seventh decade of life. Metachronous
bilaterality has been observed in up to 6% of cases.
AIDS-related lymphoepithelioma is related to involvement
of intraparotid lymph nodes and may result in ductal obstruc-
tive phenomena and multicystic glandular involvement, which
Parotid may be both deforming and painful. Treatment is external
beam radiotherapy.
Common Malignant Salivary Gland Tumors

Submandibular Adenoid cystic carcinoma is neurophilic with a high incidence
of occult perineural spread (outside the immediate opera-
Sublingual tive field) and soft-tissue invasion. This feature mandates the
Figure 30.11. Location and staging of major salivary glands.2 use of postoperative adjuvant radiotherapy in most cases.
Hematogenous metastases to the liver, lung, and bone are

T Primary Tumor (T)

TX = Primary tumor cannot be assessed
1 2 3 4 T0 = Noevidence of primary tumor
0 Stage I Stage II Stage III Stage IV Tis = Carcinoma in situ
T 1–4 = See respective sites
N 1 Stage III Stage III Stage III Stage IV
Metastasis (M)
2 Stage IV Stage IV Stage IV Stage IV MX = Distant metastasis cannot be assessed
M0 = No distant metastasis
3 Stage IV Stage IV Stage IV Stage IV M1 = Distant metastasis
• Table applies to M0 tumors

• M1=Stage IV
• Tis/N0=Stage 0
Regional lymph nodes (N)

N0 N1 N2a
No nodes Ipsilateral Ipsilateral

<3 cm >3 cm to <6 cm
N2b N2c N3
Ipsilateral multiple Bilateral/contralateral >6 cm

<6 cm <6 cm
Figure 30.12. AJCC nodal staging for head and neck cancer.24 Note: Nasopharyngeal cancer nodal staging is the same as the above except for:
Nodes in the supraclavicular fossa defined as (1) the superior margin of the sternal end of the clavicle, (2) the superior margin of the lateral end
of the clavicle, (3) the point where the neck meets the shoulder are stage N3b. Note that this would include caudal portions of levels IV and VB.
frequent and may occur with a long latency period. Patients entity represents metastasis from a frontotemporal scalp
may live with significant metastatic tumor burden for an cutaneous carcinoma to a periparotid or intraparotid
extended period (years). Survival period statistics may exceed lymph node. The mass is noted 1 to 2 years after treatment
5 years for this tumor, with survival curves diverging at 10 of the primary lesion (usually large and long-standing) and
to 15 years. Carcinoma ex pleomorphic adenoma (malignant represents a failure to adequately treat the original lesion,
mixed tumor) may arise in isolation, but is more commonly that is, postoperative adjuvant radiotherapy to the pri-
the concomitant of a long-standing pleomorphic adenoma. mary site and regional nodes (levels I, II, and III). Total
Malignant transformation is rare, occurring in fewer than parotidectomy is often required to remove all intraparotid
10% of these tumors. Acinic cell carcinoma is bilateral in 3% nodes. Skip metastasis to the upper neck is also observed,
of cases and is the second most common malignant salivary but should also include parotidectomy for occult or in-
neoplasm in children. transit disease. These treatment principles also apply to
Squamous cell carcinoma is rarely of primary parotid malignant melanomas of the temporal region. Lymphomas
origin; however, if it is, then it is most commonly high- of the salivary glands are characterized by massive enlarge-
grade mucoepidermoid carcinoma. More commonly, this ment, and the role of surgery is limited to incisional biopsy.

6. SEER Program. National Cancer Institute. Incidence data are from the
Table 30.12 SEER 9 Areas. http://seer.cancer.gov/registries/terms.html. Accessed June
23, 2011.
Histopathologic Grades of Salivary Malignancy 7. Bleyer A. Cancer of the oral cavity and pharynx in young females: increas-
ing incidence, role of human papilloma virus, and lack of survival improve-
n Low grade n High grade ment. Semin Oncol. October 2009;36(5):451-459.
8. Visconti V, Antonilli M, Bellati F, et al. HPV induced triple neoplasms: a
Acinic cell carcinoma Adenoid cystic carcinoma case report. Am J Obstet Gynecol. August 2009;201(2):e9-e12.
9. Slaughter DP, Southwick HW, Smejkal W. Field cancerization in oral
Low-grade mucoepi- Squamous cell carcinoma stratified squamous epithelium: clinical implications of multicentric origin.
dermoid Cancer. 1953;6(5):963.
10. Wang CC, ed. Radiation Therapy for Head and Neck Neoplasms. 3rd ed.
Adenocarcinoma New York, NY: Wiley-Liss; 1997.
11. Jones KR, Lodge-Rigal RD, Reddick RL, et al. Prognostic factors in the
Carcinoma ex pleomorphic recurrence of stage I and II squamous cell cancer of the oral cavity. Arch
adenoma Otolaryngol Head Neck Surg. 1992;118(5):483-485.
12. Hien YC, Chen JY, Liu MY, et al. Serologic markers of Epstein-Barr virus
High-grade mucoepidermoid infection and nasopharyngeal carcinoma in Taiwanese men. N Engl J Med.
2001;345(26):1877-1882.
13. Chen L, Gallicchio L, Boyd-Lindsley K, et al. Alcohol consumption and
the risk of nasopharyngeal carcinoma: a systematic review. Nutr Cancer.
Adenocarcinoma of the parotid gland exhibits a 7:1 female- 2009;61(1):1-15.
14. Nasopharyngeal Cancer Survival Rates. http://www.cancer.org/cancer/
to-male preponderance. nasopharyngealcancer/detailedguide/nasopharyngeal-cancer-survival-rates.
A number of factors influence survival from malignant Accessed June 23, 2011.
salivary cancer including histologic grade (Table 30.12), age 15. Lin JC, Jan J, Hsu C, Liang W, Jiang R, Wang W. Phase III study of concur-
greater than 35 to 50 years, site (submandibular, sinus, and rent chemoradiotherapy versus radiotherapy alone for advanced nasopha-
ryngeal carcinoma: positive effect on overall and progression-free survival.
larynx), clinical stages III and IV (Figure 30.9), and male gen- J Clin Oncol. 2003;21(4):631.
der. Multivariate analysis has shown that histologic grade 16. Rudat V, Wannenmacher M. Role of multimodal treatment in oropharynx,
and stage are the most important determinants of survival larynx, and hypopharynx cancer. Semin Surg Oncol. 2001;20(1):66.
outcomes. Survival for stage I tumors is approximately 90%; 17. Lefebvre JL, Chevalier D, Luboinski B, et al. Larynx preservation in pyri-
Head and Neck

form sinus cancer: preliminary results of a European Organization for
this number drops to 65% for stage II and 20% for stage III Research and Treatment of Cancer phase III trial. EORTC Head and Neck
malignant salivary tumors. Squamous and anaplastic carci- Cancer Cooperative Group. J Natl Cancer Inst. 1996;88(13):890-899.
nomas carry the worst prognosis. Acinic cell and low-grade 18. Kim S, Wu HG, Heo DS, et al. Advanced hypopharyngeal carcinoma treatment
mucoepidermoid carcinomas fare best. Parotid malignancies results according to treatment modalities. Head Neck. 2001;23(9):713-717.
19. Okamoto M, Takahashi H, Yao K, et al. Clinical impact of using chemo-
do better than those of other subsites. Tumor recurrence rates radiotherapy as a primary treatment for hypopharyngeal cancer. Acta
are 39%, 60%, and 65% for parotid, submandibular, and Otolaryngol Suppl. 2002;547:11-14.
minor salivary gland malignancies, respectively. Because this 20. American Cancer Society. Cancer Facts and Figures 2010. Atlanta,
may happen years after the initial treatment, long-term follow- GA: American Cancer Society; 2010. Also available online. Accessed
January 6, 2011.
up is essential. Survival for adenoid cystic carcinoma should 21. Hong WK, Lippman SM, Itri LM, et al. Prevention of second primary
be measured in decades as survival curves may only begin to tumors with isotretinoin in squamous-cell carcinoma of the head and neck.
diverge from the population around 15 years posttreatment. N Engl J Med. 1990;323(12):795-801.
22. Mendenhall W, Werning J, Pfister D, et al. Treatment of head and neck
cancers. In: DeVita VT Jr, Hellman S, Rosenberg SA, eds. Cancer: Principles
References and Practice of Oncology. 8th ed. Philadelphia, PA: Lippincott Williams &
Wilkins; 2008:809-877.
1. Carvalho AL, Nishimoto IN, Califano JA, Kowalski LP. Trends in incidence 23. Thawley SE, Panje WR, Batsakis JG, et al., eds. Comprehensive Management
and prognosis for head and neck cancer in the United States: a site-specific of Head and Neck Tumors. 2nd ed. Philadelphia, PA: WB Saunders; 1999.
analysis of the SEER database. Int J Cancer. 2005;114(5):806. 24. Gilbert RW, Neligan PC. Microsurgical laryngotracheal reconstruction.
2. Edge SB, Byrd DR, Compton CC, et al., eds. AJCC Cancer Staging Manual. Clin Plast Surg. 2005;31(3):293.
7th ed. New York, NY: Springer; 2010 25. O’Sullivan B, Shah J. New TNM staging criteria for head and neck tumors.
3. Robbins KT, Clayman G, Levine PA, et al. Neck dissection classification Semin Surg Oncol. 2003;21(1):30.
update: revisions proposed by the American Head and Neck Society and 26. Garden AS, el-Naggar AK, Morrison WH, et al. Postoperative radiotherapy
the American Academy of Otolaryngology-Head and Neck Surgery. Arch for malignant tumors of the parotid gland. Int J Radiat Oncol Biol Phys.
Otolaryngol Head Neck Surg. 2002;128(7):751. 1997;37(1):79-85.
4. 5 Year Survival Rates for Invasive Cancers of Head and Neck. http://www. 27. Chen AM, Granchi PJ, Garcia J, et al. Local-regional recurrence after sur-
seer.cancer.gov. Accessed June 23, 2011. gery without postoperative irradiation for carcinomas of the major salivary
5. Davies L, Welch HG. Epidemiology of head and neck cancer in the United glands: implications for adjuvant therapy. Int J Radiat Oncol Biol Phys.
States. Otolaryngol Head Neck Surg. September 2006;135(3):451-457. 2007;67(4):982-987.

Chapter 31 n Reconstruction of the Scalp,
Calvarium, and Forehead
J. Guilherme Christiano, NICHOLAS Bastidas, and Howard N. Langstein
Scalp and forehead defects result from trauma, burns, onco- Deep to the galea lies the loose areolar layer, a relatively
logic resection, infection, radionecrosis, and congenital abnor- avascular plane also known as the subaponeurotic layer, sub-
malities. Reconstruction is dictated primarily by the size and galeal fascia, or innominate fascia. It enables the layers above
depth of the defect and is accomplished by the simplest means it (skin, subcutaneous connective tissue, and galea) to slide
possible following the reconstructive ladder. Nevertheless, as a unit over the cranium. As such, this layer is easily dis-
complicating features of the soft tissues and underlying bone sected and is often the plane of cleavage in avulsion or scalp-
may require a more complex approach. ing injuries.
The pericranium is the periosteum of the calvarium.
Laterally, at the superior temporal line, it is continuous with
Anatomy the deep temporal fascia (temporalis muscle fascia). More
The forehead and scalp share five distinct anatomic layers: inferiorly, the deep temporal fascia divides into two layers,
Skin, subcutaneous Connective tissue, galea Aponeurotica deep and superficial, which envelop the superficial temporal
or muscle, Loose areolar tissue, and Pericranium (SCALP) fat pad and insert into the superficial and deep aspects of the
(Figure 31.1). The first three layers are bound together by zygomatic arch, respectively (Figure 31.2).1
numerous vertical septae between the skin and the galea apo-
neurotica, forming a single unit that glides along the loose Blood Supply
areolar tissue over the pericranium.
The scalp and forehead are supplied by five paired arteries
The skin of the scalp is the thickest in the body (between 3
that form rich interconnections within the subcutaneous layer
and 8 mm) and has numerous sebaceous glands. Immediately
(Figure 31.3). From anterior to posterior, these are the supra-
beneath the skin lies a layer of dense connective and fatty tis-
trochlear and supraorbital arteries (internal carotid), and the
sue, which contains a rich net of arteries, veins, lymphatics,
superficial temporal, posterior auricular, and occipital arteries
and sensory nerves, along with the hair follicles of the scalp.
(external carotid).
The underlying galea aponeurotica is part of a broad fibromus-
The main blood supply to the anterior scalp and forehead
cular layer that covers the upper cranium from the forehead
derives from the supratrochlear and supraorbital arteries,
to the occiput and serves as the central tendinous confluence
which arise from the ophthalmic artery (first branch of the
of the occipitalis muscle posteriorly and the frontalis muscle
internal carotid) and enter the forehead vertically at the level
anteriorly. The occipitalis and frontalis muscles are thin,
of the supraorbital rim. These vessels become superficial above
quadrilateral muscles, each consisting of two bellies joined in
the brow, piercing the frontalis muscle to reach the superficial
the midline by extensions of the galea. The occipitalis muscle
layer, where they anastomose with anterior branches of the
arises from the lateral two thirds of the superior nuchal line
superficial temporal arteries.
of the occipital bone and from the mastoid part of the tem-
As terminal branches of the external carotid arteries, the
poral bone. The frontalis muscle has no bony attachments. Its
superficial temporal arteries are the largest of the scalp ves-
medial fibers are continuous with those of the procerus mus-
sels and supply blood to the temporal and central scalp. They
cles, while its lateral fibers blend with those of the corrugator
course through the superficial lobes of the parotid glands and
and the orbicularis oculi. The frontalis muscle joins the galea
ascend in front of the auricles, traveling with the auriculo-
aponeurotica in the upper forehead. The galea aponeurotica
temporal nerves. Above the zygomatic arch, the superficial
is contiguous with the temporoparietal fascia (also known as
superficial temporal fascia) and with the subcutaneous mus-
culoaponeurotic system (SMAS) of the face (see Chapter 47).
Figure 31.1. Layers of the forehead and scalp. Figure 31.2. Anatomic relationships in the temporal region.
342
Chapter 31: Reconstruction of the Scalp, Calvarium, and Forehead 343
scalp region and hence no barriers to lymphatic flow. Lymph
from the scalp drains freely toward the parotid, pre- and post-
auricular nodes, upper cervical nodes, and occipital nodes.
Innervation
The muscles of the forehead are innervated by the frontal
(also known as temporal) branches of the facial nerve (cranial
nerve VII). As many as five separate branches may course in
the loose areolar plane below the SMAS, cross the midpor-
tion of the zygomatic arch, and reach the undersurface of the
frontalis muscle (Figure 31.2). The occipitalis muscle is inner-
vated by the posterior auricular branches of the facial nerve.
The temporalis muscle is supplied by motor branches from the
third division of the trigeminal nerve (cranial nerve V).
The sensory nerve supply to the anterior scalp and forehead
derives from the ophthalmic division of the trigeminal nerves.
The supratrochlear and supraorbital nerves arise from this
branch and leave the skull through the supraorbital foram-
ina or grooves at the supraorbital rim. The temporal scalp
is supplied by the maxillary division of the trigeminal nerve
(zygomaticotemporal nerve) and the preauricular scalp by the
mandibular division (auriculotemporal nerves). The postau-
ricular scalp is supplied by dorsal rami of the cervical spinal
nerves (greater occipital nerve and third occipital nerve).
Head and Neck

Scalp Reconstruction
Figure 31.3. Blood supply to the scalp and forehead. Several variables need to be taken into account when devising
the best therapeutic approach for a scalp defect. While size
and depth are the most obvious, other features may prove to
be just as important in each individual case. As always, the
temporal arteries lie within the superficial temporal fascia and plastic surgeon should employ the procedure at the lowest
divide into anterior and posterior branches. These branches level of the reconstructive ladder that suits both the defect and
anastomose liberally with anterior and posterior blood sup- the patient.
plies of the scalp. The anterior branch usually crosses the most
anterior temporal branch of the facial nerve just above the lat-
eral brow, an important anatomic landmark for finding either
Key Planning Points
the nerve or the vessel. 1. The Defect
The occipital arteries provide blood supply to the poste- Size and shape along with depth (see below) are the main
rior scalp above the nuchal line. They run from the exter- determinants of the amount of tissue needed for closure.
nal carotid arteries along the vertebral muscles and join Categorizing scalp defects by their size can facilitate an algo-
the scalp through the cranial attachments of the trapezius rithmic approach to reconstruction. However, defects come in
muscle or in the space between the trapezius and sternoclei- different shapes, and a 2 × 10 cm defect may represent a com-
domastoid muscles. These arteries are usually found within pletely different reconstructive challenge compared with a 4 ×
2 cm of the midline at the nuchal line and usually divide 5 cm wound, even though both span 20 cm2. For this reason,
into medial and lateral branches above this location. The while recognizing that most scalp wounds in the real world
blood supply of the posterior scalp caudal to the nuchal line are not perfectly round, the authors choose to categorize the
derives from perforating branches of the trapezius and sple- size of the defects based on diameter, as depicted below.
nius capitis muscles. Location. The parietal regions allow the most advance-
The region of the mastoid is supplied by the posterior ment of scalp tissue. Therefore, parietal defects are more
auricular arteries, the smallest of the main vessels of the scalp. amenable to scalp undermining and primary closure, while
They are sufficient for some local flaps in this vicinity but not defects in other areas may take advantage of full advance-
robust enough to support the entire scalp. ment of parietal scalp as a flap. Reconstruction of the tem-
The scalp is drained by veins that accompany the named poral scalp may benefit from the extra soft tissue padding
arteries. Venous blood also flows through the diploe of the provided by the underlying temporalis muscle. The occipital
cranium to the dural sinuses via emissary veins. These emis- region provides very limited scalp mobility. Finally, for best
sary veins do not have valves and can be a portal for intra- cosmetic results, defects in hair-bearing areas should be cov-
cranial spread of infections in the scalp, especially those in ered using hair-bearing scalp, unless hair transplantation is
the loose areolar layer.2 The supratrochlear and supraorbital planned.
veins join to form the angular vein on each side. They also Depth. Lacerations involving the galea require specific clo-
communicate with the ophthalmic veins. The superficial sure of this layer. When skin grafting over the calvarium, an
temporal veins descend in front of the auricle and enter the intact pericranium is needed for reliable and durable take. In
parotid glands to join the maxillary veins and form the ret- defects involving the calvaria, all exposed devitalized bone
romandibular veins. The posterior auricular veins join the needs to be debrided before coverage. Exposed dura fre-
posterior division of the retromandibular veins to form the quently requires some form of calvarial reconstruction for
external jugular veins. The occipital veins pierce the cranial brain protection, but small areas may be resurfaced with well-
attachments of the trapezius muscle and join the deep cervi- vascularized scalp or other soft tissue.
cal and vertebral veins in the venous plexus of the posterior 2. The Surrounding Tissues
triangle on each side. Quality. Thickness, elasticity, and vascular supply to the
The scalp lymphatics are mainly located in the subdermal tissues surrounding the defect can be compromised by sev-
and subcutaneous levels. There are no lymph nodes in the eral factors. In addition, scars from previous operations are

frequently seen in the scalp in patients referred for oncological a trial period with xeno- or allografts can provide the wound
reconstruction, further limiting the usefulness of local tissues. with time to improve and at the same time be informative
Burns and previous radiation therapy also diminish the use of to the surgeon, with no expense of the patients’ donor sites.
local flaps. Infections should be controlled before the creation Immediate or early loss of the xeno/allograft indicates that
of flaps or insertion of tissue expanders. the wound bed is not healthy, while good take of the xeno/
For oncological defects, clear margins of malignancy are allograft prompts the surgeon to proceed with the definitive
verified, before reconstruction, especially in repairs involv- reconstruction.
ing large areas of undermining, as these may be then need Split-thickness autografts are used in scalp reconstruc-
to be removed in an oncological re-excision. Local wound tion for coverage of the primary defect, the secondary
care or temporizing reconstruction with dermal regenera- defect (donor area of a local flap), or a flap devoid of skin
tion templates, allografts, or xenografts is considered when (pericranial, muscular, omental, etc.) and require a healthy
clear margins cannot be confirmed at the time of tumor vascularized bed for success. Alopecia and some degree of
excision. color mismatch are expected. When placed over the cal-
The hair line can be distorted by excessive tissue undermin- varium, an intact pericranium is preferred (Figure 31.4).
ing and recruitment. It should also be addressed when design- Skin grafts over pericranium, however, have low tolerance
ing rotational flaps or planning scalp tissue expansion. Defects to shearing forces and are prone to wound breakdown.
involving the hair line may require reconstruction with hair- Burring down the outer cortical layer of the skull to induce
bearing and non–hair-bearing tissues. the formation of granulation tissue prior to grafting is also
3. The Patient discouraged for the same reason. When available, pericra-
Before considering complex procedures or multi-stage scalp nial or temporoparietal fascial flaps can be used to recreate
reconstruction, it is paramount to assess the patient’s overall a thicker vascularized wound bed and decrease the wound’s
health, level of function, compliance, and personal preference. depth. For best cosmetic results, skin autografts to the scalp
Patients with significant comorbidities may not be candidates are not meshed.
for prolonged surgical procedures. Patients’ compliance and
ability to keep pressure off the surgical site are required after Dermal Regeneration Templates. Integra (Integra
pressure ulcer reconstruction. Individuals undergoing tissue LifeSciences, Plainsboro, NJ) is a synthetic bilaminate com-
expansion need to cope with a lengthy process, some level of posed of a collagen lattice covered with a thin silastic sheet,
pain, and significant disfiguration. Some may prefer a single- which renders it impermeable to water. Vascularization of the
stage surgical treatment instead. deeper layer usually occurs in a few weeks, at which point
Oncological patients require special considerations. the silastic sheet is removed and a thin split-thickness skin
Attention is given to preoperative chemotherapy agents autograft is applied. Advantages of the use of Integra in scalp
that could compromise wound healing. Nutritional state reconstruction include the simplicity of initial wound man-
is checked. Patients may present for reconstruction before agement, the potential as a wound-temporizing technique,
radiation and/or chemotherapy and require a reliable short- the increase in thickness of the wound bed allowing for more
term reconstructive approach that will allow them to con- stable coverage with a subsequent autograft, and the decrease
tinue cancer treatment in a timely fashion. Therefore, in donor site morbidity because a thinner skin graft is needed.
tissue expansion is usually not an initial option. In severe Disadvantages may include the availability and cost of the
cases, patient’s life expectancy may influence the choice of product, the relatively long period required with a pressure
reconstruction. dressing, and alopecia.
Reconstructive Options Local Flaps. Local scalp flaps can be designed as partial or
full thickness. Partial-thickness flaps, such as pericranial and
Primary Closure. Primary closure is possible for scalp galeal flaps, are most useful to create a vascularized wound
defects up to 3 cm in diameter. The scalp has a rich vas- bed when full-thickness scalp flaps (FTSFs) are not available
cular supply, which allows for some degree of tension. On or desired. Unlike coverage with dermal regeneration tem-
the other hand, the galea is relatively inelastic and prevents plates, which require time for vascular ingrowth, partial-thick-
tissue recruitment. Undermining the surrounding tissues at ness scalp flaps can be covered with a skin graft immediately.
the subgaleal plane yields some mobilization, which may be The pericranial flap includes the periosteum of the skull along
sufficient for wound coaptation. Open wounds are irrigated with the overlying loose areolar tissue (Figure 31.5). The flap
and devitalized or fibrotic edges are sharply debrided before
closure.
Secondary Closure. Although this is an option for all soft

tissue wounds, wound healing by secondary intention should be
discouraged in the scalp, unless other reconstructive techniques
are not available to the surgeon. Complete wound healing can
be a lengthy process, depending on its size and depth. Exposed
calvarial bone devoid of pericranium is prone to osteomyelitis
and stable spontaneous coverage is unlikely. Finally, the hair-
less scar that results is cosmetically problematic.
Skin Grafts. Skin allografts and xenografts can be used for

temporary closure of scalp defects of any size. One to two
weeks may pass before the graft is lost by rejection. During
this time, for instance, conclusive pathological information
can be obtained on the resected specimen (benign versus
malignant tumor, margin status, need for radiation therapy,
etc.) before a final reconstructive plan is implemented. In
other occasions, the surgeon may not be certain of the abil-
ity of a scalp wound to accept a skin graft and heal, most
commonly because of lingering infection, injury from radia- Figure 31.4. Scoring of the galea of a scalp flap.
tion therapy, tissue ischemia, or malnutrition. In such cases,

sometimes a substantial back-cut is required to provide the
necessary flap mobilization.3,5 Two flaps can also be used,
skin grafting the donor site, if necessary (Figure 31.8).
For defects ranging from 6 to 9 cm in diameter, one large
scalp flap based on a major pedicle can be used, but the sec-
ondary defect will likely require skin grafting (Figure 31.9).
For this reason, it is important to preserve the pericranium
in the donor defect. A “bucket-handle” flap, based on both
superficial temporal vessels, can be used to resurface anterior
scalp defects, and the requisite skin graft can be placed in
the vertex, which can be camouflaged by hair. Alternatively,
multiple scalp flaps are used, frequently in the shape of a pin-
wheel. Another variant of using multiple scalp flaps involves
elevation of the remaining scalp, with one posterior flap
based on the occipital or posterior auricular vessels and two
anterior flaps based on the superficial temporal vessels. The
posterior flap is based on the side opposite to the defect and
recruits excess tissue found in the nape of the neck region.
These flaps are widely undermined and then interdigitated,
covering the defect but often leaving an anterior secondary
Figure 31.5. Closure of a cerebrospinal fluid leak following crani- defect that requires grafting when the primary defect is poste-
otomy for tumor ablation. rior. Conversely, when the defect is anterior, one of the ante-
rior flaps is used to cover the primary defect. The other flaps
are pieced together to close any secondary defects. Skin grafts
should be based on one of the named scalp vessels or originate are used as needed.6
Head and Neck

from their general vicinity. Perfusion across the midline, often Whichever flap design is chosen, the main reconstructive
meager, can be enhanced by including the galea with the flap. principles are as follows: (1) mobilize as much scalp tissue
This galeal–pericranial flap is a much more robust parcel of as available to cover the primary defect (flap + wide under-
tissue that can be dissected off the neighboring scalp, placed mining) and to minimize the size of the secondary defect
over the bare skull, and covered with a skin graft.3,4 This dis- (wide undermining) and (2) plan the location of the second-
section is tedious and bloody and may result in some alopecia ary defect so as to maximize cosmetic and functional results.
at the donor site. Patients tolerate surprisingly well a favorably located area of
In general, coverage of scalp defects with FTSFs provides alopecia (ideally occipital) that can be camouflaged with their
superior functional and aesthetic results compared with own hair.
reconstruction with grafts, especially when postoperative
radiation therapy is anticipated. An FTSF is an axial flap, Tissue Expansion. Tissue expansion represents an invalu-
based on the scalp’s major supplying vessels. Although the able asset in scalp reconstruction, allowing the replacement
rich subcutaneous anastomotic connections would allow the of like with like (Chapter 10). In an optimal situation, time
entire scalp to live on a single major vessel, FTSFs should is available for scalp expansion. Most commonly, however,
incorporate as many vessels as possible without compromis- patients present to the surgeon with an open wound already
ing the mobilization needed. A long, wide flap is preferable present or with one that is covered in a temporary or subopti-
to a small flap. Long, curvilinear incisions (Figure 31.6) facil- mal fashion, limiting the practicality of scalp expansion.
itate flap advancement and allow primary closure of the sec- A major advantage of scalp expansion is the potential to
ondary defect (donor area). A large flap is also advantageous use expanded hair-bearing tissue, therefore, avoiding alopecia
in the event of peripheral wound breakdown, being more or treating existing alopecia. In addition, when given enough
amenable to re-advancement than a small flap. The spherical time, scalp tissue can be expanded to a significant degree. As
shape of the calvaria is to be considered, as two-dimensional much as 50% of the scalp can be reconstructed by expanding
measurements of a scalp defect (from a photograph, for the remaining scalp. Unfortunately, the use of tissue expand-
instance) underestimate the size of flap needed for coverage. ers has many limitations. The wound needs to be free of
For this reason, measurements of the defect are performed in infection. The tissues to be expanded should be healthy and
vivo and after calvarial reconstruction. Scalp flaps are raised well vascularized. Expanding previously radiated tissue is not
below the galea, making use of the relatively avascular plane advisable. Alternatively, adjacent non-radiated areas can be
at the loose areolar layer. When incising hair-bearing scalp, expanded and subsequently used to cover radiated wounds
an attempt is made to bevel the cut parallel to the hair shaft and/or replace radiated tissues. The patient needs to be well
direction to avoid follicular damage and incisional alopecia. informed and preoperatively screened in regard to social sup-
Scalp flaps using in radiated scalp tissue are less robust and port, medical compliance, status of the underlying disease and
require skin grafting the pericranium of the donor site or sur- its treatment course, and the will to endure the lengthy expan-
gical delay. sion period, the consequent physical deformity, and the multi-
Most defects with a diameter of 3 to 6 cm are amenable to stage reconstruction. Expander complication rates may be as
closure with FTSFs. Donor sites are usually closed primarily. high as 25% and include infection, exposure, extrusion, and
If necessary, once the scalp incisions are made, a few maneu- device failure.
vers can be used to facilitate mobilization of the flap and Scalp tissue expanders are placed in the subgaleal plane.
decrease wound closure tension: (1) wide undermining of the In general, one or more expanders are inserted through
surrounding tissues, (2) galeal scoring, and (3) back cutting remote incisions, oriented radially to the defect. It is critical
of the flap, in that order. Frequently, significant undermining to anticipate where the future flap incisions will be made prior
is required to close the donor site. Galeal scoring is performed to expander insertion. Overexpansion by up to 50% of the
perpendicular to the main advancement axis of the scalp flap. estimated amount is necessary, because the flaps do not yield
Incisions are made 1 to 2 cm apart in the galea, trying to the theoretical tissue gain. Significant back-cuts are usually
avoid injury to the vessels lying just superficial to it. One can required to advance the expanded tissue and are well toler-
expect 1 to 2 mm of release for each galeal incision score line, ated due to the vascular delay effect from expansion. The peri-
sometimes adding up to 1 cm or more (Figure 31.7). Finally, prosthetic capsule is incised to allow maximal flap movement

A B
C D
Figure 31.6. Skin graft reconstruction of anterior scalp and fore-

head. A. Anterior scalp and forehead defect following re-resection of
persistent low-grade sarcoma. B. Re-resection defect with inner table
burred down. C. Full-thickness skin graft placed. D. Full take of graft.
E. Hairstyle change covering graft.
E
(Figure 31.10). See Chapter 10 for further information on tis- one-step solution for resurfacing large scalp defects with
sue expansion. good results, especially in patients with preexisting alope-
cia.3,8 The superficial temporal vessels are frequently avail-
Regional Flaps. Some posterior scalp defects can be recon- able as recipient vessels, although the vein is occasionally
structed with regional pedicled flaps such as the trapezius inadequate or absent, in which case interpositional vein
musculocutaneous flap and the latissimus dorsi musculocu- grafting to the neck may be necessary. They are easily found
taneous flap.7 Preliminary delay of these flaps should be con- through a preauricular incision with elevation of the skin
sidered to enhance vascularity and maximize flap success. flap to the location of the palpable pulse of the artery. The
depth of these vessels decreases as the incision advances
Free Tissue Transfer. Scalp defects greater than 9 cm in superiorly, such that they are quite superficial in the tem-
diameter are usually not amenable to closure with pedicled poral region and lie within the parenchyma of the parotid
flaps and require free tissue transfer. Although tissue expan- gland more inferiorly. Occasionally, the occipital vessels
sion might still be applicable, free tissue transfer offers a can be used as recipients.

without the need for vein grafts and is a good choice for
smaller defects. Fasciocutaneous flaps, such as the anterolat-
eral thigh, have recently grown in popularity. Primary clo-
sure of the thigh donor site is usually not possible when the
harvested skin paddle is wider than 8 cm, requiring a skin
graft from the contralateral thigh.
Forehead Reconstruction
A few unique features of the forehead should be considered
when planning reconstruction. The forehead comprises the
upper part of the face. It forms a single, relatively large, and
conspicuous facial aesthetic unit, whose limits may depend on
the presence and location of the hairline. The eyebrows are
adjacent to its lower border. Their position and function are
intrinsically related to the soft tissues of the forehead.
Wide undermining and primary closure of defects is
facilitated by the substantial soft tissue laxity usually found
in the forehead. Defects up to 2.5 cm may be closed primar-
ily. Shape and orientation of the wound are very impor-
tant, as the main vector of tissue mobilization should be
horizontal, to avoid disruption of the eyebrows. Significant
wound tension is well tolerated and subsides with time.
Different from the scalp, the forehead heals secondarily
very well and surprisingly good results can be expected,
Head and Neck

as observed in forehead flap donor sites in older patients
(Figure 31.12).
When contemplating the use of flaps or skin grafting for
forehead reconstruction, the surgeon adheres to aesthetic unit
principles. Reconstruction of wounds comprising more than
50% of the forehead often yields a superior aesthetic result by
Figure 31.7. Large, wide-based full-thickness scalp rotation flap is replacing the entire unit, even if it means excising healthy tis-
raised to cover exposed skull in occiput. Multiple galeal scorings are sue. Alternatively, the forehead is amenable to tissue expansion.
evident, running parallel to the axial blood supply. Incisions placed around the aesthetic unit (at the hairline and
just above the brows) are the least conspicuous. Older patients
may provide the surgeon with plenty of skin rhytids to help
camouflage scars in other locations. It is preferable to lower
Available options include musculocutaneous and fas- the anterior hairline rather than leave mid-forehead incisions.
ciocutaneous flaps, as well as muscle and omental flaps in Free tissue transfer may be required for coverage of total or
combination with non-meshed split-thickness skin grafts. near total forehead defects, especially in the presence of exposed
Muscle flaps show significant atrophy with time. The latis- bone without pericranium or after local radiation therapy.
simus dorsi and the rectus abdominis muscle flaps are tra-
ditional favorites for coverage of large defects of the scalp.
They have consistent vascular pedicles and a large muscle
Calvarial Reconstruction
mass (Figure 31.11). A large omental flap can also be used, Cranioplasty or other forms of calvarial reconstruction are
but it often becomes thin over time and may not be suitable considered to be among the oldest recorded surgical proce-
for long-term durable coverage. The serratus anterior muscle dures in history, dating back to 3000 BC.9 The Incas filled the
free flap has a long pedicle that can reach the neck vessels trephination defects created (to allow evil humors/spirits to
A B
Figure 31.8. A. Exposed cranium in a vertex defect following re-excision for recurrent skin cancer. Opposing scalp flaps are designed. B. Scalp
flaps are rotated, advanced, and inset. Split-thickness graft was needed to cover one of the secondary defects.

Figure 31.9. A. Large anterior scalp defect with exposed cranium
following resection of neglected skin cancer. B. Posteriorly based
scalp flap rotated and advanced, leaving large secondary defect, which
required skin grafting. C. Inset of large rotational scalp flap demon-
strating dog-ear at base, which was not removed at this setting, as it
frequently resolves without surgery, and resection may limit vascular-
ity of the flap.
C
egress from the body) with gold and silver. Callus formation (<90 days) and late reconstructions, with a mean re-infection
noted in ancient skulls indicates that some patients survived. rate of 7.9%.11
Today, the plastic surgeon is often consulted for calvarial
defects resulting from vascular accident, trauma, infection,
and post-oncologic resection. The current indications for cra- Reconstruction Options
nioplasty include the following: restoration of the aesthetic The ideal calvarial replacement after craniotomy is the origi-
contour of the calvarium, protection of the underlying brain, nal “bone flap.” At the time of craniotomy, bone flaps may
and to provide treatment for “syndrome of the trephined” be preserved for delayed replacement by banking the bone
(characterized by dizziness and fatigue after craniectomy and flap either subcutaneously (typically in the abdomen) or in
thought to be related to intracranial transmission of atmo- a deep freezer (recommended temperatures ranging from
spheric pressures altering cerebral circulation). Prior to recon- −30°C to −80°C).12 After resolution of cerebral edema or
struction, the surgeon must take into account patient stability infection, the bone flap is then replaced. The bone flap then
and systemic complicating factors, and must determine if ade- functions as a conduit for “creeping substitution,” where
quate soft tissue exists for coverage. it serves as a scaffold for ingrowth of new bone from the
Loss of bone flaps from infection after craniotomy has a edges of the defect. Proponents of subcutaneous banking of
reported incidence of 2%. Retrospective studies have suggested the bone flap suggest a lower rate of resorption and subse-
delaying calvarial reconstruction for at least 90 days after quent secondary surgery in comparison to the deep freezing
the infection to reduce the potential for recurrence.10 Other method.13 Subcutaneous placement, however, may require
authors advocate waiting up to 1 year. A recent meta-analysis fracturing of the bone flap and adds the morbidity of an
suggested comparable infection rates for early reconstruction abdominal wound and scar.
A B
Head and Neck

C D
Figure 31.10. Tissue expansion and scalp flap reconstruction for unstable skin graft on posterior skull. A. Unstable skin graft
following dermatofibrosarcoma protuberans excision and radiation therapy. B. Placement of large crescent tissue expander at
anticipated donor region. C. Rotation of expanded scalp allowed coverage of exposed skull. D. Postoperative result showing stable
wound but persistent alopecia from irradiation.
More often, the original bone flap is not available when table is thought to maintain 67% of its breaking strength after
the plastic surgeon is consulted, and the options for recon- splitting, increasing the risk of skull fracture in this area.10 In
struction then include autologous and alloplastic methods of children less than 4 years of age, the bone may be too thin to
calvarial reconstruction: split even if a full-thickness bone flap is removed and split-
ting is attempted on the back table. Harvesting full-thickness
grafts and splitting them ex vivo may help facilitate the pro-
Autogenous Bone Grafting cess in older children or when larger defects are grafted. Using
Autologous reconstruction is considered the gold standard trans-illumination techniques, thicker bone segments with a
particularly in the setting of bone flap loss after infection. well-defined diploic space can be identified and split using a
Bone grafts replace “like with like,” are thought to have a sagittal saw or scalpel. The posterior table is placed on the
lower incidence of infection, and allow calvarial growth in the graft site and the anterior table is returned to the donor.
pediatric population. Donor sites typically include the calvar- Additionally, full-thickness defects in neonates may heal spon-
ium, rib, and iliac crest, all of which may be split to increase taneously, likely an effect of the growing brain (dura) on the
the surface area and reduce donor site defects. induction of osteogenesis.
Split calvarial bone is the optimal autologous donor graft, Particulate bone graft harvested from the inner or outer
reportedly offering less resorption (thought to be related to cortex may also be used to repair critical size defects, with
a high density of cortical bone and its intra-membranous some authors reporting up to a 97.8% success.14 These grafts
embryologic origin). Some studies, however, still suggest are easily harvested using a Hudson brace and flat craniot-
a 25% rate of resorption at 5 years, which may lead to the omy bit and can be stabilized using fibrin glue. A disadvan-
necessity for secondary cranioplasty.10 Since the donor site is tage is the irregular, “bumpy” contour, making these grafts
located in the same operative field as the defect, additional more useful for filling donor site defects in less visible areas
scarring is avoided. Cranial bone is typically harvested from of the calvarium. Split rib and iliac crest grafts are considered
the parietal bone, splitting the bone using a sagittal saw and/ secondary options, given the necessity of an additional scar,
or an osteotome in the diploic space. The remaining posterior donor site pain, and the potential for donor site complications

A B
Figure 31.11. Free latissimus dorsi flap reconstruction of scalp defect. A. Large scalp
defect following angiosarcoma resection, radiation therapy, and unsuccessful skin graft
placement. B. Latissimus dorsi free flap placed on defect with anastomoses to superficial
temporal vessels. C. Postoperative result with satisfactory contour.
C
(such as pneumothorax and painful neuroma, respectively).

Rarely, free vascularized bone may be transferred along with
soft tissue coverage for calvarial defects, such as a free latis-
simus/serratus with rib, though this is typically in the setting
of large radiation defects.15
Alloplastic Materials
Alloplastic materials offer a potentially unlimited off-the-shelf
resource without donor site morbidity. The ideal implant
material would be biologically inert, osteoconductive, and
biomechanically compatible. Numerous materials have been
described historically, with currently titanium, polymethyl-
methacrylate (PMMA), and hydroxyapatite (HA) being most
frequently used today (Chapter 7).
Titanium mesh offers a corrosive resistant, biocompat-
ible, strong material that produces minimal encapsulation.
Titanium implants can be obtained pre-formed (CAD/CAM)
or can be contoured in the operating room from a straight
piece of mesh. A review of the literature reports infection
rates from 0% to 4.5%.16 Critics of titanium mesh cite the
conduction of hot and cold temperature as uncomfortable for
the patient postoperatively and also the difficulty of obtaining
high-quality imaging post-cranioplasty due to artifact scatter. Figure 31.12. Reconstructive choices for forehead defects with
PMMA is the most widely used alloplastic material in local flaps. Solid lines, “H” flap advancement; dashed lines, and rota-
cranioplasty. PMMA does not integrate, which helps facili- tion advancement.
tate removal in revision surgery when compared with other

alloplastic implants.17 Similar to titanium mesh, it can be While calvarial reconstruction using modeling has been
pre-formed using CAD/CAM to help achieve a more accurate found to be accurate within 2% of the normal, the surgeon
reconstruction. One study reported a 9.6% infection rate in must be aware of the soft tissue limitations that exist from
a series of 31 patients, requiring removal of the implant and skin contracture/debridement from the previous surgeries pre-
secondary cranioplasty.18 When the reagents are mixed and venting a fully symmetric anatomic reconstruction.
sculpted intraoperatively, there is a risk of thermal damage
to the underlying brain from an exothermic reaction, with References
temperatures potentially reaching as high as 100°C. Actively
1. Zide BM, Jelks GW. Surgical Anatomy of the Orbit. New York, NY: Raven
cooling the surrounding tissues with water may decrease Press; 1985:13-20.
thermal conduction during the maturation process. 2. McCarthy JG, Zide BM. The spectrum of calvarial bone grafting: introduc-
HA is a calcium phosphate salt putty that is easily mold- tion of the vascularized calvarial bone flap. Plast Reconstr Surg. 1984;74(1):
able, but may be prone to fracture and/or fragmentation. HA 10-18.
3. Hoffman JF. Management of scalp defects. Otolaryngol Clin North Am.
is the only alloplastic material to offer the potential for osteo- 2001;34(3):571-582.
conduction and integration with the native bone.19 In large 4. Horowitz JH, Persing JA, Nichter LS, Morgan RF, Edgerton MT.
defects, it is often combined with titanium mesh since it can- Galeal-pericranial flaps in head and neck reconstruction. Anatomy and
not tolerate axial loading stresses alone. High rates of compli- application. Am J Surg. 1984;148(4):489-497.
5. Worthen EF. Transposition and rotation scalp flaps and rotation forehead
cations have been reported in the setting of large-scale defects flap. In: Strauch B, Vasconez LO, Hall-Findlay, EJ, eds. Grabb’s Encyclopedia
(>25 cm2) or areas of previous irradiation. An infection rate as of Flaps. Boston, MA: Little Brown and Company; 1990:5-10.
high as 40% can be seen particularly if the material communi- 6. Ortico chea M. New three-flap reconstruction technique. Br J Plast Surg.
cates with the frontal sinus.19 1971;24(2):184-188.
7. Mustoe TA, Corral CJ. Soft tissue reconstructive choices for craniofacial
reconstruction. Clin Plast Surg. 1995;22(3):543-554.
Outcomes 8. Hussussian CJ, Reece GP, W. Microsurgical scalp reconstruction in the
patient with cancer. Plast Reconstr Surg. 2002;109(6):1828-1834.
Overall complication rates are relatively high in cranioplasty 9. Marbacher S, Andres RH, Fathi AR, Fandino J. Primary reconstruction
procedures, with a typical range of 20% to 30%.20 Contour of open depressed skull fractures with titanium mesh. J Craniofac Surg.
deformities and infection being the most common, followed 2008;19(2):490-495.
Head and Neck

by exposure, hematoma, and seroma. Higher rates of compli- 10. Zins JE, Langevin CJ, Nasir S. Controversies in skull reconstruction.
J Craniofac Surg. 2010;21(6):1755-1760.
cations are reported in the post-tumor ablation group, likely 11. Yadla S, Campbell PG, Chitale R, Maltenfort MG, Jabbour P, Sharan AD.
a result of adjunctive chemotherapy and radiation. Contour Effect of early surgery, material, and method of flap preservation on
irregularities from autologous bone graft are reported in high cranioplasty infections: a systematic review. Neurosurgery. 2011;68:
frequencies due to partial resorption of the graft over time. 1124-1129.
12. Grossman N, Shemesh-Jan HS, Merkin V, Gideon M, Cohen A. Deep-freeze
Some authors advocate the following tips to decrease preservation of cranial bones for future cranioplasty: nine years of experi-
potential complications10: (1) obliterate dead space, if any, ence in Soroka University Medical Center. Cell Tissue Bank. 2007;8(3):
between the cranial reconstruction and underlying dura, (2) 243-246.
obliterate sinuses (bone, pericranial flap), and (3) eliminate 13. Movassaghi K, Ver Halen J, Ganchi P, Amin-Hanjani S, Mesa J, Yaremchuk MJ.
Cranioplasty with subcutaneously preserved autologous bone grafts. Plast
gaps if bone graft is used. Reconstr Surg. 2006;117(1):202-206.
Staphylococcus aureus is the most common organism iso- 14. Rogers GF,Greene AK, Mulliken JB, Proctor MR, Ridgway EB. Exchange
lated in cranioplasty infections, which may occur up to 6 or 7 cranioplasty using autologous calvarial particulate bone graft effec-
months after surgery.21 One study demonstrated a 5% overall tively repairs large cranial defects. Plast Reconstr Surg. 2011;127(4):
1631-1642.
incidence of infection of 5%, which rose to 14% after a docu- 15. Afifi AM, Gordon CR, Pryor LS, Sweeney W, Papay FA, Zins JE. Calcium
mented previous infection. Exposure of the graft or implant phosphate cements in skull reconstruction: a meta-analysis. Plast Reconstr
to a sinus significantly increases the incidence of postopera- Surg. 2010;126(4):1300-1309.
tive infection, illustrating the importance of sinus ablation in 16. Cabraja M, Klein M, Lehmann TN. Long-term results following titanium
cranioplasty of large skull defects. Neurosurg Focus. 2009;26(6):E10.
these defects. Treatment of infections should include broad- 17. Marchac D, Greensmith A. Long-term experience with methylmethacrylate
spectrum antibiotics, cultures, operative exploration, and, cranioplasty in craniofacial surgery. J Plast Reconstr Aesthet Surg.
most importantly, debridement. Reports of salvage have been 2008;61(7):744-752; discussion 753.
described combining debridement with continuous irrigation/ 18. Goh, RC, Chang CN, Lin CL, Lo LJ. Customised fabricated implants after
previous failed cranioplasty. J Plast Reconstr Aesthet Surg. 2010;63(9):
drainage systems.22 1479-1484.
19. Cheng YK, Weng HH, Yang JT, Lee MH, Wang TC, Chang CN.
Preoperative Planning Factors affecting graft infection after cranioplasty. J Clin Neurosci.
2008;15(10):1115-1119.
Three-dimensional computed tomography imaging has been 20. Moreira-Gonzalez A, Jackson IT, Miyawaki T, Barakat K, DiNick V.
instrumental in performing accurate reconstruction of calvarial Clinical outcome in cranioplasty: critical review in long-term follow-up.
J Craniofac Surg. 2003;14(2):144-153.
defects based on mirror imaging of the unaffected side. Acrylic 21. Kumar AR, Bradley JP, Harshbarger R, et al. Warfare-related craniectomy
models can now be affordably casted for use in preoperative defect reconstruction: early success using custom alloplast implants. Plast
planning and conforming of alloplastic material, reducing intra- Reconstr Surg. 2011;127(3):1279-1287.
operative time. Some companies offer custom-designed allo- 22. Baumeister S, Peek A, Friedman A, Levin LS, Marcus JR. Management of
postneurosurgical bone flap loss caused by infection. Plast Reconstr Surg.
plastic implants without the need for constructing an acrylic 2008;122(6):195e-208e.
model. Medical models may also allow for the creation of tem- 23. Molnar JA, DeFranzo AJ, Marks MW. Single-stage approach to skin
plates for patching together autologous bone grafts.23 grafting the exposed skull. Plast Reconstr Surg. 2000;105(1):174-177.

Chapter 32 n Reconstruction of The Eyelids,
Correction of Ptosis, and
Canthoplasty
Nicholas T. Haddock
The eyelids provide globe protection and preserve vision. In native tarsal plate, but thinned conchal grafts are a reasonable
addition, variations in periorbital structures provide for iden- alternative. Nasal chondromucosa provides both a structural
tifiable differences in ethnicity, gender, and age and display layer and the mucous membrane but has more potential donor
characteristic signs of various emotional states. Reconstruction site problems and is used infrequently. Resurfacing defects of
of the eyelid mandates consideration of both function and aes- the posterior lamella can only be accomplished with a tarso-
thetics. Anatomic considerations are vital in eyelid reconstruc- conjunctival graft. Donor tissue is limited, however, and buc-
tion, and eyelid anatomy is presented in detail in Chapter 46. cal or hard palate mucosal grafts are better options.2
Eyelid Reconstruction Reconstruction By Zone

Periorbital defects can be congenital, traumatic, or ablative. Periorbital reconstruction by zone is summarized in
Regardless of the etiology, reconstruction begins with an Figure 32.2.
ophthalmologic examination and by analyzing the defect in
terms of the location of the defect and the layers involved. Zone 1: Upper Eyelid Reconstruction
Spinelli and Jelks divided this region into five zones—zone 1,
Proper repair of the upper eyelid is necessary for globe pro-
the upper eyelid; zone 2, the lower eyelid; zone 3, the medial
tection. Partial-thickness defects of the anterior lamallae are
canthus; zone 4, the lateral canthus; and zone 5, the surround-
divided by size into those that are less than or greater than
ing tissues (Figure 32.1).5 In addition, consideration is given to
50% of the horizontal lid dimension. For defects that are
each layer that requires replacement. Typically, tissue grafts,
less than 50% of the lid, local tissue advancement and pri-
local flaps, or a combination are required.
mary closure are performed. For defects larger than 50% of
the lid length, a full-thickness skin graft is typically required.5
Tissue Grafts Incisions should be made in the natural lid crease if possible.
Autologous tissue grafts are often required, either alone or Treatment of full-thickness defects is also based on defect
in concert with a local flap. In full-thickness defects, either size. For defects of less than 25%, primary closure by convert-
the anterior or posterior lamella must be reconstructed with ing the defect into a pentagonal shape can help avoid defor-
a vascularized flap, providing a recipient site for a graft to mity.5 In youth, there is less eyelid laxity, and primary closure
reconstruct the other layer. An ideal donor site in anterior may not be possible in wounds greater than 20%. In elderly
lamellar defects with a healthy wound bed is a full-thickness patients, whose lids have more laxity, defects up to 30% of
skin graft from the contralateral upper eyelid. When upper the horizontal lid dimension may be closed primarily but
eyelid skin is limited, the retroauricular region or the supracla- may require a lateral canthotomy for a tension-free repair.2
vicular region offers a secondary source. Fascia grafts, either Care should be taken to precisely approximate the lid margin.
from the deep temporal fascia or the tensor fascia lata, can be A layered closure is performed with attention to the alignment
used to provide structural integrity for the eyelid or canthal of the tarsal plates.
regions. These can act as spacer grafts or can play a role in For defects greater than 25% but less than 75% of lid
procedures for the treatment of upper eyelid ptosis. Cartilage length, there are a number of reconstructive options. Most of
grafts are typically used as a spacer or to replace the missing these require a vascularized regional flap, which provides a
tarsal plate. Ear cartilage from the scapha most resembles the recipient bed for a graft to separately reconstruct the ante-
rior or posterior lamella. A sliding tarsoconjunctival flap bor-
rows tissue from the uninjured portion of the ipsilateral upper
eyelid. This flap is an option for posterior lamella defects
I involving the medial or lateral aspect of the upper eyelid. The
V inferior incision for this horizontally based flap is 4 mm above
the lid margin and extends to create a flap that is equal to the
defect size. The superior incision is designed to fit the defect,
and a vertical relaxing incision is required in the tarsal plate to
allow for advancement.2 A full-thickness skin graft is required
for coverage of this flap to reconstruct the anterior lamella.
IV In central wounds, a tarsoconjunctival flap can be developed
III from the lower eyelid as is done for lower eyelid reconstruc-
tion in the Hughes procedure.6 (See section “Zone 2: Lower
Eyelid Reconstruction.”) This approach has the obvious dis-
advantage of a second procedure and obstruction of vision for
the period prior to flap division.
II The Cutler-Beard bridge flap is a full-thickness composite
flap from the lower eyelid.7 A transverse full-thickness incision
V is made approximately 5 mm inferior to the lid margin in the
FIGURE 32.1. Periorbital zones as described by Spinelli and Jelks.5 lower eyelid, which allows flap elevation without compromis-
ing vascularity to the remaining lower eyelid. The horizontal
352
Chapter 32: Reconstruction of the Eyelids, Correction of Ptosis, and Canthoplasty 353
Zone I Zone I
PT < 50% PT > 50%
Zone 1˚ closure with local tissue advancement FTSG from opposite upper lid
Zone
III
IV
Zone II
FT < 25% FT > 25% FT > 75%

1˚ closure with canthotomy and Sliding tarsoconjunctival flap, Cutler-Beard Bridge flap, Lower-lid switch flap
cantholysis, local tissue advanced Tenzel semicircular flap for very large defects
Marginal arcade
Zone II
Head and Neck

PT < 50% PT > 50% OR myocutaneous transposition
1˚ closure with local tissue advancement FTSG from opposite upper lid flap from same upper lid
FT < 50% FT > 50% FT > 75%

1˚ closure with canthotomy and cantholysis, Sliding tarsoconjunctival flap with skin graft Composite graft with
local tissue advanced with Tenzel semicircular flap, cheek advancement
or sliding tarsoconjunctival flap with skin graft Hewes procedure Hughes procedure
Zone III
All: Routinely probe and intubate Medially based myocutaneous
the lacrimal system flap from upper lid Other local flaps
Zone IV
Cheek advancement flap All: Lateral canthal support procedure OR Skin graft with FTSG
FIGURE 32.2. Reconstructive algorithm based on reconstructive zones.

width of the flap should match the width of the upper eyelid For superficial defects greater than 50% of lid length with
defect, and vertical full-thickness incisions are made to the a healthy wound bed, a full-thickness skin graft is a good
inferior fornix at this width. The flap is advanced posterior option. Alternative options are local myocutaneous flaps,
to the remaining lid margin and secured into the upper eyelid including the unipedicled Fricke flap and the bipedicled
defect with a multilayer closure. The conjunctiva can be sepa- Tripier flap. The Tripier flap is a bipedicled flap from the
rated from the musculocutaneous flap, and a cartilage graft upper eyelid transposed to reconstruct lower eyelid defects.
can be placed for added support as this flap typically has little This flap includes preseptal orbicularis oculi muscle. The
or no tarsus within it.2 The flap is divided at approximately Fricke flap is similar but is a unipedicled flap and is adequate
6 weeks with 2 mm excess vertical height. This allows for for defects that extend to the mid-lower eyelid or just beyond.
the removal of 1 to 2 mm of musculocutaneous tissue and The bipedicled option is better utilized in larger defects. Both
anterior rotation of a conjunctival flap, which in turn pro- flaps incorporate more soft tissue than a full-thickness skin
vides a lid margin with a mucous membrane lining instead of graft and, thus, provide for a thicker reconstruction that may
keratinized epithelium. The lower eyelid often requires revi- require revisional debulking.
sion. The disadvantages of this repair include (1) a two-stage Small full-thickness lower lid defects are closed primar-
reconstruction with obstructed vision between stages, (2) dis- ily. Care is taken to align and repair the tarsal plate. As in
turbance to the lower eyelid that may require future revision partial-thickness defects, a lateral inferior cantholysis may be
and/or lid-tightening procedures, and (3) lack of lashes in the required to prevent tension. To avoid dog-ear formation at the
reconstructed segment. inferior aspect of the closure, the incision should be slanted
The Tenzel semicircular flap is a regional flap that pro- laterally or a Burow’s triangle can be removed.
vides tissue for both the anterior and posterior lamellae.8 A Once defects are greater than a few millimeters, they are
superiorly based semicircular flap of up to 6 cm in diameter best divided into those that involve <50% of the lower eye-
is designed and advanced medially. A canthotomy is required; lid, 50% to 75% of the lower eyelid, and >75% of the lower
and once advanced, the flap must be secured to the lateral eyelid. Full-thickness defects that are 50% or less of the lower
orbital wall to provide support and help recreate the natural eyelid can be approached with the inferiorly based Tenzel
convexity of the upper eyelid. The conjunctiva is also under- semicircular flap.8 The semicircular incision extends superi-
mined and advanced to provide the lining of the flap. This flap orly and laterally with a diameter of 3 to 6 cm depending on
is ideally suited for those defects that encompass 40% to 60% the defect size and tissue laxity. Dissection is in a submuscu-
of the upper eyelid.2 lar plane, and the inferior ramus of the lateral canthal tendon
For large defects (those greater than 75%), the Mustarde is divided to allow medial rotational advancement. In larger
lower lid switch flap is an option.9 A large full-thickness por- defects, there may be a paucity of support laterally since the
tion of the lower eyelid is rotated based on the marginal ves- tarsus is advanced medially. In these cases, the flap can be
sels to fill the upper eyelid defect. This flap is typically delayed supplemented with a laterally based periosteal flap, conchal
up to 6 weeks before pedicle division and inset. This flap cartilage, or septal cartilage. The flap can also be supported
provides a composite reconstruction of the upper eyelid and, with sutures to the lateral orbital periosteum.
therefore, the possibility for adequate protection of the globe. For defects larger than 50%, the anterior and posterior
The disadvantage is that it sacrifices a significant portion of lamellae are typically reconstructed separately. For lateral
the lower eyelid that must then be reconstructed with cheek full-thickness defects involving 50 to 75% of the lower eyelid
advancement and posterior lamella grafts. margin, the posterior lamella can be addressed with the Hewes
Other options for large upper eyelid defects that involve procedure.10 A laterally based upper eyelid tarsoconjunctival
other surrounding zones include a forehead flap, a Fricke flap is pedicled on the superior tarsal artery and transposed to
flap, or a glabellar flap (see section “Zone 3: Medial Canthal the lower eyelid. The anterior lamella can then be reconstructed
Reconstruction”). The Fricke flap borrows lower forehead tis- with a skin graft or a second upper eyelid flap such as the Tripier
sue as a laterally based unipedicled flap, which can be trans- flap. When defects of this size are centrally located, the Hewes
posed to reconstruct either an upper or lower eyelid defect. procedure may not provide enough length for transposition;
and a tarsoconjunctival graft is an alternative option. When the
posterior lamella is reconstructed with a nonvascularized graft,
Zone 2: Lower Eyelid Reconstruction the anterior lamella must incorporate well-vascularized tissue.
Lower eyelid defects are more common than defects in other Options include a myocutaneous flap from the upper eyelid or
zones because of the higher incidence of lower eyelid skin can- vertical myocutaneous flap from the lower eyelid and cheek.2
cer (Chapter 14). The lower eyelid is anatomically analogous The vertically based myocutaneous flap is developed just as a
to the upper eyelid, that is, where the capsulopalpebral fascia skin muscle flap is elevated in a lower blepharoplasty. On ver-
is homologous to the levator aponeurosis and the inferior tar- tical advancement, triangles of redundant tissue are removed.
sal muscle is homologous to Mueller’s muscle. The main dif- An alternative method for reconstruction of the poste-
ference is that the lower eyelid is shorter and the tarsal plate rior lamella is the Hughes tarsoconjunctival flap procedure6
is 4 mm in vertical height compared with 10 mm in the upper from the upper lid which is best for defects greater than 50%,
eyelid. Although lower eyelid position is extremely important including total lower eyelid reconstructions. The flap is devel-
in protecting the globe and preventing dryness, it plays a rela- oped starting 4 mm above the upper eyelid margin to avoid
tively passive role when compared with the upper lid. compromising upper eyelid integrity and consists of a segment
Reconstruction of the lower eyelid can be approached of tarsus and conjunctiva. The width is designed to match
algorithmically. Similar to the upper eyelid, lower eyelid the missing posterior lamella segment of the lower eyelid and
defects are treated based on size and on which layer is miss- advanced into the lower eyelid defect. The advanced tarsal seg-
ing. For superficial defects involving up to 20% of lower lid ment is secured to the remaining lower eyelid tarsal borders,
length, primary closure is usually possible in older patients; canthal tendons, or periosteum depending on what remains.
younger eyelids have less laxity. As the wound approaches This vascularized flap is then covered with a full-thickness
50%, closure with local tissue advancement is required skin graft or a myocutaneous flap obscuring vision for sev-
and, in many cases, a lateral canthotomy is required. A ten- eral weeks. Separation of the Hughes flap can be performed at
sion-free repair is necessary or lid malposition will result. 3 to 6 weeks. At this stage, care is taken to allow both Muller’s
There are aesthetic benefits to using the normal lid margin muscle and the levator to retract to their native positions to
when local tissue advancement is utilized in comparison to preserve upper eyelid function. In addition, in the lower eye-
reconstructive options that reconstruct the lid margin with lid the conjunctiva is rolled over the recreated lid margin to
other tissues. prevent irritation from corneal contact with keratinized skin.

The alternative for defects greater than 75% is the inferiorly based cheek flap, two small semicircular flaps, or
Mustarde flap.11 The traditional Mustarde approach includes a superiorly based rotational flap. Rhomboid transposition
a large rotational cheek flap advanced to reconstruct the ante- flaps can also be used. The goal is to create an acute angle
rior lamella and a nasal chondromucosal graft to reconstruct with a lateral canthus slightly higher than its corresponding
the posterior lamella. As highlighted earlier, alternatives are medial canthus (Chapter 46).
available for posterior lamella grafts. The flap is designed
to extend superiorly toward the brow so that closure will Zone 5: Periocular Defects Reconstruction
result in upward tension on the lower lid. Once elevated and
Zone 5 defects include the periocular areas that are contigu-
advanced, the flap is secured either to the medial canthus or
ous with zones 1 through 4. Often a zone 5 defect occurs in
to medial orbital periosteum. The flap is sutured to the perios-
conjunction with defects in other zones, and, in these situa-
teum laterally at a point above the lateral canthus.
tions, the principles discussed above are modified to allow
reconstruction from the remaining available tissue. When an
Zone 3: Medial Canthal Reconstruction isolated zone 5 defect occurs, the other zones are often still
The medial canthal region is anatomically complex and affected. For instance, cheek reconstruction will often result in
requires attention to the lacrimal system. When defects of both lower lid malposition, even if the lower lid is normal if insuf-
the upper and lower eyelids encroach on the medial canthus, ficient attention is paid to lower lid and/or canthal support.
one must address the canalicular system via intubation with
a silicone tube. Once the lacrimal system is protected, atten-
tion is directed to the supporting structures of the medial can- Complications
thus. If the medial retinaculum is detached from the bone, it Complications occur more commonly in large reconstruc-
must be reattached via the posterior reflection on the lacrimal tions, specifically when the defect is greater than 50% in zone
crest posterior to the lacrimal sac. This location of fixation 1 or 2 and when the defect is greater than 4 cm in zones 3,
serves the dual function of avoiding damage to the lacrimal 4, and 5. All medial canthal reconstructions are fraught with
system and maintaining the natural curve of the lower eyelid higher complication rates. Inadequate lateral canthal support
Head and Neck

directly apposed to the globe. When a medial canthal tendon also results in higher complication rates.5 Early complications
deficiency is present, a fascial graft can be incorporated into include corneal abrasion, chemosis (which can often be lim-
the repair. Methods for fixation include sutures to the perios- ited by a Frost stitch or temporary tarsorrhaphy), hematoma,
teum, drill hole fixation, bone anchors, and in cases of bone and/or flap/graft failure. Late complications include corneal
deficiency, transnasal wires or to a gap spanning plate. exposure, canthal laxity, lid malposition, abnormal lacrimal
The skin defect is addressed in a number of ways. In the drainage, and an unsatisfactory cosmetic result.
appropriately selected patient, healing by secondary intention
is an acceptable method in the medial canthus. This method
may result in epiphora, epicanthal folds, and medial ectropion. Adjunctive Procedures
As in other periorbital defects, a full-thickness skin graft is also Periorbital anatomy is a critical component of appearance.
a valid option, but contraction may yield an unsightly result. A Therefore, a thorough understanding of secondary procedures
medially based upper eyelid myocutaneous flap, based on the to optimize the aesthetic outcome is paramount. Contour
infratrochlear vessels, can be rotated to cover relatively small defects often occur following periorbital reconstruction. These
defects. Unique to the medial canthus is the glabellar flap, defects can be related to fat atrophy and/or adhesions between
which is a modified rhomboid flap or a V-Y flap that pro- the various layers. As in other areas, fat grafting is a validated
vides for immediate closure of large medial canthal defects.5 periorbital adjunctive procedure (Chapter 44).
Cutaneous coverage in this region by any method frequently In both the medial and lateral canthal zones, epicanthal
results in cicatricial epicanthal folds requiring revision. folds can develop following reconstructive efforts. These
are addressed with a single Z-plasty, double Z-plasties, or
Zone 4: Lateral Canthal Reconstruction a Mustarde “jumping man” flap. 12 In addition, a larger
The crucial element of zone 4 is the fixation provided by the transposition Z-plasty and canthal tendon repositioning are
lateral canthal tendon, which almost always requires attention required for vertical displacement of either the medial or lat-
in zone 4 reconstructions and a large number of other peri- eral canthus.
orbital reconstructions. When the tendon is present but lax,
a simple canthopexy is performed. When the lateral canthus
is disrupted but present, a canthoplasty is performed. In both
Lower Eyelid Malposition
situations, the goal is to overcorrect the tissue laxity as recur- Lower eyelid position is dictated by the balance of intrinsic
rent laxity is expected.5 and extrinsic forces. When in equilibrium, the lower eyelid
When no lateral canthus remains, alternative reconstruc- is positioned approximately 1 mm above the lower limbus
tive methods must be employed. If sufficient upper and lower firmly in contact with the globe. Imbalance in these forces
tarsal plates are present, then lateral advancement is pos- results in lower lid malposition, producing scleral show and
sible. The tarsal plates can be secured to the lateral orbital potentially ectropion (eversion of the lid) or entropion (inver-
periosteum at the level of Whitnall’s tubercle. If needed, a sion of the lid). Age produces involutional changes, and scar-
tarsal strip can be fashioned to help with lateral fixation (see ring from trauma or surgical intervention produces cicatricial
section “Lower Eyelid Malposition”). If no orbital perios- changes, both of which affect the balance of forces resulting in
teum is present, then drill holes are made; and in situations lid malposition.
of bone deficiency, a bone spanning plate is used.2,5 If there Age-related instability in the lower eyelid is caused by pro-
is no preexisting eyelid laxity, then a tarsal strip may not gressive laxity in the tarsoligamentous sling. Ectropion may
be sufficient; in these situations, crossing periosteal flaps result from orbicularis oculi atrophy, and entropion may
can be elevated from the lateral orbital rim. When larger result from orbicularis oculi hypertrophy. The approach is
defects of the upper or lower eyelid tarsal plates are pres- similar between the two conditions with the focus on tighten-
ent, then the reconstructive technique utilized for posterior ing of the tarsoligamentous sling with various types of can-
lamella reconstruction is incorporated into the lateral canthopexy or canthoplasty. In contrast, cicatricial ectropion or
thal reconstruction. entropion is typically caused by scarring in one of the lower
The skin defect is approached either with a local flap eyelid layers resulting in a tissue deficiency and is treated by
or a full-thickness skin graft. Local flap options include an tissue replacement.2

film breakup test. In addition, any signs of corneal irritation

Preoperative Evaluation are documented.1,3
As in all periorbital procedures, a standard eye examination
is important. Specific to lower lid malposition, evaluation Surgical Approaches
focuses on the important regional anatomy, including the can- Lower eyelid malposition can be addressed with a number of
thal position, the lower lid position, the extent of eversion or corrective procedures.14 A procedure addressing the lateral
inversion, anterior distraction and snap tests to asses tone and canthus is always required. Cases of cicatricial abnormal-
laxity, and the malar support. The snap test is performed by ity require addition of tissue and cases of lid laxity require
pulling the lower eyelid down and away from the globe, hold- removal of the tissue. In cicatricial ectropion, the anterior
ing it there for a few seconds, and grading its propensity to lamella can be reconstructed with a skin graft or local flap
return to the initial position. A normal lid returns to a normal as described in the eyelid reconstruction section. In cicatricial
anatomic position immediately, and an abnormal examina- entropion, the posterior lamella can be reconstructed with a
tion is any deviation away from this. The relationship between palatal mucosal graft. There are also complex forms of ectro-
malar support and the globe has been described by Jelks in pion and entropion involving multiple layers that require a
terms of a positive or negative vector and is discussed in terms combination of procedures including a cartilage spacer graft.2
of cosmetic surgery in Chapter 46. If the cornea projects past
the inferior orbital rim, then a negative vector exists. A nega- Canthopexy. In a standard canthopexy (Figure 32.3), the
tive vector is a known risk factor for lower eyelid malposition canthal tendon is not divided or shortened but is resecured
in periorbital surgery.13 The adequacy of globe lubrication via in a new position. Only mild lower lid laxity can be treated
tear production is evaluated with the Schirmer test and the tear in this fashion. Canthopexy is attractive because it involves
A Eyelid droop due to lateral canthal

tendon attenuation
Line of division
of lateral retinaculum
for common canthoplasty
B Common canthal tendon is retracted laterally

and superiorly then anchored to periosteum
Closeup of common canthopexy
C Effect of completed repair
FIGURE 32.3. Canthopexy. The canthopexy is a common procedure used in adjunct to other periorbital procedures. Reproduced from Spinelli HM.
Eyelid malpositions. In: Spinelli HM, ed. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Elsevier; 2004:47, with permission.

inimal tissue disruption, can be performed from either a
m be combined with a lid-shortening procedure for laxity. The
transcutaneous or transconjunctival approach, is relatively degree of lower lid excision is determined by pulling the lower
easy to perform, and does not risk deforming the normal acute eyelid laterally to the lateral orbital rim. The new tarsal border
angle of the lateral canthal region like the canthoplasty. is then secured inside the lateral orbital rim. In some situations,
specifically in cases of involutional entropion, redraping of the
Canthoplasty. Canthoplasty involves division of the lateral orbicularis oculi muscle is important for successful correction.2
canthus with reconstitution and repositioning and is more
complex and versatile than canthopexy. When repositioning Tarsal Strip Canthoplasty. The tarsal strip canthoplasty
the canthal tendon, it should be reinserted on the inside of (Figure 32.4) is similar in design to the combined procedures
the lateral orbital rim to maintain lower eyelid contact with the described above but incorporates a canthoplasty with a lid-
globe. As mentioned in Chapter 46, the more prominent the shortening procedure. The redundant lower eyelid tissue is not
globe, the higher the canthus is placed. The canthoplasty can completely excised but instead a strip of tarsus is denuded of
Head and Neck

A Lateral canthotomy
B Division of lowar crus and wide

lateral lysis
C Denude lateral
tarsal strip
D Suture location of strip to internal

periosteum of lateral orbital rim
F Commissuroplasty
E Trim excess skin and/or orbicularis muscle

FIGURE 32.4. The lateral tarsal strip procedure provides for a great deal of versatility in repositioning the lateral canthus. Reproduced from Spinelli
HM. Eyelid malpositions. In: Spinelli HM, ed. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Elsevier; 2004:39, with permission.

skin and is used to recreate the inferior component of the lat- The goal of ptosis surgery is to restore the upper eyelid
eral canthal tendon. An approximately 3 mm wide segment of to its correct position while creating as little lid stiffness and
tarsus (depending on shortening required) is circumferentially lagophthalmos as possible. In an effort to avoid compromis-
stripped of all tissues, including the skin, lashes, conjunctiva, ing protection of vision, a preoperative examination should
and capsulopalpebral attachments. This strip is then advanced verify an intact Bell’s phenomenon and the protective capacity
and secured inside the lateral orbital rim. Redundant superfi- of both eyelids.
cial tissue is excised, and care is taken to appropriately align
the gray line of the upper and lower eyelids. This validated Surgery
powerful tool has produced long-term satisfactory results, The surgical approach to ptosis typically involves leva-
but has the potential disadvantages of distorting the punc- tor manipulation (Table 32.1). Regardless of the chosen
tual position of the inner canthus and creating a discrepancy procedure, some technical points are worth emphasizing.
between the upper and lower eyelids.2,14 Epinephrine can stimulate Muller’s muscle and produce a
1 to 2 mm elevation of the upper lid and must be accounted
Upper Eyelid Ptosis for during final eyelid adjustments. When assessing upper eye-
lid position, the lights should be dimmed as bright lights cause
Blepharoptosis, or ptosis, is an upper eyelid malposition in squinting. If available, transparent corneal shields are used to
which the upper eyelid falls below its normal level of 1 to 2 allow for visualization of the pupil.
mm below the upper limbus. Upper eyelid ptosis is caused by
a number of anatomic problems involving the levator pal- Levator Repair or Resection with Advancement. The
pebrae superioris muscle or its aponeurosis and/or Muller’s levator repair or advancement procedure is the versatile pro-
muscle. In addition to recognition of the anatomic problem, cedure used for upper eyelid ptosis and is applicable to a wide
the etiology is relevant. Ptosis can be congenital or acquired. range of severity. As long as greater than 5 mm of levator excur-
Congenital cases have poor levator function. sion exists, this procedure is an option. A standard upper bleph-
aroplasty incision is used, allowing for concurrent removal of
redundant skin and orbicularis oculi muscle. The septum is
Evaluation and Examination opened and preaponeurotic fat is retracted exposing the leva-
Initial examination is focused on the levator palpebrae supe- tor aponeurosis. If intact, the aponeurosis is incised near the
rioris muscle and the levator aponeurosis. The levator func- tarsal border; and the levator is elevated off of Muller’s muscle.
tion, or excursion, is measured by immobilizing the brow and The levator is advanced over the tarsal border to simulate the
monitoring the upper eyelid movement from downward gaze levator advancement. In general, 1 mm of levator advancement
to upward gaze. The difference between levels of the upper gives a 1 mm correction of ptosis, but results vary based on the
lid margin in each position is recorded. Normal excursion is degree of levator function and can be difficult to standardize.
12 mm with an acceptable range of 10 to 15 mm. Fair func- An awake patient can cooperate to help guide the appropriate
tion is 6 to 9 mm and poor function is 5 mm or less. amount of advancement. If this technique is utilized, a tempo-
Levator dehiscence is typically from a thinning and stretch- rary suture is placed at the presumed level of advancement, the
ing of the levator aponeurosis, allowing dehiscence from the patient is repositioned to a sitting position, the overhead lights
tarsal plate and ptosis. In many cases, the connections to the are pointed away from the patient, and the patient is asked
dermis are not attenuated, which results in an increasingly to look up and down. Once the appropriate advancement is
elevated supratarsal fold as the ptosis worsens. Levator dehis- determined, the aponeurosis is secured to the tarsal border and
cence is an acquired involutional problem in older adults but excess is excised.3 An alternative technique involves placement
can occur in trauma as well. of a double-arm suture 2 to 3 mm below the superior border
As in the other areas of periorbital surgery, standard oph- of the tarsal plate at the pupil midline brought out at the mus-
thalmologic examination is important. Specific to the upper culoaponeurotic junction. A surgeon knot is then tightened
eyelid ptosis, important clinical information includes a stan- until the upper and lower eyelids are gapped; and a spring back
dard history to elicit systemic disorders that could cause test, similar to that utilized for evaluating lower eyelid laxity, is
eyelid ptosis. There should be a low threshold for a formal employed to set final tension.2
neurological examination, especially when there are other A levator plication can alternatively be performed with
signs of a neuromuscular process, such as myasthenia gravis. a similar approach. In this technique, the levator aponeuro-
Regionally, pseudoptosis can present as an inferiorly displaced sis is exposed but not divided or elevated and vertical plica-
upper eyelid that is not actually related to the eyelid retractors tion sutures are placed to tighten the levator aponeurosis. It
but instead to a separate orbital issue. This is seen in enoph- requires less dissection than the levator advancement but can
thalmos, brow ptosis, orbital tumors, and dermatochalasia. result in a bulge from redundant tissue.
Table 32.1
PTOSIS Algorithm: Based On The Extent of Levator Excursion And The Degree of Ptosis The
Appropriate Procedure Can Be Systematically Determined
n Upper Eyelid Ptosis
n Ptosis
Mild (2–3 mm) Moderate (3–5 mm) Severe (>5 mm)

Good (10–15 mm) Levator advancement Levator advancement Levator advancement
Excursion
Levator plication Levator plication

Tarsal conjunctival mullerectomy
Fair (6–9 mm) Levator advancement Levator advancement Levator advancement
Poor (<5 mm) Frontalis sling Frontalis sling Frontalis sling

Tarsoconjunctival Mullerectomy (Fasanella-Servat the clamp with its ends exiting through the anterior skin.
Procedure). In situations of mild ptosis with good leva- The suture is secured, clamped tissue is sharply resected,
tor excursion, the tarsoconjunctival Mullerectomy is an and the clamps are removed. The conjunctiva is smoothed,
option (Figure 32.5).15 This procedure involves a posterior and the eyelid is reduced. The suture must be placed in
approach in which the upper eyelid is everted and hemo- a manner so that it can be pulled out at approximately
static clamps are used to grasp the conjunctiva, tarsus, 1 to 2 weeks. This procedure has the disadvantage of limited
and Muller’s muscle at the tarsal muscular junction. The flexibility and inability to adjust the amount of ptosis
clamps are positioned in a symmetrical fashion and follow correction. In addition, with the posterior approach and
the normal curve of the lid. A running horizontal mattress resection of the conjunctival surface there is increased risk
suture of nonabsorbable monofilament is then placed under of corneal abrasion.3
TARSAL CONJUNCTIVAL MULLERECTOMY
Mild upper lid ptosis, 1–2 mm
Head and Neck

Cross section of suture placement
Running suture (full thickness)

behind clamps, lateral to medial
Trim excess
clamped tissue
Closure—suture tied on skin surface

and covered with Steri-Strip
FIGURE 32.5. The tarsoconjunctival mullerectomy (Fasanella-Servat procedure). Reproduced from Spinelli HM. Eyelid malpositions. In:
Spinelli HM, ed. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia, PA: Elsevier; 2004:100, with permission.

Subcutaneous placement
of suspension material
to create a static sling
Protective
contact lens
A B
FIGURE 32.6. Frontalis sling. A. The single strand repair and (B) the double strand repair.
Frontalis Sling. The frontalis sling is employed in situa- or injury. The most common of these is asymmetry from
tions of poor or absent levator function. In this procedure, undercorrection, which often requires operative revision.
the upper eyelid is tethered to the frontalis muscle such that In cases of overcorrection, lagophthalmos results in dry eye
upper eyelid elevation relies on brow elevation. Despite inad- and corneal irritation. This can be treated temporarily with
equate levator function, the eyelid must have good excursion a tarsorrhaphy suture and lubrication but will require opera-
on passive movement for this procedure to be successful. The tive revision if persistent. Asymmetry of the lid crease can
main variations in this procedure revolve around the type of occur if it is not appropriately reapproximated at the time of
suspensory material (either autologous or alloplastic) and the closure. Surgical correction of unilateral ptosis can result in
configuration of the suspension. The standard autologous postoperative contralateral ptosis if subclinical ptosis is not
options are tenser fascia lata and palmaris longus tendon, and recognized preoperatively. See Chapter 46 for a discussion of
the alloplastic material commonly used is silicone. Autologous Herring’s law.
reconstruction has advantages, but alloplastic material is
a good choice in the very young patient that does not have Suggested Readings
sufficient donor material or when concerns exist for globe 1. Spinelli HM. Atlas of Aesthetic Eyelid and Periocular Surgery. Philadelphia,
protection that may require procedure reversal. The popular PA: Saunders; 2004.
configurations are a two-strand repair with double triangular 2. McCord CD, Codner MA. Eyelid and Periorbital Surgery. St. Louis, MO:
and rhomboid design or a single-strand repair with a single Quality Medical Publishing, Inc.; 2008.
3. Newman MI, Spinelli HM. Reconstruction of the Eyelids, Correction of the
rhomboid design. Either multiple stab wounds or an eyelid Ptosis, and Canthoplasty. 6th ed. Philadelphia, PA: Lippincott Williams &
crease incision is used to expose the tarsal plate. The material Wilkins; 2007.
of choice is then tunneled in a submuscular plane toward the 4. Zide BM. Surgical Anatomy Around the Orbit: The Systems of Zones.
brow. In the single-strand method the lateral arm is passed to Philadelphia, PA: Lippincott Williams & Wilkins; 2006.
5. Spinelli HM, Jelks GW. Periocular reconstruction: a systematic approach.
a point midway between the lateral limbus and the canthus Plast Reconstr Surg. 1993;91:1017-1024; discussion 1025-1016.
and the medial arm is passed to a similar position medially. 6. Hughes W. Reconstruction of the lids. Am J Ophthalmol. 1945;28:1203.
The lateral vector should be slightly stronger and, therefore, 7. Cutler NL, Beard C. A method for partial and total upper lid reconstruc-
the lateral arm is tunneled to a slightly higher position than the tion. Am J Ophthalmol. 1955;39:1-7.
8. Tenzel RR. Reconstruction of the central one half of an eyelid. Arch
medial arm (Figure 32.6A). The double-strand configuration Ophthalmol. 1975;93:125-126.
involves four points of fixation to the tarsal plate and three 9. Mustardé JC. Eyelid reconstruction. NORB. 1982;1:33-43.
points of fixation in the brow (Figure 32.6B). At a final point, 10. Hewes EH, Sullivan JH, Beard C. Lower eyelid reconstruction by tarsal
the suspensory material is secured to the brow and the tarsal transposition. Am J Ophthalmol. 1976;81:512-514.
11. Mustarde JC. Reconstruction of Eyelids. Ann Plast Surg. 1983;2:1-21.
border. The brow is then elevated to simulate the function of 12. Mustardé JC. Epicanthus, telecanthus, blpeharophimosis and hyper-
frontalis and gauge the ptosis correction. Lagophthalmos is a telorism. In: Mustardé JC, ed. Repair and Reconstruction in the Orbital
common problem following the frontalis sling, especially in Region. Edinburgh: Churchill-Livingstone; 1980:332-363.
the immediate postoperative time period. 13. Jelks GW, Jelks EB. Preoperative evaluation of the blepharoplasty patient.
Bypassing the pitfalls. Clin Plast Surg. 1993;20:213-223; discussion 224.
14. Glat PM, Jelks GW, Jelks EB, et al. Evolution of the lateral canthoplasty:
Complications techniques and indications. Plast Reconstr Surg. 1997;100:1396-1405;
discussion 1406-1398.
Complications following ptosis repair include wound dehis- 15. Fasanella RM, Servat J. Levator resection for minimal ptosis: another sim-
cence, hematoma, infection, asymmetry (overcorrection or plified operation. Arch Ophthalmol. 1961;65:493-496.
undercorrection), entropion, ectropion, and corneal irritation

Chapter 33 n Nasal Reconstruction
Frederick J. Menick
Nature will heal almost any wound by secondary intention over residual, well-vascularized subcutaneous tissue can be
eventually. Any skin graft or flap or physician can close skin grafted. However, a skin graft will not take on exposed
a defect. But human beings want to look normal. So nasal cartilage or bone without perichondrium or periosteum unless
reconstruction is both a challenge and an opportunity for the the wound is allowed to granulate to improve the vascular
specialty of plastic surgery. Success is determined by choice bed. The defect may be resurfaced with a local flap, regardless
and compromise. The problem is analyzed, options are identi- of vascularity, with more predictable skin quality.
fied, limitations are appreciated, and the best solution is cho- A skin graft adds skin to the nasal surface and can be
sen to achieve the desired outcome.1,2 applied to a defect of any size if its bed is well vascularized.
In contrast, local flaps do not add skin to the nose. They
rearrange residual skin and redistribute it over the nasal
The Patient surface. Although a modest amount of excess skin is pres-
In some cases, age (a child less than 5 years of age or the ent within the dorsum and sidewall, no extra skin is available
extreme elderly), associated illness, or patient desire dictates within the tip and ala. Most single-lobe local flaps, because
a less complicated, quicker repair with minimal surgery or of skin laxity and mobility, can be effectively employed for
stages. The wound can be allowed to heal secondarily, closed defects of the dorsum and sidewall, but not for wounds within
with a skin graft or local flap, or, if full thickness, the skin the thick adherent skin of the inferior nose. No local flap will
and lining can be sutured to one another, accepting a perma- reach into the infratip or columella. When used inappropri-
nent deformity. Unless underlying vital structures are exposed, ately, local flaps may compromise the underlying residual or
Head and Neck

an aesthetic repair can always be performed in the future. repaired cartilage support because of the tension of local skin
The occasional patient chooses a prosthetic reconstruction. rearrangement.
However, most patients wish to live without deformity and A large, deep defect is greater than 1.5 cm or one that
seek surgical repair. requires cartilage grafts for support or lining replacement. If
If a complex repair is planned, the surgeon must be aware the defect is greater than 1.5 cm, there is often not enough
that past surgical treatments for skin cancer, radiation,
trauma or rhinoplasty may add scars, interfere with blood
supply, impair healing, and exclude some of the reconstructive
options. The operative time, anesthetic requirements, need for
hospitalization, number of stages, and the time to completion
must be considered and shared with the patient.
The Nose
Anatomically, the nose is covered by external skin with a soft
tissue layer of subcutaneous fat and facial muscle, supported
by a mid-layer of bone and cartilage, and lined by stratified
squamous epithelium within the vestibule and mucoperi-
chondrium internally. If missing, each layer must be replaced.
Thin, conforming skin cover, shaped mid-layer support, and
thin, supple lining are required.
Aesthetically, the nose is a central facial feature of high pri-
ority. To appear normal, it must have the proper dimension,
volume, position, projection, and symmetry. The surface con-
tour is divided into aesthetic regional subunits—adjacent top-
ographic areas of characteristic skin quality, border outline,
and three-dimensional contour: the dorsum, tip, columella,
and the paired sidewalls, alae, and soft triangles.3 Restoration
of these “expected” visual characteristics must occur to make
the nose “appear normal” (Figure 33.1).
The character of nasal skin varies by location. The skin of
the dorsum and sidewall (zone 1) is thin, smooth, pliable, and
mobile. A small amount of excess skin is present within the
upper nose. The skin of the tip and ala (zone 2) is thick, stiff, Alar
and adherent, pitted with sebaceous glands. The skin of the Dorsum
lobule
columella and alar rim (zone 3) is thin but adherent.
A single-lobe local flap can be efficacious within zone 1,
but not within zone 2 or 3. A skin graft can blend satisfacto-
rily within the thin skin of the dorsum and sidewall but may Soft
triangle
look like a shiny and atrophic patch when used to replace
thick tip skin. Traditionally, a local or regional skin flap will
blend more accurately within the thick skin of the tip or ala. Tip
Nasal defects can be classified as small and superficial or FIGURE 33.1. The aesthetic subunits of the nose are determined by
large and deep. A small, superficial defect is less than 1.5 cm the three-dimensional contour of the nasal surface.
in size, with intact underlying cartilage. A superficial defect
361
residual skin to spread over the entire nasal surface without poorly and create a patch-like appearance. A skin graft har-
distorting the mobile tip or alar rims. A local flap is precluded, vested from the forehead is an exception.
although a skin graft may still be employed if its bed is well In contrast, a well-healed flap, which maintains its per-
vascularized. A regional flap from the forehead or cheek will fusion, retains the skin quality of its donor site. If harvested
be needed to supply missing skin cover or to vascularize a from a site where the skin quality matches that of the defect, it
reconstructed support framework or lining. maintains its characteristics after transfer.
Bones and cartilage support the nose, impart a nasal shape Remember that myofibroblasts lie within a bed of scar
to the soft tissues of both lining and cover, and brace a repair between a skin graft or flap and its recipient bed. Although
against the force of myofibroblast contraction. If missing, sup- a full-thickness skin graft may shrink minimally within its
port must be restored. boundaries, it does not rise above the level of the adjacent
The normal ala is shaped by compact fibrofatty soft tissue recipient skin. In contrast, flaps often “pin cushion,” as the
and contains no cartilage. However, if significant external skin underlying scar contracts. This creates a trapdoor effect that
or internal lining is missing from the ala, the internal fibrofatty may raise the skin surface of a facial flap into a convex form.
support becomes inadequate. Cartilage must be placed along For this reason, flaps are best used to resurface convex recipi-
the new nostril margin to maintain shape and projection, even ent sites—the tip or ala—as a subunit. Fibroblast contraction
though the ala normally contains no cartilage. under a subunit flap enhances the repair of a convex sur-
In the past, bone and cartilage grafts were placed second- face subunit but will distort a repair if the defect lives within
arily, months after the initial reconstruction. Unfortunately, the flat sidewall. A skin graft is best for planar or concave
once soft tissues are healed, scarring makes secondary recipient sites, such as the dorsum, sidewall, soft triangle, and
re-expansion and reshaping more difficult. In almost all columella. A subunit flap is best for larger convex tip and
instances, support should be resupplied prior to the comple- alar units.
tion of wound healing and prior to the pedicle division of
regional flaps used for skin coverage.
Soft tissue foreign bodies, such as injectable or implant- The Donor Site
able allografts, increase the risk of infection, fibrosis, and later Each defect requires variable amounts of cover, support, and
extrusion. As a result, nasal reconstruction is usually best per- lining. Donor materials are chosen by determining the dimen-
formed with autogenous tissues. sion and quality of missing tissues, the available excess within
the donor site, and its ability to be transferred as a skin graft
The Wound over a vascularized bed or a flap on a vascular pedicle with an
adequate arc of rotation.
The approach to repair will be influenced by the site, size,
depth, and condition of the wound. A fresh wound or healed
injury may not reflect the true tissue deficiency. The apparent Principles of Aesthetic Nasal
defect may be enlarged by edema, local anesthesia, gravity,
and resting skin tension or diminished by wound contraction
Reconstruction
due to secondary healing. A prior repair may be distorted 1. Establish a goal. The objective may be a healed wound or
by inaccurate tissue replacement—too much or too little. the restoration of normal appearance.
Infection or borderline vascularity may preclude immediate 2. Visualize the end result. Normal is described by the skin
reconstruction. quality, border outline, and three-dimensional contour.
A preliminary operation may be required to debride 3. Create a plan. Specific operative stages, donor materials,
necrotic tissue or control infection, or release old scars, replace and methods of transfer of cover, lining, and support are
normal tissue to its normal position, open the airway, or per- outlined, prior to the repair. Reconstructive choices will
form preliminary surgical delay, prefabrication, or expansion determine the ability to achieve success.
of the donor site. 4. Consider altering the wound in site, size, depth, or posi-
Missing tissues must be replaced in exact dimension and tion. Most nasal wounds heal with minimal scarring. Scars
outline. If too little tissue is replaced, underlying support interfere with a successful reconstruction only when they
grafts collapse under tension and adjacent normal landmarks distort the contour or quality of expected subunits. If a
are dragged inward, distorting the residual landmarks and defect of the convex tip or alar subunit is resurfaced with a
pushing the lining downward, obstructing the airway. If too flap and the wound encompasses greater than 50% of that
much tissue is supplied, adjacent landmarks are pushed out- subunit, consider discarding adjacent normal skin within
ward, distorting the external shape of the nose. The surface the subunit. Resurface the entire subunit, rather than
area of missing tissue is often underestimated and almost just patching the defect. Subunit resurfacing of a convex
8 × 8 cm of both lining and cover surface must be supplied in subunit harnesses the deleterious effects of the trapdoor
a total nasal defect. contraction that occurs under a flap. The pincushioned
convexity contributes to the uniform restoration of sub-
unit contour. This is in contrast to the visible “bulge” cre-
Wound Healing ated by a small flap placed within part of the tip or ala. If
Traditionally, the method of tissue transfer is chosen based on residual tissues are distorted by the old scar or a previous
wound vascularity and depth. Skin grafts are used to resurface repair, normal landmarks must be returned to their nor-
well-vascularized, superficial defects. Skin flaps are used to mal position at the start of repair.
supply bulk to a deep defect or to cover a poorly vascularized 5. Use the ideal or the contralateral normal as a guide. A
recipient site, a wound with exposed vital structures, or an template of the contralateral normal is made to create a
exposed or restored support framework or lining. mirror image of the true defect or subunit and then used to
Unfortunately, the ischemia associated with skin graft design flaps and grafts.
“take” leads to unpredictable color and texture match. Even 6. Replace missing tissue exactly to avoid overfilling or
when harvested from traditional facial donor sites (preauricu- underfilling of the defect.
lar, postauricular, or submental areas), the quality of a skin 7. Use ideal donor materials. Covering the skin must be thin,
graft is unpredictable. Skin grafts often appear shiny and conform to the underlying subcutaneous architecture, and
atrophic. Skin grafts are ideally suited to supply thin skin to match the face in color and texture. Cartilage and bone
the dorsum/sidewall or columella/nostril margin, rather than grafts must be thin, but supportive. The nasal framework
within the thicker skin of the tip and ala where they blend must extend from the nasal bone superiorly to the alar

Chapter 33: Nasal Reconstruction 363
margin inferiorly and from the tip anteriorly to the max- Prelaminated Skin Graft and Cartilage for Lining
illa posteriorly. Cartilage grafts support the repair against under a Forehead Flap. A preliminary operation can be
gravity, shape the overlying cover and underlying lining, performed several weeks prior to formal nasal reconstruc-
and brace the repair against scar contraction. Each graft tion. A composite graft from the ear or septum or separate
is carved to create a subsurface framework, which will be pieces of skin and cartilage are placed under the distal end of
visible through thin, supple covering skin. Lining materi- the planned forehead flap 6 weeks prior to its elevation and
als must be vascular enough to support the early cartilage transfer to the nose. Once healed to the undersurface of the
grafts and supple enough to conform to the shape of the forehead, these preinstalled lining grafts can create a satisfac-
overlying support grafts. Lining must be thin, neither stuff- tory alar margin. However, the reconstructed nose is poorly
ing the airway nor bulging outward, distorting the exter- supported and bulky. The technique is limited to small defects
nal shape of the nose. in elderly patients to avoid a more complex procedure.
8. Ensure a stable platform. The defect may be limited to the
nose. However, a composite nasal defect that includes two Intranasal Lining Flaps. Residual nasal lining remains
or more facial units may extend onto the adjacent cheek within the nose and piriform aperture after injury. It is per-
and lip. The lip and cheek provide the maxillary platform fused by the anterior ethmoid artery along the dorsum, the
on which the nose sits in specific position and projection. angular artery at the alar base, and from branches of the supe-
A shifting lip/cheek platform pulls the repaired nose inferior labial artery that perfuse the right and left septal mucop-
riorly and laterally, under the influence of edema, gravity, erichondrium (Figure 33.2).5,6
and tension, distorting an otherwise satisfactory result. In smaller unilateral defects, residual vestibular skin, lying
Unless the underlying platform is stable, composite defects above the defect, can be elevated as a 6 mm bipedicle flap,
should be reconstructed in stages. The lip and cheek are based laterally at the alar base and medially on the septum.
repaired during a preliminary procedure. The nose is The flap is advanced inferiorly to line the nostril margin. The
repaired at a later date. defect that remains within the lining donor site is filled with
a contralateral intranasal lining flap, based on the dorsum, or
a skin graft.
An Approach To Nasal
Head and Neck

In larger unilateral defects, an ipsilateral septal flap can be
Reconstruction hinged laterally to line the lower vestibule and alar margin. A
second contralateral mucoperichondrial flap, based dorsally
An appreciation of normal determines the principles of aes- on the nasal bridge, is hinged laterally to line the upper vault.
thetic reconstruction that restore a normal appearance.1,2 The This dorsal flap can be used alone to reconstruct an isolated
anatomic loss determines the stages, materials, and methods defect of the sidewall or can be combined with the bipedicle
required to replace missing tissues. vestibular flap.
Injury to the nasal platform, lining, support, and covering An anteriorly based septal composite mucoperichondrial
skin is identified and an operative plan developed. Assessment flap, based at the nasal spine and composed of the entire
and surgical repair begins with platform, lining, support, and septum, can be advanced out of the piriform aperture, based
finally covering skin. This basic approach is modified by train- on the right and left superior labial vessels. This flap can
ing and experience. supply dorsal support and bilateral leaves of septal mucop-
erichondrium to line a central nasal defect. Excess mucop-
The Nasal Base Platform erichondrium can be reflected laterally to provide a modest
If the nasal defect extends onto the lip and cheek, the nasal amount of additional lining for the dorsum and vestibules.
platform must be re-established first.4 If the composite defect These extensions will not reach the alar base.
is limited to the skin and superficial soft tissues of the cheek Overall, intranasal lining flaps are thin, vascular, and sup-
and lip, nasal repair can be combined with immediate shift- ple enabling the placement of primary cartilage grafts. They
ing of the cheek and lip skin flaps for cover and a subcutane- require moderate to significant intranasal manipulation and the
ous fat island flap (Gillies/Millard fat flip flap) to supply soft associated morbidity of bleeding and crusting. They are useful
tissue bulk. for moderate-sized lining defects. Prior traumatic, surgical, or
Deeper and more extensive composite defects should be radiation injury to their blood supply precludes their use.
repaired in stages, after the completion of wound healing. The
nose is repaired only when the facial platform of the lip and Skin Grafts for Lining. A full-thickness skin graft can
cheek is stable after a preliminary operation using major cheek survive on the deep surface of a full-thickness forehead flap.
flaps, a cross-lip Abbe flap, or microvascular tissue transfer. One month later, the skin graft is integrated and vascularized
into the adjacent normal lining. The forehead flap can be re-
elevated, excess soft tissue excised, and delayed primary car-
Nasal Lining tilage grafts placed for support and to prevent significant skin
The Composite Skin Graft. Composite skin grafts, graft contracture. Or, a primary cartilage graft can be placed
taken from the ear, can be used to repair small defects, which within a subcutaneous tunnel within a full-thickness forehead
include both cover and lining, along the alar margin or colu- flap and a skin graft applied simultaneously for lining. Either
mella. They survive if placed on a well-vascularized recipient technique is useful, although not a first choice, for small lin-
bed and immobilized. They are best employed for defects not ing defects. Because of the risk of poor take and significant
greater than 1.5 cm, which have been allowed to granulate contracture, large lining defects should not be repaired with
for 7 to 10 days. The color and texture of a composite skin skin grafts.2
graft are unpredictable and they may appear thin and atrophic
over time. Folded Forehead Flap for Lining. An extension of a
full-thickness forehead flap can be folded to supply lining.
Local Hingeover Lining Flaps. If a full-thickness defect Traditionally, the distal end of a two-stage forehead flap was
has been healed, the external skin bordering the defect can be thinned and folded inward, without cartilage support; the
turned over for lining, based on the scar along the border of result was poorly contoured and unsupported reconstruction
the full-thickness defect. Such flaps are thick, stiff, and risk usually followed. In recent years, a full-thickness forehead
necrosis, if greater than 1.5 cm in length. The airway, at the flap has been folded for lining, but an intermediate opera-
point of the hingeover, is often constricted. Although useful tion is performed prior to pedicle division to integrate flap
for limited rim defects or in salvage cases, they are unpredict- thinning and delayed primary cartilage grafts. Support and a
able and are not a first choice in significant defects. three-dimensional nasal shape are provided.
Ipsilateral flap
Ipsilateral
septal flap
Bipedicle flap
Contralateral
septal flap
Contralateral
muco-perichondrial Ipsilateral septal
muco-perichondrium
incised as slit
Contralateral
muco-perichondrium
pulled through
incised ipsilateral
muco-perichondrium
Ipsilateral muco-perichondrial flap Contralateral flap
FIGURE 33.2. Intranasal lining flaps—residual lining which remains within the defect can be shared, based on individual axial vessels, to restore
missing lining. Defects of the lateral midvault can be lined with a dorsally based contralateral mucoperichondrial flap, perfused by the anterior
ethmoid vessels. Defects of the nostril margin can be lined with a bipedicle vestibular flap or ipsilateral mucoperichondrial flap. The composite
flap of the entire septum based on the nasal spine can restore lining and basic support to the dorsum and columella.

Composite flap:
Mucoperichondrium
and septum Fixation point
X
Future
X X cartilage
trim
Pedicle
Septal branch
from superior
labial artery
FIGURE 33.2 (Continued)
Folded skin becomes re-vascularized by adjacent residual it may be useful to reinforce tip support with sutures or
Head and Neck

lining and is no longer dependent on the covering flap for a columellar strut. Although the ala normally contains no
blood supply. One month after forehead flap transfer, the cartilage, a cartilage graft may be needed within the recon-
more proximal covering skin of the forehead flap is incised structed ala after soft tissue injury or tumor excision to
along the planned alar rim margin, during an intermediate maintain support and shape. Septal, ear, or rib cartilage are
operation. Thin forehead skin is elevated with a few mil- used depending on the size, volume, contour, and strength
limeters of subcutaneous fat. Underlying excess soft tissue required.
is excised from the exposed surface of the lining, revealing
a thin, supple, and well-vascularized lining surface. Delayed
primary support grafts are placed to support the ala and
sidewall. A complete support framework is restored prior to
pedicle division without the intranasal manipulation asso-
ciated with intranasal lining flaps and without the unpre-
dictability of skin graft “take.” The modified folded flap
should be the “workhorse” for the repair of common lining
defects.1,7
Microvascular Lining. The site, size, and depth of tissue

loss, prior irradiation, or a massive composite injury to the
adjacent cheek and lip may make local tissues inadequate or
Distal single paddle
unavailable. A regional forehead flap can be combined with a radial forearm flap
free flap, most often a radial forearm flap.
A forearm flap can be folded for the vault and columella
with a skin extension for the nasal floor, permitting primary
dorsal grafting and providing a long vascular leash for micro-
vascular anastomosis.8
Others have designed separate vascularized skin paddles on
the radial artery (like a string of beads), sutured together to
provide individual lining flaps for the vault, columella, and
nasal floor. The short vascular leash and the need to tem-
porarily skin graft the external raw surface of the forearm
flap, which precludes primary dorsal support, may make this
approach less desirable.9
During later stages, a subunit support framework and a
forehead flap for covering the skin are added (Figure 33.3).
Nasal Support
An architectural framework must be in place to establish sup-
port, shape, and resist scar contraction. Ideally, it is established
prior to pedicle division with primary or delayed primary car- FIGURE 33.3. Microvascular lining—a single distal paddle of radial
tilage grafts placed at the time of flap transfer or during an forearm skin, with an extension for the nostril floor, can be folded
intermediate operation. Cartilage grafts can be placed second- to provide lining for the nasal vaults, columella, and nasal base and
allow the placement of primary dorsal support within the folded skin
arily, months after reconstruction, but their ability to provide envelope. Alternatively, multiple individual paddles can be incised to
projection and contour is less predictable due to the scarring create individual islands of skin for the vault, columella, and nasal sill.
of soft tissues.1,2 Primary support is precluded by the temporary skin grafting of the
If the underlying normal bone and cartilage remain external raw surface of these individual paddles.
intact, support replacement may be unnecessary, although

*
Radial artery
and vein *
Distal flap folded

under to line vault
and columella
Extension sweeps
under to resurface floor

1 Radial artery
and vein
2
3: Columella
3 3x3 cm
Radial a. & v. 2: Nasal floor
1: Lining 3x4 cm
8x6 cm
Head and Neck

Paddle 1
Provides
lining for nose
Paddle 2
Repairs lip
& floor of nose
Paddle 3
Foundation
for columella

When support is missing, each graft is fashioned to mold Composite chondrocutaneous grafts from the auricu-
the overlying skin and the underlying lining into the expected lar helix, rim, or earlobe can repair small defects (less than
nasal shape: a dorsal buttress, a sidewall brace, tip graft 1.5 cm) of cover and lining along the alar rim and columella.
for projection and definition, and an alar batten to support Composite grafts consist of variable amounts of cartilage posi-
and position the alar margin. Support grafts are designed tioned in a sandwich of outer and inner skin, with or without
to replace the missing nasal bones, upper lateral cartilage, a skin-only extension. Any part of the graft that lies more
tip cartilages, and the missing soft tissue support of the ala than 5 mm from the vascular recipient inset will probably not
(Figure 33.4). survive. The “skin-only” extension of a composite graft will
In extensive midline defects, the septum may be absent. A behave as any full-thickness skin graft and is not really part of
strong central midline support must be re-established to pre- the composite graft. Initially, composite grafts appear white,
vent soft tissue collapse of the tip and dorsum. Several methods but over 48 hours, they become blue and congested. Over the
are useful, often in combination. When the septal composite next 3 to 7 days, they become pink as the blood supply is re-
lining flap is pivoted anteriorly, lining and central support are established. Some believe that cooling for the first 36 hours
positioned simultaneously out of the piriform aperture. This decreases the metabolic demands of the composite graft and
creates a basic platform on which to rest other grafts—a dor- improves “take.”
sal graft, columellar strut, alar battens, and sidewall grafts. Except as a temporary wound dressing, split-thickness
The dorsum can also be supported with a cantilever dorsal skin grafts are not employed on the nose because they provide
graft of rib or cranial bone fixed with a wire, screw, or plate insufficient soft tissue bulk, contract, and hyperpigment.
to the nasal bones. Single-lobe transposition flaps provide an excellent color
match.10 They are useful for defects less than 1.5 cm in the
Nasal Cover lax mobile skin of the upper one third of the nose, as an alter-
native to a skin graft. Their 90° arc of rotation makes them
Small, Superficial Defects. Small, superficial defects unreliable within the thick, stiff skin of the tip or ala due to
within planar or concave surfaces and that do not border
dog-ear and vascularity concerns.
adjacent mobile landmarks that might be distorted by wound
The geometric bilobed flap (Figure 33.5) is useful for
contracture can be allowed to heal by secondary intention.
defects up to 1.5 cm within the thick skin zones of the tip and
Defects less than 0.5 cm can be closed primarily within the
ala.11 A bilobed flap moves the tissue from an area of excess
more mobile skin of the dorsum or sidewall.
within zone 1 to an area of deficiency within zone 2. Rules for
Full-thickness grafts from the forehead, postauricular,
its design are:
preauricular, or supraclavicular areas are useful within the
thin skin zones of the upper two thirds of the nose. Although 1. Allow no more than 50° of rotation for each lobe.
unpredictable in color and texture, the smooth and atrophic 2. Excise the triangular dog-ear between the defect and the
surface of a skin graft tends to blend within these smooth, thin rotation point, prior to flap rotation.
skin zones. Uniquely, a full-thickness forehead skin graft can 3. Undermine widely above the perichondrium on both sides
blend well within the thick skin of the tip or alar subunit and of the incision.
is a useful option to repair small, superficial defects within the 4. Make the diameter of the first lobe equal to the defect.
thick skin zones.1 It is often advisable to allow the wound to The second lobe may be reduced in size to ease primary
granulate for 7 to 10 days before skin graft application. closure of the secondary defect.
Skin grafts are immobilized with a light bolus dressing for
5 to 7 days and must be placed on a well-vascularized bed.
Correct
The principle of subunit excision is not applied when resurfac- Submuscular plane
ing the nose with a skin graft.
Alar cartilage
90–100˚
Pivot point
Incorrect
Subcutaneous
plane
Muscle
Submuscular
undermining
Trim
Dorsal buttress
Sidewall brace Excise
A B
Septal cartilage
Ethmoid bone
Columellar strut
Alar margin batten
Auricular
cartilage C
Septal and FIGURE 33.5. The bilobed flap. A. The skin of the superior two
auricular cartilage thirds of the nose is mobile. The skin of the tip and ala is thick and
tight. The excess in the superior nose is transferred in one stage with
FIGURE 33.4. Support grafts—primary or delayed primary grafts a bilobed flap. The pivot point dog-ear is excised. The defect created
of cartilage or bone are placed to shape and support the soft tissues by the first flap is closed with a second flap, which is closed primarily.
against gravity and scar contracture and are designed to restore the B. The flap is elevated in the areolar layer above the perichondrium
shape of the individual nasal subunits. and includes fat and nasalis muscle with the skin. C. Closure.

Large, Deep Defects. A two-stage nasolabial flap can
provide a moderate amount of excess skin from the nasola-
bial fold to reconstruct the ala, as a subunit.13 Its size and arc
of rotation are short and it will not reach the tip or dorsum
or resurface a heminasal defect. It will not tolerate tension
(Figure 33.8). When greater than 50% of the alar subunit
is missing, residual normal skin is discarded within the sub-
unit. An exact foil template of the contralateral normal ala
is positioned along the nasolabial fold. The flap is elevated
with a few millimeters of subcutaneous fat distally, maintain-
ing a proximal deep superior subcutaneous base, perfused by
perforators from the facial and angular arteries.14 A primary
cartilage graft is applied to the underlying residual or recon-
structed lining, and the flap is transposed medially to resurface
the ala. The donor site within the nasolabial fold is closed pri-
marily. A few weeks later, the pedicle is divided and partially
re-elevated, excising excess soft tissue. A two-stage nasola-
bial flap can achieve an aesthetic alar subunit reconstruction.
Although hidden in the nasolabial fold, the scar created by
this technique is in the central face and distorts the contour of
the medial cheek. It is best applied to the elderly patient with a
defined nasolabial crease and medial cheek excess.
Forehead skin is acknowledged as the ideal donor for nasal
reconstruction due to its color and texture, vascularity, and
the ability to resurface all or part of the nose. Supplied by
Head and Neck

vessels from the supraorbital, supratrochlear, superficial tem-
FIGURE 33.6. Dorsal nasal flap—residual skin and soft tissue of the poral, postauricular, and occipital vessels, forehead skin has
superior nose is transferred to the dorsum and tip. A Burow’s triangle been transposed on numerous pedicles.14
excision of the glabella or nasal root may be needed on closure. Most commonly, a vertical paramedian flap, based on a
single supratrochlear pedicle, is designed extending from the
brow to the hairline. The pivot point is lowered by incising
A dorsal rotation advancement flap can be employed to across the medial brow toward the medial canthus, lengthen-
resurface dorsal and tip defects with residual dorsal skin ing the flap, and minimizing the presence of hair-bearing scalp
(Figure 33.6).12 on the distal flap. If hair follicles are present on the recon-
All local flaps can provide good coverage for defects up to structed nose, they are removed later by depilation. The fore-
1.5 cm in size that lie at least 0.5 cm above the alar rims and head skin is thicker than nasal skin. The flap must be thinned
above the tip-defining points. When used for other defects, by excising frontalis and subcutaneous fat at the time of trans-
local flaps may create significant distortion of the tip and nos- fer or during an intermediate operation.
tril margins. A two-stage forehead flap is useful for smaller, more super-
A superiorly based, single-stage, nasolabial flap can be ficial defects. At the time of transfer, the distal flap is thinned
designed as an extension of a sliding cheek advancement by excising frontalis and subcutaneous fat before transposi-
flap.1 It is used to resurface defects of the sidewall and ala. tion and inset to the nose. Three to 4 weeks later, the pedicle
A Burow’s triangle is excised at the pivot point toward the is divided and the proximal aspect is debulked and inset, com-
inner canthus. Periosteal sutures re-create the nasofacial sul- pleting the repair (Figure 33.9).1,2
cus and minimize tension on the advanced flap. Rather than A three-stage forehead flap is used in smokers, in patients
just redistributing nasal skin, this flap adds regional skin from with scars within the flap’s territory, or to resurface major
the cheek to the nose, minimizing the risk of alar rim or tip defects. The 3 stage forehead flap method maximizes the sur-
distortion (Figure 33.7). geon’s ability to restore complex three-dimensional contour
Deep sutures
Undermine
to contour
cheek
nasofacial sulcus
Incision should
not go higher
than alar remnant
FIGURE 33.7. The one-stage nasolabial flap—defects of the sidewall and ala can be
resurfaced by advancement of a cheek flap with a skin extension of the cheek excess
adjacent to the nasal labial fold. A Burow’s triangle is excised toward the medial canthus
to allow flap advancement.

Cartilage
Defect
NL fold
Flap design
D E F
FIGURE 33.8. The two-stage nasolabial flap. A. Because of its convex surface contour, a significant defect within the ala is best resurfaced as
a complete alar subunit to minimize pin cushioning. Residual normal skin is discarded if the defect is greater than 50% of the subunit. Lining is
supported with a primary cartilage graft. B. Based on an exact pattern of the opposite ala, the template is designed and placed precisely along
the nasal labial fold. Distally, the flap is tapered to prevent excision of the dog-ear on closure. Proximally, the skin pedicle is tapered to keep the
final scar of closure from extending onto the nasal subunit. A wider vascular subcutaneous pedicle base is maintained during flap elevation. The
distal flap is thin, maintaining 2 to 3 mm of subcutaneous fat. C. and D. At the first stage, the flap was transposed to resurface the entire subunit.
The cheek donor site was closed by advancement. E. and F. Three weeks later, the pedicle is divided. The proximal inset is re-elevated and excess
soft tissue sculpted to create a convex alar shape. Final inset is completed. Excess soft tissue in the medial cheek is excised and the donor closure
completed.
with primary and delayed primary cartilage grafts and soft tis- In the rare circumstance where the forehead donor is
sue excision.1,7 Initially, the flap is transferred as a full-thickness unavailable and the nasal defect cannot be repaired with a
flap without thinning, after restoration of missing lining and skin graft or a local flap, the nose must be resurfaced with
primary support. One month later, the forehead skin is elevated distant skin. Arm flaps, abdominal tube pedicles, deltopec-
from the recipient site with 2 to 3 mm of subcutaneous fat, toral flaps, or cervical flaps are of historic interest only. Free
maintaining the proximal pedicle intact. The underlying excess flaps, principally the radial forearm flap, have been employed.
frontalis and subcutaneous fat are excised from the recipient Unfortunately, distant tissues provide poor color and texture
bed. Thin forehead skin is then returned to the recipient site, match to the adjacent facial skin. The future of free flap nasal
now contoured by soft tissue excision and delayed primary car- reconstruction lies not as cutaneous coverage but in its use to
tilage grafts, if needed. The pedicle is divided 1 month later restore missing lining in massive defects, irradiation, or the
(2 months after the initial forehead flap transfer). The three- cocaine or immunologic injury.
stage approach maximizes vascularity and the surgeon’s abil-
ity to create nasal contour by soft tissue excision and delayed
primary cartilage grafting. Most importantly, it permits modi-
Complications
fication of the distal tip and ala, after flap transfer, but prior Most repairs heal uneventfully. Small areas of necrosis of lin-
to pedicle division. The full-thickness three-stage forehead flap ing or cover flaps may be allowed to heal secondarily, but in
allows two additional modifications: the folded distal extension larger areas of necrosis, early debridement and replacement
of a forehead flap and the use of skin grafts for nasal lining. with vascularized tissue are vital to prevent underlying carti-
If the upper aspect of the forehead donor site cannot be lage infection and progressive chondritis, scarring, and con-
closed primarily, it is best left to heal by secondary intention. traction. Once demarcation is obvious and prior to infection,
Multiple flaps can be taken from the forehead without signifi- if cartilage grafts are exposed, they are covered by advance-
cant deformity. Preliminary forehead skin expansion is not used ment of the covering flap or a second vascularized flap.
routinely but can be invaluable in the short (3 to 4 cm), tight, or Exposed cartilage after lining debridement is removed, banked
scarred forehead or after previous forehead flap harvest. if possible, and a skin graft placed for temporary lining.

Corrugator
frontal
crease
Supraorbital a.
Supratrochlear a. Subcutaneous
Infratrochlear a. Subfrontalis
Subperiosteal
Axial dermal
Angular a. vessels preserved
Dorsal nasal a.
A B
Figure 33.9. Forehead flap. A. The paramedian forehead flap is based on the supratrochlear vessels just lateral to the frown crease. The blood
supply is abundant in the central forehead. B. Vertical paramedian design. The flap is designed vertically directly above the supratrochlear vessels.
The forehead, which includes several millimeters of subcutaneous fat and frontalis muscle, is thicker than the nasal skin. The excess soft tissue
bulk must be excised prior to the completion of repair. As shown here, in the two-stage technique, frontalis muscle is left at the forehead donor
Head and Neck

site and only distal forehead skin is transferred to the defect at the first stage. In the three-stage technique, the full thickness of the forehead is
transferred to maintain flap viability at transfer, permit the use of a skin graft or folded lining technique, and maximize the use of delayed primary
cartilage grafts for contour.
Infection may occur in patients with a history of multiple to further refine the nasal landmarks, such as the alar crease,
facial repairs or infection, in contaminated wounds, or in may be required through direct incisions.
complex defects. Culture-specific antibiotic treatment with
early debridement of all infected cartilage must be preformed References
to limit chondritis. Replacement of support is delayed for 4 to 1. Menick FJ. Nasal Reconstruction: Art and Practice. Philadelphia, PA:
6 weeks. Saunders–Elsevier; 2008.
2. Burget GC, Menick FJ. Aesthetic Nasal Reconstruction. St Louis, MO:
Mosby; 1994.
Late Revision 3. Burget GC, Menick FJ. Subunit principle in nasal reconstruction. Plast
Most major reconstructions require a revision to establish 4. Menick FJ. Defects of the nose, lip, and cheek: rebuilding the composite
defect. Plast Reconstr Surg. 2007;120:887.
near-normal appearance and function.1 In fact, many local 5. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty
flap repairs of smaller, superficial defects create significant and blood supply. Plast Reconstr Surg. 1989;84:189.
scars and contour distortions that require revision. 6. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension.
Since edema and induration require about 4 months to 7. Menick FJ. 10-Year experience in nasal reconstruction with a 3 stage fore-
resolve, revisions are usually performed at that time. head flap. Plast Reconstr Surg. 2002;109:1839.
When the overall dimension and volume of the nose are 8. Menick FJ, Salibian A. Microvascular repair of heminasal, subtotal and
correct, soft tissue excision and secondary cartilage graft total nasal defects with a folded radial forearm flap and a full-thickness
forehead flap. Plast Reconstr Surg. February 2011;127:637-651.
placement are performed through new incisions, hidden in the 9. Burget GC, Walton R. Optimal use of microvascular free flaps, cartilage
junctions between subunits. Disregarding the original scars, grafts and a paramedian forehead flap for aesthetic reconstruction of the
soft tissues are excised to define the alar crease or nasolabial nose adjacent facial defects. Plast Reconstr Surg. 2007;120:1171.
fold. Rim excisions are performed to thin or reposition a mal- 10. Elliot RA. Rotation flaps of the nose. Plast Reconstr Surg. 1969;44:147.
11. McGregor JC, Soutar DS. A critical assessment of the bilobed flap.
positioned nostril margin. Local tissue excess is used to open Br J Plast Surg. 1981;34:197.
the stenotic airway. 12. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr
When overall dimension and volume are incorrect, gross Surg. 1985;76:686.
debulking of excess tissue is performed through peripheral 13. Menick F. The two-stage nasolabial flap for subunit reconstruction of the
ala. In: Cordeiro P, ed. Operative Techniques in Plastic and Reconstructive
incisions along the border of the previous transferred flap. Surgery. Vol 5. Hoboken, NJ: John Wiley; 2006;59-64.
Underlying soft tissue and cartilage support are modified after 14. McCarthy JG, Lorenc PZ, Cutting C, et al. The median forehead flap revis-
extensive re-elevation of the old flap. An additional operation ited: blood supply. Plast Reconstr Surg. 1985;76:866.

Chapter 34 n Reconstruction of Acquired
Lip Deformities
Evan Matros and Julian J. Pribaz
The lips’ cutaneous portions terminate at the vermilion–

Function cutaneous junction termed the white roll or white skin roll.
The lips play an important role in both human physiology and The color and elevation of the white roll is created by par
culture. As the portal of entry for the gastrointestinal system, marginalis fibers of the orbicularis oris.2 The white roll is most
the mouth and lips take part in the cephalic phase of diges- distinct in the lip center tapering gradually toward the com-
tion. The sphincteric action of the orbicularis oris closes the missures. The vermilion, which is composed of keratinized
oral stoma creating a seal. Oral competence prevents drooling squamous epithelium, transitions distinctly at the red line into
while the tongue and cheeks manipulate intraoral solid and nonkeratinized squamous epithelium of oral mucosa. Similar
liquids. Contraction of perioral musculature positions the lips to the white roll, the vermilion is widest in the central lip.
against the bony skeleton, thereby obliterating the gingivobuc- Muscles of the lip and perioral region are best understood
cal sulci for manipulation of the food bolus toward the teeth by grouping them into functional categories. The maxillary
for chewing and oropharynx for swallowing. The same com- region muscles that are responsible for the upper lip eleva-
plex set of muscular actions enables newborns to suckle. tion include the zygomaticus major, zygomaticus minor, leva-
The lips participate in both verbal and nonverbal com- tor labii superioris alaeque nasi, levator labii superioris, and
munication. Articulation, the physical production of speech levator anguli oris (Figure 34.2A). The levator labii superioris,
sounds, is modified by lip movement. Lip position, shape, and levator anguli oris, and zygomaticus minor contribute to the
motion are gestures used to express emotion. Indeed, a smile formation of the nasolabial crease. Retraction and depression
or a frown can be as effective in communication as the spoken of the lower lip are due to combined actions of muscles located
word. Finally, kissing is a common means of social greeting as around the central mandible, including the platysma, depres-
well as a form of intimate expression. sor anguli oris, and depressor labii. The mentalis muscles force
the lower lip against the mandible, indirectly elevating it and
creating a pout. Muscles of the intermaxillary region include
Anatomy the orbicularis oris, buccinator, and risorius. The orbicularis
Topographically, the lips are distinct from surrounding struc- oris is composed of two components: the pars marginalis and
tures. The upper lip extends cephalad to the nostril sills and pars peripheralis. The par marginalis lies anterior to the pars
alar base on each side and terminates laterally at the nasolabial peripheralis and is mostly limited to the area directly deep to
creases (Figure 34.1). The upper lip is further divided into sub- the vermilion. The pars peripheralis extends from deep to the
units by the philtral columns that extend from the nasal sills pars marginalis to behind the cutaneous portion of the lip.
to the cutaneous–vermilion junction inferiorly. The philtral The orbicularis is the most important lip muscle, providing
columns are created by contralateral orbicularis oris fibers that oral competence through its sphincteric action in the coro-
cross the midline to insert directly into the overlying dermis.1 nal plane. The maxillary and mandibular perioral muscula-
The central depression between the philtral columns is termed ture adjust the sagittal and axial positions of the orbicularis
the philtral groove or dimple. The Cupid’s bow is the area of oris. In the axial plane, the combined action of the orbicularis
the cutaneous–vermilion junction between the philtral columns, risorius, buccinator, and pharyngeal constrictors forms a mus-
termed as such because its shape resembles the mythologic char- cular ring that presses the lips against the gingiva and teeth
acter’s weapon. The lower lip begins laterally at the continuation clearing intraoral sulci (Figure 34.2B). The modiolus refers to
of the nasolabial creases and is bordered inferiorly by the labio- a complex interdigitation of the perioral muscles that retract
mental crease. The upper and lower lips join at the commissure. the corners of the mouth.
The facial and perioral muscles are arranged into four lay-
ers based upon relative depth to one another. All of the mus-
cles are innervated on their deep surface, with the exception
of the deepest layer that includes the mentalis, levator anguli
oris, and buccinator muscle.
Blood supply to the lips is based upon the network off the
(A) Philtral external carotid artery system. As the facial artery branches
columns (G) Philtral groove or dimple from the external carotid artery, it hooks around the mandible
(B) Cupid’s bow (D) White roll: body immediately anterior to the masseter muscle. It courses
most distinct centrally
(F) Tubercle
deep to the risorius, zygomaticus major, and superficial lamina
(C) Commissure of the orbicularis oris muscle and lies superficial to the bucci-
nator, the levator anguli oris, and deep lamina of the orbicu-
(E) vermilion: laris oris muscle. The facial artery is located approximately
widest in 1.5 cm (range 9.2 to 19.8 mm) lateral to the oral commissure
central lip where it gives rise to the superior and inferior labial arteries.3
Since labial vessels reliably anastomose with their contralat-
eral counterparts, a lip switch flap can be based at either side.
The superior labial artery lies within 10 mm of the lip margin.
Figure 34.1. External lip anatomy. Philtral columns (A). Cupid’s This may or may not be within the actual red lip. The inferior
bow (B). Commissure (C). White roll: most distinct centrally (D). labial artery is positioned 4 to 13 mm from the margin of the
Vermilion: widest in central lip (E). Tubercle (F). Philtral groove (G). lower lip. The labial vessels lie either within or posterior to
the orbicularis oris muscle, but never anterior to it. Within the
372
Chapter 34: Reconstruction of Acquired Lip Deformities 373
Muscles of
Facial Expression
Levator labii superioris Pharyngeal

alaeque nasi muscle constrictors
Levator labii superioris muscle
Minor zygomatic muscle
Buccinators
Major zygomatic muscle
Risorius muscle
Orbicularis oris muscle
Depressor anguli oris muscle Orbicularis oris
Depressor labii muscle
A B
Figure 34.2. Lip musculature. Perioral muscles acting in the coronal plane (A). Perioral muscles acting in the axial plane (B).
lips, the facial vein is not a well-formed single anatomic struc- results, so this should be followed particularly for the upper
ture, but more closely resembles a venous plexus. Lymphatic lip, where distinct anatomical structures are present.5 Finally,
Head and Neck

drainage proceeds via submental and submandibular nodal reconstruction of large defects can be associated with a
chains. negative impact on the quality of life with patients avoiding
Motor innervation to the lip musculature is provided by activities such as social interaction or public eating; therefore,
facial nerve (VII) branches. Zygomatic and buccal branches potential sequelae should be discussed preoperatively. The
innervate lip elevators and retractors, whereas the marginal plastic surgeon should keep all these aspects in mind when
mandibular nerve innervates lip depressor muscles. Sensibility planning any lip reconstruction.
to the upper and lower lips is provided by the infraorbital
(V2) and mental (V3) branches of the trigeminal nerve, Vermilion
respectively. The vermilion should be carefully realigned on each side of
any defect since small discrepancies are noticeable from a
Defect Etiology short distance. To avoid misalignment, regional anesthesia
such as mental and infraorbital nerve blocks are preferable to
The major etiology of acquired lip deformities is cancer. the tissue distortion caused by direct local anesthetic infiltra-
Ninety-six percent of lip cancers occur on the lower lip pre- tion. Alternatively, the white roll can be temporarily tattooed
sumably from prolonged sun exposure.4 Overall, squamous with methylene blue prior to anesthetic infiltration. During
cell is the predominant tumor cell type (96%), followed lip reapproximation, sutures should be placed either above or
thereafter by basal cell cancers, verrucous carcinomas, and below the white roll, but not directly on it to avoid blurring
adenocarcinomas. Ninety-seven percent of patients with lip this distinct anatomical landmark.
cancer are male. Female patients are significantly more likely The smallest vermilion defects can be repaired either pri-
than men to have upper lip involvement (20% versus 4%). marily or be allowed to heal by secondary intention. If pos-
Uncommon indications for lip reconstruction include trauma, sible, primary repairs should avoid crossing the white roll.
infectious diseases such as noma, vasculitis, vascular anoma- When required, local flaps are harvested from the same lip if
lies, and burn injury. possible. The simplest method of repair is undermining of the
immediately adjacent intraoral mucosa with defect closure by
Historical Review advancement. This technique is commonly indicated for total
lip shaves when a “field defect” is present on the entire lower
Historical review of lip reconstruction informs current meth- lip vermilion. The drawback of this approach is that the lip
ods of repair. Similar to other areas of plastic surgery, ideas is pulled inward with flattening of its normal pouty appear-
are continually “re-invented” or modified. Crediting a single ance. To improve the bulk of vermilion reconstructions, a
surgeon with a reconstructive technique can be incorrect since portion of orbicularis oris muscle can be included with the
modern reconstruction has evolved after multiple iterations. advancement flap. Wilson and Walker proposed the creation
Table 34.1 is a timeline of lip reconstruction, including a par- of a laterally based bipedicle mucosal flap harvested from the
tial list of each author’s contribution. depth of the gingivobuccal sulcus (Figure 34.3A).6 Skin graft-
ing or secondary intention healing of the donor site facilitates
tension-free closure at the vermilion suture line with absent lip
Reconstruction retraction. Full-thickness defects of the vermilion that include
General goals of reconstruction include maintaining a a majority of the underlying orbicularis but do not extend
dynamic oral sphincter, a sufficiently sized stoma, and an beyond the white roll can be reconstructed with lateral ver-
acceptable cosmetic result. As defect size increases, an ade- milion musculomucosal advancement flaps supplied by labial
quate reconstruction is progressively more difficult to achieve vessels on either side of the remaining lip (Figure 34.3B). An
since additional muscle groups, sensory/motor nerves, and incision made exactly at the white roll takes advantage of
soft tissue are sacrificed. When feasible, the best functional inherent lip elasticity while keeping the scar hidden along this
and cosmetic outcomes can be achieved by adhering to line. Alternatively, musculomucosal flaps composed of intra-
the axiom of replacing “like with like.” If possible, a sub- oral mucosa and orbicularis can be advanced from the sulcus
unit approach to reconstruction leads to superior aesthetic in a V-Y fashion.

Ta b l e 3 4 . 1
Time Line of Contributions To Modern Lip Reconstruction
n Year n Surgeon(S) n Contribution
Vermilion 1892 Johannes von Esmarch Mucosal advancement flap for total lip shave defect
1901 Multiple: Eiselsberg, Lexer, Tongue flap for either mucosal or vermilion reconstruction
Bakamjian
1981 John Wilson Laterally based bipedicle mucosal advancement flap from
the labial sulcus
1984 Morton Goldstein Vermilion musculocutaneous advancement flap
1987 Colin Rayner Random cheek musculomucosal flaps based at the angle
of the mouth
1992 Julian Pribaz Musculomucosal flap containing the facial artery
Adjacent cheek 1834 Johann Dieffenbach Reconstruction of the entire lower lip using full-thickness
tissues bilateral cheek transposition flaps
1857 Victor von Bruns Reconstruction of the lower lip using full-thickness
nasolabial flaps based either superiorly or inferiorly
1853 Camille Bernard Reconstruction of the lower lip using full-thickness cheek
advancement flaps with excision of redundant triangles of
excess tissue at the flap base
1855 Carl Burow Formalized excision of triangles from the bases of bilateral
cheek advancement flaps
1946 Jerome Webster Formalized perialar crescentic excisions for partial- and
full-thickness upper lip defects, crediting Dieffenbach with
the earliest example of this technique
1957 Harold Gilles Full-thickness quadrilateral rotation advancement
flap resembling a “fan” for either upper or lower lip
reconstruction
1958 Bromley Freeman Modification of the Bernard cheiloplasty with partial thick-
ness, rather than full thickness, excision of the Burow’s
triangles
1960 Richard Webster Modification of the Bernard cheiloplasty with inclusion of
1 cm of buccal mucosa for vermilion reconstruction
1974 Miodrag Karapandzic Musculocutaneous rotation advancement flap of the
remaining lip that preserves the neurovascular supply
1983 Ian McGregor Full-thickness quadrilateral flap similar to a “fan,” but
rotates cheek skin into the lip defect rather than the remain-
ing red lip; requires vermilion reconstruction
Opposite lip 1756 Johann Hjertzeel Lip switch from lower to upper lip for noma
1838 Pietro Sabattini Lip switch from lower to upper lip for post-traumatic
defect
1848 Sophus Stein Bilateral upper lip switch flaps to central lower lip
oncologic defect
1864 Gordon Buck Lip switch from lower to upper lip, including commissure
for post-traumatic defect; secondary commissuroplasty
1872 Jakob Estlander Lip switch from upper to lower lip, including commissure
for oncologic defect
1898 Robert Abbe Lip switch from lower to central upper lip for cleft
deformity
1981 Jerry Templer Hybrid lip switch referred to as Abbe-Estlander since
an upper lip rectangular flap is based away from the
commissure and rotated for a lower lip defect
Distant tissues 1974 Kiyonori Harii Free scalp flap reconstruction of commissure defect
2005 Bernard Devauchelle Midface transplant, including entire upper and lower lips

Head and Neck

B
Figure 34.3. Vermilion reconstruction. Bipedicle flap released from gingivobuccal sulcus (A). Musculomucosal advancement flap (B).
Unipedicle vermilion lip switch flap (C).

B
A C
Figure 34.4. Partial-thickness defect involving the philtrum, Cupid’s bow, and vermilion. Advancement flap of right
cutaneous lip with V-Y advancement for vermilion reconstruction. Skin graft reconstruction of Cupid’s bow (A). Inset (B).
Final result (C).
When ipsilateral mucosa or vermilion is not available for (Figure 34.4). Cheek tissue advancements frequently require
reconstruction, regional donor sites must be sought. One removal of redundant tissue along the alar-facial groove
solution is to create a unipedicle vermilion lip switch flap referred to as perialar crescents (Figure 34.5).8 V-Y and naso-
from the opposite lip which is divided after 10 to 14 days labial flaps from adjacent cheek tissues are other valuable
(Figure 34.3C). Flaps for reconstruction can also be created alternatives. When using cheek tissue for lip reconstruction,
from the buccal mucosa. Paired 1 cm wide random musculo- patient gender is a special consideration. For example, in men,
mucosal flaps based at the angle of the mouth can be rotated a superiorly based nasolabial flap is more appropriate for the
120° for the closure of lower lip vermilion defects. A more upper lip since it replaces the hair-bearing tissue, although
reliable intraoral musculomucosal flap is the facial artery mus- hair growth will be not be oriented properly. An inferior V-Y
culomucosal flap (FAMM).7 This axial flap that includes the advancement from the cheek can also introduce hair-bearing
facial artery and buccinator muscle can be based either superi- tissue to the lip. In contrast, an inferiorly based nasolabial flap
orly (retrograde) or inferiorly to reconstruct the vermilion and using tissue from higher on the cheek does not include hair in
other intraoral defects. One drawback of all techniques that the reconstruction.
use nonkeratinized oral mucosa for vermilion reconstruction Skin grafting is not routinely employed for superficial lip
is the tendency for the tissue to desiccate. defects since sufficient adjacent laxity usually exists to permit
As an alternative to intraoral cheek–based flaps for vermil- either local flap or primary closure. Exceptions may include
ion reconstruction, the tongue provides an alternate source of small central philtral defects, where primary closure leads to
regional donor tissue. Tongue flaps require two stages, so they distortion of the cupid’s bow (Figures 34.4 and 34.5). Full-
are significantly more cumbersome. These flaps should be based thickness rather than partial-thickness grafts are preferred
on either the lateral or ventral surface of the tongue mucosa because of the superior cosmetic appearance.
since the dorsal tongue papillae has a sandpaper texture.
Small Full-Thickness Defects
Partial-Thickness Defects Due to the elastic nature of lip tissue primary closure is pos-
Superficial defects involving the cutaneous lip can be closed sible in many instances. Lower lip defects up to 40% can gen-
in a variety of ways, including primary closure, local flaps, or erally be reapproximated using layered closure. The upper
skin grafting. When closed primarily, circular defects should lip’s distinct topographic landmarks, such as the philtrum and
be closed in a vertical line carrying dog-ears superiorly and cupid’s bow, can only tolerate primary closure of defects up
inferiorly along anatomical boundaries, such as the philtral to 25% without significant distortion. All full-thickness lip
columns, alar groove, nasolabial crease, labiomental groove, repairs should be performed in three layers with careful appo-
and white roll. Many partial-thickness defects are better man- sition of the mucosa, orbicularis oris, and skin. To eliminate
aged by conversion into a full-thickness wedge excision if notching that tends to occur along the vermilion, wound edge
excess tissue develops intraorally or along the vermilion. eversion is compulsory. Furthermore, placement of a V-plasty
Local flaps are generally designed as either advancement or double-limb Z-plasty can prevent or correct linear scar
or transposition flaps using cheek and/or adjacent lip tissue contracture. Similar to partial-thickness closures, incisions
A B C
Figure 34.5. Partial-thickness defect involving Cupid’s bow, philtrum, cutaneous lip, and vermilion. Advancement
flap of right cutaneous lip with excision of perialar crescent. Skin graft of Cupid’s bow, vermilion musculomucosal
advancement (A). Inset (B). Final result (C).

continuity, although scarred, has the greatest likelihood of
neurotization and achieving a competent stoma. Furthermore,
lip switch flaps correct length discrepancies between the two
lips. The utility of lip switch procedures is limited by the
amount of available lip remaining following resection. At
some point, insufficient residual lip remains for an adequate
stoma. Microstomia has significant functional consequences,
including an inability to use utensils, place certain food items
in the mouth, perform oral care, and insert dentures. In con-
trast, reconstructions that recruit cheek tissue, while aestheti-
cally inferior, are not routinely associated with microstomia.
A requisite for using these flaps is sufficient cheek laxity to
permit advancement; patients with regional scars or radiation
Original Flared W fibrosis may not be candidates. The principal limitation of
cheek advancement is that the normal trilaminar structure of
the lip is not replaced with potentially inferior functional and
cosmetic outcomes.
Although many of the flaps commonly used for lip recon-
struction were originally described specifically for either upper
or lower lip defects, with modifications in design and incision
placement, they can be used for either lip.
Large central upper lip defects are best repaired with an
Abbe flap harvesting tissue from the central segment of the
lower lip based on either inferior labial artery (Figure 34.8).9
When the Abbe flap alone is inadequate to fill a central upper
Head and Neck

lip defect, lateral cheek tissue can be advanced with concomi-
tant excision of perialar crescents.8 The Abbe flap can be cre-
Single barrel Double barrel ated as wide as needed as long as primary closure of the lower
lip is achievable. The flap is designed in the center of the lower
Figure 34.6. Small full-thickness lower lip defects. Four patterns of lip, thereby preserving lateral innervation to the orbicularis
lower lip excision.
oris. Basic reconstruction techniques can be used when har-
vesting large lower lip segments (Figure 34.6). Flap tissue har-
vested inferior and lateral to the labiomental sulcus is a source
of additional tissue for nasal sill or columella reconstruction.
for full-thickness defects should be placed at the junctions of
To adequately perform an Abbe flap or other lip switch proce-
anatomical boundaries. Full-thickness lower lip defects can
dure, knowledge of the inferior labial artery position is impor-
be closed in a variety of ways with incisions concealed in the
tant. In general, the artery is located at a level equivalent to
labiomental crease (Figure 34.6).
the white roll on sagittal section. The artery’s position can
In special circumstances, such as central upper lip defects
also be evaluated at the cut margin of the non-pedicle side
involving the philtrum, closure with an Abbe flap (see later
of the flap. The remaining connection to the lower lip should
section) may be preferable even though primary closure can
be as small as safely possible to permit adequate rotation to
easily be achieved. A primary closure results in a single lin-
the upper lip. Case reports document flap survival despite
ear scar and flattens the contour of the upper lip, whereas the
inadvertent pedicle ligation with blood supply based on the
scars on either side of the Abbe flap replace the two philtral
mucosa only, although this is not recommended. As much sur-
columns. This scenario is more important for women, whereas
face area as possible of the flap should be inset into the upper
men can conceal a single upper lip scar within a moustache
lip defect to ensure adequate vascularization prior to pedicle
(Figure 34.7).
division approximately 2 to 3 weeks postoperatively.
Application of the Abbe flap for central lower lip recon-
Large Full-Thickness Defects structions is not as ideal. Although both the single- and
Tissue for large lip defects can be obtained from one of two double-reverse flaps have been described for medium-sized
resources: the opposite lip or the adjacent cheek. Each donor central lower lip defects, the upper lip is a suboptimal donor
site has benefits and drawbacks. Lip switches are composite site because harvest of relatively small amounts can distort
flaps that replace “like with like,” including the orbicularis its unique anatomical landmarks. A better alternative for
oris, mucosa, and vermilion. From a functional and aesthetic large central lower lip defects, or central upper lip defects not
standpoint, these flaps are superior. Restoration of orbicularis amenable to an Abbe flap with perialar crescents, is bilateral
A B C D
Figure 34.7. Full-thickness defect involving central upper lip. Bilateral upper lip advancement flaps with excision of perialar crescents (A). Flap
elevation (B). Prior to inset (C). Final result (D).

B C D
Figure 34.8. Full-thickness defect involving central and left upper lip. Schematic of an Abbe flap (A). Central
Abbe flap with bilateral upper lip advancement flaps and excision of perialar crescents (B). Inset (C). Final
result (D).
versions of the Karapandzic, modified Bernard, or nasolabial incision ensures preservation of an adequate gingivobuccal
flaps. The Karapandzic flap is a musculocutaneous rotation sulcus. Spreading rather than division of regional cheek mus-
advancement flap that uses remaining portions of the lip for culature preserves the underlying neurovascular supply with
reconstruction with preservation of its neurovascular supply better long-term functional results. Similar to other rotation
(Figure 34.9).10 The flap is designed as a semicircle around the flaps, redundant skin along the outer circumference of the flap
remaining portion of lip with a radius corresponding to the can be excised as a Burow’s triangle.
defect height. The first 1 cm of the incision is carried through An alternative to the Karapandzic flap is the modi-
all the lip layers, but beyond that the mucosa is preserved fied Bernard operation. The original Bernard cheiloplasty
while only the skin and muscle are divided. The small mucosal described in 1853 for lower lip reconstruction has been
Figure 34.9. Full-thickness defect involving lateral lower lip. Schematic of a bilateral Karapandzic flap (A). Schematic of a reverse bilateral
Karapandzic flap (B). Unilateral Karapandzic flap with full-thickness lip advancement flap (C). Flap inset (D).
Head and Neck

C D
modified many times, so it carries with it numerous names Large lateral and commissure defects of either lip can be
(Figure 34.10).11 The technique in principle creates a later- repaired in a number of ways. Although originally described
ally based horizontal advancement flap by making incisions by Estlander as a medially based rotation-advancement flap
through the lip commissure with a second parallel incision at from the upper to lower lip, a reverse Estlander can be per-
a level corresponding to the height of the missing lip. Incisions formed by rotating a lower lip segment to a lateral upper lip
are made through skin and mucosa intraorally. Muscle or commissure defect (Figure 34.11).13 The technical principles
is divided for 1 cm only along the leading edge of the flap. of this operation are the same as an Abbe flap. The flap size
At the flap base, Burow’s triangles, equivalent in size to the should be one half the defect width, so correct proportions
amount of advancement, are excised to eliminate redundancy. are maintained between the lips. Secondary commissuroplasty
The Burow’s excisions remove excess skin and subcutaneous or commissurotomy may be required to correct the rounded
fat only, but preserve the underlying muscle. A stair step of appearance of the lip neocommissure.
extra buccal mucosa harvested along the commissural incision The rotation-advancement fan flap described by Gillies
of the flap is advanced for vermilion reconstruction. A final is a modification of the Estlander flap with the exception
reconstructive alternative to consider for large central upper of its shape.14 Whereas the Estlander flap is a “V” or pen-
or lower lip defects is either partial- or full-thickness bilateral nant, the fan flap is a quadrilateral with an arc of rotation
interdigitating nasolabial flaps.12 Proponents of this technique that resembles the opening of a fan. Variations of the fan flap
argue that no normal tissue is sacrificed, in contrast to the were described by McGregor and Nakajima, who pivoted
Bernard technique where “normal” tissue from the Burow’s the cut vertical margin of the quadrilateral flap around the
triangles is discarded. Partial-thickness nasolabial flaps have commissure rather than forward to meet the resection mar-
a random blood supply when based on the subdermal plexus, gin of the residual lip. The disadvantage of this method is
whereas full-thickness “gate flaps” include the facial artery. the need for vermilion reconstruction; however, the commis-
When raised full thickness, these flaps denervate the upper lip sure is not displaced and the stomal size is unchanged as with
with potential for further functional embarrassment. the Estlander or fan flaps. An alternative method for lateral

A B C
B C
Figure 34.10. Full-thickness defect involving central and lateral

lower lip. Schematic of a bilateral modified Bernard flap. Note the
stair-step incision in the mucosa to include extra tissue for vermilion
reconstruction (A). Right unilateral Bernard flap with left unilateral
Karapandzic flap (B). Inset (C).
defects that preserve the commissure is to perform an Abbe stage in all instances for flap division as well as the inconve-
flap, also termed as Abbe-Estlander since it retains properties nience of temporary microstomia. Finally, unilateral versions
of both flaps. The advantage of this technique is the natural of the Karapandzic, Bernard, and nasolabial flaps can also be
appearance of the preserved commissure and inconspicuous considered for large lateral lip defects (Figures 34.9 C, D and
donor site scar when the flap is harvested from the central 34.10). Of these options, the Karapandzic flap is preferred
lower lip. Its shortcoming is the necessity to perform a second because of its superior functional and cosmetic results.
C D E
Figure 34.11. Full-thickness defect involving central and left upper lip.

Schematic of an Estlander flap (above) and reverse Estlander (below) (A)
(B). Reverse Estlander flap with cheek advancement flap and excision of perialar
crescent (C). Inset (D). Final result (E).
B

A B C D
Figure 34.12. Near total lower lip defect with involvement of adjacent chin soft tissue. Proposed resection (A). Defect (B). Folded radial fore-
arm flap with palmaris tendon graft (C). Early postoperative result (D).
alternative to consider in some cases of total lip loss.

Total Lip Reconstruction Possible indications include soft tissue defects of both
Adequate total lip reconstruction is difficult to achieve lips or composite defects of either the maxilla or man-
with regional tissues. For defects greater than 80%, the dible with adjacent entire lip. Although the field is in its
Karapandzic technique creates a significant microstomia, so infancy, composite tissue allotransplantation is promis-
either bilateral Bernard or nasolabial flap is the best recon- ing with superior cosmetic and functional results in some
structive method if sufficient laxity permits. The use of instances (Chapter 6).
cheek tissues for such large defects makes the lip tight with An algorithm for lip reconstruction is presented in
poor function and relative protrusion of the uninvolved lip. Figure 34.14. Since each reconstructive scenario is unique and
Head and Neck

Functional sequelae are magnified particularly for lower lip many flaps are suitable for a given defect, the algorithm pro-
defects since its contribution to oral competence is greater vides a list of considerations rather than a single reconstruc-
than the upper lip. tive method.
A final flap to consider from the reconstructive armamen-
tarium for total lip reconstruction is the submental flap. Based Lip Replantation
on the submental branch of the facial artery, the flap can be
transferred as an island to reach either lip. For benign pro- Although uncommon, traumatic amputation of the lip occurs
cesses, the flap can be prelaminated in advance with a skin most commonly from dog bites (Figure 34.15). If the segment
graft or pre-expanded to increase its size. The main advantage is large enough, it should be carefully evaluated under micro-
of any regional tissue reconstruction over free tissue transfer is scopic magnification to identify and assess the quality of the
the superior cosmetic results. labial artery for microsurgical transfer. The major obstacle
Free tissue transfer for total lip reconstruction was first to lip replantation is the poorly formed labial veins that are
reported in 1974.15 It remains the best option for total lip unsuitable for microsurgical anastomosis. Venous outflow
defects not amenable to regional flaps or when a defect can be generally achieved with leeches. Hospital stays are pro-
includes soft tissues extending beyond the lip (e.g., com- longed with the need for blood transfusions. When possible all
bined lower lip and chin defect). The thin and pliable radial efforts should be made at replantation since restoration with
forearm free flap is used most commonly and can be ele- native tissue is superior both cosmetically and functionally to
vated either longitudinally or transversely on the forearm any reconstruction.
(Figure 34.12). The palmaris longus tendon, harvested as
a free graft (longitudinal skin island) or composite graft
(transverse skin island), is weaved into remaining portions
Conclusion
of the orbicularis oris or modiolus. Simultaneously, vermil- The long history of lip reconstruction provides a wide array
ion reconstruction can be performed with bilateral FAMM of surgical techniques from which the surgeon can choose.
flaps or in a delayed fashion with any of the aforementioned The rich blood supply and elasticity of the lip and cheek
techniques (Figure 34.13). Cosmetic results for upper lip allow for some of the most creative and unique reconstruc-
reconstruction in men can be improved through the use of tive procedures in all of plastic surgery. Firsthand knowledge
hair transplantation (Chapter 52). of lip history, anatomy, and function along with an under-
Depending upon the etiology and extent of the lip standing of basic reconstructive principles will yield the best
defect, partial face transplantation may be a valuable outcomes.
A B C D
Figure 34.13. Total lower lip and chin defect following arteriovenous malformation (AVM) excision. Preoperative (A). Template for folded
radial forearm flap (B). Antegrade bilateral FAMM flaps for vermilion reconstruction (C). Four-year postoperative result (D).

Defect size Defect location Reconstruction
Upper lip up to 25% Primary closure

Lower lip up to 40%
Lip switch (e.g., Estlander/Abbe)

or
unilateral karapandzic/
Bernard/nasolabial flap
25–80%
Bilateral karapandzic/Bemard
flaps
Abbe +/–perialar crescents
>80%
Bilateral Bemard/nasolabial flaps
or
free tissue transfer
Figure 34.14. A reconstructive algorithm for full-thickness defects.
A B C D
Figure 34.15. Near total upper lip amputation. This 17-year-old male had the majority of his upper lip amputated by a dog (A). The part was
replanted but swelling prevented immediate inset, and venous congestion necessitated leach therapy (B). After serial inset, the anatomic land-
marks were restored, and at 6 months full function and sensation had returned (C, D) (photo courtesy of Dr. Helena Taylor).

9. Abbe R. A new plastic operation for the relief of deformity due to double
References harelip. Plast Reconstr Surg. 1968;42:481-483.
1. Briedis J, Jackson IT. The anatomy of the philtrum: observations made on 10. Karapandzic M. Reconstruction of lip defects by local arterial flaps.
dissections in the normal lip. Br J Plast Surg. 1981;34:128-132. Br J Plast Surg. 1974;27:93-97.
2. Mulliken JB, Pensler JM, Kozakewich HP. The anatomy of Cupid’s bow in 11. Webster RC, Coffey RJ, Kelleher RE. Total and partial reconstruction of
normal and cleft lip. Plast Reconstr Surg. 1993;92:395-403; discussion 404. the lower lip with innervated musclebearing flaps. Plast Reconstr Surg
3. Schulte DL, Sherris DA, Kasperbauer JL. The anatomical basis of the Abbe Transplant Bull. 1960;25:360-371.
flap. Laryngoscope. 2001;111:382-386. 12. Rudkin GH, Carlsen BT, Miller TA. Nasolabial flap reconstruction of large
4. Zitsch RP 3rd, Park CW, Renner GJ, et al. Outcome analysis for lip carci- defects of the lower lip. Plast Reconstr Surg. 2003;111:810-817.
noma. Otolaryngol Head Neck Surg. 1995;113:589-596. 13. Sundell B. The classic reprint: translation of “Eine Methode aus der Eincn
5. Burget GC, Menick FJ. Aesthetic restoration of one-half the upper lip. Plast Lippe Substanzverluste der Anderen Zu Ersetzen”, by JA Estlander. Plast
Reconstr Surg. 1986;78:583-593. Reconstr Surg. 1968;42:7.
6. Wilson JS, Walker EP. Reconstruction of the lower lip. Head Neck Surg. 14. Gillies H. The Principles and Art of Plastic Surgery, Vol. 2, 1st ed. Boston,
1981;4:29-44. MA: Little, Brown and Company; 1957.
7. Pribaz JJ, Meara JG, Wright S, et al. Lip and vermilion reconstruction with the 15. Harii K, Omori K, Omori S. Successful clinical transfer of ten free flaps by
facial artery musculomucosal flap. Plast Reconstr Surg. 2000;105:864-872. microvascular anastomoses. Plast Reconstr Surg. 1974;53:259-270.
8. Webster JP. Crescentic peri-alar cheek excision for upper lip flap advance-
ment with a short history of upper lip repair. Plast Reconstr Surg (1946).
1955;16:434-464.
Head and Neck

Chapter 35 n Reconstruction of the Cheeks
Babak J. Mehrara
The cheeks represent the largest surface area of the face and possible. Distortion of surrounding structures such as the
frame the central facial units. This anatomic arrangement lower eyelid and upper lip is disfiguring and is an important
exposes the skin of the cheek to trauma and to the effects of consideration in any reconstructive plan. According to Zide
sun exposure, and, in turn, there is a frequent requirement for and colleagues, vertical incisions placed medial to a line drawn
reconstructive surgery. Reconstruction must be planned care- from the lateral canthus remain obvious on frontal view and
fully and executed meticulously to (1) restore the natural con- ideally should be replaced by incisions along the nasolabial
tours; (2) maintain hair patterns; and (3) camouflage scars. fold or by blepharoplasty incisions.3 Defects involving the full
The face can be divided into units based on a number of thickness of the cheek occur from invasion of skin cancers,
characteristics, including skin color, skin texture, hair, con- from extensive trauma, or as a result of advanced intraoral
tour, relaxed skin tension lines, and boundaries between cancers. Appropriate reconstruction of all layers, while main-
anatomic structures. The cheek, however, is less amenable taining reasonable contour, is planned if possible. A successful
to “aesthetic unit” analysis. Zide and Longaker 1 divided reconstruction will recreate the missing tissues using the most
the cheek into three overlapping zones: suborbital, preau- similar tissues. As with nasal reconstruction, plans for lining,
ricular, and buccomandibular based on reconstructive needs. support, and coverage are developed individually. Secondary
Similarly, Jackson divided the cheek into five areas based on revisions for contour may be necessary, particularly for com-
reconstructive techniques and anatomic characteristics (lat- plex reconstructions, and should be described to the patient
eral, lower, malar, superomedial, and alar base–nasolabial).2 prior to initiation of therapy.
The classification systems are helpful for planning, but princi- Facial nerve reconstruction is ideally performed as a
ples used for subunit reconstruction in other areas (e.g., resur- planned procedure, with the ends of the nerve stimulated
facing entire units, discarding remaining tissues of a subunit, and tagged at the time of resection since later identification
and using the contralateral side to make exact templates) are of nerve ends is difficult and tedious. In addition, nerve tran-
less applicable to cheek reconstruction. section is performed sharply to avoid cautery damage at the
site of neurorrhaphy. Nerve grafts may be harvested from the
neck (ansa cervicalis and great auricular nerve) or from dis-
Anatomy tant sites (e.g., sural nerve).
The cheek is bounded by the preauricular crease laterally, the For a given defect, more than one reconstructive option is
zygomatic arch and lower eyelids superiorly, the nasal side- usually available. The best option is determined based on the
wall and nasolabial fold medially, and the mandibular border relationship of the defect to the surrounding structures, hair-
inferiorly. bearing status, skin laxity, natural wrinkles, previous surgical
The sensory innervation of the cheek is provided by the scars, relaxed skin tension lines, and avoidance of lower eye-
maxillary and mandibular divisions of the trigeminal nerve, as lid and lip distortion. Contaminated wounds undergo serial
well as a small contribution from the anterior cutaneous nerve debridement and dressing changes until bacterial content is
of the neck and the great auricular nerve, both of which arise reduced to an acceptable level before definitive reconstruc-
from the cervical plexus. tion is accomplished. Previous radiation therapy may prohibit
Motor innervation of the superficial facial muscles is pro- local flap reconstruction.
vided by the facial nerve. The masseter and temporalis mus-
cles (muscles of mastication) are innervated by the trigeminal
nerve. In the preauricular area, the facial nerve is protected by
Reconstructive Options
the superficial lobe of the parotid gland and runs deep to the Healing by Secondary Intention
parotid masseteric fascia over the masseter muscle.
The arterial supply of the cheek is provided by branches The simplest method of closure is healing by secondary inten-
of the external carotid artery, including the facial artery, the tion. Unfortunately, the indications for this technique are limited
superficial temporal artery, and the transverse facial artery. as large wounds may result in contour irregularities, distortion
Venous drainage follows the arteries and is abundant. The of surrounding structures, and unstable coverage. This tech-
lymphatic drainage of the cheek is provided by lymphatic nique may be useful for small (<1 cm), superficial defects located
channels within the parotid nodes and along the facial vessels in cosmetically inconspicuous areas (e.g., below the sideburns)
to the submandibular nodes. in patients with solar-damaged, irregularly pigmented skin.
Primary Closure
Defect Analysis Primary closure is the reconstructive method of choice if
Analysis of the defect or anticipated defect is a critical part of excessive tension and distortion of surrounding tissues can be
any reconstructive procedure. Defects may be superficial (sim- avoided. The scars are ideally placed along minimal skin ten-
ple) and include only the skin and subcutaneous tissues, or sion lines or within natural skin contours, such as the nasola-
may be more complex and include the muscle, parotid gland, bial or preauricular folds (Figure 35.1). This technique results
facial nerve, mucosa, and bone. Ideally, surgical incisions are in the simplest scar, avoids donor-site deformity, and avoids
placed at the cheek margins or within established skin creases interpolation of distant tissues into the defect. The size of the
to camouflage the resulting scars. Care is taken to avoid, if defect suitable for primary closure is variable and depends on
possible, placement of hair-bearing skin into non–hair-bearing the amount of skin laxity present. Wide undermining in an
areas. Similarly, rotation of non–hair-bearing skin into areas elderly patient with significant skin laxity may allow closure
of the male beard and distortion of the sideburn are avoided. of relatively large defects. Dog-ears created by wound closure
Contour deformities and color mismatches are avoided when should be excised while avoiding excessive lengthening of the
384
Chapter 35: Reconstruction of the Cheeks 385
Head and Neck

A B
Figure 35.1. Primary closure. Preoperative (A) and postoperative (B) photographs of a patient treated with primary closure of Mohs excision
for basal cell cancer. Note the closure along nasolabial fold with well-concealed scar and minimal distortion. Also note the new basal cell cancer
excision on nasal sidewall (arrow).
scar. The disadvantage of primary closure for larger defects is are random pattern flaps raised in the subcutaneous plane and
the long, straight scar in an area where there are normally no should be of appropriate width to avoid tip necrosis. A base-to-
straight lines. The nonlinear scar from a local flap is prefer- length ratio of 1:1 is usually safe. In addition, advancement flaps
able in many circumstances. should be anchored to the periosteum of zygoma or maxilla at
points higher than the lower eyelid to prevent ectropion.
Skin Grafts V-Y advancement flaps are an excellent choice for closure
of defects that lie along the medial cheek and alar base, par-
On rare occasions, skin grafts are useful for cheek reconstruc- ticularly if primary closure of the defect results in distortion of
tion. Although skin grafts may be associated with shiny, patch- the lower eyelid or nasal base (Figure 35.2).4 The excision is
like, depressed scars, they may be reasonable in patients with
significant comorbid conditions. Skin grafts have also been
advocated by some authors in patients at high risk for local
recurrence. In addition, skin grafts may be used to resurface
less critical areas of the cheek (e.g., just below the sideburns),
particularly when the defects are donor sites of flaps used to
resurface more critical, medial areas. Full-thickness skin grafts
exhibit less secondary contraction and should be used in situa-
tions where contracture would result in distortion of adjacent
structures (e.g., lower eyelid). Full-thickness skin grafts have
the additional advantage of better color match if harvested
from the neck, preauricular/postauricular skin, or upper back.
Full-thickness skin grafts are also thicker than split-thickness
skin grafts and may be more useful for deeper defects. In gen-
eral, excisions greater than 5 mm in thickness treated with
skin grafts will likely exhibit a permanent contour deformity.
Local Flaps
Advancement Flaps. Advancement flaps are useful for
reconstruction of superomedial defects, particularly in elderly A B
patients with significant skin laxity. These flaps may be per- Figure 35.2. V-Y advancement flap to medial cheek defect. A. Flap
formed as advancement flaps with excision of Burrow triangles design. B. After advancement. Note the advancement of nasolabial
or as V-Y advancements. Ideally, the lesion is excised as a rect- flap with rectangular excision of the defect.
angle or square to avoid trapdoor scarring. Advancement flaps

performed as a square or rectangle in the medial cheek or as a spreading, thus enabling advancement of the remaining cheek
wide crescent at the alar base. Skin incisions are preformed to unit. Dog-ears are excised as an upper or lower blepharoplasty
the subcutaneous tissues and the flap is advanced based on a incision. Alternatively, the redundant upper eyelid skin may
subcutaneous blood supply. The length of the flap should be be used to reconstruct lower-lid defects, while the advance-
sufficient to avoid tension on the closure. ment flap is used to reconstruct the cheek defect (Figure 35.3).
Zide and colleagues described the deep-plane cervicofacial
“hike” repair as an advancement flap that removes dog-ears Transposition Flaps. Transposition flaps such as b anner
in a cosmetically acceptable blepharoplasty incision.3 The flap flaps, bilobed flaps, and rhomboid flaps are useful for most
is dissected together with the SMAS (superficial musculoapo- medium to large defects of the cheek and are designed to
neurotic system), and the authors believe that it has a better transfer lax skin while the donor sites are closed primarily.
blood supply than a subcutaneous flap. The dissection of the Although these flaps have some drawbacks (e.g., complex
facial nerve is performed with blunt scissors, using vertical scars, pincushioning, trapdoor scarring, patchlike scarring,
A B
Figure 35.3. Cervicofacial flap to upper cheek

defect. Redundant upper eyelid skin was used to
repair lower eyelid defect while the cheek advance-
ment flap was used to repair the cheek defect.
A. Defect before operation. B–D. Postoperative
appearance. Note the well-camouflaged scar and
lack of lower eyelid distortion.
C D

and alterations in hair pattern), good results can be obtained
in appropriately selected patients and with carefully designed
flaps. Donor scars are planned carefully to fall, as much as
possible, within relaxed skin tension lines or existing folds.
Dog-ears are excised without narrowing the base of the flaps.
Banner flaps are the simplest form of transposition flap and
transfer the skin from the preauricular or nasolabial area to
close the defect (Figure 35.4). Secondary revisions may be nec-
essary to remove remaining dog-ears or to defat pincushioned
flaps. Although these repairs usually have excellent contour
and reasonable color match, the scars may be conspicuous,
particularly with facial animation.
Bilobed flaps are an extension of the banner flap and use
a secondary flap to close the defect created by the primary
flap (Figure 35.5). Bilobed flaps are used when the defect cre-
ated by the primary flap (i.e., the banner flap) is too large to A B
close primarily. The flaps are designed on a 45° to 90° axis Figure 35.5. Bilobed flap closure of central cheek defect. A. Flap
to the primary defect and are elevated in the subcutaneous design. B. After transfer. See text for details.
plane. Generally, the primary flap may be drawn somewhat
smaller than the defect and is designed, as much as possible, to
place the scars along minimal tension lines and within natural
skin creases. Flaps designed at 45° angles minimize dog-ear There are a variety of cheek rotation flaps (Figure 35.7).
formation. The resultant scars are complex and may be quite In their 1979 description, Juri and Juri popularized the
conspicuous. Pincushioning is a problem with bilobed flaps, inferomedially based rotation flap. This flap is designed
particularly relatively small flaps, and may require secondary such that the incision starts at the superior aspect of the
Head and Neck

revisions. Because of the laxity in the cheek, bilobed flaps are defect and extends to the outer canthus and along the
infrequently used on the cheek. zygomatic arch (Figure 35.8). The incision is then brought
Rhomboid flaps are a geometric modification of banner along the preauricular fold, extended below the ear, and
flaps and are useful in the treatment of medium to large defects along the retroauricular hairline to the midposterior line
(Figure 35.6). These flaps are more difficult to design but have of the neck. Wide subcutaneous undermining of the skin
a decreased propensity for trapdoor scarring or pincushioning. flap is then performed, enabling advancement and rota-
Rhomboid flaps are useful primarily for lateral, lower cheek, tion of the flap into the defect with primary closure of the
and temporal defects. The excision is performed using a rhom- donor site. The flap is anchored to the periosteum of the
bus with 60° and 120° angles. The donor flap bisects the 120° zygoma and lateral orbital wall in such a way that there
angle. The flap is drawn to place the donor site scar within a is absolutely no tension on the lower eyelid. Simultaneous
normal facial crease or wrinkle. This can be determined by
identifying the area of adjacent skin with the greatest laxity.
Thus, redundant surrounding skin is transferred to the defect
while the donor area is closed primarily. Modifications of the
flap may be performed to avoid unnecessary excision of nor-
mal skin; however, more circular excisions resembling banner
flaps may be complicated by pincushioning.
Rotation Flaps
Cervicofacial Flaps. Cheek rotation flaps are useful for mod-
erate to large defects of the upper medial region. These flaps
use the loose preauricular and neck skin and are most useful
for full-thickness skin and subcutaneous excisions. Repair of
deeper defects may result in contour abnormalities.
A B
A B C D
Figure 35.4. Banner flap to central cheek defect. A. Flap design. Figure 35.6. Rhomboid flap closure of cheek defects. A and C. Flap
B. After transfer. Note the location of final incision corresponds to design. B and D. After transfer. Note that the flap is drawn along
lines of minimal tension/natural skin creases. minimal tension lines and within natural skin creases.

lower-lid tightening may be considered, particularly in

patients with excessive lower-lid laxity. Skin excess formed
at the nasolabial fold is excised carefully so as to avoid nar-
rowing the base of the flap. Occasionally, a full-thickness
skin graft is necessary for closure of the donor site to avoid
undue tension and is best hidden below the sideburn. The
primary drawback of this procedure is skin necrosis of the
distal flap. This complication is more likely in smokers.
A B C
Disadvantages include rotation-advancement shifts of the
normal hair-bearing of the cheek and creation of ectropion
or prolonged lower-lid edema. Hematoma is also common
and should be closely monitored as it can lead to large
areas of skin necrosis.
Inferolaterally based rotation flaps are designed to trans-
fer the lax skin along the nasolabial fold and jowls to recon-
struct upper medial defects (Figure 35.9).5 The skin incision
may be extended across the mandible and back-cut to enable
D E F
tension-free closure. In addition, extension of the incision
to the contralateral neck along an established neck crease
may increase the reach of the flap. These flaps are less likely
to undergo necrosis at the distal end than the previously
described inferomedially based flaps. The disadvantage is
the scar in the central face. For smaller defects, excision of a
Burow triangle may be necessary to allow rotation-advance-
ment of the flap. Although these flaps are susceptible to the
effects of gravity with resulting ectropion, this is usually pre-
vented by anchoring securely to the underlying bone/peri-
G H I
osteum in the medial canthal region. Resections performed
close to the lower eyelid may be complicated by lower-lid
Figure 35.7. Various designs for cervicofacial rotation flap closure
of cheek defects: A. Esser; B. Blascowicz; C. Ferris Smith; D. Mustarde;
edema, medial ectropion, pin cushioning, and nasolabial
E. Converse; F. Stark; G. Juri and Juri; H. Zide and Schruder; I. Kroll. fold asymmetry. In addition, scars crossing the mandibular
(Adapted from Al-Shunnar B, Manson P. Cheek reconstruction with lat- border may be difficult to hide or result in contracture. The
erally based flaps. Clin Plast Surg. 2001;28:283-296, with permission.) use of Z-plasty incisions to cross the mandibular border may
obviate this problem.
A B
Figure 35.8. Inferiorly based cervicofacial rotation flap closure of Mohs resection for basal cell cancer. Note the excision of dog-ear along
nasolabial fold. A. Planned resection. B. Defect and flap design. C and D. Postoperative appearance.

Head and Neck

C D
Figure 35.8 (Continued)
In an effort to improve the blood supply and reliability of defects extending significantly above this line may be com-
of the cheek rotation flap, several authors have described a plicated by skin necrosis. The incisions are marked along
composite dissection of the skin flap.3,6 This dissection is per- the posterior aspect of the defect, around the ear lobe, and
formed in the deep plane by elevating the skin together with along the retroauricular hairline. The incision is continued in
the SMAS. The flap is elevated with vertical spreading below the neck approximately 2 to 3 cm behind the anterior border
the SMAS, and the facial nerve branches are preserved. This of the trapezius and across the clavicle at the deltopectoral
modification enables larger flap design and may be more reli- groove. A back-cut may be performed as necessary. Larger
able in smokers and patients with poor skin quality. In addi- defects may require further dissection of the flap by running
tion, the use of these thicker flaps enables repair of deeper along the border of the pectoralis muscle and extending across
defects without resultant contour abnormalities. Conversely, the chest (Figure 35.10). This flap is based primarily on the
these flaps may require secondary revision (thinning) if used internal mammary perforating vessels with variable contribu-
for the repair of simple excisions. tion from perforators emanating from the thoracoacromial
artery and vein. Cervicopectoral flaps are raised subcutane-
Cervicopectoral Flaps. Cervicopectoral flaps use the excess ously over the cheek and lower mandible and enter the deep
skin of the neck and chest to cover lower lateral cheek defects. plane below the platysma approximately 3 to 4 cm below the
The upper border of the defects suitable for cervicopectoral mandibular border. The platysma can be safely transected at
flap reconstruction can be estimated by drawing a line con- this level to improve the reach of the flap. The flap is advanced
necting the tragus to the lateral commissure. Reconstruction and rotated into the defect, and the donor area of the flap lat-
eral to the pectoralis muscle is closed in a V-to-Y fashion. Skin
grafting of the donor site is occasionally necessary to provide
tension-free closure. The head is lightly immobilized postop-
eratively using rolled sheets to avoid violent movements.
Local Composite Flaps

Pectoralis Major Flap. The pectoralis major flap is occasion-
ally useful for the repair of lower lateral cheek defects. The
pectoralis muscle is supplied by the pectoral branches of the
thoracoacromial vessels that are located along a line drawn
from the acromion to the xiphoid process. The vessels emerge
from below the clavicle and can be located easily using a
Doppler probe. The skin of the pectoralis flap is reliable and
rarely undergoes total necrosis; however, partial skin necro-
A B sis can occur if the flap is not elevated meticulously. The flap
Figure 35.9. Laterally based cervicofacial rotation flap. Skin flaps tends to be bulky and is primarily used for complex recon-
are raised in the subcutaneous plane and rotated/advanced to fill in structions, involving the skin, subcutaneous tissues, parotid,
the defect. A. Defect and flap design. B. After flap transfer. and masseter. Although a folded pectoralis major myocutane-
ous flap has been described for repair of through-and-through

A B
C D
Figure 35.10. Cervicopectoral rotation flap. Preoperative (A, B), intraoperative (C, D), and postoperative (E, F) photographs of cervicopec-
toral rotation flap for large cheek defect resulting from basal cell cancer excision. The flap is elevated in the subcutaneous plane until a point
approximately 2 cm below the angle of the mandible at which point the platysma is included with the flap (dark arrow in C). A small skin graft
was necessary below the hairline to obtain tension-free closure (arrow in D). Note the good contour and acceptable final scar.

Head and Neck

E F
cheek defects to provide both intraoral and extraoral cover- in most instances are branches of the thyrocervical trunk
age, this option is significantly disfiguring because of excessive (80%). The distal portions of the muscle receive a variable
bulk and should probably be avoided except in extenuating contribution from the dorsal scapular artery and vein, which
circumstances. The flap may be transferred as a muscle-only course deep to the rhomboid muscles. These vessels are usu-
flap, or together with an overlying skin paddle. The skin pad- ally branches of the transverse cervical artery and vein, but
dle is usually designed as an ellipse medial to the nipple–areola may arise separately from the subclavian vessels, leading to
complex. A width of approximately 6 to 7 cm is usually closed distal ischemia if divided. Three distinct musculocutaneous
without excessive tension. The superior extent of the skin flaps based on the trapezius system are available (superior,
paddle ideally avoids the internal mammary perforating ves- lateral, and lower). The lower and lateral flaps are more use-
sels saving the option for a future deltopectoral flap. Closure ful for cheek reconstruction because of their arc of rotation.
of this defect may cause significant distortion of the breast. The lower flap is designed with the patient in the lateral decu-
An alternative is a skin paddle below the nipple. This skin bitus position. The skin flap is marked between the midline
paddle has longer reach and a better scar; however, the blood and the medial border of the scapula overlying the inferior
supply may be tenuous. In addition, extensive undermining aspect of the trapezius muscle. The lower extent of the skin
in a female patient may lead to breast or nipple necrosis. The paddle is variable, although the inferior border of the scapula
muscle may be thinned proximally to avoid an unsightly bulge is in general reliable. Skin, subcutaneous tissues, and fibers of
in the lower neck. In addition, near-complete disinsertion of the trapezius muscle are incised and the flap is elevated above
the muscle may prevent postoperative neck contracture and the plane of the rhomboid muscles. If a large dorsal scapu-
torticollis. Care is taken when tunneling the flap into the lar artery is encountered, the contribution of this vessel to the
defect to avoid avulsion of the skin paddle, kinking or exces- skin flap perfusion should be assessed using a microvascular
sive twisting of the pedicle, or external compression from an clamp. If the dorsal scapular vessels are critical for perfusion
inadequate tunnel. of the distal aspect of the flap, these vessels can be mobilized
by incising a cuff of rhomboid muscle and ligating their deep
Trapezius Flap The trapezius flap is similar to the pectoralis branches. Careful dissection can enable the preservation of the
major flap in that it is occasionally useful for complex lower spinal accessory nerve branches to the upper trapezius muscle,
lateral cheek defects. The arterial and venous anatomy of the thus preserving its function.
trapezius (Mathes and Nahai type II vascular pattern) is vari-
able and can be a potential pitfall in dissection. The domi- Tissue Expansion. When timing of reconstruction is not
nant pedicle is the transverse cervical artery and vein, which critical (i.e., excision of a benign lesion), tissue expansion

(Chapter 10) may represent an alternative option. In addition,

this technique may be useful in secondary revision of exist- Microsurgical Reconstruction
ing scars, skin grafts, or excision of skin paddles of previously Microsurgical reconstruction is an important option for com-
performed free flaps. In these settings, tissue expansion has plex defects involving multiple tissue layers. These techniques
the advantage of transferring potentially sensate skin that is of are also useful for resurfacing massive skin resections and in
similar color, texture, and hair-bearing status while minimiz- patients in whom local flaps are not available (e.g., previous
ing donor defects. neck dissection and facial burns) or advisable (contaminated
Although simple in concept, tissue expansion of the wounds and history of radiation therapy). Resurfacing of
cheek is highly technical and can be associated with high extensive intraoral or through-and-through defects and con-
rates of complications.7 Despite these difficulties, however, tour deformities are additional potential indications for the
the expanded skin is salvageable in most instances, and suc- use of microsurgical tissue transfer.
cessful reconstruction is usually achieved. Careful preopera- Although a number of flap options have been described,
tive planning with regard to patient selection, expander size, the radial forearm, parascapular, rectus abdominus, anterolat-
and incisions used for expander and fill-valve placement eral thigh flap, and free fibula flap have been the most useful
are critical determinants of success.8 No expander is placed in our experience. The choice of free flap is dependent on the
before the surgeon has decided exactly what incisions will amount of external skin, intraoral lining, and soft-tissue con-
eventually be required to transfer the expanded skin at the tour requirements. In addition, the availability and location of
second stage. the recipient vessels must be carefully determined.
Wieslander8 has outlined guidelines for tissue expansion
of the head and neck based on his experience with more than Radial Forearm Flap. The radial forearm flap is a fascio-
100 patients over a 6-year period. These guidelines include cutaneous flap based on the radial artery. The flap is an excel-
the following: the width and length of the expander are at lent source of thin, pliable skin with a long, reliable pedicle.
least as large, preferably larger, than the defect; the access The flap has dual venous drainage via the cephalic vein and
incisions are kept small and as far away from the lesion as radial vena comitans. Sensate reconstructions may be per-
possible; access incisions are oriented perpendicular to the formed using the lateral antebrachial cutaneous nerve. The
lesion; expansion of the lesion should be avoided; straight forearm flap is an excellent choice for defects requiring a thin
incisions bordering the defect are avoided; fill-valves are coverage of skin (Figure 35.11). In addition, the flap may be
placed away from (>7 cm) and below or lateral to the folded upon itself to provide more bulk or to provide cov-
expander pocket; expanders are filled intraoperatively to the erage of through-and-through cheek defects (Figure 35.12).
safest maximal amount to avoid seroma/hematoma; post- Multiple skin islands may be designed along the length of the
operative expansion should be delayed for 10 to 14 days; flap, and the flap may be de-epithelialized or thinned to allow
overexpansion by 30% to 50% is recommended; and the soft-tissue contouring. A short segment of the radial bone may
capsule is incised but capsulectomy is avoided at the time of be harvested as vascularized bone with the flap. The main
flap transposition. drawbacks of this flap include donor-site scarring and color/
A B
Figure 35.11. Radial forearm free flap. Intraoperative (A, B, C) and postoperative (D, E) photographs of a free radial forearm flap used for
reconstruction of deep, wide, central cheek defect resulting from resection of a desmoplastic melanoma. The flap was folded upon itself medially
to correct the volume deficiency. Note the postoperative ectropion (D) despite intraoperative canthoplasty and flap suspension.

Head and Neck

E

D
texture mismatch with local tissues. In addition, the flap may Rectus Abdominus Flap. The rectus abdominus myocu-
be hair-bearing in some men. taneous flap is a workhorse flap for facial reconstruction. The
use of this flap for cheek reconstruction is more limited, how-
Parascapular Flap. The parascapular flap is a fasciocutane- ever. The flap is usually designed with a vertical skin paddle,
ous flap based on the circumflex scapular vessels. This flap has and its primary indications are reconstruction of complex
more bulk than the radial forearm flap and is useful in recon- defects including multiple layers. The pedicle vessels are the
struction of composite resections such as radical parotidectomy deep inferior epigastric artery and vein and are highly reliable.
(Figure 35.13). The flap may be harvested with a segment of Pedicle length may be lengthened through intramuscular dis-
scapular bone (up to 14 cm). In addition, the latissimus dorsi section and may be as long as 14 to 15 cm. The flap may be
muscle can be harvested on a common pedicle, resulting in a bulky, particularly in obese patients, and secondary revisions
large amount of soft tissues useful in reconstruction of massive with liposuction and direct excision may be required. The flap
defects. In general, this flap has a better color match with facial can be folded upon itself for reconstruction of through-and-
skin than most other microvascular flaps and is associated with through defects of the cheek, but is too bulky in most patients.
minimal functional deficits, although the donor-site scar tends The amount of muscle harvested with the flap can be tailored
to widen if large flaps are designed. The flap is not usually to fit the defect and is particularly useful for obliterating radi-
useful for through-and-through defects and its pedicle length cal resections involving the maxillary sinus and the overlying
is shorter and more difficult to dissect than the radial forearm cheek skin. Perforator flaps (deep inferior epigastric perfora-
flap. In addition, parascapular and scapular flap dissection tor flap) that include only perforating vessels without harvest-
require lateral positioning of the patient, making simultaneous ing rectus muscle have become more popular for the head and
flap harvest and tumor resection difficult. neck reconstruction. These flaps have the advantage of being

C D
Figure 35.12. Folded radial forearm flap. Preoperative (A) and intraoperative (B, C, D) photographs of a folded radial forearm flap for intra-
oral and external coverage of a complex cheek defect. Note that lip continuity was restored using lip rotation flaps (right, Karapandzic; left,
Estlander), thereby avoiding interposition of the radial forearm flap in the lip defect.
less bulky and may be associated with less donor-site pain and on the patient’s body habitus, and is useful for providing a
abdominal wall laxity or hernias (Chapter 62). The potential large amount of skin together with a variable amount of vas-
drawbacks to the use of the rectus flap for cheek reconstruc- tus lateralis muscle to fill complex defects (Figure 35.14). The
tion include donor-site complications and bulkiness of the flap flap may be thinned somewhat at the time of flap harvest;
necessitating secondary revisions. however, aggressive thinning may be associated with partial
flap necrosis. Alternatively, secondary revisions with liposuc-
Anterolateral Thigh Flap. The anterolateral thigh flap tion and direct excision may be required. Thin patients may be
is a fasciocutaneous flap based on the perforating vessels good candidates for reconstruction of through-and-through
of the descending branch of the lateral circumflex femoral cheek defects based on the dissection of multiple perforating
artery and vein. The flap may be thin and pliable, depending branches. Pedicle dissection is more difficult than the radial

Head and Neck

A B
C D
Figure 35.13. Parascapular flap. Preoperative (A) and intraoperative (A, B, C, D) and postoperative (E, F) photographs of a free parascapular
flap for reconstruction of a complex cheek defect resulting from resection of a recurrent malignant melanoma of the right parotid gland. Facial
nerve repair was performed using sural nerve grafts. Postoperative photographs were taken 1 year postoperatively without further revision. Note
the good color match and contour.

E F
Figure 35.14. Anterolateral thigh flap. Intraoperative (A, B, C), and

postoperative (D, E) photographs of a massive cheek and neck defect
resulting from resection of osteoradionecrosis and infection of the right
mandible. The patient had a previous parotid tumor treated with wide
resection, radical neck dissection, and maximal doses of external beam
radiation therapy. Note the severe atrophy of the surrounding tissues.
A thin anterolateral thigh flap together with a small portion of the vas-
tus lateralis muscle (C) was used to cover the cheek defect and close the
small intraoral defect resulting from resection.
A

Head and Neck

C D

E

Figure 35.15. Summary of reconstructive technique for acquired cheek defects. See text for details. FTSG, full-thickness skin graft.
forearm flap because of anatomic variability; however, large- and ankle instability, respectively. In addition, the vascular
caliber vessels are available in most instances. Dissection supply of the leg should be carefully evaluated preoperatively,
of the pedicle vessels to their origin can result in a lengthy either by physical examination or in combination with radio-
pedicle that enables microvascular anastomosis to the neck logic studies, to avoid lower extremity ischemia.
vessels while avoiding vein grafting. The advantages of this
flap include more favorable donor-site scarring than the radial
forearm flap, potential for simultaneous flap harvest and
Conclusion
tumor ablation, and the ability to tailor the thickness of the Reconstruction of cheek defects requires careful planning and
flap by altering the amount of vastus lateralis muscle resec- execution. Although the choice of surgical options must be
tion. Knee extension is rarely affected unless there is inadver- individualized, an overall guide for the practitioner is sum-
tent injury to the femoral nerve. Color match to the facial skin marized in Figure 35.15.
is poor, however, as is the hair pattern.
References
Fibula Osteocutaneous Flap. The fibula osteocutane- 1. Zide, B, Longaker, M. Cheek surface reconstruction: best choices according
ous flap (Chapter 37) is an excellent source of vascularized to zones. Oper Tech Plast Reconstr Surg.1998;5:26.
bone (up to 30 cm) and a variable amount of skin and soft 2. Jackson I. Local Flaps for Head and Neck Reconstruction. St. Louis, MO:
tissues. Portions of the soleus muscle and flexor hallucis lon- Quality Medical Publishing; 2002.
3. Longaker M, Glat P, Zide BM, et al. Deep-plane cervicofacial “hike”: ana-
gus muscle can be harvested as vascularized muscle. The flap tomic basis with dog-ear blepharoplasty. Plast Reconstr Surg. 1997;99:16.
is based on the peroneal vessels and is useful for reconstruc- 4. Chadawarkar R, Cervino A. Subunits of the cheek: an algorithm
tion of segmental mandibular defects with or without exter- for the re-construction of partial-thickness defects. Br J Plast Surg.
nal skin resections. The flap may be harvested at the time of 2003;56:135-139.
5. Al-Shunnar B, Manson P. Cheek reconstruction with laterally based flaps.
tumor ablation, and the skin paddle may be folded upon itself Clin Plast Surg. 2001;28:283.
to provide both intra- and extra-oral lining. The fibula skin 6. Kroll S, Reece G, Robb G, et al. Deep-plane cervicofacial rotation-advance-
paddle is most reliable in the distal portions of the leg where ment flap for reconstruction of large cheek defects. Plast Reconstr Surg.
the perforating vessels tend to follow a septocutaneous pat- 1994;94:88.
7. Antonyshyn O, Gruss J, Zuker R, et al. Tissue expansion in head and neck
tern. Care must be taken during flap harvest to avoid injury reconstruction. Plast Reconstr Surg. 1988;82:58.
to the neurovascular structures of the lower extremity and to 8. Wieslander J. Tissue expansion in the head and neck. Scand J Plast Reconstr
preserve adequate bone proximally and distally to avoid knee Hand Surg. 1991;25:47.

Chapter 36 n Facial Paralysis
Julia K. Terzis And Katerina Anesti
genu), and the extracranial segment. Several branches are

Introduction given off during the intracranial course.
Injury to the facial nerve results in facial paralysis, a devastating The geniculate ganglion is the location of the first three
condition, as it deprives the afflicted patients of their ability to branches and mediates parasympathetic functions: the greater
communicate and express their emotion and negatively affects petrosal nerve (to the lacrimal gland), the external petrosal
all aspects of the patient’s life. The subsequent loss of voluntary nerve, and the lesser petrosal nerve (to the parotid gland).
action of the muscles of facial expression results in facial laxity The next three branches of the facial nerve occur in the
and a mask-like expression, especially in bilateral cases. mastoid segment: the nerve to the stapedius muscle, a sensory
In addition to the aesthetic deformity, there are functional auricular branch, and the chorda tympani, which supplies
problems related to competence of the eye and oral sphincters taste sensation to the anterior two-thirds of the tongue and
causing difficulties with eating, drinking, swallowing, articu- parasympathetic innervation to the submandibular and sub-
lation, and speech. Ocular problems include inability to close lingual glands. As the facial nerve exits the stylomastoid fora-
the eyelids, decreased tear production, loss of blink, and ectro- men, it passes anteriorly to the posterior belly of the digastric
pion of the lower eyelid. Speech is variably affected with a muscle and lateral to the styloid process of the temporal bone.
degree of dysarthria, as the facial nerve innervates many of the The extracranial segment gives off branches to the poste-
muscles for articulation. rior digastric, stylohyoid, and postauricular muscles, before the
The aim of reconstructive surgery in established facial nerve splits into the upper (frontozygomatic) and lower (cervi-
palsy is to restore symmetry and coordinated animation. cofacial) divisions at the posterior edge of the parotid gland.
Head and Neck

This overview on the most effective reconstructive techniques The facial nerve further divides in the parotid gland into
for reanimation of the unilaterally or bilaterally paralyzed face several branches. Most commonly, the upper division gives off
includes dynamic procedures of neuromuscular rehabilitation, the frontal, zygomatic, and buccal branches, and the lower
along with supplementary static procedures, which contribute division gives off the mandibular and cervical branches. These
significantly to the overall functional and aesthetic result. five terminal branches form a rich plexus that supplies the
Factors that influence surgical strategies and prognosis in facial musculature (Figure 36.1).
facial reanimation include the patient’s age, denervation time, The facial nerve innervates 23 paired muscles and the orbicu-
availability of the proximal facial nerve, whether the paralysis laris oris muscle. Seventeen of the paired muscles responsible for
is partial or complete, and availability of motor donors that can facial expression are derived from the mesenchyme of the second
be used for reinnervation. Procedures that attempt to restore branchial arch and are arranged in four layers. The muscles in the
neural input to a neuromuscular junction give the best results. three most superficial layers are innervated on their deep surfaces,
The choice of surgical procedures is based on the duration while the fourth layer muscles (mentalis, levator anguli oris, and
of the facial paralysis, the age of the patient, the cause of the buccinator) are innervated through their superficial surface.
lesion, and the compliance of the patient for a long-lasting and
complex rehabilitation program. Etiology of Facial Paralysis
Function can be restored by nerve repair or nerve graft-
ing of the facial nerve, or by using the contralateral healthy Facial paralysis is a sign or symptom of many disorders, the
facial nerve via cross-facial nerve grafts (CFNGs) as long differential diagnosis of which has been reviewed by May.2 The
as the time since onset of the palsy is short enough that the etiologies can be classified into three major categories: intracra-
paralyzed muscles can still be reinnervated (up to 6 months). nial, intratemporal, and extracranial, depending on the loca-
Longer denervation times (6 to 24 months) demand the use of tion of the facial nerve lesion. The intracranial causes include
a powerful ipsilateral “babysitter” motor donor (for example, vascular abnormalities, brain tumors (CPA tumors being the
partial hypoglossal) that will maintain the musculature, until
the CFNGs take over in 9 to 12 months.
For unilateral, irreversible, complete palsy, a three-stage
concept is described including CFNGs, free functional muscle
transplantation, and several ancillary/revisional procedures.
The role of local muscle transpositions, such as temporalis
muscle transfer, and the value of static procedures are also
presented.
Anatomy of the Facial Nerve

The facial nerve arises from the brain stem nuclei.1 The motor
fibers loop dorsally around the abducens nerve nucleus and
exit at the cerebellopontine angle (CPA). The parasympathetic
and sensory fibers form the nervus intermedius, which join the
motor component of the facial nerve as it exits the brain stem.
The course of the facial nerve is divided into six segments:
the cisternal segment in the CPA, the intracanalicular seg-
ment, the labyrinthine segment, the tympanic segment (sepa- Figure 36.1. Anatomy of the extratemporal facial nerve and the
rated by the anterior genu where the geniculate ganglion is corresponding facial musculature.
located), the mastoid segment (separated by the posterior
399
Figure 36.3. Two-year-old boy with Möbius syndrome. Möbius

syndrome is classically characterized by bilateral facial nerve and
abducens nerve paralysis leading to the typical mask-like face. In addi-
tion to the sixth and seventh cranial nerves, the fifth, ninth, tenth, and
Figure 36.2. Complete facial paralysis after extirpation of a brain twelfth cranial nerves may be involved.
tumor.
commonest) (Figure 36.2), developmental abnormalities or Bell demonstrated that the facial nerve innervates the mus-
agenesis of the facial nerve nuclei, trauma, and/or degenera- cles of facial expression and in 1829 described cases of facial
tive disease of the central nervous system. Intratemporally, the paralysis due to trauma. The second period, 1873 to 1960,
causes can be developmental, infectious (bacterial or viral), was the era of facial nerve repair. The focus of facial nerve
cholesteatoma, tumors of the middle ear or mastoid area surgery in the third period, 1908 to 1969, was decompression
(acoustic neuroma being the commonest), trauma involving of the facial nerve.
fractures of the temporal bone and skull base, or surgery in The fourth period, 1970 to 2000, has been characterized as
the region. Extratemporal causes include trauma, malignant the “bottleneck” period in honor of the contributions by Ugo
tumors of the parotid gland and skin, and iatrogenic. Fisch and other surgeons who sought ways to operate on the
Idiopathic (Bell’s) palsy is the most common cause of facial proximal intraosseous portion of the facial nerve. Scaramella
palsy, followed by trauma, infections, and tumors. Bell’s palsy and Smith independently introduced the concept of CFNG,
resolves in the majority of cases (85%), leaving occasionally while Anderl popularized its use. The concept brought about
some residual weakness in 10% to 15% of patients. new possibilities in restoration of facial expression. In 1976,
In the pediatric population, facial palsy present at birth Harii et al.4 transferred the first gracilis muscle to the face by
should be investigated thoroughly, as the early recognition of microneurovascular technique using the deep temporal nerve
developmental facial palsy will lead to appropriate treatment as the motor donor. O’Brien and Morrison5 recommended
and eliminate long-term sequelae. Congenital facial paralysis the combination of CFNG with microneurovascular muscle
refers to conditions that are acquired during or at birth (e.g., transfer, but their use of the extensor digitorum brevis mus-
from trauma or infection), while developmental facial paraly- cle lacked the bulk and power to yield an adequate smile. In
sis (DFP) is the result of anomalies of fetal development. DFP 1979, Terzis introduced the pectoralis minor transfer, which
can present in isolation or as part of a recognized syndrome, subsequently was followed by other authors.6
such as Möbius (Figure 36.3), Goldenhar, and CHARGE. In the fifth period, 2000 to the present day, further refine-
ments have been made with the introduction of new techniques.
Vascularized nerve grafts are indicated when unfavor-
Historical Review able perioperative factors inhibit regeneration (e.g., scarring
Paul of Aegina (626 to 696 AD) was the first to describe repair of recipient bed or radiotherapy). Direct muscle neurotization
of divided nerves, while Avicenna introduced epineurial coap- introduced at the beginning of the 19th century has received
tation in the 10th century. Facial nerve surgery developed as recent attention. The use of nerve transfers has also received
a result of research in nerve injuries during the 18th century. a following recently (such as the use of the masseteric nerve)
The history of facial nerve surgery can be viewed as five for “quick fix” reconstruction. Improvements in surgical out-
overlapping periods.3 In the first period (1829), Sir Charles comes are anticipated especially with microsurgical techniques.

Chapter 36: Facial Paralysis 401
The need for comparison of functional results among different A variety of topographic tests exist because of the complex
centers in a more standardized fashion is generally expressed. anatomy of the nerve in the CPA and petrosal bone and the
fact that the facial nerve is a mixed nerve with motor, sen-
sory, and secretory fibers. To detect the anatomical site of the
Aims of Reconstruction lesion, tests such as the Schirmer test, stapedius reflex, taste
The aim of reconstructive surgery is to restore symmetry and examination, and salivary flow test can be used to assess the
coordinated dynamic animation with normal appearance severity of nerve degeneration and its evolution over time.7
at repose, and symmetry during voluntary and involuntary Electroneurography provides an objective record of evoked
expression, competent ocular and oral sphincters, preserva- compound muscle action potentials and can quantify nerve
tion of existing facial function, and minimal loss of function in fiber degeneration. Other studies include needle electromy-
other donor motor nerves should be the goal. ography (EMG), nerve conduction, blink reflex, and nerve
excitability testing. In addition, the high spatial resolution of
multisliced spiral computed tomography and magnetic reso-
Preoperative Examination nance imaging has yielded a more coherent picture of facial
The history and physical examination are imperative for nerve disorders. The integrity and dimensions of the osseous
establishing a management plan. The physical examination facial canal can be delineated along with other central nervous
includes a complete cranial nerve examination and a careful lesions. This is particularly important in the differential diag-
evaluation of the facial musculature, parotid gland, and neck. nosis of neonatal facial palsy.
The optimal assessment of the neonate born with unilateral
facial paralysis is performed as soon after birth as possible,
with the goal to distinguish between a congenital and devel- Operative Techniques
opmental etiology. It is also important to identify dysmorphic
features and multisystem syndromal pathology. May in 19817
Direct Repair
provided a list of factors that can aid in differentiating the two When possible, primary neurorrhaphy is performed.
forms. The presence of other anomalies and/or bilateral facial Immediate reconstruction of sharp transections of the facial
Head and Neck

paralysis suggests developmental paralysis, while the absence nerve by primary, direct end-to-end coaptation produces the
of these signs and the presence of a history of prolonged labor, best results. However, this is only possible in a small percent-
forceps delivery, hematotympanum, or marks over the ear/ age of patients. Injuries resulting in long nerve gaps or presence
mastoid suggest birth trauma. following a significant delay requires alternative techniques,
DFP does not improve, whereas traumatic palsy often does. such as nerve grafts, nerve transfers, regional muscle transfers,
With recovery following trauma, there may be faulty regenera- free tissue transfers, or static procedures.
tion, yielding synkinesis, spasm, or mass action (Figure 36.4). Epineurial repair is the preferred method for monofas-
cicular nerve stumps, but when dealing with multiple neural
segments, perineurial repair is advocated in order to obtain
optimal alignment of the severed bundles.
Nerve Grafting
The most common way to overcome a wide neural gap is by
the use of autologous nerve grafts (mainly the sural nerve).
The average rate of nerve regeneration is 1 to 1.5 mm/d and
can be monitored by an advancing Tinel’s sign. Although
autologous nerve grafts produce good results, the disadvan-
tages include numbness at the donor site, leg scars, inadequate
size match of donor and recipient nerves, and nerve suture
sites. In addition, if executed in the intraosseous part of the
facial nerve, aberrant motor activities (synkinesis) in selected
mimetic muscle groups are frequent occurrences.
Cross-Facial Nerve Graft

Alternative methods of reconstruction of neural defects are
required in two occasions: when there is loss of the proximal
nerve stump and loss of the distal nerve stump and/or muscles
of facial expression.
When the proximal nerve stump is unavailable, the contra-
lateral unaffected facial nerve can be utilized to serve as donor
nerve, by borrowing axons from selected branches. These are
then connected with nerve grafts that cross the face to reach
the affected side, thereby providing motor axons from the
normal to the affected side. With this method, coordinated
facial motion can be achieved, with the fibers from the intact
facial nerve functioning as “pacemakers” for the affected side
(Figure 36.5). In a second stage, 9 to 12 months later, the axons
in the CFNGs are connected to branches of the affected facial
nerve or reach the facial muscle targets directly (direct neuroti-
zations) if the distal nerve stumps were unavailable. The latter
Figure 36.4. Posttraumatic synkinesis. Forty-three-year-old male
patient who presented with a 24-year history of left facial paralysis sec-
requires that the preoperative needle EMGs indicate that some
ondary to cranial bone fracture and subdural hematoma. Note synki- muscle fibers are still present (fibrillations or occasional poten-
nesis between the eye and oral sphincter and paresis of the commissure tials). If needle EMGs are totally silent, direct neurotization
and upper lip elevators along with paresis of the left depressor complex. cannot be performed and muscle substitution is recommended,
with the CFNG fibers innervating the new muscle unit.

Nerve Transfers
Requirements for nerve transfers8 include a) unavailability
of the proximal facial nerve stump, b) intact distal nerve, c)
viable facial muscles, and d) inability to use the contralateral
facial nerve as a motor donor (e.g., in Möbius syndrome). The
ideal time window is determined by the availability of facial
musculature. The major disadvantage is loss of function of
the donor cranial nerve unless end-to-side coaptation is used.
Extensive preoperative electrophysiological testing of all pos-
sible motor donors is necessary prior to nerve transfer surgery.
The Principle of “Babysitters”

Although the concept of CFNG is ingenious, it necessitates a
prolonged denervation period of the affected facial muscles
while regeneration and elongation of the contralateral axons
take place. This could lead to irreversible muscle atrophy,
Figure 36.5. Cross-facial nerve graft (CFNG) procedure. The unless the CFNG procedure is undertaken soon after the facial
number of grafts placed is determined by the number of contralat- nerve injury (within the first 6 months).
eral paretic muscle targets that will require surgical rehabilitation. For later cases (over 6 months to 2½ years), Terzis in
Note that the upper graft always carries motor facial nerve fibers that 1984 introduced the “babysitter” procedure.9 This is a two-
innervate the normal eye sphincter. Secondary coaptations 9 to 12 stage procedure (Figure 36.6): the first stage involves the use
months later of the distal end of the CFNG to similar branches on the of 40% of the ipsilateral hypoglossal nerve, which provides
affected side will allow synchronous, coordinated, and physiological powerful motor fibers to the affected facial nerve, reaching
eye closure and blink. In a similar fashion, the middle CFNG car-
rying “smile” fibers is destined for corresponding distal facial nerve
target connectivity quickly, and therefore preserving the facial
branches on the paretic side or is “banked” for future neurotization muscle bulk. At the same time, several CFNGs are placed,
of a free muscle for smile restoration. Finally, the lower graft is for which are connected to selected branches of the unaffected
depressor restoration. facial nerve. The second stage, usually 9 to 12 months later,
involves secondary microcoaptations between the CFNGs and
A B
Figure 36.6. Example of the “babysitter” procedure. A. Twenty-seven-year-old female 19 months after a closed head injury with skull frac-
tures and complete left facial paralysis. She had mini-hypoglossal to the left facial nerve transfer and placement of four cross-facial nerve grafts
(CFNGs) followed a year later by microcoaptations of the CFNGs to selected branches of the left facial nerve. B. Patient is shown 2 years after
completion of the two-stage “babysitter” procedure.

selected distal branches of the affected facial nerve. Variations Augmentation of Residual Function. Treatment of the
of the “babysitter procedure” have been reported,10 includ- patient with facial paresis, due to either a partial nerve injury
ing techniques such as end-to-side grafting11 and concomitant or suboptimal recovery after reconstruction, is a challenging
CFNG and hypoglossal facial grafting using a single sural problem. Direct muscle neurotization can be a useful proce-
nerve graft.12 dure for augmenting muscle contraction and promoting facial
expression.13
Direct Neurotizations
When there is no peripheral stump, direct neurotizations to
the muscle target13,14 can take place, provided that the period
Reanimation of The Upper,
elapsed is no more than 2 years and preoperative EMG yields Middle, and Lower Face
fibrillations. In direct muscle neurotization, the contralateral
facial nerve or other ipsilateral motor donors (such as part of Reanimation of the Eye
the hypoglossal or masseteric, or ipsilateral C7 root, or part of One area often neglected in the restoration of the chronically
the accessory nerve) can be used.15 paralyzed face is the eye. Lagophthalmos, or inability to close
the eyelids, is a significant functional deficit and exposure ker-
Muscle Transposition atitis and tearing are common sequelae. The primary aim is to
limit ocular exposure, protect the eye, restore eye closure and
In long-standing facial paralysis, introduction of a new muscle
blink, and improve appearance.18 Temporary measures such
is required. For older less demanding patients or those who
as eye protection with tapes or other occlusive measures dur-
are not candidates for lengthy surgery and prefer a one-stage
ing sleep, protective glasses, and routine eye lubrication may
procedure, a regional muscle such as the temporalis can be
be adequate for the recovery period. However, patients that
used.16
will not have return of function require more permanent solu-
The transferred muscles are innervated by cranial nerves other
tions. Static maneuvers include insertion of a gold weight or
than the facial nerve. Thus, coordinated movements are not
eye spring for patients with partial blink.19 The lower eyelid
produced and require the patient’s conscious efforts to activate
position can be improved with canthoplasty, tendon graft for
Head and Neck

the muscle. Extensive re-training and biofeedback in motivated
suspension,20 or lid shortening (wedge excision).
patients can lead to some degree of coordinated movement.
For restoration of a natural, reflexive blink, dynamic eyelid
reanimation is required. Primary repair of the injured upper
Free Muscle Transfer zygomatic branch of the facial nerve and direct neurotizations
These procedures are ideal for patients with long-standing via implantation of motor donor nerves via nerve graft in the
paralysis and pediatric patients with DFP. Free microneuro- orbicularis oculi muscle are both applicable when there are
vascular muscle transfers may include muscles such as the still viable muscle fibers in the eye sphincter (Figure 36.7).
gracilis,4 pectoralis minor,6 latissimus dorsi,17 serratus ante- For natural reflexive blink, if there is no orbicularis oculi
rior, split rectus abdominis, coracobrachialis, oblique internal muscle available, importation of a new neuromuscular unit
abdominis, and extensor digitorum brevis.5 However, many of either as a regional or as a free muscle transfer is appropri-
these have been aborted because of poor excursion or contrac- ate.18,21 The neurovascular muscle units that were introduced
tion such as the extensor digitorum brevis. by Terzis in the early 1980s for orbicularis oculi muscle substi-
The free muscles are neurotized usually with the contra- tution are the contralateral platysma and the frontalis muscle,
lateral facial nerve via CFNGs or from an ipsilateral motor which have shown promise in reestablishing a dynamic and
donor such as the hypoglossal or the masseteric nerve. In the reflexive blink,18 as long as the transferred muscles are neu-
latter case, the produced muscle contractions may be stronger, rotized by the contralateral facial nerve “eye” fibers (Figure
but in adults there is no possibility of coordinated animation 36.8). Mini-temporalis transposition can also be used for eye
with the normal side of the face, which necessitates intensive sphincter substitution but unfortunately does not restore syn-
muscle retraining by the patient. In contrast, use of CFNGs chronous blink.
produces harmonious, coordinated, and synchronous anima- While muscle and nerve transfers may be used to reanimate
tion with the normal side. the paralyzed face, static procedures, such as eyelid weighting
A B
Figure 36.7. Example of direct muscle neurotization (DMN) to the right eye sphincter. A. Four-year-old boy with right developmental facial paral-
ysis. Note inability to close right eye sphincter. Patient was treated with four cross-facial nerve grafts (CFNGs) and a free gracilis muscle for smile
(the left pectoralis minor was explored but was found not to be transferrable due to the absence of dominant vessels). B. The upper CFNG was used
for orbicularis oculi muscle direct neurotization. The patient’s eye closure is seen here 10 years after the DMN of the upper and lower eye sphincter.

A B
Figure 36.8. Contralateral pedicle frontalis transfer for restoration of eye closure and blink. A. Twenty-three-year-old male with left facial
paralysis and left hemifacial microsomia noted at birth. Note inability to close left eye. He was treated with cross-facial nerve grafts (CFNGs) ×
4, followed a year later by a pedicle transfer of the right frontalis to substitute for the atrophic left orbicularis oculi sphincter. The nerve to the
frontalis was neurotized by the first CFNG carrying “eye” motor fibers from the right facial nerve to achieve coordinated eye closure and blink.
B. Patient is shown 4 years after the pedicle frontalis transfer to the left eye sphincter.
and/or sling procedures, also enhance both functional and aes- alloplastic materials such as expanded polytetrafluoroethyl-
thetic results.19,20 The use of gold weights has been the stan- ene (Gore-Tex; WL Gore, Flagstaff, AZ),28 acellular dermal
dard technique to correct this problem.19 The palpebral eye matrix (AlloDerm; LifeCell, Branchburg, NJ), or a multi-
spring is an option for patients with a partial blink.19 vectored suture suspension technique that has been recently
reported as an alternative to the traditional fascial sling.
Reanimation of the Smile
Reanimation of Lip Depressors. Lower lip paralysis has
Use of Regional Muscles. Partial or total transfer of been traditionally managed with selective myectomy or neu-
the masseter muscle, originally described by Lexer, has been rectomy on the normal side. Similar effects on a temporary
described, but the direction of pull was suboptimal and the basis can be produced by botulinum toxin type A injection.
results were substandard. This can produce a lower lip with good symmetry, but which
The utilization of the temporalis muscle initially proposed becomes incontinent.
by Gillies is more popular for provision of static symmetry By contrast, dynamic restoration of the depressor com-
and dynamic voluntary motion. Segmental rather than full plex by neural manipulation and muscle substitution are
transfer is currently the preferred method of the majority of surgical interventions that have been used successfully by
surgeons. Although inferior to free muscle transfer, the advan- the senior author.29 Mini-hypoglossal nerve transfer to cer-
tages of a short procedure, early results, and low complication vicofacial division of the ipsilateral facial nerve or use of
rate make the temporalis transposition a favorable option in CFNGs can produce satisfactory results if remaining muscle
selected cases. Commitment to motor re-education is essential is present. Direct muscle neurotization can take place when
to achieve adequate outcomes.16 the distal nerve stumps are not available. In long-standing
facial palsy or unilateral lower lip developmental palsy,
Free Microneurovascular Muscle Transfer. These pro- regional muscles such as the anterior belly of the digastric
cedures involve one or two stages. The two-stage operation
or the lateral platysma muscle if available can be trans-
by CFNGs and later free microneurovascular muscle transfer
ferred as pedicled muscles with remarkable results (Figures
has been established as the gold standard of management for
36.12–36.15).29
the long-standing paralysis or DFP. The two most frequent
Finally, soft tissue rejuvenative techniques such as the
muscles used are the gracilis muscle (Figure 36.9)22 and the
superficial musculoaponeurotic system cervicofacial rhytidec-
pectoralis minor (Figures 36.10 and 36.11).6
tomy, blepharoplasty, browlift, and lower lid tightening can
One-Stage Free Tissue Transfers. Over the last two augment aesthetic restoration. Furthermore, nasal valve dys-
decades, a number of reports advocated one-stage free mus- function can be addressed with functional rhinoplasty, static
cle transfer for facial reanimation.23,24 These groups report slings, or dynamic reanimation procedures.
muscle recovery as early as 6 months after one-stage pro-
cedures and successfully treated children with hemifacial
microsomia.25 Harii et al.26 give two explanations for the
The Authors’ Approach
rapid muscle reinnervation. First, the retrograde blood flow Advances in microsurgery over the past 30 years have led to
from the muscle converts the supplying nerve into a vascu- greater expectations and allowed for the realization of a coor-
larized nerve and second, the single neurorrhaphy needed dinated dynamic panfacial reanimation.
for one-stage transfer versus the two coaptations required Our unit stresses panfacial reanimation and follows a mul-
in CFNGs. tistage approach for long-standing facial paralysis for reani-
Although long-term follow-up of one-stage transfers is war- mation of the paralyzed face, with CFNGs on the first stage,
ranted, this technique is gaining favor for its shorter recovery free muscle transfer on the second stage, followed by further
period. However, so far the published results have not been revisional stages.30 During the first stage, functional motor
comparable to the time-tested two-stage strategy. nerve fibers are introduced to the paralyzed side of the face for
For patients with long-standing palsy who are not can- direct neurotization or banking for future free muscle trans-
didates for multiple lengthy procedures, due to age, medi- fer. In unilateral facial palsy, a preauricular incision is made
cal comorbidities, or patient preference, static correction of on the uninvolved side, and the entire extratemporal facial
facial asymmetry has been attempted using fascial slings,27 nerve with its branches are identified with electrophysiologic

Head and Neck

A B
Figure 36.9. Free gracilis muscle to the right face for smile restoration. A. Thirty-six-year-old male with right facial paralysis since the age of
6 months following a febrile illness. Note absence of a right nasolabial fold. He was treated with cross-facial nerve graft (CFNG) × 3 followed a
year later with a free gracilis muscle to the right cheek for smile restoration. The obturator nerve was neurotized by CFNG #2 (the second CFNG)
which was carrying “smile” fibers from the left facial nerve. B. The patient is shown 2 years following the free muscle transfer with symmetrical
dental show and a coordinated smile.
mapping (Figure 36.1). Bilateral sural nerve grafts are har-

vested and tunneled across the face. The degree of the paralysis
determines the number of CFNGs placed. Microcoaptations
are accomplished between selected branches of the facial nerve
and the CFNGs. Axonal regeneration across the face is fol-
lowed by the advancing Tinel’s sign.
The “babysitter principle” introduced by Terzis in the early
1980s is a technique used to provide neuronal input to the
denervated muscles while the contralateral facial nerve fibers
are regenerating through CFNGs.
In the second stage, 6 to 9 months later, a similar incision
is used on the paralyzed side in order to expose the extra-
temporal branches of the paretic facial nerve and the distal
ends of the sural nerve grafts. Extensive microstimulation of
all branches takes place. Branches that respond powerfully
to stimulation are left alone, while branches with moderate
response are coapted to the previously placed CFNGs. In cases
Figure 36.10. Second stage of facial reanimation. Note how the right of free muscle transfer, the recipient vessels, usually facial
pectoralis minor fits on her left cheek. The length–width requirements are artery and vein, are also identified and isolated. Angiography
ideal for pediatric smile restoration; its four slips allow insetting in the lower may be helpful in evaluating the recipient facial vessels. The
lip, commissure, upper lip, alar base, and infraorbital rim. Furthermore, no muscle flap is harvested at the same time by a second team
debulking is necessary and the muscle grows in harmony with the facial and sculptured (in the case of gracilis) accordingly prior to
skeleton of the child. The dual nerve supply allows reinnervation by two transfer.
separate cross-facial nerve grafts, thus increasing the possibilities of facial
expressivity. Note the typical preauricular incision, through which the req-
The senior author favors the use of gracilis in adults, due
uisite “pocket” is formed to receive the free muscle. Finally, the muscle to its reliable vascular supply, ease of harvesting, and the abil-
will be inserted under its original tension. This was facilitated by placing ity to sculpture the muscle unit in situ, prior to transfer. In
sutures at measured distances on the muscle surface prior to transfer. children, her preferred option is the pectoralis minor mus-
cle, because of excellent length–width characteristics, dual

A B
Figure 36.11. Right free pectoralis minor muscle for smile restoration. A. Five-year-old girl presented with left developmental facial paralysis.
She was treated with two cross-facial nerve grafts and a year later, the right pectoralis minor was transferred to the left cheek for smile r estoration.
B. The patient is shown 3 years after the free muscle transfer with a symmetrical coordinated smile. No rehabilitation was necessary due to great
cortical plasticity.
innervation, and no need for debulking in this age group. The tension in situ. The origin is anchored to the superior portion
insetting of the free muscle is guided by preoperative videos of the zygomatic arch and on occasion to the deep temporal
and photographs, and the tension of the individual slips to fascia.
the lower lip, commissure, upper lips, nasolabial fold, lateral Microvascular anastomoses are accomplished with the
ala, and infraorbital area is adjusted to reproduce pretransfer facial vessels while microneural repairs are carried out very
A B
Figure 36.12. Mini-hypoglossal transfer to right cervicofacial branch of the facial nerve for depressor complex augmentation. A. Twenty-
seven-year-old male presented with a right partial facial paralysis that occurred 20 months earlier. He was treated with cross-facial nerve grafts
× 3 and mini-hypoglossal transfer to the right cervicofacial branch of the affected facial nerve. B. The patient is shown 3 years after the nerve
transfer procedure.

A B
Figure 36.13. Direct muscle neurotization for depressor restoration. A. Nine-year-old girl with left developmental facial paralysis. She was
treated with cross-facial nerve grafts (CFNGs) × 3, free muscle for smile restoration, and direct neurotization of the depressor complex with the
lower graft (CFNG #3) carrying motor fibers that innervated the depressor complex on the unaffected side. B. Patient is shown 3 years later. Note
restoration of dynamic and symmetrical depression.
close to the muscle entry zone, with the CFNG carrying smile If the accessory nerve is not involved, reinnervation can be
fibers from the contralateral VII. achieved with nerve grafts using an end-to-side coaptation. In
Head and Neck

rare cases with multicranial nerve involvement, the ipsilateral
C7 root of the brachial plexus can be used.15 The use of ipsi-
Möbius Syndrome lateral C7 as motor donor allows the neurotization of multiple
A patient with classic Möbius syndrome has a mask-like face targets and also provides motor fibers for future free muscle
that is immobile because of bilateral facial and abducens transfers.
nerve paralysis (Figure 36.3). Because of the variety of cranial Muscles used for facial reanimation are the gracilis and
nerves involved, a standard procedure for dynamic restora- the pectoralis minor. However, because there is an associa-
tion cannot and should not be promoted; instead, a careful tion of absence of the pectoralis minor if Poland syndrome
preoperative objective and quantitative assessment should is present, alternative targets should be identified. The graci-
guide the reconstructive surgeon to the optimal reconstruc- lis muscle is a safe source for muscle transplantation but it
tive strategy. needs to be sculpted to adjust to the hollow cheeks of the
In general, a multistaged approach to reconstruction is fol- Möbius patient.
lowed. If the contralateral facial nerve is minimally involved, It is our opinion that the reconstructive surgeon should be
it is preferred as a motor donor nerve even if it is not com- comfortable with the full armamentarium of facial reanima-
pletely normal. In contrast to other authors, the hypoglossal tion procedures before embarking on the surgical treatment of
nerve is never used as a motor donor because speech and swal- the Möbius patient.
lowing are severely impaired in the vast majority of Möbius
patients. The fifth cranial nerve, mostly the masseter branch,
is a tempting source because free muscle transplants can be
Conclusion
connected directly. Further, it is a good idea to coapt the obtu- Treatment of facial nerve lesions requires a detailed under-
rator nerve to the masseter nerve in an end-to-side fashion, standing of anatomy, accurate clinical examination, and
thus avoiding paralysis of this important masticator muscle. timely and appropriate diagnostic studies. Reconstruction
A B
Figure 36.14. Pedicled digastric transfer for depressor restoration. A. Sixteen-year-old girl who developed left facial paralysis at the age of 10
years, of unknown etiology. Note complete paralysis of left depressor. She was treated with cross-facial nerve grafts (CFNGs) × 3 and the pedicle
digastric transferred for left depressor substitution. The lower CFNG, carrying fibers from the contralateral marginal mandibular nerve, was used
to neurotize the anterior digastric muscle for coordinated lower lip depression. B. Post-op function.

A B
Figure 36.15. Pedicle platysma transfer for depressor restoration. A. Seventeen-year-old girl with a 9-year history of left facial paralysis
secondary to revision of stapedectomy surgery, during which there was a transection of the facial nerve. This was repaired a few weeks later
by end-to-end coaptation, leading to paresis of the levators, the left depressor, and synkinesis. She was treated with cross-facial nerve grafts × 2
and a year later a transfer of the right pectoralis minor for smile restoration. During the revisional stage of her facial reanimation, the left lateral
platysma was transferred to the left lower lip for depressor restoration. B. Patient is shown a year after the pedicle transfer of the left platysma
demonstrating synchronous, coordinated, and symmetrical depression.
depends upon the extent of injury, the availability of the prox- 9. Terzis JK, Tzafetta K. The “babysitter” procedure: minihypoglossal to
facial nerve transfer and cross-facial nerve grafting. Plast Reconstr Surg.
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stage or one-stage dynamic reconstruction followed by facial paralysis. J Plast Reconstr Aesthet Surg. 2011;64:174-184.
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tion. Plast Reconstr Surg. 2000;105:1289-1297. muscle outcomes for smile. Plast Reconstr Surg. 2008;122:1723-1732.
20. Levine RE, Shapiro JP. Reanimation of the paralyzed eyelid with the 45. Terzis JK, Olivares FS. Secondary surgery in paediatric facial paralysis rean-
enhanced palpebral spring or the gold weight: modern replacements for tar- imation. J Plast Reconstr Aesthet Surg. 2010;63:1794-1806.
sorrhaphy. Facial Plast Surg. 2000;16:325-336. 46. Wang W, Zuoliang Q, Xiaoxi L, et al. Free split and segmental latissimus
21. Lexer E, Eden R. Uber die chirurgische behandlung der peripheren facialis- dorsi muscle transfer in one stage for facial reanimation. Plast Reconstr
liihmung. Beitr Klin Chir. 1911;73:116. Surg. 1999;103:473-480.
22. Lifchez SD, Matloub HS, Gosain AK. Cortical adaptation to restoration of 47. Wang W, Qi Z, Lin X, et al. Neurovascular musculus obliquus internus
smiling after free muscle transfer innervated by the nerve to the masseter. abdominis flap free transfer for facial reanimation in a single stage. Plast
Plast Reconstr Surg. 2005;115:1472-1479. Reconstr Surg. 2002;110:1430-1440.
23. Manktelow RT, Zuker RM. Cross-facial nerve graft—the long and short 48. Whitney TM, Buncke HJ, Alpert BS, et al. The serratus anterior free-
graft: the first stage for microneurovascular muscle transfer. Oper Tech muscle flap: experience with 100 consecutive cases. Plast Reconstr Surg.
Plast Reconstr Surg. 1999;6:174-179. 1990;86:481-490; discussion 491.

Chapter 37 n Mandible Reconstruction
Joseph J. Disa and Evan Matros
The mandible contributes to airway stability, is important in importantly, a significant portion of flap volume is used just to
speech, deglutition, and mastication, and largely determines reach the recipient site. The distal portion of the flap, which is
the shape of the lower face. Consequently, functional and aes- used for the actual reconstruction, often has a marginal blood
thetic goals are equally important considerations in mandible supply and is at risk for ischemic necrosis. Perhaps the great-
reconstruction. Specific functional goals include preservation est limitation of these flaps is that they do not provide enough
of temporomandibular joint function with maximal opening tissue in the proper configuration to be useful. The bone avail-
ability and maintenance of occlusion. In more severe cases in able with the pectoralis major muscle (rib) and the trapezius
which many teeth are missing, restoration of normal interarch (spine of the scapula) is limited compared with free-flap alter-
distance and alignment is critical for the facilitation of subse- natives. In addition, the osseous components of these flaps
quent dental rehabilitation. Key aesthetic goals include sym- have poor blood supply, derived only from the periosteum,
metry, preservation of lower facial height and anterior chin resulting in high rates of non-union and limiting the surgeon’s
projection, and correction of submandibular soft-tissue neck ability to perform shaping osteotomies. Although the pecto-
defects. ralis has been used to reconstruct the anterior mandible and
The vast majority of segmental mandible defects are the trapezius to reconstruct the lateral mandible, these flaps
caused by cancer. Squamous cell (epidermoid) carcinoma is are generally not recommended as primary methods of
the etiology in the majority of cases with the mandible com- mandible reconstruction.
monly invaded by adjacent tongue or floor of mouth tumors. Prosthetic mandible replacement has evolved as an alterna-
Osteogenic sarcoma is the second most common cause of tive method of reconstruction that still has legitimate, but lim-
segmental mandibular defects resulting from cancer resection ited, application. Mesh trays made of Dacron or metal were
and the most common primary bone tumor. Mucoepidermoid introduced in the 1970s as scaffolds that were filled with bone
carcinoma, adenoid cystic carcinoma, leiomyosarcoma, and graft chips and used for segmental bone defects. Long-term
fibrous histiocytoma are examples of other tumors. A small follow-up has shown this method to be ineffective. Problems
number of segmental mandibular defects result from exten- with extrusion and bone graft dissolution commonly occurred.
sive benign cystic or fibrotic bone disease. Gunshot wounds Metal reconstruction plates developed as a result of orthope-
are the most common traumatic cause, but their number is dic hardware advances in other areas. These plates are avail-
small compared with tumors. Segmental loss because of able today in a variety of lengths and styles.
infection is rare, but can occur after complications of man- Metal reconstruction plates offer advantages of decreased
dible fractures. operating time and avoidance of a bone graft donor site.
Mandible defects requiring reconstruction are sometimes They have important disadvantages: risk of exposure or
caused by bone loss alone (e.g., osteoradionecrosis). However, infection; risk of plate fracture; preclusion of dental recon-
the majority of defects usually include adjacent intraoral soft struction; and a thin shape that does not provide adequate
tissue as well as submandibular soft tissue. Some bone defects bulk for reconstruction. These disadvantages are par-
include external skin loss instead of mucosa, and the most ticularly problematic in the setting of radiation therapy.
complex include bone, mucosa, and skin. Another important drawback is the functional limitation
Two classification schemes have been proposed for mandi- seen with the use of metal plates for hemimandible defects
ble defects. The most practical describes bone loss in terms of that include the condyle. The prosthetic condyle is a poor
central segments (designated C and defined as lying between substitute for the native structure. The long-term effects of
the two canine teeth), lateral segments (L), and hemimandible a metal condyle in the native glenoid fossa are unknown,
segments (H).1 Hemimandible and lateral segments are similar and occlusion is often poorly maintained with a metal plate
except that the former includes the condyle, whereas lateral that includes a condyle. As a result of these disadvantages,
segments do not. A defect commonly is a combination of more the first choice for reconstruction of segmental mandibu-
than one segment, for example, LC, HC, or LCL. Although lar defects is with vascularized bone flaps. However, pros-
this description may appear tedious, it is actually useful as a thetic reconstruction may be useful in scenarios when bone
common language to standardize the variable reconstructive reconstruction is not possible such as extensive oncologic
problems posed by these entities (Figure 37.1). resection, absence of suitable bone flaps, or presence of sig-
Mandible reconstruction can be accomplished by a variety nificant medical comorbidities.
of means, including nonvascularized bone grafts, metal plates, When reconstruction of segmental mandibular defects is
pedicled flaps, and free flaps. Nonvascularized grafts, such performed with reconstruction plates, adequate soft-tissue
as an iliac crest segment, can be used for a short bone gap coverage is critical to prevent plate extrusion. The pectoralis
(<3 cm) in a setting of benign disease. This is a rare appli- major myocutaneous flap is commonly used for this purpose;
cation. Although conceptually and technically simple, this however, plate exposure still occurs, particularly with anterior
method relies on creeping substitution for long-term mandible reconstructions in which the tension on the flap is greatest.
stability. One in three plate reconstructions fails when a pedicled flap is
Pedicled flaps include the trapezius and pectoralis osteo- used for coverage.
myocutaneous flaps. The primary attraction of these donor The most reliable soft-tissue coverage for a reconstruction
sites is that they lie adjacent to the head, thus permitting their plate is provided by a free flap, which provides abundant tis-
movement into this area without disconnecting their blood sue and can be inset without tension. The vertical rectus flap,
supply. Although this is an attractive concept, there are sev- forearm flap, or the anterior lateral thigh (ALT) flaps are com-
eral important drawbacks. First, use of these flaps enlarges monly used for this purpose and flap selection is guided by
the size of the primary wound considerably compared with the volume of soft tissues required for reconstruction. The
harvesting tissue from a distant donor site. This increases the sole advantage of this approach (reconstruction plate plus
potential for morbidity at the site of the reconstruction. More forearm flap) is that it is somewhat quicker to perform than
410
Chapter 37: Mandible Reconstruction 411
Free-Flap Donor-Site Selection

Since early in the development of free-flap mandible recon-
struction, there have been multiple donor sites from which to
choose. Rib, metatarsal, and ilium were among the first flaps
developed.4 The ilium had been the most popular of the three
owing to its abundant bone, which even resembles a hemi-
mandible when harvested in a particular way and was the
workhorse for the first decade of free-flap mandible recon-
struction. Further evolution has led to the development of
the radius, scapula, and fibula donor sites.5 These additional
options have increased the flexibility and precision of the tech-
nique as the specific assets and limitations of each donor site
have become clear.
A review of 155 free-flap mandible reconstructions at
Memorial Sloan-Kettering Cancer Center has shown that the
fibula is currently the donor site of choice for most patients
(Table 37.1).6 The radius, the scapula, and the ilium (to a
diminishing extent) are better choices in a few specific set-
tings. Each has unique advantages and disadvantages. A com-
A parison of the donor sites is helpful in selecting the proper flap
for a particular problem (Table 37.2). Some have better bone
qualities, some have better skin, and some have significant dis-
advantages that make them seldom the flap of choice despite
their good qualities (Figure 37.2).
Head and Neck

Ilium
The ilium has abundant bone but has a predetermined shape
that makes flap shaping inherently less precise than other
donor-site options. It may be useful in some hemimandible
reconstructions because its shape most closely resembles this
portion of the mandible. The ilium is said to have a segmental
blood supply from the deep circumflex iliac artery, although
this is debatable on a practical level. This type of vascular
anatomy is preferred because it allows segmental osteotomies
with survival of each portion of the flap. Long ilium flaps,
however, tend to have less robust, even marginal, circulation
at the distal end of a multiply osteotomized flap.
The skin island available with the ilium does not have a reli-
able circulation in many patients. In addition, the soft-tissue
B
component of the flap is often bulky and lacks mobility with
FIGURE 37.1. Examples of mandibular defects. A. A typical lateral respect to the bone. This makes insetting difficult and limits use-
defect of the L type. Note how the intermaxillary fixation maintains fulness of the soft-tissue component of the flap. Some authors
occlusion for flap insetting. B. An LCL anterior defect showing the
mobile lateral mandibular segments, submental soft-tissue defect, and
propose including a portion of the internal oblique muscle with
the lack of reference points to guide accurate flap insetting. the flap as an alternative source of soft tissue. The muscle is
covered with a skin graft when used inside the oral cavity.
Closure of the ilium donor site is arduous and there is a
possibility of hernia formation or late attenuation of the lat-
an osteocutaneous free flap. The disadvantage is that it com- eral abdominal wall. This donor site is painful and limits early
bines the worst features of its two component parts: the risks mobilization of the patient. Splitting the ilium and leaving its
of infection and exposure from a foreign body and the risk outer rim intact is proposed as a means of facilitating the clo-
of free-flap failure. The combination of a soft-tissue free flap sure process, but this makes flap harvest more tedious.
and a reconstruction plate is probably best reserved for lateral
defects in those patients who are poor candidates for an osteo-
cutaneous free flap. Elderly patients with multiple medical TABLE 3 7 . 1
comorbidities may benefit from a shorter operative procedure Free-Flap Donor-Site Selection In Mandible
and are more likely to accept the permanent dentition defect Reconstruction a
than are young patients.2
Osteocutaneous free-flap reconstruction is often the n Donor Site n Number (%)
most effective method of mandible repair. These flaps
have both soft tissue and bone components, which are Fibula 120 (77.4)
available in an optimal configuration for solving specific Radius 17 (11.0)
composite tissue problems. This technique is ultimately
dependent on the integrity of the microvascular anasto- Scapula 8 (5.2)
moses for success. Fortunately, the favored donor sites all Rectus 5 (3.2)
have excellent flap pedicle qualities (vessel diameter and
Ilium 3 (1.9)
length), and the head and neck area generally has excel-
lent recipient vessels available, despite previous surgi- Other 2 (1.3)
cal treatment and radiation. Free-flap survival rates are Used in 155 consecutive cases at Memorial Sloan-Kettering Cancer Center.
a
approximately 95%.3

TABLE 3 7 . 2
Free-Flap Donor-Site Comparison For Mandible Reconstruction a
Tissue Characteristics Donor-Site Characteristics

n Donor Site n Bone n Skin n Pedicle n Location n Morbidity
Fibula A C B A A
Ilium B D D B C
Scapula C B C D B
Radius D A A C D
a
Ranked in each category from best (A) to worst (D).
Source: Hidalgo DA, Rekow A. A review of 60 consecutive fibula free flap mandible reconstructions. Plast Resconstr Surg.
1995;96:585.
Today, the indications for use of the ilium are limited.

Perhaps the best indication is a short lateral or hemimandi-
ble segment not requiring mucosal lining replacement.
The problems with the ilium described above often make
other donor sites preferable, even for this type of defect
(Figure 37.3).
Radius
The radius has the best quality skin island compared with
other donor-site alternatives. It is thin, pliable, and abundant.
A
The vascular pedicle is also ideal, with long, large-diameter
vessels capable of reaching the opposite side of the neck for
difficult recipient vessel problems. The bone, in contrast, is
the worst compared with other choices. The radius must be
carefully split during harvest to prevent postoperative fracture
B at the donor site, and some authors have advocated primary
bone grafting and plating of the radius donor site to decrease
the incidence of this complication. Length is generally limited
to a segment located between the insertion of the pronator
teres and the brachioradialis muscles (approximately 10 cm),
although some authors describe taking longer pieces. The
bone thickness is marginal for later placement of osseointe-
grated implants for dental rehabilitation.
There is insufficient soft tissue available with this flap to
provide the necessary bulk to fill submandibular neck defects.
The donor-site appearance is often poor postoperatively
owing to a need for skin graft closure and the additional prox-
C imal forearm scar necessary for obtaining adequate pedicle
length (Figure 37.4).
The best indication for a radius free flap is a bone defect
that is limited to the ramus and the proximal body with a
large associated intraoral soft-tissue defect. The split radius is
adequate to restore mandibular continuity. Dental rehabilita-
tion is usually superfluous posteriorly, and so the thin nature
of the bone is not a factor. The cheek soft tissues are thick
and maintain facial contour despite this flap’s inherent lack of
bulk. The skin island is ideal for resurfacing a large posterior
mucosal defect. Reconstruction of most anterior defects is a
relative contraindication to the use of the radius flap because
adequate soft tissue and bone volume are essential in this area
for the best functional and aesthetic reconstruction.
Scapula
The scapula offers the greatest amount of soft tissue compared
D with other donor sites. It is possible to include a skin island as
long as 30 cm and to include the entire latissimus dorsi muscle
if needed. The skin island is somewhat thick compared with
FIGURE 37.2. Free-flap donor sites for mandible reconstruction.
the forearm donor site. A useful feature of this flap is that the
A. Scapula. B. Ilium. C. Radius. D. Fibula. Note the relative amounts bone and the soft-tissue components (skin and latissimus dorsi
of skin, the relationship of the pedicle to the bone, and the bone muscle) are independent of each other except for a common
configurations available. vascular pedicle. Up to 14 cm of bone is available from the lat-
eral scapula. The bone does not have a segmental blood supply;

Head and Neck

C
FIGURE 37.3. A. Design of osteocutaneous iliac

crest flap. Note the design of the lateral mandible
reconstruction and position of the skin island.
B. Panorex of iliac crest in place. C. Postoperative
appearance.
B
therefore, multiple osteotomies can be hazardous to the viabil- The best indication for a scapula free flap in mandible
ity of portions of the flap. The blood supply of the proximal reconstruction is a bone gap associated with a large soft-
scapular segment is derived from branches of the circumflex tissue defect. This applies most to patients who require simul-
scapular artery, while the distal most portion is supplied by taneous intraoral and external soft-tissue replacement. The
branches arising from the thoracodorsal vessels. The primary priority in these cases of advanced local disease is to achieve
disadvantage of this flap is its donor-site location, requir- uncomplicated primary wound healing. The precision of the
ing delay in flap harvest until after the resection. The patient bony reconstruction is often a secondary concern. The result
typically has to be repositioned several times throughout the is compromised whenever a skin island is placed externally
operation. Shoulder function is sometimes compromised fol- on the face owing to color mismatch and partial facial nerve
lowing scapula flap harvest. Patients can exhibit weakness and paralysis associated with the defect. Although rarely indicated,
decreased range of shoulder motion (Figure 37.5). In addition, a combined scapula and latissimus dorsi flap is useful for large
the pedicle length is somewhat short (6 to 8 cm), precluding defects, including those resulting from a radical neck dissec-
access to the contralateral neck vessels. tion. The latissimus dorsi restores neck contour and protects
FIGURE 37.4. Radial forearm osteocutaneous flap (A and B).

A. Design of an osteocutaneous forearm flap. B. Note the limited
diameter of bone relative to available skin.
B

C D
FIGURE 37.5. Resection and reconstruction using a scapula osteocutaneous flap (A and B). A. Planned resection of cheek and mandible.
B. Full-thickness defect, including skin, mandible, mucosa, and associated soft tissues. C. Osteocutaneous scapula flap. D. Postoperative appearance.
the exposed vessels. This can actually produce an elegant is reliable in approximately 91% of patients. It is thicker
result, but constitutes a massive effort when performed in con- than the forearm skin, but thinner than the scapula skin. A
junction with a mandible reconstruction. The scapula flap is large skin paddle can be harvested for complex defects, but
also a reasonable choice for straight lateral segments when the the donor site will require skin graft closure. Of all poten-
fibula flap is not available. tial donor sites, the fibula is the most convenient because it is
located farthest from the head and neck area.
The main disadvantage is the unreliability of the skin
Fibula blood supply in 9% of cases,5 although the incidence of this
The fibula donor site has many advantages.5 The bone is avail- complication has been debated. There are no reliable pre-
able with enough length to reconstruct any mandible defect. operative tests to identify the patients who are at risk for
The straight quality of the bone with adequate height and an inadequate skin blood supply. Despite this problem, it
thickness constitutes the ideal bone stock for precisely shap- is uncommon to be faced with a need for skin and to have
ing a mandible flap. Unlike the ilium, there are no nuances of none available. The forearm or anterolateral thigh flaps can
shape that limit the flap contouring process. Also unlike other be used as a second free flap, should the need for extra skin
donor sites, the periosteal blood supply is functionally of a unexpectedly arise, combining the best features of both flaps.
segmental type. Osteotomies can be planned wherever neces- This practice is actually preferable to using a single flap, such
sary and can be placed as close as 1 cm apart without concern as the scapula, in which neither the bone nor the skin is in the
for bone viability. The vascular pedicle has sufficient length ideal configuration.
and is of large diameter. The flexor hallucis longus muscle The fibula is indicated for all anterior defects and most lat-
located along the posterior border of the bone is ideal for fill- eral defects. It is the flap of choice for the majority of mandible
ing adjacent soft-tissue defects in the submandibular portion defects except for a few special situations in which the radius
of the upper neck. The skin island available with the fibula or scapula may constitute a better choice.6 It is particularly

well suited to anterior defects because the skin island can be or advanced disease and in those lacking suitable bone donor
used to reconstruct the floor of the mouth. The flexor hallu- sites. Regardless of the reconstructive scenario, primary heal-
cis longus muscle is perfectly situated to fill in the dead space ing of the incisions is a priority in the head and neck cancer
within the anterior arch of the mandible and restore upper patients, many of whom need to receive adjuvant therapy.
neck contour. Although like tissue is not being replaced with like, retrospec-
tive series demonstrate equivalent aesthetic and functional
Soft-Tissue Flaps outcomes of soft-tissue flaps compared with osseous flaps,
with the exception of an inability to place osseointegrated
Depending upon the defect location, soft-tissue flaps serve one
dental implants.7,8
of two purposes in mandible reconstruction. They can be used
A reconstructive algorithm for the mandible using osseous
either as an adjunct to an osteocutaneous flap with insuffi-
and/or soft-tissue flaps is presented in Figure 37.6.
cient skin or in lieu of osseous reconstruction altogether.
For anterior mandible defects, osseous flaps are mandatory
to provide sufficient rigidity to prevent the Andy Gump defor-
mity, with airway collapse, drooling, and facial distortion. A
simultaneous soft-tissue flap may be indicated when the fib- The most serious postoperative problems in patients under-
ula skin island is inadequate to close an anterior intraoral or going mandible reconstruction are cardiopulmonary.
external soft-tissue defect. The most commonly reported soft- Pneumonia, arrhythmias, and myocardial infarction are life
tissue flap used in combination with the fibula is the radial threatening problems for which this patient population is at
forearm flap, but the anterolateral thigh, rectus abdominis, risk due to prior smoking. As a result, the patient’s medical
and pectoralis major flaps can be used as well. history should be reviewed and medical clearance obtained for
On the contrary, for lateral defects, soft-tissue flaps alone preoperative optimization and assessment of surgical risk.
are useful in specific reconstructive scenarios. These flaps reli- Preoperative consultation with the dental service is valu-
ably fill the dead space, ensure a watertight closure, and pre- able in the management of mandible reconstruction patients.
vent tethering of intraoral structures. The remaining native Intermaxillary fixation, intraoperative tooth extraction, cus-
mandible provides functional support and maintains facial tom fabrication of various splints, and other ancillary pro-
Head and Neck

proportions. For example, defects involving both the lateral cedures are best performed with forethought and the help of
mandible and extensive intraoral soft tissues located in dif- interested colleagues. This also sets the stage for the patient’s
ficult locations such as the retromolar trigone, palate, and postoperative dental rehabilitation with either conventional
oropharynx are more easily closed with a soft-tissue flap. dentures or osseointegrated implant technology.
Furthermore, large composite defects can be closed with a Two specific preoperative studies contribute to improved
single-folded double-island soft-tissue flap such as an ALT aesthetic results.9 A 1:1 computed tomography (CT) or mag-
or vertical rectus abdominis myocutaneous, rather than with netic resonance imaging scan of the mandible taken in the
the fibula flap skin island that has limited size and rotational transverse plane at a level just below the tooth roots is the
degrees of freedom around the intermuscular septum. Soft- basis for fabrication of a template showing the full-size shape
tissue free-flap reconstructions are also useful in cases where of the mandible. A lateral cephalogram will allow fabrica-
the temporomandibular joint has been resected, creating a tion of a second template showing the shape of the mandi-
large defect in the posterior skull base. This approach may ble in the sagittal plane. These images can be transferred to
also be adopted in patients who are suboptimal candidates for acrylic plastic or used directly as radiographic film cut-outs to
two-flap surgery, such as those with significant comorbidities assist in the flap-shaping process. Together with the surgical
Bone defect location Soft-tissue Flap

deficit
Small Radius
Fibula or (ramus
defect)
Large/composite
Soft Soft
Fibula or Fibula or
tissue tissue
Hemimandible/lateral
Small
Fibula
Large/composite
Fibula or Fibula Soft or Scapula
tissue
Anterior
FIGURE 37.6. Reconstructive algorithm for mandibular defects. Depending upon bony defect location and quantity of soft-tissue resection, an
osseous flap, soft-tissue flap, or a combination of both can be used to reconstruct the mandible.

Reconstructive surgeons should also be aware of the rare vas-

cular anomaly of a dominant peroneal artery (peroneal arteria
magna), in which harvest of the fibula flap could lead to leg
ischemia. The precise incidence of this congenital variation is
not well established.
Surgical Technique
With rare exception, all patients should have a tracheostomy
A B for safety. It is often possible to begin donor-site dissection at
FIGURE 37.7. Preoperative planning (A and B). Templates are fash- the same time as the ablative portion of the procedure. If there
ioned from tracings of a lateral cephalogram (left) and a 1:1 scale is significant doubt as to the extent of the disease, it is better
axial plane CT scan of the mandible (right). These templates serve as to wait until the situation is clarified before beginning.
valuable references during flap shaping. Flap shaping can be performed while ablation is in prog-
ress with the aid of the templates described previously. The
surgical specimen is also a valuable visual aid. Measurements
of total graft length can be obtained, as well as measurements
specimen as a reference, this permits the bone to be completely to identify where osteotomies are best made to duplicate
shaped at the donor site, while the vascular pedicle remains mandible shape.9 Subtle nuances in shape can be appreciated
intact (Figure 37.7) and contributes to improved accuracy in by direct examination of the specimen. Typical locations or
reconstruction. fibula osteotomies include the parasymphyseal, midbody, and
Technology from other fields is finding new applications mandibular angle regions.
in mandible reconstruction with goals of improving accuracy, Bony fixation can be accomplished with the use of mini-
precision, and efficiency.10 Through the use of computer- plate fixation.12 This method is efficient, safe, and strong.
aided design and manufacturing (CAD–CAM), reconstruc- Preformed reconstruction plates have been preferred by oth-
tive and ablative surgeons can perform virtual operations ers, but this method does not allow subtle nuances of man-
in advance of the actual surgery with the assistance of engi- dible shape to show when a bulky plate is applied to the
neers. The first step is osteotomy design, including those outer surface of the flap. When hardware requires removal to
made by the ablative team, based on high-resolution three- facilitate osseointegrated dental implants, the mini-plate tech-
dimensional CT images of the native mandible (Figure 37.8). nique limits the exposure necessary by allowing for removal
Next, virtual osteotomies that optimize bone apposition are of only the hardware in the region of the implants. Other
planned using CT images of the patient’s fibula to recon- methods, such as interosseous wires, do not provide enough
struct the contour of the excised mandible. Using computer- resistance to torsional stress in a multiply osteotomized bone
aided manufacturing, cutting jigs for the native mandible flap. Intermaxillary fixation is used only as an adjunctive form
and fibula, and a contoured reconstruction plate are gener- of fixation. Its primary role is to maintain occlusion during
ated for the operating field. Intraoperatively, the cutting jig the insetting of lateral flaps (Figure 37.1A). External fixators,
is shifted along the fibula to optimize skin island position previously popular for stabilizing the lateral segments when
and pedicle length. Closing wedge osteotomies are made reconstruction is deferred, are rarely indicated in mandible
through cutting slots without additional measurement. The reconstruction.
remainder of the operation proceeds in a standard fashion. Lateral defects differ from anterior defects in terms of the
Advantages of such technology are evident in cases where approach to shaping the flap. In the case of the fibula, ilium,
tumor distortion of the mandible precludes accurate speci- and scapula, the angle of the mandible is generally planned
men measurement or for reconstruction of anterior defects where the vascular pedicle enters the bone (Figure 37.9). This
where anatomic orientation of ramus fragments cannot be provides maximum pedicle length to reach the recipient ves-
reliably maintained. sels in the neck. This is where the first osteotomy is made in
Routine use of preoperative imaging is not necessary for the bone, with the second osteotomy made to form the curve
the fibula donor site in the majority of patients. The main indi- in the midbody. The ramus height is determined by measure-
cations for preoperative imaging are signs and symptoms of ments taken from the specimen. The condyle can often be har-
peripheral vascular disease or an abnormal pedal pulse exami- vested from the surgical specimen and then mounted directly
nation. Improvements in noninvasive imaging techniques, onto the flap. Frozen-section examination of bone scrapings
such as CT angiography or magnetic resonance angiography, are performed to rule out tumor in the condyle. It must not
have obviated the need for angiograms. Furthermore, because be used if doubt exists. This method is better than the alterna-
fibula reconstruction has been successfully performed even tive of transecting the ramus high and leaving the condyle in
with overt peroneal artery atherosclerotic disease, its pres- situ. It is difficult to fix the fibula flap to the condyle in this
ence does not necessarily rule out the use of this donor site.11 situation.13
FIGURE 37.8. Application of computer-aided design and manufacturing in mandible reconstruction. Virtual osteotomies of the native mandible
are planned by the ablative surgeon on high-resolution three-dimensional CT images (left). Virtual osteotomies of the patient’s fibula are planned
to reconstruct missing portions of the mandible (center). Cutting jigs for the native mandible and fibula are generated using computer-aided
manufacturing. Closing wedge fibula osteotomies are made intraoperatively without further measurement. Proximal and distal cutting slots on
both the mandible and fibula jigs match exactly (right). (Image provided by Medical Modeling, Golden, CO.)

A
B
Head and Neck

FIGURE 37.9. Osteotomies and fixation of typical lateral and central
flaps (A and B). A. A typical lateral flap (with transplanted condyle). B
B. Typical anterior flap. Note the location of the pedicle in each.
FIGURE 37.10. Postoperative result after reconstruction of a lateral
defect (A and B). A. Postoperative views of a patient after lateral
reconstruction. Note the symmetry. B. The Panorex shows the flap
with miniplate fixation and osseointegrated implants.
Anterior flap shaping begins by planning the loca-
tion of the central segment so as to maximize flap pedicle
length (Figure 37.9). The central segment usually measures
2 cm. An osteotomy is made on each end in two planes. that can result in prognathism, retrognathia, increased or
The body segments curve away from the central segment decreased lower facial height, asymmetry caused by a twist
in both a posterior and superior direction. The body seg- in the flap, or a shift in the midline to one side as a result of
ments are usually of unequal length. It is important to unequal lengths of the mandible body.9 It is also important to
use the transverse template to accurately reproduce the establish the correct interarch distance in anticipation of later
splay of the body segments away from the central segment dental reconstruction (Figure 37.11).
and each other. As in the case of lateral flap, it is best to After the bone is inset, the microvascular anastomoses are
leave the ends of the flap long and make the final osteoto- performed. The facial artery is often selected as a recipient ves-
mies, which determine overall flap fit, at the time of flap sel, although the external carotid (end-to-side) and the supe-
insetting. rior thyroid artery are also good choices. The lingual artery
The recipient site is prepared prior to dividing the flap should be used with caution if the contralateral lingual artery
pedicle. The ends of the mandible segments are dissected in a has been previously ligated. The external jugular vein can be
subperiosteal plane for approximately 2 cm to allow room for used as the recipient vein if it is suitable for use. An end-to-
mini-plate fixation. Recipient vessels are identified, and the end anastomosis is easily performed. The internal jugular vein
intraoral wound closed as much as possible. Intermaxillary can also be used and has the advantage of decreased tendency
fixation is placed in the case of a lateral flap, and the remain- for kinking. Often both of the peroneal vena comitantes are
ing portion of the mandible is placed in fixation to maintain anastamosed to the internal and external jugular veins.
occlusion during flap insetting. Final wound closure follows completion of the micro-
Lateral flaps containing a condyle are inset by seating vascular anastomoses. Watertight closure of the intraoral
the condyle first and then finalizing the overall flap length. wound is critical. A leak will often lead to contamination
An additional osteotomy is often required near the mid- of the miniplates, which can develop into an orocutaneous
line to recreate the curve of the mandible in this area. The fistula that results in considerable morbidity. Despite all
transverse template is useful during the insetting process as efforts, however, patients with head and neck cancers are at
an aid to achieving symmetry. To avoid the cheek appearing risk for salivary leakage, particularly if they have a history
either “bowed-out” or “caved-in,” depending on the type of of radiation therapy. Fortunately, the viability of the flap is
error (Figure 37.10), the angle of the mandible flap must be usually not threatened, particularly if the drainage is con-
set at the correct distance from the midsagittal plane during trolled by opening the wound and performing good wound
insetting. care with intra- and extra-oral packing. Suction drains are
Anterior flaps are more difficult to inset correctly. Often always placed as the neck flaps are closed, but they are care-
the only visual guides are the maxillary arch and the midline fully positioned away from the microvascular anastomoses.
(Figure 37.1B). The lateral segments usually cannot be stabi- A feeding tube is routinely placed at the conclusion of the
lized because of a lack of dentition. It is easy to make errors procedure.

be salvaged, and the actual incidence of total flap loss is

generally less than 5%. Reconstruction plate exposure and
intraoral wound dehiscence (which may lead to orocutane-
ous fistula formation) constitute other serious problems.
Donor-site complications are uncommon and rarely require
additional surgery. They include abdominal wall attenua-
tion (ilium donor site), seroma (scapula), exposed tendons
or fracture (radius), and delayed skin graft healing (fibula).
Cellulitis can occur at the donor site or in the head and neck
area. Despite the complexity of mandible reconstruction
cases, the incidence and severity of postoperative complica-
tions are low.
Other Postoperative Issues

Many patients undergoing mandible reconstruction require
A postoperative radiation therapy. The presence of microvascu-
lar anastomoses does not affect the timing of postoperative
radiotherapy. Radiation can begin as soon as complete wound
healing is assured and the patient has recovered sufficiently.
This usually requires at least 4 weeks.
Mandible reconstruction is functionally incomplete with-
out dental restoration. A small percentage of patients can be
fitted with conventional dentures if there is dentition present
on either side of the defect. Patients with reconstruction plates
cannot have dentition restored over the plate.
Osseointegrated implant reconstruction is the method of
choice for dental restoration when conventional dentures are
B not feasible. These implants are placed into the bone flap and
serve as a permanent foundation upon which a dental prosthe-
FIGURE 37.11. Postoperative results after reconstruction of a central
sis is mounted.14 These implants are usually placed at a later
defect (A and B). A. Postoperative views of an anterior reconstruction.
B. The Panorex for this patient shows the flap and miniplate fixation. date when the patient has proven to be free of disease, usu-
ally no sooner than 6 months, and more appropriately 1 year,
after mandible reconstruction. Three to four implants are usu-
ally sufficient for a long dental defect.
Implant placement is usually an office procedure.
Postoperative Care Preparation of the site of implantation usually requires a pre-
liminary procedure to remove bone flap miniplates, which
Early patient mobilization is encouraged. Ambulation is possi- may interfere with implant placement. The skin island overly-
ble within the first postoperative week even when the fibula is ing the bone is thinned at the same time. The implants must
used. Weight bearing is usually limited for 3 weeks, when the be correctly aligned during placement. They are uncovered
fibula flap donor site is skin grafted. Tube feedings are begun after osseointegration has occurred, usually about 4 months
within 48 hours of the conclusion of the procedure. Irrigation later. The implants are lengthened by the placement of abut-
of the oral cavity for hygiene is generally begun after 3 days. ment collars on which the dental prosthesis is mounted
The tracheostomy is left in place for 10 to 14 days, or until (Figure 37.12).
wound healing is assured and it is clear that additional surgery Osseointegrated implants are usually unsuitable for
is not needed. placement in irradiated bone flaps. There is concern that
Free-flap monitoring is not precise in most cases of free- the implants will not integrate into irradiated bone or, if
flap mandible reconstruction because the bone is buried and they do, that they may not remain stable once loaded. It has
the skin island, if present, usually lies within the oral cavity. A been proposed that implants be placed immediately at the
conventional or implantable Doppler ultrasonography device time of mandible reconstruction. Although they are more
often can be used to monitor the vascular pedicle of the flap. likely to integrate prior to irradiation, their long-term fate
A clear arterial signal usually can be obtained over the man- will not necessarily be better once the bone is irradiated.
dible away from the neck vessels. Frequently, a venous hum Moreover, there are issues of threatened flap viability and
also can be heard. Skin island bleeding in response to pin- proper implant alignment when they are placed immedi-
prick is a useful confirmatory test when there is doubt about ately. This practice adds more time to an already lengthy
flap viability. procedure.
Physical therapy to address donor-site problems is rarely Although the size and number of series on pediatric man-
necessary. Follow-up studies of the mandible are limited to dible reconstruction is limited, some general concepts can be
periodic Panorex radiographs. Radionuclide scans are not gleaned. First, fibula transfer can be performed safely with
necessary. low complication rates in children as young as 1 year old.
Second, since the fibular epiphysis is not routinely included
in the reconstruction, normal growth of the transferred bone
Complications does not occur.15 Anticipatory modifications can be made at
There are three categories of potential complications in the time of primary reconstruction, including substitution of
mandible reconstruction: general medical problems, head lag screws for titanium plates, use of absorbable plates, and
and neck wound problems, and donor-site problems. preservation of fibula length for later use by overlapping it
Pulmonary and cardiac problems are the most common on the native mandible. Finally, as the child grows secondary
source of general medical complications. Free-flap failure procedures may be necessary, such as distraction osteogenesis
is the single most important complication pertaining to or sagittal split osteotomy of the neomandible, or secondary
the head and neck area. Fortunately, most failing flaps can addition of osseous and soft-tissue flaps.

Figure 37.12. Dental restoration using osseointegrated implants.
Head and Neck

A. Postoperative Panorex shows three osseointegrated implants in a
previously placed fibula flap. B. The abutment collars are shown with
the metallic superstructure in place. C. The completed dental prosthe-
sis is shown after it has been applied to the superstructure.
B
3. Hidalgo DA, Disa JJ, Cordeiro PG, Hu QY. A review of 716 consecutive free
Conclusion flaps for oncologic surgical defects: refinement in donor-site selection and
technique. Plast Reconstr Surg. 1998;102(3):722-732; discussion 733-734.
Mandible reconstruction is most commonly performed for 4. Taylor GI. Reconstruction of the mandible with free composite iliac bone
tumors, of which squamous cell carcinoma and osteogenic grafts. Ann Plast Surg. 1982;9(5):361-376.
sarcomas are the most common types. Lateral and anterior 5. Hidalgo DA. Fibula free flap: a new method of mandible reconstruction.
defects constitute two distinct types of reconstructive prob- 6. Cordeiro PG, Disa JJ, Hidalgo DA, Hu QY. Reconstruction of the mandible
lems. Reconstruction is most commonly performed either with with osseous free flaps: a 10-year experience with 150 consecutive patients.
reconstruction plates and regional flaps or with microvascular Plast Reconstr Surg. 1999;104(5):1314-1320.
free flaps. 7. Hanasono MM, Zevallos JP, Skoracki RJ, Yu P. A prospective analysis of
bony versus soft-tissue reconstruction for posterior mandibular defects.
Free flaps usually yield the best functional and aesthetic Plast Reconstr Surg. 2010;125(5):1413-1421.
results. These lengthy procedures consist of multiple sub- 8. Mosahebi A, Chaudhry A, McCarthy CM, et al. Reconstruction of exten-
components, including bone harvesting, shaping, and fixa- sive composite posterolateral mandibular defects using nonosseous free tis-
tion; insetting; microvascular anastomoses; and soft-tissue sue transfer. Plast Reconstr Surg. 2009;124(5):1571-1577.
9. Hidalgo DA. Aesthetic improvements in free-flap mandible reconstruction.
closure. Preoperative planning, such as cardiopulmonary Plast Reconstr Surg. 1991;88(4):574-585; discussion 586-587.
screening and fabrication of shaping templates, increases 10. Sharaf B, Levine JP, Hirsch DL, et al. Importance of computer-aided design
safety and improves the aesthetic and functional results of and manufacturing technology in the multidisciplinary approach to head
free-flap reconstruction. Among the most important compli- and neck reconstruction. J Craniofac Surg. 2010;21(4):1277-1280.
11. Disa JJ, Cordeiro PG. The current role of preoperative arteriography in free
cations in mandible reconstruction are reconstruction plate fibula flaps. Plast Reconstr Surg. 1998;102(4):1083-1088.
exposure, free-flap failure, and serious cardiopulmonary 12. Hidalgo DA. Titanium miniplate fixation in free flap mandible
problems. reconstruction. Ann Plast Surg. 1989;23(6):498-507.
13. Hidalgo DA. Condyle transplantation in free flap mandible reconstruction.
References Plast Reconstr Surg. 1994;93(4):770-781; discussion 782-783.
14. Frodel JL Jr, Funk GF, Capper DT, et al. Osseointegrated implants: a
1. Boyd JB, Gullane PJ, Rotstein LE, Brown DH, Irish JC. Classification of comparative study of bone thickness in four vascularized bone flaps. Plast
mandibular defects. Plast Reconstr Surg. 1993;92(7):1266-1275. Reconstr Surg. 1993;92(3):449-455; discussion 456-458.
2. Singh B, Cordeiro PG, Santamaria E, et al. Factors associated with complica- 15. Guo L, Ferraro NF, Padwa BL, Kaban LB, Upton J. Vascularized fibu-
tions in microvascular reconstruction of head and neck defects. Plast Reconstr lar graft for pediatric mandibular reconstruction. Plast Reconstr Surg.
Surg. 1999;103(2):403-411. 2008;121(6):2095-2105.

Chapter 38 n Craniofacial and
Maxillofacial Prosthetics
George C. Bohle Iii, Cherry L. Estilo and Joseph M. Huryn
During the preoperative visit, patients are counseled to pro-

Introduction vide a realistic functional prognosis of the expected outcomes.
Prosthetic rehabilitation of the oral cavity and the head and In addition, a complete intraoral and head and neck exami-
neck is a critical component of rehabilitation following tumor nation is performed to evaluate dentition and anticipated
extirpation, trauma, and congenital deformities. 1,2 Recent prosthetic shape, size, and fixation technique. Impressions
advances in imaging and manufacturing have improved surgi- of the maxillary and mandibular arches are made at the ini-
cal planning by virtual surgery and the availability of custom tial consultation. In general, patients with healthy dentition
craniofacial prosthetics. Prosthodontists are important mem- and smaller defects have better overall comfort and efficacy
bers of the interdisciplinary team who care for the head and of the obturator. Obviously, patients who have loss of peri-
neck patients. odontal support and resultant loose teeth, active caries, frac-
Prosthetics for head and neck reconstruction can be cat- tured teeth, or heavily restored teeth have more difficulties
egorized based on the anatomic location of the defect. For with hard palate prostheses. In some cases, the use of dental
example, a variety of custom or prefabricated implants and implants should be considered for patients missing teeth in the
corresponding prostheses are available for acquired defects remaining arch in an effort to provide the maximum obtura-
of the palate, mandible, or external features of the face. tor stability.
When used in this manner, dental and craniofacial implants
serve a functional role, aiding in mastication or separating Surgical Prosthesis
the oral and nasal cavities, or a cosmetic purpose camouflag- The surgical obturator is fabricated prior to surgery and
ing scars or improving facial appearance. Custom prostheses placed intraoperatively to stabilize packing and provide func-
can be constructed to replace missing nasal or auricular tis- tion upon awaking from the surgery.6 Although the surgical
sues matching the patients’ skin color and tone. Similarly, obturator can be retained with wires or screws, wires are usu-
prostheses may be used to replace all periorbital tissues ally easier and equally retentive in patients with good dentition
after orbital exenteration. Careful analysis of the defect and (Figure 38.1). Typically, a 24 gauge wire is used in a similar
functional purpose of the prosthesis are integral steps in manner as arch bars for intermaxillary fixation (Figure 38.2).
fabrication. Bone wax over the cut wire ends is useful to prevent irri-
tation of the cheek and lip. In some cases, the intramaxil-
Hard Palate Defects lary defect is covered with a split-thickness skin graft by the
reconstructive team to accelerate tissue healing and optimize
Hard palate defects result from oncologic resection, trauma, postoperative care.
or congenital defects. The purpose of prosthodontic rehabili- Prosthetic reconstruction of hard palate defects in edentu-
tation is to separate the oral and nasal cavities so that speech lous patients is challenging, and patients should be counseled
and swallowing function are restored. The prosthesis also that they might experience difficulty with prosthetic function
serves to restore cosmetic appearance by supporting the cheek postoperatively. In these cases, placement of dental implants
and lip. either at the time of the ablative surgery or after recovery is
A variety of classification schemes have been proposed by a good option. All available bone should be used to place as
head and neck surgeons, reconstructive surgeons, and prosth- many implants as possible with a minimum of two implants.
odontists for acquired defects of the hard palate based on Placement of mini or conventional dental implants can usually
the individual roles of these groups in the multidisciplinary be performed with little extension of the overall operating time
treatment of head and neck defects 3-5 (Chapter 39). For
example, head and neck or oral surgery classification schemes
describe the anatomical structures to be removed and possible
approaches for the operation. In contrast, classification sys-
tems proposed by plastic and reconstructive surgeons primar-
ily address the missing anatomic structures and algorithms for
reconstruction. Lastly, the prosthodontic systems describe the
size and location of the defect and the proposed prosthetic
rehabilitation for the patient.
Ideally, patients are evaluated by a prosthodontist prior
to surgical treatment. Inevitably, however, some patients
present after flap reconstruction. In either case, the goal of
prosthodontic rehabilitation is a well-fitting, rigidly supported
obturator that provides maximum functional and cosmetic
outcomes. In many cases, this process involves a series of pros-
theses designed to allow wound healing and changes in shape
and size due to scarring and adjuvant radiation treatment.
Most patients have an surgical obturator fabricated prior to FIGURE 38.1. Surgical obturators. Obturator with fixation screw in
surgery and placed in the hard palate defect at the time of the remaining hard palate on the left for edentulous patient, and surgical
operation. This is followed by an interim obturator when the obturator for a dentate patient with wires to wrap around the teeth
immediate wound healing issues have been resolved. Finally, on the right.
patients are fitted with the definitive obturator.
420
Chapter 38: Craniofacial and Maxillofacial Prosthetics 421
portion of the prosthesis after adjusting the denture exten-
sions and roughening the surface to allow adhesion of the new
material. In addition, retentive elements can be incorporated
into the interim obturator giving the prosthesis greater stabil-
ity by physically connecting to the dental implants.
Definitive Prosthesis
The definitive prosthesis differs from the interim in that it is
usually a metallic framework custom cast to fit the remaining
teeth and is much stronger than the plastic interim prosthesis.
In addition, because healing has nearly completely occurred
when the definitive prosthesis is placed, less adjustment is
necessary and patients are more accustomed to the feel and
routine of wearing a prosthesis. Figure 38.4 demonstrates a
FIGURE 38.2. Fixation of the obturator. Surgical obturator fixated well-healed non-reconstructed maxillary defect rehabilitated
by wires around the remaining teeth, stabilizing the medicated gauze with dental implants and a definitive obturator. The implants
packing and allowing speech and swallowing upon awakening. were placed at the time of surgery since the patient had only
two remaining teeth to support the obturator.
by placing the implants while awaiting the pathology results

Prosthetic Rehabilitation of Hard Palate
of the frozen sections.7 Upon completion of implant place- Defects in Patients Reconstructed with Flaps
ment, the surgical obturator can be held in place with fixation In some cases, hard palate defects are surgically reconstructed
screws, wires, or sutures as outlined above. Alternatively, a with free flaps (Chapter 39), thereby separating the mouth
Head and Neck

24 gauge wire can be passed in a transalveolar fashion from and nasal cavities with vascularized tissues. These patients
lingual to buccal (Figure 38.3). are typically referred for prosthetic dental fabrication
months after surgery when swelling is decreased and the flap
Interim Prosthesis has completely healed. In other circumstances, patients are
Following a brief recovery period, fabrication of the interim referred postoperatively after partial or complete flap loss.
obturator is initiated to account for changes in tissue healing Failing flap reconstructions may be treated with a prosthesis
and dentition. This obturator is fabricated using a plastic resin as an interim measure until the patient can return for addi-
and can be shaved/shaped as needed. The original surgical tional surgery or as a definitive treatment in conjunction with
prosthesis is usually removed 5 to 14 days after surgery, the other measures.
packing is removed, and the interim obturator is adjusted for Provided there is physical space available in the oral cav-
gross contact and refined for postoperative changes. This pro- ity, a custom prosthesis can usually be fabricated in patients
cess can be repeated and the interim prosthesis further refined who have undergone flap reconstruction; however, as is the
as the patient recovers and the wound contracts. Patients are case with all prosthetics, the efficacy of these devices is depen-
taught how to place and care for their prosthesis and are typi- dent on the support provided by teeth and dental implants
cally followed every 2 or 3 weeks for fine adjustments as neces- (Figure 38.5). Therefore, bulky flaps that protrude into the
sary or until wound healing has occurred. Patients undergoing oral cavity must, if possible, be reduced in size prior to pros-
radiation therapy will usually remain in this interim prosthe- thetic fabrication in order to provide physical space for the
sis for 6 to 12 months, while those not requiring radiation prosthesis. Flap reduction is also helpful in stabilizing the
may be healed sufficiently in 3 months to begin the definitive prosthetic as the additional weight of a bulky flap usually can-
prosthesis. not be overcome with traditional clasps or with implant reten-
In edentulous patients who have previously worn maxillary tive elements. With a taut flap there is adequate room for the
dentures, the interim obturator can be designed using the pre- prosthesis, and the patient’s function and cosmesis are greatly
vious device, which provides several advantages: the patient improved.
is accustomed to the feel of the teeth, the occlusion is known,
and cosmetic appearance has not been changed. Resilient Soft Palate Defects
lining or tissue conditioners are used to add the obturator
Prosthetic rehabilitation of a soft palate defect is one of the
most challenging intraoral treatments a maxillofacial prosth-
odontist will render. Surgical, traumatic, or developmental
alterations of the soft palate alter normal palatopharyngeal
closure, resulting in hypernasal speech and food bolus/liquid
regurgitation. This muscular sphincter is made of the posterior
and lateral pharyngeal walls that move anteriorly and medi-
ally to meet the superiorly elevated soft palate to close the
oropharynx from the nasopharynx. A speech aid obturator
prosthesis allows palatopharyngeal closure in these patients
by allowing the lateral and posterior walls of the nasopharynx
to contract against the prosthesis. The obturator must there-
fore be sized precisely to allow unimpeded nasal breathing
and should not interfere with the tongue during swallowing
and speech.
Velopharyngeal inadequacy (VPI) is the inability of
the sphincter to separate the nasopharynx from the oral
FIGURE 38.3. Transalveolar wires passed from palatal to buccal to pharynx. VPI can be caused by one or a combination of
retain obturator in an edentulous patient. the following conditions. Velopharyngeal insufficiency
results from loss of anatomic structure from the sphincter.

A B
C D
FIGURE 38.4. Rehabilitation using obturator and dental implants.

A. Preoperative panoramic radiograph allowing for the surgical
planning of dental implants at the time of ablative surgery. B. Well-
healed maxillectomy defect with three dental implants and Locator
attachments to retain the obturator. C. The definitive obturator with
blue retentive elements to retain the obturator and improve function
during speaking and swallowing. D. The final oral rehabilitation of
the patient with obturator in place. Dental implants were also placed
in the posterior mandible bilaterally giving a stable and functional
occlusion. E. Postoperative panoramic radiograph demonstrating
well-healed implants and closely guarded remaining teeth.
E
The remaining musculature continues to form some part of the Similar to hard palate defects, a series of obturators (sur-
sphincter but there is a physical defect present. This condition gical, interim, and definitive) is fabricated in patients with
is treated by surgery or fabrication of a soft palate obturator. expected soft palate defects and based on the same princi-
Velopharyngeal incompetency results from an anatomically ples, including supporting structures and remaining palatal
intact sphincter with muscle incompetency due to disruption elements.
of nerve innervation or damage secondary to radiation ther- Soft palate defects are more difficult to obturate due to the
apy. All of the muscles of the sphincter are present in complete overall length of the prosthesis extending into the pharynx,
form but one or more do not function adequately to form the as well as the muscle activity of the tongue, remaining soft
seal, resulting in hypernasal speech and regurgitation of food palate, and pharyngeal walls acting on the prosthesis during
and fluids through the nose upon swallowing. This condition speech and swallowing. As a result, it is imperative that pre-
can be treated with surgery or with the fabrication of a palatal operative mandibular and maxillary impressions capture the
lift prosthesis. By lifting and holding the anatomically intact extent of the soft palate in order to fabricate a well-extended
soft palate in place, the sphincter is restored and speech and surgical obturator. The surgical obturator is prepared in the
swallowing improved. laboratory by approximating the length and height of the soft
Patients with acquired defects of the soft palate can have palate when raised in function (Figure 38.6). Typically, the
VPI due to direct injury to the sphincter from surgical abla- plane of the hard palate is extended 1 to 3 cm depending on
tion or develop incompetency secondary to radiation injury. the size of the patient and can be modified in the operating
In these cases, a combination of prostheses may be necessary room if excessively long. Just as with a surgical obturator
to fill the void left by surgery and support the remaining struc- for a hard palate defect, it is usually fixated with 24 gauge
ture in the closed position. Patients reconstructed with flaps wires. Dental implants should be considered for placement at
for the soft palate or pharyngeal walls are often more difficult the time of surgery for partially dentate patients and highly
to treat as bulky flaps can impede access to the defect or com- recommended for completely edentulous patients. It cannot
plicate positioning of the obturator. be stressed enough that the action and weight of the muscles

A B
Head and Neck

C D
FIGURE 38.5. Prosthetic reconstruction after free flap to maxillectomy defect. A. Postoperative panoramic radiograph demonstrating the right
maxillectomy and three dental implants. B. Maxillary prosthesis with three retentive elements. Note the smaller posterior size of the prosthesis
opposite the retentive elements denoting the change in anatomy from the flap. C. The prosthesis in place retained by the three implants. In this
case, the retentive elements were able to overcome the weight of the flap. D. Final oral rehabilitation with maxillary and mandibular removable
prostheses in place.
acting on the soft palate prosthesis will require greater support be incorporated into the prosthesis at this time to give even
for maximum efficacy in speech and swallowing. Completely greater stability and retention.
edentulous patients will be at a severe disadvantage as their
prosthesis will be forced to dislodge anteriorly and inferiorly
with function. Routine denture adhesives do little to combat Complex Hard and Soft
these forces.
Following surgery, the surgical obturator and packing are
Palate Defects
removed and the interim prosthesis is delivered. As with the The optimal treatment of complex hard and soft palate defects
edentulous obturator patient, the existing denture may be has been the source of some debate with some authors rec-
converted to the interim prosthesis by fabricating an extension ommending flaps and others relying primarily on prosthetics.
into the surgical defect. One technique uses a wire extension, Proponents of surgery have suggested near pre-surgical level of
contoured to the defect, customized with compound impres- speech intelligibility, good swallowing function, and the com-
sion material, and converted to acrylic resin to match the den- fort of not wearing a prosthesis as well as the necessary adjust-
ture. If implants were placed, then the retentive elements may ments and expense that come with it. Opponents to surgery
A B
FIGURE 38.6. Surgical obturator for soft palate defect. A. Preoperative stone cast that has been altered for a surgical obturator extending into
the soft palate. B. The completed surgical obturator that will be retained by transalveolar wiring.

have suggested that speech is better with a prosthesis as it against the prosthesis and toward the tongue base. These
can be refined as necessary, surgeons will have direct visual prosthetics are made of acrylic resin and are molded to the
access to the defect on follow-up, and swallowing is at a near palatal vault and held in place with wire clasps. The palatal
pre-surgical level. Although widely debated, neither side has augmentation portion of the prosthesis is custom molded by
shown conclusive evidence to support one treatment method having the patient speak and swallow in order to optimize the
over another. Our studies favor flap surgery for smaller ability of the tongue to conform to the shape of the palate
defects and obturator prosthesis for large defects with similar through its full range of motion (Figure 38.7). It is important
functional results. The approach to each case is planned indi- to remember, however, that a palatal augmentation prosthesis
vidually after assessments by our multidisciplinary team and only assists in transmitting the food bolus to the base of the
input from the patient.8,9 tongue but does not aid in food transfer to the remaining por-
tions of the alimentary canal.
Mandibular Defects
Segmental Mandibulectomy Defects
Marginal Mandibulectomy Defects Segmental mandibulectomy defects are reconstructed with
Marginal mandibulectomy defects are created when a seg- osseous flaps or metal plates, or left unreconstructed in some
ment of the mandible, usually the lingual surface, is removed patients due to technical or medical issues (Chapter 37).
during oncologic resections to provide a clear surgical margin Patients who have a large, non-reconstructed segmental man-
of oral tumors abutting the mandible. These resections leave dibulectomy defect often have significant cosmetic and func-
the mandible intact, but decrease the height and width of the tional problems. Unfortunately, in these cases, there is also
remaining mandible component. Although a marginal man- little that can be done from a prosthodontic standpoint. Most
dibulectomy facilitates intraoral reconstruction by avoiding commonly, these patients are referred to physical therapy and
segmental defects and preserving the mandibular arch, dental a speech and language pathologist to learn exercises designed
reconstruction in this setting can be a challenge due to post- to enable the patient to consciously bring the native mandible
surgical changes in the soft tissue bed. Usually, the buccal and/ into occlusion during function despite the surgical defect. If
or lingual vestibules are obliterated, and routine prosthetic possible, these exercises should be initiated early in the post-
extensions are compromised by scarring. Tissue scarring, operative setting as they become increasingly difficult to per-
loose tissues, or bulky flap reconstructions may compromise form if training is delayed or if radiation therapy is necessary.
retention and fit of removable prostheses, thereby limiting In some patients, removable guide-flange prostheses may be
their function and the length of time they can be comfortably used; however, in general these devices have limited success
worn each day. Additionally, inadequate mouth opening or in preventing mandible rotation and deviation. Additionally,
intraoral space may make a fixed prosthesis impossible to fit most patients cannot tolerate these prostheses or are simply
or to care for with routine daily hygiene. unable to fit them in their mouth.
If possible, the vestibular sulci should be preserved by avoid- Ideally, segmental mandibulectomy defects are recon-
ing primary closure of the tongue or cheek to the resected site, structed with osseous flaps and dental implants placed either
or reconstructed, using a skin graft with a customized prosthe- at the time of the initial surgery/reconstruction or after heal-
sis to shape the recipient bed. In other instances, it may be nec- ing has occurred postoperatively. Immediate dental implant
essary to revise flaps to decrease bulk and excess soft tissues to placement has been significantly improved by recent advances
improve prosthetic fitting. If postoperative radiation therapy is in imaging, software design, and implant fabrication. This
anticipated, then implants may fare better if placed at the time approach has the advantage of placing implants prior to radia-
of ablative surgery. Radiation significantly increases complication therapy and decreasing the number of surgeries necessary
tions and failure rates of dental implant placement. for oral rehabilitation. However, immediate dental implant
Surgical resection of the tongue in conjunction with mar- placement increases the operative time and may, in a small
ginal mandibulectomy adversely affects speech and swal- number of cases, result in healing complications. As a result,
lowing. Although soft tissue flaps can be used to replace the in some patients, dental implants are placed after wound heal-
volume of tissue and provide some mobility to the remaining and adjunctive treatment has completed.
ing native tongue, these reconstructions may not restore In most patients who undergo delayed dental implant place-
enough function during swallowing to move the food bolus ment, flap revision is necessary to thin the overlying tissues
to the esophagus. In these circumstances, a palatal augmen- and to provide a stable keratinized tissue bed for the prosthe-
tation prosthesis may be helpful by enabling patients to use sis. Patients who undergo dental implant placement following
their remaining/reconstructed tongue to push the food bolus radiation therapy are at risk for developing osteoradionecrosis
A B
FIGURE 38.7. Palatal augmentation and soft palate obturator. A. Defect after resection of right base of the tongue, tonsil, and soft palate.
B. Palatal augmentation prosthesis combined with soft palate obturator to aid in food bolus transit and swallowing.

(ORN) and must be advised appropriately. In some cases, using removable prostheses. This process is usually initiated
software planning can be used to fabricate implant drill guides with a provisional removable prosthesis (Figure 38.8) that is
designed to minimize soft tissue injury and flap revision and subsequently transitioned to a definitive mandibular prosthe-
decreasing the chances of ORN. sis after complete wound healing and tissue remodeling. This
Dental implants may not be feasible in patients with severe prosthesis has a metallic framework and is custom cast to the
radiation injury, inadequate bone stock, or compromised soft patients healed but altered anatomy. Although these prosthe-
tissues. In these instances, oral rehabilitation is performed ses provide adequate cosmetic appearance, they are not ideal.
A B
Head and Neck

C D
E F
FIGURE 38.8. Oval rehabilitation for pediatric patient after man-

dible reconstruction with fibula flap. A. Well-healed pediatric
patient following fibula free flap reconstruction for osteosarcoma.
B. Removable provisional prosthesis allowing for changes in growth
and accounting for a mixed dentition. C. Interim oral rehabilitation
allowing for future changes as deciduous teeth are lost, permanent
teeth erupt, and orthodontic treatment. D. Postoperative panoramic
radiograph of fibula free flap reconstruction of left mandible. E. Loss
of the buccal and lingual vestibules making prosthesis fabrication and
function difficult. F. Definitive removable prosthesis resting on soft
tissue of the fibula flap. G. Final oral rehabilitation with a removable
prosthesis.
G

They often have inadequate bony support resulting in com- A physical impression (moulage), digital image, or laser
promised function and dependence on the native side of the scan of the defect is obtained. Irreversible hydrocolloid,
mouth for chewing. vinylpolysiloxane, or plaster is used to make a mold of the
patient’s face or a medical model is made from digital data.
The missing anatomy is either hand sculpted or computer
Facial Prostheses milled/printed in wax or clay on the model as well as on the
Defects involving the face are challenging to surgeons and patient for contouring, coloring, and placement of margins.
prosthodontists. Reconstructive surgery is limited by the Additionally, the ease of placement of the prosthesis and
quantity and quality of the donor tissue available that its retention must be verified as they directly contribute to
will match the texture and color of the surrounding area. a successful outcome. Prostheses are designed to use physi-
Prosthetic treatment is limited by tissue movement with cal undercuts, chemical adhesives, and mechanical retain-
facial expression or chewing and the fact that prostheses ers either alone or in combination to secure the prosthesis
require removal, subjecting the patient to embarrassment. to the face (Figure 38.9 A to E). The type of retention is
Tissue movements can cause problems with retention and planned based on the complexity of the surgical site, skin
matching because the prosthesis remains immobile. The type, and ease of mechanical retention utilizing craniofacial
choice between surgical reconstruction and prosthetic reha- implants or glasses, straps, or clips (Figure 38.9 F to H).
bilitation is not always clear. Prosthetic rehabilitation may Silicon prostheses can be expected to last for 12 to
decrease operative time, thereby decreasing operative mor- 24 months and are cared for daily with soap and water.
bidity in patients with medical comorbidities. Prosthetics With increased sun or chemical exposure, the edges of the
can be easily revised to account for changes in shape or prosthesis can begin to breakdown and degrade the color.
color to improve cosmetic appearance and outcomes in This color can sometimes be corrected with additional tint-
patients with defects in complex structures such as the ear ing; however, in most cases, a new prosthesis is required
and nose. Finally, surgical and prosthetic reconstruction can every 2 years. A case of prosthetic ear reconstruction is
be combined in difficult or complex cases to improve the shown in Figure 38.10 and a prosthetic periorbital recon-
facial appearance. struction is shown in Figure 38.11.
A B
C
FIGURE 38.9. Prosthetic reconstruction of the nose after rhinectomy and maxillectomy. A. Patient post maxillectomy and rhinectomy wearing
his definitive obturator but in need of a nasal prosthesis. Note the lip contracture and little means of retaining an adhesive prosthesis. B. The facial
moulage is poured in stone, and pictured is the magnetic prosthesis that attaches to his obturator and aids in retaining his nasal and lip prosthesis.
C. The magnetic attachment is combined with adhesive for retention. There will be some movement, however, as the patient chews due to the
connection to the obturator. D. Frontal view of the final prosthesis retained by both magnets and adhesive. E. Profile of the resected tissue and
resulting defect. F. Profile view of the restored patient with his magnetic and adhesive retained prosthesis. G. Lateral defect of the nose that could
be rehabilitated with adhesive retained prosthesis, however, the patient is legally blind and the caregiver is unable to glue the prosthesis to place. H.
The nasal prosthesis attached to his glasses enabling him to reliably position the prosthesis. I. The completed prosthesis and glasses combination.

E F
Head and Neck

G H
Adjunctive Measures
Patients with head and neck cancer face secondary sequelae
that can impact prosthetic rehabilitation. While advances in
the delivery of radiation therapy for head and neck malig-
nancies show promising results, xerostomia, trismus, and
the risk of ORN continue to be the most notable issues when
developing a prosthetic treatment plan.10 Xerostomia causes
a number of problems, including an increased rate of caries
that places the teeth supporting the prosthesis at risk of being
lost, lack of lubrication for the tissues supporting a remov-
able prosthesis and for the food bolus in swallowing, and
loss of the constant flushing action of the saliva to remove
food particles from the teeth/prosthesis and buffering of acids
after eating. Xerostomia is usually relieved with frequent use
of water; however, prescription medications and over-the-
counter products can provide some additional relief.11 It is
imperative that the patients who have received head and neck
radiation therapy have access to fluoride supplements and be
instructed to schedule more frequent visits to the dentist for
routine examinations.
Irradiation of the masticatory muscles produces fibrosis
and leads to acute or chronic trismus resulting in discomfort,
difficulty eating solid foods, and impaired dental/oral hygiene.
In addition, this complication greatly reduces the ability of
medical professionals to visually inspect or perform physical
examination to evaluate tissue healing and diagnose recurrent
disease. Finally, trismus significantly decreases the potential
for dental/oral rehabilitation by decreasing mouth opening
and effective placement of functional prosthetics.
Regular stretching of these muscles can decrease and pos-
sibly prevent significant limited jaw opening hopefully main-
taining an opening of 35 to 50 mm measured from the incisal
edges of the maxillary and mandibular incisors. These exer-
I cises should begin prior to radiation therapy and resume as
FIGURE 38.9. (Continued) soon as possible after surgery to avoid permanent decreased
opening.12 The exercises should be performed multiple times

A B
FIGURE 38.10. Prosthetic ear reconstruction. A. Well-healed left ear resection for squamous cell carcinoma. B. Definitive auricular prosthesis
retained by the remaining anatomy and adhesive.
D
FIGURE 38.11. Prosthetic reconstruction of periorbital defect.
A. The patient with a well-healed tissue bed. B. The wax sculpting is
tried to place and refined as necessary to blend with natural contours.
C. The final prosthesis retained by the undercut of the superior orbital
rim and adhesive. D. The use of glasses is recommended to detract
from the prosthesis and to protect the remaining eye.
C
per day using manual manipulation with the fingers, tongue

depressors stacked together, an acrylic resin “corkscrew,” or
commercial devices (Figure 38.12). Early involvement of phys-
iatrists and physical therapists may help patients by providing
improved education, support, and encouragement.
The third and possibly the most devastating sequelae of
head and neck radiation therapy is the risk of ORN. Most lit-
erature indicates that the bone irradiated to more than 55 Gy,
specifically the posterior mandible, is at high risk for spon-
taneously or traumatically developing ORN. Several theories
continue to be tested in an effort to explain the etiology of
ORN whether it is a decrease in blood flow due to damage to
fine vasculature or cellular damage making the bone unable to
repair itself when insulted.13 In either case, prevention remains
at the forefront of treatment planning as ORN may develop at
any time during the patient’s life span. Once diagnosed, con- FIGURE 38.12. From left to right the acrylic resin “cork screw”
servative measures are initially undertaken in the hope that device, Therabite, and Dynasplint are used to exercise and treat tris-
mandibulectomy and free flap reconstruction can be avoided. mus following surgery and radiation therapy.
Hyperbaric oxygen may be helpful.14 Nearly all cases of ORN

occur secondary to surgical insult such as tooth extraction. 7. Bohle GC, Mitcherling WW, Mitcherling JJ, et al. Immediate obtura-
tor stabilization using mini dental implants. J Prosthodont. 2008;
The patient must be informed and constantly reminded that 17(6):482-486.
vigilant oral hygiene, frequent visits to the dentist, monitor- 8. Bohle G, Rieger J, Huryn J, et al. Efficacy of speech aid prostheses for
ing sugar and starch intake, and the use of fluoride supple- acquired defects of the soft palate and velopharyngeal inadequacy—clinical
ments are a priority. Caries leading to extraction in a highly assessments and cephalometric analysis: a memorial Sloan-Kettering study.
Head Neck. 2005;27:195-207.
irradiated field places them at high risk for complication and 9. Rieger J, Bohle G, Huryn J, et al. Surgical reconstruction versus prosthetic
developing ORN. obturation of extensive soft palate defects: a comparison of speech out-
comes. Int J Prosthodont. 2009;22:566-572.
References 10. Kubicek GJ, Machtay M. New advances in high-technology radiotherapy
for head and neck cancer. Hematol Oncol Clin North Am. 2008;22(6):
1. Kornblith AB, Zlotolow IM, Gooen J, et al. Quality of life of maxillectomy 1165-1180.
patients using an obturator prosthesis. Head Neck. 1996;18(4):323-334. 11. Vissink A, Mitchell JB, Baum BJ, et al. Clinical management of salivary
2. Depprich R, Naujoks C, Lind D, et al. Evaluation of the quality of life of gland hypofunction and xerostomia in head-and-neck cancer patients: suc-
patients with maxillofacial defects after prosthodontic therapy with obtura- cesses and barriers. Int J Radiat Oncol Biol Phys. 2010;78(4):983-991.
tor prostheses. Int J Oral Maxillofac Surg. 2010;40:71-79. 12. Stubblefield MD, Manfield L, Riedel ER. A preliminary report on the effi-
3. Spiro RH, Strong EW, Shah JP. Maxillectomy and its classification. Head cacy of a dynamic jaw opening device (dynasplint trismus system) as part of
Neck. 1997;19:309-314. the multimodal treatment of trismus in patients with head and neck cancer.
4. Cordeiro PG, Santamaria E. A Classification system and algorithm for Arch Phys Med Rehabil. 2010;91(8):1278-1282.
reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. 13. Chrcanovic BR, Reher P, Sousa AA, et al. Osteoradionecrosis of the jaws—a
2000;105:2331-2346. current overview-part 1: physiopathology and risk and predisposing factors.
5. Okay DJ, Genden E, Buchbinder D, et al. Prosthodontic guidelines for Oral Maxillofac Surg. 2010;14(1):3-16.
surgical reconstruction of the maxilla: a classification system of defects. 14. Fritz GW, Gunsolley JC, Abubabker O, et al. Efficacy of pre- and post-
J Prosthet Dent. 2001;86(4):352-363. irradiation hyperbaric oxygen therapy in the prevention of postextrac-
6. Huryn JM, Piro JD. The maxillary immediate surgical obturator prosthesis. tion osteoradionecrosis: a systematic review. J Oral Maxillofac Surg.
J Prosthet Dent. 1989;61(3):343-347. 2010;68(11):2653-2660.
Head and Neck

Chapter 39 n Reconstruction of the
Maxilla and Skull Base
Eric G. Halvorson, Duc T. Bui, and Peter G. Cordeiro
define the maxillary defect in terms of bony and soft-tissue

Reconstruction of components. Adjacent critical structures, such as the eye,
Maxillary Defects nose, and lips, are assessed. A history of radiotherapy or pre-
vious neck dissection is noted. The necessary length of the
The maxilla is an essential component of the midface and has vascular pedicle and donor-site morbidity are assessed. The
both functional and aesthetic roles. It contributes to facial amount, location, and quality of residual bone, dentition, and
appearance, determines midfacial width and height, and denture-bearing alveolar arch largely determine whether a
serves as support for the orbit, cheek, nose, and upper lip. The bone-containing flap is necessary.
maxilla also supports critical functions such as mastication, Visualizing the maxilla as a six-sided box with the roof
speech, and deglutition. Most maxillary defects result from being the orbital floor and the floor being the palate is help-
the surgical ablation of maxillary tumors or tumors arising ful in determining which walls are missing (Figure 39.1).
from adjacent structures, including the paranasal sinuses, pal- The three walls that require reconstruction are the superior
ate, nasal cavity, orbital contents, overlying skin, and intraoral (orbital floor), floor (palatal), and anterior (cheek) walls.
cavity. Another cause of maxillary defects involves traumatic Reconstruction of the highly complex three-dimensional
injuries resulting from gunshot wounds to the midface or less nature of the maxillary defect can be simplified by combining
commonly blunt injury. Because of its close relationship to bone grafts with a soft-tissue flap. Bone grafts can be rigidly
other facial components and unique three-dimensional struc- fixed without interfering with flap inset. Vascularized bone is
ture, reconstruction of maxillary defects can be a formidable essential only in the maxillary arch, and possibly to replace
challenge for the reconstructive surgeon. a vertical buttress if both are resected. Although a variety of
The goals of maxillary reconstruction are: alloplastic products are available for bone replacement, these
1. Reconstruct the orbital floor to maintain globe position or are not indicated in patients who have either received or will
fill the orbital cavity following orbital exenteration receive radiation therapy, and in general do not perform as
2. Reconstruct the intraoral, cheek, palatal, and nasal lining well as autologous grafts.
to restore speech, mastication, and oral continence Bone replacement for the orbital floor is essential to main-
3. Separate the oral and nasal cavity from the skull base and tain globe position. The orbital floor can be reconstructed
orbit with autologous bone grafts because this area requires mini-
4. Restore external skin and three-dimensional facial contour mal supportive strength. The maxillary arch of the midface is
5. Obliterate the maxillectomy defect reconstructed to provide anterior projection and dental sup-
port. Ideally, bony replacement of the maxillary arch must
Traditionally, prosthetic appliances were used to recon- have adequate bone stock for osseointegrated dental implants.
struct maxillary defects and are still a reasonable option in Hence, vascularized bone is required for reconstructing the
some patients (see Chapter 38). This method of reconstruc- maxillary arch. The palate can be repaired with the skin island
tion relies on adequate support from the remaining tissues of a free flap or replaced with an obturator. The anterior wall
and split-thickness skin grafting to line the defect. Despite suc- of the hypothetical box requires reconstruction but does not
cesses in many cases, there are several disadvantages to the require bony reconstruction. The maxillary sinus in the cen-
use of obturators. Leakage and oronasal regurgitation because ter of the hexahedron can be filled with soft tissue (muscle or
of bulky dentures, inadequate dentition, and poor retentive fat). The nasal lining may or may not be restored, and if the
surfaces, the need for cleaning, and repeated prosthetic refine- only remnant following extirpation is the septal mucosa, one
ments are common problems. option is to elevate the mucosa off the septum, fold it back,
Autologous tissue is frequently preferable. Small defects of and suture it to the posterior nasal airway remnant to close off
the maxilla can be reconstructed with local soft-tissue flaps and obliterate the nasal airway on that side.
with or without supplemental bone grafting. Prior to the
advent of free tissue transfer, larger maxillary defects were
repaired with a variety of pedicled flaps, including the delto-
pectoral, pectoralis major, latissimus dorsi, temporalis, sterno-
mastoid, and trapezius myocutaneous flaps. These flaps were
limited by their reach without tension on the vascular pedicle,
circulatory compromise at the distal (and often most critical)
portion of the flap, inadequate tissue to fill the defect, and/or
the requirement for multiple stages to achieve a final result.
More recently, microvascular free tissue transfer has signifi-
cantly expanded the reconstructive surgeon’s armamentarium
for maxillary reconstruction. There are many composite flaps
that can be transferred to the midface without limitations of
vascular pedicle length or flap geometry. Flaps can be chosen
FIGURE 39.1. The maxilla compared with a hexahedron. The roof
based on the precise tissue, volume, and surface area require- of the maxilla is the floor of the orbit. The floor of the maxilla is the
ments of each defect. hard palate. The anterior, posterior, medial, and lateral walls are
Although free flap reconstruction now is the preferred the vertical buttresses, and the maxillary antrum is contained within
method for the vast majority of extensive maxillary defects, the six walls of the bone.
flap selection is somewhat complex. The initial step is to
430
Chapter 39: Reconstruction of the Maxilla and Skull Base 431
One difficulty in midface reconstruction with free flaps is greater than 50% of the palate (Figure 39.3). Resection of
that the closest recipient vessels are in the ipsilateral neck. The these defects includes the classic hemimaxillectomy, or “infra-
ideal free flap, therefore, must have a pedicle length of 10 to structure maxillectomy,” that involves most of the lower five
13 cm to reach the neck without vein grafting. Although a walls of the maxilla with a medium surface-area-to-volume
variety of free flaps, including fibula, scapula, anterolateral ratio (large surface area and medium volume). Both type IIA
thigh, and iliac crest flaps, can be used to reconstruct max- and type IIB maxillectomy defects are moderate-volume defi-
illary defects, the two flaps most commonly used that have ciencies with large surface area requirements, which usually
large and long pedicles are the rectus abdominis myocutane- require two skin islands.
ous and radial forearm flaps. The rectus flap provides reli- For type IIA defects, reconstruction may involve either a
able skin and a large soft-tissue bulk. The radial forearm flap free flap or a combination of a skin graft and an obturator,
provides a large surface area of pliable skin with minimal soft depending on the patient and the surgeon preference. If a free
tissue and can be combined with a vascularized bone segment. flap is selected to avoid the inconvenience and maintenance
Both flaps can provide multiple skin islands that can be ori- of a palatal obturator, our flap of choice is the radial fore-
ented in different three-dimensional positions. arm fasciocutaneous free flap. To keep the soft palate taut,
Many classification systems have been developed to recreate the buccal sulcus, and to avoid prolapse into the oral
describe the extent of resection of maxillary and midfacial cavity the skin paddle must be equal to or smaller than the
tumors and to provide algorithms for reconstruction. A simple original defect. If adequate teeth or bone stock remain, den-
classification system we have previously described is presented tures or osseointegrated dental implants are used. Smaller
below. type II defects or defects in patients who are not free flap can-
didates can be reconstructed with a temporalis muscle flap
Classification System for Maxillary and (Figure 39.4).
An osteocutaneous radial forearm flap folded into a “sand-
Midfacial Defects wich” is ideal for reconstruction of type IIB defects that by
Type I (limited maxillary) defects involve resection of one or definition include much of the maxillary arch and hard palate.
two walls of the maxilla, excluding the palate (Figure 39.2). This technique provides anterior projection and vascularized
Head and Neck

These defects usually include the anterior and medial walls of bone for dental implant osseointegration. Additionally, the
the maxilla, and occasionally the orbital rim, in combination bone provides support for the upper lip. The folded skin sur-
with the soft tissues and skin of the face. Hence, the defect has faces restore the palatal mucosal lining and nasal floor lining.
a high surface-area-to-volume ratio. The radial forearm flap This flap has a “moderate” amount of volume when folded
is an ideal flap because it has a good surface-area-to-volume over and still maintains an adequate surface area to resurface
ratio, that is, it consists of a small amount of soft-tissue vol- the nasal floor and palate. Anterior bilateral subtotal maxil-
ume and large skin surface area. Defects of the orbital rim or lary defects are ideally suited for an osteocutaneous sandwich
orbital floor are reconstructed with split-calvarial or rib bone flap. Patients with these defects and intact upper external lip
grafts. Other thin flaps with a high surface-area-to-volume structures can be reconstructed with excellent aesthetic and
ratio include the scapular, parascapular, and anterolateral functional results (Figure 39.5). Other options for reconstruc-
thigh fasciocutaneous flaps, depending on the patient’s body tion of type IIB defects include the scapula and fibula osseo-
habitus. Our preference for the radial forearm flap is due to cutaneous flaps. The scapula flap has more tenuous blood
the reliability of the anatomy, the length and caliber of the supply, does not tolerate multiple osteotomies, and requires
pedicle, and the consistently thin and pliable tissue. repositioning the patient preventing a two-team approach.
Type II (subtotal maxillary) defects include resection of The fibula flap supplies abundant well-vascularized bone that
the maxillary arch, palate, and anterior and lateral walls with can tolerate multiple osteotomies. We have found, however,
preservation of the orbital floor. These defects have recently that maxillary arch defects do not require more bone than the
been subdivided into type IIA defects that involve resection of radial forearm fasciocutaneous flap provides, that the fibula
less than 50% of the palate and type IIB defects that involve bone can be bulky in the maxilla, and that the fibula flap
FIGURE 39.2. Type I (limited maxillary) defect. The anterior and medial walls of the maxilla (left) have been resected.
The illustration demonstrates skin/soft-tissue resection in combination with bony resection (center, left) creating a large-
surface-area/low-volume defect. The radial forearm fasciocutaneous flap (donor site depicted in inset) provides multiple
large skin surface areas with minimal volume (center, right). The flap is shown in place, demonstrating skin islands to
resurface anterior cheek and medial nasal lining (right).

FIGURE 39.3. Type II defects. A. Type IIA defects comprise less than 50% of the palate. The illustration demonstrates a folded fasciocutaneous
forearm flap used for reconstruction. The skin island used for palate lining must be taut to prevent prolapse into the oral cavity. A second skin
island may be used for maxillary sinus lining, or the flap may be deepithelialized and allowed to mucosalize. B. Type IIB (subtotal maxillary)
defect. The lower five walls of maxilla have been resected, including the palate, but sparing the orbital floor (roof of the maxilla) (left). The
illustration demonstrates palatal/nasal floor lining and bony resection. This creates a large-surface-area/medium-volume defect (center, left).
The radial forearm osteocutaneous “sandwich” flap (donor site depicted in inset) provides a large skin surface area with vascularized bone and
moderate volume (center, right). The flap is shown in place, demonstrating a strut of vascularized bone to reconstruct the anterior maxillary arch
deficit sandwiched between two skin islands that replace palatal and nasal lining (right).
pedicle is not as long as that of the forearm flap. In addition, floor is required to maintain a functional eye. The floor is
the leg skin is often bulkier than the forearm skin, making restored with nonvascularized bone graft, which must be sup-
inset more difficult and secondary procedures more likely. ported by a well-vascularized flap. The rectus abdominis flap
Type III (total maxillary) defects include resection of all six provides muscle coverage for bone grafts and adequate subcu-
walls of the maxilla. This type of defect is further subdivided taneous fat that can be contoured to fill the dead space. It can
into type IIIA, where the orbital contents are preserved and provide multiple skin islands for the palate and/or external
orbital floor is resected (Figure 39.6), and type IIIB, which is skin and/or nasal lining as needed. A temporalis muscle flap
a total maxillary defect combined with orbital exenteration can also cover the bone grafts for the orbital floor; however,
(Figure 39.7). it may not replace the palate. Consequently, an obturator
Type IIIA defects have medium-large volume and medium- may be required for palate reconstruction. Temporalis flaps
large surface area requirements. Reconstruction of the orbital are indicated in older patients who are not candidates for free

Head and Neck

C
B D
FIGURE 39.4. Type IIA defect following maxillectomy. A, B. A temporalis muscle flap was utilized to reconstruct the palate in this edentulous
patient with significant comorbidities. A split calvarial bone graft was utilized to reconstruct the orbital floor, covered by the temporalis muscle
flap. C, D. Postoperative result.
tissue transfer. Preservation of the malar eminence is helpful often exposed. A rectus abdominis flap is the flap of choice. If
to maintain upper midface projection. Primary bone grafting the external skin of the cheek is present, the skin island of the
in this area can be challenging because it can compress the flap rectus flap can be used to close the palate. If the flap is not too
pedicle. Another option for reconstruction of type IIIA defects bulky, then a second skin paddle can be used to reconstruct
is the fibula flap, as it can be used to reconstruct the orbital the lateral nasal wall. A third skin island can even be used to
floor, vertical buttresses, and alveolar ridge. Muscle and/or restore the external skin. The aesthetic outcome for patients
skin taken with the flap can be used to fill dead space and with reconstructed external skin is fair because of the variabil-
provide lining. Disadvantages include a shorter pedicle length ity of skin color and contour. The contour abnormality can be
and higher complexity; however, it is an option when dental revised at a later time using liposuction and/or skin excision.
restoration is desired. In both IIIA and IIIB defects, the lateral nasal lining may
Type IIIB defects are extensive and have a large volume be missing. Reconstruction with a skin island of the flap will
and large surface area requirement. The palate and nasal lin- maintain the nasal passage, but often the bulk of the flap
ing often require closure to obviate oronasal fistulae. The and loss of bony support can cause collapse of the nasal air-
external defect usually comprises the eyelids and cheek, and way, rendering it nonfunctional. This can result in crusting
occasionally the lip. In addition, the anterior skull base is and even infection. Another option is to elevate a posteriorly

FIGURE 39.5. Bilateral subtotal maxil-

lectomy (type IIB maxillary defect) and
partial upper lip resection in a 30-year-
old man with osteosarcoma of the maxilla
extending into the oral and nasal cavity.
A. Intraoperative defect. B. The radial fore-
arm osteocutaneous flap harvested with
D
segment of the distal radius bone and long
vascular pedicle. C. Vascularized bone graft
rigidly fixed to remaining maxillary tuber-
cles. The skin island has been folded over
the bone and fixed to resurface the floor of
the nose and the palate. D. Postoperative
photograph of a patient after inset of the
flap and closure of the lip defect.
C
FIGURE 39.6. Type IIIA defect. All six walls of the max-
illa, including the floor of orbit and hard palate, have been
resected. The orbital contents have been preserved (left). The
illustration demonstrates the orbital floor, vertical maxillary
buttresses, and palatal resection (center, left). This creates a
medium-surface-area–medium-volume defect. Cranial or rib
bone graft is used to reconstruct the orbital floor and is covered
with a single-skin island rectus abdominis myocutaneous flap
(center, right). The rectus abdominis myocutaneous flap (donor
site depicted in the inset) provides medium surface area with
medium volume. The bone graft is rigidly fixed to reconstruct
the orbital floor. The rectus abdominis myocutaneous flap with
the skin island is used to close the roof of the palate, soft tissue
is used to fill in the midfacial defect, and muscle is used to cover
the bone graft. Note the extended length of the deep inferior
epigastric vessels to neck (right). (Below) Patients who are not
free flap candidates can be reconstructed with split calvarial
bone grafts, covered with the temporalis muscle, transposed
anteriorly. The zygomatic arch should be osteotomized and
temporarily removed to increase excursion of the temporalis
muscle.

FIGURE 39.7. Type IIIB defect. All six walls of

the maxilla, including the floor of the orbit and
orbital contents (left), have been resected. The illus-
tration demonstrates resection of external eyelid,
cheek skin, and orbital contents, in combination
with the entire maxilla and palate (center, left).
This creates a large-surface-area–large-volume
defect. A three-skin island rectus abdominis myo-
cutaneous flap design (inset) provides multiple
large surface areas with a large volume of soft tis-
sue and muscle to fill in the defect (center, right).
based ipsilateral nasal septal mucosa flap and fold it laterally with a single free flap reconstruction can be accomplished.
to obliterate the nasal passage (Figure 39.8). The flap can be Either type IIIA or IIIB flaps can also be reconstructed with a
sewn to the lateral cut edge of the posterior nasopharynx, thus vastus lateralis fascio cutaneous or myocutaneous flap (includ-
obliterating the nasal passage. ing half or more of the vastus lateralis). This flap is of similar
Palatal closure can be accomplished with an obturator volume and surface area as a vertical rectus abdominis flap in
or the flap skin island. The palatal skin island often bulges some patients and can be preferable in patients with a protu-
downward, making denture fitting difficult. Despite this, berant, obese abdomen, or with a history of abdominal sur-
palatal closure with a skin island is preferable because these gery precluding the use of the rectus abdominis flap. A variety
patients are usually able to speak well and eat soft solids with- of other myocutaneous flaps can be utilized, but most require
Head and Neck

out a denture (Figure 39.9). repositioning the patient (preventing a two-team approach),
There is a separate group of type IIIB patients who undergo such as the latissimus dorsi flap, or have a short pedicle, such
resection of the hemimandible in addition to the maxilla and as the gracilis flap.
orbit. These are large volume and large surface area defects. Type IV (orbitomaxillary) defects include resection of the
Reconstruction of the bony defect would require a vascular- orbital contents and the upper five walls of the maxilla, spar-
ized fibula flap, but this would not provide adequate soft tis- ing the palate (Figure 39.10). The reconstructive goal consists
sue or skin for the external and intraoral defect. The rectus primarily of filling the dead space and resurfacing the exter-
flap can provide multiple skin islands to replace the cheek nal skin. The rectus abdominis flap is the ideal flap for this
lining, palate, lateral nasal wall, and external skin. In addi- goal. Although conceptually simple from a reconstructive
tion, the flap’s significant bulk allows contouring of the cheek. standpoint, achieving this goal can be technically challenging.
Remarkably, good function and reasonable aesthetic result The temporal and facial donor vessels are usually resected or
A B
FIGURE 39.8. A and B. A 57-year-old man with a type IIIB maxillectomy defect including much of the nasal septal lining. The remaining septal
mucosa (arrow) was elevated as a posteriorly based mucosal flap, folded laterally, and sewn to the lateral cut edge of the posterior nasopharynx
to obliterate the left nasal passage (arrow).

A B
FIGURE 39.9. A 65-year-old man who underwent total maxil-

lectomy with orbital exenteration and segmental mandibulec-
tomy (type IIIB defect) for excision of a recurrent squamous cell
cancer of the cheek skin invading maxilla, orbit, and oral cavity.
A. Intraoperative defect. B. Reconstruction of the defect was per-
formed using a two-skin island rectus abdominis free flap for intra-
oral/palatal lining and external skin. C. Final appearance after two
revisions of the flap to decrease bulk.
C
unreliable. The flap pedicle can be lengthened by intramuscu- An algorithm for reconstruction based on the above clas-
lar dissection up to 20 cm to reach the neck vessels. A superfi- sification system is shown in Figure 39.11.
cial tunnel can be created in the facelift plane or medial to the A unique challenge of maxillary reconstruction involves
mandible by a parapharyngeal approach to gain access to the repair not only of the maxillary defect but also of adjacent
neck vessels without vein grafts. important structures of the face, such as the lip and oral

FIGURE 39.10. Type IV (orbitomaxillary) defect. The upper five walls of the maxilla have been resected, including the
orbital contents, but sparing the palate (left). The specimen demonstrates resection of orbital contents, eyelid, and cheek
skin in continuity with bone (center, left). This creates a large-surface-area–large-volume defect. Note the design of the
single-skin island rectus abdominis myocutaneous flap (inset). This flap provides large surface area with large volume to
reconstruct the defect (center, right). Rectus abdominis myocutaneous flap in place, demonstrating skin island to resurface
the external skin defect with muscle and subcutaneous fat used to fill in the soft-tissue deficit (right).
Head and Neck

commissure, eyelids, and nose that may be resected dur- results of functional eyelid reconstruction are usually unsat-
ing tumor extirpation. Reconstruction of a functioning lip is isfactory, a patch, dark eyeglasses, or an external glue-on
extremely difficult and involves restoring a competent oral type of prosthesis (cosmetic patch) is preferable to recon-
sphincter. The primary restoration of the lips with local lip- struction for type IIIB defects. Preoperative consultation
switch procedures prior to maxillary reconstruction with a with an experienced anaplastologist can assist in providing
free flap is advocated. The free flap should not be attached the best possible result when a prosthesis is planned, espe-
directly into the sphincter, or used to reconstruct any por- cially when secondary contouring procedures are planned to
tion of the lips, unless more than 80% of either the lower or improve prosthetic fit. An orbital hollow at least 1 cm deeper
upper lip is missing. The disadvantage of microstomia is less than the contralateral cornea is required for an ocular pros-
debilitating than oral incompetence and constant drooling. thesis (Figure 39.12).
Reconstruction of upper lip defects with flap tissue is not as Large maxillary resections may involve the nose. Although
debilitating as reconstruction of the lower lip with an atonic, the nose is aesthetically important, it is not essential from a
adynamic flap. functional standpoint. Usually, local tissues (septum, nasal
Eyelid reconstruction may be necessary in types I and III lining flaps, nasolabial flaps) are unavailable or irradiated.
defects. Ectropion is the most common postoperative prob- Reconstruction using local tissues, or even a second free
lem. This can usually be corrected with a variety of secondary flap, is usually difficult and yields poor aesthetic results.
procedures, including a tarsal strip procedure, skin grafting, Consequently, delayed nasal reconstruction is advocated in all
and canthopexy. Type IIIB defects involve orbital exentera- cases. Although prosthetic nasal reconstruction is preferable,
tion, making eyelid restoration less important. Because the delayed autologous reconstruction is also an option.
Defect Limited (I) Subtotal (II) Total (III) Orbitomaxillectomy (IV)

(Type)
III a III b
Surface area/ Large/ Large/ Large/ Large/ Large/

volume require medium medium medium large large
Palate No Yes Yes Yes No
Orbital floor Yes No No Yes No No
Bone graft Bone graft

Flap Radial Radial Single-skin island Two- or three- One- or two-
forearm forearm rectus abdominis skin island skin island
fasciocutaneous osteocutaneous MC free flap or rectus rectus
free flap free flap temporalis abdominis abdominis
muscle MC free flap MC free flap
pedicle flap
FIGURE 39.11. Algorithm for maxillary reconstruction. MC, musculocutaneous.

A
B
C D
FIGURE 39.12. A and B. Following vertical rectus abdominis myocutaneous flap coverage of a type IIIB defect, this patient had too much bulk
in the orbit preventing placement of an ocular prosthesis. Direct excision combined with liposuction improved flap contour and provided an
appropriate platform for prosthetic fitting. A staged “nasolabial” flap was elevated to increase the oral aperture and add intraoral lining. C and
D. An ocular prosthesis greatly improves the aesthetic outcome for patients undergoing coverage of type IIIB or IV defects with large soft-tissue
flaps. An adequate orbital hollow should be recessed at least 1 cm from the normal cornea.

requiring larger flaps. In the 1970s, regional flaps, such as the
Summary latissimus dorsi, pectoralis major, sternocleidomastoid, and
Maxillectomy and midfacial defects are classified into four trapezius flaps, were used to reconstruct these larger defects.
types of defects based on the extent of maxillary resection. These regional flaps are limited by pedicle location below the
This classification allows for a simplified approach to midface clavicle, which restricts the arc of rotation superiorly. The
reconstruction. The algorithm is based on the type of maxil- development of free tissue transfer in the 1980s provided a
lary defect, which will usually have specific skin, soft-tissue, highly reliable method for repairing large, complex wounds
palatal, orbital floor, and bony structure deficits. Bone recon- in the skull base. Free flaps are well vascularized and can be
struction is best accomplished with bone grafts for the floor used in irradiated sites or in patients who will receive adju-
of the orbit and a vascularized bone flap for the maxillary vant radiotherapy. They provide enough tissue bulk and ease
arch. Soft-tissue and skin coverage is commonly provided by of insetting to obliterate dead space and seal the intracranial
free flaps. The choice of flap is determined by the surface area contents from the external environment and aerodigestive
and tissue volume requirements. Large surface area and small- tract. In addition, adequate composite tissue can be harvested
to medium-volume defects are best reconstructed with radial to replace external skin, mucosa, soft tissue, and bone in large
forearm fasciocutaneous or osteocutaneous flaps. Large- skull base defects in a single stage.
volume and medium to large surface area defects are best Although either pedicled flaps or free tissue transfer can
reconstructed with rectus abdominis free flaps. Other options be used to reconstruct large skull base defects, several authors
include the fibula and anterolateral thigh flaps. Critical mid- have compared outcomes using free flaps versus local or
facial structures, such as the lips, eyelids, and nose, should be regional flaps to repair difficult skull base wounds. Each study
addressed separately, using local flaps if possible. The major- has demonstrated that free tissue transfer is associated with
ity of patients whose maxillary defects are reconstructed using fewer complications than local or regional flaps for large dif-
free tissue transfers have remarkably good function. Aesthetic ficult wounds. In addition, a steady decline in the complica-
results are mainly dependent on whether the orbital contents tion rate of skull base surgery in the last 10 years has been
are removed and on the extent of external skin resection. observed. Consequently, free tissue transfer is frequently used
for reconstruction of extensive, difficult skull base defects.
Head and Neck

Although skull base surgery has become less invasive, the need
Reconstruction of Skull to reconstruct large defects still arises.
When determining the most appropriate technique for
Base Defects reconstruction, it is useful to identify the location of the skull
The most common cause of skull base defects is tumor resec- base resection and the type of defect. Most skull base defects
tion. Other etiologies include trauma, late posttraumatic cere- can be categorized as either an anterior or lateral skull base
brospinal fluid leak, craniofacial deformity, recurrent frontal defect. The defect is assessed for the extent of dural defect,
mucocele, and midline dermoid cyst with intracranial extension. exposure to the aerodigestive tract, and skin, soft tissue, bone,
Surgical ablation of skull base tumors can result in an extensive and mucosal lining deficits. Furthermore, resection of key
defect with exposed brain, dura, cranial bone, and associated adjacent structures, specifically, the orbit, ear, maxilla, pal-
defects of adjacent structures, requiring composite tissue recon- ate, and mandible, is considered in the flap selection process.
struction to restore a combination of skin, soft tissue, bone, and Finally, radiation, prior surgery, and availability of local tis-
mucosa. The goals of skull base reconstruction are to: sues for repair must be assessed.
The first priority in skull base reconstruction is to repair
1. Repair and seal the dura
the dural defect in a watertight fashion through either direct
2. Separate the intracranial contents from the aerodigestive
closure or patching with autologous (pericranium, temporalis
tract
fascia, or fascia lata) or alloplastic material. Fibrin glue is an
3. Re-establish orbital and oropharyngeal function
excellent adjunct to prevent cerebrospinal fluid leak. After a
4. Restore form by providing structural support, adequate
watertight dural closure is accomplished, vascularized tissue is
soft-tissue bulk, and external skin coverage
interposed between the intracranial contents and the oropha-
5. Obliterate dead space
ryngeal cavity. This provides a barrier and prevents dural con-
Repair of skull base defects is challenging because an tamination with the oropharyngeal bacterial flora. Usually, a
unsuccessful reconstruction can lead to life-threatening com- flap with extensive soft-tissue bulk is required to obliterate
plications. Early complications following skull base surgery the dead space and to restore adequate surface contour of the
include dural exposure, cerebrospinal fluid leak, pneumocra- face. Musculocutaneous free flaps (latissimus dorsi or rectus
nium, wound infection, meningitis, epidural abscess, brain abdominis) or fasciocutaneous flaps (radial forearm, para-
abscess, hemorrhage, and neurologic injury. Late complica- scapular, or anterolateral thigh) can be used for soft-tissue
tions include globe malposition, diplopia, malocclusion, reconstruction of the skull base.
nasopharyngeal stenosis, trismus, chronic sinusitis, nasal Often key aesthetic structures, such as the ear, nose, and
obstruction, and facial deformity. To avoid potentially dev- eyes, are resected during ablative skull base surgery. Definitive
astating postoperative complications, the ideal reconstruction reconstruction of these structures is usually not undertaken
for skull base defect must be reliable regardless of technical at the initial stage of reconstruction. Prosthetic reconstruc-
difficulty. tion remains a common and excellent method for replacing
Prior to the 1960s, skull base surgery was limited because unique facial structures. However, simple soft-tissue filler over
of the associated high morbidity and mortality and the pau- the anatomic defect and wearing a patch to cover the missing
city of reliable reconstructive techniques. During this period, aesthetic structure is another alternative.
repair of skull base defects was performed using skin grafts The indications for bone reconstruction in skull base sur-
and local available tissues, such as scalp, galeal, pericranial, gery include extremely large bony defects of the skull base
and temporalis flaps. The application of local flaps is limited that will result in gross brain herniation; near-total or com-
by their small size, short arc of rotation, and donor-site defect. plete orbital roof defects that may result in pulsatile exoph-
In addition, these local flaps are unreliable in patients who thalmos; orbital wall or floor defects that carry a high risk
have had previous radiation therapy, multiple craniotomies, of enophthalmos; cranio-orbital defects that will result in
or a larger skull base resection. With the advent of the com- inadequate soft-tissue support and deformity; and associated
bined extracranial–intracranial approach by Ketcham et al., in maxillary or mandibular/glenoid fossa defects that will result
1963, and improved reconstructive techniques, the number of in facial deformity, malocclusion, and masticatory dysfunc-
skull base surgeries has increased and resulted in larger defects tion. Alloplastic materials or nonvascularized bone grafts in

FIGURE 39.13. Lateral skull base defect. A. Lateral defect follow-

ing tumor extirpation with medial antebrachial cutaneous nerve graft
to reconstruct facial nerve defect. B and C. Reconstruction of lateral
skull base defect with vertical rectus abdominis myocutaneous flap.
B
conjunction with vascularized tissue can be used for bone

reconstruction for most isolated bone defects. Free osseous Anterior Skull Base
composite tissue transfer is indicated only in specialized cases For small defects of the anterior skull base that do not require
where bone grafts combined with soft-tissue flaps are inade- obliteration of dead space, the workhorse flaps are the peri-
quate, and the bone flap can incorporate enough soft tissue to cranial and galea–pericranial flap. These flaps provide a thin,
fulfill the other requirements for reconstruction listed above. well-vascularized sheet of fascia that can easily reach the ante-
Common composite vascularized osseous flaps include fibula, rior skull base and reinforce dural repair, separating the dura
scapula, and radial forearm flaps. from the subjacent spaces.

Head and Neck

FIGURE 39.14. Lateral skull base defect. A. Lateral skull base defect
following tumor extirpation with medial antebrachial cutaneous
nerve graft to reconstruct facial nerve defect. B. Reconstruction of
lateral skull base defect with muscle-sparing anterolateral thigh flap.
A
For patients with a history of prior surgery or radiation and abdominis harvest, the anterolateral thigh myocutaneous or
large extensive anterior skull base defects, free tissue trans- fasciocutaneous flap is a good alternative with less reliable
fer is required. A variety of different free flaps can be used, anatomy but good pedicle length and adequate soft tissue
including rectus abdominis, latissimus, radial forearm, fibula, depending on the patient’s body habitus (Figure 39.14).
anterolateral thigh, and scapular flaps. Flap selection is based
on a variety of factors, including the size of defect and degree
of involvement of adjacent structures such as the scalp, orbit,
Conclusion
maxilla, and mandible. In general, the surface and volume Local or regional flaps are used for the reconstruction of small
deficits of the defect are assessed and the flap that best fits the skull base defects. The morbidity and mortality of aggressive
defect is selected. In some cases, the location of the defect may skull base resection has decreased as a result of a multidis-
determine the flap selection based on the availability of recipi- ciplinary approach involving neurosurgeons, head and neck
ent vessels. The superficial temporal vessels can be used for surgeons, and plastic surgeons, and advances in ablative and
defects high in the skull base, involving the scalp or orbit. For microsurgical techniques. Free tissue transfer is the preferred
defects involving the orbit, maxilla, or lower face, the recipi- method for complex anterior skull base reconstruction involv-
ent vessels are usually found in the neck (Figure 39.9). ing dura, brain, or other major structures adjacent to the skull
base, including the orbit, maxilla, and other structures. Free
Lateral Skull Base flaps are occasionally required for lateral skull base defects as
well. Successful reconstruction can be safely achieved, restoring
The workhorse for small defects of the lateral skull base is form and function, with adherence to basic principles of recon-
the temporalis muscle flap. It has the greatest utility in reconstruction, including watertight dural repair, coverage of dura
structing defects of the infratemporal fossa. However, the and separation from nasopharyngeal cavity, and obliteration of
temporalis is frequently devascularized during the ablative dead space.
surgery and is not usable. In addition, its use is associated with
a distinct contour defect in the temporal fossa. Suggested Readings
For larger and more complex defects of the lateral skull
1. Califano J, Cordeiro PG, Disa JJ, et al. Anterior cranial base reconstruction
base, free tissue transfer is indicated. Options include rectus using free tissue transfer: changing trends. Head Neck. 2003;25:89.
abdominis, latissimus dorsi, anterolateral thigh, and lateral 2. Chang DW, Langstein HN, Gupta A, et al. Reconstructive manage-
arm flaps. These defects of the lateral skull base usually require ment of cranial base defects after tumor ablation. Plast Reconstr Surg.
filling and resurfacing the defect. Consequently, flap selection 2001;107:1346.
3. Cordeiro PG, Bacilious N, Schantz S, et al. The radial forearm osteocutane-
is based on the extent of volume and surface area, which is ous “sandwich” free flap for reconstruction of the bilateral subtotal maxil-
determined by the defect. The rectus abdominis myocutaneous lectomy defect. Ann Plast Surg. 1998;40:397.
flap is very commonly used because of its location (allowing 4. Cordeiro PG, Chen CM. A 15-year review of midface reconstruction after
for simultaneous dissection during resection of tumor), large total and subtotal maxillectomy: part I: algorithm and outcomes. Plast
Reconstr Surg. 2012;129:139-147.
skin island, soft-tissue volume, and reliable vascular pedicle 5. Cordeiro PG, Santamaria E. A classification system and algorithm for
(Figure 39.13). In patients with a large protuberant abdo- reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg.
men or with a history of abdominal surgery precluding rectus 2000;105:2331.

6. Cordeiro PG, Santamaria E, Kraus D, et al. Reconstruction of total maxil- 12. Imola MJ, Sciarreta V, Schramm VL. Skull base reconstruction. Curr Opin
lectomy defects with preservation of orbital contents. Plast Reconstr Surg. Otolaryngol Head Neck Surg. 2003;11:282.
1998;102:1874. 13. Izquierdo R, Leonetti JP, Origitano TC, et al. Refinements using free-tissue
7. Cordeiro PG, Wolfe SA. The temporalis muscle flap revisited on its cen- transfer for complex cranial base reconstruction. Plast Reconstr Surg.
tennial: advantages, newer uses and disadvantages. Plast Reconstr Surg. 1993;92:567.
1996;98:980. 14. Neligan PC, Mulholland S, Irish J, et al. Flap selection in cranial base recon-
8. Disa JJ, Rodriguez VM, Cordeiro PG. Reconstruction of lateral skull struction. Plast Reconstr Surg. 1996;98:1159.
base oncological defects: the role of free tissue transfer. Ann Plast Surg. 15. Rodriguez ED, Bluebond-Langner R, Park JE, Manson PN. Preservation of
1998;41:633. contour in periorbital and midfacial craniofacial microsurgery: reconstruc-
9. Futran ND, Wadsworth JT, Villaret D, Farwell DG. Midface reconstruction of the soft-tissue elements and skeletal buttresses. Plast Reconstr Surg.
tion with the fibula free flap. Arch Otolaryngol Head Neck Surg. February May 2008;121(5):1738-1747; discussion 1748-1749.
2002;128(2):161-166. 16. Teknos TN, Smith JC, Day TA, et al. Microvascular free tissue trans-
10. Georgantopoulou A, Hodgkinson PD, Gerber CJ. Cranial-base surgery: a fer in reconstructing skull base defects: lessons learned. Laryngoscope.
reconstructive algorithm. Br J Plast Surg. 2003;56:10. 2002;112:1871.
11. Halvorson EG, Cordeiro PG, Disa JJ, Wallin EF, Mehrara BJ. Superficial 17. Yamamoto Y, Hawashima K, Sugihara T, et al. Surgical management of
temporal recipient vessels in microvascular orbit and scalp reconstruction of maxillectomy defects based on the concept of buttress reconstruction. Head
oncologic defects. J Reconstr Microsurg. 2009;25(6):383-387. Neck. 2004;26:247.

Chapter 40 n RECONSTRUCTION OF THE
ORAL CAVITY, PHARYNX,
AND ESOPHAGUS
Matthew M. Hanasono
the proximal esophagus, while adenocarcinoma is the most

Introduction common cancer of the distal esophagus.
The oral cavity, pharynx, and esophagus are responsible for
the critical functions of speech, mastication, swallowing, and
maintenance of the airway. Head and neck reconstruction Oral Cavity
aiming to restore or preserve these functions is performed
after surgical ablation of malignant tumors, congenital and Floor of Mouth Reconstruction
acquired benign conditions, and traumatic injuries. The pur- Small- or partial-thickness defects of the floor of mouth can be
pose of this chapter is to highlight the reconstructive chal- skin grafted or repaired with a facial artery musculomucosal
lenges associated with each of these anatomic regions. (FAMM) flap. The FAMM flap is based on the facial artery
and includes a portion of the buccinator muscle in addition to
the buccal mucosa and is usually useful for small defects (2 to
Anatomy 3 cm) that enable primary closure of the donor site.1 This vas-
Head and Neck

The oral cavity is bounded by the lips anteriorly and the base cularized flap is useful for the coverage of exposed bone and
of the tongue and soft palate posteriorly. Subsites of the oral to prevent tethering of the tongue that may occur as a result
cavity include the floor of the mouth, oral tongue (anterior of graft contracture.
two-thirds of the tongue, up to the circumvallate papillae), The pedicled pectoralis major myocutaneous (PMMC) flap
buccal mucosa, hard palate, mandibular and maxillary alveo- or pectoralis major muscle flap covered by a skin graft can be
lar ridges, and retromolar trigones. The oral tongue is a criti- also used for extensive floor of mouth as well as many other
cal structure for speech articulation and manipulating food. oral cavity reconstructions. These flaps are based on the thora-
The hypoglossal (XII) nerve innervates all the muscles of the coacromial artery and can reliably reach as high as soft palate.
tongue except for the palatoglossus, which is innervated by The skin paddle of the PMMC flap is reliable when designed
the vagus (X) nerve. The facial (VII) nerve, via the chorda tym- to include adequate cutaneous perforators.2 Limitations of
pani, and the lingual (V3) nerve are responsible for taste and the pedicled pectoralis major flap include limited reach, neck
sensation of the oral tongue, respectively. Squamous cell car- contracture due to fibrosis of the proximal muscle, and the
cinomas arising from the mucosa are the most common type potential for an unsightly bulge in the neck. Despite these
of cancer affecting the oral cavity (see Chapter 30). Salivary drawbacks, the PMMC and pectoralis muscle flaps are still
gland cancers, arising from the submandibular, sublingual, frequently used in patients who are poor free flap candidates,
and minor salivary glands, are the next most common. as an additional flap in conjunction with a free flap to recon-
The pharynx is divided into the nasopharynx, orophar- struct massive defects, or as a secondary option in the event of
ynx, and hypopharynx. The nasopharynx extends from the a free flap failure. Anatomic studies suggest that a PMMC flap
skull base to the level of the soft palate. Most cancers of the skin paddle centered over the 4th intercostal space is optimal
nasopharynx are treated with combined radiation and che- in terms of reliability and reach.
motherapy, and surgical defects in this region are rare. The Free flaps are the preferred method of reconstruction of
oropharynx extends from the soft palate to the hyoid bone. floor of mouth defects in patients who have acceptable medical/
The soft palate, tonsils, tonsillar pillars, base of the tongue, surgical risk factors. In these cases, free flaps typically have a
and pharyngeal walls at this level are all considered parts of more robust blood supply and a better arc of rotation than ped-
the oropharynx. The soft palate prevents nasal regurgitation, icled flaps. In addition, free flaps can be harvested from a vari-
while the base of tongue and pharyngeal walls, which contain ety of areas enabling the surgeon to transfer tissues that more
constrictor muscles, play a critical role in deglutition. The closely resemble the resected structures. For example, the radial
hypopharynx extends from the hyoid bone to the cricopharyn- forearm fasciocutaneous (RFF) free flap is useful for moderate
geus muscle, which is the most important component of the to large floor of mouth defects since it is thin and pliable, thus
upper esophageal sphincter. The piriform sinuses, postcricoid preventing compromised speech or swallowing due to excess
area, and posterior pharyngeal wall comprise the hypophar- bulk or tethering of the tongue. The RFF is based on the radial
ynx. The hypopharynx may be the site of primary cancers, artery and is rapidly harvested with a long pedicle, thereby
again most commonly squamous cell carcinomas, or may be facilitating head and neck reconstruction. Drawbacks of the
involved in laryngeal cancers, which are more common, by RFF flap are decreased circulation to the hand, risk of tendon
direct extension. exposure due to incomplete skin graft take, radial nerve injury,
The esophagus begins distal to the cricopharyngeus muscle and an unfavorable donor site appearance in some patients. A
and ends at the gastroesophageal junction. It is a mucosa- suprafascial harvest, in which the fascia investing the forearm
lined tube surrounded by a submucosa that contains secretory muscles and tendons is spared, may decrease donor site morbid-
glands, an inner circular and outer longitudinal layer of mus- ity without compromising flap viability.3
cles that are responsible for peristalsis, and an outer adventitia For floor of mouth resections that result in substantial
but not a true serosa. The walls of the proximal third of the submandibular dead space, slightly bulkier flaps, such as the
esophagus contain striated muscle and the walls of the dis- anterolateral thigh (ALT) free flap, are useful. The ALT free
tal third of the esophagus contain smooth muscle, while the flap is based on skin perforators arising from the descending
walls of middle third contain a mix of the two types of muscle. branch of the lateral circumflex femoral artery and vein and
Squamous cell carcinoma is the most common cancer affecting is particularly useful in head and neck reconstruction because
443
it can be transferred either as a fasciocutaneous flap or as at least 8 to 9 cm in most cases, anticipating some atrophy of
a myocutaneous flap depending on the reconstructive needs. the flap with time, particularly if postoperative radiation will
When harvested as a fasciocutaneous free flap, it is usually be administered (Figure 40.2). Additionally, many surgeons
intermediate in thickness between the RFF flap and the ver- believe that laryngeal suspension using permanent sutures
tical rectus abdominis myocutaneous (VRAM) flap. The between the hyoid bone and mandible helps prevent prolapse
VRAM flap is based on the deep inferior epigastric vessels of the flap and improve functional results. If at all possible,
and is too bulky in most patients with isolated floor of mouth concave reconstructions creating a trough-like area should
defects. Although the bulk of the VRAM can be decreased be avoided since pooling of oral secretions is associated with
by harvesting it as a fasciocutaneous flap based on the deep aspiration. In any case, the patient should be counseled preop-
inferior epigastric perforatoring (DIEP) vessels, even without eratively about the possibility of unintelligible speech, inabil-
the rectus abdominis muscle the DIEP flap is often thicker ity to swallow, and chronic aspiration.
than the ALT free flap. Although the complex motor function of the tongue can-
not be restored with current reconstructive techniques, sen-
Buccal Mucosa Reconstruction sory re-innervation of free flaps is well documented.7 The RFF
free flap can be made potentially sensate by coapting the lat-
The goal of reconstruction for defects involving the buccal eral antebrachial cutaneous nerve to the stump of the lingual
mucosa is to prevent cicatricial trismus. Primary closure can nerve using standard techniques. Similarly, the ALT and RAM
be used for small defects, and split- or full-thickness grafts can free flaps can be made sensate by anastomosis of the lateral
be used for moderate ones. For defects involving the major- circumflex femoral and intercostal nerves, respectively, to the
ity of the buccal mucosa, a thin, pliable fasciocutaneous free lingual nerve. Sensory recovery is variable and likely depen-
flap such as the RFF flap is indicated to prevent scar contrac- dent on a number of factors, including postoperative radia-
ture from limiting mouth opening. The ALT flap may also be tion. Interestingly, low volume free flaps, such as the RFF,
used in thin patients and may have the advantage of decreased have been shown to recover some sensation spontaneously
donor site morbidity as compared with the RFF. Alternatively, even if nerve repair is not performed. It remains unclear, how-
the ALT free flap can be thinned considerably at the time of ever, whether the amount of sensibility typically recovered
surgery, taking care not to injure the perforator blood sup- secondary to nerve repair actually translates into improved
ply and the subdermal vascular plexus of the flap, or can be speech or swallowing.
reduced secondarily. Buccal mucosa resections that result in
through-and-through cheek defects often require reconstruc-
tion with flaps that can either be folded on themselves, de- Reconstruction of Other Oral
epithelializing a portion of the flap to allow wound closure at Cavity Structures
the flap margin, or allow harvest with dual skin paddles. ALT
Tumors involving the mandible are relatively common and
and VRAM free flaps, and less commonly the RFF, can be
usually necessitate an osseous or osteocutaneous flap for
designed with more than one skin paddle, allowing separate
reconstruction (see Chapter 38). Simple mandibular resections
reconstruction of the buccal mucosa and external cheek skin
that include the mandibular ramus or posterior mandibular
with a single flap.
body are usually reconstructed with osseous free flaps such
as the fibula or iliac crest. In contrast, complex retromolar
Tongue Reconstruction trigone resections that include the condyle-bearing portion
Partial tongue defects can be closed primarily or with of the mandible and adjacent soft tissue structures, such as
full-thickness skin grafts to prevent graft contracture. If the lateral pharyngeal wall or external skin, are commonly
primary closure or a graft is likely to result in significant reconstructed with bulky soft tissue flaps and usually lead
tongue tethering or an inability to effectively obliterate the to satisfactory cosmetic and functional results.8 Resection of
oral cavity space due to the size of the defect, a flap is usu- the anterior mandible requires osseous flaps in most cases to
ally indicated for closure. In practical terms, flaps are com- restore facial projection. In some cases, two free flaps or a
monly required for defects approaching half the tongue and combination of a free and pedicled flap is necessary for mas-
larger. Additionally, a through-and-through defect commu- sive defects involving soft tissue and bone resection.
nicating with the dissected neck is usually best addressed Similar to mandible reconstruction, the posterior maxillary
with a flap to decrease the risk of fistula. The goal is to alveolar ridge and/or hard palate can be reconstructed with
allow the residual tongue to contact the premaxilla and pal- osteocutaneous free flaps or soft tissue free flaps. In addi-
ate for speech articulation, as well as to be able to sweep tion, these defects may be amenable to skin grafting of the
and clear the oral cavity, and move food and secretions maxillary sinus and reconstruction (see Chapter 39) using
from anterior to posterior.4 a prosthetic obturator if the orbital floor is intact. Anterior
For hemiglossectomy defects, a thin, pliable flap is needed defects of the maxilla, similar to the mandible, require rigid
to preserve tongue mobility, although a small amount of reconstruction either with an osseous flap or an obturator to
bulk is needed to obliterate the oral cavity dead space with restore facial projection. The temporalis muscle flap is occa-
the mouth closed and not create a funnel for secretions to sionally useful in small defects of the hard palate or maxillary
drain directly into the larynx. Here again, most surgeons sinus. The reach of the flap can be extended by transposing it
prefer the RFF free flap oriented such that the distal end of beneath the zygoma (the zygoma is temporarily removed and
the flap is used to reconstruct the anterior portion of the then replaced after flap rotation).9
tongue (Figure 40.1). Adequate flap width is needed to pre-
vent tethering the tip of the tongue to the floor of mouth
and to recreate a sulcus. Bulkier free flaps or the PMMC
Pharynx
flap can also be used in more extensive resections; how- Many oropharyngeal cancers are more radiosensitive than oral
ever, these options typically have inferior results in terms of cancers and radiotherapy is increasingly used as primary treat-
speech and swallowing. ment in an effort to decrease morbidity secondary to surgical
The strategy for reconstruction following near-total and resection. Nevertheless, surgical resection is still indicated for
total glossectomy is different. In these cases, a bulkier flap extensive tumors, such as those that involved both the oral
is required to reconstruct the greater volume of resection, cavity and the oropharynx, and for recurrent cancers. The
and flaps such as the VRAM and ALT are commonly used. goals of reconstruction for the oropharynx include restoring
Swallowing and speech outcomes are better when the flap can continuity to the aerodigestive tract and replacing the volume
be made convex into the oral cavity.5,6 To do so, it is helpful of the tongue base to maintain swallowing function without
to design the flap to be somewhat wider than the oral defect, aspiration.
Chapter 40: Reconstruction of the Oral Cavity, Pharynx, and Esophagus 445
Defects of the tonsillar fossa and pharyngeal walls can be
reconstructed with a skin graft or allowed to heal by secondary
intention when they are small and superficial. Deep wounds,
such as those that result in communication with the neck con-
tents, usually require a flap for closure. These defects are typi-
cally closed with low volume flaps such as the RFF and ALT
since care must be taken to avoid interference with the airway
or swallowing. Isolated base of tongue defects can sometimes
be closed primarily. Partial defects, including those occurring
in continuity with a tonsillar or retromolar trigone resection,
are best reconstructed with a thin- to moderate-thickness fas-
ciocutaneous free flap. Reconstruction of tongue base defects
occurring as part of a near-total or total glossectomy requires
bulkier flaps as discussed in the Oral Cavity section.
Most tumors involving the hypopharynx, including both
primary hypopharyngeal tumors and extensive laryngeal
tumors, are malignant and are treated by laryngopharyngec-
tomy. In such cases, reconstruction involves restoring a part
or the entire circumference of the hypopharynx, sometimes
extending to the cervical esophagus, thus restoring the con-
tinuity between the oral cavity and the distal esophagus for
swallowing. Microvascular free flaps have largely replaced
regional pedicled flaps, such as the PMMC flap, due to their
lower fistula rates. Free flap options include the jejunal free
flap and fasciocutaneous free flaps, such as the ALT and the
Head and Neck

RFF free flaps.
The jejunal free flap is supplied by vascular arcades aris-
ing from the superior mesenteric artery and vein. A suitable
segment located 20 to 30 cm from the ligament of Treitz is
selected and the flap is isolated on a single arcade. The length
of the jejunal segment required for the reconstruction is based
on the defect in the pharynx and a segment measuring 10
to 15 cm is usually required. The flap can be split along the B
antimesenteric border to increase the diameter so that it is of
suitable diameter to match that of the oropharynx and is inset
into the defect in an isoperistaltic manner. Care must be taken
to avoid redundancy as this may result in regurgitation and
C
FIGURE 40.1. Radial forearm flap for the tongue defect. A. A left
hemiglossectomy defect following removal of a squamous cell cancer.
B. Reconstruction of the defect with a radial forearm fasciocutaneous
(RFF) free flap. C. Appearance 9 months after surgery.
A
dysphagia.10 Warm ischemic time should be limited to less

than 2.5 hours to avoid ischemia reperfusion injury. Intestinal
continuity is restored in the abdomen and the wound is closed
in a standard fashion.
The ALT free flap is another option for hypopharyngeal
reconstruction.11 To create a 3 cm diameter “tube,” a 9.4 cm
wide flap is required, based on the formula, circumference =
p x diameter. Compared with the RAM free flap or the DIEP
flap, the ALT free flap is usually thinner in most patients and
a wider skin paddle, needed for reconstruction of circumferen-
tial defects, can usually be obtained. The RFF free flap is also
useful for hypopharyngeal reconstruction, particularly in par-
tial circumference defects or in obese patients with excessive
thigh thickness. Some hypopharyngeal resections may spare a
significant amount of the pharynx, and, occasionally, small or
benign tumors can be resected with preservation of the larynx.
In such cases, small fasciocutaneous flaps, such as the RFF
free flap, are best suited to restoring pharyngeal continuity as
a “patch.” For intermediate-sized noncircumferential defects,
such as those that spare the posterior pharyngeal wall, the jeju-
nal free flap can be split along its antimesenteric border or an
appropriately narrower ALT free flap can be used for recon-
struction. In addition, the PMMC flap is useful in medically
high-risk patients who have acquired defects of the anterior
wall of the pharynx.
An advantage of the jejunal free flap is the avoidance of
an additional suture line when reconstructing circumferential
defects. The primary disadvantage of the jejunal free flap is
the need for a laparotomy, which may result in postopera-
tive ileus, and the risks of anastomotic leakage of the repaired
small intestine as well as potential late bowel obstruction due
to adhesion formation. The ALT free flap is associated with
A minimal donor site morbidity, but may be excessively thick
and difficult to inset in obese patients. Both flaps are reliable
with low rates of postoperative pharyngocutaneous fistula
formation.
Combined radiation and chemotherapy are increasingly
used as primary therapy even for advanced laryngeal cancers.
Thus, surgical resections tend to most commonly be performed
for recurrent cancers, increasing the difficulty of reconstruc-
tion and the risk of postoperative complications, such as
fistula. In addition, previously irradiated neck skin tends to
contract after skin flap elevation and may be at high risk for
wound healing problems if closed under tension. Suture lines
may be especially tight along the tracheal stoma when a distal
tracheal resection has been performed. In addition to potential
exposure of the major neck vessels, a wound dehiscence in the
region of the tracheal stoma or pharyngeal closure can result
in significant further morbidity.
Reconstruction of the anterior neck skin often requires a
second flap, either another free flap or a pedicled flap. The
PMMC flap or pectoralis major muscle flap covered by a skin
graft is frequently used to reconstruct the peristomal neck
skin. Unilateral or bilateral deltopectoral flaps can also be
used for this application. An elegant solution is to use a single
flap to reconstruct both the pharynx and the anterior neck
skin. The ALT free flap can often be designed with two skin
paddles based on independent cutaneous perforating blood
vessels that join together proximally within the main vascular
pedicle, thus requiring only a single set of arterial and venous
anastomoses to complete the reconstruction (Figure 40.3).12
When more than one perforator is not available, the vastus
lateralis muscle can be included with the ALT free flap and
skin grafted to reconstruct the neck skin defect. Alternatively,
the ALT free flap or other fasciocutaneous free flaps can be
partially de-epithelialized, and a portion of the skin paddle
B can be used to reconstruct the neck skin defect.
Vocal rehabilitation following laryngopharyngectomy can
FIGURE 40.2. Anterolateral thigh flap for total glossectomy defect. be accomplished by a number of methods, including use of an
A. Reconstruction of a total glossectomy defect with an anterolateral thigh
(ALT) free flap. B. Postoperative appearance 12 months after surgery fol-
electrolarynx device or a tracheoesophageal puncture (TEP)
lowed by radiation therapy. Note the significant amount of atrophy. prosthesis. The TEP prosthesis is inserted into a surgically cre-
ated hole between the common wall of the posterior trachea
Head and Neck

A B
C D
FIGURE 40.3. ALT flap after laryngopharyngectomy. A. A circumferential hypopharyngeal defect following laryngopharyngectomy for recur-
rent laryngeal cancer. B. An ALT free flap harvested from the right thigh with two skin paddles based on separate cutaneous perforating blood
vessels arising from the descending branch of the lateral circumflex femoral artery. C. Reconstruction of the hypopharynx by creating a fasciocu-
taneous tube with the ALT free flap. D. The neck skin is reconstructed with a separate skin paddle of the ALT free flap. E. Postoperative barium
swallow study demonstrating patency of the reconstructed hypopharynx.

flap is anastomosed to the posterior wall of the stomach with

a circular stapler. Jejunal continuity is also restored by a sta-
pled anastomosis. The proximal segment of the jejunal flap is
connected to the cervical esophagus or hypopharynx, and a
microvascular anastomosis between the proximal jejunal mes-
enteric arcade and the internal mammary vessels or branches
of the external carotid artery and internal jugular vein is per-
formed. In rare cases, very long tubed fasciocutaneous flaps
have also been used for thoracic esophageal reconstruction.
Recipient Vessel Dissection

In most cases of previously untreated disease, recipient blood
vessels of adequate length, caliber, and flow for microvascular
anastomoses are readily available in the head and neck. Most
reconstructive surgeons prefer to perform end-to-end anas-
tomoses to branches of the external carotid artery, such as
the facial or superior thyroid arteries, and to branches of the
internal jugular vein when these vessels are available. End-to-
side anastomoses to the external carotid artery and/or internal
jugular vein are also reasonable options. The external jugular
vein is also frequently used as a recipient vein, although care
must be taken to ensure that external compression, such as by
E tight tracheostomy ties, is avoided postoperatively. However,
FIGURE 40.3. (Continued) in cases of prior irradiation and/or neck dissection, adequate
recipient blood vessels may have been ligated or thrombosed.15
In other cases, extensive scar tissue formation may render dis-
section of the carotid and jugular vessels so perilous due to
and the cervical esophagus. The preferred location of this the risk of irreparable rupture that dissection is best avoided.
hole is about 1 to 2 cm below the superior rim of the tracheal In these cases, it is important to dissect the recipient vessels
stoma. In some cases, this hole is placed through the recon- prior to preparation of the free flap such that the length of the
structive flap. The creation of the TEP can be performed at pedicle required can be reliably calculated.
the time of reconstruction or in a delayed manner, following The transverse cervical artery and vein are excellent alter-
flap healing. A one-way valve is part of the TEP prosthesis and natives to the external carotid artery and internal/external
allows shunting of air from the trachea to the pharynx and jugular vein systems. These vessels are usually preserved
mouth for phonation when the stoma is occluded. during neck dissections. The transverse cervical artery arises
medially in the neck from the thyrocervical trunk, or occa-
Esophagus sionally from the subclavian artery directly. The transverse
cervical vein drains into the external jugular vein or the sub-
Cervical esophageal defects are usually reconstructed by clavian vein. The omohyoid muscle is a surgical landmark for
the same methods as hypopharyngeal defects, using jejunal the transverse cervical artery and vein, which are deep to the
free flaps or tubed fasciocutaneous free flaps. For defects of muscle within the supraclavicular fatty tissue.
the thoracic and the entire esophagus, a number of options The cephalic vein can also be an excellent source of
exist. Nonmicrosurgical methods include the gastric pull-up venous drainage in the head and neck microvascular surgery.
and colonic interposition procedures.13 In the gastric pull-up Advantages of the cephalic vein are that it provides a long pedi-
procedure, the stomach is mobilized and anastomosed to the cle, lies outside the zone of radiation or prior surgery, and can be
proximal esophagus or pharynx via a posterior (orthotopic) dilated to a generous diameter, which simplifies microvascular
or anterior (heterotopic) route. The gastric pull-up is the pre- anastomosis. The proximal cephalic vein can be located in the
ferred method of thoracic and cervicothoracic esophageal deltopectoral groove and traced distally into the upper extrem-
reconstruction in most institutions. ity where it travels adjacent to the lateral bicipital groove.
When used for esophageal reconstruction, the ascending The use of the internal mammary vessels has not com-
portion of the colon is often preferred. It is divided from the monly been reported for head and neck surgery but is well
cecum and the transverse colon then interposed in the isoperi- known in breast reconstruction with autologous free tissue
staltic direction between the cervical esophagus/hypopharynx transfer. The internal mammary vessels are usually located by
and the stomach, which is connected by an end-to-side anas- removing the second or third costal cartilage after dividing the
tomosis. The right and middle colic arteries are ligated and overlying pectoralis muscle.
the colonic segment continues to receive its blood supply from The thoracoacromial artery and vein have also been
the inferior mesenteric artery via the marginal artery within the described as potential recipient vessels in head and neck recon-
mesocolon. The cecum is reconnected to the transverse colon struction. The thoracoacromial artery arises from the axillary
by an end-to-end anastomosis. The viable length of the colonic artery and divides into acromial, deltoid, clavicular, and pec-
interposition segment can be extended by distal revasculariza- toral branches. Use of the pectoral branch of the thoracoacro-
tion of its cervical end, resulting in a “supercharged” colon. mial trunk for end-to-end anastomoses obviously prevents the
When gastric pull-up or colonic interposition are not use of the pedicled PMMC or pectoralis major muscle flap as
options due to disease, inadequate length, or prior failure, a secondary flap for reconstruction.
another option is the supercharged jejunal flap.14 The jejunum
is divided proximally between the first and second branches of
the superior mesenteric artery arising beyond the ligament of
References
Treitz. The second and third branches arising from the supe- 1. Pribaz J, Stephens W, Crespo L, et al. A new intraoral flap: facial artery
musculomucosal (FAMM) flap. Plast Reconstr Surg. 1992;90:421-429.
rior mesenteric artery are divided while the fourth branch is 2. Rikumaru H, Kiyokawa K, Inoue Y, et al. Three-dimensional anatomi-
left intact to supply the distal portion of the mobilized jejunal cal vascular distribution in the pectoralis major myocutaneous flap. Plast
conduit. The distal jejunum is divided and the distal jejunal Reconstr Surg. 2005;115:1342-1352.

3. Lutz BS, Wei FC, Chang SC, et al. Donor site morbidity after suprafascial 9. Hanasono MM, Utley DS, Goode RL. The temporalis muscle flap for
elevation of the radial forearm flap: a prospective study in 95 consecutive reconstruction after head and neck oncologic surgery. Laryngoscope.
cases. Plast Reconstr Surg. 1999;103:132-137. 2001;110:1719-1725.
4. Chepeha DB, Teknos TN, Sharogorodsky J, et al. Rectangle tongue tem- 10. Disa JJ, Pusic AL, Hidalgo DA, et al. Microvascular reconstruction of the
plate for reconstruction of the hemiglossectomy defect. Arch Otolaryngol hypopharynx: defect classification, treatment algorithm, and functional out-
Head Neck Surg. 2008;134:993-998. come based on 165 consecutive cases. Plast Reconstr Surg. 2003;111:652-660.
5. Yu P. Reinnervated anterolateral thigh flap for tongue reconstruction. Head 11. Yu P, Hanasono MM, Skoracki RJ, et al. Pharyngoesophageal reconstruc-
Neck. 2004;26:1038-1044. tion with the anterolateral thigh flap after total laryngopharyngectomy.
6. Kimata Y, Sakuraba M, Hishinuma S, et al. Analysis of the relations Cancer. 2010;116:1718-1724.
between the shape of the reconstructed tongue and postoperative func- 12. Yu P. One-stage reconstruction of complex pharyngoesophageal, tracheal,
tions after subtotal or total glossectomy. Laryngoscope. 2003;113: and anterior neck defects. Plast Reconstr Surg. 2005;116:949-956.
905-909. 13. Chen HC, Tang YB. Microsurgical reconstruction of the esophagus. Semin
7. Kimata Y, Uchiyama K, Ebihara S, et al. Comparison of innervated and Surg Oncol. 2000;19:235-245.
noninnervated free flaps in oral reconstruction. Plast Reconstr Surg. 14. Ascioti AJ, Hofstetter WL, Miller MJ, et al. Long-segment, supercharged,
1999;104:1307-1313. pedicled jejunal flap for total esophageal reconstruction. J Thorac
8. Hanasono MM, Zevallos JP, Skoracki RJ, et al. A prospective analysis of Cardiovasc Surg. 2005;130:1391-1398.
bony versus soft-tissue reconstruction for posterior mandibular defects. 15. Hanasono MM, Barnea Y, Skoracki RJ. Microvascular surgery in the previ-
Plast Reconstr Surg. 2010;125:1413-1421. ously operated and irradiated neck. Microsurgery. 2009;29:1-7.
Head and Neck

part V
n Aesthetic Surgery
Chapter 41 n Skin Resurfacing

Fritz E. Barton
dermal–epidermal (DE) junction, and “elastotic” thickening

Layers of The Skin in the superficial dermis all seem to play a role. What empiri-
In basic terms, the skin is divided into two layers: the epidermis cally seems clear, however, is that correction of skin wrinkles
and the dermis (Figure 41.1). The epidermis provides a water requires some type of ablative therapy through the DE junc-
exchange barrier (via its lipid intercellular mortar) and sun pro- tion into the papillary dermis at least.5-7
tection (via pigment). A vertical series of oxytalan elastic fibers
attach the epidermis to the underlying dermis (Chapter 13). Resurfacing Mechanisms
The dermis is the structural layer of the skin. The more super-
ficial papillary dermis provides flexibility and elastic recoil. The The concept of resurfacing is to destroy the layers of the skin
deeper reticular dermis provides a thick, sturdy foundation. down past the level of the abnormality, followed by healing of
Natural aging is a process of atrophy of all skin elements— the skin to replace the removed layers with fresh, healthy tissue.
epidermis, dermis, and appendages. Actinic damage, to the If the level of destruction is confined to the epidermis,
contrary, is a process of thickening—particularly of the epi- the re-epithelialization occurs from the basal layer of the
dermis. The face, neck, chest, and hands are the most sun epidermis. If the level of destruction removes the epidermis,
exposed and the most frequent sites of skin resurfacing. re-epithelialization occurs from lateral migration of adjacent
keratinocytes and vertical migration of epithelial cells from
Aesthetic Surgery
the underlying dermal appendages (sweat glands and hair
The Maladies follicles). Destruction into the dermis stimulates a healing
Common benign maladies of the skin surface include dyschro- response characterized by new collagen production. The type
mias (solar lentigines), keratoses (actinic and seborrheic), and of collagen response varies with the injury mechanism.
wrinkles. For practical purposes, there are three methods of resur-
With age, asynchrony of keratinocyte proliferation can facing: mechanical sanding (dermabrasion), chemical burn
produce seborrheic keratoses. These lesions are usually indi- (chemical peels), and photodynamic treatments (laser ablation
vidually curetted, since they involve only the superficial epi- or coagulation).
dermis. Actinic keratoses commonly occur with chronic sun There are several side effects of skin resurfacing that influ-
exposure. If few, they may be individually treated with cryo- ence the choice of method and application: rate of healing,
therapy or trichloroacetic acid (TCA). If diffuse, overall skin loss of skin texture, depigmentation, and potential for visible
resurfacing may be required. scarring.
Skin pigmentation occurs from melanocytes that are prin- Any injury that removes all epithelium and enters the der-
cipally distributed along the basement membrane. Each mela- mis can cause scarring. The exact limits of dermal depth and
nocyte normally controls the production and distribution of injury type which exceeds the normal healing capacity and
melanin to approximately 15 to 18 keratinocytes. produces visible scarring are not known. However, it is appar-
With age and irradiation-induced DNA damage, asyn- ent that the deeper the dermal injury, the greater the likeli-
chrony of melanin production and/or distribution occurs. hood of scarring. In addition, certain topographic areas are
Thus, collections of excess pigment (lentigines) occur. Solar more prone to scar—such as the mandibular border and neck
lentigines are common on the face, chest, and dorsal hands. where the dermis is thinner and there are fewer underlying
Histologically, both increased number of basal melanocytes skin appendages for re-epithelialization.
and increased deposition of melanin in keratinocytes are The vast majority of melanocytes occur along the basal
present. Cryotherapy is a common treatment for isolated epithelial layer, although some also reside in the hair follicles.
lesions, since melanocytes are particularly susceptible to cold Complete removal of the basal melanocytes by destruction or
injury.1,2 Broader fields of lentigines are more conveniently selective melanocyte injury (such as heat from coagulative lasers
treated with TCA peels or intense pulsed light treatments.3,4 or phenol peel) can result in unwanted hypopigmentation.
Eradication requires destruction to the basal layer of the The opposite can also occur. Freshly re-populating mela-
epidermis. nocytes are particularly sensitive to sunlight stimulation and
On rare occasions, abnormal pigment may be distributed “post-inflammatory hyperpigmentation” can occur for the
into the dermis—a condition known as melasma. Melasma first several months of healing.
occurs most commonly in young females and is felt to be hor-
monally induced. Treatment is unpredictable. Topical Retin A
and hydroquinone 2% to 4% to block melanin production is
Epidermal Corrections
useful and is critical for avoiding recurrence. Dermal chemi- Epidermal treatments usually focus on actinic keratoses, dys-
cal peels, intense pulse light, and non-ablative laser treatments chromias, and dull skin from excess accumulation of old kera-
may also be useful. tinocytes in the stratum corneum.
The exact cause of fine lines and wrinkles remains undeter- The skin abnormalities may be diffuse or patchy, but since
mined. Changes in the epidermis, loss of oxytalan fibers at the the depth of treatment is superficial to the basement membrane,
451
452 Part V: Aesthetic Surgery
Free nerve ending

Hair shaft
Sweat pore
Epidermis
Meissner’s corpuscle
Sebaceous (oil) gland
Dermal papillae Arrector pili muscle
(papillary layer of dermis)
Reticular layer of dermis
Dermis
Sensory nerve fiber
Eccrine sweat gland
Hypodermis
Adipose (fat) tissue
(subcutaneous
tissue)
Hair follicle receptor

Hair root
Artery
Hair follicle
Vein
Pacinian corpuscle
FIGURE 41.1. Skin elements, cross section.
repair is rapid from migration of surface epithelium. Therefore, hydroxyl groups in α-hydroxy acids. The most commonly used
a complete coverage treatment is safe and effective. β-hydroxy acid is salicylic acid. Salicylic acid in concentrations
The most common superficial treatments are chemical up to 30% can be used for peeling. Salicylic acid produces a visi-
peels (Chapter 13). ble white frost (even more visible under fluorescent light), which
α-Hydroxy acids are naturally occurring acids derived makes the end point easier to assess. It is particularly effective in
from fruits and milk products.8 They are shown in Table 41.1. acne skin patients. Historically, salicylic acid lost favor because
Glycolic acid has received the most wide use in topical of the side effect of tinnitus with higher concentrations.
products, primarily due to the fact that its smaller molecu- The most commonly used superficial peeling agent is
lar size (two carbon chain) makes it penetrate the epidermis Jessner’s solution (formerly Coombes formula).9 It is a combi-
most readily. Both the concentration and the pH influence its nation of α- and β-hydroxy acids, providing benefits of both,
penetration. As a topical peel, the FDA has suggested limits but each in low enough concentration to limit side effects. The
of 30% concentration and pH 3.0 or greater. It has been used formula is usually mixed as follows:
“off label” in concentrations of 50% and lower pH’s. From a
practical standpoint, patchy or uneven penetration is a prob- Resorcinol 14 g
lem that limits its use as an epidermal peeling agent. For this Salicylic acid 14 g
reason, glycolic acid peels are often administered in a gel base Lactic acid 14 mL
rather than in aqueous solution. OS ethanol 100 mL
Lactic acid is a three carbon chain. As such, it penetrates Premixed Jessner’s solution is commercially available. The
more slowly and perhaps more evenly than glycolic acid. It mixture has several advantages. First, a light frost end point
can be applied in concentrations up to 70%. can be visualized. Second, it rapidly volatizes, so it does not
The “frosting” end point of effect in α-hydroxy acid peels is need neutralization. Depth is controlled by the number of lay-
often indistinct. As a result, they are usually applied on a time ers applied. Jessner’s peels are not only used alone as an epi-
of application basis, followed by dilution with water rinsing. dermal peeling agent, but they are also commonly used for
β-Hydroxy acids are a chemical variant with two car- initial dekeratinization to facilitate the penetration of other
bons between hydroxyl groups, versus one carbon separating chemical peels such as TCA.
TCA has been used as a variable depth skin peel since at
Ta b l e 4 1 . 1 least 1962.10 It is used in strengths of 15% to 20% for epider-
mal peels. Coagulation of keratinocyte protein produces a light
α-Hydroxy Acid Naturally Occurring Source white frost, which is easy to read as an end point. Epidermal
TCA peels desquamate in approximately 5 days and are effective
Glycolic acid Sugarcane for correction of superficial actinic changes and dyschromias.
Lactic acid Sour milk
Malic acid Apples Dermal Correction
Tartaric acid Grapes Wrinkles and fine lines involve at least the DE junction, if not
the dermis itself. Correction requires a treatment that penetrates
Citric acid Citrus fruits
to the dermis and causes secondary fibroblastic production of

Chapter 41: Skin Resurfacing 453
Ta b l e 4 1 . 2
Reading The Trichloroacetic Acid Frost
n TCA PEEL DEPTH n CLINICAL END POINT

Partial depth epithelial ight white frost with stable
L
epidermis
Full thickness epithelial ight white frost with
L
epidermal sliding
Papillary dermis hite frost with pink color
W
beneath
Reticular dermis Opaque white frost
TCA, trichloroacetic acid.
Adapted from OBagi ZE. Obagi Skin Health Restoration and Rejuve-
nation. New York, NY: Springer; 2000.
When used in a concentration of 35% to 42.5%,11 TCA is

FIGURE 41.2. The frost of a papillary dermal trichloroacetic acid an excellent peeling agent for the face. One of the advantages
(TCA) peel. of TCA is the ability to read the depth by clinical end points
(Table 41.2).
Preparatory dekeratinization of the epithelium with either
collagen. While elastin replacement has been theorized, there is topical retinoic acid for several weeks or immediate dekera-
yet no predictable way to stimulate normal elastin replacement. tinization with Jessner’s solution enhances uniformity of the
The more aggressive resurfacing methods—deeper peels, depth of penetration. TCA does not volitize quickly, so con-
dermabrasion, and lasers—are most commonly employed for tinued depth of penetration is achieved with increased concen-
dermal problems. Scarring risk, however, increases signifi- tration as well as with friction in application. Postoperatively
Aesthetic Surgery
cantly as the dermis is injured. The key to each of the dermal peeled skin is usually treated with ointment rather than an
treatments is determining the depth of treatment—the clinical occlusive dressing until re-epithelialization is complete.
end point. Each technique has different visual signs and all the TCA is excellent for the cheeks, forehead, and eyelids
signs are relatively subtle. Experience is required to learn to (Figure 41.3). In general, it is less effective for deep perioral
accurately “read” those end points. rhytids.
In the 1960s, phenol mixed with croton oil was popular-
ized by the Baker-Gordon formula.12 This formula was the
Chemical Peels standard for many years, but the strength of the peel solution
The two most common dermal depth peels are TCA and was suitable only for severely thickened, sun-damaged skin.
phenol/croton oil. Both create a definite white “frost” by In response to the popularity of varying strength TCA
coagulation of epidermal proteins (Figure 41.2). peels, the roles of the Baker-Gordon ingredients were studied
A B C
FIGURE 41.3. Patient with severe sun-damaged skin. A. Before treatment; B. Four days after 42.5% TCA to face and dermabrasion of upper
lip; and C. 6 weeks post peel.

Ta b l e 4 1 . 3
Hetter Phenol Peel Formulas
n HEAVY PEEL FORMULA (NOT FOR LIDS, TEMPLES,

PRE-AURICULAR OR NECK)
4 cc phenol 88% (1.3 cc) 33% phenol
6 cc water (2 cc)
16 drops septisol (5 gtts)
3 drops croton oil (1 gtt) 1.1% croton oil

n HEAVIEST PEEL FORMULA (BAKER-GORDON FOR
PERIORAL OR SEVERE KERATOSES)
3 cc phenol 88% 50% phenol
2 cc water
8 drops septisol
3 drops croton oil 2.1% croton oil

From Hetter GP. An examination of the phenol–croton oil peel: part IV.
Face peel results with different concentrations of phenol and croton oil.
A
Ta b l e 4 1 . 4
Hetter Phenol Formulas
n MEDIUM-LIGHT PEEL FORMULA (MOST COMMON)

4 cc phenol 88% 33% phenol
6 cc water
16 drops septisol
1 drop croton oil 0.35% croton oil

n VERY LIGHT PEEL FORMULA (EYELIDS AND NECK)
3 cc of med-light mix
2 cc phenol 88% 27.5% phenol

5 cc water 0.105% croton oil
From Hetter GP. An examination of the phenol–croton oil peel: part iv.
Face peel results with different concentrations of phenol and croton oil.
Plast Reconstr Surg. 105(3):1061-1083, 2000.
B
Regardless of the formula of preference, phenol/croton
FIGURE 41.4. Patient previously peeled with TCA wanted additional oil remains the most aggressive of the clinically useful face
benefit. Shown on fourth post-peel day (A) and 3 months post peel (B). peels and is more efficacious than any other peel for perioral
rhytids.
by Hetter.13,14 Hetter concluded that the croton oil is, in fact,

the actual peeling agent. He went on to suggest varying con- Ta b l e 4 1 . 5
centrations for varying depths of correction (Figure 41.4,
Tables 41.3 and 41.4). Stone Formulas
A different, but equally analytical evaluation of the phenol/
croton oil peel was presented by Stone.15-17 Stone suggests n Stone Venner-Kellson n Stone II
that the phenol is of equal or greater importance and that the • 60 ml phenol 88% • 159 ml phenol 88%
friction of application is a major factor. Stone suggested the (final conc 62.5%) (final conc 60%)
formulas shown in Table 41.5.
As with TCA, the end point of treatment is determined by • 10 ml septisol • 12 drops croton oil
reading the appearance of the “frosted” tissue. While simi- • 3 drops croton oil • 3 drops olive oil
lar to TCA, the frosting from phenol/croton oil is more gray-
white and is distorted somewhat by the erythema from the • 5 ml olive oil • 4.5 ml glycerin
caustic croton oil component. Posttreatment care usually con- • 8 ml distilled water • 73.5 ml water
sists of ointment or occlusive dressing until re-epithelialization
From Stone PH. Clin Plast Surg. 1998;25:21.
is complete.

FIGURE 41.5. Dermabrasion fraises (left) and brushes (right).
Posttreatment care usually consists of wet dressings for a

Dermabrasion few hours until bleeding stops, followed by ointment until
Surgical sanding—dermabrasion—was perhaps the first resur- re-epithelialized.
facing method.
Most commonly it was used to correct acne scarring. The
concept was to remove the skin thickness until the surround-
Laser Resurfacing
ing tissue was at the same level as the depth of the scar. The The use of light energy as a LASER (Light Amplification
same concept has been applied to wrinkles. by Stimulated Emission of Radiation) began in the 1960s.
Histologic studies have indicated that dermabrasion per- Lasers are classified by their wavelength on the electromag-
manently reduces the thickness of the dermis, and that healing netic spectrum (Chapter 18). The refinement of medical laser
does not completely replace the lost thickness.18 This is in dis- application was facilitated by the identification of “selective
tinction to chemical peels and coagulative lasers that appear photothermolysis,”24 meaning that different laser wavelengths
to produce compensatory dermal thickening. are attracted to different biologic targets (“chromophores”).
Dermabrasion can be performed manually with sandpa- For practical purposes in skin resurfacing for fine lines and
per.19,20 However, it is mechanically awkward and sterility is wrinkles, the chromophore is water in the skin. The two lasers
Aesthetic Surgery
an issue. most useful in targeting water are erbium:YAG and carbon
Microdermabrasion has been popularized as an office pro- dioxide.
cedure. Course crystals are blown onto the skin and recol- The prototypical laser for skin resurfacing has been car-
lected. For practical purposes, microdermabrasion is a salon bon dioxide. The earliest CO2 (10,600 nm) lasers used a
procedure that is confined to epidermal exfoliation.21 continuous-wave technology. The duration of the heated pulse
Surgical dermabrasion is usually performed with power created char of the epidermis and superficial dermis. While
rotary using either wire brush or diamond fraise (Figure 41.5). very effective at ablating wrinkles, the side effects of scarring,
The fraise is less aggressive. The challenge with dermabra- depigmentation, and loss of skin texture largely extinguished
sion is adequate stabilization of the tissue for sanding. It is its use.
excellent for individual scars and along the lip borders, but The next major modification was pulsing the energy.
dermabrading larger areas of the cheeks is more technically Originally the pulses were long and exceeded the thermal relax-
demanding. Dermabrasion cannot be performed on the eye- ation time of skin (0.2 to 1 milliseconds). Gradual shortening of
lids. Temporary freezing of the skin to increase stiffness is the pulses and patterning the cores of energy have refined the
commonly employed22,23. method. It should be noted that all of the original CO2 lasers
The end points of dermabrasion are determined by der- were applied with overlap of the heat cores in order to achieve
mal bleeding patterns. The superficial papillary dermis shows complete skin coverage. Collagen shrinkage and secondary pro-
almost confluent bleeding points with a fine lattice stroma. liferation occurred in the papillary and upper reticular dermis in
As the sanding reaches the deeper reticular dermis, bleed- response to heat coagulation injury. The exact depth of injury
ing points become wider spaced and more discrete, and the was dependent on energy and pulse duration. It is critical to
stroma becomes coarse. In general, the depth of a wrinkle recognize that pulse duration varies significantly among CO2
must be reached to correct it. lasers, so comparison is difficult (Figure 41.6).
Confluent papilary dermal injury
Normal Abdomen Skin Ultrapulse Single Pass Ultrapulse Double Pulse

A B C
FIGURE 41.6. Typical epidermal and papillary dermal ablation of pulsed CO2 laser with complete coverage (Coherent Ultrapulse 5000):
(A) untreated skin; (B) single pass removes epithelium and reaches papillary dermis; (C) second pass reaches the upper reticular dermis.
Courtesy of Jeff Kenkel, MD.

Continuous Injury Discontinuous Injury
Stratum corneum
Stratum granulosum
Epidermis Stratum spinosum
Basal layer
Papillary dermis
Upper reticular dermis
Dermis Mid-dermis
Lower reticular dermis
Subcutaneous tissue
Peel, dermabrasion, laser Fractionated laser
FIGURE 41.7. Comparison of continuous (complete) coverage and fractionated coverage with laser.
Whether skin contraction after laser resurfacing is perma- lasers (CO2) may only need to reach the papillary dermis to
nent remains controversial.25-27 Continuous (contiguous) cov- correct wrinkles. “Cold” lasers (erbium:YAG), dermabrasion,
erage CO2 laser resurfacing is still the most effect laser method and chemical peels may need to reach greater dermal depth to
of wrinkle removal and is still widely used. However, pro- stimulate adequate contracture to efface wrinkles.
longed recovery, delayed hypopigmentation, and the risk of As of this writing the results from fractionated CO2 treat-
scarring remain limiting factors. ment are still not as good as the wrinkle effacement from com-
The other major skin resurfacing laser to achieve widespread plete coverage pulsed CO2 laser treatments.
use is the erbium:YAG. As opposed to CO2, which is a heat-
coagulative ablative laser, erbium can be calibrated to deliver
either cool ablation or coagulation. In the cool ablation mode, Complications
erbium functions as a laser dermabrader. Specific depths of
tissue can be removed with minimal heating of the tissue, due Post-Peel Infection
to the fact that erbium (at the 2,940 nm wavelength) has much Any procedure that disrupts the DE junction exposes the skin
greater affinity for water than CO2. As with dermabrasion, to infection. Post-resurfacing infections can be of three types:
since there is minimal surrounding damaged collagen, the over- viral, fungal, and bacterial.
all dermis could be thinner after treatment. Collagen response is Herpes virus types HSV-1 (herpes simplex virus),
proportional to the depth of the wound.28,29 HSV-2, and HH3 (Candida) infection can occur in facial
In 2004 “fractionated photothermolysis” was introduced.30
The concept was to provide intermittent microscopic columns
of thermal injury (“microthermal zones”) while sparring tis- In Vitro Characterization—Fraxel re:pair Treatment
sue between the columns. The hope was to preserve skin pig-
ment, preserve skin appendages (skin texture), and promote
rapid healing (minimal “downtime”) (Figure 41.7).
The first fractionated medical laser utilized erbium:glass
at a 1,540 wavelength. Fractionated “microthermal zones”
penetrated through the papillary dermis while leaving micro
eschars of epithelium intact on the surface. A variety of non-
ablative lasers in the erbium:YAG 1,540 to 1,550 wavelength
have been developed. Their advantage is rapid healing (only
24 to 48 hours of erythema), but benefit in terms of reversal of
significant wrinkling or actinic lines is minimal.
In 2007 the concept of fractionated delivery was applied
to CO2 lasers, in an effort to achieve greater wrinkle correc-
tion,31 while preserving the rapid healing time. What followed
was a marketing rush by companies to produce the devices.
Spot sizes vary from 130 to 350 μm. Pulse durations, density
of treatments, and pattern of application also vary. The two
basic application types of fractionated lasers are striping and Increasing Laser Pulse Energy
stamping (Figure 41.8). FIGURE 41.8. Ablative cores (“microthermal zones”) of fractionated
To date, specific treatment parameters of fractionated lasers CO2 laser (Courtesy of Solta Medical).
correlating to clinical results are lacking. It appears that “hot”

resurfacing. Since the virus can lay dormant prior to References
resurfacing, prophylactic treatment is common. The
response to antiviral agents is variable, but the most 1. Ortonne JP, Pandya AG, et al. Treatment of Solar Lentigines J Am Acad
Dermatol. 2006;54:S262.
common prophylactic treatment is valcyclovir 500 mg 2. Lugo-Janer A, Lugo-Somolinos A, Sanchez JL. Comparison of trichloroace-
po starting the day prior to treatment. Herpes infection usually tic acid solution and cryotherapy in the treatment of solar lentigines. Int J
appears as vesicles in patchy areas of moderate erythema. In Dermatol. 2003;42:829.
the case of clinical infections, valcyclovir doses are increased 3. Weiss RA, Weiss MA, Beasley KL. Rejuvenation of photoaged skin: 5 years
results with intense pulsed light of the face, neck and chest. Dermatol Surg.
to 2,000 mg per day (refer http://www.skintherapyletter. 2002;28:1115.
com/2005/10.1/1.html). 4. Kligman DE, Zhen Y. Intense pulsed light treatment of photoaged skin.
Bacterial infection can occur in resurfacing as with any Dermatol Surg. 2004;30:1085.
open wound. Purulent exudate indicates secondary infec- 5. Contet-Audonneau JL, Jeanmarie C, Pauly G. A histological study of human
wrinkle structures: comparison between sun-exposed areas of the face, with
tion, but can be difficult to distinguish from normal desqua- or without wrinkles, and sun-protected areas. Brit J Derm. 1999;140:1038.
mation. Immediate recognition is critical because secondary 6. Bosset S, Barré P, Chalon A, Kurfurst R, Bonté F, André P, Perrier P, Disant F,
bacterial infection can deepen the wound and cause scar- Le Varlet B, Nicolas JF. Skin ageing: clinical and histopathologic study of
ring. Gram stain of the exudate and culture diagnosis is permanent and reducible wrinkles. Eur J Dermatol. 2002;12:247.
7. Lee JY, Kim YK, Seo JY, Choi CW, Hwang JS, Lee BG, Chang IS, Chung
imperative. JH. Loss of elastic fibers causes skin wrinkles in sun-damaged human skin.
Candida albicans is a regular inhabitant of normal skin. J Dermatol Sci. 2008;50:99.
The moist environment of resurfacing wounds can be a fertile 8. Murad H, Shamban AT, Premo PS. The use of glycolic acid as a peeling
bed for yeast infection. Clinically, the wound becomes fire red agent. Dermatol Clin. 1995;13(2):285.
9. Stagnone JJ. Superficial peeling. J Dermatol Surg Oncol. 2003;42:829.
with fine vesicles. Treatment with topical antifungals such as 10. Ayres S III. Superficial chemosurgery in treating aging skin. Arch Dermatol.
nystatin, often combined with mild topical steroid, will usu- 1962;85:385.
ally eradicate the yeast infection without sequelae. 11. OBagi ZE. Obagi Skin Health Restoration and Rejuvenation. New York,
NY: Springer; 2000.
12. Baker TJ, Gordon HL. The ablation of rhytids by chemical means: a
preliminary report. J Fla Med Assoc. 1961;48:451.
Pigmentary Changes 13. Hetter GP. An examination of the phenol-croton oil peel: Part I. Dissecting
the formula. Plast Reconstr Surg. 2000;105:227.
Skin pigmentary changes are not uncommon after resurfac- 14. Hetter GP. An examination of the phenol-croton oil peel: Part IV. Face peel
ing. Response may be over (hyperpigmentation) or under results with different concentrations of phenol and croton oil. Plast and
(hypopigmentation). 15. Stone P. The use of modified phenol for chemical face peeling. Clin Plastic
Source melanocytes reside in the basal layer of the epi- Surg. 1998;25:21.
dermis as well as in hair follicles. Melanin in the skin is pro- 16. Stone P. Modified phenol chemical face peels: recognizing the role of
duced by the conversion of tyrosine by the enzyme tyrosinase. application technique. Clin Plast Surg. 2001;28:13.
Aesthetic Surgery
17. Stone PA. Chemical peeling. In: Rubin MG, ed. Chemical Peels. Philadelphia,
Production of melanin by melanocytes is stimulated by ultra- PA: Elsevier; 2007:87.
violet irradiation (particularly UVB) and by irritation. 18. Baker TJ, Gordon HL. Chemical face peeling and dermabrasion. Surg Clin
In the early healing phase of a wound, there is little remain- North Am. 1971;51:387.
ing protective melanin in the superficial epithelium to absorb 19. Poilos E, Taylor C, Solish N. Effectiveness of dermasanding (manual derm-
abrasion) on the appearance of surgical scars: a prospective, randomized,
ultraviolet irradiation stimulation. Thus, for up to 3 months blinded study. J Am Acad Dermatol. 2003;48:897.
after resurfacing, sunscreen protection is important. The use 20. Emsen IM. An update on sandpaper in dermabrasion with a different and
of a tyrosinase blocking agent, such as hydroquinone, is help- extended patient series. Aesthetic Plast Surg. May 2002 Epub.
ful. If rebound hyperpigmentation should occur, it can usually 21. Karimipour DJ, Karimipour G, Orringer JS. Microdermabrasion: an
evidence-based review. Plast Reconstr Surg. 2010;125:372.
be corrected with topical bleaching agents. 22. Orentreich N, Orentreich DS. Dermabrasion. As a complement to dermatol-
Of greater potential significance is post-resurfacing ogy. Clin Plast Surg. 1998;25(1):63.
hypopigmentation. Any procedure that destroys the basal 23. Gold MH. Dermabrasion in dermatology. Am J Clin Dermatol. 2003;4(7):467.
layer of epithelium—that is, dermal treatments for wrinkle 24. Anderson RR, Parish JA. Selective photothermolysis: precise microsurgery
irradiation—can permanently alter pigmentation. by selective absorption of pulsed radiation. Science. 1983;22:525.
25. Dover JS. Histology of CO2 laser skin resurfacing. J Watch Dermatol.
The risk is greatest with uniform (contiguous) injuries, August 1, 1996.
such as dermabrasion, chemical peels, and dense laser treat- 26. Fitzpatrick RE, Rostan EF, Marchell N. Collagen tightening induced by car-
ments. Since the entire surface melanocyte population in bon dioxide laser versus erbium:YAG laser. Lasers Surg Med. 2000;27:395.
27. Trelles MA, Garcia L, Rigau J, Allones I, Velez M. Pulsed and scanned car-
area is removed, repigmentation is dependent upon mela- bon dioxide lasers resurfacing 2 years after treatment: comparison by means
nocyte migration from the wound edges and from dermal of electron microscopy. Plast Reconstr Surg. 2003;111:2069.
appendages. 28. Ross EV, Nasef GS, et al. Comparison of carbon dioxide laser, erbium:YAG
It appears that heat (CO2 laser), cold (liquid nitrogen), laser, dermabrasion and dermatome. Dermatol Surg. 2000;42:92.
29. Fitzpatrick RE, Rostan EF, Marchell N. Collagen tightening induced by car-
and phenol (chemical peel) may have selective melanocyte bon dioxide laser versus erbium:YAG laser. Lasers Surg Med. 2000;27:395.
toxicity. Conversely, treatments of discontinuous injury 30. Manstein D, Herron GS, Sink RK, Tanner H, Anderson RR. Fractional pho-
(fractionated lasers) spare melanocytes in the untreated tothermolysis: a new concept for cutaneous remodeling using microscopic
areas. Hypopigmentation may not be fully evident for patterns of thermal injury. Lasers Surg Med. 2004;34:426.
31. Hantash BM, Bedi VP, Kapadia B, Rahman Z, Jiang K, Tanner H, Chan KF,
several months after injury, and when it occurs, it is Zachary CB. In vivo histologic evaluation of a novel ablative fractional
irreparable. resurfacing device. Lasers Surg Med. 2007;39:96.

Chapter 42 n DERMAL AND Soft-Tissue Fillers:
Principles, Materials, and
Techniques
Z. Paul Lorenc
(CaHA) soft-tissue fillers have explored the relationship of their

Introduction physiochemical properties to performance on rheologic tests,
As Baby Boomer and Gen X populations transition to mid- which measure the flow of fluids and physical changes of solids
and later life, numerous nonsurgical cosmetic procedures under applied stresses and strains.9-11
and materials have been developed for this demographic. A soft-tissue filler’s utility is determined in part by its vis-
The American Society for Aesthetic Plastic Surgery reported cosity (h*), elasticity (G′), and plasticity, all of which constitute
a 155% increase in cosmetic procedures from 1997 to 2010. a product’s rheology.9,11 Rheologic testing replicates the move-
Nine and a half million of these procedures were performed ment and action of gravity on facial tissues, by applying shearing
in the United States. Second only to injections of neuromodu- force to popular HAs and CaHA.9-11 In one study, investigators
lators (Chapter 43), such as OnabotulinumtoxinA (Botox), found that, largely due to the products’ high G′ value, CaHA
AbobotulinumtoxinA (Dysport), and IncobotulinumtoxinA (Radiesse, Merz Aesthetics, San Mateo, CA) retained structural
(Xeomin), the use of dermal filler/volumizing agents topped integrity, viscosity, and elasticity.10,11 In clinical applications,
the list for nonsurgical rejuvenation.1 injecting stiffer (high G′, more lifting capacity) products into the
Dermal fillers have been used for decades. Early applica- skin could prove more challenging for the practitioner. Agents
tions involved autologous fat grafting with only short-term with low G′ may be more effective for filling superficial wrin-
benefits.2 The popularity (and profit) of bovine collagen as kles, areas around the lips, and lips themselves, while gels resis-
a filler material in the 1980s generated an explosion in the tant to dynamic force (high G′) may be more suitable for deeper
development of injectable soft-tissue fillers, with varying prop- fold correction, to volumize the malar eminence, augment the
erties, longevity, and ease of use that have significantly altered mentum, or volumize the temporal hollow9 (Figure 42.1).
the landscape of minimally invasive cosmetic correction.2 Molecular cross-linking confers strength and structural
In the past decade alone, the vast array of dermal fillers/ integrity to HA-based gels, allowing the filler to retain its
volumizing agents on the market, coupled with their efficacy, shape until it is degraded and metabolized by the body.9
versatility, biocompatibility, resorbability, cost-effectiveness, Cross-linking entails a delicate balance to simultaneously
and relative ease of administration, has created both opportu- provide effective biomechanical properties while maintaining
nities and challenges for patients and practitioners. Involving biocompatibility and tissue interactivity.9 The amount and the
little downtime for the patient, minimal adverse events, and degree of cross-linking—not the HA concentration alone—
generally less than an hour to administer in a practitioner’s determines filler duration. 12,19 When gels undergo similar
office, injectable agents help restore youthful vitality by modifications with like concentration, the higher cross-link to
effacement of wrinkles, repleting volume, and recontouring in pendant (partially bound cross-linker) ratio will assure a less
the face, hands, and less visible parts of the body.3 degradable, more stable, and longer lasting effect.9
The field of facial rejuvenation has evolved along with the
growth in noninvasive applications. Once focused on filling wrin-
kles, lines, and depressions, practitioners now attempt to recon- Ta b le 4 2 . 1
tour by volume replacement. The face does not age uniformly,
and corrective modalities and materials are selected based on the Physiochemical Characteristics of
relationship of the whole to its parts.4,5 The ideal filler/volumizing Fillers/Volumizing Agents
agent would be safe, biocompatible, noninflammatory, nonaller-
genic, stable, easily deliverable, pliable, nonmigratory, and dura- • Biocompatibility/biofilms
ble.6,7 The clinical performance of any agent depends upon its • Viscosity
physiochemical characteristics and interaction with the recipient.
• Gel/fluid ratio
• HA concentration
Physiochemical
Considerations • % of cross-linking/pendant crosslinker
• Particulate vs. liquid vs. fibrillar
The in vivo and in vitro characteristics of soft-tissue fillers are
outlined in Table 42.1. An understanding of physiochemical • Particle size
characteristics enables the practitioner to assess their deliver-
• G′ (lifting ability/Pa)
ability, performance, immunogenicity, applications, aesthetic
effectiveness, and longevity.2,8 • Extrusion force characteristics
The ultimate behavior of soft-tissue fillers is a function of a • Particle size >20μm
number of scientific variables. These include biocompatibility/
biofilm formation, viscosity, gel/fluid ratio, Hyaluronic Acid • Particle shape
(HA) concentration, percentage of cross-linking with degree of • Surface topography
pendant cross-linker, particulate versus liquid versus fibrillar
constituency, particle size, elastic modulus (G′), complex viscos- • Contact angles
ity (h*), and extrusion characteristics. Especially critical to the • Surface tension
mechanism of action are lifting ability/elasticity and viscosity.
Recent assessments of HA-based and calcium hydroxylapatite • Surface charge
458
Chapter 42: Dermal and Soft-Tissue Fillers: Principles, Materials, and Techniques 459
G′ Prime Modulus Characteristics of Dermal Fillers
10,000 Ta b le 4 2 . 2
Fda Cleared Filler/Volumizing Agents (Items In
Parentheses are No Longer Available)
Radiesse • Collagen • Calcium
Restylane Sub Q
1,000
Perlane (Zyderm, Zyplast) Hydroxylapatite
G ′ [Pa]
Restylane Cymetra Radiesse

Juvederm Voluma Fascian • Poly-l-lactic acid
100 (CosmoDerm, CosmoPlast) Sculptra
Juvederm Ultra Plus ArteFill • Silicone
Juvederm Ultra
(Evolence) Silikon 1000
10 • Hyaluronic acids PRP

0.1 1.0 10.0 Restylane-L, Perlane-L Laviv
f [Hz]
Belotero
FIGURE 42.1. Elasticity characteristics of dermal fillers. From
Sundaram H, et al. Comparison of the rheological properties of viscos- (Hylaform, Hylaform Plus)
ity and elasticity in two categories of soft tissue fillers: calcium hydrox-
(Captique)
ylapatite and hyaluronic acid. Dermatol Surg. 2010;36:1859-1865.
Juvederm Ultra XC/Plus XC
Hydrelle
Particle size, shape, and distribution (G*) have an influ- Prevelle Silk
ence on extrudability and potential bruising. If the particles
are dispersed too loosely or closely and still remain large, they
may prevent a smooth flow of filler and result in subsequent and burn and scar treatment, Cymetra is obtained from tissue
bruising from sporadic delivery. These inherent physiochemical banks or cadavers, which have been tested and screened for
characteristics affect the forces necessary to inject an agent.8 In immunologically threatening risk factors.15
Aesthetic Surgery
general, higher G′ helps assure stability for optimum sculpting/ Fascian (Fascia Biosystems, Beverly Hills, CA), a par-
lifting, while higher h* enables materials to withstand applied ticulate replacement agent indicated for upper and lower lip
forces once injected.11 augmentation, correction of facial rhytides, and volume resto-
Particle size is another consideration. An evaluation of ration of the face, is obtained from human cadaver fascia lata
the impact of particle size on phagocytosis was performed. and prepared for delivery in a sterile normal saline solution
Polymethylmethacrylate (PMMA) microspheres of <20 μm and 0.5% lidocaine.15,16
in diameter promoted phagocytosis, potentially inducing Artefill (Artes Medical, Inc., San Diego, CA) is a long-
adverse skin reactions and rendering the particles nonviable.7 lasting biostimulatory agent, comprised of round, smooth
In another study, PMMA particles of different sizes demon- PMMA microspheres of 30 to 50 μm in diameter, suspended
strated that larger sized microspheres >40.2 μm were not in an 80% gel matrix of denatured bovine collagen with 0.3%
phagocytized.7,13 In addition to particle size, inflammatory lidocaine hydrochloride.17,18 As the collagen degrades, the
response is affected by particle shape, contact angles, collision body produces a collagenous matrix around the implanted
factors, surface tension, and surface charge. In one study, an spheres. Artefill, indicated for NLF volumizing, is considered
in vivo implantation of irregularly shaped polymer implants permanent. Skin test is required 2 weeks before application.17
initiated host inflammatory response in contrast to smooth-
surfaced PMMA microspheres.7 For now, particle size >20 μm
appears less likely to induce an inflammatory response than
Replacement Agents
smaller sized microspheres. This category includes HAs, which occupy deep dermal or
subcutaneous space before dissipation.5 Drawn from animal
or nonanimal sources (nonanimal-stabilized hyaluronic acid
Classification of Agents By [NASHA]), HA is water soluble and cross-linked to create a
Function gelatinous substance that does not break down rapidly in the
system20 (Figure 42.2).
In spring 2011, a panel of physicians recommended cat-
The concentration of HA and amount of cross-linkage play
egorization of injectable fillers by their function and clini-
large roles in the agent’s performance and persistence.9 These
cal outcomes.14 The categories include neuromodulators,
NASHA fillers are approved as soft-tissue injectable agents for
collagen-based agents, replacement agents, biostimulatory
NLFs of moderate to severe facial rhytides but are used off-
agents, long-lasting agents, and autologous fat (Table 42.2).
label for diverse applications such as tear trough correction
(Neuromodulators are covered in Chapter 43.)
and soft-tissue augmentation of the dorsum of the hands.10 In
2011, Restylane (Medicis, Scottsdale, AZ) received an expan-
Collagen sion of its label from the Food and Drug Administration
Derived from bovine, porcine, and live or cadaveric human (FDA) to include lip augmentation.
dermal tissue, collagen provides support and strength to the HAs are sometimes referred to as either heavy HAs or light
skin. Skin testing is required for agents containing bovine HAs, based on the length of their chains of repeating disac-
collagen. charides, degree of cross-linking, and content of free HA and
Cymetra (LifeCell Corporation, Branchburg, NJ), an asep- HA concentration among many other factors. Heavy HAs
tic particulate, injectable form of AlloDerm prepared for include Restylane-L, Perlane-L (Medicis, Scottsdale, AZ), and
delivery in 0.5% lidocaine with 1:200,000 epinephrine, is Juvederm Ultra XC/Ultra Plus XC (Allergan, Irvine, CA).9
derived from isogenic human tissue. Indicated for augment- Light HAs include Prevelle Silk (Mentor Corp., Santa
ing lip volume, nasolabial fold injection (NLF) correction, Barbara, CA) and Belotero (Merz Aesthetics, San Mateo, CA).

FIGURE 42.3. Thick-section light microscopy at 9 months showing

FIGURE 42.2. Photomicrograph of restylane. Each scale bar = microspherules surrounded by thick collagen and histiocytes. Courtesy
100 μM. From Stcoks D, et al. Rheological evaluation of the physi- of David J. Goldberg, M.D., J.D.
cal properties of hyaluronic acid dermal fillers. J Drugs Dermatol.
September 2011;10(9):974–980.
Prevelle Silk, with an HA concentration of 5.5 mg/mL is filler allows continuous water exchange with the surrounding
prepared with lidocaine for comfortable injection and indi- tissue, reducing the risk of biofilm formation. Aquamid is at
cated for moderate to severe facial lines, folds, and wrinkles, present awaiting FDA clearance.24
such as NLF. This particular HA formulation behaves in an LAVIV (Fibrocell Science, Exton, PA), approved for the
“isotonic” manner once injected, with no appreciable edema treatment of moderate to severe NLFs, is derived from a
post injection. Belotero, FDA cleared in 2011, is produced patient’s own fibroblasts after obtaining via a skin punch
with cohesive polydensified matrix technology, a homogenous biopsy. LAVIV is being investigated for the treatment of roll-
gel matrix that permits the material to integrate uniformly into ing, depressed acne scars, but is not currently approved for
the skin without volume loss or dispersal.20 Belotero’s indica- this indication.25
tion in the United States is for injection into the mid- to deep Platelet-rich plasma (PRP), drawn from the patient’s blood,
dermis for correction of moderate to severe facial wrinkles is processed to contain a high concentration of platelets
and folds, such as NLFs. This agent’s particular physiochemi- and growth factors to promote soft-tissue healing.26 Widely
cal characteristics are ideal for superficial dermal injections applied in orthopedics, PRP has been also used off-label for
with long duration and avoidance of the Tyndall effect. fine lines and wrinkles using superficial intradermal injection
techniques.
Biostimulatory Agents
These agents stimulate new collagen growth.
Long-Lasting Agents
CaHA (Radiesse; Merz Aesthetics, Inc., San Mateo, CA), Silicone (Si) (Silikon 1000; Alcon, Fort Worth, TX) is injected
suspended in an aqueous carboxymethylcellulose carrier, in microdroplets. Over 3 months, collagen capsules surround
immediately volumizes the area of implantation and is a dura- and support the liquid silicone microdroplets.27 Si is used for
ble corrective agent indicated for moderate to severe facial off-label augmentation of NLFs, labiomental folds, mid-malar
folds and wrinkles but effective as an off-label volumizing depressions, lip atrophy, and correction of acne and scar tis-
agent for the malar area, temporal hollow, and the dorsum sue28,29 (Chapter 7).
of the hands.21 Over time, macrophages begin to dissolve the PMMA (ArteFill; Suneva Medical, Inc.; San Diego, CA).
gel carrier, while CaHA microspheres become surrounded by See Collagen Based Agents section.
fibroblasts, forming a matrix to support neocollagenesis. In
12 to 18 months, the microspheres are degraded by macro- Autologous Fat
phages and disappear2 (Figure 42.3). The body’s own subcutaneous fat is harvested, processed, and
Poly- l-lactic acid (PLLA) (Sculptra Aesthetic; Sanofi- injected to volumize or augment areas of the body that have
Aventis; Bridgewater, NJ) comprises microparticles of PLLA undergone atrophy (Chapter 44).
suspended in carboxymethylcellulose, non-pyrogenic manni-
tol, and sterile water for injection. The vial contains 367.5 mg
of lyophilized PLLA microparticles requiring dilution with Anatomical Considerations
sterile water. Depending on the area of the body to be treated,
the vial may be reconstituted using a range of sterile water
For Agent Selection
volumes (5 to 24 cc) in an off-label manner.22 The injectable While the youthful face presents with smooth transitions
implant stimulates fibroblasts to produce collagen, enabling among fat compartments, the face does not age uniformly.4
correction for up to 2 years and is especially effective for Investigators have demonstrated that subcutaneous facial fat
restoring volume to enable facial contouring after atrophy23 resides in discrete compartments that respond independently
(Figure 42.4). to the aging process. For example, patients with midface hol-
Polyacrylamide hydrogel (Aquamid; Contura SA, Montreux, lows and facial volume loss display intact NLF and jowl fat.4
SW) is a soft volume filler, which integrates naturally into the In studies, dyes were injected into the hemi-faces of cadaver
body’s own tissue. Consisting of approximately 97.5% water dissections of men and women from 47 to 92 years old to
and 2.5% cross-linked polyacrylamide gel, the highly elastic examine fat compartments in the areas near the NLFs, cheeks,

A B
Aesthetic Surgery
FIGURE 42.4. B/A of patient, 54 years old, with PLLA injections, 12 months after PLLA injections to temporal fossa/cheeks, two vials/session
× 2 sessions, 9 cc sterile water dilution per vial.
forehead and temporal space, orbital muscles, and jowls.4 The

dye revealed distinct boundaries, suggesting highly compart- Other Considerations In
mentalized subcutaneous fat tissue as well as vascular con- Filler Selection
nectivity between these zones. The studies also revealed the
presence of multiple layers of deep fat residing above and Patient Counseling
beneath the facial muscles. A candid conversation between the practitioner and the
These pivotal anatomical observations have contributed to patient regarding available, recommended correction options
the way in which practitioners approach restoration of facial and protocols, expectations and realistic outcomes, and poten-
volume. Adding volume to the midface, deep medial fat com- tial posttreatment complications may help reduce anxiety and
partment, indirectly affects the NLFs, the hollow tear trough, discomfort and manage patient expectations. Informed con-
and even the oral commissure, as the middle third of the face sent is recommended for all procedures, as are pre- and post-
supports the upper and lower third.30 Augmenting the pyri- treatment photographs of the affected areas.
form region with PLLA, CaHA, or HA can enhance the entire
NLF and midface.
Studies have assessed the qualities constituting attractive- Durability of Effect
ness: youthfulness, sexual dimorphism, averageness, and side- Injectable agents and devices may remain in the body for
to-side symmetry.31 Further assessment of the perioral and varying lengths of time, depending upon the physiochemical
periorbital areas and midface volumization provides a frame- composition of the agent, the extent of perceived correction,
work for restorative intervention.5 In addition, the face has and movement of the treatment area. The durability differ-
been analyzed and mapped three-dimensionally by regions entiates each agent in terms of cost and recovery time. The
that may dictate technique, treatment, and agent selection.30 collagens, generally shorter term agents that correct for 3 to
Evaluating the face in thirds affords a reliable guide to 6 months, entail frequent treatments, while HAs may persist
sculptural treatment. Horizontally dividing the face into thirds for 12 months. Synthetic fillers and compounds tend to per-
offers an evaluative tool for the clinician in determining both sist for 12+ months (CaHA and PLLA, from 6 to 18 months;
approaches and agent selection. Left-to-right symmetrical PMMA, 5+ years; and Si, permanent).
evaluation assists both the practitioner and the patient in eval-
uating which areas of the face may require more correction
than others. Combining and Layering Agents
Implantation of volumizing agents may also be used to Given the interrelationships and interactivity of structural
compensate for diminished skeletal support. Ultimately, how- facial anatomy, a clinician may combine technique, modali-
ever, the choice of injectable agent is anatomically based, i.e., ties, and agent selection to the overall corrective protocol
the corrective needs of the patient’s face drive filler selection. to achieve a comprehensive goal. Off-label combination
It is of critical importance to be familiar with each agent’s approaches to aesthetic rejuvenation may include layering der-
physiochemical properties in order to match a particular ana- mal fillers/volumizing agents at different depths or combining
tomical area with the proper agent. neuromodulators to relax the muscles and increase the agent’s

persistence.2 In clinical practice, determining which fillers crosshatching, and fanning allow for horizontal, vertical,
most effectively rejuvenate in tandem depends on the interac- crosshatch (gridding), fanning, or diagonal, parallel layering.34
tion of agent physiochemical properties; the mechanical and
aesthetic interrelationship among the areas of the face; desired Depot Injection
corrective intervention; and patient/physician experience with
Depending upon the desired augmentation, a quantity of filler
each material. These variables will guide the practitioner’s
is deposited as a bolus. The bolus is then molded and mas-
choice, application, technique, and delivery of the injectable
saged into the desired shape and contour. Depot injections are
filler/volumizing agent.
often used in the hand or in augmenting the temporal hollow
via a supraperiosteal placement.
Custom Formulations
Efforts to enhance and optimize the patient’s experience upon Serial Puncture
injection of dermal fillers/volumizing agents have led prac-
Small quantities of filler are injected in close proximity along
titioners to study the salutary effects of premixing lidocaine
the same wrinkle or crease to form a continuous line of volu-
with agents such as CaHA and HA. The amount of injectable
mization. This particular technique allows for predictable
anesthetic may be calibrated based upon the anatomical area
agent placement and is easily mastered.
targeted for treatment. For example, when employed with a
tiered approach, CaHA retains its integrity when combined
with lidocaine. The three-tiered approach of lidocaine dilu- Adverse Events and Treatment
tion with CaHA permits varying degrees of dermal and sub-
Every injectable filler has the potential to cause adverse
cutaneous injection with no compromise to G′ lifting ability.
events. The degree of possible complication, time of onset
Depending upon the anatomical injection site the diluent vol-
from injection, and the type of reaction (i.e., immunologic
ume varies. The recommended initial diluent is 1% lidocaine.32
versus technical error) dictate treatment.35 Even though FDA-
In addition, Restylane-L, suitable for correction of severe to
cleared dermal filler/volumizing agents undergo rigorous test-
moderate wrinkles and folds, also works to improve the tear
ing before approvals are issued, patients and practitioners
trough deformity.15,32 Combining Restylane-L 1.0 cc with 1%
should be well informed about the possibility of postinjection
lidocaine in a 1:1 ratio disperses the filler to lower its viscosity
adverse events. As the popularity and development of dermal
and concentration upon injection, allowing for smooth and
filling/volumizing agents grow worldwide, patients and phy-
uniform deposition as well as minimizing the possibility of the
sicians should resist using potentially contaminated, unregu-
Tyndall effect.32
lated agents that have not been approved by the appropriate
governing agencies.
Injection Techniques The physician should conduct a thorough patient evalu-
ation, eliciting a comprehensive clinical history to determine
Injection technique and the plane of injection for filler/
individual immunological contraindications, bleeding disor-
volumizing agent implantation is a function of the agent’s
ders, or hypersensitivity to the physiochemical properties of
characteristics and the patient’s anatomy. Physiochemical
a given agent.36 Thoughtful consideration of the agent’s com-
properties of the agent, facial zone, treatment area, and extent
patibility, injection technique, needle size, patient anatomy,
of indicated correction determine several variables: needle
and duration of the filler in the body may prevent serious reac-
size, cannula gauge, angle and injection pattern; filler volume,
tions.34 Prior to treatment candidates should be counseled to
quantity and dilution; plane of injection; and pre- and post-
discontinue the intake of anticoagulants, anti-inflammatory
procedure protocols.
medications, vitamin E or other medicines, or nutritional
Although needle sizes relate primarily to filler viscosity and
supplements that may inhibit clotting or platelet adhesions.
its impact upon extrusion, G′ and h* help enable a filler to
Antiviral prophylaxis is appropriate for patients with a his-
resist movement imposed by an external force.9 Lower h* fill-
tory of “cold sores.” Application of a topical anesthetic or
ers (e.g., Prevelle and Belotero) that are easily extruded can
nerve block, mixing filler with lidocaine, and/or applying ice-
be administered with smaller bore 30G needles, while larger
packs may reduce the discomfort of injection.
bore needles (27G) afford less resistance to the flow of highly
Immediate complications include redness, swelling, and
viscous products (e.g., Juvederm Ultra Plus and Perlane).33
vascular compromise, requiring aggressive, early intervention
Manufacturers are keenly aware of the ergonomics of
and treatment. In the rare instance of impending necrosis,
injection and are addressing the subject with new designs
after the injection is stopped, aggressive therapy employing
and adaptive strategies. For example, the growing trend in
gentle massage, warm compresses, use of acetyl salicylic acid,
blunt cannula and automated injection assist devices (Artiste)
and topical application of nitroglycerin 2% should be started.
requires fewer punctures and allows continuous, predictable
If HA fillers have been injected, hyaluronidase injection will
filler placement with less pain for the patient and less fatigue
remove some of the product and reduce pressure on the blood
for the physician. Advocates of cannula point to a theoreti-
vessel limiting the area of possible necrosis. Low molecular
cally decreased chance of intravascular injection.
weight heparin injections into the area may limit the progres-
Prior to treatment, a patient should be administered topi-
sion of the necrosis as well.37-39
cal anesthetics, nerve blocks, ice packs, and dermal or filler-
Up to 6 months posttreatment, adverse events may include
diluted (i.e., Radiesse, Restylane, and Sculptra) lidocaine
nodule development due to excessively superficial placement,
injections. During treatment, one must always strive to avoid
use of an agent in an inappropriate anatomical area, or inap-
the vascular network during product delivery. Utilizing lido-
propriate dilution of the agent. Clinicians must be able to
caine-containing epinephrine may decrease the chance of
differentiate between nodules and granulomas, the latter of
intravascular injection. A slow, uniform injection in the cor-
which represents a delayed immunological response. This is
rect plane minimizes the likelihood. Post injection, massaging
critical since the treatment varies significantly. Nodules are
the injected area helps attain even filler distribution.2
secondary to the material placed; treatment may involve mas-
sage, hyaluronidase injection, I/D, or excision. Granulomas
Threading, Crosshatching, and Fanning may respond to steroid injections combined with antimetab-
Filler/volumizing agents may be delivered slowly through an olites such as 5-fluorouracil. For HA-induced granulomas,
antegrade (i.e., forward) or retrograde (i.e., backward) lin- hyaluronidase may be indicated as the initial treatment.40
ear threading technique, which delivers the filler in a con- Attention to sterile technique during injecting will likely
tinuous, uninterrupted flow along the depression. Threading, reduce the introduction of pathogens into the area. However,

9. Kablik J, Monheit GD, Yu L, Chang J, Gershkovich J. Comparative physical
Ta b le 4 2 . 3 properties of hyaluronic acid dermal fillers. Dermatol Surg. 2009;35:302-312.
10. Stocks D, Sundaram H, Michaels J, Durrani MJ, Wortzman MS, Nelson
Filler First Aid Kit DB. Rheological Evaluation of the Physical Properties of Hyaluronic Acid
Dermal Fillers J Drugs Dermatol. 2011;10(9):974-980.
• Cerebral cortex 11. Sundaram H, Voigts MS, Beer K, Meland M. Comparison of the rheo-
logical properties of viscosity and elasticity in two categories of soft tis-
• Epi pen sue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol Surg.
2010;36:1859-1865.
• D/C injection/aspirate 12. Laurent UBG, Reed RK. Turnover of hyaluron in the tissues. Adv Drug
Deliv Rev. 1991;7:237-255.
• Vigorous massage 13. Laeshke K. Biocompatibility of microparticles into soft tissue fillers. Semin
• Warm compress Cutan Med Surg. 2004;23:214-217.
14. Rohrich RJ, Hanke CW, Busso M, et al. Facial soft-tissue fillers: assessing
• Hyaluronidase the state of the science conference—proceedings report. Plast Reconstr Surg.
April 2011;127(4 Suppl):22S.
• ASA 15. Bergeret-Galley C. Comparison of resorbable soft tissue fillers. Aesthet Surg
J. January-February 2004;24(1):33-46.
• NTP 16. Dermal filler product comparison. Aesthetic Buyers Guide. May/June 2007.
www.miinews.com. Accessed November 3, 2011.
• Heparin 17. Cohen SR, Berner CF, Busso M, et al. Five-year safety and efficacy of a
• Hyperbaric oxygen? novel polymethylmethacrylate aesthetic soft tissue filler for the correction of
nasolabial folds. Dermatol Surg. 2007;33:S222-S230.
ASA, acetyl salicylic acid; NTP, nitropaste. 18. Lemperle G, Knapp TR, Sadick NS, Lemperle SM. ArteFill permanent
injectable for soft tissue augmentation: I. Mechanism of action and injec-
tion techniques. Aesthetic Plast Surg. June 2010;34(3):264-272. Epub 2009
September 29. Presented in part at the First World Congress on PMMA
biofilms, rare but possible with any injectable implant, may Fillers, Guadalajara, Mex, 5-6 December 2008. http://www.escholarship.
org/uc/item/45b4s0jb?display=all. Accessed November 5, 2011.
present after more than a year postinjection and require 19. Tezel A. Frederickson GH. The science of hyaluronic acid dermal fillers.
aggressive antibiotic treatment. The concern about the possi- J Cosmet Laser Ther. 21 December 2007; 1-8.
bility of biofilm supports earlier cautions against importation 20. Lorenc, ZP. HA-cohesive polydensified matrix technology – clinical impli-
or use of unapproved products27 (Table 42.3). cations. Presented at aesthetic plastic surgery and anti-aging medicine: the
next generation. June 12, 2011.
21. Busso M, Applebaum D. Hand augmentation with Radiesse (calcium
Conclusion hydroxylapatite). Dermatol Ther. November-December 2007;20(6):
385-387.
Although the practice of filler/volumizing agent injection is 22. Lorenc ZP. Techniques for the optimization of facial and non-facial
volumization with injectable poly-L-lactic acid. Aesthetic Plast Surg.
aesthetically driven, the practice of aesthetic medicine is based
Aesthetic Surgery
2012;36:1222-1229.
upon science. To meet patient’s expectations, practitioners 23. Vleggaar D. Soft-tissue augmentation and the role of poly-L-lactic acid.
consider a range of products and protocols to recontour, rev- Plast Reconstr Surg. September 2006;118(3 Suppl):46S-54S.
olumize, and restore vitality and elasticity to the face. The 24. Wolters M, Lampe H. Prospective multicenter study for evaluation of
safety, efficacy and esthetic results of cross-linked polyacrylamide hydrogel
physiochemical properties of these fillers determine their clini- in 81 patients. Dermatol Surg. 2009;35(Suppl):338-343.
cal performance, longevity, ease of delivery, safety, efficacy, 25. Fibrocell Technologies, Inc. Highlights of prescribing information. http://www.
and cost. Thoughtful assessment of the patient’s needs com- mylaviv.com/pdf/LAVIV-prescribing-info.pdf (2011). Accessed November 9,
bined with a thorough knowledge of available options will 2011.
26. Mehta V. Platelet-rich plasma: a review of the science and possible
benefit the physician, patient, and industry as it continues to clinical applications. Orthopedics. February 2010;33(2):111. doi:
mature. 10.3928/01477447-20100104-22.
Growing exponentially in popularity, minimally inva- 27. Jones D. Semipermanent and permanent injectable fillers. Dermatol Clin.
sive aesthetic correction has become a dynamic field. 2009;27:433-444.
28. Fulton JE Jr, Porumb S, Caruso JC, Shitabata PK. Lip augmentation with
Development of new soft-tissue filler/volumizing agents with liquid silicone. Dermatol Surg. November 2005;31(11 Pt 2):1577-1586.
more versatility, efficacy, and biocompatibility has generated 29. Barnett JG, Barnett CR. Treatment of acne scars with liquid silicons injec-
an international market for affordable, durable, safe, and tions: 30-year-perspective. Dermatol Surg. 2005;31(11 pt 20):1542-1549.
effective agents that can offer a refreshing, youthful appear- 30. Fitzgerald R, Gravier MH, Kane M, et al. Facial aesthetic analysis. Aesthet
Surg J. July-August 2010; 30 (Suppl):25S-27S.
ance to a generation reluctant to succumb to the external 31. Bashour M. History and current concepts in the analysis of facial attractive-
aging process. ness. Plast Reconstr Surg. 2006;118:741-756.
32. Lorenc ZP. A three-tiered approach to the use of premixed lidocaine with
References calcium hydroxylapatite for treatment areas of the face. Cosmetic Dermatol.
2012;25(6):266-270.
1. American Society of Plastic Surgeons. Cosmetic Surgery National Data Bank: 33. Sherman R. Avoiding dermal filler complications. Clin Dermatol.
Statistics 2010. http://www.surgery.org/sites/default/files/Stats2010_1.pdf. 2009;27:523-532.
Accessed November 2, 2011. 34. Jones D, Flynn TC, Hyaluronic acids: clinical applications. Injectable Fillers.
2. Alam M, Gladstone H, Keamer EM, et al. ASDS guidelines of care: inject- http://www.medscape.org/viewarticle/709469_2. Accessed November 8,
able fillers. Dermatol Surg. 2008:34:S115-S148. 2011.
3. Lemperle G, Holmes RE, Cohen S, et al. A classification of facial wrinkles. 35. Lemperle G, Rullan PP, Gauthier-Hazan N. Avoiding and treating dermal
Plast Reconstr Surg. 2001;108:1735-1750. filler complications. Plast Reconstr Surg. 2006;118(3 Suppl):92S-107S.
4. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and 36. Grimes PE. Aesthetics and Cosmetic Surgery for Darker Skin Types.
clinical implications for cosmetic surgery. Plast Reconstr Surg. June Chicago, IL: Lippincott Williams and Wilkins (Wolters Kluwer Health);
2007;119(7):2219-2227; discussion 2228-31. 2007.
5. Lorenc ZP. New consensus recommendations for injectable shaping agents: 37. Schanz S, Schippert W., Ulmer A, et al. Arterial embolization caused by
an expert interview with Z. Paul Lorenc, MD. Medscape Educ Dermatol. injection of hyaluronic acid (Restylane). Br J Dermatol. 2002:146:928-929.
http://www.medscape.org/viewarticle/732944. Accessed November 5, 2011. 38. Hirsch RJ, Cohen JL, Carruthers JD. Successful management of an unusual
6. Lemperle G, Morehenn V, Charrier U. Human histology and persistence of presentation of impending necrosis following a hyaluronic injection
various injectable filler substances for soft tissue augmentation. Aesthetic embolus and a proposed algorithm for management with hyaluronidase.
Plast Surg. September-October 2003;27(5):354-366; discussion 367. Epub Dermatol Surg. 2007:33:357-360.
2003 December 4. 39. Hirsch RJ, Lupo M, Cohen JL, Duffy D. Delayed presentation of impend-
7. Morhenn VB, Lemperle, G, Gallo RL. Phagocytosis of different particulate ing necrosis following soft tissue augmentation with hyaluronic acid and
dermal filler substances by human macrophages and skin cells. Dermatol successful management with hyaluronidase. J Drugs Dermatol. 2007;6:
Surg. June 2002;28(6):484-490. 325-328.
8. Lorenc ZP, Nir E, Azachi M. Characterization of physical properties and 40. Brody HJ. Use of hyaluronidase in the treatment of granulomatous hyal-
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Chapter 43 n Botulinum Toxin
Michael A.C. Kane
Injections of botulinum toxin type A are the most frequently writing, there are more than 300 different conditions reported in
performed cosmetic procedure in the United States. The the scientific literature that can be treated with the toxin, includ-
change from little-known specialty drug used by ophthalmolo- ing blepharospasm, strabismus, cervical dystonia, torticollis,
gists to the most frequent cosmetic procedure occurred in just achalasia, spasmodic dysphonia, anal fissure, writer’s cramp, par-
over a decade. Despite the widespread use, the toxin is still not kinsonian tremor, spasm of sphincter of Oddi, synkinesis, hyper-
completely understood and poorly used by many physicians. hidrosis, migraine headache, tetanus, and cerebral palsy.
The paradox is not hard to understand when one considers
the time allotted to teaching the various components of plas- Applied Mechanism of Action
tic surgery during residency training. Whereas years are spent
teaching the finer points of rhytidectomy, blepharoplasty, Because the toxin acts on presynaptic nerve terminals, it is
rhinoplasty, and liposuction, only an afternoon, or perhaps most commonly injected into the muscle where these termi-
1 or 2 days, is typically spent teaching proper technique for nals reside. It is not an all-or-nothing phenomenon. A certain
botulinum type A injection. In 2010, more botulinum type A amount of toxin will block a certain number of terminals.
injections were performed than rhytidectomy, blepharoplasty, Thus, fine control over the amount of denervation desired is
rhinoplasty, and liposuction combined. possible. Despite the common use of the word paralysis when
Dr. Alan Scott, an ophthalmologist, pioneered the use of discussing about the toxin, it is rare that this is the desired
botulinum toxin type A in humans. His first publication, detail- effect. Rather, a selective weakening of the musculature is
ing the effect on rhesus monkeys appeared in 19731; his first performed to achieve a pleasant cosmetic effect.
publication concerning the injection of the toxin into humans Facial aging consists of many components. Thinning of the
was published in 1980.2 For years, the toxin was an effective, dermis, elastosis, loss of facial volume, genetic factors, grav-
although seldom used, medication for blepharospasm and stra- ity, skeletal changes, and smoking, all play a part in the aging
bismus. Rare anecdotal reports of its use for wrinkle reduction process, so does facial animation. Certain rhytides are primar-
are in existence.3 The first comprehensive report detailing cos- ily caused by facial movement. As long as a wrinkle is caused
metic applicability was published by the Carruthers, an oph- or partially caused by muscular action, it can be treated with
thalmologist/dermatologist team, in 1992.4 This study reported botulinum toxin A. This explains why nearly all facial rhytides
the effects of the toxin on glabellar rhytides in 18 patients. are treatable by the toxin with varying degrees of success. For
Although the glabellar muscles are still the most commonly instance, a glabellar rhytid is nearly completely caused by the
injected muscles for cosmetic reasons, every mimetic muscle of actions of the corrugator and procerus muscles and can be com-
the face has been treated with the toxin, with varying success. pletely eradicated in a young patient. Vertical lip rhytides in an
elderly woman with thin skin, sun damage, a history of smoking,
and loss of lip volume can only be partially improved by careful
Mechanism of Action injection of the toxin into the orbicularis oris muscle, which con-
The mechanism of action of the toxin has been carefully tributes to the accordionlike scrunching of the overlying lip skin.
researched, but is often misstated. Because botulism is still a How well a rhytid responds to treatment with the toxin depends
serious health threat throughout undeveloped nations and on how much of the rhytid is a result of factors other than ani-
because sporadic outbreaks still occur in the United States, mation. Although this chapter is primarily concerned with alter-
hundreds of publications by many different specialties are gen- ations in animation, it is the overlying skin’s ability to resist these
erated each year concerning botulinum toxin. The toxin is a forces that is paramount when discussing rhytides. Once facility
1,295 amino acid chain that has been fully sequenced. It con- is obtained treating simple rhytids, the toxin can then be used to
sists of a heavy chain of 97 kilodaltons (kDa) connected by restore the face to a more youthful and pleasing shape.
a disulfide bond to a light chain of 52 kDa. The heavy chain
binds to the neuronal cell membrane, allowing passage of the Botulinum Toxins and
light chain into the cytoplasm of the nerve. The light chain is
a metalloprotease that cleaves the protein known as SNAP-25
Preparation
(synaptosomal-associated protein 25). SNAP-25 is necessary for The Clostridium botulinum bacteria secretes eight dis-
the transmitter vesicle containing acetylcholine to fuse with the tinguishable exotoxins.6 The most potent of these sero-
cell membrane. Without fusion of the vesicle to the cell mem- types is A. Both toxins A (Botox, Allergan, Irvine, CA
brane, the neurotransmitter cannot be released into the synapse and Dysport, Medicis, Scottsdale, AZ) and B (Myobloc,
and a presynaptic neural blockade is created. Consequently, the Solstice, Louisville, KY) are available in the United States.
toxin does not directly affect the skin and only indirectly affects Onabotulinum toxin A (Botox Cosmetic) is currently
the muscle, which loses its stimulus. Properly stated, botulinum approved for the treatment of glabellar furrows in patients
toxin A only directly affects the nerve. aged 65 years and younger. Another preparation of botuli-
Clinically, the beneficial effects of the toxin are apparent num toxin type A, AbobotulinumtoxinA (Dysport), has been
for 3 to 6 months. However, when carefully scrutinized, it approved for the treatment of glabellar furrows in patients
typically takes 6 to 7 months for all of the clinical effects to under 65 since 2009. All other applications described in this
disappear. As patients continue to have the toxin injected on chapter are off-label uses. RimabotulinumtoxinB (Myobloc)
a regular basis over 2 or more years, many note an increased is a type B toxin which is not approved for cosmetic pur-
duration of botulinum toxin (Botox) action.5 poses. It has a relatively minor role for cosmetic, off-label
The fact that botulinum toxin A disrupts such a basic pathway applications. Toxin B also exerts its effect via a presynaptic
leads to its efficacy in treating a wide range of pathologic states. neural blockade but via a different mechanism. It does not
Any pathologic condition mediated by acetylcholine release act on SNAP-25; instead it acts on synaptobrevin. Although
from a peripheral nerve has the potential to be treated. As of this the onset of action is faster than that of Botox, the increased
464
Chapter 43: Botulinum Toxin 465
pain on injection (it is supplied premixed in a vial with a rel-
atively low pH of 5.6) and decreased duration of action limit Functional Anatomy
its cosmetic usefulness. I currently use Myobloc in isolated The difference between a proficient BoNTA injector and a tech-
instances such as when a patient has a social event within nician is an understanding of the functional anatomy of the face.
1 or 2 days of injection. Myobloc has a much faster onset of Anatomy texts demonstrate the location of the facial muscles.
action than both type A products, usually within 24 hours. Although these texts allow for anatomic variations, they do not
By the time this chapter is printed, another type A toxin is prepare us for the overwhelming differences in functional anat-
likely to be on the market. Xeomin (Merz Aesthetics, San omy between individuals. A classic example is Rubin’s descrip-
Mateo, CA) is a BoNTA that is free from complexing pro- tion of the different smile patterns.7 Even though all individuals
teins and has a dosing regimen similar to Botox. Revance have the same mimetic muscles, their smile patterns vary tre-
(Newark, CA) has a topically applied BoNTA currently in mendously, depending on which muscles dominate within the
clinical trials for lateral canthal lines (crow’s feet). group. Even within a single muscle, different portions of that
Botox injection is contraindicated in disorders of neu- muscle may dominate and alter animation. The key is a careful
romuscular transmission, such as myasthenia gravis and analysis of each patient’s face to discern which muscles cause
Lambert-Eaton syndrome. It should not be used in patients unaesthetic lines or shaping of the face.
taking aminoglycoside antibiotics whose use may potenti-
ate the effects of the toxin. Although there is no evidence to
suggest teratogenicity, I do not treat pregnant women, women Glabella
actively attempting to become pregnant, or those who are The glabella was the first area to be treated cosmetically with
breast-feeding. The toxin does not cross the blood–brain bar- Botox (Figure 43.1). As with the other areas of the upper face
rier. Complications occur from drift of the toxin to adjacent to be treated with Botox, there was a longstanding surgical
muscles, thereby weakening them. This is especially hazard- procedure upon which this treatment was based. The glabel-
ous when injecting the perioral musculature. Other complica- lar musculature is commonly debulked during brow lift pro-
tions include headache, ecchymosis, and eyelid ptosis. cedures to ease glabellar furrowing and to reduce downward
OnabotulinumtoxinA and abobotulinumtoxinA are sup- pull on the brow. Chemodenervation of these muscles has the
plied as vacuum dried and lyophilized complexes in glass vials. same effect. My median dose for treating the corrugator and
Complexing proteins, which in nature protect the toxin from procerus muscles is 17.5 Botox/50 Dysport units for women
stomach acid, are also present with onabotulinumtoxinA hav- and 20/60 units for men.
ing more complexing protein present. Both preparations also Even in a relatively straightforward area of the face such as
contain varying amounts of excipients such as human serum the glabella, there is a great deal of variation in functional anat-
albumin and sodium chloride. To be injectable, each prepa- omy. When most people frown, they bring their brows together
Aesthetic Surgery
ration is reconstituted with normal saline. The label indicates and down. In some patients, however, the brow’s movement is
that onabotulinumtoxinA be reconstituted with 2.5 cc of non- mostly vertical, whereas in others it is mostly horizontal.
preserved saline and abobotulinumtoxinA with 2.5 or 1.5 cc After observing a patient through normal animation, I ask
of non-preserved saline. However, common usage for both the patient to frown, relax, frown again, and then scrunch the
products is primarily off-label. Reconstitution varies among nose as if smelling something unpleasant. The injection pattern
providers from 1 to 10 cc dilution. Preserved saline due to its varies depending on the frowning pattern. Horizontal frowners
mild anesthetic agent (benzyl alcohol) is the preferred diluent are not injected in the procerus muscle. Vertical frowners are
for most injectors. Time period after reconstitution for use is injected in the medial portion of the corrugator and procerus
24 and 4 hours on label but most practitioners use the product muscles with the nasalis muscles injected as well.
within 5 to 7 days after reconstitution. There is one article in
the literature which supports use up to 6 weeks after recon-
stitution. Both products are labeled as single patient use but Forehead
I have been a chairman and participant at many expert con- The frontalis muscle is injected to weaken the forehead to
sensus panels but almost no experts follow this guideline. I relieve horizontal forehead rhytides (Figure 43.1). The fron-
have used 4 cc of non-preserved saline to reconstitute onabotu- talis also has highly variable functional anatomy. My dosage
linumtoxinA since 1991 and 3 cc of non-preserved saline to range for the frontalis is 3.75 to 30 Botox/7.5 to 60 Dysport
reconstitute abobotulinumtoxinA since 2009. units, although most fall within the range of 5.0 to 7.5/15
to 20 units. Care must be taken to not overly denervate the
frontalis because it can lead to an overly smooth, artificial
Dosage appearance, brow ptosis, and eyelid ptosis in the patient who
Just as dilution of BoNTA is a personal choice, so is dosage has been using the frontalis as an accessory eyelid elevator.
in most circumstances. Different muscles in different people Despite its appearance in most anatomy texts, the frontalis is
have different strengths. To have a standard dose per area usually continuous across the forehead, with muscle present
or muscle group makes about as much sense as having a even in the midline.
standard amount of fat to remove during liposuction. Every After the patient is observed in normal animation, the
patient is different and requires a different dose placed differ- patient is asked to raise and lower the brows several times,
ently across the muscle being treated. For example, most prac- almost to the point of exhaustion. Upon observation of the
titioners inject about 25 Botox units or 60 Dysport units, on motion, the strongest portions of this muscle are targeted, not
average, per glabella. Some dermatologists advocate as much the rhytides. No standard pattern of injection is used.
as 80 Botox units. My median dose is 17.5 Botox units or 50
Dysport units, but some patients have excellent results with as Crow’s Feet and Lower Eyelid
little as 5/10 units. Men typically require higher doses as the
muscle mass tends to be greater.1 I refer to doses in the follow- The lateral and inferior orbicularis oculi is weakened to dimin-
ing text with the reservation that it is up to each injector to ish crow’s feet and lower eyelid rhytides in selected patients
determine the optimum dosage for an individual patient. (Figure 43.1). The effects of surgically weakening the lateral
orbicularis had been known for several years prior to the cos-
1
Kane MAC et al. Evaluation of Variable-Dose Treatment with a metic use of Botox injections.8 The confluence of the crow’s feet
New U.S. Botulinum Toxin Type A (Dysport) for Correction of and lower-lid rhytides and the fact that they are both created
Moderate to Severe Glabellar Lines: Results from a phase III, by the same muscle makes concomitant treatment appropriate.
Randomized, Double-Blind, Placebo-Controlled Study. The functional anatomy of this area leads to a classification of

crow’s feet patterns.9 The most common pattern is the full-fan important as the recognition that different patterns exist and
pattern where the lateral orbicularis contracts and wrinkles the that asymmetry occurs in individual patients.
overlying skin from the lateral brow to the lower lid–upper This is an area where overzealous injection can yield an
cheek junction; yet even this pattern occurs in less than half unpleasant deer-in-the-headlights appearance and even cheek
of all patients. The exact incidence of each pattern is not as ptosis. Although most plastic surgeons are aware that the upper
A B
C D
FIGURE 43.1. A. This woman in her forties is seeking rejuvenation of her upper face. She is frowning prior to injection. She was last treated with
BoNTA 5 months previously. She exhibits characteristic glabellar lines and musculature. B. Four weeks after injection of her corrugators and pro-
cerus muscles. She is unable to frown or lower her medial brows after injection of 20 units of Xeomin into her corrugators and procerus and 2.5 units
into her nasalis muscle. C. The patient is raising her eyebrows prior to injection. Notice the asymmetry with the left forehead apparently stronger and
the left brow noticeably higher than the right brow. D. The patient is raising her brows 4 weeks after injection of 5 units of Xeomin into her frontalis.
Her frontalis muscle was injected asymmetrically, with 3 units into her left side and 2 units into her right side. This was done in an attempt to raise
her right brow more than her left. In order to maximize brow lift, a moderate amount of motion was left resulting in small frontal rhytids. E. The
patient is smiling and exhibiting a stronger orbicularis oculi along her lower eyelid than her upper eyelid. She has a classic full fan-shaped rhytid
distribution. F. Four weeks after injection of 7.5 units of Xeomin into her right orbicularis oculi motion the patient has near-normal animation
with a moderate reduction of rhytids. Xeomin was injected cephalad and medial to the tail of her brow to attempt to raise it more than the right
brow. Caution must be taken to not overly chemodenervate the cheek elevators in an attempt to remove the rhytids which continue down the
lateral cheek. Her pretarsal orbicularis was also injected laterally. G. The patient in repose prior to injection. Note her frontal and crow’s feet
rhytids, glabellar rhytids and overhang, and low brows. The right brow is significantly lower than the left and causes an apparent excess of right
upper lid skin. H. Four weeks after the injections described above, the patient has obvious improvement in her glabellar, frontal, and crow’s feet
rhytids. She also has a pleasant small elevation of both brows (right greater than left) which open up her eyes and decrease the apparent skin
excess of her upper eyelids (especially on the right).

E F
Aesthetic Surgery
G H
lateral orbicularis oculi is a brow depressor, many fail to realize extreme, compensatory motion. This produces an unattractive
that the lower lateral portion of the muscle is an important cheek line of demarcation.
elevator. If overly denervated in its lower lateral section, malar
flattening, as well as an extra “roll” of skin between the lower
lid and cheek, can occur. Excessive chemodenervation of the
Brow Elevation
orbicularis oculi across the lower lid can cause ectropion, lower- BoNTA can easily and reliably lift the brows in excess of 6 mm
lid retraction, or even lymphedema. In the patient with minimal but it is not always an aesthetic improvement. Two concepts
to borderline orbital fat prolapse, weakening the middle lamella are at play. The first is simple: to lift the brows, one injects
can exaggerate and hasten the appearance of fat “bags” of the muscle segments that depress the brows. The second concept
lower lids. Thus, these areas are injected judiciously. is not simple: nonweakened sections of muscle react to weak-
Although there are no standard doses or dosing patterns, ened sections by increasing their pull in a compensatory fash-
most patients receive between 3.75 and 5.0 Botox units/ 10 to ion creating hyperactive sections. This explains why lateral
20 Dysport units per side. The key is to not waste your injec- orbicularis injection can cause lower-lid rhytides to increase.
tion on relatively adynamic sections of the muscle. To do this, This is not simply an illusion as a result of smoothing of the
one must recognize that the functional anatomy of the lateral skin laterally, but a real phenomenon caused by an increase in
periorbita varies widely. I inject the most dynamic area of the tone of the noninjected portion of the muscle. When the cen-
muscle first, followed by smaller injections radiating out from tral frontalis is injected strongly, the lateral brows will often
this point. The idea is to create a gradient of motion so as not peak in an unattractive “Mr. Spock” or Mephisto appearance,
to have an area of no motion directly bordering an area of with concomitant worsening of lateral suprabrow rhytides.

When portions of the frontalis are weakened, the other por- peaked and arched brow, the lateral depressor is weakened
tions of the frontalis lift more strongly. To maximize brow and the frontalis over the junction of the middle and lateral
lift, injecting the portions of the frontalis not responsible for third of the brow is left strong. For men, a wider band of
raising brows will induce the frontalis responsible for brow frontalis is left working to raise the brows while keeping them
elevation to pull harder. Usually this means injecting the fron- flat. For a unilateral brow lift, in addition to the zones not
talis strongly centrally, in the zone above and medial to the directly over the brows, the frontalis is weakened slightly over
brows. This causes the frontalis directly over the brows to the higher brow, inducing the frontalis over the lower brow
lift more strongly. Although the frontalis directly above the to pull harder. It is important to note that brow lifting by
brows is responsible for brow elevation, the lower frontalis is injection of toxins can create bizarre, unnatural appearance
more responsible than the upper frontalis. Thus, occasionally, in some patients.
the upper frontalis above the brows can also be weakened to
further increase the action of the lower frontalis.
There are 11 muscle segments that can depress the medial
The Neck
brow: the procerus, transverse heads of the corrugator, BoNTA injections in platysmal bands can yield excellent
oblique heads of the corrugator, depressor supercilii, medial results (Figure 43.2). Two articles on neck injection were
orbicularis oculi, and in some patients, the nasalis muscles. published simultaneously in 1999 with drastically different
In most patients, the effect of the nasalis on brow position dosage, patient populations, results, and complications.10,11
is negligible. However, in a small number of patients, I have One paper advocated up to 250 units be injected, noted that
fully injected the other medial brow depressors and been patients received a lift of the lower face, had better results in
disappointed in the ensuing brow elevation. With the other patients with greater skin laxity, and reported dysphagia as
segments completely nonfunctional, these patients were able a complication.10 I would caution against injecting such high
to depress their brows by wrinkling their nasalis. Subsequent doses in the neck. In addition to dysphagia, high doses can
nasalis injection gave the brows additional elevation. also lead to dry mouth by affecting the salivary glands.
The lateral brow is depressed by the cephalic portion of the The key to evaluating the neck as a potential site for
lateral orbicularis oculi. The dynamics of this phenomenon cosmetic improvement lies in the relative contributions of
differ greatly among patients, and thus there is no single point the skin and the platysma to banding. The best patients have
that can be injected to reliably elevate the lateral brow. In fact, minimal skin excess and relatively strong bands. Despite the
in some patients, this muscle is not a reliable brow depres- results (based on 1,500 patients) of the aforementioned paper,
sor, and injecting it will not raise the brow. The problem is to the patient with lax neck skin is a poor candidate for injection.
determine whose brows can be elevated and what portion of Even with the bands completely paralyzed, the lax neck skin
the muscle should be injected. With the head in neutral posi- will continue to hang.
tion and primary gaze, the patient is asked to smile repeat- My current dose range is 15 to 35 Botox units/50 to 80
edly and forcefully. When doing this, some patients will not Dysport units for the neck, with most patients receiving
depress their lateral brow at all. These patients will not reli- around 20/60 units. The patient is asked to show the lower
ably achieve brow elevation by injecting the upper lateral teeth with teeth clenched. The platysma band becomes appar-
orbicularis. Patients who do depress their brows are studied ent and is grasped between the thumb and the index finger of
carefully and then injected in the portion of the muscle that the noninjecting hand. The patient is then told to relax and the
is pulling downward on the lateral brow. Sometimes this is muscle is injected starting just below the mandibular border
at the lateral tail of the brow, sometimes directly beneath the and progressing inferiorly to the point at which the band is
brow more medially. Treatment is individualized based on visible. Early horizontal “necklace” rhytides can also be very
each patient’s functional anatomy. mildly improved by injecting toxin just above and below them.
There is no standard pattern of injection for brow eleva- Good candidates for injection fall into two basic categories.
tion. For a more medial brow elevation, the medial depressors The relatively young (35 to 45 years of age) patient with strong
are eliminated and the lateral frontalis is weakened, leaving bands and minimal skin laxity is an excellent patient. Likewise the
the medial frontalis strong. For a more lateral elevation, the patient of any age who has had a surgical procedure on the neck
lateral depressor and the medial frontalis are injected. For a and has relatively little excess skin and recurrent bands is a good
A B
FIGURE 43.2. A. This woman in her mid-thirties requested neck rejuvenation. She especially complained about the cords that she would see
in photographs when smiling fully. She is straining in this photo. She is an ideal candidate as she has very little skin excess. B. The patient had
20 units of Botox injected into her right primary platysmal band and 7.5 units into her left band and muscle body. She still has a mild prominence
of her right secondary band at maximal strain but it is not visible in normal animation.

candidate. A smaller set of patients, but one that is being seen more bone where it meets the maxilla. Thus, half of the finger is
frequently, is the young patient who has had an aggressive fat falling into the pyriform aperture while the other half lies in
removal procedure in the neck and now has visible bands. the groove between the nasal bone and maxilla. The patient is
then asked to smile strongly. The levator labii superioris alae-
que nasi muscle can usually be felt just lateral to this groove.
Nasolabial Fold It is injected once on each side, just above the periosteum. My
Treatment of the nasolabial fold demands appropriate patient dose range for this muscle is 5.0 to 10 Botox units/10 to 20
selection. In addition, the patient must understand the implica- Dysport units total, with most patients falling closer to the
tions of treatment in this tricky area. The levator labii superi- 5.0/10 unit range. This technique changes the functional anat-
oris alaeque nasi muscle is the muscle mainly responsible for the omy of the patient by changing their smile pattern.
medial nasolabial fold and the final 3 to 4 mm of central upper
lip elevation. Weakening of this muscle results in smoothing of
the medial nasolabial fold and a change in the smile pattern of
Perioral Lines
the patient. Rubin described the three major smiling patterns The perioral rhytides are a common area of complaint
in 1974. The most common, or “Mona Lisa,” smile pattern (Figure 43.3). The radially oriented rhytides are brought
is dominated by the zygomaticus muscle and elevates the oral about by intrinsic aging of the skin (dermal thinning, sun
commissures to the highest point of the smile. The canine smile damage, and smoking), a loss of volume over time, and
pattern is dominated by the levator labii superioris and the high- forced wrinkling of the skin caused by its densely adherent
est part of the smile is the central upper lip. This pattern occurs underlying muscle, the orbicularis oris. The most common
in 35% of the population and they are the potential candidates rejuvenative procedure for this area is the injection of filler
for this procedure. Because injection of the levator labii superi- materials. Injection of hyaluronic acid into the lip improves
oris alaeque nasi muscle results in a drop of the central upper the rhytides, restores lost volume, and offers immediate
lip upon smiling, it converts canine smilers into Mona Lisa results with negligible recovery time. However, BoNTA is an
smilers. Injecting Mona Lisa smile patients results in an exag- increasingly effective rejuvenate modality for several differ-
gerated Mona Lisa smile that most patients find unattractive. ent patient populations. First, there is the patient group that
Patients with gummy smiles demonstrate extreme canine is already having BoNTA injected into other areas of the face
smile patterns. This group benefits the most from BoNTA and asks if BoNTA could help their lip lines as well. A sec-
injection. 12 Gummy smilers often smile asymmetrically, ond group wants improvement of their wrinkles but is ada-
requiring asymmetric injection. They also tend to have deeper mant about not increasing the size of their lips at all, for fear
medial nasolabial folds, which is the area of primary improve- of looking “done.” The third, and largest, group receives
ment with this technique. The resulting drop of the upper lip concomitant BoNTA and filler injection. The filler material
Aesthetic Surgery
hides the gingiva and results in a more pleasing smile. partially obliterates the wrinkles and restores volume while
The technique for this injection is relatively straightfor- the BoNTA relieves some of the force applied to the skin
ward. Before injection, the patient is given a preview of the from the underlying orbicularis oris. In this way, combined
proposed change. The patient looks into a mirror at eye level with skin care, the patient receives the maximal amount of
and smiles. Using a cotton applicator stick, I pushed the upper improvement without forced downtime. In the patient with
lip down 3 to 4 mm, giving the patient a rough approximation severe perioral rhytides, maximal rhytid improvement using
of the change to be expected to the smile and to the nasola- fillers alone would necessitate injecting high volumes, which
bial fold. For injection, the index finger of the noninjecting would be unaesthetic. For combination therapy, the lip is
hand is pressed firmly against the inferior portion of the nasal injected with a filler material up to the point where the lip
A B
FIGURE 43.3. A. This patient in her forties has a large, wide mentalis muscle when straining to elevate her lower lip. B. After 5 Botox units were
injected in a threading motion across her superficial mentalis, her chin is noticeably smoother yet still strong enough to fully raise her lower lip.
C. The patient is retracting her lower lip. This shows her lower gingiva and reveals her classic depressor anguli oris (DAO) dimples below the
oral commissures. D. A total of 7.5 units of Botox have been injected into her DAO muscles. She can no longer reveal her gingiva and her DAO
dimples are not visible. The depression of her lower lip remains symmetric. E. The patient is puckering her lips. F. After 2 units of Botox were
injected into each of the upper and lower lips (4 units total), her puckering is improved but not gone. G. The patient in repose prior to injection.
Her mentalis is wide and irregular. She has clear depressions and an apparent volume deficit over her DAO insertions. H. After injection, the
surface of her chin is narrower and smoother due to chemodenervation of her mentalis. The area over her DAOs appears more full. The lips also
appear more full due to the relaxation of the orbicularis oris which hides the lips. I. Smiling prior to injection. J. The patient maintains a natural,
symmetric smile after injection. The lower lip is slightly elevated which adds to a youthful appearance. Multiple lower face injections are not for
the novice injector as these patients may sometimes experience weakness.

C D
E F
G H

I J
would look “done.” Botox is then used to weaken the orbi-

cularis oris. If a filler material containing a local anesthetic is Depressor Anguli Oris
used, the filler is injected first. The depressor anguli oris is a triangularly shaped muscle that
The patient is asked to purse the lips, then relax, and purse depresses the oral commissures. This action contributes to the
again, repeatedly. This is done to judge the relative strength of marionette lines and often creates a distinct horizontal rhytid
the sphincter muscle. Beware the elderly patient with severe below the commissure. Injection of this muscle raises the oral
rhytides and decreased muscle mass. My current dosing range commissures, decreasing show of the lower dentition when
is only 2 to 5 Botox/5 to 10 Dysport units per lip, with most smiling. It also helps to improve marionette lines and the hori-
Aesthetic Surgery
patients receiving 3/5 units per lip. As opposed to other areas zontal crease below the commissure.
of the face where precise, small drops of BoNTA are injected, My current dosage range for this area is between 2.5 and
this area is injected broadly to effect a diffuse, general weak- 12.5 Botox/5 to 20 Dysport units total, with most patients
ening of the sphincter. The philtrum is rarely injected as it falling in the 5.0/10 units range. The patient is repeatedly
rarely contains strong rhytides. A more dilute solution is used. asked to show the lower teeth with the dentition occluded.
The extra volume allows more even placement of the Botox. This usually creates a horizontal rhytid below the commis-
The needle is inserted parallel to the vermilion border, a few sure. Each muscle is injected twice, with the first injection
millimeters above it, and the BoNTA is injected as the needle point at the level of the horizontal rhytid. The second point
is withdrawn. The upper and lower lips can be treated in the is midway between the first point and the lower border of
same session. Complications can easily result in this area and the mandible in the direction that the muscle pulls the com-
are usually a result of overinjection. Overly weakening the missure when contracting. Most patients pull the commis-
upper lip leads to problems with plosive sounds, then gen- sures down and laterally when contracting. Some patients,
eral speech, and, finally, oral competence. Overinjection of however, will pull their commissures down and medially.
the lower lip more readily leads to drooling and competence It is along this axis of motion that the second injection is
problems. placed. Care must be taken not to attempt to inject this
muscle in its cephalad portion as has been taught previ-
ously. First, there is very little active muscle there as the
Mentalis muscle tapers and becomes aponeurotic. Second, the muscle
Patients who have difficulty with oral competence tend to that is there, the lower orbicularis oris, does not tolerate
form an unattractive, dimpled pattern on the chin during concentrated injections laterally. This can easily lead to oral
active speech or when closing the lips (Figure 43.3). This incompetence and drooling. The depressor labii inferioris is
appearance results from contraction of the underlying men- also cephalad and care must be taken not to inject it inad-
talis muscle. Dimpling and occasional ridging of the skin vertently. When properly injected, the depressor anguli oris
in patients with hypertrophy of the mentalis can result. is one of the safest muscles to inject in the lower face as
This pattern of mentalis strain is particularly common in even if it is slightly overinjected, it does not lead to oral
patients with vertical maxillary excess (gummy smilers), incompetence, but rather, an actual raising of the lower
the same patients who benefit from levator labii superioris lip. In fact, if a patient has oral competence problems from
injection. injection of the lower orbicularis oris or mentalis or facial
Dosing range for the mentalis is 2.5 to 12.5 Botox/5 to nerve injury, injection of the depressor anguli oris can give
20 Dysport units, with most patients in the 5.0/10 units the patient relief. Injection of the lower lip with a viscous
range. Care is taken to inject the superficial mentalis only, hyaluronic acid product at the same time can also add some
leaving the deep mentalis fully functional. The needle is static support.
threaded cephalad, parallel to the skin surface, aiming for
the plane between the superficial muscle and its overlying
fascia. Care must be taken to leave enough of the deep mus- Hyperhidrosis
cle functional so that lower lip elevation and oral compe- BoNTA injection can also decrease secretion of the eccrine
tence is maintained. Injection of the mentalis is often paired glands in the axillae, palms, and soles of the feet. Care
with depressor anguli oris injection to maintain the height must be taken to inject the BoNTA intradermally in
of the lower lip. the palms and soles to minimize the risk of weakening

the muscles of the hands and feet. Results for this appli- References
cation typically last somewhat longer, approximately
6 months. 1. Scott AB, Rosenbaum A, Collins CC. Pharmacologic weakening of extra-
ocular muscles. Invest Ophthalmol Vis Sci. 1973;12:924-927.
2. Scott AB. Botulinum toxin injection into extraocular muscles as an alterna-
Surgical Complications tive to strabismus surgery. Ophthalmology. 1980;87:1044.
3. Clark RP, Berris CE. Botulinum toxin: a treatment for facial asymmetry
Complications from aesthetic surgical procedures can often be caused by facial nerve paralysis. Plast Reconstr Surg. 1989;84:353.
4. Carruthers JDA, Carruthers JA. Treatment of glabellar frown lines with
treated with BoNTA. Incomplete corrugator or procerus resec- Clostridium botulinum A exotoxin. Dermatol Surg. 1992;18:17-21.
tion after brow lift is an ideal indication. If excessive down- 5. Kane MAC. The Long-Term Effects of Botox Injections. The Aesthetic
ward muscle pull on the brows is seen in the early postoperative Meeting. Dallas, TX; 1998.
period, it can be treated aggressively, maintaining brow eleva- 6. Osako M, Keltner JL. Botulinum A toxin in ophthalmology. Surv
Ophthalmol. 1991;36:28-46.
tion. Surgical misadventures with chin augmentation can lead 7. Rubin LR. The anatomy of a smile: its importance in the treatment of facial
to mentalis disinsertion and dimpling of the chin, which can be paralysis. Plast Reconstr Surg. 1974;53:384.
ameliorated by Botox. Overly elevated brows after brow lift 8. Aston SJ. Orbicularis oculi muscle flaps: a technique to reduce crow’s feet
can be lowered with aggressive frontalis injection. Prolonged and lateral canthal skin folds. Plast Reconstr Surg. 1980;65:206.
9. Kane MAC. Classification of crow’s feet patterns among Caucasian
spasm of the pectoralis major after breast augmentation can be women: the key to individualizing treatment. Plast Reconstr Surg.
treated with injection of the portion of the muscle. Facial nerve 2003;112(suppl):33s.
injuries after surgery or trauma can often be effectively masked 10. Matarasso A, Matarasso S, Brandt F, et al. Botulinum A exotoxin
by weakening the unaffected muscle on the contralateral side for the management of platysma bands. Plast Reconstr Surg. 1999;103:645.
11. Kane MAC. Nonsurgical treatment of platysmal bands with injection of
of the face. Marginal mandibular nerve injury after facelift can botulinum toxin A. Plast Reconstr Surg. 1999;103:656.
be disguised by injection of the contralateral depressor anguli 12. Kane MAC. The effect of botulinum toxin injections on the nasolabial fold.
oris muscle. Plast Reconstr Surg. 2003;112(suppl):66s.

Chapter 44 n
Fat Grafting In Plastic Surgery
Louis P. Bucky, Ivona Percec, And Daniel Del Alexander Vecchio
Introduction Managing the Variables—From Donor

The role of autologous fat grafting or fat auto-transplantation to Recipient
in plastic surgery has evolved from a controversial technique
designed for simple volume augmentation to the foundation Donor and Harvest. The most common graft donor sites
for the innovative and burgeoning field of regenerative medi- are the hips, saddlebags, thighs, abdomen, and inner knee.
cine. Neuber (1893) initially reported the use of small pieces There are no data that suggest one anatomical site is superior
of fat from the upper arm to reconstruct a depressed area of to another, yet all donor sites need to have adequate fat volume
the face resulting from tuberculous osteitis. Today, fat graft- to avoid a potential concavity or dimpling deformity after har-
ing plays diverse and far-reaching roles in plastic surgery. Its vest. Infrequently, harvesting from more than one site is neces-
application currently extends from simple volume augmenta- sary to acquire sufficient volume for grafting. Pre-infiltration
tion of the face to total reconstruction of a post-mastectomy with dilute lidocaine and epinephrine into donor sites typically
breast. Because many of the variables in fat transplantation provides adequate graft volume, hemostasis, and analgesia.
were not well understood initially, early results with fat Most surgeons employ a version of the Coleman technique
grafting were disappointing, and the technique was largely that calls for gentle suction through small 10 cc syringes and
abandoned. microinjection using 1 cc blunt-end cannulae. Usually, this
Recent enhancements in fat grafting applications lie not technique results in a 3:1 ratio of harvested to purified fat.
only in more reliable volume augmentation to the face, breast,
and buttocks, but perhaps more importantly in pioneering the Fat Preparation. Fat must be processed to separate oil,
potential regenerative aspects of fat via its rich source of stem blood, and lidocaine from potentially viable fat cells. This can
cells. Though fat grafting to the face has been used relatively be accomplished by gravity sedimentation, by centrifugation,
consistently since the introduction of the Coleman technique by Telfa pad rolling, or by a combination of these techniques.
in the mid-1990s, fat transplantation to the breast and body There are no current data to suggest one technique is superior
was largely abandoned for more than 20 years. By 2006, to another. Irrespective of purification technique, the limita-
Aesthetic Surgery
reports of fat transplantation emerged in presentations and tion of ischemic time and cellular trauma should be a priority.
in case report papers suggesting the long-term viability of fat For low volume augmentation, we prefer gravity sedimenta-
transplantation to the breast. In 2007, Coleman published his tion followed by Telfa rolling until the fat becomes yellow
review of 17 patients who were grafted using autologous fat in color and thick in consistency, as unwanted fluids are
and were followed up with serial photography. The specific absorbed. The fat is then gently transferred into 1 cc syringes
grafting techniques employed in a given case depend upon a prior to injection (Figure 44.1).
series of factors, including the characteristics of the recipient
site, the goals of surgery (volume and shape), and abundance
Fat Grafting Injection. Small aliquots of fat are microin-
jected into discrete facial units using a 1 cc syringe, with the
of donor tissue. Because of the intrinsic differences in fat graft-
goal of predictable viability and avoidance of contour irreg-
ing to the face versus the body, this chapter has been divided
ularities (Figure 44.2). Areas of the face that have the least
into fat grafting applications for cosmetic and reconstructive
motion have the best survival outcomes. Therefore, the deep
uses in the face followed by large volume fat grafting applica-
tions for the breast and body.
Facial Fat Grafting

Autologous fat grafting to the face provides a naturally appeal-
ing solution to a vital aspect of facial aging. Soft tissue loss or
deflation occurs routinely in middle-aged adults. As fat content
is reduced, soft tissues collapse and the face globally “deflates”
permitting gravitational changes to arise. Lipoatrophy in the
face can also result from disorders such as Perry-Romberg
syndrome, trauma, and infection. Hypoplasia of fat can be
congenital, as in hemifacial microsomia (Figure 44.1). The use
of fat as a filler for volume restoration of the face is optimal
due to its easy acceptance, excellent safety profile, and natural
appearance and feel. Historically, the major limitation of fat
grafting has been unpredictability of “take” or viability, typi-
cally ranging from 40% to 60% of what has been grafted. In
our experience, small volume fat grafting to the face behaves
like other biologic grafting in that it requires adequate vascu- A
larization of grafted tissue for long-term viability. Fat graft-
ing to the face, as opposed to the body, utilizes concentrated Figure 44.1. Small syringe technique for facial fat grafting. Telfa-
processed fat is loaded into 1 cc syringes and injected using small,
smaller volumes of fat, typically 20 to 60 cc of purified fat. typically blunt cannulae (A, B). Long-term treatment of right facial
Since large volumes are not necessary, and overfilling is unde- lipoatrophy secondary to Parry-Romberg syndrome with fat grafting:
sirable in the face, gentle harvest, adequate processing, and preop (C), 6 months postop, (D), and 8 years postop (E). (Patient of
small volume injection become even more paramount as the Louis Bucky, MD.)
tenets of successful fat grafting technique.
473

E

Chapter 44: Fat Grafting in Plastic Surgery 475
Figure 44.2. Small syringe technique for facial fat grafting. Long- Aesthetic Surgery
term correction of age-related lipoatrophy with isolated fat grafting:
preop (A), 6 months postop (B), and 2 years postop (C). (Patient of
Louis Bucky, MD.)
C
compartments of the cheek, malar, and upper nasolabial folds when fat infiltration is preceded by neuromodulation to limit
are excellent recipient sites due to their relative immobility, muscle motion. Additional regions where fat grafting can be
preexisting fat content, and depth of location (Figure 44.1). used successfully are the temples, forehead, prejowl sulci, and
The perioral region, lips, marionettes, and lower nasolabial labiomental crease.
folds are more variable due to significant motion and thinner
overlying tissues (Figure 44.3). In contrast, the periorbital Complications. The complications of facial fat grafting
region has excellent survival of small volumes, but is perhaps are typically limited to contour irregularities secondary to
the most challenging due to its thin, delicate, and unforgiv- superficial placement and fat necrosis, frequently in the older
ing nature. Filling to the periorbital region should be limited patient. Both usually necessitate direct excision. Variable graft
to small volumes using small blunt cannulae with injections survival is still common, though it can be limited by atten-
placed under the orbicularis oculi muscle. In areas of signifi- tion to detail, careful preparation, and infiltration. The two
cant motion such as the glabella, results are best obtained most significant complications are intravascular injection and

surgeons, it is recommended to use small to moderate grafts in

the face with minimal overfilling in most patients.
Large Volume Fat Grafting

Large volume fat grafting required for effective body augmen-
tation and reconstruction has to be distinguished from the
A B
relatively smaller volume fat grafting needed to improve small
breast contour defects or to restore age-related fat atrophy in
the face. In the former category, small volumes of fat on the
order of 30 to 100 cc are used, and these procedures are not
performed using pre-expansion. To build an entirely natural
breast or buttock from fat is a completely different procedure
requiring a modified strategy and application of the principles
of fat transplantation. Nevertheless, success in large volume
fat transplantation requires meticulous analysis of similar vari-
ables to small volume grafting: donor and recipient site and
the surgical technique. In mega-volume fat transplantation,
it is paramount to optimize the entire technique, rather than
maximize any one factor of the process, as described below
(Table 44.1).
Managing the Variables—From Donor

C D to Recipient
Figure 44.3. Small syringe technique for facial fat grafting. Donor and Harvest. There is no current scientific evi-
Long-term correction of age-related lipoatrophy with isolated fat dence that the anatomic location of the donor site is signifi-
grafting. Fat grafting augmentation of the lips, 3 cc total, preop cant to clinical outcomes. Rather, adipocyte cell size, which
(A), 6 months postop (B). Fat grafting to the nasolabial folds, perioral varies between different anatomical depots and also between
area and malars, 20 cc total, in conjunction with rhytidectomy, preop patients, may be the more important variable. The use of
(C), 2 years postop (D). (Patients of Louis Bucky, MD.)
smaller harvest cannula sizes creates less donor site trauma
resulting in smaller, more uniform lobules of fat, which may
in turn improve flow characteristics during graft injection.
Although there are several harvesting technology platforms
vergrafting. Fortunately, these phenomena are exceedingly
o including water jet–based, laser-assisted, and ultrasonic-
rare. Injection injury can be limited by using blunt cannu- assisted systems, there are to date no published clinical results
lae and low-pressure injection in a layered fashion. On the that demonstrate the benefits of any of these technologies over
contrary, overgrafting is becoming an increasing problem fat harvested with a standard tumescent liposuction or power-
due to large volume injection, as practitioners become more assisted system. Harvesting the fat can be accomplished at less
at ease with fat grafting techniques. This is seen more fre- than 1 atm (760 mm Hg), with a mechanical liposuction aspi-
quently in younger patients who have had superficially placed rator vacuum source or with a handheld syringe.
injections. Unfortunately, weight gain causes all fat grafts to
enlarge, which, in the face, can result in significant and dispro- Fat Preparation. Centrifuging lipoaspirate at 1,300 times
portionate distortion. The treatment of overgrafting requires the force of gravity (1,300G) for 3 minutes is the method of
microliposuction with only limited improvements and risks fat processing most commonly used for facial or small volume
of excessive scar formation. Therefore, even for experienced fat grafting. The penchant for centrifugation arose from the
TA B LE 4 4 . 1
A Summary Of Facial And Mega-Volume Technique
n Small Syringe “Coleman” n Large Syringe and Reverse

Method Liposuction Method
Aspiration cannula 12G Single Hole Coleman Cannula 3–4 mm 12 Hole Ergonomic Handle
Aspiration force Manually activated syringe Motorized vacuum pump
Ease of use Effort on fingers Easy, vacuum unit
Air exposure Mild to moderate Moderate
Pressure Erratic Constant
Collection chamber Multiple syringes, syringe racks One 1,200 cc rigid canister
Crystalloid separation 1,300G Force Centrifuge Individual Syringes Low (40G) G Force Spinning
Injection cannula 14G Single Hole 14G Single Hole
Injection force 1–3 cc syringe (high pressure) 60 cc syringe (low pressure)
Injection technique Switch individual syringes and cannulas Reverse liposuction
Op. time for breast augmentation Long (4–6 h) Shortest (1–2 h)

need to graft as much adipocyte biomass as possible into a upon axial withdrawal of the needle only. Generally, soft pli-
limited space. Although centrifugation can yield concentrated able nonscarred tissues without underlying implants can be
fat, there are four potential problems with this strategy when treated more efficiently with reverse liposuction, while graft-
applied to mega-volume fat transplantation: cellular damage, ing in scarred, or irradiated beds, or over implants requires the
time and labor consumption, clumping, poor flow, and lower mapping approach.
engraftment potential from excessively high fat concentra-
tions. Advances in pre-expansion of the recipient site have Recipient Site Management. Recipient site management
emancipated fat grafting from the need for high-speed cen- has only recently been suggested as an important variable
trifugation and its potential disadvantages. In the expanded in fat grafting (Table 44.2). The size, vascularity, and com-
space, a larger amount of loose fat slurry can be more dif- pliance of the recipient site are the most prominent compo-
fusely dispersed and may survive better. Using a hand-crank nents. The BRAVA® bra was developed as an external soft
syringe centrifuge, fat loaded in 60 cc syringes can be effi- tissue expander to enlarge the breast. As long as the device
ciently separated from crystalloid with little trauma at 20 to is worn continuously for 10 to 12 hours per day for several
40G (Figure 44.4). months, reliable and enduring augmentation of the breast
volume ensues (Figure 44.5). The increased subcutaneous
Fat Grafting Injection. There are currently two estab- space created by BRAVA pre-expansion allows more graft
lished methods of mega-volume fat grafting—the “mapping” volume to be inserted before high subcutaneous interstitial
technique and the “reverse liposuction” technique. Reverse pressures are reached, thereby requiring less concentrated
liposuction refers to a constant motion of the injection cannula fat. Because less concentrated fat flows more easily and can
while fat is injected. In the mapping technique, fat is injected be inserted at lower pressures via larger sized syringes, the
procedure time using this approach is reduced from 6 to 2
hours, and volumes injected can reach 700 cc. The use of
BRAVA for external pre-expansion prior to the fat grafting
can serve two additional valuable roles in re-shaping breasts:
deformities can be demonstrated to the patient prior to any
surgical intervention and during fat grafting, and internal
scar ligaments can be selectively lysed using a “percutaneous
3D meshing” technique to reshape the breast immediately
after grafting the fat.
Aesthetic And Anatomic
Aesthetic Surgery
Considerations
From augmentation enhancement of an existing perfectly
shaped breast with fat (Figure 44.6) to the multistage creation
of a breast mound in a post-mastectomy patient (Figure 44.7),
the technique of nonsurgical pre-expansion and autologous fat
grafting exhibits a spectrum of different fill effects. Generally,
the more parenchyma one has to begin with the larger volumes
of fat that can be grafted. Smaller or otherwise constricted
breasts require on average more sessions to achieve the same
final volume because smaller breasts cannot expand as much
as larger breasts. Dense or irradiated breasts also expand with
more difficulty than soft, multiparous breasts and thus these
patients must be encouraged to increase the negative pres-
sure on the BRAVA domes to achieve an adequate expansion
preoperatively. These patients require the highest number of
grafting sessions and three-dimensional release of internal
scarring. The anticipated volume of grafting will therefore
depend on the preoperative assessment of the recipient vol-
ume. The “V/C” ratio, the volume of graft to the recipient
site capacity ratio, must be appreciated and must not exceed
1:1. That is, for any given volume of recipient site, one cannot
exceed this volume in graft material. The more pathology in
the site (radiation damage) the lower this V/C ratio must be
to avoid overgrafting the recipient site. For irradiated cases,
one should be extremely careful not to overgraft and should
expect a minimum of four to five sessions. The long-term inci-
dence of cysts and masses and calcifications following mega-
volume fat transplantation to the breast is not well established
but may range from 10 to 20%. The variability of the clinical
applications and techniques likely accounts for the range.
Controversies And
Future Directions
Figure 44.4. Large syringe technique. Decanted fat (A, B) is loaded
into 60 cc syringes and is spun for 2 minutes at 40G (C). Fat that At the time of this publication, we are in the initial phases
looks like “pure fat” at 1G (D) is actually 20% crystalloid when spun of using fat transplantation for breast augmentation and
at 40G (E). reconstruction. Currently, there are still more questions than
answers. The following topics represent some of the biggest

TA B LE 4 4 . 2
Comparison Of Conventional Fat Transplantation With External Volume Expansion And Fat Transplantation
n Conventional Fat n External Volume Expansion +

Transplantation Fat Transplantation
The expander Injected adipocytes The BRAVA expander
Role of fat in expansion internal pressure expander “Backfills” expansion in place
Apparent interstitial pressure
a
High Lower
Use of centrifuge Dependent Not necessary
Syringe size 5 cc 5–60 cc
Av. safe graft volumes for a cup breast or 150 cc 300–700cc
a mastectomy defect
Estimated operating time 6h 2h
Number of assistants 2–3 0–1
Ecchymoses Significant Minimal
a
(Assumed, not proven.)
Figure 44.5. The BRAVA external tissue expander worn by a

patient just prior to the fat grafting procedure (A). Patient pre-BRAVA
Expansion (B) and 3 weeks post-BRAVA expansion (C), immediately
prior to grafting. Note the volumetric increase is three to four times
that of the pre-expansion state. A total of 480 cc of fat was subse-
quently injected in this case into each breast. (Patient of Daniel Del
Vecchio, MD.)
C
cell–enriched fat graft is that the additional stem cells
improve volume and viability through the differentiation of
new adipocytes and stromal vascular cells. In small volume
fat transplantation, especially where there may be a need for
regenerative effects, stem cell–enriched fat may have early
clinical relevance. Although this may be an effective strategy
for the future, this stem cell technique is neither clinically
proven nor Food and Drug Administration approved at the
time of this writing, and the authors therefore do not employ
this method. More importantly, basic science advances in adi-
pose tissue and stem cell biology are likely to provide criti-
cal contributions and advancements in both small and large
A B volume fat grafting applications. Over the next decade, we
Figure 44.6. Laterally constricted breasts, pre-expansion (A) and must optimize clinical fat grafting through technique refine-
6 months postoperative (B) with fat transplantation. This patient ment and standardization, and we must carry on our history
required aggressive release of the lateral mammary constrictions to of innovation by incorporating anticipated scientific advance-
achieve this lateral roundness and fullness. (Patient of Daniel Del
ments in adipose tissue biology.
Vecchio, MD.)
Suggested Reading
Baker T. Presentation on BRAVA Non-surgical Breast Expansion. ASAPS 2006
Annual Meeting, Orlando, FL.
controversies and challenges facing this technique in the Bucky LP, Percec I. The science of autologous fat grafting: views on current and
future. future approaches to neoadipogenesis. Aesthet Surg. 2008;28(3):313-321.
Imaging and Detection of Breast Cancer Risk: In 1987, Coleman SR, Saboeiro AP. Fat grafting to the breast revisited: safety and
the American Society of Plastic Surgeon position paper efficacy. Plast Reconstr Surg. March 2007;119(3):775-785.
Coleman SR. Structural fat grafting: more than a permanent filler. Plast
strongly condemned fat grafting to the breast suggesting that Reconstr Surg. 2006;118(suppl 3):108D-120S.
fat grafting would distort breast cancer detection secondary Czerny V. Plastischer Ersatz der Brustdruse durch ein Lipom. Zentralbl Chir.
to the formation of postgrafting calcifications. However, 1985;27:72.
these calcifications have been classified as Bio-RAD 1-2, and Del Vecchio DA, Bucky LP. Breast augmentation using pre-expansion and
autologous fat transplantation- a clinical radiological study. Plast Reconstr
are generally felt to be easily distinguishable from calcifi- Surg. June 2011;127(6):2441-2450.
cations of higher grade that are suggestive of malignancy, Del Vecchio DA, Rohrich RJ. A classification of clinical fat grafting—different
when digital mammography is used. While fat grafting to problems, different solutions. Plast Reconstr Surg. 2012;130(3):511-522.
Aesthetic Surgery
the breast is still in its infancy, it is important to establish Gutowski KA. Current Applications and Safety of Autologous Fat Grafts: A
Report of the ASPS Fat Graft Task Force. Evanston, IL: ASPS Fat Graft
safety standards for patients and clinicians for the future. Task Force; 2009.
The establishment of an international registry of breast fat Heit YI, Lancerotto L, Mesteri I, et al. External volume expansion increases
grafting patients, followed over a 40- to 50-year period, will subcutaneous thickness, cell proliferation and vascular remodeling in a
be necessary to compare this cohort of women with the gen- murine. Plast Reconstr Surg. 2012;130(3):541-547.
Kanchwala, Suhail K, Glatt, BS, Conant EF, Bucky LP. Autologous fat
eral population and examine statistical differences in breast grafting to the reconstructed breast: the management of acquired contour
cancer detection and incidence. deformities. Plast Reconstr Surg. August 2009;124(2):409-418.
Role of Stem Cell Enrichment: Enriching processed fat Khouri RK, Schlenz I, Murphy BJ, Baker TJ. Nonsurgical breast enlargement
grafts with adipose stem cells has been proposed to increase using an external soft-tissue expansion system. Plast Reconstr Surg. June
2000;105(7):2513-2514.
cell viability in grafting. The theoretical benefit of a stem Melvin A. Shiffman MD, Sid Mirrafati MD. Fat transfer techniques: the effect
of harvest and transfer methods on adipocyte viability and review of the
literature. Dermatol Surg. 2001;27(9):819-826.
A B
Figure 44.7. Bilateral breast reconstruction in a non-mastectomy
patient. When there is a relatively large starting capacity preoperatively (A),
primary core volume reconstruction can be performed in one stage using
pre-expansion (B). (Patient of Daniel Del Vecchio, MD.)

Chapter 45 n
Forehead and Brow
Rejuvenation
BENJAMIN Z. Phillips, ERIK A. Hoy, Johnny T. Chang, JHONNY A. Salomon, And PATRICK K. Sullivan
depressor supercilii muscles. The corrugator supercilii origi-

Introduction nate from the frontal bone just superior to the nasal bones and
The upper third of the face, specifically the forehead, can insert into the dermis of the medial brow. The corrugator is
be an area of major concern for individuals as aging occurs. composed of two heads, the oblique and the transverse. The
Culturally, great emphasis is placed on the eyes and sur- coordinated actions of the two heads pull the brow down
rounding soft tissues as they relate to interpersonal inter- and medial across the glabella, resulting in vertical glabel-
actions. This focus on the forehead can lead individuals to lar lines. Thus, hyperactivity may lead to the classic “angry”
feel uncomfortable or self-conscious about skin redundancy appearance. The orbicularis oculi muscles are oriented at right
and creases. For the majority of individuals, the hair-bearing angles to the inferior border of the frontalis muscle for much
brow is the most conspicuous region of the forehead. For of the brow’s length. Their strong sphincter function exerts
this reason, procedures such as forehead lifts and forehead a downward pull on the frontalis, creating periorbital wrin-
plasties have been referred to as “brow lifts.”1 For nearly a kles or “crows’ feet.” The procerus muscles originate on the
century, the aesthetic improvement of the aging forehead has nasal bones and cartilages as a single muscle belly. Superiorly,
been a challenge to the surgeon. Since its first description in the muscles are paired and insert into the medial aspect of
the literature by Passot in 1919, the brow lift procedure has the frontalis muscle and the overlying dermis. Contraction
undergone evolutionary changes from the coronal open brow of the procerus results in depression of the medial brow and
and anterior hairline techniques, to modern, less invasive the creation of transverse skin lines along the root of the nose.
techniques, such as the minimal incision lateral brow lift and The depressor supercilii is found superficial to the corrugator
endoscopic brow lift.2 Procedures aimed at correcting fore- muscle and its origin is on the frontal process of the maxilla,
head and brow ptosis are among the most commonly per- inferior to the origin of the corrugators. It inserts obliquely
formed in plastic surgery. In 2010, surgeon members of the onto the medial fibers of the frontalis muscle, superior to the
American Society of Plastic Surgeons performed over 42,000 medial brow. The superficial position of the depressor super-
brow lift procedures, 5.3 million botulinum treatments, and cilii is important to be aware of because inadvertent transec-
1.7 million soft-tissue filler procedures.3 All these procedures, tion may result in over-elevation of the medial brow and a
in addition to repositioning the brow, are directed at combat- “shocked” appearance. In unison with the oblique head of the
ing the three types of hyperkinetic lines of the aging forehead: corrugators and the medial aspect of the orbicularis oculi, the
vertical glabellar furrows, horizontal glabellar furrows, and depressor supercilii opposes the action of the frontalis caus-
horizontal forehead rhytids. ing depression of the medial brow and oblique glabellar skin
creases.
Motor Innervation
Anatomy
The facial nerve (cranial VII) supplies the motor innervation
Muscle and Effect on Aging to the mimetic muscles of the forehead and brow. The frontal
(temporal) branch of the facial nerve supplies the frontalis, the
There are two types of paired muscles in the forehead and
superior portion of the orbicularis oculi, the superior aspect
brow, elevators and depressors. Brow elevation is due to the
of the procerus, and the transverse head of the corrugator
paired frontalis muscles that are composed of two distinct
supercilii muscles. The zygomatic branch supplies the medial
parts, a static component and a mobile component. The fron-
orbicularis oculi, the oblique head of the corrugator supercilii,
talis muscle does not originate from or insert into the bone.
the inferior aspect of the procerus, and the depressor superci-
The superior half of the frontalis is relatively static secondary
lii muscles. The frontal branches course from a point 5 mm
to its close adherence to the galea aponeurotica, which serves
below the tragus to a point 15 mm above the lateral brow.
as its origin. The inferior half of the frontalis hangs freely and
Over the zygomatic arch, they are found about 2.5 cm lateral
inserts into the orbital portion of the orbicularis oculi. This
to the lateral canthus, placing them halfway between the lat-
mobile component provides the entire range of motion for
eral canthus and the inferior helix.5
the muscle resulting in eyebrow elevation. When the fronta-
lis muscle contracts superiorly directed forces are translated
across the orbicularis oculi and the lower brow skin adherent Sensory Innervation
to it. The mobile soft tissue of the lower brow is pulled up into Sensory innervation to the brow is by means of branches of the
the fixed superior forehead skin and soft tissue, resulting in ophthalmic division of the trigeminal nerve (cranial nerve V).
deep transverse lines in the planes created by the deep dermal The paired supraorbital and supratrochlear nerves supply the
insertions between the skin and frontalis muscle. Laterally, the central and medial forehead, respectively. The supraorbital
frontalis muscle fuses into a dense network of fascia referred nerves exit from the supraorbital foramen an average distance
to as the zone of adherence. This region lies along the palpable from midline of 2.42 ± 0.04 cm in females and 2.56 ± 0.05 in
superior temporal line and ends inferiorly at the zygomatico- males.6 They then split into superficial (or medial) and deep
frontal suture at a convergence of fascia known as the orbital (or lateral) branches to supply the forehead and scalp. The
ligament.4 deep division supplies the frontoparietal region and can be
Several paired muscles are found along the brow and antag- injured along its course from the main nerve trunk, where it
onize the action of the frontalis. Collectively, these muscles runs superiorly between the galea and periosteum. It pierces
are referred to as forehead depressors. These include the cor- the galea 2 to 2.5 cm above the orbital rim and continues
rugator supercilii, the orbicularis oculi, the procerus, and the superiorly within 1 to 2 cm of the temporal fusion plane. If
480
Chapter 45: Forehead and Brow Rejuvenation 481
this nerve branch is injured, it is often secondary to traction has been less studied and has several key differences.14 First of
injury with the dissector or to transection by the coronal inci- all, the male brow should lie at the level of the superior orbital
sion and results in paresthesia over the temporoparietal scalp. rim and is less arching than the female brow. Still, the peak
The superficial branch is shorter, more medial, and less often should lie at the junction of the two lateral thirds.
injured in browlifts. The superficial branch pierces the fronta- Unlike other areas of the face, bony changes contribute
lis muscle early in its course, running superficial to the muscle minimally to the aging process of the forehead and brow.
belly. It supplies the area of the lower/mid-forehead along the Barton describes a spectrum of orbital rim anatomy seen in
mid-pupil line. The lateral forehead is supplied by the auricu- the aging face.1 The superior orbital rim may take the form
lotemporal branch of the mandibular division (V3) of the of a gradual transition from orbital roof to inferior brow,
trigeminal nerve (cranial nerve V). with its details masked by profuse orbital and periorbital fat.
Alternatively, some patients may have a more severe appear-
Vasculature ance of their superior orbital rim, relatively devoid of upper
lid and periorbital fat to disguise the bony anatomy. Whatever
The blood supply to the forehead and brow is robust. Several
the configuration, in terms of bony anatomy, what one sees
major blood vessels to the upper face and brow, including the
is what one gets: Rarely is bony anatomy changed in fore-
superficial temporal artery and facial artery, are branches of
head rejuvenation, though volume restoration in the form of
the external carotid artery. These vessels supply the medial
autologous tissue transfers such as fat grafting has been used
canthal region via the angular artery and lateral canthal
to good effect by the senior author.
region via the frontal or anterior branch of the superficial tem-
Increasing laxity and ptosis of the soft tissues of the brow
poral artery. The majority of the forehead and mid-scalp is
are responsible for the stigmata of aging in this area. Since the
supplied by branches of the internal carotid artery, specifically
descent of the brow is a soft-tissue process, attempts at reju-
the supraorbital and supratrochlear arteries.
venation involve release, redraping, and resuspension of these
The venous drainage mirrors the arterial supply with some
tissues, with occasional resection of excess skin. Difficulty in
variation. One specific vein is relatively consistent and is
obtaining precise control of the medial, middle, and lateral
referred to as the sentinel vein (medial zygomatico-temporal
thirds of the brow spurred further studies into the anatomy
vein). The sentinel vein travels perpendicular through the tem-
of this area.
poralis fascia approximately 2 cm lateral to above the lateral
The senior authors conducted a cadaveric dissection study
canthus.4 Because of the consistent nature of its location, the
of 12 hemi-foreheads, with close attention to the ligamentous
sentinel vein must be identified and care must be taken not
attachments of the brow.15 Notable findings included an area
to accidentally tear the vessel during lateral dissection. This
1 cm above the superior orbital rim where two attachments
approach will avoid post-op ecchymosis and impaired visual-
were identified: (1) a superomedial ligamentous attachment
ization of the surgical field.
Aesthetic Surgery
was found to originate on average 10.8 mm above the supraor-
bital rim and 13 mm from the midline and (2) a superior lateral
ligamentous attachment originating an average of 10.3 mm
Aesthetic Brow above the supraorbital rim, and 23 mm from the midline
Multiple authors have defined the aesthetic brow, includ- (Figure 45.1). A third retaining structure was identified at the
ing Westmore,7 Cook et al.,8 Connell et al.,9 Matarasso and orbital rim. This inferomedial ligamentous attachment was
Terino,10 McKinney et al.,11 and Gunter and Antrobus.12 Most identified below the aforementioned attachments and origi-
authors acknowledge that the aesthetic ideal has changed over nated 12.6 mm from the midline (Figure 45.2). Though these
time. Westmore proposed that the aesthetic brow had the attachments appeared to serve a similar purpose to those of
following attributes: a medial brow that began at the same the midface, the ligamentous thickenings of the forehead are
vertical intercept as the medial canthus and ending laterally broad-based. They continued from the bone, pierced the peri-
along an axis connecting the nasal ala with the lateral canthus, osteum, and inserted into the frontalis muscle and the tightly
medial and lateral end points along the same horizontal axis adherent overlying skin. Also identified was a long and broad
with a peak directly above the lateral limbus.7 However, it is ligamentous structure that extended from the lateral aspect
more aesthetically pleasing to most patients and surgeons to of the supraorbital rim and extended laterally to the superior
achieve a final brow orientation with a more elevated lateral aspect of the lateral orbital rim (Figure 45.3). This structure
third relative to the medial and middle thirds of the brow. inserted to the superficial temporal fascia, as described by
A trend has emerged away from qualitative descriptors of Knize.16,17 Without release of this structure in its entirety, the
the aesthetic brow toward a more quantitative definition. The lateral brow cannot be optimally elevated. The short and stout
brow should begin medially directly at the caudal aspect of the fibers of the retinaculum cutis help secure the skin tightly to
superior orbital rim. The superior portion of the brow should the frontalis muscle, and in dissection, no definite ligamentous
be 1 cm superior to the orbital rim and 5 to 6 cm inferior to attachments were encountered.
the hairline. Additionally, the brow should be 1.6 to 2.5 cm
above the eyelid crease.13 The superior peak of the brow
should lie at the juncture of the middle and lateral thirds, lat-
eral to the location described by Westmore. The interrelations between development of brow ptosis
More recently, Gunter and Antrobus reviewed pre- and and changes in the upper eyelid are notoriously misunder-
postoperative photos of a patient cohort and compared their stood by patients presenting for rejuvenation of the upper
brow position versus that of a number of fashion models in third of the face. In addition to a thorough medical his-
print magazines.12 They found that the patients tended to tory and physical exam, a series of photos and an exam in
have flatter brows that started medial to, peaked more lateral front of a large mirror are vital in evaluating prospective
to, and ended more inferolaterally than those of the models patients to set expectations. Documenting patient’s facial
studied. They therefore refined the ideal brow to include the asymmetries preoperatively is extremely important. Most
periorbital structures, since intuitively more attractive perior- patients are unaware of their unique facial abnormali-
bital anatomy either enhanced an attractive brow or helped to ties; however, postoperatively patients may perseverate on
compensate for the less attractive one. By their specifications, these preexisting findings as they scrutinize their face after
the brow should lie along a slightly inclining axis when viewed surgery. Preoperative photographs should include the stan-
from medial to lateral. dard anterior–posterior, oblique, and lateral views, as well
A cautionary note should be mentioned here: these “ideal” as close-up views of the periorbital area in repose with eyes
brow descriptions are for the female patient. The male eyebrow open and closed, smiling, with eyes tightly closed, and with

Superomedial Inferomedial
osteoperiosteal osteoperiosteal
Superolateral
osteoperiosteal Supraorbital nerve
A A
B B
Figure 45.2. The inferomedial ligamentous attachment is at the
level of the orbital rim and averages 2.6 mm from the midline just
medial to the supraorbital nerve (A). (B). Fresh cadaver dissection.
NVB, neurovascular bundle.
indicated. These images should be printed and readily avail-

able during the surgical procedure for easy reference, as the
facial anatomy is easily distorted in the supine position. As
always, the patient is examined again on the day of surgery,
in the preoperative area, and after observing the brow in
motion and at rest, the transverse brow and glabellar creases
C
Figure 45.1. (Above and center) Superomedial and superolateral
ligamentous attachments are defined in the subperiosteal space. The
superomedial structure averages 10.8 mm above the supraorbital rim
and 13 mm from the midline. The superolateral structure averages
10.3 mm above the supraorbital rim and 23 mm from the midline (A).
(B,C). Appearance of ligamentous attachments in cadaver dissection.
NVB, neurovascular bundle.
full corrugator/procerus and frontalis muscle contractions.

These views along with a dynamic exam in front of a large Figure 45.3. The broad ligamentous attachment extending across
mirror should help educate the patient and surgeon about the lateral aspect of the supraorbital rim at the subgaleal level.
what features of aging are present, and which procedures are

are marked. Preoperative markings are also placed if a bleph- hairline and allows for excision of forehead skin to correct a
aroplasty is planned. Typically, limited-length or endoscopic long forehead. This is the senior author’s preferred incision in
access incisions are marked in the preoperative setting. those patients with a relatively high hairline or anteriorly thin-
ning hair. However, either approach results in a rather long
scar, across the whole of the temporoparietal scalp.
Operative Goals In 1994, Vasconez and Isse reported their experience with ele-
vating the forehead soft tissue at the subperiosteal plane utilizing
As with much of aesthetic surgery, the aims in rejuvenative an endoscopic approach. Knize further refined these approaches
procedures for the brow are straight forward, the difficulty with a limited scar technique for brow, temporal, and upper
lies in their implementation. The main goal is to restore eyelid rejuvenation. These minimally invasive techniques are in
a more youthful appearance to the brow region, without most cases, as potent in terms of brow elevation as the coro-
brow spreading and over-elevation conveying the perpetu- nal approach, with a reduced incidence of scalp paresthesias
ally surprised unnatural appearance. As Barton states in or alopecia. Though fewer surgeons are relying on the coronal
his book, the depressed brow is unaesthetic but it is natu- approach, it is still the technique used by some plastic surgeons
ral. The elevated brow is a postsurgical look.1 The goal is despite these shortcomings. We have not used it in over 10 years.
to elevate the elements of the brow smoothly and to the
correct extent. As discussed above, the lateral brow in a
female always needs to be lifted more than the remainder Senior Author’s Technique
of the brow. In most patients, the medial brow needs little,
if any, elevation. Elevation of the medial and central brow The senior author prefers not to use a coronal incision as part
is usually what conveys that “surprised look.” 18 In lifting of his operative technique. A hairline incision with or without
and redraping the brow, transverse forehead lines and gla- scalp advancement may be employed in certain patients with
bellar creases should soften. If necessary, autologous or a high forehead. An endoscopic approach is most often the
off-the-shelf fillers can be employed to fill deeper creases. surgical approach utilized by the senior author. The technique
Neurotoxins are also helpful to address glabellar frown involves two vertically oriented incisions that are made 1 to
lines and forehead creases. Hair follicle concentration and 2 cm posterior to the hairline; (depending on the thickness of
thickness should be preserved, as well as scalp sensation the hair) dissection is performed posteriorly in the subperios-
and the hairline location should be either preserved or teal plane to release the attachments of the posterior scalp.
lifted to a minor extent. If indicated, an upper blepharo- Attention is then given to the lower forehead area where an
plasty can be performed to excise excess upper eyelid skin endoscope is employed to develop a supraperiosteal dissection
prior to redraping of the brow. Whenever possible, the plane from lateral to medial (Figure 45.4). Special care is taken
to preserve the medial brow retaining structures and perform
Aesthetic Surgery
tenets detailed above for the aesthetic brow should be the
goal. The appearance of the brow and upper lids can vary a selective release of retaining ligaments as needed to achieve
greatly between individuals and should be tailored to best the aesthetic goals. Of course, special emphasis is made lat-
suit the patient. erally to avoid the sentinel vein. The lateral retinacular liga-
ment is released lateral to the supraorbital nerve, avoiding any
traction on the nerve. Adequate exposure for resection of the
medial corrugators and procerus muscles is obtained by dis-
Techniques secting a central tunnel between the two superomedial retain-
Gonzalez-Ulloa first described the coronal approach in an ing structures. Preserving these medial retaining structures
isolated procedure for elevation of the forehead and brows. allows the surgeon to control the position of the lateral brow
Ortiz-Montasterio then incorporated this as an element of his while helping to prevent over-elevation or lateral spreading of
rhytidectomy technique in 1978 (Table 45.1). Two variations the medial brow. This is one element that prevents the “sur-
on this long coronal incision have become commonplace, the prised look” patients (Figures 45.5 and 45.6).
standard coronal incision with curvilinear deviations such Once the dissection is completed, the process of brow ele-
that the incision is always 7 to 9 cm posterior to the frontal vation and suspension can begin. Characteristically four uni-
hairline and a modified anterior hairline incision. This modi- cortical tunnels (two per side) are created using a drill with
fied anterior hairline incision is located anterior to the frontal an 8 mm stop. The anterior tunnel is made by entering the
Table 45.1
Historical dates
1962 Gonzalez-Ulloa Coronal incision for
forehead/browlifta
1978 Ortiz-Montasterio Coronal forehead lift with
rhytidectomyb
1994 Vasconez and Isse Endoscopic browliftc
1996 Knize Limited—incision browliftd
a
Gonzalez-Ulloa M. Facial wrinkles, integral elimination. Plast
Reconstr Surg. 1962;29:658-673.
b
Ortiz-Montasterio F. The coronal incision in rhytidectomy: the
browlift. Clin Plast Surg. 1978;5(1):167-179.
c
Vasconez LO, Core GB, Gamboa-Bobadilla M, et al. Endoscopic
techniques in coronal brow lifting. Plast Reconstr Surg. 1994;94:
788-793.
d
Knize DM. Limited incision forehead lift for eyebrow elevation to
enhance upper blepharoplasty. Plast Reconstr Surg. 1996;97(7):
1334-1342. Figure 45.4. Endoscope dissection of the forehead.

A B C
D E F
Figure 45.5. Preoperative (A–C) and postoperative (D–F) photographs of a patient who underwent endoscopic forehead rejuvenation. The
medial retaining ligamentous attachments were left intact to control the position of the medial brow.
bone at a 45° angle and sweeping the drill from 5 to 7 o’clock.

The posterior tunnel starts approximately 2.5 mm posteriorly
Postoperative Care
from the anterior tunnel. Three individual holes are created Postoperative care of the patient begins on the operating
in a row, and by moving the drill superiorly and inferiorly table at the conclusion of the procedure. First, emergence
the three holes are connected and produce the completed infe- from sedation should be smooth, with good communication
rior tunnel. Once this is completed, a suture needle is passed between the surgeon and the anesthesiologist, and without
into the anterior tunnel and out the posterior tunnel. This hypertension, coughing, or retching. About 99% of the time
cleat provides a strong anchor point to suspend the forehead we use intravenous sedation without intubation or paralysis.
flap. The suspensory sutures consist of permanent (3-0) nylon With the combination of meticulous intraoperative hemosta-
sutures in the deep dermal plane. Three passes of the suture sis and strict adherence to postoperative activity restriction,
are made through the deep dermis, aponeurotic tissues, and the incidence of hematoma should be rare. As with rhytidec-
galea for each point of fixation. Using a rocking motion (in a tomy, patients should be instructed to sleep with their head
vertical plane), the first tie is placed so that there is NO slack elevated, and their neck extended slightly. The senior author
and the suture is completely tight. Then subsequent throws also instructs his patients to place a wedge beneath the head
are placed. The skin edges of the scalp incisions are everted when sleeping. NSAIDs (nonsteroidal anti-inflammatory
and closed with sutures or skin staples. This manner of closure drugs) and anticoagulants should be held for a number of days
has the advantages of easy postoperative removal. before and after brow rejuvenation. Finally, ensuring good

A B C
Aesthetic Surgery
E F
D
Figure 45.6. Preoperative (A–D) and

postoperative photographs (E–H) of a
patient who underwent endoscopic fore-
head rejuvenation. The medial retaining
ligamentous attachments were left intact
to control the position of the medial
brow.
G H

communication between the surgeon and the patient through- 3. ASPS Procedural Statistics 2010. www.plasticsurgery.org. accessed 5/11/01.
4. Knize DM. Forehead lift. In: Grab & Smith’s Plastic Surgery. Charles H Thorne,
out the process increases cooperation and helps achieve better ed. 6th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2007:509-516.
outcomes. 5. Stuzin JM, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal
branch of the facial nerve: the significance of the temporal fat pad. Plast
Reconstr Surg. 1989;83(2):265-271.
Complications 6. Agthong S, Huanmanop T, Chentanez V. Anatomical Variations of the
supraorbital, infraorbital, and mental foramina related to gender and side.
Paralysis of the frontalis muscle is possible secondary to J Oral Maxillofac Surg. 2005;63(6):800-804.
7. Westmore MG. Facial cosmetics in conjunction with surgery. Paper pre-
traction injury to the temporal branch of the facial nerve. sented at: Aesthetic Plastic Surgical Society Meeting; May 7, 1974;
Fortunately, this is usually not permanent; however, recov- Vancouver, British Columbia.
ery may take upward of 3 to 6 weeks. Permanent paralysis is 8. Cook TA, Brownrigg AJ, Wang TD, Quatela VC. The versatile midforehead
rare and we have not seen it, but it is a real complication that browlift. Arch Otolaryngol Head Neck Surg. 1989;115:163-168.
9. Connell BF, Lambros VS, Neurohr GH. The forehead lift: technique to
should be discussed with the patient prior to surgery. Scalp avoid complications and produce optimal results. Aesthetic Plast Surg.
sensation may be altered and is also usually temporary and a 1989;13(4):217-237.
limited complication. 10. Matarasso A, Terino EO. Forehead-brow rhytidoplasty: reassessing the
Alopecia is associated more with the coronal technique goals. Plast Reconstr Surg. 1994;93(7):1378-1389.
11. McKinney P, Mossie RD, Zuckowski ML. Criteria for the forehead lift.
when the hair-bearing scalp is closed under tension. This risk Aesthetic Plast Surg. 1991;15(2):141-147.
may be reduced if closure takes place at the deeper galeal/ 12. Gunter JP, Antrobus SD. Aesthetic analysis of the eyebrows. Plast Reconstr
superficial temporal fascia level, allowing for a tension-free Surg. 1997;99(7):1808-1816.
closure at the surface of the scalp. 13. Ellenbogen R. Transcoronal eyebrow lift with concomitant upper blepharo-
plasty. Plast Reconstr Surg. 1983;70(4):490-499.
Hematoma formation is a risk of any technique. Achieving 14. Price KM, Gupta PK, Woodward JA, Stinnett SS, Murchison AP. Eyebrow
excellent hemostasis throughout the procedure is required. and eyelid dimensions: an anthropometric analysis of African Americans
If a hematoma is encountered prompt evacuation is neces- and Caucasians. Plast Reconstr Surg. 2009;124(2):615-623.
sary with possible operative exploration if brisk bleeding is 15. Sullivan PK, Salomon JA, Woo AS, Freeman MB. The importance of the
encountered. retaining ligamentous attachments of the forehead for selective eyebrow
reshaping and forehead rejuvenation. Plast Reconstr Surg. 2006;117(1):
95-104.
References 16. Knize DM. The Forehead and Temporal Fossa: Anatomy & Technique.
Philadelphia, PA: Williams & Wilkins; 2001.
1. Barton FE. Forehead Lift. “Facial Rejuvenation”. St. Louis, MO: Quality 17. Knize DM. An anatomically based study of the mechanism of eyebrow pto-
Medical Publishing; 2008. sis. Plast Reconstr Surg. 1996;97:1321-1333.
2. Malcom PD. The Evolution of the browlift in aesthetic plastic surgery. Plast 18. Rohrich RJ. Limited incision foreheadplasty (discussion). Plast Reconstr
Reconstr Surg. 2001;108(5):1409-1424. Surg. 1999;103:285-287.

Chapter 46 n Blepharoplasty
Mark A. Codner and Renee M. Burke
The upper eyelid crease is formed by the insertion of the

Introduction levator aponeurosis into the dermis after it has penetrated the
The eyes are the focal point of the face and require detailed orbicularis oculi muscle. The lid fold is formed by excess skin
analysis before attempts at rejuvenation. The goal of and muscle that overhangs the crease. In the Occidental eye-
blepharoplasty is to restore a more youthful appearance to lid, the crease is approximately 7 mm above the lash margin
the upper and lower eyelids while preserving their natural at the midpupillary line in males and 8 to 10 mm in females.
shape and appearance. Aging results in changes in the skin, In the Asian upper eyelid, if a crease is present at all, it is
muscle, fat, bone, and ligamentous attachments. One surgi-
cal technique is not suitable for all patients. For example,
volume changes of the soft tissue can be addressed with
soft tissue fillers or soft tissue transfer. Bone resorption can
be addressed with bone fillers or implants to build up the
underlying skeletal support. Distinct differences in surgical
technique are applied to patients of differing gender and eth- Upper lid crease
nicity. There are fundamental differences between blepha- Upper lid fold
roplasty methods for men and women and for patients who
are of Asian, African, or Occidental origin. Furthermore,
patients who have signs of periorbital aging such as the tear Canthal tilt
trough deformity or malar bags require a unique surgical
approach; traditional blepharoplasty techniques alone may
exacerbate these findings.
Lateral canthus
Despite being one of the most commonly performed surgi- Medial canthus
cal procedures, blepharoplasty is a more complex and chal-
Lower lid crease
lenging procedure than has been traditionally appreciated.
Aesthetic Surgery
Nasojugal groove
Complications are not only common but are noticeable,
extremely bothersome to patients, and can be functionally
devastating. One must be familiar with the nonsurgical as well
as the surgical management of complications, including treat- Lid–cheek junction
ment of corneal irritation, ectropion, lid malposition, chemo-
sis, and hemorrhage.
While blepharoplasty is aimed at the eyelids, the entire
periorbital region requires evaluation and treatment. In upper
blepharoplasty, goals include preservation, stabilization, and/
or elevation of the brow and maintaining natural upper orbital
fullness. Brow ptosis and eyelid ptosis are ideally corrected at
the time of blepharoplasty.
During lower blepharoplasty, it is ideal to create a
A
smoother transition between the junction of the lower lid
and the cheek. Malar bags and descent of the malar fat pad
may require treatment. Analysis of globe position relative
to the inferior orbital rim and Hertel exophthalmometry
to define the relationship of the globe to the lateral orbital
skeleton are performed. To maintain the natural shape of Upper lid crease
the eyelids, treatment of tarsoligamentous laxity may be
required with lateral canthal support via lateral canthopexy Upper lid
or canthoplasty. fold
Pretarsal space
Surface Orbital Anatomy and

Age-Related Changes
The distance from the medial to lateral palpebral fissure is 28
to 30 mm transversely and 8 to 10 mm vertically. While there
is great individual variability, the lateral commissure is ideally
positioned approximately 2 mm superior to the medial canthal
angle, defining an upward lateral canthal tilt (Figure 46.1).
The position of the lateral canthus, however, varies with age,
B
family traits, race, and sex. In primary gaze, the upper eyelid
margin forms a smooth arch with the highest point positioned FIGURE 46.1. Surface anatomy. A. Surface anatomy of the upper
superior to the pupil. With age, there is a gradual lateral shift eyelid, eyelid folds, and canthal tilt. B. Close-up of the upper lid
of this apex as the tarsal plate migrates laterally due to weak- showing the differences between the fold, crease, and pretarsal space.
ening of the medial levator horn.
487
approximately 4 to 6 mm above the lash margin. An absent

crease results from the lack of levator insertion into the skin, Eyelid Anatomy
causing preseptal fat to descend into the pretarsal space. The eyelid is traditionally described as a bilamellar structure
With aging, numerous changes are observed in the orbital comprising an anterior lamella and a posterior lamella. The
region and at the multiple levels. Loss of skin elasticity pres- anterior lamella consists of skin and orbicularis oculi muscle;
ents as periorbital rhytids and the eyelids become puffy due the posterior lamella includes the tarsoligamentous sling,
to orbital fat bulging through the weakened orbital septum. which is comprised of the tarsal plate, medial and lateral can-
Furthermore, periorbital hollowing develops from atrophy of thal tendons, capsulopalpebral fascia, lid retractors, and con-
periorbital soft tissue. The combination of soft tissue loss and junctiva. The septum originates at the arcus marginalis along
descent around the fixed points of the retaining ligaments cre- the orbital rim separating the two lamellae and is therefore
ates an aged surface contour defined by a series of convexities often referred to as the “middle lamella” (Figure 46.2).
and concavities. The eyelid bags accentuate the appearance of
the deepening lid–cheek junction and vice versa. Brow pto-
sis is recognized by lateral upper eyelid hooding as well as a The Anterior Lamella
narrowed brow–eyelash distance. Brow ptosis accentuates the The orbicularis oculi muscle lies posterior to the thin eyelid
amount of loose skin in the upper lid. Vertical creases between skin, originating from the medial canthus and the bone of
the brows are commonly seen and are the result of corrugator medial orbit and inserting at the lateral canthus and lat-
and procerus activity. eral orbital rim. The orbicularis oculi muscle is divided into
Asian Non-Asian
12
Range of fusion
10
Tarsal Range of fusion

plate 5
height
Posterior lamella
Anterior lamella
Orbital septum
Middle lamella
FIGURE 46.2. Cross-sectional anatomy. A. Cross-sectional
anatomy of the upper lid demonstrating the differences in crease
position in Asian and Occidental patients. B. Cross-sectional
anatomy of the lower lid demonstrating the anterior and poste-
B rior lamella.

Chapter 46: Blepharoplasty 489
Depressor supercilii
muscle
Orbital orbicularis Procerus Corrugator

muscle muscle supercilii muscle
Preseptal Procerus muscle

Corrugator
orbicularis supercilii
muscle Superficial
muscle
buccal branch
Pretarsal Nasalis Zygomaticus
orbicularis muscle minor muscle
muscle
Zygomaticus
major muscle
Deep
buccal branch
A B
FIGURE 46.3. Orbicularis oculi muscle. A. Divisions of the orbicularis oculi muscle and surrounding periorbital mimetic muscles. B. Innervation
of the orbicularis oculi with contributions from the frontal, zygomatic, and buccal branches.
three components: the pretarsal, preseptal, and orbital divi- in a voiding lower lid malposition and problems with eyelid
sions (Figure 46.3). The pretarsal portion of the orbicularis closure following lower lid blepharoplasty.
is superficial to the tarsal plate and functions to close the
lid during involuntary blinking. The preseptal orbicularis
assists in voluntary blinking and functions as part of the The Posterior Lamella and the
lacrimal pump mechanism for tear drainage. The pretarsal Tarsoligamentous Structures
and preseptal orbicularis each have a deep and superficial
Aesthetic Surgery
While the skin and muscle make up the anterior lamella, the
component. The orbital orbicularis is the largest division of tarsoligamentous sling creates the support structure for the
the orbicularis muscle, extruding well beyond the lids, and posterior lamella (Figure 46.5). The tarsal plates constitute
functions to protect the globe with forced eyelid closure. the connective tissue framework of the upper and lower eye-
Orbicularis Muscle Innervation. The motor innervation lids. The upper lid tarsal plate is approximately 24 mm hori-
to the orbicularis oculi muscle is multiple in nature with con- zontally and 8 to 10 mm vertically at its widest dimension.
tributions from several branches of the facial nerve, includ- Attachments of the upper lid tarsal plate include the pretarsal
ing the frontal, zygomatic, and buccal branches (Figure 46.3). orbicularis and levator aponeurosis on the anterior surface,
Cadaver dissection reveals a diffuse network of nerves inner- Muller’s muscle on the superior border, and conjunctiva on
vating the orbicularis oculi. It is important to recognize the posterior surface. The lower lid tarsal plate is approxi-
that the buccal branches supply a plexus of nerve branches mately 24 mm in horizontal dimension and 4 mm in vertical
to the medial orbicularis in both the upper and lower eye- dimension. Attachments to the lower lid tarsal plate include
lids that contribute to voluntary and involuntary lid closure the pretarsal orbicularis, capsulopalpebral fascia, and con-
(Figure 46.4). Therefore, proper lateral canthal anchoring and junctiva. The tarsal plates of the upper and lower eyelid are
preservation of buccal innervation are important principles attached to the orbit by the medial and lateral canthal liga-
ments and retinacular support structures.
The medial canthus is a complex support structure that
forms the medial fixation point for the medial commissure. It
Orbital orbicularis
consists of an anterior reflection, which inserts anterior to the
oculi muscle
lacrimal sac on the nasolacrimal crest, and a posterior reflec-
Preseptal orbicularis tion, which inserts deep to the lacrimal sac on the posterior
oculi muscle lacrimal crest. The medial retinaculum is formed by several
structures, including the deep head of the pretarsal orbicu-
Pretarsal orbicularis laris, orbital septum, and medial extension of Lockwood’s
oculi muscle ligament, medial horn of the levator aponeurosis, medial rec-
tus cheek ligaments, and Whitnall’s ligament. The medial reti-
Jones’s muscle
naculum represents a fixed point maintaining medial canthal
Horner’s muscle position, allowing the orbicularis muscles to act on lid posi-
tion rather than medial canthal position (Figure 46.6).
Pretarsal orbicularis The lateral canthus also functions as an integral fixa-
oculi muscle tion point for the lower lid. The lateral canthal ligament is
Preseptal orbicularis formed by the fibrous crura, which connects the tarsal plates
oculi muscle to Whitnall’s bony lateral orbital tubercle within the lateral
orbital rim. In addition, the lateral retinaculum is formed by
Orbital orbicularis several ligamentous structures from the lateral horn of the
oculi muscle levator aponeurosis, lateral rectus check ligaments, Whitnall’s
FIGURE 46.4. Muscle contributions to the medial canthus. The com- suspensory ligament, and Lockwood’s inferior suspensory lig-
plex origin of the deep and superficial heads of the canthal portion of ament. Although the lateral retinaculum represents the lateral
the orbicularis muscle. point of fixation, there is some mobility of the lateral commis-
sure to increase the visual field upon lateral gaze. This mobility

Levator muscle
Whitnall’s Levator
ligament aponeurosis
Medial horn
Muscle of levator
aponeurotic
junction Tarsus
Lateral horn
Inferior retractors
A (capsulopalpebral fascia)
Anterior reflection
of medial
canthal ligament
Pretarsal orbicularis
Deep head of preseptal
Tarsus
orbicularis (Jones’s muscle)
Posterior lacrimal crest

Lateral
Posterior reflection of palebral raphe
medial canthal ligament Left canthal
tendon
Deep head of
pretarsal orbicularis Left retinaculum
(Horner’s muscle)
Lateral orbital
Medial retinaculum tubercle
FIGURE 46.5. Ligamentous attachments. A. Anatomy of the deep supporting structures of the posterior lamella, including the tarsoligamentous
sling and the medial and lateral horns of the levator muscle. B. Axial view of the orbit demonstrating the anterior and posterior vectors of the
medial and lateral canthus, respectively.
predisposes the lateral canthus to laxity and medial migra- ligament, Lockwood’s ligament, which arises from the medial
tion with age or trauma compared with the immobile medial and lateral retinaculum and fuses with the capsulopalpebral
canthus. fascia inserting on the inferior tarsal border. It functions to
In addition to the tarsal plates and canthal ligaments, stabilize the lower lid on downward gaze, while the lower lid
support structures in the upper and lower eyelid stabilize retractors cause depression of the lower lid to increase the
the tarsoligamentous sling. The superior transverse ligament inferior visual field during downgaze.
of Whitnall is partially formed by the fascia of levator pal-
pebrae superioris. Whitnall’s ligament inserts medially at the
trochlea of the superior oblique and laterally at the lacrimal Retractors of the Upper and Lower Lids
gland pseudocapsule and the frontal bone of the lacrimal sac The upper eyelid retractors include the levator palpebrae
fossa. The lower eyelid has an analogous inferior suspensory superioris muscle and Muller’s superior tarsal muscle. The

Preaponeurotic upper eyelid and the central and lateral fat pads in the lower
fat pad eyelid. Appreciation of the anatomy of the septum is impor-
tant particularly when surgical procedures such as resetting,
Lacrimal gland tightening, and excising the septum are performed.
The periorbital fat pads are found posterior to the orbital
septum (Figure 46.6). There are two main fat pads in the
Interpad septum upper eyelid and three fat pads in the lower eyelid. The two
upper fat pads are referred to as the central and nasal fat pads
and are located in the preaponeurotic space just superficial
to the levator aponeurosis. The interpad septum separates
the central and nasal fat pads and is continuous with a septal
Nasal fat pad
fascial connection to the trochlea. The nasal fat pad is more
fibrous and pale in color compared with the central fat pad.
Temporal
fat pad
The medial palpebral artery is located in the medial fat pad
and can cause significant bleeding during blepharoplasty. The
central fat pad is superficial to the levator aponeurosis in the
so-called preaponeurotic space and contributes to the fullness
of the upper lid fold.
Path of inferior There are three fat pockets in the lower eyelid: central,
oblique muscle nasal, and lateral. The nasal compartment in the lower eye-
Central fat pad lid is similar to its counterpart in the upper eyelid. The infe-
rior oblique muscle commonly visible during blepharoplasty
Interpad septum separates the nasal and central fat compartments. The central
(arcuate expansion of and lateral fat compartments are also separated by an inter-
Lockwood’s ligament) pad septum as well as a fascial extension from Lockwood’s
FIGURE 46.6. Anatomy of the orbital fat pads and the interpad sep- ligament, the arcuate expansion. The arcuate expansion of
tae that are addressed during blepharoplasty. Lockwood’s ligament should be preserved during lower lid
dissection to maintain lateral lid support. Since the nasal and
central fat pads envelope the inferior oblique muscle, aggres-
sive fat transposition techniques that suture the fat below the
rim can result in diplopia from impaired inferior oblique func-
levator muscle is striated muscle innervated by the oculomotor
Aesthetic Surgery
tion. The lateral extent of the lateral fat pocket includes the
nerve (cranial nerve III). The levator muscle originates from
lateral retinaculum and lateral canthal tendon.
the lesser wing of the sphenoid and inserts along the anterior
surface of the tarsal plate. The levator muscle becomes apo-
neurotic 5 to 7 mm above the superior border of the tarsus The Lacrimal Gland
and 10 to 14 mm below Whitnall’s ligament. The levator apo- The lacrimal gland lacks a true capsule and is divided into the
neurosis has a lateral horn that divides the lacrimal gland into orbital and palpebral lobe by the lateral horn of the levator.
orbital and palpebral lobes and inserts into the lateral orbital The orbital lobe is positioned in the fossa glandulae lacrimalis,
tubercle and lateral retinaculum as well as the capsulopalpe- which is a shallow fossa in the frontal bone at the superolateral
bral fascia of the lower eyelid. The medial horn of the levator orbit. The smaller palpebral lobe is connected to the orbital
aponeurosis inserts into the posterior reflection of the medial lobe by an isthmus posterior to the lateral horn of the levator.
canthal tendon. Together, the medial and lateral horns distrib- Lacrimal gland ptosis is caused by dehiscence of Sommering’s
ute the force of the levator muscle equally along the aponeu- ligaments, which are the fibrous interlobular septa that con-
rosis, causing the majority of lid elevation to occur centrally. nect the gland to the orbital rim fossa. Fullness in the lateral
Muller’s muscle is smooth muscle, which originates from aspect of the upper eyelid is often caused by lacrimal gland
the posterior surface of the levator muscle and inserts into the ptosis. Lateral to the lacrimal gland is a separate compartment,
superior tarsal border. Muller’s muscle is innervated by the just above Whitnall’s tubercle, called Eisler’s pocket. Eisler’s
sympathetic nervous system. fat pad is a small accessory fat pad located in Eisler’s pocket,
Upper lid ptosis can be caused by mechanical dehiscence which serves as a useful anatomical landmark for Whitnall’s
of the levator aponeurosis, abnormalities of cranial nerve III, tubercle. The location of this fat pad is clinically useful during
or loss of sympathetic nerve supply causing Muller’s muscle placement of the lateral canthoplasty suture.
weakness (Horner’s syndrome).
The lower lid retractors include the capsulopalpebral fas-
cia and the inferior tarsal muscle, which are closely applied.
The Conjunctiva
The capsulopalpebral fascia originates from the inferior rectus The most posterior layer of the eyelid is the conjunctival lin-
fascia and envelops the inferior oblique muscle. The capsu- ing, which continues over Tenon’s capsule. The palpebral
lopalpebral fascia is analogous to the levator aponeurosis of portion of the conjunctiva is closely adherent to the posterior
the upper lid and the inferior tarsal muscle is analogous to surface of the tarsal plate and the lid retractors. At the fornix,
Muller’s muscle. the conjunctiva is termed bulbar conjunctiva and overlies the
globe up to the corneoscleral limbus. Small accessory glands
The Orbital Septum and Orbital Fat Pads are located within the conjunctiva creating the aqueous por-
tion of the tear film.
The orbital septum separates the anterior and posterior
lamella and helps maintain periorbital fat within the anatomic
confines of the orbit. The orbital septum originates from the Forehead Anatomy
orbital rim at the arcus marginalis and is discontinuous at In the superior and lateral orbit, the forehead is more firmly
the medial canthus. In the upper eyelid, the septum fuses with attached to the underlying periosteum. Specifically, there is
the levator aponeurosis, several millimeters above the tarsal fibrous fusion between the orbicularis fascia and the underly-
plate. In the lower lid, the septum fuses with the capsulopalpe- ing periosteum and deep temporal fascia. These attachments
bral fascia below the tarsal plate. There are numerous fibrous are released to mobilize the forehead for browlifting. The
structures that separate the central and nasal fat pads in the frontalis muscles are brow elevators and are continuous with

Lateral
condensation
preperiosteal
Orbital fat
Orbitomalar ligament
SOOF
Zygomaticocutaneous
ligament
Malar fat pad
Orbitomalar Zygomaticus major

ligament muscle
Zygomaticofacial
A B
ligament
FIGURE 46.7. Lower eyelid anatomy. A. The septum and osteocutaneous supporting ligaments of the lower lid, including the lateral orbital
thickening, the zygomaticofacial ligament, and the orbitomalar ligament. B. The cross-sectional relationship of the orbitomalar ligament and the
orbicularis oculi. SOOF, suborbicularis oculi fat.
the galea aponeurotica and the occipitalis posteriorly. The blepharoplasty, it is important to establish a pre-op baseline.
frontalis muscles insert into the dermis above the supraorbital Visual field testing is performed in patients with upper eyelid
rim and are responsible for transverse forehead furrows. ptosis and upper eyelid skin folds that interfere with the visual
The orbital orbicularis oculi, depressor supercilii, oblique axis. Finally, standard photographs are taken for three rea-
and transverse heads of the corrugator supercilii, and procerus sons: preoperative planning, intraoperative reference, and for
muscles act in synergy to depress the medial brow and pro- reviewing with the patient postoperatively.
duce glabellar furrows. Motor innervation to the frontalis and
superior orbicularis oculi is by the frontal (temporal) branches Upper Orbit and Brow
of the facial nerve. The brow depressors receive motor inner-
An organized sequential assessment of the orbit, including the
vation from the buccal and zygomatic branches in addition to
upper lid and brow, is performed. The brow is evaluated in a
the frontal branches.
relaxed posture for ptosis, symmetry, and, most importantly,
shape. Traditional teaching indicates that the female brow
Midfacial Anatomy should arch above the supraorbital rim with a peak above the
Knowledge of anatomy in this region allows understand- lateral limbus. In males, the brow should be lower and more
ing of the changes seen in the lower eyelid/cheek junction. horizontal, traversing the supraorbital rim. The modern trend,
Mendelson described the prezygomatic space. The upper however, is to concentrate on brow shape more than its height.
border of the prezygomatic space is formed by the orbitoma- As a general rule, only the lateral brow requires lifting. Signs
lar ligament (also called the orbicularis retaining ligament), of lateral brow ptosis include lateral upper eyelid hooding and
a structure that arises from a thickened area of periosteum descent of the tail of the brow. Glabellar wrinkling can be
inferior to the inferior orbital rim inserts on the deep surfaces treated with botulinum toxin (Chapter 43) or surgical manip-
of the orbicularis muscle (Figure 46.7). The orbitomalar liga- ulation, including open coronal lifting, endoscopically, or via
ment along with the origin of the orbicularis from the bone transpalpebral corrugator resection. Transpalpebral corruga-
below the infraorbital rim is responsible for defining the tear tor resection is a good alternative to more invasive procedures
trough and its lateral continuation, the lid–cheek junction and can improve the glabellar frown lines. No surgical treat-
(Figure 46.8). The lower border of the prezygomatic space is ment of glabellar creases can compete with botulinum toxin,
framed by the zygomatic ligaments. From the skeletal plane, however, as long as it is administered every 3 to 4 months.
these osteocutaneous ligaments radiate outward to insert into Upper eyelid fold asymmetry may be due to upper lid pto-
the dermis of the cheek. This prezygomatic space is triangular sis, upper lid retraction, an asymmetry in the amount of tissue
in shape with the apex being nasal. Malar mounds are the in the upper lid, or asymmetrical brow position. In patients
result of edematous fat in the prezygomatic space. presenting with upper lid ptosis, it is important to identify
The malar fat pad, a totally separate structure, is a sub- the etiology on history and clinical evaluation. The differen-
cutaneous fat pad that contributes to the fullness of the mid- tial diagnosis includes congenital ptosis, acquired aponeurotic
face. Elevation of the malar fat pad and/or correction of malar dehiscence, myogenic ptosis including myasthenia gravis, neu-
mounds requires a more aggressive subperiosteal midface lift. rogenic ptosis including Horner’s syndrome, and mechanical
ptosis secondary to tumor or trauma.
On physical examination, the levator function is measured
Preoperative Evaluation by stabilizing the eyebrow and measuring lid margin excursion.
Visual acuity is measured and documented in all patients prior Congenital ptosis is present from birth and is characterized
to blepharoplasty. Ocular motility is then assessed by testing by poor levator function. The measured excursion is generally
the six cardinal positions of gaze. Since diplopia can result less than 4 mm and often requires correction by means of a
from injury to the inferior or superior oblique muscles during frontalis suspension procedure with a silicone, suture, or fascia

Tear trough
Scleral show
deformity
Malar bag
Nasojugal
groove Orbitomalar
ligament
Zygomaticofacial
ligament
Aesthetic Surgery
Orbital fat
SOOF
Malar fat pad
FIGURE 46.8. Tear trough and cheek fat pads. A. Surface anat-
omy of the tear trough deformity and midfacial aging. B. Three-
dimensional anatomy of malar bags created by edematous soft tis-
sue that is surrounded by the orbicularis oculi, the malar periosteum,
and the zygomaticocutaneous and orbitomalar ligaments. C. Three
fat compartments in the periorbital region include the orbital, SOOF
(suborbicularis oculi fat), and malar fat pads.
C
sling. In acquired ptosis, levator function is most often normal oculi fat), and bony fullness or resorption. If lacrimal gland
with an excursion of 10 mm or greater. The eyelid crease is prolapse is identified, lacrimal gland suspension is added to the
typically high in these patients as the dermal anchor of the blepharoplasty. Excess ROOF or brow fat may be removed in
levator fibers forming the crease has been disrupted. This can a conservative manner lateral to the supraorbital nerve. This
be corrected by Mullerectomy, by Fasanella-Servat, or with procedure may be combined with a browpexy to raise and sus-
the authors’ preferred technique of tarsolevator advancement pend the lateral aspect of the brow. Significant bony fullness
through the blepharoplasty incision. The cover test is recom- in the region of the lateral orbital rim can be contoured using
mended in cases of minimal unilateral acquired ptosis to rule a burr. Modern teachings have recognized that the youthful
out subclinical ptosis on the other side. The ptotic lid is cov- upper orbit is characterized by fullness, not emptiness. Bony
ered with an eye pad for 5 minutes. Due to Hering’s law of or soft tissue deficiency resulting in an A-frame deformity can
equal innervation, subclinical ptosis in the “normal” lid will be corrected with fillers or fat transfer. Fat grafting in addition
be unmasked resulting in a ptotic position of the “normal” lid. to a fat-conserving blepharoplasty should be considered if the
In that case, bilateral tarsolevator advancement is performed. orbit has become skeletonized with age or by previous surgery.
Excess of skin and preaponeurotic fat is evaluated as well Floppy eyelid syndrome, while uncommon, may be pres-
as lacrimal gland prolapse, excess ROOF (retro-orbicularis ent in large, burly males who present for blepharoplasty. The

syndrome is characterized by upper eyelid eversion during

forced lid closure and may be addressed by shortening the lid Systemic Conditions
laterally. This requires resection of a portion of the lateral tar- In addition to anatomical findings, certain medical conditions
sal plate along with a canthoplasty of the upper eyelid. If a increase the risk of complications following blepharoplasty.
floppy upper eyelid is not corrected, post blepharoplasty com- The history is directed toward identification of eyelid inflam-
plications including an overriding upper eyelid during eyelid matory disorders, Graves’ disease, benign essential blepharo-
closure, persistent chemosis, and lid separation from the globe spasm, and dry eye syndrome.
may occur. Additionally, blepharoplasty technique must be deferred or
conservative in nature to minimize the risk of corneal dryness
Lower Orbit and Midface and/or lid malposition.
Blepharochalasis is a specific disorder of eyelid tissue dis-
The lower eyelid is evaluated for excess skin, muscle, orbital
tinct from dermatochalasis caused by repeated episodes of
fat, malar bags, lateral canthal descent or disinsertion, lower
extreme periorbital edema. This condition is rare and is seen
lid laxity, and scleral show. The lateral canthal position is ide-
in women who have eyelid edema exacerbated during their
ally 2 mm superior to the medial canthal position, and a line
menstrual cycle. Chronic stretching of the eyelid skin and sep-
drawn from the medial to lateral canthus indicates the can-
tum results in blepharochalasis or chronic puffy eyelids.
thal tilt. A positive canthal tilt is one where the lateral can-
The most common cutaneous inflammatory disorders that
thus is positioned superior to the medial canthus. A negative
affect the eyelids are rosacea and pemphigus. Patients with
canthal tilt may indicate descent of the lateral canthus from
rosacea often have decreased tear film production, which
disinsertion, laxity, or the presence of a prominent eye. This
causes corneal dryness and possible ulceration from exposure
orbital morphology may also be present as a hereditary trait.
following blepharoplasty. Pemphigus is an autoimmune disor-
The lower lid tone is evaluated in two ways: 1) the distraction
der that leads to chronic inflammatory changes of the conjunc-
test wherein the lid is distracted from the globe (lid distraction
tiva and ocular adnexa. Scar contracture of the conjunctival
greater than 6 mm indicates significant lid laxity); 2) the snap
fornix may occur causing foreshortening and lid malposition.
test wherein the lid is retracted caudally and allowed to snap
In addition to patients with rosacea and pemphigus, patients
back (slow return indicates poor lid tone). Poor lid tone and/or
with known history of sarcoidosis are at increased risk for
laxity may necessitate lid shortening and lateral canthoplasty
healing complications following blepharoplasty. Noncaseating
(Chapter 32). Inferior malposition of the lower lid, or scleral
granuloma formation in blepharoplasty incisions has been
show, is a major “red flag.” Scleral show may be caused by
reportedly caused by sarcoidosis of the surgical scar.
prominent eyes, lower lid laxity, poor infraorbital support, or
Undiagnosed hyperthyroidism may present with puffy
a combination of the above, and it places that patient at high
eyelids. Preoperative evaluation includes free T4, thyroid cir-
risk for postoperative complications.
culating antibodies, as well as consideration for endocrine
The globe position relative to the bony orbital rim is
consultation. Ocular manifestation of Graves’ disease often
evaluated. Patients with a negative vector relationship have
includes upper and lower lid retraction, diplopia, exophthal-
a prominent eye with poor vertical support of the lower lid;
mos, and puffy eyelids. Standard blepharoplasty techniques
on lateral view, the anterior aspect of the globe projects ante-
must be avoided in patients with significant thyroid eye dis-
rior to the underlying soft issue over the infraorbital rim. A
ease. Another periorbital disorder associated with increased
positive, or normal, vector is when the globe does not project
risk of complications is benign essential blepharospasm. This
beyond the infraorbital rim and overlying soft tissue. Hertel
is an involuntary spastic disorder of the orbicularis oculi mus-
exophthalmometry is used to assess globe prominence rela-
cle, frequently contributing to redundant upper eyelid skin.
tive to the lateral orbital rim. Normal globe prominence is in
Blepharoplasty is avoided because improvement in symptoms
the range of 16 to 18 mm. Patients with enophthalmos have
after surgery is unlikely. Current management is nonoperative
a measurement less than 16 mm and with exophthalmos have
with orbicularis oculi muscle injections of botulinum toxin.
measurements greater than 18 mm. Both prominent and
Patients who have had recent laser in situ keratomileusis
deep-set eyes are at increased risk for complications, and the
(LASIK) surgery for vision enhancement should avoid blepha-
degree of prominence influences the level at which the lateral
roplasty for at least six months in order to allow the corneal
canthus will be anchored during lateral canthoplasty. Lateral
incision adequate time to heal to avoid complications of dryness
canthal anchoring in prominent eyes requires supraplacement.
after blepharoplasty.
Canthal anchoring in deep-set eyes requires no overcorrection
but does require more significant internal placement to avoid
anterior malposition. Furthermore, primary lower lid spacers Operative Technique
and infraorbital rim implants may be considered in patients
with prominent eyes to correct the poor globe support. Upper Lid Markings
Preliminary markings are made while in the preoperative area
Dry Eye to ensure that the eventual scar will lie in the upper lid crease.
Contact lens intolerance is another “red flag” and indicates The markings are completed on the operating room table. The
high risk for postoperative eye dryness. These patients are fur- upper eyelid crease is marked at the level of the midpupillary
ther evaluated using a Shirmer’s test. The conjunctiva is anes- line. In women, this is 8 to 10 mm superior to the lash margin
thetized in the inferior lateral fornix with Tetracaine eye drops. and roughly 7 mm above the lash margin in men (Figure 46.9).
Any excess tear film is then blotted away and a Shirmer’s strip The marking is tapered caudally at the nasal and lateral lid
is placed in the lateral fornix while the patient is asked to gaze margins following the gentle curve of the upper lid crease. The
straight ahead. Decreased tear production is identified by less nasal aspect of the marking should not extend medial to the
than 10 mm of wetting after a 5-minute period. A poor Bell’s caruncle, to avoid webbing or the development of epicanthal
phenomenon also predisposes patients to significant postop- folds. At the lateral canthus, the lateral marking should be
erative corneal dryness. Patients with dry eyes should have 5 to 6 mm above the lash line. The lateral extension should be
no skin excision and consideration is given to lateral canthal hidden in a skin tension line and not extend past the lateral
anchoring. At a minimum, a temporary tarsorrhaphy suture is orbital rim. The superior margin is marked, preserving 10 to
placed to limit the corneal exposure during the postoperative 15 mm of skin between the lower border of the eyebrow and
edematous phase. Liberal use of perioperative lubrication is the upper lid marking, at the level of the lateral canthus. The
advocated, and postoperative insertion of punctal plugs may superior mark is drawn parallel to the contour of the lower
be needed in refractory cases. marking. The marks are then tapered nasally, to reduce the

lid margin to the inferior incision and from the brow to the
superior incision.
Lower Lid Markings

The lower lid is first marked with a single point at the level
of the lateral canthus. If a skin incision is planned, a line is
extended inferiolaterally for approximately 6 to 10 mm
within a prominent skin tension line. Roughly 10 mm of skin
10 mm is preserved between the lateral extension of the upper and
6 mm
lower blepharoplasty incisions. If the incisions are placed too
close together, postoperative webbing or distortion can occur.
The nasal extension of the marking parallels the lid margin
approximately 2 to 3 mm below the eyelashes.
A Anesthesia
Blepharoplasty can be performed under local anesthesia with
sedation, MAC, or general anesthesia. Local anesthesia con-
sisting of lidocaine 1% with epinephrine 1:100,000 is injected
using a 27-gauge needle into the upper eyelid, lateral canthus,
lower eyelid, and inferior orbital rim. If midfacial dissec-
tion is planned, the injected area is extended to include the
bony malar prominence at the level of the periosteum avoid-
ing the infraorbital neurovascular bundle. Care is taken to
avoid injury to the marginal arterial arcades and the deep
orbital structures to reduce the risk of eyelid or retrobulbar
D hematoma.
A Upper Lid Blepharoplasty

B
C Using a scalpel, upper lid skin is excised as marked preopera-
tively. A strip of orbicularis oculi muscle is excised exposing
Aesthetic Surgery
the orbital septum. The septum is opened along the length of
the incision. This technique is described as an “Open Sky”
approach to the preaponeurotic space (Figure 46.10). Care
is taken to preserve the interpad septum separating the cen-
tral and nasal fat pads. Over-resection of fat in this area will
B result in a hollow “A-frame” or peaked arch deformity of the
FIGURE 46.9. Upper blepharoplasty markings. A. Upper blepharo- supratarsal crease. Preservation of fat at the interpad septum
plasty distances are shown and (B) the points to consider during the will maintain a symmetrical gentle arch below the new upper
markings. lid fold. When fat excision is indicated, it can be performed
by direct sculpting with the needle tip cautery, which allows
amount of skin and muscle to be excised, as over-resection in

this area is poorly tolerated and may result in lagophthalmos
in addition to a poor aesthetic outcome.
In the Asian eyelid, one must determine if a single eyelid
fold (absent crease) or a double eyelid fold (single crease) is
desired. It is also important to define the desired location of
the crease, as this is typically lower than in the Caucasian
upper eyelid. A distance of 4 to 6 mm above the lid margin is
usually used depending on the patients’ desires. A plan is made
to limit the amount of skin and preaponeurotic fat excision
since this can lead to an unnaturally high crease and supra-
tarsal hollowness. Furthermore, the epicanthal fold is usually
preserved unless the change is specifically requested by the
patient. Proper communication with the patient regarding the
desired outcome is of utmost importance as the aesthetic goals
of Asian blepharoplasty are different from those achieved by
standard techniques.
Special attention is given to the presence of eyebrow and
lid fold asymmetry. Asymmetric brow positions are extremely
common. If asymmetry is due to unilateral bow ptosis, the
upper eyelid markings should closely approximate one
another and a browlift should be planned to lift the lower
brow. However, if the lid folds are asymmetric due to eye- FIGURE 46.10. Removal of preaponeurotic central fat pad and expo-
lid asymmetry or ptosis, the markings should aim to estab- sure of levator aponeurosis. Reprinted from McCord CD, Codner
lish symmetry and correct the underlying ptosis. Symmetry MA. Eyelid and Periorbital Surgery. St. Louis, MO: Quality Medical
can be improved by removing different amounts of skin and Publishing; 2008.
muscle from each eyelid and equalizing the distances from the

greater precision and visualization of the medial palpebral Asian Upper Lid Blepharoplasty. A low crease incision
artery. Clamping, resecting, and cauterizing fat should be typically 4 to 6 mm above the lash line is made. A conser-
discouraged since this can result in uncontrolled bleeding. vative amount of skin is excised and minimal preaponeurotic
Inadequate cauterization can result in bleeding from the nasal fat is removed. To create a dynamic fold, multiple three-point
fat pad. Poor visualization and indiscriminate cauterization sutures are placed through the junction of the upper tarsal
within the deep nasal orbit has contributed to injury to the margin, levator insertion, and dermis of the upper skin m
argin.
trochlea and the superior oblique muscle. Patients with injury
to the superior oblique muscle will exhibit diplopia and head Lower Lid Blepharoplasty
tilt toward the side of the superior oblique injury following
blepharoplasty. Fat preservation should be considered to Approaches to the lower lid differ widely. Some experienced
avoid creation of a hollow more aged-appearing orbit. surgeons never make a subciliary incision, preferring to use
Inadvertent surgical disinsertion of the levator aponeuro- the transconjunctival plus skin pinch approach, while oth-
sis during upper blepharoplasty may result in postoperative ers make a subciliary incision routinely. If a skin incision
acquired ptosis. To minimize this risk, some surgeons perform is planned, it is initiated lateral to the canthus exposing the
supratarsal fixation of the pretarsal skin muscle to the levator underlying orbicularis oculi muscle. The orbicularis oculi
aponeurosis as a routine part of upper blepharoplasty using a muscle is divided with electrocautery lateral to the canthus.
horizontal mattress suture of 6-0 Vicryl at the midpupillary Scissors are used to incise the remainder of the lower lid skin
line. incision along the lid margin with a second stair-step incision
The ROOF pad should be evaluated, and conservative through the orbicularis preserving a 5 mm strip of pretarsal
resection of the brow fat pad can be performed. Ptosis of orbicularis muscle (Figure 46.12). Electromyelogram analysis
the orbital lobe of the lacrimal gland may be present and is has revealed normal function of the pretarsal muscle strip after
corrected with suspension of the lacrimal gland into the lac- use of the skin muscle flap with minimal risk of denervation.
rimal sac fossa (Figure 46.11). The lateral horn is placed on The skin muscle flap is then dissected anterior to the septum to
traction and the levator aponeurosis is sutured to the arcus the infraorbital rim. The orbitomalar ligament is encountered
marginalis with 6-0 Vicryl suture just at the level of the lacri- several millimeters below the infraorbital rim and is divided.
mal gland to prevent future lacrimal gland ptosis. The levator A tear trough deformity may be improved by release of the
aponeurosis is placed on downward stretch to eliminate the medial origin of the orbicularis oculi from the bone. Once
risk of postoperative lagophthalmos. Resection of the lacrimal the orbitomalar ligament is released, the SOOF (suborbicu-
gland can cause postoperative dry eye syndrome and is not laris oculi fat) becomes visible and preperiosteal dissection is
recommended. performed approximately 10 mm below the orbital rim pre-
If lateral brow ptosis is present, a browpexy can be per- serving the zygomaticofacial nerve. Release of the orbitomalar
formed through the upper blepharoplasty incision. The ligament allows elevation of the SOOF with the skin muscle
orbicularis and ROOF are dissected just superficial to the flap. Orbital fat can be removed in a conservative fashion
periosteum along the lateral third of the eyebrow, lateral from all three lower lid compartments (Figure 46.12). Care is
to the supraorbital nerve, exposing the periosteum and the taken to avoid injury to the inferior oblique muscle between
temporalis fascia. Internal browpexy is performed using 4-0 the nasal and central fat pads. The inferior oblique muscle is
Prolene interrupted mattress sutures between the orbicularis the most common extraocular muscle injured during blepha-
just deep to the dermis at the level of the inferior brow mar- roplasty. The arcuate expansion of Lockwood’s ligament
gin and the underlying periosteum and temporalis fascia. The between the central and lateral fat pad should be preserved for
inferior margin of the brow at the level of the lateral limbus additional support to prevent further herniation of periorbital
should be sutured 10 to 15 mm above the lateral orbital rim fat. Alternative procedures are considered including arcus
depending on the desired position. marginalis release with fat repositioning, or fat grafting to the
The incision is closed with interrupted 6-0 nylon suture orbital rim.
lateral to the lateral canthus. The remainder of the incision is Transconjunctival Lower Blepharoplasty. The orbital
closed with a running nylon suture, which can be placed in an fat can be removed by a transseptal approach that divides
intradermal fashion or in a simple, running fashion. the conjunctiva, capsulopalpebral fascia, and septum, or by a
retroseptal incision through the conjunctiva and capsulopal-
pebral fascia that leaves the septum intact. We reserve trans-
conjunctival fat removal for young patients with congenital
fat excess and minimal laxity, as well as for African-American
and Asian patients. The transconjunctival approach has the
advantage of leaving the orbicularis muscle intact, which
minimizes the risk of complications. In addition to removing
fat, the transconjunctival approach can be combined with a
“pinch” skin excision and/or fat redraping.
Lateral Canthal Anchoring

The degree of lower lid laxity is reevaluated intraoperatively
by placing anterior traction on the lower eyelid and using
caliper measurement to determine the amount of lid distrac-
tion from the globe. Lid distraction of 1 to 2 mm indicates
minimal lid laxity, while measurements of 3 to 6 mm of lid
distraction indicate moderate laxity of the lower eyelid. Some
surgeons believe that a lateral canthopexy should be used to
correct both minimal and moderate lid laxity to provide long-
lasting lower eyelid support and preserve the natural shape
FIGURE 46.11. Demonstration of lacrimal gland ptosis. Reprinted of the eyelid (Figure 46.13). When the lid can be distracted
from McCord CD, Codner MA. Eyelid and Periorbital Surgery. greater than 6 mm away from the globe, significant lid laxity
St. Louis, MO: Quality Medical Publishing; 2008. is present. The consensus is that lateral canthal anchoring is
necessary.

Gray line
Tarsal plate
Zygomatic Buccal
branches branch
Tarsus height
at 3.8 mm Anchor
for mildly
prominent eye
Inferior arcade
at 4 mm
Level of incision
at 6 mm
Standard
Aesthetic Surgery
Inferior retractors anchor
released
B
B
Lateral
fat
pocket Medial Lateral
(nasal) orbital rim
fat pocket
Arcuate
expansion
Inferior
oblique
muscle
Central pocket
C C
FIGURE 46.12. Lower blepharoplasty technique. A. Lower blepha- FIGURE 46.13. Lateral canthoplasty. A. Lateral canthoplasty is per-
roplasty markings of the skin muscle flap with preservation of inner- formed by placing a suture through the incised edge of the tarsal plate.
vation from the zygomatic and buccal branches of the facial nerve. B. Placement of the canthoplasty suture demonstrates slight vertical
B. Sagittal view demonstrating the stair-step technique that preserves overcorrection in patients with prominent eyes. C. The canthoplasty
pretarsal orbicularis muscle. C. Removal and redraping of fat from suture is placed posteriorly to the lateral orbital rim to ensure that the
the nasal, central, and lateral orbital fat compartments. lid follows the curve of the globe.

The objective of lateral canthopexy (Chapter 32) is to exposure-related desiccation. The head should remain in an
suture the tarsal plate and lateral retinaculum to the perios- elevated position and iced gauze or ice packs applied to the
teum of the lateral orbital rim, thereby tightening the lower periorbital region for 24 hours. Ophthalmic antibiotic oint-
lid tarsoligamentous sling. A nonabsorbable horizontal mat- ment is applied along the suture line as well as on the globe to
tress suture is used to incorporate the tarsal plate and lateral prevent or to reduce evaporative tear film loss after surgery.
retinaculum. The suture is placed inside the lateral orbital rim Patients are asked to avoid the use of eyelid makeup on the
periosteum from deep to superficial, allowing the lateral can- suture lines and the use of contact lenses for 7 to 10 days fol-
thus and lower lid to be tightened posteriorly and superiorly lowing surgery.
and pulling the lower lid margin against the globe. The verti- If significant chemosis is present at the end of the case, the
cal position of the lateral canthal fixation suture depends on use of a Frost suture or temporary tarsorrhaphy is considered.
the amount of eye prominence, the amount of lower lid laxity, A 6-0 nylon suture is placed in the lower lid margin lateral to
and the preoperative shape of the lower eyelid. Care is taken to the limbus and either suspended to the eyebrow or sutured
maintain the preoperative shape of the lower eyelid, avoiding to the upper eyelid along the gray line. These techniques will
overcorrection or alteration in the preoperative canthal posi- minimize corneal exposure in the immediate postoperative
tion. The position of the lateral canthal suture is most com- period. All sutures, including the Frost suture, are removed
monly at the horizontal midpupillary line. However, patients 5 to 7 days after surgery.
with prominent eyes require supraplacement of the canthal Persistent postoperative chemosis can be treated with con-
support suture with overcorrection and minimal tightening to tinuous use of ophthalmic ointments in addition to ocular
avoid “clothes-lining” of the lower lid below the inferior lim- decongestants (Neo-Synephrine, 2.5%) and steroid eye drops
bus. Conversely, patients with deep-set eyes require more pos- (Tobradex). If the chemosis persists into the second postoper-
terior placement of the canthopexy suture taking care to avoid ative week, second-line steroid drops may be used (FML Forte
overcorrection in a superior direction. The downward force of Liquifilm or Pred Forte) along with patching the eye closed
the prominent globe on the lower lid will cause descent of the for 24 to 48 hours, and applying gentle pressure from an
lid margin following lateral canthopexy; however, this force Ace wrap to reduce the swelling. If chemosis persists beyond
does not exist in patients who have deep-set eyes. 2 weeks, and especially if significant lagophthalmos is pres-
Patients who have significant lid laxity with lid distraction ent, conjunctivotomy with possible tarsorrhaphy is performed
greater than 6 mm probably require lateral canthotomy and and oral steroids (Solumedrol dose pack) may be given.
canthoplasty. Lateral canthoplasty is performed by selective Ophthalmic steroid eye drops are contraindicated in patients
canthotomy of the inferior limb of the lateral canthal tendon with glaucoma or for more than 2 weeks due to the risk of
followed by cantholysis, which allows mobilization of the elevated intraocular pressure. Surgeons who perform the more
lower lid. Two to 3 mm of full-thickness lid margin is resected limited transconjunctival fat removal and pinch skin excision
to correct significant lid laxity. A 4-0 nonabsorbable suture do so because, among other things, chemosis does not occur.
is placed through the edge of the tarsal plate from inferior
to superior ensuring vertical alignment while controlling lash Complications
rotation. The mattress suture is then placed inside the lateral
This chapter focuses on the most common complications,
orbital rim periosteum at the appropriate level. The suture is
including ectropion, lid malposition, chemosis, and the need
tied with a surgeon’s knot until the desired amount of tension
for reoperation. The most devastating complication after
is achieved, allowing 1 to 2 mm of lid distraction away from
blepharoplasty is visual loss, which has been reported from
the globe (Figure 46.11). Over-tightening of the lateral cantho-
periorbital filler injection due to intra-arterial injection and
plasty is avoided. The lateral commissure is then reconstructed
embolization to the central retinal artery (Figure 46.14).
with a 6-0 plain catgut suture placed in the gray line to prevent
Although rare, the estimated incidence of visual loss with
postoperative lateral canthal webbing. In order to recreate a
blepharoplasty is 0.04% and may be caused by retro-orbital
normal appearing lateral commissure, the suture is placed in
hemorrhage compromising central retinal arterial circulation
the posterior aspect of the upper lid gray line and the anterior
or by direct globe perforation with a needle, instrument, or
aspect of the lower lid gray line to allow the upper lid to slightly
laser. Management of retro-orbital hematoma includes imme-
overlap the lower lid in a normal anatomical relationship.
diate surgical decompression with lateral canthotomy and
Following lateral canthal support, the skin muscle flap is
cantholysis in the recovery room or emergency room followed
redraped in a superior lateral vector, and a triangle of excess
skin and muscle is resected according to the amount that over-
laps the lateral extent of the lower blepharoplasty incision. The
orbicularis muscle flap is then resuspended to the lateral orbital
rim at the level of the lateral canthus using a 4-0 Vicryl suture
placed as a three-point quilting suture from the incised edges
of skin and muscle to periosteum along the inner aspect of the Supratrochlear
lateral orbital rim to recreate the normal concavity associated artery
with the lateral orbital raphe. Similarly, interrupted absorbable
sutures are placed in the lateral cut edge of the orbicularis flap Internal carotid
to the lateral orbital rim periosteum and temporalis fascia to artery
properly resuspend the orbicularis under appropriate tension.
Resuspension of the orbicularis provides additional lower lid
support as well as elevation of the SOOF overlying the inferior
orbital rim. Minimal skin and muscle are resected parallel to
the lower lid margin to minimize the risk of lid malposition. A
small strip of orbicularis is removed from the undersurface of
the skin muscle flap to avoid a redundant layer overlying the
Ophthalmic Central
preserved pretarsal orbicularis, thereby completing the tension- retinal
artery
free stair step with a 6-0 fast absorbing catgut suture. artery
Postoperative Care FIGURE 46.14. Blindness from injectable agents. Diagram show-
ing the anatomy that results in embolization from the supratrochlear
Frequent moisturizing with wetting drops, ophthalmic lubri- artery to the central retinal artery.
cating, and intermittent forced lid closure helps prevent

by surgical exploration, administration of mannitol, acetazol- or persistent lid malposition following a 2- to 3-month period
amide, and oxygen. Diplopia can also occur following bleph- of conservative management may require surgical interven-
aroplasty; it is usually caused by edema and is temporary. tion, including placement of a posterior lamella spacer graft
Permanent diplopia can occur from thermal or surgical injury and lateral canthoplasty with possible drill hole to fix the lat-
to the inferior oblique or superior oblique muscles from elec- eral canthus.
trocautery or direct clamping or excision. Strabismus surgery Infectious and inflammatory complications are rare fol-
may be required for patients who do not improve with conser- lowing blepharoplasty and can be differentiated according
vative management. In the upper lid, ptosis may occur from to the time of presentation. Hypersensitivity reactions in the
failed recognition of a preexisting condition or from levator perioperative period can occur as a reaction to preservative
injury during surgery. To minimize this risk, supratarsal fixa- drops containing benzalkonium chloride or ointment con-
tion of the pretarsal skin muscle to the levator aponeurosis is taining neomycin and usually resolve with discontinuation
considered. of the offending agent, antihistamines, and cold compresses.
Signs of corneal irritation require ophthalmological evalua- Inflammatory reactions to suture material may occur dur-
tion, including a slit lamp examination with the use of fluores- ing the first 2 weeks after surgery. Sutures in the skin for
cein eye drops. Liberal use of Tobradex ophthalmic ointment more than 7 days may result in epithelialized tracks and sub-
on the cornea three to four times a day with patching at night sequent formation of subcutaneous epidermoid cysts, which
is the first line of treatment. Bandage contact lenses can also can be unroofed with local anesthesia and an 18-gauge
be considered. Lid malposition may contribute to lagophthal- needle. Finally, minor cellulitis around the incision can be
mos and corneal exposure, which can be managed with verti- treated with oral antibiotics; however, atypical infections
cal lower lid massage and steri-strip tape support to the lower should be considered.
lid. Timing of reoperation should be in the immediate 2-week Symptoms of visual impairment or pain with ocular
postoperative period if ectropion or severe lid malposition movement require a thorough evaluation, including a com-
is attributable to technical failure of the canthopexy suture. puted axial tomography, to rule out deep orbital celluli-
This can save the patient weeks of conservative management tis with possible extension to the cavernous sinus, which
and discomfort. If mild lid malposition gradually occurs after requires treatment with emergent surgical debridement
the initial 2-week postoperative period, conservative manage- and intravenous antibiotics. Erythema and nodules pre-
ment should continue for 2 months to avoid operating dur- senting 2 to 6 weeks after blepharoplasty include suture
ing the 6-week postoperative period when there is poor tissue abscesses, pyogenic granulomas, and foreign body granu-
compliance due to the peak proliferative phase of healing. lomas. These lesions are treated with excisional biopsy to
Furthermore, a significant number of patients will improve confirm the diagnosis . Additional, low-dose, oral steroids
without reoperation after this timeframe. Lower lid ectropion may improve inflammatory reactions as long as infection
Aesthetic Surgery
has been excluded. Patients presenting with erythema or
signs of infection more than 6 weeks after surgery should be
considered to have atypical infections, the majority of which
are caused by mycobacteria or fungus. Drainage from these
lesions should be sent for special stains (acid-fast and KOH
prep), culture, and sensitivity. Patients should be placed
on broad-spectrum antibiotics (Ciprofloxacin, Avelox, or
Zyvox), with the addition of oral clarithromycin for 6 weeks
if there is culture confirmation of mycobacteria. Though
rare, noncaseating granulomas can occur after blepharo-
plasty and present as nontender, inflammatory processes
appearing more than 6 weeks after surgery. The differential
diagnoses include chalazion, dermoid cysts, and cutaneous
sarcoidosis. If there is no drainage for culture, incisional
or excisional biopsies may be performed in the subacute
phase. Once the subacute phase subsides, which can take
up to a year, the lesion may be safely excised. If cutaneous
sarcoidosis is suspected, the workup should include serum
angiotensin-converting enzyme level, chest radiography, and
A possibly a rheumatology referral.
FIGURE 46.15. Blepharoplasty results.

A. A middle-aged male patient before
and after upper and lower blepharoplasty
with fat excision and release of orbitoma-
lar ligament to blend lid–cheek junction.
B. A younger female patient before and
after lower blepharoplasty with fat trans-
fer for correction of tear trough deformity.
C. An older female patient before and after
upper and lower blepharoplasty. Reprinted
from McCord CD, Codner MA. Eyelid and
Periorbital Surgery. St. Louis, MO: Quality
Medical Publishing; 2008.
B

include fat preservation with conservative removal of the skin,

muscle, and fat to avoid a hollow upper lid sulcus and supra-
tarsal fixation to avoid acquired post-blepharoplasty ptosis.
Browlifting procedures should be considered as an adjunct to
blepharoplasty.
Conclusion
Blepharoplasty has evolved over the past decade from the
routine removal of skin, muscle, and fat to a sophisticated
surgical procedure that is individualized for each patient.
The current techniques are aimed at not only improving age-
related changes but also modifying periorbital changes associ-
ated with ethnicity, gender, and ligamentous attachments. The
adjacent anatomical areas should be addressed by techniques
that improve the forehead and midface.
C Suggested Readings
FIGURE 46.15. (Continued). 1. Carraway JH. Lower lid blepharoplasty with fat grafts for correction of
the tear trough. In: Codner MA, de Castro C, Boehm KA, eds. Techniques
in Aesthetic Plastic Surgery: Midface Surgery. Philadelphia, PA: Saunders
Elsevier; 2009:47-58.
2. Codner MA, Day CR, Hester TR, Nahai F, McCord C. Management
of moderate to complex blepharoplasty problems. Perspect Plast Surg.
Outcomes 2001;15(1):15-32.
3. Codner MA, Locke MB. Applied anatomy of the eyelids and orbit. In:
Emphasis is placed on maintaining the preoperative shape of Nahai F, ed. The Art of Aesthetic Surgery Principles and Technique. 2nd ed.
the palpebral fissure with particular attention to maintaining St. Louis, MO: Quality Medical Publishing; 2011:807-830.
lower eyelid position (Figure 46.15). In this author’s opinion, 4. Codner MA, Mejia JD. Lower eyelid blepharoplasty. In: Nahai F, ed. The
lateral canthal support, most commonly with lateral cantho- Art of Aesthetic Surgery Principles and Technique. 2nd ed. St. Louis, MO:
Quality Medical Publishing; 2011:907-940.
pexy, represents an important step in the technique to main- 5. Hamra ST, Choucair RJ. Orbital aging and harmony in orbital rejuvena-
tain lid shape and reduce the risk of lower lid malposition or tion. In: Codner MA, de Castro C, Boehm KA, eds. Techniques in Aesthetic
postoperative round-eye syndrome. The trade-off that should Plastic Surgery: Midface Surgery. Philadelphia, PA: Saunders Elsevier;
be discussed with patients prior to surgery is that the lower lid 2009:93-104.
6. Hirmand H, Codner MA, McCord CD, Hester TR, Nahai F. Prominent
may appear tight for 2 to 3 weeks after surgery. The natural eye: operative management in lower lid and midface rejuvenation and the
S-shaped curve to the lower lid and palpebral aperture is pre- morphologic classification system. Plast Reconstr Surg. 2002;110:620.
served following completion of the healing process. 7. Kikkawa DO, Lemke BN, Dortzbach RK. Relations of the superficial mus-
Complications associated with lateral canthoplasty include culoaponeurotic system to the orbit and characterization of the orbitomalar
ligament. Ophthalmic Plast Reconstr Surg. 1996;12:77.
canthal webbing or asymmetry, which requires surgical revi- 8. Knize DM. The superficial lateral canthal tendon: anatomic study and clini-
sion. The risk of frank ectropion is reduced when conserva- cal application to lateral canthopexy. Plast Reconstr Surg. 2002;109:1149.
tive skin excision and lateral canthal support are performed 9. McCord CD, Codner MA. Involutional entropion and ectropion.
in routine combination. In addition to minimizing the risk In: McCord CD, Codner MA, eds. Eyelid and Periorbital Surgery. St. Louis,
MO: Quality Medical Publishing; 2008:627-654.
of complications, maximizing the aesthetic result is directly 10. McCord CD, Codner MA, Hester TR. Redraping the inferior orbicularis
related to safe management of periorbital fat, the orbicu- arc. Plast Reconstr Surg. 1998;102:2471-2479.
laris muscle, SOOF, and release of the periorbital ligaments. 11. Muzaffar AR, Mendelson BC, Adams WP. Surgical anatomy of the ligamen-
Elevation of the skin muscle flap and release of the orbitoma- tous attachments of the lower lid and lateral canthus. Plast Reconstr Surg.
2002;110:873.
lar ligament mobilize the SOOF, which is elevated with the 12. Pacella SJ, Codner MA. Minor complications after blepharoplasty: dry
orbicularis muscle. Using the orbicularis muscle as a sling with eyes, chemosis, granulomas, ptosis, and scleral show. Plast Reconstr Surg.
secure lateral orbital fixation is the key to maximizing the 2010;125:709-718.
aesthetic appearance of the infraorbital region. The posterior 13. Ramirez OM, Santamarina R. Spatial orientation of Motor Innervation to
the lower orbicularis oculi muscle. Aesthet Surg J. 2000;20(2):107-113.
lamella (tarsoligamentous sling) has a more posterior point 14. Weinfeld AB, Burke R, Codner MA. The comprehensive management of
of periosteal fixation than the anterior lamella (skin muscle chemosis following cosmetic lower blepharoplasty. Plast Reconstr Surg.
flap). Similarly, key principles for upper blepharoplasty 2008;122:579-585.

Chapter 47 n Facelift
Charles H. Thorne
No procedure is more closely associated with plastic surgery 3. Facial harmony—The goal is to help a patient look better,
in the eyes of the public than facelifting, and perhaps rightfully not weird or operated on. Excessive tension, radical defat-
so. When performed with appropriate attention to detail in a ting, exaggerated changes, and attention to one region
properly selected patient, the procedure provides consistently while ignoring another may result in disharmony. The face
satisfactory results, creating a natural, unoperated appearance is best analyzed and manipulated with the entire face (and
and leaving the patient looking like a crisper version of him- the entire patient) in mind, not the individual component
self or herself. When not properly performed, the procedure parts, lest the “forest be lost for the trees.”
can be catastrophic, resulting in visible scars, distorted ears 4. Recognition of atrophy—The process of aging involves not
and hairlines, unnatural creases, and a disharmonious, obvi- only sagging of the tissues and deterioration of the skin
ously operated look. itself but also atrophy of tissues, especially fat, in certain
This chapter summarizes the author’s personal approach to areas. Most patients are best served with limited defatting
facelifting, as well as the most common techniques employed and may require addition of fat to areas of atrophy. It is
by other plastic surgeons. Many of the components of the pro- the author’s impression that fat grafting at the time of
cedure are easily summarized in a chapter of this type; other facial cosmetic surgery has also swung back slightly in the
components such as how much to do, and how tight to pull, direction of conservatism. Too much fat grafting can result
are difficult to describe in words, vary between patients, and in a large, puffy face which is less attractive than the atro-
require experience to master. phied face that the patient started with.
In the author’s opinion, there is one principle of overriding
importance in facelifting and in selecting the ancillary proce-
dures to be performed concomitantly with faceliftng: The sur-
Benefits and Limitations of
geon should always perform the fewest number of maneuvers Facelifting
and the simplest possible maneuvers in order to address the Facelifting addresses only ptosis and atrophy of facial tissues.
patient’s complaints in a realistic fashion. The more that is It does not address, and has no effect on, the quality of the
done, the longer the recovery but more importantly, the more facial skin itself. Consequently, facelifting is not a treatment
Aesthetic Surgery
likely that the patient will have an operated look or a compli- for wrinkles, sun damage, creases, or irregular pigmentation.
cation. Less is more. Fine wrinkles and irregular pigmentation are best treated
with skin care and resurfacing procedures (see Chapters 13
and 41). Most facial creases will not be improved by face-
State Of The Art lifting (nasolabial creases), and even if improved somewhat,
Facelifting was first performed in the early 1900s and for may still require additional treatment in the form of fillers or
most of the 20th century involved skin undermining and skin muscle-weakening agents (see Chapters 42 and 43).
excision. A revolution occurred in the 1970s when the pub- The above disclaimer notwithstanding, the facelift is the
lic became exponentially more interested in the procedure single most important and beneficial treatment for most
and Skoog described dissection of the superficial fascia of the patients older than 40 years who wish to maximally address
face in continuity with the platysma in the neck. Since then facial aging changes. Patients who believe that fillers and
techniques have been described that involve every possible neurotoxins can be used instead of, or to delay, a facelift
skin incision, plane of dissection, extent of tissue manipula- are generally incorrect. Injectables can be complimentary
tion, type of instrumentation, and method of fixation. Many to facelifting but do not address the same aging changes as
of these “innovations” provide little long-term benefit when facelifting.
compared with skin undermining, and expose the patient to Patients have individual aging patterns determined by
more risk. The trends in facelifting at the present time are best genetics, skeletal support, and environmental influences
summarized as follows: (Figure 47.1). Some combination of the following, however,
will occur in every patient (those characteristics improved
1. Volume versus tension—Placing tension on the skin is an
by facelifting are in bold—a minority of the changes
ineffective way of lifting the face and is responsible for the
enumerated):
“facelifted” look and for unsightly scars and distortion of
the facial landmarks such as the hairline and ear. The cur- 1. Forehead and glabellar creases
rent trend is toward redistributing, or augmenting, facial 2. Ptosis of the lateral eyebrow
volume, rather than flattening it with excessive tension. 3. Redundant upper eyelid skin
The redraping of skin flaps in facelifting is more of a rota- 4. Hollowing of the upper orbit
tion than it is a direct advancement under tension. 5. Lower eyelid laxity and wrinkles
2. Less invasive—Some of the more “invasive” techniques 6. Lower eyelid bags
have not yielded benefits in proportion to their risk. This, 7. Deepening of the nasojugal groove and palpebral-malar
combined with the public demand for rapid recovery, has groove
led to simplified procedures. It is the author’s impression, 8. Ptosis of the malar tissues
however, that the pendulum has swung back somewhat 9. Generalized skin laxity
away from the least invasive procedures because of inad- 10. Deepening of the nasolabial folds
equate correction of aging changes with these less invasive 11. Perioral wrinkles
techniques. The author tends to employ a high, extended 12. Downturn of the oral commissures
superficial musculoaponeurotic system (SMAS) procedure 13. Deepening of the labiomental creases
with open treatment of the submental region in the major- 14. Jowls
ity of patients, a procedure that lies toward the invasive 15. Loss of neck definition and excess fat in neck
end of the facelift spectrum. 16. Platysmal bands
501
surgery, and smoking and drinking habits. The most com-

mon complication of facelifting is a hematoma and therefore
the history focuses on factors that predispose to postopera-
tive bleeding, specifically hypertension and medications that
affect clotting. Surgery is not performed until the patient has
been off of aspirin for 2 weeks. Facelifting is probably con-
traindicated in patients on warfarin (Coumadin) or clopido-
grel (Plavix), even if they are allowed by their physicians to
stop these medications. At the very least, facelifting on such
patients is performed with extreme conservatism and only
1 after every possible means of eliminating the effects of these
medications has been pursued. Hypertension is probably the
single factor that most closely correlates with postoperative
hematomas; thus, blood pressure must be under strict control.
While consultation with an internist may be helpful in man-
aging blood pressure, the plastic surgeon must be facile with
4
3 2 antihypertensive medications and, in the author’s opinion, be
involved with every decision regarding blood pressure and
blood pressure management in the perioperative period.
5
6 Cigarette Smoking
7 Smoking increases the risk of skin slough, the second most
8 common complication after facelifting.1 Patients are encour-
aged to quit smoking permanently. Cigarette smoking, with
11 10
9 all its deleterious effects on health, and having a facelift to
feel better about oneself are fundamentally contradictory.
12 At the very least, patients should cease smoking 2 weeks prior
to surgery. It is important that smokers know that they will
13
never become “nonsmokers”; that is, the effects of smoking
never totally disappear and are certainly not gone in 2 weeks.
14 Because aesthetic surgery is elective, whenever there is a
question about a preoperative medical condition, the proce-
15 dure is postponed until appropriate consultations are obtained
and all issues settled.
Preoperative Photographs
16 Photographs are essential for at least four reasons: (a) assis-
tance in preoperative planning; (b) communication with
patients preoperatively and postoperatively; (c) intraoperative
decision making; and (d) medicolegal documentation.
FIGURE 47.1. Aging changes in the face. 1. Forehead and glabella
creases. 2. Ptosis of the lateral brow. 3. Redundant upper eyelid skin. Psychological Considerations
4. Hollowing of the upper orbit. 5. Lower eyelid laxity and wrinkles. One of the most difficult challenges for the plastic surgeon is
6. Lower eyelid bags. 7. Deepening of the nasojugal groove. 8. Ptosis deciding which patients are not candidates, on an emotional
of the malar tissues. 9. Generalized skin laxity. 10. Deepening of naso- or psychological basis, for elective aesthetic surgery. Studies
labial folds. 11. Perioral wrinkles. 12. Downturn of oral commissures.
suggest that patients frequently harbor secret or unconscious
13. Deepening of labiomental crease 14. Jowls. 15. Loss of neck defi-
nition and excess fat in neck. 16. Platysmal bands. motivations for undergoing the procedure. A patient may state
that he/she wants to feel better about himself or herself when
the real motivation is to recapture a straying mate (unlikely to
succeed).
Patients who have difficulty delineating the anatomic
A minority of aging characteristics is improved by facelift- alterations desired or in whom the degree of the deformity
ing. Those that are addressed, however, are of fundamental does not correlate with the degree of personal misfortune
importance to the attractive, youthful face. The facelift con- ascribed to that deformity are not candidates for aesthetic sur-
fers another benefit that is more difficult to define. Aging gery. The demanding, intimidating, 50-year-old lawyer who
results in jowls and a rectangular lower face. A facelift lifts states that she does not like her jowls is a far better candidate
the jowls back into the face, augmenting the upper face and than the seemingly docile patient who cannot articulate what
narrowing the lower face, producing the “inverted cone of bothers her and defers to “whatever you think doctor.” The
youth.” This change in overall facial shape from rectangular surgeon will regret proceeding with an operation when his
to heart shaped is subtle but real and is a benefit that no other or her instincts indicate that the patient is an inappropriate
treatment modality can provide. candidate.
Preoperative Preparation Preoperative Counseling

At the time of the preoperative consultation, the patient is
History given written information concerning the planned procedure
The same compulsive medical history that is indicated before that reinforces the verbal information provided.
any surgical procedure is obtained when evaluating a patient In addition to describing to the patient the anticipated
for aesthetic surgery of the face. Specific inquiry is made results of the procedure, it is necessary to point out the areas
regarding medications, allergies, medical problems, previous where little or no benefit is expected. As described above, the

Chapter 47: Facelift 503
nasolabial creases may be softened slightly by a facelift but
will reappear when the swelling disappears. Ptotic subman- Blood Pressure Control
dibular glands preclude a totally clean appearance to the neck. An ideal anesthetic for facelifting would be associated with a
Fine wrinkles around the mouth will require a resurfacing constant blood pressure and no need for vasoactive medica-
procedure. tions to either raise or lower it. Dips in blood pressure treated
with vasoconstrictors, or spikes in blood pressure treated with
Preoperative Instructions vasodilators, are to be avoided if at all possible. Blood pressure
is ideally kept at approximately 100 mm Hg systolic, depend-
Patients are instructed to shower and wash their hair on the
ing on the patient’s preoperative blood pressure. Excessive
night before surgery. On the morning of surgery another
hypotension may obscure bleeding vessels that are best coagu-
shower and shampoo are desirable. At a minimum, the face
lated. Hypertension may be associated with excessive bleed-
is thoroughly washed. Although patients are not allowed to
ing. The anesthesiologist should inform the surgeon of every
eat anything after midnight, they are instructed to brush their
medication administered, and the surgeon should inform the
teeth and rinse their mouths with mouthwash.
anesthesiologist of any increased tendency for bleeding. There
Given that the single most important step in avoiding a
are no secrets in the operating room. The surgeon will be man-
hematoma is control of the blood pressure, patients with any
aging the patient postoperatively so it behooves him/her to
tendency to high blood pressure are given clonidine 0.1 mg by
learn as much as possible from the anesthesiologist about the
mouth preoperatively. Some surgeons administer the drug rou-
particular patient’s blood pressure and response to any agents
tinely to all patients. Clonidine is long-acting, however, and
employed intraoperatively.
may lead to hypotension in healthy patients. Consequently,
this author prefers to use it selectively.
Local Anesthetic Solution
Regardless of the type of sedation/anesthesia chosen, the face
Anesthesia is injected with local anesthetic solution prior to the dissection.
The subjects of anesthesia and which technique is the safest There is some controversy and little definitive data regarding
are poorly understood by patients. A facelift can be safely the maximal amount of local anesthetic that can be used. The
performed under local anesthesia with sedation provided by package insert in the lidocaine bottle states that no more than
the surgeon, under intravenous sedation provided by an anes- 7.5 mg/kg of lidocaine should be administered when given in
thesiologist, or under general anesthesia. If the surgeon is to combination with epinephrine. We know, however, that when
perform the procedure without an anesthesiologist, the patient dilute solutions are used in liposuction of the body, more than
must be completely healthy. The patient is given diazepam 30 mg/kg of lidocaine is safe. There is evidence that the face
(Valium) 10 mg by mouth 2 hours preoperatively and brought differs from the body and that the lidocaine doses used in the
Aesthetic Surgery
to the facility by an escort. Meperidine (Demerol) 75 mg body are too high for the face. It is reasonable to conclude
and hydroxyzine pamoate (Vistaril) 75 mg are administered that doses higher than the 7.5 mg/kg recommended by the
intramuscularly. Once the effect is demonstrable, the patient manufacturer but less than the 30 mg/kg used in the body
is moved to the operating room to initiate the procedure. are probably safe in the face, but this is unproven. Until such
Midazolam (Versed) is given intravenously in 1-mg increments proof exists, plastic surgeons should limit the total dose to
until the patient is sufficiently sedated to tolerate the injections approximately 7.5 mg/kg. In the author’s practice, the author
of local anesthetic solution. Additional midazolam (Versed) is dilutes 500 mg lidocaine (one 50 mL vial of 1% lidocaine,
given as needed throughout the procedure, also in 1-mg doses. which is the approximate maximum dose for a 70-kg patient)
In most cases, however, facelifts are performed with the to whatever volume is necessary to perform the entire proce-
help of an anesthesiologist. If the procedure is to be longer dure, no matter how dilute that solution is.
than 3 hours because of ancillary procedures, or if the patient The most common solution used by the author is 50 mL
has medical problems, then an anesthesiologist is always 1% lidocaine plus 1 mL epinephrine 1:1,000 plus 250 mL
present. normal saline for a final volume of 301 mL and a final solu-
The anesthesiologist decides where on the spectrum from tion concentration of 0.17% lidocaine with epinephrine
conscious sedation to general anesthesia the patient is best 1:300,000.
kept, and it may vary during a procedure. The patient may Because of the dilute nature of the solution used and the
be under general anesthesia, by any definition, during the fact that the total dose of lidocaine does not exceed the manu-
injection of the local anesthetic solution, and conscious dur- facturer’s recommendation, the author usually injected both
ing other phases of the procedure. In other patients, despite sides of the face at the beginning of the procedure, despite
the efforts of the anesthesiologist to provide conscious seda- recommendations by some that only one side should be
tion, the medication will result in loss of the airway, requir- injected at a time. If the patient has an especially heavy neck
ing that the anesthesiologist converts the procedure to general or is a large male patient, the author may inject one side at a
anesthesia. time because the first side will be more time-consuming than
Patients and some other physicians incorrectly believe average.
that patients are safer with “twilight” anesthesia, whatever If the patient is adequately anesthetized, the injection of
that is. Local anesthesia is safe and general anesthesia is usu- the anesthetic solution is rarely accompanied by any change
ally safe, but the least safe anesthetic and the one requiring in heart rate or blood pressure. The surgeon must constantly
the most skill to administer is the “in between” anesthetic keep the injecting needle moving, however, to avoid a large
that patients call “twilight.” Patients who are sedated but intravascular injection of the epinephrine-containing solu-
who do not have an endotracheal tube in place to control tion. If a major change in blood pressure occurs, the surgeon
the airway are more likely to have airway problems than a and anesthesiologist must assume that an intravascular injec-
patient who is completely asleep with the ventilation con- tion has occurred and must act quickly to limit the extent of
trolled by the anesthesiologist. Many patients who undergo hypertension.
facelift procedures believe they are receiving “sedation,”
but they are really receiving intravenous, general anesthe-
sia without an endotracheal tube. There is nothing wrong Facelift Anatomy
with the technique in the hands of an expert, but patients If either skin undermining alone or subperiosteal undermin-
should be disabused of the notion that it is safer than general ing alone is performed, the surgeon can, to some extent,
anesthesia. ignore the anatomy. These two planes of dissection are safe.

Manipulation of the tissues between these two planes, how-

ever, necessitates an understanding of and constant attention Facial Nerve
to the anatomy to avoid complications. If the surgeon remembers that the facial nerve branches
innervate the respective facial muscles via their deep sur-
Anatomic Layers faces, the safe planes of dissection become obvious.
Dissection in the subcutaneous plane, superficial to the
There are five layers of critical anatomy: skin, subcutaneous fat,
SMAS–muscle layer, is safely performed anywhere in the
the SMAS–muscle layer, a thin layer of transparent fascia, and
face, whether it is the temporal region, cheek, or neck.
the branches of the facial nerve (Figure 47.2). These five layers
Dissection deep to the SMAS, superficial to the facial nerve
are present in all areas of the face, forehead, and neck, but they
branches, requires care.
vary in quality and thickness, depending on the anatomic area.
There are three to five frontal (or temporal) branches
The first two layers, the skin and subcutaneous fat, are
of the facial nerve that cross the zygomatic arch and inner-
self-explanatory. The third layer (SMAS) is the most heteroge-
vate the frontalis muscle, orbicularis oculi, and corrugator
neous.2 It is fibrous, muscular, or fatty, depending on the loca-
muscles via their deep surfaces.3 Because the layers of anat-
tion in the face. The muscles of facial expression are part of
omy, although present, are compressed over the arch, these
the SMAS layer (e.g., frontalis, orbicularis oculi, zygomaticus
branches are vulnerable to injury in this region. Dissection in
major and minor, and platysma). In the temporal region, this
this region can either be performed superficial to the nerve
layer is not muscular but is fascial in quality and is represented
branches in the subcutaneous plane, or deep to the branches
by the superficial temporal fascia (or temporoparietal fascia).
on the surface of the temporalis muscle fascia (deep temporal
The fourth layer consists of a layer of areolar tissue that is
fascia).4
not impressive in thickness or strength, but is always present
The zygomatic branches innervate the orbicularis
and is a key guide to the surgeon as to the location of the facial
oculi and zygomaticus muscles. One must remember that
nerve branches. In the temporal area, this layer is known as the
although the facial nerve branches travel deep to the SMAS
innominate or subgaleal fascia; in the cheek, it is the parotid–
layer, at some point these branches turn superficially to
masseteric fascia; and in the neck, it is the superficial cervical
innervate the overlying muscles. Any dissection in the sub-
fascia. Once under the SMAS, the facial nerve branches can
SMAS plane in the cheek, whether as part of a compos-
be seen through this fourth layer. If the layer is kept intact,
ite rhytidectomy or standard dissection of the SMAS as a
it serves as verification to the surgeon that he or she is in the
separate layer, necessitates a change of surgical planes at
correct plane of dissection. If a nerve branch is encountered
the zygomaticus major muscle to avoid transection of the
without this fascial covering, the surgeon must be aware that
branch to this muscle. The dissection plane changes from
the dissection is too deep and nerve branches may have been
sub-SMAS to subcutaneous by passing over the superficial
transected. Just as it is convenient, but not totally accurate,
surface of the zygomaticus major and thereby preserving its
to think of the galea–frontalis–temporoparietal fascia–SMAS–
innervation.
orbicularis oculi–platysma as a single layer, it is useful to think
The buccal branches lie on the masseter muscle and are
of the subgaleal fascia–innominate fascia–parotid/masseteric
easily visualized through the parotid–masseteric fascia. Some
fascia–superficial cervical fascia as a single layer.
buccal branches merge with branches of zygomatic origin to
The fifth layer is the facial nerve, which is discussed in
innervate the procerus muscle and provide additional innerva-
detail below.
tion of the corrugator muscle. Consequently, the corrugator
muscle receives innervation from the frontal, zygomatic, and
Skin buccal branches.
Subcutaneous fat Earlier publications indicated that the marginal mandib-
Temporoparietal fascia/
frontalis muscle ular branches were located above the inferior border of the
Innominate fascia mandible in many cases. More recent studies demonstrate
Frontal branch-facial nerve
Deep temporal fascia
that, in fact, these branches are always located caudal to the
Temporalis muscle inferior border of the mandible. The cervical branches inner-
vate the platysma muscle.
Anatomic studies indicate that there are fewer crossover
Skin
Subcutaneous fat communications between the frontal branches and marginal
SMAS/Zygomaticus major m. mandibular branches, which helps to explain why injuries
Parotid/masseteric fascia
Zygomatic branch-facial n. to these nerves are less likely to recover function in their
respective muscles than injuries to the zygomatic or buccal
Parotid branches.
gland
Retaining Ligaments
In at least two areas of the face the anatomic layers are con-
densed and less mobile with respect to each other. These “liga-
ments” are areas where the skin and underlying tissues are
Skin relatively fixed to the bone.5 The zygomatic ligament (previ-
Subcutaneous fat
ously known as the McGregor patch) is located in the cheek,
Platysma m. anterior and superior to the parotid gland, and posteroinferior
Cervical fascia
Marginal mandibular
to the malar eminence. The mandibular ligament is located
branch - facial n. along the jaw line, near the chin, and forms the anterior bor-
der of the jowl.
The retaining ligaments restrain the facial skin against
FIGURE 47.2. The anatomic layers of the face. Although the quality gravitational changes at these points. The descent of tissues
of the layers differs in various areas of the face, the arrangement of adjacent to these points forms characteristic aging changes
layers is identical. The facial nerve (cranial nerve [CN] VII) branches such as the jowl. In addition, some surgeons feel that the liga-
innervate their respective muscles via their deep surfaces. ments must be released in order to redrape tissues distal to
these points.

Platysma Muscle Subcutaneous Facelift

Although the platysma muscle is a component of the previ- The original facelift consisted of subcutaneous undermining
ously discussed SMAS/muscle layer, it deserves special atten- only. The technique is still useful for an occasional patient,
tion because of its clinical importance. The medial borders of but more importantly, it is a component of other techniques
the two muscles decussate to a variable degree in the midline such as the SMAS technique, extended SMAS technique, and
of the neck, helping to explain the variability of aging pat- the SMASectomy–SMAS plication techniques.
terns in the neck.6 The medial borders of the muscles tend to Incisions are designed to avoid distortion of the hairline
become redundant with age and contribute to the appearance and ear and to maximally disguise the final scars (Figure 47.3).
of bands in the submental region. The goal is a scar that is so inconspicuous that one has to look
for it. Although this is not always the case given the variable
Malar Fat Pad and unpredictable nature of wound healing, it is always the
The malar fat pad is part of the subcutaneous layer of the face. goal. If the patient has never had surgery before and has a nor-
It is superficial to the SMAS layer represented in this region by mal hairline and sideburn, the incision is initiated within the
the zygomaticus muscles. The malar fat pad appears to descend hair, just above the ear. In patients with previous facelifts, the
with age, leaving a hollow infraorbital region behind it and cre- sideburn may already be significantly raised and posteriorly
ating larger nasolabial folds and deeper nasolabial creases. Each displaced, and an incision within the hair will result in fur-
of the major facelift techniques includes a method to mobilize the ther distortion of the sideburn. These patients are candidates
malar fat pad and restore volume to the upper part of the face for an incision along the anterior hairline. Patients with thin,
and malar region. As is discussed below, the extended SMAS sparse hair may be candidates for the pre-hairline incision,
technique involves mobilizing the malar pad in continuity with even if it is the first procedure they have ever had. A transverse
the SMAS layer. Other techniques involve mobilizing and repo- incision is also designed just below the sideburn to allow addi-
sitioning the malar pad independent from the SMAS dissection. tional excision of cheek skin during the redraping portion of
the procedure, without raising the sideburn any higher than
Buccal Fat Pad desired by the surgeon.
The incision proceeds caudally along the junction of the
The buccal fat pad is deep to the buccal branches of the facial ascending crus of the helix and the cheek. The eventual scar
nerve, anterior to the masseter muscle, and superficial to the tends to migrate forward slightly and therefore should be
buccinator muscle. Access to the buccal fat pad is achieved by placed 1 to 2 mm on the ear side of the ear–cheek junction.
performing a sub-SMAS dissection in the cheek and spreading The author’s preference is to make the incision in the same
it between the buccal branches of the facial nerve or through location in men. The incision is continued either at the pos-
the mouth, by a stab wound in the buccinator muscle. Despite
Aesthetic Surgery
terior margin of the tragus (retrotragal) or in the pretragal
occasional indications to remove the fat pad in patients with region, usually in a natural skin crease. Patients, and many
very full faces, removal of cheek fat tends to ultimately make surgeons, erroneously believe that the incision along the pos-
the patient look older. As a general rule, rejuvenation of the terior aspect of the tragus is always preferable. In fact, this
face involves redistribution, not removal, of fat. incision frequently results in distortion of the tragus and is
more likely a “tip-off” to a facelift than the preauricular inci-
Great Auricular Nerve sion. The novice surgeon is encouraged to perfect the pretra-
The facelift operation inevitably disrupts branches of sensory gal incision prior to tackling retrotragal incisions.
nerves to the skin. Normal sensibility always returns eventu- When the retrotragal incision is made, the cheek skin is
ally but numbness may persist for months postoperatively. redraped over the tragus. The normal tragus is covered with
The only named sensory nerve that is important to preserve thin, shiny, hairless skin (even in most men), and cheek skin is
is the great auricular nerve. With the head turned toward the frequently not the ideal covering. The author tends to use the
contralateral side, the great auricular nerve crosses the superfi-
cial surface of the sternocleidomastoid muscle 6 to 7 cm below
the external auditory meatus.7 At this point it is 0.5 to 1 cm
posterior to the external jugular vein. The vein and nerve are
deep to the SMAS–platysma layer, except where the terminal
branches of the nerve pass superficially to provide sensibility
to the skin of the earlobe. Transection of the great auricular
nerve will result in permanent numbness of the lower half of
the ear and may result in a troublesome neuroma.
Tear Trough
The tear trough or nasojugal groove is an oblique indenta-
tion running inferiorly and laterally from the medial canthus.
This groove is a subject of much attention at the present time.
Although it is probably better included in a discussion of eye-
lid surgery, it deepens with age and is a frequent complaint of
patients interested in facial aesthetic surgery (see Chapter 46).
FIGURE 47.3. Standard facelift incision. Regardless of the technique
Facelift procedures do not address the tear trough. Redraping chosen, some form of this incision is employed. In the temporal region,
of orbital fat or microfat grafting/filler injection is required. the incision is shown within the hair. In patients with extremely thin
hair, previous facelifts, or if performing the minimal access cranial
Facelift Techniques suspension (MACS) lift, the incision is made along the anterior side-
burn and temporal hairline, rather than as shown here. In this illustra-
and Alternatives tion, the incision is shown along the posterior margin of the tragus.
In men, and in women with oily or hairy preauricular skin, an incision
The facelift procedure can be performed in the subcutaneous in the preauricular crease may be preferable. In the short-scar technique,
plane, the sub-SMAS (deep) plane, the subperiosteal plane, or the incision is terminated at the bottom of the earlobe or just behind it,
a combination of the above. Each of the most commonly used and the entire retroauricular portion of the incision is eliminated.
techniques is described in the following sections.

retrotragal incisions in young women with thin, hairless cheek not to redrape the transverse neck creases up on to the face.
skin. In men, and in women with irregular pigmentation in This creates another bizarre “facelift look.” Once these two
the preauricular region, thick, oily cheek skin, or with furry tension-bearing sutures have been placed, the flap is incised so
cheeks, the incision is made in a preauricular crease. The key that the ear can barely be withdrawn from beneath the flap.
to an invisible scar is absolute lack of tension, not its location. The cheek flap is tucked up under the earlobe, leaving no pos-
If the retrotragal incision is chosen, the initial undermining is sibility that the scar will be visible. The excess skin in front
performed slowly and with care to avoid any damage to the of and behind the ear is trimmed with extreme conservatism
tragal cartilage. so that there is absolutely no tension on the closure. There
The incision passes beneath the earlobe and extends into should be almost no need for sutures because the coaptation
the retroauricular sulcus. The incision is placed slightly up on of the skin edges is so precise. If a retrotragal incision is used,
the ear because it is also prone to migration and is best hid- the tragal flap is cut so that it is redundant in all directions.
den if the final scar rests in the depth of the sulcus. The inci- The skin over the tragus tends to contract and, if there is not
sion traverses the hairless skin in the retroauricular region at sufficient excess, will pull the tragus forward, opening the
a point sufficiently high to be invisible if the patient were to view to the external auditory canal.
have short hair or be wearing hair in ponytail. The incision Attention is then turned to the excess skin behind the ear
then extends along the hairline for a short distance (1.5 cm) and the realignment of the hairline. If the skin is redraped in
and passes back into the occipital scalp in the form of an “S” the direction of the transverse neck creases only, there will
or an inverted “V.” When the neck skin is redraped, it is diffi- be a large step off in the hairline. On the other hand, if the
cult to completely avoid a step-off in the hairline, but the sur- hairline is simply realigned, there will be too much extra skin
geon should struggle to limit that step-off regardless of how behind the ear and visible pleating and bunching will occur.
much time it adds to the procedure. Step-offs in the hairline An incision is made along the occipital hairline from the point
that are greater than 1 cm can be obvious in certain hairstyles where the incision crosses it, which allows the hairline on the
and are a dead giveaway that a facelift has been performed. flap to be readjusted forward. If carefully performed, the hair-
If the incision extends too far down the hairline before passing line step off can be limited to 1 cm or less which is acceptable.
into the scalp, this step-off, however small, is more noticeable. A closed suction drain is left in the neck in the most depen-
Hence, the recommendation to limit the hairline portion to dent portion of the incision. Since the author tends to open the
1.5 cm. neck in most patients, these drains extend across the midline,
one at the lowest possible point in the neck and the other in
Undermining. Once the incisions are made, undermining is the submental region near the submental incision. While stud-
performed. The extent of undermining depends on the degree ies show that drains do not decrease the incidence of hema-
of aging changes, the area where these changes exist, the sur- toma, this author would not consider doing the procedure
geon’s instinct about the health and vascularity of the tissues, without drains given the large amounts of bloody fluid that
and the manipulation planned for the deeper tissues. The may drain in the first few hours.
various options for deep-tissue manipulation are summarized Regardless of the technique chosen for facelifting, the inci-
below. Depending on the extent of undermining performed, sions and the final redraping are critical. If the incisions are
a fiberoptic retractor may provide useful visualization. Many performed properly, the redraping is appropriate, and the
experienced surgeons undermine using a “blind” technique, patient experiences uncomplicated wound healing, then it is
gauging the depth of the dissection by feel and by watching frequently difficult for the surgeon or the hairdresser to find
the skin as the knife or scissors move beneath it. The author the scars.
prefers—and strongly recommends—that dissection be per-
formed under direct vision. The tissues involved are thin and
it only takes a minor slip of the scissor tip to cut a branch
Superficial Musculoaponeurotic
of the facial nerve and result in permanent disability for the System Dissections
patient. Some surgeons also find that countertraction applied
by an assistant facilitates the dissection. The neophyte should Traditional Superficial Musculoaponeurotic System
be aware that the stronger the countertraction, the thinner Dissection. SMAS dissections vary in extent. The “tradi-
the skin flap that is usually dissected. Although one wants to tional” SMAS dissection involves a transverse incision in the
avoid dissection that is too deep, a flap that is too thin is also SMAS at a level just below the zygomatic arch and an inter-
not desirable. secting preauricular SMAS incision just in front of the ear that
extends over the angle of the mandible and along the anterior
Redraping. After all the deep-tissue manipulations and jaw- border of the sternomastoid muscle. The SMAS is elevated off
line contouring have been performed, the undermined skin the parotid fascia, a separate anatomic structure, in continuity
flap is redraped in a cephaloposterior direction. Redraping/ with the platysma muscle in the neck. The end point of the
trimming/insetting of skin flaps is the least discussed and dissection is just beyond the anterior border of the parotid
potentially the most important part of the entire procedure. gland. The SMAS over the parotid gland is relatively immo-
At the least, this portion of the procedure allows the surgeon bile, compared with the SMAS beyond the gland. If dissection
to “do no harm” but realigning the hairline and not distorting is not performed beyond the gland, insufficient release occurs,
the ear. The transverse incision is made below the sideburn. and tension on the SMAS is less efficiently transmitted to the
The superior flap, with the sideburn on it, is fixed at the level jowls and neck. The SMAS–platysma flap is rotated in a ceph-
of the ear–cheek junction—and no higher! The cheek skin aloposterior direction, trimmed, and sutured to the immobile
is redraped as vertically as possible while making sure there SMAS along the original incision lines. The platysma portion
will be no visible dog ear anterior to the transverse incision. of the flap is sutured to the tissues over the mastoid, increasing
The author redrapes the skin in the desired direction and then the definition of the mandibular angle.
adds enough posterior vector to that traction that the dog ear The traditional SMAS dissection is effective for minimizing
ends at the anterior extent of the tragus. A triangle of hairless, the jowls and highlighting the mandibular angle.
excess cheek skin is excised and the cheek is fixed under some
tension with a single suture at the top of the ear, in such a way Extended Superficial Musculoaponeurotic System
that there is no dog ear at the anterior end of the transverse Dissection. The extended SMAS dissection differs in two
incision. The neck skin is redraped more horizontally, paral- ways from the traditional SMAS dissection: the level of the
lel to the neck creases. A second suture is placed under some transverse incision and the anterior extent of the dissection.
tension at the apex of the retroauricular incision. Care is taken The transverse incision is made above the zygomatic arch.

Although concern has been expressed about the safety of this
maneuver, it can be performed safely on a consistent basis
with appropriate training. The same intersecting incision is
made in the preauricular region and along the sternocleido-
mastoid muscle. The flap is elevated well beyond the ante-
rior end of the parotid. The zygomaticus major is visualized.
Dissection continues over the superficial surface of this mus-
cle to avoid its denervation (Figure 47.4). The large SMAS–
platysma flap is rotated in a cephaloposterior direction,
trimmed, and sutured along the original incision lines. The
platysma is sutured to the mastoid periosteum.
The extended SMAS has the advantage of providing malar
augmentation as well as an effect on the jowls and neck.
As mentioned above, the author employs this technique in the
majority of patients.
Superficial Musculoaponeurotic
Systemectomy and SMAS Plication Platysma
sutured to
Superficial Musculoaponeurotic Systemectomy. Baker mastoid
described the lateral SMASectomy procedure,8 and some vari- periosteum
ation of this technique is probably the most frequently per-
formed facelift technique in the United States today. A strip of SMASectomy
SMAS is excised on an oblique line between the angle of the
mandible and lateral canthus (Figure 47.5). The mobile SMAS
is sutured to the immobile SMAS, accomplishing all the ben-
efits of both the traditional and extended SMAS procedures.
The platysma is sutured to the mastoid in a manner identical FIGURE 47.5. SMASectomy. The oblique strip of SMAS to be
to a formal SMAS dissection. excised is shown, extending from the angle of the mandible to the lat-
eral canthal region. The platysma muscle in the neck is sutured to the
Superficial Musculoaponeurotic System Plication. In mastoid periosteum. The mobile SMAS anterior to the SMASectomy
thin patients, the SMAS can be plicated along the same line, is advanced to the immobile SMAS. This illustration shows the SMAS
Aesthetic Surgery
without removing any tissue. Although it may be necessary to being advanced in an oblique cephaloposterior direction. In fact, the
remove a small amount of redundant SMAS over the angle of oblique SMASectomy defect can be closed in a vertical fashion (imag-
the mandible, the rest of the tissue is preserved. With the cur- ine the black arrows pointing vertically). The more vertical the clo-
sure, the greater the effect on the neck.
rent trend of fat preservation, this is an appealing alternative.
In heavier faces, the SMASectomy alternative is preferable.
The technique has enormous advantages. It is simple in

design, can be modified to suit different facial shapes, and
is less time-consuming than other techniques. It provides the
malar augmentation of the extended SMAS with the more effi-
cient effect on the jowls of the traditional SMAS procedure.
It has the theoretical additional benefit that the SMAS is not
undermined and thus not subject to the devascularization and
atrophy that can occur when SMAS flaps are elevated. The
disadvantage is that injury to buccal branches of the facial
nerve can occur if sutures are placed too deeply.
Deep Plane or Composite Rhytidectomy

SMAS
Hamra9 described the deep plane facelift that he modified to its
incision
current iteration, the composite rhytidectomy. This brief descrip-
tion does not do the technique justice, but does outline the key
points. The SMAS and skin are dissected together as a single flap,
rather than independently, as in the techniques described above.
The benefit of the procedure is that theoretically the flap is better
vascularized and less likely to slough. The technique, as Hamra
performs it, includes a superomedial elevation of the malar tis-
Zygomaticus sues and orbicularis oculi muscle and a brow lift with a similar
major m. superomedial vector. The disadvantage of the technique is the
SMAS- magnitude of the procedure and the prolonged recovery period.
platysma It is author’s opinion, never having performed this proce-
flap dure myself, that the benefits of the procedure do not justify
the invasiveness, risk, and prolonged recovery associated with
the procedure.
FIGURE 47.4. Extended superficial musculoaponeurotic system
(SMAS) dissection. The SMAS flap is elevated, revealing the buc- Rejuvenation of the Neck
cal branches of the facial nerve lying on the surface of the masseter
muscle. The dissection passes over the superficial surface of the zygo- The procedures outlined above have a beneficial effect on
maticus major, preserving its innervation. the neck. In some patients, however, additional procedures
are required, in combination with the above, to provide

better definition to the neck. Some of these procedures are neck after facelifting. The question of whether excision of the
controversial. glands is worth the risk of bleeding and nerve injury has not
been answered. Sullivan reports an acceptably low complica-
Submental Dissection and Platysmaplasty. The tion rate for submandibular gland resection associated with
SMASectomy procedure, with its efficient elevation of the jowl facelifting.
and submental tissues, has decreased the need for submental The author has not had a complication from submandib-
incisions and open-neck procedures. As mentioned above, the ular gland resection accompanying a facelift, but no longer
closure of the SMAS (or the plication of the SMAS if no tissue believe that the benefits are worth the additional time required
is removed) is performed at a shorter distance from the jowls or the risk of bleeding and nerve injury.
and submental region, and this has a profound effect on those
areas. There are, however, patients with enough redundant Digastric Muscle Resection. Connell recommends shav-
skin, excess fat, and redundant platysma who still require a ing of the anterior belly of the digastric muscles to further
formal submental dissection. define the cervicomental angle. The author believes that this
In these patients, an incision is made just caudal to the creates an excessively sculpted, overdone look in many necks
submental crease. This author performs this portion or and is best avoided.
the procedure first, prior to the lateral incisions/redraping
described above. Subcutaneous undermining is performed. Full-Width Platysma Transection. The single most
A judgment is made about defatting of the platysma mus- powerful way to create a well-defined neck is to perform
cle, as mentioned below. An independent decision is made full-width transection of the platysma muscle across the
regarding removal of subplatysmal fat. The medial borders neck (Figure 47.7C). The muscle is divided under direct
of the platysma muscle are plicated in the midline using bur- vision at least 6 cm below the inferior border of the
ied interrupted sutures (Figure 47.6). Compulsive attention mandible.
to both hemostasis and perioperative blood pressure control The author only employed this technique in the most dif-
is essential to prevent a hematoma when this larger dead ficult necks, because irregularities and an overoperated look
space is created. can be created and there is additional risk of hematoma and
prolonged induration in the neck.
Corset Platysmaplasty. Feldman described the corset pla-
tysmaplasty. The medial borders of the platysma are plicated
with a continuous monofilament suture that is run up and
down the midline of the neck until the desired contour has
been achieved. No manipulation of the lateral border of the
platysma is performed.
The author has had better results with buried, interrupted
sutures, which cause less bunching of the muscle. The author
also prefers to combine the midline platysmaplasty with lat-
eral tightening of the platysma as described above under
“Superficial Musculoaponeurotic System Techniques” and
“Superficial Musculoaponeurotic Systemectomy.”
Defatting of the Neck. A guiding principle is preservation

of facial fat. This principle also applies to the neck but less
so. Many patients benefit aesthetically from cervical defat-
ting. The surgeon is meticulous about avoiding overdefatting
because unsightly adhesions between the skin and platysma A B
can occur. The same applies to the removal of subplatysmal
fat. Overskeletonization of the neck is one stigmata of an
amateurish facelift.
Submandibular Glands. The presence of large and/or

ptotic submandibular glands prevents the creation of a clean
C
FIGURE 47.7. Lateral platysma modification. Alternatives include
A (A) advancement of lateral platysma parallel to mandibular border
with suture fixation to the mastoid periosteum; (B) partial transection
C of lateral platysma with similar fixation; and (C) full-width transec-
tion of platysma with similar suture fixation. Most SMAS flap and
B SMASectomy/SMAS plication procedures include tightening of the
lateral platysma. The most common alternative is (A). Alternative
FIGURE 47.6. Treatment of medial platysma and platysma bands. (B) may provide additional contouring to the mandibular angle in
Alternatives include (A) defatting of the anterior platysma without patients who require increased definition. Alternative (C) is the single
muscle modification; (B) midline platysmaplasty with wedge excision; most powerful technique to increase neck definition but is associated
and (C) resection of platysma bands without midline approximation. If with a higher incidence of neck irregularities, adhesions between the
a submental incision is elected, option (B) is usually the best alternative. skin and muscle, and an overcorrected appearance in some patients.

in patients of both sexes. Some men may have a tremendous
Short-Scar Technique amount of excess skin in the neck. When this is redraped into
Baker described the “short-scar” procedure, in which all the the retroauricular area, care is required to avoid a large step-
elements of the subcutaneous dissection with SMASectomy off in the hairline. The previously reported higher incidence of
and lateral platysma tightening are performed, but the skin hematomas in men than in women seems to be largely related
incision is limited to the preauricular portion. It is useful in to blood pressure. When blood pressure is controlled, the
younger patients with minimal excess neck skin. The inci- hematoma rates are very similar.
sion is not extended beyond the earlobe, thereby avoiding the
postauricular incision and the extension into the hairline. The Barbed Sutures
technique relies on vertical redraping of the skin. Bunching of
In an effort to make facelifting quicker and less invasive, sev-
skin behind the earlobe often occurs but improves with time.
eral authors describe the use of barbed sutures in facelift-
Care is taken, however, to distribute the bunching as much
ing. The longevity of the result does not compare favorably
as possible because patients will complain about it, even if it
with traditional methods. At the present time, the sutures are
eventually improves. There is no question that the absence of
made of polypropylene and are permanent. Concerns have
the retroauricular incision is an advantage. While the retro-
been raised regarding the safety of permanent barbed sutures
auricular incision in most patients having traditional facelift
in the subcutaneous position. Long-term data are not yet
incisions heals well and is sometimes virtually invisible, there
available.
are patients in whom this is not the case and the scar is visible,
slightly hypertrophic, and, despite the surgeon’s best efforts,
there is a slight step-off in the occipital hairline. Postoperative Care
Although in most cases the patients do not require hospital-
Minimal Access Cranial Suspension Lift ization, ideally they do have an experienced nurse to moni-
Tonnard described the minimal access cranial suspension tor them closely. Patients are instructed to rest with the head
lift, which employs purse-string sutures in the SMAS struc- elevated for the first several postoperative days. Blood pres-
tures and malar fat pad with vertical suspension.10 The verti- sure is monitored and kept under strict control for the first
cal nature of the lift requires an incision along the anterior 24 hours. The drains are usually removed on the first post-
sideburn and anterior temporal hairline. The procedure can operative morning, and showering and shampooing are
be performed in combination with midline platysmaplasty encouraged at that point. Pain medication is usually required,
to improve the results in the neck. Excess skin may appear especially at night, for several days. Oral antibiotics are gen-
below the earlobe, which may require posterior cervicoplasty erally prescribed, although there is no evidence that they are
to correct. beneficial. Studies show that steroids are of no benefit in
Aesthetic Surgery
reducing swelling. Sutures are removed progressively begin-
Subperiosteal Facelift ning on the fourth postoperative day. All the sutures are usu-
ally gone by the eighth postoperative day.
Originally described by Tessier, Heinrichs and Kaidi11 have Swelling and bruising are variable. Depending on the ancil-
reported a large series of subperiosteal facelifts. The proce- lary procedures performed, patients look reasonably accept-
dure is designed to rejuvenate the upper and middle thirds of able after 1 week, good with makeup after 2 weeks, and able
the face. Subperiosteal undermining is performed through the to attend social functions after 3 weeks. An occasional patient
following incisions in various combinations, depending on the will have prolonged bruising that may limit activity for a lon-
surgeon: coronal incision or endobrow approach, subciliary ger period of time.
incision, or an upper buccal sulcus incision. Hester et al.12
have described a subperiosteal midface lift using endoscopic
assistance through the lateral aspect of a lower eyelid incision. Patient Safety and
The author is not impressed with the effectiveness or the Complications
longevity of subperiosteal lifts, but surgeons who have exten-
sive experience with the technique probably have better Despite constant attention to detail, complications do occur.
results. Postoperative swelling can be profound after subperi- The most common problems and methods to prevent and
osteal undermining. The author believes that the closer one to treat such complications are summarized in the following
is to that which is being lifted (i.e., the skin), the more effec- sections.13
tive the lift and considers subcutaneous undermining the gold
standard. Hematoma
Hematomas are by far the most common complication after
Secondary Facelifting facelifting and vary from large collections of blood that
threaten the survival of the skin flaps (and even compromise
The goals of secondary facelifting are to (a) relift the face and
the airway) to small collections that are evident only when
neck, (b) remove the primary facelift scars, and (c) preserve
facial edema has subsided. Most major hematomas occur dur-
maximum temporal and sideburn hair. Dissection is usually
ing the first 10 to 12 hours postoperatively.
easier than the primary dissection. Intraoperative bleeding and
The most common presentation of a hematoma is an
postoperative hematomas are also less frequent. The amount
apprehensive, restless patient experiencing pain isolated to
of skin excised at a secondary lift is much less than at the pri-
one side of the face or neck. Because localized and worsening
mary procedure. For this reason pre-excision of skin is never
pain is unusual following an uncomplicated facelift, it must
performed for a secondary facelift. The risk of nerve injury
be regarded as a sign of hematoma until proven otherwise.
may be slightly higher in secondary facelifts, however. The
Rather than providing analgesics for pain relief, the surgeon
first procedure may have distorted the anatomy and the tis-
or nurse removes the dressing immediately to permit examina-
sues may be abnormally thin.
tion. In addition to causing skin flap ischemia, a large expand-
ing hematoma under tight skin flaps has the potential to cause
Facelifting in Men respiratory compromise.
The shorter hairstyles of men are less forgiving than the lon- The treatment for a hematoma of any degree is evacua-
ger hairstyles of women. Male faces tend to be larger and tion. If the collection is rapidly enlarging or if the flaps appear
dissection is more time-consuming. Modified incisions have compromised, then sutures may be removed at the bedside
been described for men, but the author uses the same incision for immediate relief of some of the pressure. Depending on

the extent of the bleeding, the emotional state of the patient, can be distressing to the patient and prevent the patient from
and the availability of an operating room, the hematoma is wearing certain hairstyles. If the skin necrosis occurs in the
either evacuated at the bedside or in the operating room. The preauricular area, it is a devastating complication.
important thing is to get the blood out. If formally explored, a The incidence of skin necrosis is 1% to 3%. The most
specific bleeding point will rarely be found. If evacuated at the likely causes of skin slough are (a) unrecognized hematomas,
bedside, the patient must be sedated and the blood pressure (b) a skin flap that is too thin or is damaged during flap dis-
reduced. Catheters are inserted and the hematoma is evacu- section or burned with electrocautery, (c) excessive tension on
ated. The region is irrigated with saline until clear, and then wound closure, (d) cigarette smoking, and, possibly, (e) dehy-
with a 0.25% solution of lidocaine containing epinephrine dration. There is no question that smoking increases the risk
1:400,000. Gentle pressure is placed on the flap for 20 minutes. of skin slough. It is author’s impression that patients who are
If this method does not result in complete removal of the well hydrated tend to heal faster with a lower incidence of
hematomas, then the facelift wound is formally explored skin slough.
under adequate anesthesia to permit visualization and precise If the skin appears compromised at any point in the post-
control of any bleeding. operative period, antibiotic ointment or silver sulfadiazine
The reported incidence of hematomas requiring evacuation (Silvadene) cream is applied. The surgeon would much rather
ranges from 0.9% to 8.0%, but is approximately 3% to 4% apply ointment to an area that turns out to be a partial-
when all studies are combined. Because most patients in the thickness injury than miss an area that is dying where some of
reported studies were women, this 3% to 4% range represents the damage could be limited by aggressive wound care.
the incidence in female patients. Early studies demonstrated a The treatment of skin slough is not surgical; it is conserva-
hematoma rate in men of 7% to 9%, or twice that of women. tive wound care. Areas of necrosis will contract dramatically
More recent studies suggest that this difference between the and eventually epithelialize. The final scar, although perma-
two sexes is at least partly a consequence of blood pressure. nent, is almost always better than would be anticipated from
When blood pressure in male patients is compulsively con- the initial wound appearance. If a secondary facelift is per-
trolled, the incidence falls precipitously, approaching that of formed in an attempt to remove the scars, minimal excess skin
women. will be present, and it may not be possible to remove scar that
As mentioned in the “Preoperative Preparation” and is more than 1 cm from the previous incision.
“Anesthesia” sections, blood pressure control is the single
most important preventative measure. Ranking next in impor- Nerve Injury
tance is the avoidance of medications that interfere with clot- Injury to a branch of the facial nerve (cranial nerve VII) is
ting or coagulation. Finally, every attempt is made to prevent the complication most dreaded by patients. Motor nerve
vomiting, coughing, anxiety, or pain. injury occurs in 0.9% of patients who receive subcutaneous
Small hematomas of 2 to 20 mL that are not apparent undermining only, but is more common with dissection of
until edema begins to subside are a totally different entity the SMAS, either as an independent layer or in a composite
and occur in 10% to 15% of patients. Initially, an area of rhytidectomy. Many nerve injuries are temporary, presumably
firmness is palpable followed by ecchymosis in the overly- the result of traction or cautery. A nerve that has been tran-
ing skin. Although somewhat controversial, it is the author’s sected will not recover function. If the surgeon is aware that a
opinion that every effort should be made to evacuate even branch has been cut, then immediate intraoperative microsur-
the small hematomas. A syringe and a large-bore needle are gical repair is mandated. It is more likely, however, that nerve
used. Aspiration is repeated every few days until the collec- injury is not recognized during surgery, and the surgeon and
tion is completely gone or no further liquid can be withdrawn. patient are placed in the difficult position of waiting for return
Repeated aspiration attempts are especially important in the of function. Injuries to buccal branches tend to improve more
neck where larger collections can be hiding. If the blood is than those in the frontal and marginal mandibular territories,
not evacuated, the patient may develop a firm, woody, wrin- presumably because of greater degrees of connections between
kled mass that takes months to resolve, and in some cases branches in those areas.
leaves permanent changes in the skin. Compulsive attention Transient numbness of the cheeks and neck skin is a result
to hemostasis, blood pressure control, drain placement, and of interruption of the small sensory branches during skin
postoperative management is required to obtain the best pos- undermining and is unavoidable. Sensibility always recov-
sible results in the neck. Rest-on foam applied to the neck as ers although it may take months to do so. Injury to the great
the original dressing may also be of benefit. auricular nerve is another matter. It is a large sensory nerve,
Neck hematomas are more common when submental dis- as described under “Facelift Anatomy,” and transection will
sections are included in the facelift procedure. This fact, com- result in permanent numbness of half of the ear and, in some
bined with the beneficial effect on the neck that accompanies cases, a painful neuroma. The nerve is quite superficial on
the SMASectomy/SMAS plication techniques, has led to a the surface of the sternomastoid muscle, especially in thin
smaller percentage of patients having submental incisions and patients, and is easily transected. If such a transection occurs,
midline platysmaplasties. The cost-to-benefit analysis between the nerve should be approximated with appropriate microsur-
opening the neck to improve neck definition and avoiding gical suture.
submental dissections to prevent complications is a judgment
that must be made for each patient, with the knowledge that Hypertrophic Scarring
neither choice may be perfect.
Triamcinolone (Kenalog) injections to small hematomas Hypertrophic scarring is most often attributable to exces-
and areas of firmness are discouraged. They probably offer no sive tension on the incision closure. Some patients, however,
benefit over watchful waiting and hematoma aspiration and develop hypertrophic scars despite the best efforts of the sur-
can result in subcutaneous atrophy and a depression when the geon. As with skin slough, this usually involves the retroauricu-
hematoma resolves. lar area, which is less visible, but can occur in the preauricular
area where it is a bad complication. Small volumes of dilute tri-
amcinolone are injected into the scars (not the adjacent normal
Skin Slough tissue), sometimes more than once, and this usually improves
Luckily for the patient and the surgeon, the most common the appearance of the scar significantly. An occasional patient
location for skin slough is in the retroauricular area where will get true keloids of the facelift incisions, which are difficult
the scarring is less visible. The bad news is that full-thickness to treat. Scar revision with immediate treatment with radiation
skin loss will inevitably result in less-favorable scarring, which is the best option is these difficult situations.

References 7. McKinney P, Katrana DJ. Prevention of injury to the great auricular nerve
during rhytidectomy. Plast Reconstr Surg. 1980;66:675.
1. Rees JD, Liverett DM, Guy CL. The effect of cigarette smoking on skin-flap 8. Baker DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100(2):509.
survival in the face-lift patient. Plast Reconstr Surg. 1984;73:911. 9. Hamra ST. Composite rhytidectomy. Plast Reconstr Surg. 1992;90:1.
2. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in 10. Tonnard PL, Verpaele A, Gaia S. Optimizing results from minimal
the parotid and cheek area. Plast Reconstr Surg. 1976;58:80. access cranial suspension lifting (MACS-lift). Aesth Plast Surg. 2005;
3. Gosain A, Yousif NJ, Madiedo G, et al. Surgical anatomy of the SMAS: 29(4):213.
a reinvestigation. Plast Reconstr Surg. 1993;92:1254. 11. Heinrichs HL, Kaidi AA. Subperiosteal facelift: A 200-case, 4-year review.
4. Stuzin J, Wagstrom L, Kawamoto HK, et al. Anatomy of the frontal branch Plast Reconstr Surg. 1998;102(3):843.
of the facial nerve: the significance of the temporal fat pad. Plast Reconstr 12. Hester TR, Codner MA, McCord CD, et al. Evolution of technique of the
Surg. 1989;83:265. direct transblepharoplasty approach for the correction of lower lid and
5. Furnas D. The retaining ligaments of the cheek. Plast Reconstr Surg. midfacial aging: maximizing results and minimizing complications in a
1989;83:11. 5-year experience. Plast Reconstr Surg. 2000;105(1):393.
6. Vistnes LM, Souther SG. The anatomic basis for common cosmetic anterior 13. Baker DC. Complications of cervicofacial rhytidectomy. Clin Plast Surg.
neck deformities. Ann Plast Surg. 1979;2:381. 1983;10:543.
Aesthetic Surgery

Chapter 48 n Rhinoplasty
Jeffrey E. Janis, Jamil Ahmad, and Rod J. Rohrich
approach by the transcolumellar incision. This leaves the lat-

Introduction eral nasal and dorsal nasal arteries as the remaining blood
Rhinoplasty is challenging. Over the past 20 years, the trend supply to the tip if the open approach is used. To that end,
has shifted from ablative techniques involving reduction or extended alar resections are avoided, as the lateral nasal artery
division of the osseocartilaginous framework to techniques is found 2 to 3 mm above the alar groove. Furthermore, exten-
that conserve native anatomy. Cartilage sparing suture tech- sive debulking of the nasal tip is avoided as the subdermal
niques and augmentation of deficient areas to correct con- plexus may be injured leading to skin necrosis.
tour deformities and restore structural support are commonly The veins and lymphatics lie in a subcutaneous plane,
employed.1 The rhinoplasty surgeon must understand the which is superficial to the musculoaponeurotic layer in which
underlying anatomy and have the ability to perform nasofa- the arteries travel. In the open approach, the dissection is per-
cial analysis to determine the operative plan and the training formed in the submusculoaponeurotic plane just above the
to execute techniques that manipulate bone, cartilage, and perichondrium in order to avoid injury to all of these struc-
soft tissue. These skills are augmented by an aesthetic eye in tures. In this way, both bleeding and postoperative edema are
order to produce a result that blends harmoniously with the minimized.
rest of the face.
Osseocartilaginous Framework
Nasal Anatomy The osseocartilaginous nasal framework is comprised of three
separate vaults: the bony vault, the upper cartilaginous vault,
The nose consists of external skin and soft tissue, under- and the lower cartilaginous vault. The bony vault is made up
lying osseocartilaginous framework, and ligamentous sup- of the paired nasal bones and the frontal processes of the max-
port. Familiarity with the native morphology and potential illa, which constitute the upper third to half of the nose. The
variations of each structure is essential. Furthermore, the thickness of the bones varies, with the thickest portion just
dynamic interplay between these components must be above the level of the canthus. As a result, osteotomies are
appreciated. rarely indicated above this level.
The upper cartilaginous framework, or midvault, is com-
Skin prised of the paired upper lateral cartilages (ULCs) and dorsal
The nasal skin is not uniform; its thickness, mobility, and cartilaginous septum. It begins at the “keystone” area, where
sebaceous character vary along the length of the nose.2 The the nasal bones overlap the ULCs. Normally, this is the widest
skin of the upper two-thirds is thinner, averaging 1,300 μm
versus the lower one-third, which averages 2,400 μm.3 The
upper two-thirds is also more mobile and less sebaceous than
the skin of the nasal tip. It is important to note that a straight
dorsum is actually produced by the underlying convexity in
the osseocartilaginous framework combined with the afore-
mentioned variation in dorsal skin thickness.
Skin character also varies between ethnic subpopula-
tions.4-6 Even minor alterations of the underlying framework
will be visible through thin skin, whereas thicker skin will tend
to obscure the underlying details and require more aggressive Lateral nasal
manipulation in order to achieve the desired result. artery
Muscle Arcades
While there are several muscles in the nose, two muscles are
particularly important in rhinoplasty—the levator labii alae-
que nasi and the depressor septi nasi. The levator labii alaeque
nasi assists in maintaining the patency of the external nasal Angular artery
valve, while the depressor septi nasi acts to shorten the upper Columellar
lip and decrease tip projection. Facial artery branches
The effects of an overactive depressor septi must be appre-
ciated as part of the preoperative nasofacial analysis and can Superior labial
be recognized by a depressed nasal tip and shortened upper artery
lip upon animation (especially when smiling). In the subgroup
of patients in which this muscle significantly alters the nasal
appearance, a dissection and transposition of this muscle can
be performed.7
Blood Supply
The blood supply to the nose is derived both from branches of
the ophthalmic artery and from branches of the facial artery
(Figure 48.1). Columellar branches are present in 68.2% FIGURE 48.1. Blood supply to the nose.
of patients.8-10 These branches are transected in the open
512
Chapter 48: Rhinoplasty 513
Perpendicular plate
Septal cartilage
Vomer
Nasal crest
A of maxilla
B
FIGURE 48.2. A. Upper cartilaginous framework. B. Note the “key-
stone area” where the nasal bones overlap the upper lateral cartilages
and the “scroll area” where the lower lateral cartilages overlap the
upper lateral cartilages. FIGURE 48.4. Anatomy of the nasal septum.
deformities. Furthermore, it should be noted that the cribriform

plate is contiguous with the perpendicular plate of the ethmoid,
part of the dorsum and resembles a “T” shape in cross section necessitating care when performing a resection of this structure
(Figures 48.2 A and B). to avoid potential severe consequences, such as anosmia, cere-
The inverted V deformity and/or disruption of the dorsal brospinal fluid rhinorrhea, or ascending infection/meningitis.
aesthetic lines may occur if the midvault area is overresected The turbinates are mucosa-lined bony extensions of the
during the dorsal hump reduction. A component dorsal hump lateral nasal walls. This mucosa undergoes cyclical expan-
reduction is advised to avoid these complications. sion and contraction mediated by the autonomic nervous
The lower cartilaginous framework is composed of the system. The function of the turbinates is to assist in the
medial, middle, and lateral crura and begins where the lower transport of air during respiration and to condition/humidify
Aesthetic Surgery
lateral cartilages (LLCs) overlap the ULCs in what is called the inspired and expired air. The inferior turbinate, especially
“scroll” area. The tip cartilages are connected to each other, its most anterior portion, has the greatest impact on airway
the ULCs, and the septum by fibrous tissue and ligaments resistance, providing up to two-thirds of the total airway
(Figure 48.3). Disruption of these ligaments during rhino- resistance.11 Turbinate pathology is frequently addressed
plasty can result in diminished tip projection, requiring addi- via submucosal resection and/or outfracture techniques.16,17
tional maneuvers to maintain or increase tip support. However, overresection can lead to adverse effects on regu-
latory and physiologic functions, causing crust formation,
Nasal Function bleeding, and nasal cilia dysfunction.
The internal nasal valve is the angle formed by the junction
The functions of the nose, specifically respiration, humidifi- of the nasal septum and the caudal margin of the ULC and is
cation, filtration, temperature regulation, and protection, are usually 10° to 15° (Figure 48.5). It can be responsible for up
regulated by the septum, turbinates, and nasal valves (internal to 50% of the total airway resistance and is the narrowest seg-
and external).11 ment of the nasal airway.11 Occasionally, the head (anterior-
The constituents of the septum include the septal cartilage, most portion) of the inferior turbinate can be hypertrophied
the perpendicular plate of the ethmoid bone, the nasal crest of enough to cause further diminution of the cross-sectional area
the maxilla, and the vomer (Figure 48.4). Laminar airflow is of this region. A positive Cottle’s sign (lateral traction on the
altered by septal deformities and can lead to secondary turbi- cheek leading to increased airflow) signals collapse of the
nate hypertrophy.12-15 It is paramount to analyze and address nasal valves and may indicate the need for spreader grafts to
all portions of the septum when attempting to correct septal increase the valve angle and stent the airway open.
The external nasal valve is caudal to the internal valve and
is the vestibule that serves as the entrance to the nose. This
Nasal valve
Valve angle
˚
10˚–15
Fibrous
Pyriform connections Head inferior
abutment turbinate
Suspensory
ligament
Elastic fibers
FIGURE 48.3. Ligamentous support of the cartilaginous framework. FIGURE 48.5. Internal nasal valve.

valve may be obstructed by extrinsic factors, such as foreign

bodies, or intrinsic factors, such as weak or collapsed LLCs, P
loss of vestibular skin, or cicatricial narrowing. There are a
many options to correct these problems, including cartilage t
grafting (e.g., alar contour grafts,18 alar batten grafts,19 or i
lateral crural strut grafts20) or flaps (e.g., lower lateral cru-
ral turnover flap21), soft-tissue grafting (e.g., mucosal, skin, e
or composite grafts), lysis of adhesions/synechiae, or scar n
revision. t
Preoperative Assessment c
o
The Initial Consultation n
The patient’s concerns and levels of expectation must be c
assessed prior to any operative intervention. “Danger signs”
have been described that may indicate that the patient has
e
underlying psychological issues (Figure 48.6).22-24 Patients r
that fit these criteria are approached with caution, as surgical n
intervention may not be in either the patient’s or the surgeon’s
best interest. Deformit y
Patients are appropriate surgical candidates if their concern
is proportionate to the degree of their deformity (green area; FIGURE 48.7. “GorneyGram” comparing patient concern with the
Figure 48.7). However, there are some patients with a degree actual degree of deformity.
of concern that is disproportionate to their deformity (red
area). These patients frequently have unrealistic expectations
that cannot be met regardless of the aesthetic improvement.
It is best to avoid operating on these patients. Furthermore, The skin type, thickness, and texture are evaluated. As
regardless of the degree of deformity, if the skill level and mentioned, thicker, more sebaceous skin will require more
expertise required to perform the rhinoplasty exceeds one’s aggressive modification of the underlying osseocartilaginous
ability, that patient should be referred to another surgeon who framework as changes tend to be camouflaged. Thinner skin
possesses the required proficiency. will tend to show even minor changes.
Computer imaging has proven to be a useful tool to pro- The nasofacial analysis then proceeds in a systematic,
vide the patient with a visual understanding of the anticipated methodical fashion (Table 48.1).1 Below are some of the rou-
outcome, although the images are not meant to guarantee tine relationships and proportions that are used when analyz-
surgical results.25,26 These images, combined with standard- ing the rhinoplasty patient. While derived from Caucasian
ized anterior, oblique, lateral, and basal photographs, serve as females, they can be modified depending on the ethnicity and
helpful adjuncts in the planning of the operation. gender of the patient.4-6,27,28 It is important to remember that
these proportions are only general guidelines. Each nose is
Nasofacial Analysis individualized to the patient in order to achieve optimal naso-
facial balance and harmony.
Accurate, systematic, and thorough nasofacial analysis is per-
formed to determine the subsequent operative plan. The nose 1. The face is divided into thirds using horizontal lines tan-
must be examined not only in isolation but also in the context gent to the hairline, brow (at the level of the supraorbital
of the whole face so that the procedure preserves the overall notch), nasal base, and chin (menton). The upper third
facial balance and harmony. It is also necessary to evaluate the (between the hairline and the brow) is the most variable,
patient preoperatively for any natural facial asymmetries so as it depends on the hairline and hairstyle, and therefore
that the patient gains a better understanding of exactly what is the least important. The middle third lies between the
was present before any operative intervention. brow and the nasal base. The lower third of the face can
be subdivided into thirds by visualizing a horizontal line
between the oral commissures (stomion). The upper third
of this subdivision lies between the nasal base and the
oral commissures and the lower two-thirds between the
1) Minimum disfigurement
commissures and the menton (Figure 48.8). Deviation
2) Delusional distortion of the body image.
from these proportions may signal an underlying cranio-
3) An identity problem or sexual ambivalence.
facial anomaly, such as vertical maxillary excess or max-
4) Confused or vague motives for wanting the surgery.
illary hypoplasia, that may need to be addressed prior to
5) Unrealistic expectations of change in life situations
as a result of the surgery rhinoplasty (Chapter 25).
6) A history of poorly established social and 2. The nasal length (radix-to-tip, or R-T) should be equivalent
emotional relationships to the stomion-to-menton distance (S-M) (Figure 48.9).
7) Unresolved grief or a crisis situation. 3. The lip–chin relationship is assessed by dropping a ver-
8) Present misfortunes blamed on physical appearance. tical line from a point one-half the ideal nasal length
9) Older neurotic man overly concerned about aging. tangent to the vermillion of the upper lip. The lower lip
10) A sudden anatomic dislike, especially in older men. should lie approximately 2 mm behind this line. The
11) A hostile, blaming attitude toward authority. ideal chin position varies with gender, with the chin lying
12) A history of seeing physicians and being slightly posterior to the lower lip in women, but equal
dissatisfied with them.
to the lower lip in men. Orthodontics, a chin implant,
13) The indication of paranoid thoughts.
or orthognathic surgery may be necessary to improve
overall facial harmony if there is a discrepancy in these
FIGURE 48.6. “Danger signs” that may indicate the patient has relationships (Figure 48.10).
underlying psychological issues. 4. The nose itself is addressed from the anteroposterior
view. A vertical line is drawn from the midglabellar

TA B L E 4 8 . 1
Systematic Nasal Analysis
Frontal view
Facial proportions
Skin type/quality—Fitzpatrick type, thin or thick, sebaceous
Symmetry and nasal deviation—midline, C-, reverse C-, S- or 1/3
S-shaped deviation
Bony vault—narrow or wide, asymmetrical, short or long nasal
bones
Midvault—narrow or wide, collapse, inverted V deformity
Dorsal aesthetic lines—straight, symmetrical or asymmetrical,
well or ill defined, narrow or wide
Nasal tip—ideal/bulbous/boxy/pinched, supratip, tip-defining 1/3
points, infratip lobule
Alar rims—gull shaped, facets, notching, retraction
Alar base—width
Upper lip—long or short, dynamic depressor septi muscles, 1/3
upper lip crease
Lateral view 1/3
Nasofrontal angle—acute or obtuse, high or low radix 2/3
Nasal length—long or short
Dorsum—smooth, hump, scooped out
Supratip—break, fullness, pollybeak
Aesthetic Surgery
Tip projection—over- or underprojected
Tip rotation—over- or underrotated
Alar-columellar relationship—hanging or retracted alae,
hanging or retracted columella
Periapical hypoplasia—maxillary or soft-tissue deficiency
Lip-chin relationship—normal, deficient
Basal view
Nasal projection—over- or underprojected, columellar-lobular FIGURE 48.8. The face is divided into thirds, using horizontal lines
ratio tangent to the hairline, brow, nasal base, and chin.
Nostril—symmetrical or asymmetrical, long or short
Columella—septal tilt, flaring of medial crura medial to lateral canthus. If the alar base width is greater
Alar base—width than the intercanthal distance, the underlying etiology
is examined. If the discrepancy is the result of a narrow
Alar flaring intercanthal distance, it is better to maintain a slightly
wider alar base. If there is true increased interalar width,
From Rohrich RJ, Ahmad J. Rhinoplasty. Plast Reconstr Surg. 2011;
a nostril sill resection may be indicated. If the increase in
128:49e-73e.
width is secondary to alar flaring (greater than 2 to 3 mm
outside the alar base), an alar base resection should be
considered. The bony base should equal approximately
area to the menton, bisecting the nasal ridge, upper lip, 80% of the alar base width (Figures 48.13 A and B). If
Cupid’s bow, and central incisors (if the patient has the bony base is greater than 80% of the alar base width,
normal occlusion). Any nasal deviation from this line is osteotomies may be required. Over-narrowing the dor-
likely to require septal surgery (Figure 48.11). sum should be avoided in males as this can lead to an
5. The curvilinear dorsal aesthetic lines are traced from “over-feminized” look.
their origin at the supraorbital ridges toward their con- 7. The alar rims are examined for symmetry. They should
vergence at the level of the medial canthal ligaments. normally flare slightly outward in an inferolateral direc-
From here, they flare slightly at the keystone area and tion (Figure 48.14).
then track down to the tip-defining points, slightly 8. The tip is assessed by drawing two equilateral triangles
diverging from each other along the dorsum during with their bases opposed (Figure 48.15). The supratip
their course. The ideal width of the dorsal aesthetic lines break, tip-defining points, and columellar-lobular angle
should be approximately equivalent to the width between serve as landmarks. If these triangles are asymmetric, the
the tip-defining points or the interphiltral distance patient will likely require tip modification.
(Figure 48.12). 9. The final assessment on frontal view is of the outline of
6. The normal alar base width is equivalent to the inter- the alar rims and the columella. Normally, this outline
canthal distance, or the transverse dimension from the should resemble a seagull in gentle flight. If the angles

A
T
FIGURE 48.9. The ideal nasal length is equivalent to the stomion-

to-menton distance. A, ala; M, menton; R, radix; S, stoma; T, tip.
FIGURE 48.11. Symmetry is determined by drawing a vertical line

from the midglabellar area to the menton.
Natural horizontal
facial plane
FIGURE 48.10. The ideal lower lip position is 2 mm behind a vertical

line dropped from a point half the ideal nasal length along the natural
horizontal facial plane.
are too steep, the patient likely has an increased infratip

lobular height. Conversely, if the angle/curve is too flat-
tened, it is likely the patient has decreased columellar
show, which may require columellar and/or alar rim
modification (Figure 48.16).
10. The basal view of the nose is examined focusing on the
outline of the nasal base and the nostrils themselves.
The outline of the nasal base should describe an equi- FIGURE 48.12. The curvilinear dorsal aesthetic lines extend from the
lateral triangle with a lobule-to-nostril ratio of 1:2 supraorbital ridges to the tip-defining points.
(Figure 48.17). The nostril itself should have a teardrop

A B B A
Aesthetic Surgery
FIGURE 48.13. A. The normal alar base width equals the intercan-
thal distance, or the width of one eye. B. The bony base should be
approximately 80% of the alar base width. FIGURE 48.14. The alar rims should flare outward inferolaterally.
geometry, with the long axis oriented in a slight medial (2) 0.67 × R-T (radix-to-tip) (Figures 48.19A and B). The
direction (from base to apex). second way to assess tip projection is to examine how
11. Attention is turned to the lateral view, beginning with much of the tip lies anterior to a vertical line tangent to
analysis of the nasofrontal angle. This angle connects the the most projecting part of the upper lip vermillion. If
brow and nasal dorsum through a soft concave curve. 50% to 60% of the tip lies anterior to this line, projec-
The apex of this angle (radix) should lie between the tion is considered normal. If the tip projection is outside
supratarsal fold and the upper lid lashes, with the eyes of these proportions, it likely will require tip modifica-
in primary gaze. The nasofrontal angle can vary between tion (Figure 48.20).
128° and 140°, but is ideally approximately 134° in 14. The dorsum is analyzed by drawing a line from the radix
females and 130° in males. to the tip-defining points. In women, the ideal aesthetic
12. It is important to note that the perceived nasal length nasal dorsum should lie approximately 2 mm behind and
and tip projection can be altered by the position of parallel to this line, but in men, it should approach this
the nasofrontal angle. For instance, the nose appears line to avoid feminizing the nose (Figure 48.21).
longer if the nasofrontal angle is positioned more ante- 15. The degree of supratip break is also evaluated on the lat-
riorly and superiorly than normal. In this instance, the eral view. This break helps to define the nose and sepa-
nasofacial angle (as defined by the junction of the nasal rate the tip from the dorsum. A slight supratip break is
dorsum with the vertical facial plane) is decreased and preferred in women but not in men.
the tip projection will appear diminished (yellow line). 16. The degree of tip rotation is assessed by evaluating the
Conversely, the nose can appear shorter if the nasofron- nasolabial angle, which is the angle formed between a
tal angle is positioned too posteriorly and/or inferiorly. line coursing through the most anterior and posterior
In this case, the tip may also appear more projecting (red edges of the nostril and a plumb line dropped perpendic-
line; Figure 48.18). Ideally, the nasofacial angle should ular to the natural horizontal facial plane (Figure 48.22).
measure 32° to 37°. This angle is usually 95° to 100° in women and between
13. While still analyzing the lateral view, tip projection is 90° and 95° in men.
addressed. This can be done in two ways. The first is to 17. The nasolabial angle is often confused with the columellar-
draw a horizontal line from the alar-cheek junction to lobular angle, which is formed at the junction of the colu-
the tip of the nose. The distance between these points mella with the infratip lobule (Figure 48.23). This angle is
should equal two things: (1) the alar base width, and normally 30° to 45°. A prominent caudal septum can cause

1/3
2/3
FIGURE 48.17. The outline of the nasal base should resemble an

equilateral triangle with a lobule-to-nostril ratio of 1:2.
increased fullness in this area, which can give the illusion of

increased rotation, despite a normal nasolabial angle.
18. The alar-columellar relationship is assessed by draw-
ing a line through the long axis of the nostril and a
second, perpendicular line drawn from the alar rim
to the columellar rim that bisects this axis. If the alar-
columellar relationship is normal, the distance from the
alar rim (“point A”) to the long axis line (“point B”)
should equal the distance between the long axis line
FIGURE 48.15. Tip assessment is performed by analyzing two equi- and the columellar rim (“point C”) (AB = BC ≈ 2 mm)
lateral triangles with opposing bases.
(Figure 48.24). If abnormal, the deformity can be strati-
fied into six classes.29 Classes I to III describe increased
FIGURE 48.18. Perceived nasal length and tip projection can be

altered by the position of the nasofrontal angle. A posteriorly and
inferiorly positioned nasofrontal angle can make the nose appear
shorter with increased tip projection (red). An anteriorly and supe-
FIGURE 48.16. The outline of the alar rims and columella should riorly positioned nasofrontal angle can make the nose appear longer
resemble a “seagull in gentle flight.” with diminished tip projection (yellow).

1.0
0.67
A B
A=B
FIGURE 48.19. A. Tip projection should equal alar base width. B. Tip projection should also equal 0.67 × R-T (radix-to-tip).
Aesthetic Surgery
A B
FIGURE 48.21. The dorsum is analyzed by drawing a line from the

radix to the tip-defining points.
A = 50–60%
of AB
FIGURE 48.20. About 50% to 60% of the tip should lie anterior to a
vertical line tangent to the most projecting part of the upper lip vermillion.
Natural horizontal
facial plane
columellar show, while classes IV to VI demonstrate
decreased columellar show. The treatment of the discrep-
ancy varies by class.
The final critical part of the preoperative analysis 95˚–100˚
is the intranasal exam, which is performed with a nasal

speculum, headlight, and vasoconstriction. Deformities
or abnormalities of the septum, turbinates, and internal
nasal valve are evaluated. If turbinate hypertrophy is iden-
tified, the underlying etiology should be investigated and
a detailed history taken, as the enlargement may be either
congenital or acquired. If acquired, it may be the result of FIGURE 48.22. The nasolabial angle is usually 95° to 100° in females
autonomic, environmental, medical, or anatomic factors and 90° to 95° in males.
(Table 48.2).

TA B L E 4 8 . 2
Causes of Acquired Inferior Turbinate Hypertrophy
Autonomic
Vasomotor rhinitis
Sexual stimulation
Emotions
Environmental
Allergic rhinitis
Dust
Tobacco
30˚– 45˚
Medical
Inflammatory
Hyperthyroidism
Pregnancy
Rhinitis medicamentosus
Anatomic
Associated with deviated nasal septum (deviation of nasal
septum may also be congenital)
FIGURE 48.23. The columellar-labial angle is normally 30° to 45°. From Rohrich RJ, Krueger JK, Adams WP Jr, et al. Rationale for sub-
mucous resection of hypertrophied inferior turbinates in rhinoplasty: an
evolution. Plast Reconstr Surg. 2001;108:536-544.
made to the underlying framework are more important than

which incision is used.
Many experienced surgeons prefer the open approach
because it provides better exposure of the nasal frame-
work resulting in an accurate diagnosis of all the potential
causes of either the nasal airway obstruction or the etiology
B of the cosmetic deformity. Furthermore, precise manipu-
A lation of the various structures can be performed and the
dynamic interplay between these structures appreciated,
C leading to reproducible results. The open approach is par-
ticularly advantageous in the following circumstances: (1)
posttraumatic deformities, where complete release of all
intrinsic and extrinsic deforming forces is necessary, (2)
revisional surgery, and (3) when complex tip modifications
are necessary.
The endonasal approach lends itself well to patients who
have an isolated dorsal hump deformity or where there is
minimal change needed to modify the tip structure. In these
instances, a marginal incision is useful. In cases requiring
minor tip refinement, an intercartilaginous incision allows for
Normal ACR
adequate cartilage delivery and exposure. A hemitransfixion
FIGURE 48.24. The alar-columellar relationship is assessed by or transfixion incision is used if the caudal septum requires
drawing two perpendicular lines—one through the long axis of the repositioning.
nostril (B) and the other from the alar rim to the columellar rim (A–C).
Anesthesia/Preoperative Preparation
Rhinoplasty can be performed with either local anesthesia
with IV sedation or general anesthesia. After induction, the
Operative Technique nasal vestibules are prepared by clipping the nasal vibris-
sae and swabbing the entire nostril with Betadine solution.
Type of Approach Before injecting local anesthetic, the incision is marked
There are two schools of modern rhinoplasty—those who (transcolumellar stair-step, if using an open approach) so
prefer the open approach and those who prefer the closed as not to distort the anatomy. Approximately 10 mL of
one.30-36 While both approaches have their advantages and 1% Lidocaine with 1:100,000 epinephrine is injected into
disadvantages, it is important to be familiar with both the intranasal mucosa, along the septum, and into soft-
(Tables 48.3 and 48.4). The experienced surgeon will tai- tissue envelope. Additional local anesthetic is used on
lor the approach to the patient’s anatomic deformity. the inferior turbinates when an inferior turbinoplasty is
Regardless of the approach, however, the modifications anticipated.

TA B L E 4 8 . 3
Advantages and Disadvantages of the Open
Approach
Advantages Intercartilaginous
Binocular visualization Marginal
Evaluation of complete deformity without distortion Transfixion
Precise diagnosis and correction of deformities

Allows use of both hands
More options with original tissues and cartilage grafts
Direct control of bleeding with electrocautery
Suture stabilization of grafts (invisible and visible)
Disadvantages
FIGURE 48.25. Intercartilaginous and marginal incisions for carti-
External nasal incision (transcolumellar scar) lage delivery during endonasal rhinoplasty.
Prolonged operative time
Protracted nasal tip edema
Columellar incision separation
Incision—Endonasal Approach
Delayed wound healing
There are two basic endonasal techniques, nondelivery and
delivery. The nondelivery approach is performed using either
a cartilage-splitting (transcartilaginous) incision or an ever-
sion (retrograde) incision. The transcartilaginous incision is
TA B L E 4 8 . 4 made by incising several millimeters cephalad to the caudal
Advantages and Disadvantages of the margin of the lateral crura. This preserves a rim strip to sup-
Endonasal Approach port the ala. Exposure is facilitated by double hook retraction
Aesthetic Surgery
combined with digital alar eversion. The cephalic portion of
Advantages the cartilage is then exposed for resection by dissecting the
vestibular skin off it. In the eversion approach, rather than
Leaves no external scar going through the cartilage, the vestibular incision is made
Limits dissection to areas needing modification at the cephalic-most margin of the LLC. The cephalic por-
tion of the cartilage is exposed and resected. The theoretical
Permits creation of precise pocket so graft material fits exactly advantage to this incision is that it maintains the caudal alar
without need for fixation margins and prevents potential scar contracture deformities
Allows percutaneous fixation when large pockets are made in this area.
The delivery approach is used in cases where moderately
Promotes healing by maintaining vascular bridges
complex tip modifications are necessary. This is especially true
Encourages accurate preoperative diagnosis and planning in cases where there is significant tip bifidity. The cartilaginous
margins are delineated with double hook retraction in the ala
Produces minimal postsurgical edema
and digital counterpressure, and a #15 blade scalpel is used
Reduces operating time to create an intercartilaginous incision starting just above the
Results in fast patient recovery cephalic margin of the lateral crus. Subsequently, a marginal
incision is created along the caudal margin of the LLC, from
Creates intact tip graft pocket lateral crus to medial crus, ending at the columellar-lobular
Allows composite grafting to alar rims junction (Figure 48.25). The soft tissue is then dissected off of
the cartilage in a plane just above the perichondrium, includ-
Disadvantages ing over the dorsal cartilaginous septum. The same procedure
Requires experience and great reliance on accurate preoperative is repeated on the contralateral side, and the two incisions are
diagnosis connected in the midline over the anterior septal angle, ending
in a hemitransfixion incision. This can be extended to a full
Prohibits simultaneous visualization of surgical field by t eaching transfixion incision, if indicated. The LLC is then dissected
surgeon and students free from the surrounding tissues and delivered outside the
Does not allow direct visualization of nasal anatomy incision. The incisions may be extended and the soft tissue
undermined more aggressively if there is difficulty delivering
Makes dissection of alar cartilages difficult, particularly in cases the cartilages. Modifications are made once the cartilages and
of malposition domes are delivered.
After injection, cottonoid pledgets soaked with a local Incision—Open Approach

vasoconstrictor solution are inserted to shrink the nasal A transcolumellar stair-step incision across the narrowest por-
mucosa, facilitate exposure, and minimize blood loss. tion of the columella is generally preferred. The advantages
Oxymetazoline or 4% cocaine may be used to provide vaso- of the stair-step incision include the provision of landmarks
constriction; however, cocaine has the risk of myocardial for accurate closure, the prevention of linear scar contracture,
infarction (Chapter 12).37,38 A throat pack is carefully placed and a camouflaged scar.
in the posterior oropharynx to prevent aspiration or swallow- Infracartilaginous extensions are then performed bilater-
ing of blood. The patient is prepped and draped for surgery. ally, beginning from lateral to medial along the caudal border

of the LLC. These incisions meet the transcolumellar inci- right dorsal aesthetic lines, and then centrally using the non-
sion to complete the approach. Exposure during this dissec- dominant thumb and index finger for maximal control. It is
tion is facilitated by double hook alar eversion and digital important to maintain a slightly oblique bias when rasping in
counterpressure. order to prevent mechanical avulsion of the ULCs from the
It is important that the surgeon not be in a rush during nasal bones.
this portion of the procedure, as most mistakes are made try- (4) Verification by palpation:
ing to obtain exposure. Furthermore, the incisions should be The three-point dorsal palpation test, performed with a
kept superficial and the caudal border of the LLC should be saline-moistened dominant index fingertip, is used to gen-
identified prior to cutting to prevent injury to the underlying tly palpate the left and right dorsal aesthetic lines, as well as
cartilages. Injuries to the domes are not uncommon and are centrally, in order to ascertain if there are any residual dorsal
difficult to repair. irregularities or contour depressions. This maneuver is per-
formed repeatedly throughout this process (after redraping the
Skin Envelope Dissection skin envelope).
(5) Final modifications, if indicated (spreader grafts, suturing
Extreme care is taken during the exposure of the nasal frame- techniques, osteotomies).
work so as not to injure the cartilages. The dissection should
be carried out immediately on the surface of the tip cartilage.
If performed properly, there should be no residual soft tissue Septal Reconstruction/Cartilage Graft Harvest
remaining on the LLCs. This dissection is continued superiorly The septum is harvested if there is a septal deformity or if car-
to expose the cartilaginous dorsum and ULCs until the bony tilage is needed for grafting. Septal cartilage is ideal for graft
pyramid is encountered. At this point, a limited subperiosteal material because of its minimal donor site morbidity and close
dissection is performed over the area of the bony dorsal hump geographic proximity to the operating field.
that needs to be addressed. Care is taken to avoid disruption A Killian or hemitransfixion incision is generally used
of all of the periosteal attachments to the nasal bones, as this when employing the endonasal approach. A complete trans-
can destabilize the area and lead to prolonged wound healing fixion incision can lead to decreased tip projection, especially
and potential nasal bone malposition. Care is also taken to if dissection is carried down over the anterior nasal spine.
assure that the ULCs are not detached from the nasal bones by In the open approach, the anterior septal angle is exposed
accidental dissection under the nasal bones. by separating the middle crura and incising the interdomal
suspensory ligament. The septal mucoperichondrium is
Nasal Dorsum incised with a #15 blade scalpel exposing the distinctive
bluish-gray underlying cartilage. A Cottle elevator is then
The nasal dorsum can be reduced as a composite or a com- used to carry the dissection in a submucoperichondrial plane
ponent dorsal hump reduction can be performed.Component posteriorly to the perpendicular plate of the ethmoid down to
dorsal hump reduction has the advantage of incremental con- the nasal floor and across the face of the septum. This submu-
trol and greater precision.39 It is performed using five essen- coperichondrial dissection should proceed almost effortlessly
tial steps: if performed in the correct plane. Dissection in the correct
(1) Separation of the ULC from the septum: plane is also almost bloodless. The dissection should proceed
The component dorsal hump reduction technique begins with caution, however, at the junction of the cartilaginous
with the creation of bilateral superior submucoperichondrial and bony septum, as the overlying mucoperichondrium is
tunnels in order to minimize mucosal trauma, resulting in more adherent, and mucosal perforation is more likely. The
potential internal nasal valve stenosis or vestibular webbing. identical dissection is performed on the contralateral side,
This is done by elevating the mucoperichondrium of the dor- and the entire septum is examined using a Vienna speculum
sal septum in a caudocephalad direction with a Cottle elevator in order to identify deformities and to help achieve exposure
until the nasal bones are reached. The transverse processes of for the septal harvest.
the ULCs are then sharply separated from the septum using a When resecting septal cartilage, it is important to maintain
#15 blade scalpel (without damaging the mucosa). the stability of the cartilaginous framework by preserving an
(2) Incremental reduction of the septum proper: L-strut with 10 mm of dorsal septum and 10 mm of caudal
The cartilaginous dorsal septum is separated into three septum. The harvested cartilage should be preserved in saline
components—the septum centrally and the transverse portions to prevent desiccation. Residual deviations in the ethmoid or
of the ULC laterally. The cartilaginous dorsum is then reduced vomer are resected and any mucosal perforations are repaired.
in an incremental fashion by resecting the dorsal hump defor-
mity with either a sharp scalpel or scissors in serial fashion. Correction of the Deviated Nose
In some cases, the resected dorsal septum can be used as a
Septal deviation may manifest itself as external deviation of
columellar strut graft.40 Reduction of the cartilaginous dor-
the nose. The deviated nose is classified into three basic types:
sum is performed under direct vision. Care is taken to avoid
caudal septal deviations, concave dorsal deformities, and con-
damage to the adjacent ULCs. In rare cases, the ULCs may
cave/convex dorsal deformities (Table 48.5).41
require resection, although this is not routine in our practice.
Correction of the deviated nose is based on the following
If required, it must be performed cautiously, as overresection
principles:
of the ULCs will cause internal nasal valve collapse and long-
term dorsal irregularity. Maintaining the transverse portions 1. The open approach to expose all deviated structures
of the ULC also preserves the dorsal aesthetic lines. If the sep- 2. Release of all mucoperichondrial attachments to the sep-
tum and ULCs were taken down en bloc (not in component tum, especially the deviated part
fashion), a rounded dorsum would result. Furthermore, an 3. Straightening of the entire septum while maintaining a 10
inverted V deformity could result if the ULCs were resected to mm caudal and dorsal L-strut
a greater extent than the septum. 4. Restoration of long-term support with buttressing caudal
(3) Incremental dorsal bony reduction: septal batten or dorsal spreader grafts
Large humps (generally >5 mm) are reduced by either a 5. Outfracture or submucous resection of hypertrophied
power burr with a dorsal skin protector or a guarded 8-mm anteroinferior turbinates, if necessary, for correction of the
osteotome. Smaller humps can be addressed with a sharp rasp deviated septum
(e.g., a down-biting diamond rasp). The rasping is done in a 6. Precisely planned and executed external percutaneous
controlled, methodical fashion, proceeding along the left and osteotomies

TA B L E 4 8 . 5
Classification of The Deviated Nose
n Type n Description
I. Caudal septal deviation

a. Straight septal tilt
b. Concave deformity (C-shaped)
c. S-shaped deformity
II. Concave dorsal deformity
Thin line
a. C-shaped dorsal deformity score
Scored and folded cartilage
b. Reverse C-shaped dorsal deformity
III. Concave/convex dorsal deformity
(S-shaped)
Full-
From Rohrich RJ, Gunter JP, Deuber MA, Adams WP Jr. The deviated
thickness
nose: optimizing results using a simplified classification and algorithmic
approach. Plast Reconstr Surg. 2002;110:1509-1523.
cut
FIGURE 48.26. Lower lateral crural turnover flap.
dorsal aesthetic lines or can be positioned lower (i.e., invisible)

Inferior Turbinoplasty for septal support or internal valve stenting. The grafts are
An inferior turbinoplasty is performed in those patients with secured with 5-0 PDS in a horizontal mattress fashion.
inferior turbinate hypertrophy causing symptomatic nasal Autospreader flaps are an alternative when there is ULC
airway obstruction.11,16,17 In most cases, outfracture of the excess after reduction of the dorsal septum.47 The transverse
inferior turbinate is adequate. With more significant inferior portion of the ULCs is rotated medially to function as a local
Aesthetic Surgery
turbinate hypertrophy, submucous morselization of the tur- spreader flap while reducing the profile of the dorsum and
binate bone and submucous resection of the anterior one- preserving the dorsal aesthetic lines. This surgical technique
third to one-half of the inferior turbinate may be required. adjusts the height of the ULCs in a precise and safe manner
Submucous resection technique begins with the development while preserving the function of the internal valve.
of medial mucoperiosteal flaps, which exposes the conchal
bone. The anterior portion of the conchal bone is resected, Tip Refinement
while the posterior portion is preserved to avoid bleeding
Successful tip refinement and projection depends on (1) proper
complications. The flaps are replaced after this resection with-
preoperative analysis of the deformity; (2) a fundamental
out the need for suture repair.
understanding of the intricate and dynamic relationships
between tip-supporting structures that contribute to nasal
Cephalic Trim tip shape and projection; and (3) execution of the operative
Indications for a cephalic trim of the LLCs include the need plan using controlled, nondestructive, and predictable surgical
for tip rotation, medialization of the tip-defining points, and/ techniques.
or the tip requiring better refinement and definition as in the
case of the boxy or bulbous tip.42-44 A caliper is used to mea- Altering Tip Projection. Tip projection is affected by48:
sure a 6 mm rim strip of the caudal margin of the LLC that 1. Length, width, and strength of the LLCs
is to be preserved. Subsequently, the cephalic portion of the 2. Length and stability of the medial crura
middle and lateral crura is resected and preserved for possible 3. Suspensory ligament that spans the crura over the anterior
use as a graft later in the case. septal angle
Lower Lateral Crural Turnover Flap

A lower lateral crural turnover flap is a useful technique to
address paradomal fullness while providing additional sup-
port to the LLCs (Figure 48.26).21 It is beneficial for deformi-
ties, weakness, and collapse of the lower lateral crura and can
also be used to improve lower lateral crural strength during Spreader grafts
tip reshaping.
Spreader Grafts and Autospreader Flaps

Spreader grafts are extraordinarily versatile and can be used
to help stent open the internal valve, to stabilize the sep-
tum, and to preserve or enhance the dorsal aesthetic lines
(Figure 48.27).45,46 These grafts, usually obtained from septal
cartilage, are fashioned to measure approximately 25 to 30
mm by 3 mm. They can also be made longer and placed in such FIGURE 48.27. Spreader grafts can be used to stent open the internal
a way as to project past the anterior septal angle, effectively nasal valve, stabilize the septum, or preserve or enhance the dorsal
lengthening the nose. They can also be positioned more anteri- aesthetic lines.
orly (i.e., visible) along the septum in order to recreate stronger

4. Fibrous connections between ULCs and LLCs Interdomal sutures can increase both tip refinement and tip
5. Abutment with the pyriform aperture projection. They serve to narrow the interdomal distance by
6. Anterior septal angle approximating the medial/middle crura. Sutures are placed in
7. Skin and soft-tissue thickness and availability mattress fashion and can be tightened to a variable degree in
order to achieve the desired result (Figure 48.30).
Alteration of any of these anatomic structures can result
Transdomal (or intradomal) sutures can also affect both
in incremental changes in tip projection. An algorithmic
tip refinement and projection. These mattress-type sutures are
approach to tip refinement includes the use of cephalic
placed across the dome of the middle crura after hydrodissec-
trim, nasal tip suture techniques, and cartilage grafting
tion of the underlying mucoperichondrium from the cartilage
(Figure 48.28).
in order to help prevent inadvertent intranasal exposure of the
Nasal Tip Sutures. Nasal tip suture techniques can reliably suture (Figure 48.31). Knots are left on the medial aspect of
produce an increase of 1 to 2 mm of tip projection.42-44,48-53 the dome and one end may be left long on each side, which can
The choice of suture material is surgeon dependent, though be used to tie the transdomal sutures together (i.e., an inter-
the underlying premise is to select a material that will hold the domal suture) in order to narrow the tip-defining points. It is
cartilage in its altered position long enough to allow for the important, however, to avoid over-tightening of this suture,
natural fibrotic reaction to solidify the result. which will result in an unnaturally sharp tip-defining point.
There are four general types of techniques used to alter They may also be placed asymmetrically in order to correct
projection: anatomic differences that may exist from side to side.
• Medial crural Columellar Strut Graft. The placement of a columellar

• Medial crural-septal strut is the second step in the algorithm for tip refinement and
• Interdomal projection.48 Usually fashioned from septal cartilage, the strut
• Transdomal (intradomal) can be placed in a “fixed” or a “floating” fashion, depend-
ing on whether or not it is secured to the anterior maxilla.
Medial crural sutures can be used to unify the medial
Columellar struts can control columellar profile as well as sup-
crura of the LLCs and to rectify flaring of the medial/mid-
port tip projection. A pocket is dissected between the medial
dle crura, thereby effecting a limited increase in projection
crura and the strut is inserted. Its final position is set by gently
(Figure 48.29). They are also frequently used to help stabi-
retracting the medial crura anteriorly by a double hook and
lize a columellar strut. Medial crural-septal sutures alter both
gauging the desired amount of tip projection. This configura-
projection and rotation by anchoring the medial crura to the
tion is temporarily stabilized with a transversely placed 25G
caudal septum.
Assessment of Tip Projection/Refinement and

Nostril-to-Tip Balance
Analytical (0.67 × Ideal Nasal Length)

Aesthetic (50–60% Anterior to Upper Lip Vertical)
Aesthetic Nostril-to-Tip Ratio (2:1)
Normal Tip Projection

Inadequate Tip Projection/Refinement Lateral Crural Malposition
No Operative Intervention
Cephalic Trim Lateral Crural Strut Graft
Alar Contour Graft
Invisible/Nonpalpable Techniques
Intercrural Columellar Strut

Septal Extension Graft
Medical Crural Suture
Transdomal Suture
Interdomal Suture
Medial Crural Septal Suture

Visible/Palpable Techniques
(if inadequate tip projection
Complete Adequate Reassess Tip Inadequate and/or refinement)
Projection/Refinement (Intraop) and/or
and Nostril Shaping Techniques
Nostril-to-Tip Balance (if nostril-to-tip imbalance)
Tip Grafts
FIGURE 48.28. Algorithmic approach to tip refinement.

FIGURE 48.29. Medial crural sutures can unify the medial crura and FIGURE 48.31. Transdomal sutures are mattress-type sutures placed
help stabilize the columellar strut. Medial crural-septal sutures anchor across the dome of the middle crura and can also affect tip refinement
the medial crura to the caudal septum and can alter both projection and projection. In addition, transdomal sutures with the ends left long
and rotation. can be tied together in an interdomal fashion.
needle and then sutured into position by medial crural sutures positioned with its superior margin overlying the dome/tip-
(described previously). Additional medial crural sutures can defining points and extends inferiorly a variable distance (usu-
then be placed, if necessary, to control medial crural flaring. ally 10 to 12 mm). It is fashioned with rounded graft edges in
order to avoid a visible and palpable step-off (Figure 48.33).
Nasal Tip Grafts. Nasal tip grafts are the final step in The combination tip graft is generally used in difficult
the algorithm if more tip projection or definition is desired primary rhinoplasties, thick-skinned patients, and secondary
after the preceding maneuvers.48 These grafts may take several rhinoplasties with inadequate tip projection. It is essentially
Aesthetic Surgery
forms, but have a tendency to become visible in the long term a combination of the above-mentioned onlay tip graft and
regardless of the specific type used. Tip grafts are reserved for infratip lobular graft. Superiorly, it is anchored to the ULCs
the patient in whom the prior, more predictable, methods do and inferiorly it is secured to the caudal margin of the medial
not result in satisfactory tip refinement and projection. There crura (Figure 48.34).
are three general types of tip grafts: A thorough understanding of the anatomic basis of tip sup-
• Onlay tip grafts port is also required when trying to decrease nasal tip pro-
• Infratip lobular graft jection. For instance, in the open approach where the skin
• Combination tip graft envelope has been undermined and the fibroelastic and liga-
mentous attachments have been disrupted, the primary means
The onlay tip graft is usually placed over the dome of the of decreasing tip projection lies in alteration of the length and
middle crura and can be fashioned from any type of carti- strength of the LLCs. Several techniques, such as transection,
lage54,55; the cartilage obtained from the cephalic trim harvest setback, and resuturing of the medial or lateral crura, may
(if performed) works exceptionally well (Figure 48.32).56 be used to obtain the desired result. However, regardless of
The infratip lobular graft is a shield-shaped graft used to the technique used, it is important to recognize that if the tip
increase infratip lobular definition and projection.57,58 It is projection is significantly decreased, alar flaring or columellar
FIGURE 48.30. Interdomal sutures approximate the medial/middle FIGURE 48.32. The onlay tip graft is usually placed over the dome
crura and can affect both tip refinement and projection. of the middle crura.

Osteotomies
Several techniques exist in order to perform osteotomies,
including medial, lateral, transverse, and a combination of
the above. These can be performed via an external or internal
approach.
Osteotomies are generally performed for the following
reasons:
• To narrow the lateral walls of the nose
• To close an open roof deformity (after dorsal hump reduc-
tion)
• To create symmetry by allowing for straightening of the
nasal bony framework
Contraindications include patients with short nasal bones,
elderly patients with thin, fragile nasal bones, and patients
with heavy eyeglasses.59-66
Lateral osteotomies may be performed as “low-to-high,”
“low-to-low,” or a “double level” (Figure 48.35). Furthermore,
they may be combined with medial, transverse, or greenstick
fractures of the upper bony segment. Regardless of the tech-
nique used, however, it is paramount to preserve Webster’s
FIGURE 48.33. The infratip lobular graft overlies the dome and triangle. This bony triangular area of the caudal aspect of
extends inferiorly a variable distance. the maxillary frontal process is necessary for a patent airway.
Preservation of this triangle prevents functional nasal airway
obstruction (Figure 48.36).
A step-off deformity is prevented by maintaining a
bowing may result. This, then, would require concomitant smooth fracture line low along the bony vault. The cephalic
correction. margin of the osteotomy should not be higher than the
medial canthal ligament, as the thick nasal bones above this
Altering Tip Rotation. In order to alter tip rotation, the area increase the technical difficulty, and it is possible to
existing extrinsic forces stabilizing the tip at its current posi- cause iatrogenic injury to the lacrimal system with resultant
tion must be released. The first step is usually to perform a epiphora.
cephalic trim, which separates the connection between ULCs A “low-to-high” osteotomy begins low at the pyriform
and LLCs. Another technique is to resect a variable amount of aperture and ends “high” medially on the dorsum and is
the caudal septum. This releases tension on the nasal tip and generally used to correct a small open roof deformity or to
allows for more cephalad rotation by transecting the fibrous mobilize a moderately wide nasal base. The nasal bones are
attachments of the medial crura and the caudal septum. This then medialized by a gentle greenstick fracture along predict-
maneuver can also affect tip projection. After the desired able fracture patterns obtained based on nasal bone thick-
amount of tip rotation has been achieved, its position is main- ness.59-61 Thicker nasal bones may require a separate superior
tained with suture techniques (medial crural-septal sutures) oblique osteotomy in order to mobilize them enough to be
and/or a columellar strut or septal extension graft. greensticked.
It may be necessary to perform a limited resection of nasal A “low-to-low” osteotomy starts low along the pyri-
mucosa and membranous septum in order to maintain proper nasal form aperture and continues low along the base of the
balance and harmony when altering the amount of tip rotation. bony vault to end up in a lateral position along the dorsum
near the intercanthal line. It is generally considered a more
powerful technique in that it results in more significant
medialization of the nasal bones and therefore is classically
used when there is a large open roof deformity or if a wide
bony base requires correction. This type of osteotomy tech-
nique is frequently accompanied by a medial osteotomy
in order to better mobilize the nasal bones to achieve the
desired result.
Medial osteotomies are used to facilitate medial position-
ing of the nasal bones and are generally indicated in patients
with thick nasal bones or a wide bony base in order to achieve
a more predictable fracture pattern. Although medial osteot-
omies are frequently used in combination with lateral oste-
otomies, it is not necessary to use both in all cases. If both
techniques are performed, however, the medial osteotomy is
performed first as this makes it technically easier to perform
the subsequent lateral osteotomy. The cant of the medial oste-
otomy can be oriented in a medial oblique, paramedian, or
transverse direction. Regardless of the cant, the cephalic end
of the osteotomy still should not cross the intercanthal line
for the reasons previously discussed. It is also important to
avoid placing the medial osteotomy too far medially as this
can cause a “rocker deformity,” where a widened upper
FIGURE 48.34. The combination tip graft combines the onlay tip dorsum results from the fractured nasal bone “kicking out.”
graft and the infratip lobular graft. This can be avoided by following a superior oblique angle
(Figures 48.37A and B).

Low to high Low to low Double level

FIGURE 48.35. The various types of lateral osteotomies.
A “double-level” lateral osteotomy is indicated in cases the soft triangle area, as contour irregularities and notching
where there is an excessive lateral wall convexity that is too may result.
great to be corrected with a standard single-level lateral oste- The throat pack is removed and the oropharynx and stom-
otomy or when significant lateral nasal wall asymmetries ach are carefully suctioned of any blood, which may result
exist. The more medial of the two lateral osteotomies is first in postoperative nausea and vomiting. Antibiotic ointment–
Aesthetic Surgery
created along the nasomaxillary suture line. The more lateral coated intranasal Doyle splints are placed if septal work has
of the two is then created in standard low-to-low fashion been performed, which are secured with a transseptal 3-0
(Figure 48.38). nylon suture. The nasal dorsum is then carefully taped and a
Potential complications that can occur with osteotomies malleable Denver splint is applied over the dorsum. Finally, a
(of any type) are listed in Table 48.6. drip pad is fashioned from a 2 × 2 gauze and secured under the
nose with ½ inch paper tape.
Closure
At the conclusion of the procedure, after meticulous hemo- Postoperative Management
stasis has been obtained, the skin envelope is redraped.
All preoperative and postoperative instructions are reviewed
The transcolumellar incision is closed in simple interrupted
verbally and in writing prior to as well as on the day of sur-
fashion using 6-0 nylon suture, assuring precise reapproxi-
gery. The following are prescribed routinely:
mation of the incision. The infracartilaginous incisions are
reapproximated using 5-0 chromic gut sutures. Special care 1. Medrol Dosepak for 7 days (to minimize postoperative
is taken to prevent overbiting with the suture, especially in edema)
2. Hydrocodone/acetaminophen 5/500 for postoperative pain
every 4 to 6 hours as needed
Superior oblique
osteotomy
Transverse fracture Preferred superior

Webster’s triangle oblique osteotomy
Webster’s triangle
Rocker
deformity
A B
FIGURE 48.37. A. The course of a superior oblique medial osteot-
FIGURE 48.36. Preservation of Webster triangle is paramount when omy. B. “Rocker deformity” caused by placing the medial osteotomy
performing lateral osteotomies to prevent internal nasal valve collapse. too far medially.

eye mask (Swiss Eye Therapy) to help minimize postoperative

swelling. The drip pad under the nose is changed as necessary
until the drainage stops. Any manipulation of the nose, includ-
ing rubbing, blotting, or blowing, is discouraged for the first
3 weeks postoperatively. Sneezing should be done through
the mouth during this time. It is imperative to keep the nasal
splint dry in order to prevent premature discontinuation of the
splint. The hair should be washed with assistance in the sink.
Our preference is to keep our patients on a liquid diet on
the day of surgery and then advance them to a soft regular
diet the following day. Any foods that require excessive lip
movements, such as eating apples or corn on the cob, should
be avoided for 2 weeks after surgery.
During the first 2 weeks, nasal congestion is treated with
the use of normal saline nasal spray. The patient is encour-
aged to breathe through the mouth if there is difficulty with
air passage through the intranasal splints. Extreme congestion
should be treated with office suctioning.
The sutures and nasal splints are removed at the initial
visit on postoperative days 5 to 7. The nose (especially the tip)
may appear swollen and turned up and the tip may feel numb,
Double level but the patient is reassured that both are expected and will
FIGURE 48.38. The double-level osteotomy. The medial-most one resolve over several months. Normal sensation usually returns
is made first. within 3 to 6 months. The patient is instructed to avoid let-
ting anything, including eyeglasses, rest on the nose for at least
4 weeks. During this time, glasses are taped to the forehead.
3. Normal nasal saline for postoperative nasal congestion Contact lenses may be worn as soon as the swelling has dimin-
4. Antibacterial ointment to incisions three times daily ished enough to allow easy insertion (usually less than 5 to
7 days postoperatively).
During the first 48 to 72 hours, the patient is instructed The patient’s activity is restricted for 3 weeks postopera-
to keep the head of bed elevated at 45° and use a chilled gel tively. Any contact sports or activities that may cause direct
trauma to the nose are prohibited for at least 4 to 6 weeks
TA B L E 4 8 . 6 after surgery. Although some noses look excellent within 6 to
8 weeks, some may have persistent edema for up to 1 year.
Complications of Lateral Nasal Osteotomies After 3 to 4 weeks, however, the swelling will generally not be
obvious to anyone but the patient.
Infections After the first postoperative visit, the patient returns for
Abscess follow-up at 3 and 8 weeks after the operation and then at 3,
6, and 12 months postoperatively.
Cellulitis
Granuloma
Revision Rhinoplasty
Systemic
Revision rhinoplasty offers a unique set of challenges.
Intracranial Cicatricial tissue, altered or compromised vascularity, and dis-
Operative trauma torted anatomy can be major factors that alter the planning
and execution. The septal cartilage may have already been
Local hemorrhage (hematoma, ecchymosis) harvested, which creates the need for remote cartilage harvest
Edema from locations such as the ear or rib.
In a 2009 survey of board-certified plastic surgeons and
Nasal cyst formation otolaryngologists, the majority reported revision rhinoplasty
Anosmia was required in less than 10% of patients.36 The underlying
etiology that drives the need for reoperation usually includes
Arteriovenous fistula one or a combination of the following:
Epiphora 1. Displaced anatomic structures
Canalicular bleeding 2. Undercorrection from an overconservative primary proce-
dure
Neuromuscular injury
3. Overresection/overcorrection from overzealous surgery
Intracranial injury
In the lower third of the nose, the most frequent reasons
Cosmetic problems for reoperation include further tip refinement or correction of
Excessive narrowing or convexity tip asymmetries. In the middle third, a parrot beak or narrow
mid vault deformity is responsible for most revisions. In the
Insufficient mobilization of lateral bony walls upper third, it is excessive dorsal reduction or dorsal irregu-
Unstable bony pyramid larities that require revision.
From a functional point of view, persistent nasal airway
Rocker deformity obstruction from excessive narrowing of the internal valve
Redundant soft tissue was previously the most common reason for secondary rhi-
noplasty. Once we adopted the component dorsum reduction
Stair-step deformity technique with preservation of the ULCs and placed spreader
Nasal bone asymmetry grafts when necessary, our incidence of internal valve obstruc-
tion decreased.

The open approach is preferred when performing revision 32. Friedman GD, Gruber RP. A fresh look at the open rhinoplasty technique.
rhinoplasty as it affords superior exposure of the underlying Plast Reconstr Surg. 1988;82:973-982.
33. Gunter JP. The merits of the open approach in rhinoplasty. Plast Reconstr
nasal framework, permits accurate anatomic diagnosis, and Surg. 1997;99:863-867.
facilitates complete correction.36 34. Constantian MB. Differing characteristics in 100 consecutive secondary rhi-
noplasty patients following closed versus open surgical approaches. Plast
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Chapter 49 n Otoplasty
Charles H. Thorne
This chapter reviews otoplasty for common auricular deformi- Although most prominent ears are otherwise normal in
ties such as prominent ears, macrotia, ears with inadequate shape, some prominent ears have additional deformities.
helical rim, constricted ear, Stahl’s ear, question mark ear, and The conditions enumerated below are examples of abnor-
cryptotia. mally shaped ears that may also be prominent. The term
macrotia refers to excessively large ears that, in addition to
being large, may be “prominent.” The average 10-year-old
Prominent Ears male has ears that are 6 cm in length. Most adults, men and
women, have ears in the 6 to 6.5 cm range. In men, ears that
The term prominent ears refers to ears that, regardless of size,
are 7 cm or more will look large. In women, ears may look
“stick out” enough to appear abnormal. When referring to
large even if significantly less than 7 cm. Ears with inad-
the front surface of the ear, the terms front, lateral surface,
equate helical rims or shell ears are those with flat rather
and anterior surface are used interchangeably. Similarly, when
than curled helical rims. Constricted ears (Figure 49.2) are
referring to the back of the auricle, the terms back, medial
abnormally small but tend to appear “prominent” because
surface, and posterior surface are used synonymously. The
the circumference of the helical rim is inadequate, caus-
normal external ear is separated by less than 2 cm from, and
ing the auricle to cup forward. The Stahl’s ear deformity
forms an angle of less than 25° with, the side of the head.
(Figure 49.3) consists of a third crus, in addition to the nor-
Beyond these approximate normal limits, the ear appears
mal crura of the triangular fossa, which traverses the scapha.
prominent when viewed from either the front or the back.
This may give the ear a “Mr. Spock” pointed appearance in
While these measurements provide a guideline, aesthetic judg-
addition to being prominent. Question mark ears earn their
ment is more important. In 25 years of dealing with auricular
name because deficiency of the supralobular region gives
deformities, the author has never measured either the angle
the ear the shape of a question mark. The upper portion of
with the skull or the distance from the side of the head.
the auricle tends to be large and may be prominent as well.
To correct prominent ears, the anatomic abnormality is
Cryptotia (Figure 49.4) describes the auricle in which the
determined (Figure 49.1). The three most common causes of
upper pole of the helix is buried beneath the temporal skin.
prominent ears are the following and are usually present in
Cryptotic ears are not prominent.
combination:
1. Underdeveloped antihelical fold. As a result of inadequate Goals of Otoplasty
folding of the antihelix, the scapha and helical rim pro-
trude. This anatomic abnormality causes prominence of The goal of otoplasty is to set back the ears in such a way
the upper third and, in many cases, the middle third of the that the contours appear soft and natural, there is no evidence
ear. of surgical intervention, and the setback is harmonious: that
2. Prominent concha. The concha may be excessively deep, is, each portion of the ear appears in appropriate position
the concha/mastoid angle may be excessive, or there may relative to the rest of the auricle. When examined from the
be a combination of these two factors. This anatomic various angles, the corrected auricle should have the following
abnormality causes prominence of the middle third of the characteristics:
auricle. 1. Front view. When viewed from the front the helical rim
3. Protruding earlobe. The protruding earlobe causes promi- should be visible, not set back so far that it is hidden
nence of the lower third of the ear. behind the antihelical fold.
A B
FIGURE 49.1. Comparison of normal and prominent ear anatomy. A. Normal ear. B. Components of the prominent ear. (Reproduced with
permission of Charles H. Thorne, MD. Copyright Charles H. Thorne, MD.)
530
Chapter 49: Otoplasty 531
A B
FIGURE 49.2. Constricted ear. A. Mildly constricted ear. Otoplasty requires increasing the circumference of the helical rim by advancing the
crus of the helix into the helical rim (see Figure 49.7). B. Severely constricted ear. This degree of constriction can only be repaired by discarding
some of the cartilage and performing an ear reconstruction as in microtia. (Courtesy of David Furnas, MD.)
Aesthetic Surgery
2. Rear view. When viewed from behind, the helical rim much relative to the upper and lower thirds, the helical
should be straight, not bent like a “C” or a “hockey rim will form a “C” when viewed from behind, creating
stick.” If the helical rim is straight, the setback will be the so-called telephone deformity. Similarly, if the earlobe
harmonious; that is, the upper, middle, and lower thirds is insufficiently set back, the rear view will reveal a hockey
of the ear will be set back in correct proportion to each stick appearance to the helical rim contour.
other. If, for example, the middle third is set back too 3. Lateral view. The contours should be soft and natural, not
sharp and “human-made.”
Timing of Otoplasty
There is no absolute rule about when otoplasty should be per-
formed. In young children with extremely prominent ears, a
reasonable age is approximately 4 years. In cases of macro-
tia associated with prominence, the author has performed the
procedure as early as age 2 years, thinking that any restriction
of growth is an advantage. Regardless of the exact age, the
procedure requires general anesthesia. In other cases, usually
more minor, the parents may choose to wait until the child
can participate in the decision. This may allow the procedure
to be performed under local anesthesia, although it is a rare
child that can tolerate local anesthesia before age 10 years,
and many not until they are adults.
Operative Procedure
Numerous methods have been described for correcting the ana-
tomic abnormalities described above. The techniques that have
stood the test of time are the simplest, most reliable, and least
likely to cause complications or an “operated” look. The tech-
niques described below are used alone or in combination depend-
ing on the anatomic deformity and the choice of the surgeon.
Antihelical Fold Manipulation.

• Suturing of cartilage. Mattress sutures are placed from the
scapha to the triangular fossa or concha, as described by
FIGURE 49.3. Stahl’s ear. Note the third crus that traverses the sca- Mustarde,1 and are tied with sufficient tension to increase
pha. (Courtesy of David Furnas, MD.) the definition of the antihelical fold, thereby setting back
the helical rim and scapha (Figure 49.5).

A B
FIGURE 49.4. Cryptotia. A. Patient in whom a relatively normal helical rim is buried in the temporal soft tissues. The upper portion of the
auricle can be exposed by outward traction on the ear. B. Outward traction (in a different patient) causes the upper portion of the ear to emerge
from its hiding place. (Courtesy of David Furnas, MD.)
• Stenstrom technique of anterior abrasion.2 The anterior Conchal Alteration.

surface of the antihelical fold cartilage is abraded, causing • Suturing. The angle between the concha and the mastoid
the cartilage to bend away from the abraded side (prin- skull can be decreased by placing sutures between the
ciple of Gibson) toward the side of intact perichondrium concha and the mastoid fascia as described by Furnas4
(Figure 49.6). (Figure 49.5).
• Full-thickness incisions. A single full-thickness incision • Conchal excision. From either an anterior or posterior
along the desired curvature of the antihelix permits fold- approach, a full-thickness crescent of cartilage is removed
ing with slight force, creating an antihelical fold (Luckett from the posterior wall of the concha (taking care not to
procedure). Because the fold is sharp and unnatural violate or deform the antihelical fold), thereby reducing the
appearing, this single-incision technique was modified. In conchal height. The conchal defect is meticulously closed
the Converse/Wood-Smith technique,3 a pair of incisions with sutures to avoid a visible ridge within the concha. The
is made, parallel to the desired antihelical fold, and tubing excision is designed so that the eventual closure will lie at
sutures are placed to create a more defined fold. the junction of the floor and posterior wall of the concha,
FIGURE 49.5. Otoplasty technique: The combination of a Mustarde scapha-conchal suture, conchal resection with primary closure, and a
Furnas conchal-mastoid suture. Note that the conchal closure is at the junction of the floor and posterior wall of the concha. A. Sutures placed.
B. Sutures tightened to create the desired contour. C. Same sutures as seen through the retroauricular incision. (Reproduced with permission of
Charles H. Thorne, MD. Copyright Charles H. Thorne, MD.)

A C
FIGURE 49.6. Stenstrom technique. The antihelical fold is scored.

The cartilage bends away from the scoring, moving the helical rim
closer to the head and increasing the prominence of the antihelix.
Aesthetic Surgery
B D
where it is least conspicuous and causes the least distortion FIGURE 49.7. Pre- and post-op otoplasty. (AB): Pre-op appearance.
of the normal auricular contours (Figure 49.5). (CD): Post-op appearance demonstrating straight helical contour.
• A combination of Furnas suture and conchal excision
techniques (Figure 49.5).
Correction of Earlobe Prominence. Earlobe promi- of the deformity and in part on the surgeon’s personal prefer-
nence is not corrected by the above maneuvers. In fact, these ences.6 This author’s preferred technique involves Mustarde
maneuvers may increase the prominence of the earlobe, mak- sutures to recreate the antihelix and set back the upper and
ing earlobe repositioning the most difficult and neglected part middle thirds of the ear. The abrasion techniques are unreli-
of the procedure. An auricle that has been repositioned in its able, uncontrollable, and unnecessary and may result in sharp
upper two thirds but still has a prominent lobule will appear edges or an overdone appearance. It should be noted that the
just as abnormal and disharmonious as the original defor- antihelix is not straight; rather it curves forward superiorly,
mity (Figure 49.7). It has been said that suturing the tail of to almost parallel the inferior crus. To create an antihelix of
the helical cartilage to the concha will correct earlobe promi- the correct contour, the sutures are not placed parallel to each
nence. Unfortunately, the tail of the helix does not extend into other but rather placed like spokes of a wheel, with the center
the lobule and setting it back does not reliably set back the of the wheel being the top of the tragus. If the sutures are
earlobe. Other authors have described techniques involving placed parallel to each other, the antihelix will be excessively
skin excision and sutures between the fibrofatty tissue of the straight. In the conchal region, the author most commonly uses
lobule and the tissues of the neck. The best technique in the both a conchal resection and Furnas conchal-mastoid sutures
author’s experience is the technique described by Gosain,5 or as shown in Figure 49.5. The combination allows the resec-
a variation thereof, in which a small amount of skin is excised tion to be small (1 to 2 mm), minimizing iatrogenic deformity.
on the medial surface of the earlobe. When this defect is closed When conchal excision is used alone, a deformity of the pos-
with sutures, a bite of the undersurface of the concha is taken, terior wall of the concha may result. When Furnas sutures are
which pulls the earlobe toward the head. used alone, the correction may be inadequate, the patient may
have pain, the external auditory canal can be narrowed, and
Alteration of the Position of the Upper Auricular the depth of the retroauricular sulcus is decreased. As men-
Pole. Depending on the degree of prominence of the upper tioned above, earlobe repositioning is the most difficult part
third of the ear preoperatively, the antihelical fold creation of the procedure. The Webster technique of repositioning the
may be inadequate to correct the position of the helical rim helical tail has not been effective in the author’s hands for cor-
near the root of the helix. In other words, the angle that the rection of earlobe prominence. Rather, the Webster technique
helix makes with the temporal scalp is sufficiently large that, appears to reposition the ear just above the earlobe, exagger-
even after the Mustarde sutures are placed, an excessive angle ating the earlobe prominence.
exists. An additional mattress suture between the helical rim
and the temporal fascia may be required.
Other Deformities
Choice of Otoplasty Technique Macrotia. To reduce the size of the ears, an incision is made
The final operative plan for an otoplasty is a combination of on the lateral surface of the ear, just inside the helical rim,
surgical maneuvers based in part on the anatomic diagnosis through the skin and the cartilage, stopping short of the

medial skin (Figure 49.8). A crescent of scapha is removed. A the cartilage is discarded and a complete auricular reconstruc-
segment of helical rim along with a triangle of medial skin is tion performed as in microtia (Chapter 27).
then excised and closed primarily, so that the helical rim is not
redundant relative to the smaller scapha.7,8 Stahl Ear. Various techniques have been described to excise
the extra crus. This author prefers the technique described
Shell Ear. The incision is made as described above for mac- by Kaplan and Hudson.9 An incision is made inside the heli-
rotia. The wedge excision of helical rim creates just enough cal rim, the lateral skin is carefully dissected off the cartilage,
tension not only to allow approximation of the helix but also the extra crus is excised, and the cartilage defect is closed
to create some overhang of the rim. primarily. The excised cartilage can be used as an onlay
graft to reconstruct the superior crus of the triangular fossa
Constricted Ear. A number of complex classifications and (Figure 49.9).
surgical procedures have been described for constricted ears,
but, from a practical point of view, constricted ears can be Cryptotia. The superior aspect of the auricular cartilage is
divided into three types depending on what procedure is pulled out from under the scalp, an incision is made around
required to repair them. In the mildest cases, the superior the now-visible helical rim, and the medial surface of the freed
helix is folded over, creating the lop ear. Attempts to correct cartilage is resurfaced with a graft or flap. In some cases, the
the overhang using mattress sutures will not be successful. buried cartilage is quite normal, and in other cases, it is mark-
Better options include directly trimming the overhanging skin edly abnormal and requires modification.
and cartilage (this will leave a slightly short but more nor-
mal appearing ear) or resecting the overhanging cartilage only Question Mark Ear. The supralobular deficiency is variable.
and replacing it with a conchal cartilage graft to increase the Repair requires a cartilage graft. In milder cases, this can be
height and to improve the shape of the ear. In intermediate taken from the concha and resurfaced with a V-Y advance-
cases, the circumference of the helix is inadequate for the rest ment of the medial skin. In more severe cases, a rib cartilage
of the ear, causing it to be cupped forward. These deformities graft is required and a standard two-stage reconstruction
are true to the name constricted ear because that is exactly is performed, as one would perform for a significant post-
how the ears look. To improve the appearance, the crus of the traumatic defect (Chapter 27).10,11 The deformity is often asso-
helix is advanced out of the concha and into the helical rim, ciated with excess tissue in the upper third of the ear requiring
as in the Antia-Buch procedure, and standard otoplasty tech- reduction. In the severe cases, the entire ear is reconstructed
niques are used in addition. In severe cases of constricted ear, as in microtia.
FIGURE 49.8. Technique for reduction otoplasty. (With permission from Thorne CH, Wilkes G. Otoplasty, ear deformities and ear reconstruction.
Plast Reconstr Surg. 2012;129(4):701e, Figure 2.)

Aesthetic Surgery
FIGURE 49.9. Technique for repair of Stahl’s ear. (With permission from Thorne CH, Wilkes G. Otoplasty, ear deformities and ear reconstruction.
Plast Reconstr Surg. 2012;129(4):701e, Figure 3.)
Postoperative Care Complications

14
A bulky, noncompressive dressing is placed for a day or

two. Excessive pressure from the dressing will cause pain,
Hematoma
increase swelling, and may lead to abrasion or even necrosis Hematomas are one of the few early complications of oto-
of auricular skin. When the dressing is removed, the patient plasty. Excessive pain or bleeding necessitates immediate
wears a loose headband at night only for 6 weeks. Again, the removal of the dressing to rule out and, if necessary, evacuate
headband should only be tight enough that it does not fall a hematoma.
off. The purpose is to prevent the corrected ear from being
pulled forward when the patient rolls over in bed. A tight Infection
headband can erode the lateral surface of the ear, creating an
open wound. Cellulitis is rare after otoplasty but is treated aggressively with
intravenous antibiotics in an attempt to avoid chondritis. The
latter may require debridement and leave the ear permanently
Nonoperative Technique in Infants disfigured.
During the early weeks of infancy, the auricular cartilage
has unusual plasticity, attributed to circulating maternal
estrogens. During this privileged period, prominent ears and
Suture Complications
related deformities can be corrected permanently by mold- By far the most common complication of otoplasty in the
ing the ears into the correct shape with tape and soft dental author’s experience is related to suture extrusion in the retro-
compound.12,13 The splints and tape are replaced regularly, auricular sulcus. Such sutures are easily removed but may be
and the skin is checked compulsively for erosion. The process associated with unattractive and/or painful granulomas. The
is continued for several months or until there is no further use of absorbable sutures might eliminate this complication
improvement in auricular contour. This ability to mold car- but the author has not had the courage to abandon perma-
tilage is currently being exploited in presurgical molding of nent sutures. The author prefers monofilament sutures that
the cleft nasal deformity (Chapter 23). It is not clear how are less likely to form pustules or granulomas when protrud-
long cartilage retains this “moldability” and therefore it is ing through the skin. On the other hand, the monofilament
not clear when infants are too old to have this technique sutures require more knots and may be more likely to pro-
attempted. trude through the skin in the first place.

the best choice, but the author has no experience with this
Overcorrection/Unnatural Contours suture and therefore cannot credibly recommend it.
The most common significant complication of otoplasty is 5. Degree of correction. Overcorrection of the ears is
overcorrection. Attention to the principles outlined above the most common problem. Contours should be soft,
will minimize overcorrection and the creation of unnatural round, and natural rather than sharp and surgical in
contours. appearance.
The author’s personal thoughts about otoplasty are as
follows6:
References
1. Incisions. The incision is best placed in the retroauricular
sulcus, not up on the back of the ear. The latter is more 1. Mustardé JC. Correction of prominent ears using buried mattress sutures.
Clin Plast Surg. 1978;5:459.
convenient for the surgeon and more expeditious, but may 2. Stenstrom SJ, Heftner J. The Stenstrom otoplasty. Clin Plast Surg.
leave a scar that is visible when the patient is viewed from 1978;5:465.
behind. Specific indications (macrotia, constricted ear, or 3. Converse JM, Wood-Smith D. Technical details in the surgical correction of
ears with inadequate helical rim) call for an incision on the the lop ear deformity. Plast Reconstr Surg. 1963;31(2):118.
4. Furnas D. Suture otoplasty update. Perspect Plast Surg. 1990;4:136.
front (lateral surface) of the ear, where it is ideally made 5. Gosain AK, Recinos RF. A novel approach to correction of the
just inside the helical rim. prominent lobule during otoplasty. Plast Reconstr Surg. 2003;112(2):
2. Skin excision. Skin excision is unnecessary, does not con- 575-583.
6. Thorne CH. Otoplasty. Plast Reconstr Surg. 2008;122(1):291-292.
tribute to the correction, and may lead to hypertrophic or 7. Gault D, Grippaudo F, Tyler M. Ear reduction. Br J Plast Surg. 1995;48:30.
undesirable scars. The only exception is the earlobe, where 8. Argamaso R. Ear reduction with or without setback otoplasty. Plast
it may be necessary. When performing the latter, care is Reconstr Surg. 1990;85(2):316.
taken to remove only enough skin, adjacent to the retrol- 9. Kaplan H, Hudson D. A novel surgical method of repair for Stahl’s ear: a
case report and review of current treatment modalities. Plast Reconstr Surg.
obular sulcus, to allow repositioning and to leave a full, 1999;103(2):566.
free earlobe for ear piercing and an aesthetically normal 10. Greig AVH, Podda S, Thorne CH, McCarthy JG. The question mark
earlobe. ear in patients with mandibular hypoplasia. Plast Reconstr Surg.
3. Techniques. The simplest techniques are best. Techniques 2012;129(2):368e-369e.
11. Al-Qattan MM. Cosman (question mark) ear: congenital auricu-
that involve abrasion or full-thickness incisions and/or lar cleft between the fifth and sixth hillocks. Plast Reconstr Surg.
tubing to create the antihelical fold are unnecessary and 1998;102(2):439.
should be avoided. 12. Matsuo K, et al. Non-surgical correction of congenital auricular deformities
4. Choice of sutures. The author has returned to monofilament in the early neonate: a preliminary report. Plast Reconstr Surg. 1984;73:38.
13. Matsuo K, Hayashi R, Kiyono M, et al. Nonsurgical correction of congenital
permanent sutures because of occasional granulomas associ- auricular deformities. Clin Plast Surg. 1990;17(2):383.
ated with braided sutures such as Mersilene. A long-lasting 14. Thorne CH, Wilkes G. Ear deformities, otoplasty, and ear reconstruction.
monofilament suture such as polydioxanone suture may be Plast Reconstr Surg. 2012;129(4):701e-716e.

Chapter 50 n Facial Skeletal Augmentation
With Implants
Michael J. Yaremchuk and Chad R. Gordon
The morphology of the facial skeleton is a fundamental deter- around the implant, thereby isolating the implant. The surface
minant of facial appearance. Facial skeletal augmentation is of the implant determines the nature of the capsule. Smooth
usually accomplished with alloplastic materials. Implants can implants result in the formation of smooth-walled capsules.
be used to restore or create contour during reconstruction of Porous implants allow varying degrees of soft-tissue ingrowth,
congenital, posttraumatic, or postablative deformities. They which results in a less-dense and less-defined capsule. Clinical
are useful adjuncts and, sometimes, alternatives to orthogna- experience has shown that porous implants have fewer ten-
thic surgery in patients with corrected or normal occlusion, dencies to erode underlying bone and fewer tendencies to
respectively. Most often, facial skeletal augmentation is per- migrate as a result of overlying soft-tissue mechanical forces.
formed electively to improve facial aesthetics (Figure 50.1). These attributes are presumably due to the fibrous incorpora-
tion associated with porous implants as opposed to the fibrous
encapsulation typical of smooth implants.
Preoperative Planning The most commonly used and commercially available
Physical examination is the most important element in pre- materials today for facial skeletal augmentation are solid sili-
operative assessment and planning. Reviewing life-size frontal cone, polytetrafluoroethylene, and porous polyethylene. The
and lateral photographs with the patient is useful when dis- silicone rubber used for facial implants is a vulcanized form of
cussing aesthetic concerns and goals. Although cephalometric polysiloxane, which is a polymer created from interlocking sil-
radiograph analysis can be helpful in the planning, the size icone and oxygen with methyl side groups. Silicone is derived
and position of the implants are largely aesthetic judgments. from silicon, a semimetallic element that in nature combines
Computerized tomographic (CT) data with subsequent physi- with oxygen to form silicon dioxide, or silicone. Beach sand,
cal model reconstruction can be particularly useful in planning crystals, and quartz are silica. The advantages of solid silicone
the procedure or designing and fabricating implants specific are that it is easily sterilizable by steam or irradiation, it can
for an individual patient. be carved easily with either a scissor or scalpel, and it can
Aesthetic Surgery
Although often referenced in texts discussing facial skeletal be stabilized with a screw or a suture. There are no known
augmentation, neoclassical canons describing ideal facial pro- clinical or allergic reactions. Because it is smooth, it can be
portions have a limited role in surgical evaluation and plan- removed quite easily. The disadvantages of silicone implants
ning because they are arbitrary. When the facial dimensions of include their tendency to cause resorption of the bone under-
normals and those deemed more attractive than normal were lying it, the potential to migrate if not fixed, and the likeli-
compared with artistic ideals, it was found that some theo- hood for the implant and its fibrous capsule to be visible when
retic proportions are never found, and others are one of the placed under a thin soft-tissue cover.
many variations.1,2 For these reasons, we have found it more
useful to use the anthropometric measurements of normals to Polytetrafluoroethylene. Polytetrafluoroethylene has a
guide our gestalt for the selection of implants for facial skel- carbon-ethylene backbone to which are attached four fluorine
etal augmentation. molecules. It is chemically stable, has a nonadherent surface,
In planning facial skeletal augmentation, it is important and, because it is not cross-linked, is flexible. Extensive expe-
to realize that small increases in skeletal projection have a rience has been accumulated with polytetrafluoroethylene
powerful impact on facial appearance. It is emphasized to the (Gore-Tex; WL Gore, Flagstaff, AZ) for vascular prosthe-
patient during the preoperative consultation that all faces are ses, soft-tissue patches, and sutures. A variety of preformed
asymmetric. If unrecognized preoperatively, an asymmetric implants are available for both subdermal and subperios-
postoperative result usually may be interpreted by the patient teal placement. Preformed implants are made with a pore
as a technical error by the surgeon. size between 10 and 30 μm. The porosity allows for some
soft-tissue ingrowth, for less fibrous encapsulation, and for
less tendency to migrate as compared with smooth-surfaced
Implants implants. It is easily sterilizable, smooth enough to be maneu-
Materials vered easily through soft tissues, and can be fixed to underly-
ing structures with sutures or screws.
Virtually all aesthetic facial skeletal augmentation is achieved
with alloplastic implants. The use of synthetic materials Polyethylene. Polyethylene is a simple carbon chain of eth-
avoids donor site morbidity and vastly simplifies the proce- ylene monomer. The high-density variety—Medpor (Porex,
dure in terms of time and complexity. Implant materials used Newnan, GA) and SynPOR (Synthes, West Chester, PA)—is
for facial skeletal augmentation are biocompatible, that is, used for facial implants because of its high tensile strength.
they have an acceptable interaction between the material and Although chemically similar to polytetrafluoroethylene, poly-
the host. Because the host has little or no enzymatic ability to ethylene has a much firmer consistency that resists material
degrade the implant material, the implant tends to maintain compression yet permits some flexibility. Its intramaterial
its volume and shape. Likewise, the implant has a minimal porosity between 125 and 250 μm allows more extensive
and predictable effect on the host tissue that surrounds it. This fibrous ingrowth as compared with polytetrafluoroethylene.
type of relationship is an advantage over the use of autog- Soft-tissue ingrowth lessens the implant’s tendency to migrate
enous bone which, when revascularized, will be remodeled to and to erode underlying bone. Its firm consistency allows it to
varying degrees, thereby changing volume and shape.3 be easily fixed with screws and to be contoured with a scal-
The presently used alloplastic implants used for facial pel or power equipment without fragmenting. A disadvantage
reconstruction do not have a toxic effect on the host.4 The of its greater porosity is that it allows soft tissues to adhere
host responds to these materials by forming a fibrous capsule to it, making placement more difficult and requiring a larger
537
A B
FIGURE 50.1. A 26-year-old male who in two operations had mul-

tiple implants placed. Implant augmentation of the infraorbital rim,
paranasal, malar, and mandibular body was performed. In addi-
tion, rhinoplasty, midface lift, and lateral canthopexies were also
performed. A. Preoperative; B. Diagrammatic representation of
operation; C. Postoperative. (From Yaremchuk MJ. Facial skeletal
reconstruction using porous polyethylene implants. Plast Reconstr
Surg. 2003;111:1818, with permission.)
C

Chapter 50: Facial Skeletal Augmentation with Implants 539
pocket than is required for smoother implants. Soft-tissue
ingrowth into the larger pores also makes implant removal Anesthesia
more difficult. Facial skeletal augmentation can be performed under local
or general anesthesia and is routinely performed on an out-
Requisites of Implant Shape, Positioning, patient basis. I prefer to perform most facial skeletal surgery
and Immobilization under general endotracheal anesthesia because most facial
implants are placed either in the malar midface or along the
Shape. The superficial surface of the implant determines the mandible, which requires a combination of intraoral inci-
new skeletal morphology. Its posterior surface should mold to sions. Endotracheal intubation assures protection of the
the bone to which it is applied. Gaps between the bone and airway and the optimal antiseptic preparation of the oral
the implant result in unpredictable increases in augmentation. cavity. Patient positioning and exposure for implant place-
The implant margins must taper imperceptibly into the native ment are also optimized when the airway is controlled.
skeleton so that they are neither visible nor palpable. The surgical site is infiltrated with a solution containing
Positioning. Although some surgeons prefer to place Marcaine for postoperative pain control and epinephrine to
implants in a soft-tissue pocket (supraperiosteal), clinical minimize bleeding.
experience has led to a strict policy of subperiosteal place-
ment. A subperiosteal pocket involves a dissection that is safe Areas For Augmentation
to nerves and is relatively bloodless. It allows optimal visual- The mid and lower face are areas most often altered with
ization of the skeleton and therefore the opportunity for pre- implants.
cise augmentation.
The size of the pockets is determined by the type of implant
used and its method of immobilization. The long-standing
Midface Augmentation
teaching when using smooth silicone implants is to make a Implants are specifically designed to augment the malar, para-
pocket just large enough to accommodate the implant so as to nasal, and infraorbital rim areas.
guarantee its position. Porous implants require a larger pocket
because they adhere to the soft tissue during their placement. Malar. Patients who seek malar augmentation may have
When using smooth or porous implants, I dissect widely enough normal anatomy but desire greater prominence of their
to have a perspective of the skeletal anatomy being augmented, middle malar prominence while others have midface skeletal
which allows precise and symmetric implant positioning. deficiency.5
Malar augmentation can be performed through intraoral,
Immobilization. Many surgeons stabilize the position of coronal, or eyelid incisions. An intraoral approach is pre-
Aesthetic Surgery
the implant by suturing it to surrounding soft tissues or by ferred. An upper buccal sulcus incision is made far enough
using temporary transcutaneous pullout sutures. Screw fixa- from the apex of the sulcus so that sufficient labial tissue is
tion of the implant to the skeleton has several benefits. It pre- available on either side for a secure closure. Division of the
vents movement of the implant. Because each facial skeleton lip elevators is avoided. Taking care to identify the infraor-
has a unique and varying surface topography, portions of an bital nerve, subperiosteal dissection is carried over the malar
implant may not conform to the bone, leaving gaps between eminence and onto the zygomatic arch, almost up to the zygo-
the implant and the skeleton. This results in unpredicted maticotemporal suture. Surgeons who use smooth silicone
increases in augmentation and distortions of the desired facial implants often assure the position of the implant by using
shape. Screw fixation assures application of the implant to suture suspension fixation.
the bone. Screw fixation also allows for final contouring of The position of both smooth and porous implants can be
the implant in position. This final contouring is particularly certain with screw fixation of the implant to the skeleton.
important where the edge of the implant interfaces with the Patients who are dissatisfied with malar implant surgery fre-
skeleton (Figure 50.2). Step-offs between the implant and the quently complain that the implants are too large, are placed
skeleton may be palpable and visible. asymmetrically, or are placed too far laterally, thereby exag-
gerating midface width.
Paranasal. A relative deficiency in lower midface projec-

tion may be congenital or acquired, particularly after cleft
surgery and trauma. Patients with satisfactory occlusion
and midface concavity are candidates for skeletal augmen-
tation. Implantation of alloplastic material in the paranasal
area can simulate the visual effect of Le Fort I advancement
(Figure 50.3).6 Paranasal augmentation is done through an
upper gingival buccal sulcus incision made just lateral to the
piriform aperture. Placement of incisions directly over an
Contouring distal transition implant is avoided.
Screw fixation Infraorbital Rim. Augmentation of this area is useful for
patients with deficiencies of the upper midface and infraor-
bital rim area. This skeletal deficiency is often responsible
for overly prominent eyes. Infraorbital rim augmentation can
effectively reverse the “negative” vector of midface hypoplasia
(Figures 50.1 and 50.4).7
The infraorbital rim and adjacent anatomy should be
FIGURE 50.2. Representation of a preferred technique for chin aug- exposed sufficiently to assure ideal implant placement,
mentation. Through a submental approach, a two-piece porous poly-
smooth implant facial skeleton transition, and screw fixa-
ethylene implant is fixed to the skeleton with titanium screws. This
maneuver immobilizes the implant and obliterates any gaps between tion. Subciliary skin or skin muscle flap incisions provide
the implant and the underlying bone. The implant is being contoured adequate exposure. A transconjunctival incision alone
to provide an imperceptible implant-native mandible transition. provides limited exposure and often requires concomitant
intraoral access.

A B
FIGURE 50.3. A 26-year-old woman underwent an aesthetic rhino-

plasty and paranasal augmentation. A. Preoperative. B. Postoperative.
C. Artist’s rendition of implant placement.
C
Mandibular Augmentation. Each of the anatomic areas projection of the nose, the relationship to the lips, and the
of the mandible—the chin, body, angle, and ramus—is ame- depth of the labiomental sulcus.
nable to augmentation.
Implant Design. Early implant designs augmented the
mentum only and often created a stuck-on appearance as
Chin a result of failure of the lateral aspect of the implant to
The ideal facial profile portrays a convex face, with the merge with the anterior aspect of the mandibular body.
upper lip projecting approximately 2 mm beyond the lower “Extended” chin implants first popularized by Flowers9 and
lip and the lower lip projecting approximately 2 mm beyond Terino10 have lateral extensions that enable the chin implant
the chin.8 The projection of the chin should be interpreted in to better merge with more lateral mandibular contours.
the context of the surrounding facial features, including the Myriad designs are available that give great latitude in the

Positive Vector Negative Vector “Reversed” Negative Vector
Implant
FIGURE 50.4. Globe-orbital rim relationships have been categorized by placing a line or “vector” between the most anterior projection of the
globe and the malar eminence and lid margin. (Left) Positive vector relationship. In the youthful face with normal globe-to-skeletal rim rela-
tions, the cheek mass supported by the infraorbital rim lies anterior to the surface of the cornea. The position of the cheek prominence beyond
the anterior surface of the cornea is termed a positive vector. (Center) Negative vector relationship: In patients with maxillary hypoplasia, the
cheek mass lies posterior to the surface of the cornea. The position of the cheek prominence beyond the anterior surface of the cornea is termed a
negative vector. (Right) “Reversed” negative vector relationship: Alloplastic augmentation of the infraorbital rim can reverse the negative vector.
desired effect. Extended porous polyethylene implants that Implant Augmentation versus Sliding
have limited flexibility are designed in two pieces to allow
their placement through a limited incision. The two pieces Genioplasty
Aesthetic Surgery
connected by a small bar in the midline convey an additional Sliding genioplasty involves a horizontal osteotomy of the
advantage.11 The central connecting bar can act as a hinge mandible approximately 4 mm beneath the mental foramen.
allowing the arc of the implant to be adjusted so that the A now free chin point that can be moved in any direction is
inferior border of the implant can follow the inferior bor- positioned as desired, usually anteriorly to increase chin pro-
der of the mandible. This is usually not possible with an jection. It has certain advantages over implant augmentation
extended one-piece chin implant, often resulting in unde- of the chin. First, the chin point can be lowered after oste-
sired outcomes. otomy to increase the vertical height of the chin. Vertical elon-
gation may efface the deep labiomental sulcus affecting some
Submental Incision. Ideal results from alloplastic aug- patients. Second, the chin point advancement stretches the
mentation of the chin are not routinely obtained. Problems attached suprahyoid muscles, thereby decreasing submental
result from implants that merge poorly with the mandibu- fullness to improve submental contour and, in certain indi-
lar body; implants with posterior surfaces that are inap- viduals, may improve their compromised airways.
propriate for the tilt of the anterior surface of the chin; The major disadvantage intrinsic to sliding genioplasty is
asymmetric implant placement; implant migration; and the unnatural bony and border contours that accompany the
morbidity from surgical exposure. Placing two-piece selective movement of the chin point. The contour may have
extended implants through submental incisions assures a poor transition, resulting in the stuck-on appearance of the
ideal implant placement and minimizes soft-tissue morbid- chin—much like a large button chin implant. There are also
ity. The incision is carried onto the mentum and a subperi- step-offs at the osteotomy sites along the mandibular body.
osteal pocket is created that avoids disturbing the mentalis The notchings or indentations are particularly detrimental to
muscle origin and allows easy identification of the mental those who have existing prejowl sulci. Furthermore, sliding
nerves (Figure 50.2). genioplasty requires considerable facility in bone carpentry.
For example, an unanticipated obliquity in the horizontal
Intraoral Incision. In patients in whom a submental scar osteotomy can either lengthen or shorten the vertical height of
may be objectionable, an intraoral incision is employed. An the chin after advancement.
approximately 2 cm transverse incision is made 1 cm above
the buccal sulcus in the midline. When the mentalis mus- Ramus and Body. Alloplastic augmentation of the man-
cles are encountered, these muscles are neither divided nor dibular ramus and body can have a dramatic impact on the
stripped from the mandible, but are separated in the midline appearance of the lower third of the face.12 Three different
to access the mentum where a subperiosteal pocket is created. patient populations are candidates. One group has mandibular
Placement of an extended chin implant through a midline dimensions that relate to the upper and middle thirds of the
intraoral approach alone is difficult. This intraoral exposure face within the normal range. These patients desire a wider
may result in division or damage to the mentalis muscles, lower face with a well-defined mandibular border. Patients in
damage to the mental nerve, and improper positioning of the this treatment group often present with a desire to emulate the
lateral extensions of the implants. To assure implant place- appearance of models, actors, and actresses who have well-
ment, particularly of its lateral extensions, sulcus incisions 1.5 defined, angular lower faces. This patient group benefits from
to 2 cm long are made lateral to the mental nerve. The mental implants designed to augment the ramus and posterior body of
foramen usually lies halfway between the top and the bot- the mandible and, in so doing, increase the bigonial distance.
tom of the mandible and directly between the two premolars. A second subset of patients have skeletal mandibular defi-
Once the implant is positioned, it is immobilized with sutures ciency. These patients may have normal occlusion or may have
or screws. had their malocclusion treated with orthodontics alone. The

skeletal anatomy associated with mandibular deficiency that can tooth-bearing symphysis and adjacent bodies from the non–
be camouflaged with implants includes the obtuse mandibular tooth-bearing rami. Requisites for positioning the resultant
angle with steep mandibular plane and decreased vertical and anterior and posterior segments to improve occlusion, allow
transverse ramus dimensions. The addition of an extended chin bone healing, and continue joint function may result in dis-
implant will camouflage the poorly projecting chin (Figure 50.5). pleasing postoperative contour. The advancement of the tooth-
A third group of patients who benefit from alloplastic aug- bearing segment inevitably creates a contour irregularity at
mentation of the mandible are patients who have had their the site of the body osteotomy. This area of narrowing may be
Class II dental malocclusion due to mandibular deficiency visible and even disfiguring, in certain individuals. Positioning
corrected by sagittal split osteotomy with advancement of of the posterior segment requires that the condyle be seated
the occlusal segment. This procedure splits or separates the in the glenoid fossa and that there be sufficient contact with
A B
FIGURE 50.5. A 32-year-old woman with mandibular deficiency

and corrected occlusion underwent chin and mandible implant aug-
mentation. Preoperative (A) and postoperative (B, 2 years) oblique
views. C. The artist has drawn the underlying skeleton and implant
applications.
C

with fat to increase projection by 5 mm reads as a fatty chin
pad, not as a more projecting chin.
Temporal Augmentation
Concavity in the temporal area reflects a deficiency in the bulk
of the temporalis muscle or the overlying temporal fat pad.
It may be caused by senescence, low body fat, exaggerated
adjacent skeletal or soft-tissue contours, idiopathic progres-
sive atrophy, or postsurgical atrophy. We use polymethyl-
methacrylate (PMMA) to fill depressions in the temporal area.
In instances when no previous surgery has been performed
or when the temporal area has served as a dissection plane
for surgery in adjacent areas (e.g., subperiosteal facelift),
the implant material is placed beneath the temporal muscle
through a limited incision in the hair-bearing scalp.
When previous reconstructive surgery has been performed
in the temporal area, the scars from previous incisions are used
for access and the PMMA is placed over the altered temporalis
muscle and its neighboring fossa. Titanium screws are placed
along the lateral orbital rim preventing implant motion. These
operative techniques using PMMA have been reliable, long
lasting, and relatively free of complications.14
Complications
There are no scientific data to document the complication
rate related to facial skeletal augmentation. Prospective stud-
ies that control for surgical technique, implant site, patient
selection, and follow-up time do not exist. Because all the bio-
FIGURE 50.6. A 50-year-old woman underwent custom mandible materials commonly used for facial skeletal augmentation are
biocompatible, complications are usually technique related—
Aesthetic Surgery
implants designed from computerized tomographic data to correct
mandibular deficiency and irregularity after sagittal split osteotomy. improper implant size, contour, or placement.
When infection occurs, the most reliable treatment is
implant removal.
the occlusal segment to allow bone healing. When the sagittal
osteotomies are less than ideal, the location of bone fixation
is compromised and, hence, the position of the ramus. This SUMMARY
may result in aesthetically displeasing ramus height, width, or Augmentation of the facial skeleton with alloplastic materi-
asymmetry. Mandible implants can be used to improve con- als is a powerful way to alter facial appearance. Virtually any
tour in these patients.13 Custom implants designed from the area of the facial skeleton can be augmented. Requisites for
data obtained from CT scans are particularly useful to correct success include implants of appropriate size and shape, ade-
these deformities (Figure 50.6). quate soft-tissue cover, and careful subperiosteal dissection
during exposure and implant placement.
Operative Technique. A generous intraoral mucosal incision
is made at least 1 cm above the sulcus on its labial side. The ante-
rior ramus and body of the mandible are freed from their soft References
tissues. The mental nerve is visualized as it exits its foramen. It is 1. Farkas L, Hreczko TA, Kolar JC, et al. Vertical and horizontal proportions
important to free both the inferior and posterior borders of the of the face in young adult North American Caucasians: revision of neoclas-
sical canons. Plast Reconstr Surg. 1985;75:328.
mandible of soft-tissue attachments. As determined by preopera- 2. Farkas LG, Kolar JC. Anthropometrics and art in the aesthetics of women’s
tive assessment, the implant is trimmed prior to its placement faces. Clin Plast Surg. 1987;14:599.
on the mandible. To assure the desired placement of the implant 3. Chen NT, Glowacki J, Bucky LP, et al. The role of revascularization and
and its application to the surface of the mandible, the implant resorption on endurance of craniofacial onlay bone grafts in the rabbit.
is fixed to the mandible with titanium screws. The incision is 4. Rubin JP, Yaremchuk MJ. Complications and toxicities of implantable bio-
closed in two layers with absorbable sutures. Care is taken to materials used in facial reconstructive and aesthetic surgery: a comprehen-
evert the mucosal edges. A suction drain is tunneled through the sive review of the literature. Plast Reconstr Surg. 1997;100:1346.
subcutaneous tissues to exit in the postauricular area. 5. Whitaker LA. Aesthetic augmentation of the malar midface structures. Plast
6. Yaremchuk MJ, Israeli D. Paranasal implants for correction of midface con-
Implants Used to Camouflage cavity. Plast Reconstr Surg. 1998;102:51.
7. Yaremchuk MJ. Infraorbital rim augmentation. Plast Reconstr Surg.
Soft-Tissue Depressions 2001;107:1585.
The implants discussed in this chapter are designed to increase 8. McCarthy JG, Ruff JG. The chin. Clin Plast Surg. 1988;15:125.
9. Flowers RS. Alloplastic augmentation of the anterior mandible. Clin Plast
the surface projection of the facial skeleton. Certain authors Surg. 1991;18:137.
have used implants placed on the facial skeleton to disguise 10. Terino EO. Facial contouring with alloplastic implants. Facial Plast Surg
overlying soft-tissue volume inadequacy, usually caused by Clin North Am. 1999;7:55.
involutional changes. These include the submalar, prejowl, 11. Yaremchuk MJ. Improving aesthetic outcomes after alloplastic chin aug-
mentation. Plast Reconstr Surg. 2003;112:1422.
and tear trough implants. Augmentation of the skeleton to 12. Yaremchuk MJ. Mandibular augmentation. Plast Reconstr Surg.
compensate for a soft-tissue deficiency should be conservative. 2000;106:697.
Skeletal augmentation does not give the same visual effect as 13. Yaremchuk MJ, Doumit G and, Thomas MA. Alloplastic augmentation of
the soft-tissue augmentation. Similarly, soft-tissue augmenta- the facial skeleton: an occasional adjunct or alternative to orthognathic sur-
gery. Plast Reconstr Surg. 2011;127:2021-2030.
tion beyond 1 or 2 mm provides a different visual effect than 14. Gordon CR, Yaremchuk MJ. Temporal augmentation with methyl methac-
skeletal enlargement. For example, a chin point augmented rylate. Aesthet Surg. 2011;31:827.

Chapter 51 n Osseous Genioplasty
Harvey M. Rosen
Osseous genioplasty is an autogenous method for chang-

ing the size, or shape, or both of the mandibular symphysis. Alloplastic Versus
Although by strict definition it may involve merely recon- Autogenous
touring the chin by burring away bone or by adding bone
graft material, the term generally refers to an osteotomy of The choice between alloplastic augmentation (chin implants)
the anterior mandible in the horizontal (transverse) direc- and osseous genioplasty for correction of the weak chin
tion below the mental foramina (Figure 51.1A). The oste- remains controversial. The proponents of alloplastic augmen-
otomy was first described in 1942 by Hofer.1 The procedure tation cite the technical ease, the relatively low risk of compli-
remained rather obscure until 1964 when it was popular- cations, and the ability to perform the procedure under a local
ized by Converse and Wood-Smith.2 It is now the second anesthetic. Those who favor osseous genioplasty point out
most commonly performed osteotomy of the facial skeleton the extreme versatility of an osteotomy in correcting three-
for both reconstructive and aesthetic reasons (second only dimensional deformity.
to rhinoplasty). In an effort to select the correct procedure, one should sim-
Osseous genioplasty is frequently performed for two rea- ply ask which procedure will provide the best correction for
sons: (a) versatility, the chin can be moved in any direction— the particular patient. Certain factors are indisputable: (1) Chin
sagittally, vertically, or transversely (Figure 51.1 B-D); implants can adequately correct mild to moderate volume defi-
and (b) a receding chin or small mandible, or both, are ciencies of the mandible at the level of the pogonion in the sag-
common problems among white North Americans, occur- ittal dimension. (2) Chin implants cannot correct vertical excess
ring in approximately 5% of the population.3 When these of the anterior mandible. (3) Chin implants are unreliable in
factors are coupled with the emphasis that Western culture correcting asymmetries of the anterior mandible in any plane
places on aesthetics and the belief that a well-defined jaw of space. (4) Although chin implants can modestly increase the
line characterizes an aggressive, self-confident individual, vertical dimension of the anterior mandible by covering its infe-
it is little wonder that this operation has grown in popu- rior border, this has significant potential for complications as
larity. The ready availability of alloplastic material such as the soft tissue in this area is relatively thin. (5) Provided that
silastic, however, has prevented osseous genioplasty from chin implants are positioned directly over the symphysis, as
becoming an operation that large numbers of plastic they should be, and not over the dental alveolus, the labiomen-
surgeons currently employ. tal fold will increase in depth following chin implant placement.
A
B
C
FIGURE 51.1. A. Standard location and orientation of the advancement osseous genioplasty. Note that the osteotomy is placed well below the
mental foramina to avoid injury to the inferior alveolar nerve. The osteotomy extends well posterior to the vicinity of the molar teeth. The angula-
tion of this osteotomy allows forward advancement of the chin without any vertical changes. B. Simultaneous advancement and vertical reduc-
tion of the chin. Note that the two parallel osteotomies are performed with an intervening ostectomy. C. Simultaneous advancement and vertical
elongation of the chin. The interpositional material typically employed is blocks of porous hydroxyapatite. D. Lateral shifting of the symphyseal
segment to restore lower face symmetry.
544
Chapter 51: Osseous Genioplasty 545
Given these factors, the only appropriate candidates for exceedingly deep fold who undergo advancement of the
chin implantation are those with a mild to moderate sagittal chin also should be evaluated for vertical elongation. This
deficiency of the chin accompanied by a shallow labiomental should be considered in a person with a short lower face
fold. All other patients who request surgical alteration of the and in a patient with normal height of the lower face, but
chin should be considered for osseous genioplasty. never in a patient with excessive height in the lower face.
One of the least mentioned, yet compelling, reasons to The individual who has a combination of a long lower
choose osseous genioplasty instead of alloplastic chin aug- face and a deep labiomental fold is never a candidate for
mentation occurs when surgical revision is indicated. Osseous chin surgery, and such a patient should be offered a more
genioplasty is more amenable to revision because the soft- extensive orthognathic correction.5
tissue chin has not been degloved and there is no scar cap- 5. Examination of the occlusion. The majority of individuals
sule (as occurs in smooth implants) with which to contend. who request aesthetic enlargement of the chin have class II
As a result, soft-tissue displacement closely follows skeletal skeletal deformities secondary to a small mandible.5 This
displacement. Conversely, the soft-tissue response to remov- is a tip-off that coexisting problems such as abnormalities
ing a smooth implant, or to reducing its size, or to changing of lower face height and labiomental fold depth may be
its position is unpredictable because the soft tissues have been present in addition to a “weak” chin. It is important to
degloved from the bone. In addition, the dead space created by remember that prior orthodontic treatment can convert a
the implant capsule, which does not fully collapse, fills with class II malocclusion into a class I occlusion but this does
blood, creating more scar. Surgical excision of the capsule may not correct the underlying skeletal problems.
cause mentalis muscle dysfunction with subsequent lower lip
Although the extent of soft-tissue movement closely fol-
ptosis. Accordingly, the aesthetic consequences of removing
lows that of skeletal displacement when advancing, shorten-
or changing smooth chin implants are frequently undesirable.
ing, or lengthening the chin, soft-tissue response to posteriorly
Although a scar capsule may not form with porous
repositioning of the chin is, at best, 0.5 to 1. Surgical efforts to
implants, these implants can be very difficult to remove
correct an excessively prominent chin are not as predictable as
because of the soft-tissue ingrowth.
those performed to correct a small chin.
Radiographic evaluation of the chin should include a
Treatment-Planning Panorex radiograph if periapical pathology of the anterior
mandibular teeth is suspected. Any preexisting dental pathol-
Considerations ogy in this area is an absolute contraindication to chin surgery.
Preoperative evaluation of the osseous genioplasty patient In addition, one may want to evaluate the vertical dimension
includes a history and physical examination. The surgeon should between the apices of the incisor roots and the inferior border
ascertain the patient’s specific aesthetic complaints and objec- of the mandible when correcting a short chin. It is important
Aesthetic Surgery
tives as they relate to the lower face, including any concerns that enough room exists both to perform the osteotomy and to
about the height, the projection, and the symmetry in this area. apply fixation devices without risk to the roots of these teeth.
Specific inquiries should be made into any history of orthodontic
therapy, because such therapy may have been used to disguise
an underlying class II malocclusion caused by a small mandible. Surgical Technique
Physical examination should note the following five items:
Although reports exist describing osseous genioplasty under
1. The sagittal position of the pogonion relative to the lower lip local anesthesia with intravenous sedation,5 it is best under-
and the remainder of the mid- and upper face. The lower lip, taken under general anesthesia with orotracheal or nasotra-
not the mid- or upper facial structures, determines the extent cheal intubation and full protection of the airway. Hemostasis
to which the chin should be brought forward.4 Consequently, is facilitated by infiltration with a dilute epinephrine solution.
the chin should not be brought forward any further than The soft-tissue incision is placed at least 1 cm away from the
a vertical line dropped from the lower lip. When advanc- depth of the mandibular buccal sulcus onto the lower lip and
ing the chin, the ratio of soft tissue to skeletal displacement is 2 to 3 cm in length. The mucosa and submucosa are incised,
is generally 1:1. If the lower lip is recessive, as it may be in bringing the mentalis muscle and its median raphe into view.
many individuals with small mandibles who are seeking chin Once these muscles are very superficially incised, the angle
enlargement, one must be willing to accept a residual degree of the soft-tissue incision changes so that it is parallel to the
of sagittal weakness of the lower face relative to the mid- and mucosa of the lip. This direction is maintained until the ante-
upper face. This is aesthetically preferable to a chin that is rior mandibular surface is reached, leaving a large amount
advanced beyond the lower lip, which invariably results in a of mentalis muscle attached to the mandible for later muscle
bizarre, artificial appearance. Undercorrection in the sagittal reapproximation. A subperiosteal dissection of the symphy-
dimension is always preferable to overcorrection. sis is performed. The dissection is continued inferiorly only
2. A qualitative assessment of the height of the lower face as far enough to allow exposure for performing the osteotomy
it relates to the midface. In a patient with vertical excess and for applying fixation devises. Complete degloving of the
of the lower face, one has the option to reduce the vertical symphysis is not recommended because of the unpredictable
height of the chin. This can be accomplished by two paral- reattachment of the soft tissues to the bone and the potential
lel osteotomies with an intervening ostectomy or a steeply risk for the development of soft-tissue ptosis, that is, a witch’s
oblique bone cut that allows the chin to be advanced and chin.7 Exposure is continued laterally so that both mental
superiorly repositioned. nerves are identified. Posterior dissection is carried to the infe-
3. The symmetry of the lower face. Osseous genioplasty rior border of the mandible directly below the molar roots.
presents the surgeon with the opportunity to laterally shift Once the soft-tissue dissection is completed, a fissure burr
the symphyseal segment either to the right or to the left to scores a vertical mark in the midline chin, allowing it to be
achieve a symmetric lower face. Similarly, the chin can be appropriately positioned in the transverse dimension. The
vertically elongated or shortened in an asymmetric fashion reciprocating saw is used to perform the horizontal osteotomy
to correct vertical asymmetry. at least 4 mm below the mental foramina to protect the infe-
4. The depth of the labiomental fold. Sagittal advancement rior alveolar nerves. As previously mentioned, the osteotomy
or vertical shortening, or both, of the symphyseal segment is carried as far posteriorly as possible to allow for a generous
results in deepening of the labiomental fold.5 Conversely, volume of skeletal displacement. This provides for natural-
vertical lengthening of the chin tends to efface or soften looking results and avoids waist lining and excessive visibility
the fold. Accordingly, individuals with a normal or of the inevitable step in the inferior border of the mandible.

Cortical cuts should be completed with the reciprocating saw, layers. The mentalis muscle is repaired using interrupted
avoiding unnecessary prying downward of the symphyseal sutures to help avoid soft-tissue ptosis and subsequent devel-
segment, which may cause fracturing. Following mobilization opment of a witch’s chin.7 The mucosa is repaired using inter-
of the symphysis, it might be necessary to detach the anterior rupted 3-0 chromic sutures. By placing the incision well out
belly of the digastric muscles from the lingual surface if exten- onto the lower lip, there is sufficient soft tissue to close without
sive anterior dislocation is anticipated. After full mobilization tearing the tissues. This helps minimize subsequent wound con-
is achieved, fixation devices are applied to hold the chin seg- tamination and possible infection. No dressings are applied.
ment in the desired location. Although plate and screws are
popular, it is perfectly acceptable to use wire fixation.
If vertical shortening of the chin is desired, it is usually Patient Examples
accomplished by performing two parallel horizontal osteoto- The following patient examples illustrate the versatility of the
mies and removing the intervening segment of bone. If verti- osseous genioplasty.
cal elongation is desired, it is most often done by interposing
blocks of hydroxyapatite into the osteotomy gaps created by
inferior repositioning of the symphysis. Patient 1
Following fixation, the wound is copiously irrigated with The patient (Figure 51.2) is a 35-year-old woman with a
diluted povidone-iodine (Betadine) solution and closed in small mandible, an increased lower face height, and a modest
A B
C D
FIGURE 51.2. A 35-year-old woman with a small mandible and increased lower face height. A, B. There is lip strain, with superior dislocation
of the soft-tissue chin pad and a shallow labiomental fold. Surgical correction will effect an 8-mm advancement of the chin and a 5-mm reduction
in its height. Simultaneous rhinoplasty will be performed. C, D. Postoperatively, the lip strain has been eliminated and the labiomental fold has
been deepened. Note that the chin has been advanced no further than the most anterior position of the lower lip. (From Rosen HM. Aesthetic
refinements in genioplasty: the role of the labiomental fold. Plast Reconstr Surg. 1991;88:760, with permission.)

Chapter 51: Osseous Genioplasty 547
component of lip strain. As a result, the soft-tissue chin pad 6-mm advancement and 6-mm lengthening of the chin. In the
is superiorly dislocated, causing effacement and shallowness postoperative views, note the softening of the labiomental fold
of the labiomental fold. Surgical correction involves advance- and apparent decrease in its depth. Note again that the chin
ment and vertical shortening of the chin. The segment was is advanced no further than the most anterior position of the
advanced 8 mm and shortened 5 mm. A rhinoplasty was also lower lip.
performed. Note that as the chin is advanced the labiomental
fold deepens with improved definition. The lip strain has been
eliminated. The chin has been advanced no further than the Complications
lower lip.
In a recent report of a large series of patients undergoing osse-
ous genioplasty by three experienced craniomaxillofacial sur-
Patient 2 geons, the complication rate was low.8 Lower lip paresthesia
This 28-year-old man (Figure 51.3) complained of having a occurred in 5.5% of the patients. Soft-tissue infection was
small chin. Physical examination demonstrated that he had a reported in 3% of patients.
small mandible and a class II, deep bite malocclusion. In addi- Although not reported as a complication, the most frequent
tion to a lack of projection of the chin, there was decreased problem associated with osseous genioplasty is the undesir-
height of the lower face relative to the midface and an exagger- able aesthetic result. Such an outcome is caused by errors in
ated, deepened labiomental fold. Surgical planning involved a both treatment planning and technique. The most commonly
Aesthetic Surgery
A B
C D
FIGURE 51.3. A 28-year-old man complaining of a small chin. Physical examination demonstrated a class II malocclusion with deficient sagittal
projection of the chin as well as decreased height of the lower face. A, B. In addition, there is a deepened labiomental fold. Surgical planning included
a 6-mm advancement and 6-mm elongation of the chin. C, D. The postoperative views demonstrate an increase in the height of the lower face and
an apparent decrease in the depth of the labiomental fold. Again, the chin was advanced no further than the most anterior position of the lower
lip. (From Rosen HM. Aesthetic refinements in genioplasty: the role of the labiomental fold. Plast Reconstr Surg. 1991;88:760, with permission.)

committed error in treatment planning is overadvancement that can yield dramatic results if the surgeon performing the
of the symphyseal segment, resulting in an unnatural, bizarre procedure knows that it cannot change the sagittal position of
appearance, with the chin well in advance of the lower lip. It the lower lip. It behooves plastic surgeons to become familiar
bears repeating that the osseous genioplasty is a powerful tool and comfortable with the procedure so that the alternative—
and that modest advancement of the chin goes a long way. alloplastic chin augmentation—will not be used in patients
When in doubt about the extent of advancement, one should who would be better treated by osseous genioplasty.
err on the side of conservatism and undercorrect in the sagittal
dimension. References
The most commonly encountered aesthetic problem relative 1. Hofer D. Die osteoplastiche verlaegerund des unterkiefers nach von
to the surgical technique is failure to extend the osteotomy cut Eiselberg bie mikrogenie. Dtsch Zahn Mund Kieferheilkd. 1957;27:81.
far enough posteriorly. This can result in an hourglass defor- 2. Converse JM, Wood-Smith D. Horizontal osteotomy of the mandible. Plast
mity with excessive tapering of the mandible in the area imme- Reconstr Surg. 1964;34:464.
3. Bell WH, Proffit WR, White P, eds. Surgical Correction of Dentofacial
diately posterior to the osteotomy. This can be largely avoided Deformities. Philadelphia, PA: WB Saunders; 1980:685.
if the osteotomy cut is extended back to the molar teeth, as it 4. Rosen HM. Aesthetic guidelines in genioplasty: the role of facial
is placed in an area where abundant soft tissue is present to disproportion. Plast Reconstr Surg. 1995;95:463.
mask any notching of the inferior mandibular border. 5. Rosen HM. Aesthetic refinements in genioplasty: the role of the labiomental
fold. Plast Reconstr Surg. 1991;88:760.
6. Spear SL, Mausner ME, Kawamoto HK. Sliding genioplasty as a local
Conclusion aesthetic outpatient procedure: a prospective two center trial. Plast Reconstr
Surg. 1987;80:55.
7. Zide BM, McCarthy JG. The mentalis muscle: an associated component of
The osseous genioplasty represents the most versatile proce- chin and lower lip position. Plast Reconstr Surg. 1989;83:413.
dure that the plastic surgeon has available to enhance the bal- 8. Greenberg ST, Pan FS, Bartlett SP, et al. Complications of osseous
ance and proportion of the lower face. It is a powerful tool genioplasty. Proc Northeastern Soc Plastic Surg. 1985;92.

Chapter 52 n Hair Transplantation
Carlos K. Wesley, Robin H. Unger, and Walter P. Unger
Since initial reports on grafting human scalp hair were first may be able to evaluate these characteristics with the naked
made in Japanese literature in 1939, advancements in hair eye, many practitioners prefer diagnostic tools to quantita-
restoration surgery (HRS) have benefitted all patients, includ- tively assess the donor area (Table 52.1).
ing both men in the early stages of hair loss and female Screening technology that can help includes quantitative
patients. Incorporated in 1993, the International Society for microscopic donor area measurements (e.g., Folliscope) as
Hair Restoration Surgery (ISHRS) now consists of over 1,000 well as qualitative analysis of non-androgenetic forms of alo-
members who performed approximately 279,381 HRS proce- pecia (e.g., PhotoFinder) that may benefit more from medical
dures in 2010, an increase of 11% over the previous 2 years.1 therapy (Figure 52.2). The Folliscope, capable of discerning
Modern day hair transplantation evolved over three dis- between terminal and vellus hairs, is used by some practi-
tinct eras: the “plug” era, the transition period of progressively tioners to “rule out” patients who possess more than 20%
smaller unit minigrafting and micrografting, and the current miniaturized hairs within their donor area. 4 Two separate
period of follicular unit transplantation (FUT).2 This current measurements several weeks apart are required to differentiate
method capitalizes on findings that human scalp hairs grow between a hair that is miniaturized and one that is simply in
naturally in individual bundles, called follicular units (FUs), early anagen (the growth phase in the hair cycle) and has only
comprised of clusters of one to four follicles surrounded by its thin, tapered edge protruding from the skin.
concentric layers of collagen fibers.3 When performed prop- Once a patient’s surgical candidacy is determined, he or she
erly, FUT consistently results in a cosmetic appearance indis- is informed of the risks of the procedure. The authors emphasize
tinguishable from natural scalp hair growth (Figure 52.1). In three caveats: 1) postoperative edema that is minimal in most,
addition to the more natural appearance of the transplanted but in approximately 2% of patients, may be severe enough to
follicles with FUT, the ratio of the donor-to-recipient area has cause ecchymosis around the eyes; 2) scalp hypoesthesia result-
effectively expanded. In the plug era this relationship was at ing from severed sensory nerves during the processes of both
best 1:1, but FUT now favors a ratio of 1:2 or 1:4, meaning donor harvest and recipient site creation, which may take 3 to
1 cm2 of donor scalp harvested may yield a sufficient number 18 months to return to normal, and 3) telogen effluvium, or
of FU (also referred to as grafts) to cover a 2 to 4 cm2 recipient temporary hair thinning, that may be experienced by approxi-
Aesthetic Surgery
area with adequate cosmetic density. Smaller, more superficial mately 10% to 20% of male patients and 40% to 50% of
recipient sites can be spaced much more closely, while causing female patients.5 If a patient is not emotionally prepared for this
minimal damage to the preexisting hair in the recipient area. likelihood, they should not undergo HRS.
Despite these refinements, the unavoidable progression of hair
loss over time and the limitation of donor hair for transplanta-
tion remain of paramount importance when determining the The PreOperative Period
surface area and hair density that can reasonably be treated Preoperative instructions include the discontinuation of herbal
with hair transplant surgery. medications that may increase bleeding tendency, such as
vitamin E and fish oil, 3 weeks prior to the date of surgery.
Ten days prior to surgery, acetylsalicylic acid (ASA), or any
Initial Consultation drugs containing ASA that influence platelet activity, should
and Evaluation be discontinued and the patient should abstain from alco-
hol consumption. The authors also recommend a twice-daily
Patient candidacy is determined by a careful evaluation of the application of topical minoxidil 2% to 5% to the recipient
donor area’s capacity to effectively address the current and area beginning 1 week prior to surgery due to the theoretical
future areas affected by hair loss. In addition to providing infor- decreased likelihood of temporary hair loss.6 Patients with a
mation to the prospective patient and establishing a rapport relatively tight scalp are instructed how to massage their scalp
with the patient, the physician should set realistic and prudent during the final 4 weeks prior to surgery in order to increase
short- and long-term goals. Drawing from an examination of scalp laxity within the donor area, thus enabling a wider strip
the patient’s hair phenotype, a thorough review of the patient’s harvest and a greater FU yield.7
family history of androgenetic alopecia (AGA) (including both The authors prescribe oral Cefdinir (300 mg) to be taken
the paternal and maternal lineages), and a familiarity with the 1 hour prior to surgery. However, many surgeons avoid
progressive nature of male pattern baldness (MPB) and female prophylactic antibiotics because they believe that the risk of
pattern hair loss (FPHL), the physician can propose a surgical adverse drug reaction outweighs the risk of infection. Written
recipient pattern that will be appropriate even when having to consent for the procedure, anesthesia, and photography must
“stand alone” at any future age. It is advisable to estimate the be obtained from the patient on the morning of the surgery.
number of procedures or FUs the patient will likely have avail-
able over his or her lifetime based on the projected permanent
donor fringe. Especially for young male patients, individual Surgical Preparation
projections should be based on the worst possible scenario
of MPB that can be realistically foreseen. This can help even
and Anesthesia
young patients wanting to replicate their teenage level hairlines A comfortable operative experience greatly enhances a
to modify their unrealistic expectations. patient’s overall impression of the practice. Levels I and II
A thorough evaluation of the donor area is the critical ini- sedation are commonly utilized. Preoperative sedation is often
tial step. The following elements should be considered: density in the form of an oral benzodiazepine (diazepam 10 to 20 mg
of FUs per surface unit, number of hairs per FU, anagen– or lorazepam 2 mg) along with an analgesic (hydrocodone/
telogen ratio, diversity of hair caliber, color contrast between acetaminophen 5/325 mg).
the hair and the scalp, hair texture (e.g., wave, curl, and frizz), Photographic results can be optimized and reproduced
and scalp laxity. While experienced hair restoration surgeons when standardized. Generally, a ceiling light immediately
549
A C
B D
FIGURE 52.1. A 32-year-old man shown before (A) and 16 months after (B) treatment with 2,450 FU throughout the frontal third of his scalp.
A 52-year-old female as seen before (C) and 14 months after treatment with 1,573 FU (D).
Table 52.1
Methods of Measuring Hair Characteristics. Invasive, Semi-Invasive, and Non-Invasive Techniques
Can Help Evaluate Subtle Differences In Hair Density, Hair Caliber, and Even Hair Growth Rates
n Technique n Strengths n Weaknesses

INVASIVE
Scalp biopsy I nterfollicular inflammatory changes oes not evaluate dynamic process
D
Subtle structural skin changes of individual hair follicles
SEMI-INVASIVE
Trichogram, unit area trichogram (UAT) air root analysis
H oor indicator of disease activity
P
Enables measurement of hair density, and/or severity
anagen percentage, hair length and Not easily reproducible
diameter UAT involves several (often pain-
ful) epilations
NON-INVASIVE
Global methods:
Global photographs, hair pull test, hair ase of use by investigators
E ften difficult to standardize
O
weight/count methods, calibrated scalp Measures and defines the continuum Inability to resolve subtle details of
coverage scoring, categorical classification of scalp coverage hair loss for critical analysis
systems
Analytical methods:
Trichoscan, Contrast-enhanced phototri- ccurate analysis of all important
A ay require a hair dye for contrast
M
chogram, Folliscope: hand-held phototri- parameters of hair growth (density, enhancement
chogram diameter, growth rate, vellus/terminal Measurement area must be clipped
hair density) before analysis
Quantifies subtle hair changes Requires follow-up imaging for
Reproducible results comparison
UAT, unit area trichogram.

Chapter 52: Hair Transplantation 551
FIGURE 52.2. Folliscope evaluation for density comparison as well as total vellus and terminal hair number. This figure displays four digi-
tal images captured at 50-fold magnification and includes the area of 0.34 cm2 (ovals in box) in which quantitative analyses are performed.
Calculations of hair density, growth rate, caliber, and spacing are illustrated in numerical format (right-hand panel).
behind the photographer with a uniformly bright background boundaries have since been modified for an alternative follicle-
color enhances the viewing of the scalp by creating contrast, harvesting technique called follicular unit extraction (FUE),
thus outlining the peripheral boundaries of the hair. High- which will be discussed later in this chapter (Figure 52.3). Due
Aesthetic Surgery
definition video is often a more convincing media for viewers to the less visible punctate scarring from this alternative tech-
leery of misleading photographic tricks. nique, Cole’s FUE SDA is slightly expanded (203 cm2) and
The surgical design is drawn and the hairs in the donor includes 14 subdivisions based on hair density.9
area are trimmed to 2 to 3 mm in length. This hair length Although these accepted dimensions address the surface
is chosen to facilitate correct angling of donor area incisions area of the donor area, they fall short of helping practitioners
and to assist in determining directionality within the graft dur- determine the quantity of “permanent” FU that may be trans-
ing implantation. The donor region is prepped with Betadine planted over a patient’s lifetime. In order to provide guide-
(povidone-iodine) prior to intravenous administration of an lines regarding those limits, a survey of 39 of the world’s most
anti-anxiolytic (midazolam 2 mg, diazepam 5 mg) coupled experienced practitioners of HRS with a collective professional
with an analgesic, such as fentanyl (50 μg). experience of nearly 1,000 years concluded that a 30-year-old
Local anesthesia of the donor site is achieved by creat- male destined to develop Hamilton/Norwood type V or
ing a field block inferior to the donor region using 1% lido- type VI MPB would most likely yield the numbers of FU as
caine HCl with epinephrine (1:100,000) followed by longer seen in Figure 52.4 based on the various degrees of donor hair
acting 0.25% to 0.5% bupivacaine HCl with epinephrine density upon presentation.10 Respondents suggested that the
(1:100,000). This local ring block effectively anesthetizes the aforementioned patient presenting with an average density
greater and lesser occipital nerves as well as the postauricu- donor area could yield a lifetime harvest of 6,404 or 5,393
lar nerve. Further infiltration of 1:50,000 epinephrine is used FU when destined to develop MPB types V or VI, respectively.
not only to minimize diffusion of the anesthetic but also to
enhance vasoconstriction, making surgical excision easier due Harvesting Techniques
to improved hemostasis. Additionally, sterile saline tumes-
cence may be used to increase separation between the layer Strip Excision. Strip excision is unquestionably the most
of hair follicle bulbs and the underlying nerve and vascular common method for donor harvesting, used in roughly 88.5%
plexus within the deeper subcutaneous plane. of HRS cases.11,12 The most important tenets for strip harvest-
A field block anterior to the anticipated recipient area is ing include minimizing the amount of hair follicle transection
then performed and reinforced in the same manner. Regional as incisions are made; extracting donor strip widths with cau-
nerve blocks of the supraorbital and supratrochlear nerves are tion in order to minimize closing tension; and producing only
an alternative method of anesthesia for the recipient site. a single scar regardless of the number of sessions performed
on a single patient.
In addition to using magnification to help follow the angle
The Donor Site and direction of hair shaft exit from the skin, minimal follicle
Ultimately, the objective of donor area evaluation is to deter- transection can be achieved by using a tumescent solution at the
mine the area from which hair is most likely to be permanent dermal level prior to incising in order to increase the inter-FU
and thus will ostensibly persist in the recipient area long after distance and align the follicle shafts more perpendicularly to the
transplantation. To this end, the senior author conducted a skin surface. Follicular transection may be reduced below the
study of 328 men aged 65 years or older in which areas concurrent 10% to 15% average by using a skin hook technique
taining at least 8 hairs per 4 mm diameter circle were mea- (Figure 52.5) to facilitate separating the edges of incision.13
sured.8 The dimensions established from this study represent Alternatively, a tissue spreader comprised of a modified icon-
the region of harvest that would be “safe” (i.e., the most hairs oclast instrument introduced into the superficial wound edge
that would be most likely to persist) in approximately 80% of incision may serve the same purpose and may prove especially
patients under the age of 80 years. This persisting region of the useful in gray or curly hair, which pose an added challenge to
donor scalp was termed the “safe” donor area (SDA). These minimizing follicular trauma during the donor harvest.
28 mm
Line drawn perpendiculary
from tragus
Border of existing hair

when first seen
40 mm
10 mm
Parietal Tragus 70 mm
Occipital
Inferior limit of scalp
with 10 hairs per
4 mm circle
A Alt’s safe donor area B Unger’s safe donor area
Temporal: 59–80 mm
Parietal: 81–97 mm
Occipital: 62–86 mm
2 cm Temporal
14 cm
Parietal 3.5 cm
6 cm 4 3 2 1 5 6 7 8
11 10 9 12 13 14
2 cm
C Cole’s safe donor area D Cole’s FUE safe area

FIGURE 52.3. A. The safe donor area (SDA) according to Alt. B. Unger’s safe donor area for 80% of patients under the age of 80 years, as deter-
mined from a study of 328 men aged 65 years or older. C and D. Cole’s FUE safe area. (Images courtesy of J. Devroye, M.D. and J. Cole, M.D.
Redrawn from Unger WP, Shapiro R, Unger R, Unger M, eds. Hair Transplantation 5E. London and New York: Informa Healthcare; 2011.)
The most important factor in achieving optimal donor clo- sutures (3-0 or 4-0 vicryl or monocryl). Over the mastoid
sure tension is a careful preoperative evaluation of scalp laxity. region, where excessive tension is most frequent, wedge-
In the majority of patients, the authors excise a donor strip of shaped sutures may also help relieve tension (Figure 52.6).14
0.8 to 1.2 cm width from the densest portion of the SDA. An This technique eases the work (W ) required for closure more
excessively wide strip can lead to excess tension, which may effectively than sutures placed perpendicular to the wound
result in unsightly scars, temporary hair effluvium (short-term edge by increasing the distribution of force (F) along the
loss), or tissue ischemia. Many HRS practitioners assess scalp wound edge. With F and wound edge displacement (d) being
laxity by moving the donor tissue superiorly and inferiorly, or constant in the formula for work (W = Fd cos q ), the magni-
pinching it between their fingers, using clinical experience to tude of work is reduced as the angle (q ) increases.
gauge the laxity. Others rely on mechanical devices such as the Excising a prior scar as a part of any new donor strip has
laxometer prior to incising or the intraoperative tensionom- numerous aesthetic advantages over extracting a new strip
eter to estimate scalp laxity and closing tension, respectively. inferior or superior to it. Most importantly, the harvest is then
If donor wound closure requires an unanticipated degree always removed from the densest portion of the donor area to
of tension, undermining skin edges may sometimes be cou- maximize both longevity of transplanted hair and the number
pled with a two-layered closure using interrupted absorbable of grafts per given strip width. Second, the new wound will not

Average Usable FU Estimates in
30-year-old Caucasians
8,000
6,000
4,000
2,000
Type VI
0
Above Avg Type V
Avg
Below Avg
Above Avg Density Avg Density Below Avg Density

Type V 7,904 6,404 4,963
(3,000–12,000) (2,000–10,000) (1,000–9,000)
Type VI 6,661 5,393 4,204
(2,000–10,000) (1,250–9,000) (500–8,000)
Numbers represent mean of each catergory with range in parentheses
FIGURE 52.4. A total of 34 experts with over 900 years combined experience in hair restoration surgery responded to the question: “Keeping in
mind that over the years, the hairs closest to the superior, inferior, and anterior borders of the fringe will be lost, how many FU containing very
likely permanent hairs can be harvested from (a) a 30-year-old patient who you believe is destined to develop Norwood type V MPB and has: (1)
higher than average hair density; (2) average hair density; (3) less than average hair density; (b) the same question but for a patient you believe
is destined to evolve to type VI MPB.” While these data should not be viewed as dogmatic limitations, they may provide helpful guidelines when
evaluating the lifetime donor yield of young Caucasian male patients.10
Aesthetic Surgery
A C
FIGURE 52.5. A. Two skin hooks for one assistant. B. Spreader

inserted into scoring incision and (C) the spreader open, showing intact
hair follicles at the edge of the wound. (Courtesy of D. Pathomvanich,
M.D. and R. Haber, M.D. From Unger WP, Shapiro R, Unger R,
Unger M, eds. Hair Transplantation 5E. London and New York;
Informa Healthcare; 2011.)
B

d
B
L R
θ1 < θ2
θ1 Fd cosθ1 > Fd cosθ2
W1 > W2
θ2
d
F
A C
FIGURE 52.6. A. The mastoid region, where scalp tension is often greatest, is the zone in which a wedge suture may be advantageous. A magni-
fied panel illustrating how the placement of wedge sutures is slightly wider along the interior edge of the donor area. B. A block is pulled by a
force (F) at an angle (y) to a horizontal vector (d). The work (W) required to pull the block along the horizontal plane (W = Fd cos y) is reduced
as y increases. C. The work of a suture to bring two wound edges together is minimized as the placement of sutures along the inferior donor edge
widens, increasing the angle (y) along the superior edge.
have its superior and inferior blood supply somewhat reduced 11.5% of HRS procedures, this method holds the benefits of
because it is surrounded by virgin scalp tissue rather than bor- no linear scarring in the donor area as well as a more rapid
dered by previous scarring. Old scars also bind down the adja- and comfortable postoperative recovery for patients. Despite
cent edge of the neighboring donor strip harvest, which may the overall increase in surface area of donor scarring with FUE
result in increased closing tension or a reduced available donor compared with traditional strip harvests of large (1,000+ FU)
strip width. If a new strip is harvested superior (rather than infe- sessions, when performed properly, the decreased visibility of
rior) to a linear scar from a previous surgery, lymphatic drain- scarring within the donor area may more often allow patients
age will be compromised, leading to more severe and prolonged to wear their hair relatively short after undergoing FUE. FUE
edema around the new wound. Compounding the probable less- may also be utilized for beard and body hair follicle extraction
optimal scar that results is the increased likelihood of telogen as well as for removal of improperly placed grafts during cor-
effluvium in the area between the old and new scar. rective procedures of previous hair transplants.
The final component of achieving nearly imperceptible Originally involving the use of a sharp 1-mm “cookie
donor area scarring is the closure technique. Most physi- cutter”–like punch, hair follicles trimmed to 2 mm in length
cians prefer nylon sutures over staples due to patient comfort were extracted manually in a random distribution so as to
throughout the postoperative recovery process using either avoid overharvesting any particular area, which may result in
a single-layer or two-layer closure. A “trichophytic” closure a “moth-eaten” appearance (Figure 52.7).17 Powered instru-
may be used to provide further camouflage of the donor scar.15 ments for FUE have replaced manual punches by demon-
By excising the epidermis from one edge of the donor wound strating increased extraction speed and efficiency.18 Increased
prior to closing (approximately 1 mm wide and 1 mm deep so speed, however, requires heightened attention to avoiding
that the bulge area of the follicle is not affected), one row of follicle transection or “decapitation” that may occur when a
hairs effectively lie beneath the healing wound and eventually sharp punch is introduced at the improper angle.19 Variable
grow through the resultant scar. This technique can be used in hair characteristics such as follicle curvature, angle of exit
any surgery performed in hair-bearing tissue to help prevent from the skin, or splaying arrangement beneath the skin sur-
the appearance of an alopecic linear scar. As in other fields face may further increase the challenge of avoiding graft tran-
of plastic surgery, bioactive acellular matrix products have section in order to achieve intact hair follicle dissection. To
been investigated in HRS donor wound closures. The results minimize follicle transection, non-sharp motorized punches
of using such substances are still unclear: one recent case have been developed to perform “blunt” dissection of FU
report suggests that the resultant donor scar might be slightly from the skin. Rather than cutting the deep segment of a fol-
wider and more erythematous, outweighing the benefit of the licle with an unforeseen curvature, a dull punch may push
improved texture of the scar tissue.16 the follicle within the cylinder to reduce transection rates.
Alternatively, a two-step manual process involving an initial
Follicular Unit Extraction (FUE). FUE is an alterna- sharp “scoring incision” at a 0.3- to 0.5-mm depth around the
tive method of hair follicle harvesting that involves removal follicle followed by insertion of a blunt dissecting cylinder that
of individual FUs directly from the donor area one at a time, reaches the full depth of the follicle (approximately 4 to 5 mm)
rather than from an excised strip that is subsequently dis- enables full separation of the intact follicle from its native tis-
sected into FU (see below). Performed in approximately sue prior to manual extraction using forceps. No matter what

To this end, the surgeon’s initial incision should be angled
so that the blade passes parallel to the follicles. The excised
donor strip should be fixed to a cutting board with steady
lateral tension applied to sustain inter-follicular spacing and
ease the “slivering” process. A size 15 bladed scalpel is used to
slice sections of tissue 1 or 2 FU wide depending on the size of
the grafts desired (akin to “slicing a loaf of bread”). The final
preparation converts individual slivers into the appropriately
sized grafts. Magnification (using a 6× lens with ample depth
of field) and proper lighting (both overhead from a micro-
scope and backlighting) are essential during graft preparation.
A translucent horizontal cutting surface made of polyurethane
allows for backlighting penetration.
The FU created from the naturally occurring hair group-
ings that exist in the donor area are markedly smaller than
the original 4-mm punch grafts or multi-follicular unit (MFU)
grafts referenced in prior editions of this textbook. Ultimately,
FIGURE 52.7. Punctate scarring from a previous FUE harvest per-
formed by another surgeon can result in a “moth-eaten” appearance
the ideal “pear-shaped” graft possesses little or no surplus
when FUs are harvested too close to one another or the punch used epidermis and retains an appropriate amount of protective
in larger than 1 mm. The dark outline indicates the borders of the dermis and subcutaneous adipose tissue around the follicle,
limited region from which the FUs were harvested. the intact sebaceous glands, and the dermal papilla in order
to reduce their sensitivity to traumatic handling, temperature
changes, and graft desiccation (the main cause of poor graft
survival).21 However, if more distal excess tissue is not suf-
ficiently trimmed, the grafts may require more traumatic han-
the technique employed is, a surgeon’s ability to properly posi- dling when placed into the recipient sites. The “pear shape” is
tion the punch according to the follicle’s angle of exit from generally more difficult to achieve when grafts are harvested
the skin surface typically requires 5× to 6.5× magnification. In via the FUE method because, after initial superficial inci-
addition, as mentioned earlier, use of sterile saline tumescence sions, the follicle is “pulled” from its native environment, thus
increases predictability of hair follicle angle deep to the skin causing the surrounding tissue to be stripped off the follicle
surface by making the follicles more erect and separates the (Figure 52.8). As a guideline, three- or four-haired FU should
follicle bulb from the underlying vascular and nerve plexus.
Aesthetic Surgery
fit snuggly into recipient sites made with an 18G needle while
Follicle transection rates depend on the patient charac- 20G needle sites should easily accommodate one-haired FUs.
teristics as well as the inner diameter of the punch. Among In addition to the above guidelines, which help improve
the field’s most experienced practitioners of FUE, transection graft survival, selection of the proper holding solution may
rates range from 2% to 8.5% for the 1-mm punch and from also be significant. This has grown progressively more impor-
3% to 10% using the 0.75-mm punch.20 A 1-mm punch can tant as larger surgeries involving smaller grafts have become
extract an average graft of 2.5 hairs/graft, while a 0.75-mm more common and “out –of-body” time has increased.
punch yields approximately 2.1 hairs per graft. However, Generally speaking, survival of transplanted grafts decreases
punches of 1 mm or larger can result in visually unacceptable about 1% per hour out of body with some studies indicat-
donor area scarring. ing an 88% survival at 8 hours in chilled normal saline.22 To
There are two additional considerations in using FUE for help counteract the effects of this extended time between har-
follicular harvest. First, only every third or fourth FU can be vest and implantation, three broad categories of commercially
removed from the SDA, thus reducing the total number of available holding solutions are considered as alternatives: 1)
“most likely permanent” follicles available for transplanta- intravenous fluids (e.g., Plasmalyte A and Lactated Ringer’s);
tion. Second, the overall density in the donor area is reduced; 2) culture media (DMEM, RPMI, and M199); and 3) hypo-
as opposed to strip harvest in which both the number of hairs thermic tissue-holding solutions (Viaspan, Celsior, Custodiol,
and the surface area is reduced, FUE removes hair and the and HypoThermosol). Characteristics assessed in these solu-
donor site heals by secondary intention. This effectively leaves tions include pH, osmotic balance, antioxidant capabilities,
the surface area relatively unchanged, but reduces the num- and nutrient support. Akin to organ transplantation, factors
ber of hairs within the SDA. The long-term consequences of negative influence include ischemia-induced hypoxemia
of this technique may not be fully appreciated until patients and subsequent adenosine triphosphate depletion (resulting in
experience the eventual thinning of the fringe hair, which subsequent apoptosis) as well as ischemia-reperfusion injury.
naturally occurs over time. The authors share the sentiment The events following graft implantation, specifically oxy-
of most practitioners in the field that combining FUE with genation and revascularization, are also believed to be criti-
strip harvest may provide patients with best long-term result. cal in graft survival. For this reason, platelet-rich plasma
Maximizing graft yield from the SDA with multiple strip har- (PRP) has been explored as a possible graft storage solution.
vest procedures followed by a session of FUE when minimal Obtained from the patient’s blood and concentrated via a cen-
or no remaining scalp laxity remains allows for a final session trifugation process, PRP’s release of concentrated growth fac-
of transplanted grafts into both the remaining recipient areas tors may augment graft survival and promote earlier growth
and the resultant fine linear donor scar, thus optimizing the and enhanced wound healing.23,24 This technique has been
long-term appearance of both the recipient and donor areas. reported to have mixed results to date and requires further
investigation before any conclusions can be drawn.
Graft Preparation
and Storage The Recipient Site
The stages of FU preparation during a classic FUT procedure Transplanting even the finest FUs does not ensure the cre-
are: 1) the initial donor strip harvest; 2) the “slivering” of the ation of a natural-appearing recipient pattern unless the
donor strip; and 3) the subsequent dissection of individual FU major anatomic landmarks, borders, and zones of normal
from the “slivers.” Each phase shares the common objective hair-bearing scalp are well understood and effectively repro-
of increasing graft survival by minimizing follicle transection. duced (Figure 52.9). With the increased demand for HRS

A B
FIGURE 52.8. A. Grafts produced via FUE have less protective tissue surrounding the hair bulbs within them and may or may not result in a
lower hair survival than that seen with (B) grafts that are microscopically produced from a strip. FUG, follicular unit grafting.
A B
C D
FIGURE 52.9. Common guidelines to proper placement of the midfrontal of the hairline include (A) a point on the curve of the forehead about ½
way between from the point where the horizontal plane of the scalp meets the vertical plane of the face, (B) 7 to 10 cm above the glabella. Major
landmarks and zones of the hairline: C. top view; D. side view. (Courtesy of R. Shapiro, M.D. From Unger WP, Shapiro R, Unger R, Unger M,
eds. Hair Transplantation 5E. London and New York: Informa Healthcare; 2011.)

of loss if the transplanted hair is placed too far anteriorly (thus
leaving an unnatural “island” of transplanted temporal hair).
However, when the donor-to-recipient ratio allows, temporal
points should be advanced no farther than to an intersection
Apex Superior border of two lines: one drawn from the tip of the nose, over the
of angle of angle pupil to the anterior tip of the temporal point; and a second
line drawn from the most anterior midpoint to the tragus.26
Inferior border Ethnic background should also be considered when design-
of angle ing the hairline. Whereas Caucasians generally have dolioce-
phalic, or ovoid, skulls East Asians tend to have brachycephalic,
Lateral epicanthal or rounded, skulls.27 As a result, the hairline design in East
line Asians is comparatively wider and flatter, with curved (rather
than sharp) frontotemporal angles. The relatively coarse caliber
of East Asian hair may make multi-hair FU more noticeable. It is
therefore important to camouflage these more coarse-haired FU
with additional rows of single-haired grafts anteriorly. Patients
of African descent tend to have mesocephalic skull shapes of
FIGURE 52.10. Proper placement of the fronto-temporal angle in intermediate length and width that support hairlines that are
mild-to-moderate hair loss: Common rules include (i) draw a line flatter than Caucasian patients, but not as flat as those found
from the lateral epicanthus of the eye to a point where it meets the in most East Asians. Unlike East Asian patients, however, a nat-
remaining temporal hair; (ii) make sure the hairline does not slope ural hairline appearance is more easily achieved in patients of
down toward the ear but appears parallel or slopes upward. (Photo
African descent due to not only the hair curl and the finer caliber
courtesy of R. Shapiro, M.D. From Unger WP, Shapiro R, Unger R,
Unger M, eds. Hair Transplantation 5E. London and New York: hair but also the minimal contrast between the color of the hair
Informa Healthcare; 2011.) and skin, which creates an illusion of density and camouflages
grafts.28 Therefore, multi-hair FU may be placed more anteriorly
than in East Asian patients and just behind the hairline zone.
The hairlines of Hispanics span the range between Caucasians
among young adults in the early stages of MPB, one of the and those of African descent.
most important principles of hairline placement is “do not Appropriate facial framing in female patients often entails
place a hairline too low.” The most anterior midline point of a more rounded hairline design that incorporates observa-
the frontal hairline should be somewhere in the zone in which tions from examination of 360 female volunteers: Creation of
Aesthetic Surgery
the relatively vertical forehead gradually changes to the rela- 1) a widow’s peak (observed in 81% of female hairlines), 2)
tively horizontal anterior caudal scalp. 25 The more severe the an anterior midpoint placed a mean distance of 5.5 cm supe-
ultimate MPB pattern is expected to eventually develop, the rior to the glabella, 3) lateral mounds with an apex 3.75 to 4
more superior this point should be. It should be joined in a cm from the frontal midpoint (98% of females), 4) temporal
gently arched line to two lateral points in the existing anterior mounds 3.5 to 3.75 cm lateral to the apex of lateral mounds,
temporal hairline or in a reconstructed supratemporal–pari- and 5) temporal recessions in a concave oval contour that con-
etal “hump” constructed with FU if it has been or is expected tain fine hairs (87% of females).29,30 More often with females
to be lost with the passage of time. When viewed laterally, the than with their male counterparts, native residual vellus hairs
transplanted hairline should run more or less horizontal to the can serve as a guide in re-creating their hairline pattern.
ground or tilt slightly superiorly (Figure 52.10).25 Transplanting the midscalp region, especially in men, pro-
To create the illusion of a slightly lower hairline without vides numerous aesthetic benefits and—due to its more conser-
expending too many FUs, some surgeons construct a “widow’s vative distribution—may be the most appropriate compromise
peak.” Throughout the hairline, the transition zone (the ante- in younger patients with a limited lifetime donor supply. Direct
rior 0.5 to 1 cm region) should contain both microirregulari- coverage from midscalp transplantation (Figure 52.11) not only
ties (intermittent density clusters more noticeable under close improves density from a lateral and overhead view but also pro-
examination than from a distance) and macroirregularities (provides a thickened backdrop to a thinning frontal area as well
trusions along the path of the hairline that cause it to appear as providing indirect coverage of a crown as transplanted mid-
less linear when viewed from a distance). Generally, macroir- scalp hairs cascade posteriorly over it—particularly if a trans-
regularities include one central mound and two lateral mounds. planted midline posterior “bump” is created.31
It is generally not advisable to advance temporal points in The decision to transplant a progressively thinning and
young male patients who are likely to experience a progres- expanding vertex carries an increased risk that an unnatural
sive posterior recession of their temporal hair. Their limited distribution of hair will result in the future in which an iso-
donor reserve may be inadequate to address these future areas lated island of transplanted hair may be surrounded by an
A B
FIGURE 52.11. A. A 48-year-old man with diffuse hair thinning in the midscalp and vertex areas refractory to finasteride therapy. The 2,580 FU
surgery transplanted at a density of 25 to 30 FU/cm2 covered the midscalp area and a small semi-circular “bump” protruding into the vertex.
B. One year after a session, the hair is parted through the transplanted area for critical evaluation.

alopecic scalp. Because the shingling effect of one hair lying In addition to designing the appropriate surgical pattern, a
over another is the least beneficial throughout the crown critical aspect of recipient site creation is minimizing trauma
and specifically at the vertex, patients should also be advised to both the scalp vasculature and the preexisting hair follicles
that coverage may not have the same cosmetic impact in this within the area of transplantation. By minimizing underlying
region as elsewhere and, therefore, may require one or more vascular trauma, the newly introduced follicles gain improved
additional sessions to the “whorl” of the vertex and possi- oxygenation, increased viability, and accelerated healing.31
bly including peripheral areas of future hair loss. Due to this Ultimately, what is most important is not how many hairs are
likelihood, the best candidates for vertex transplantation are transplanted but how many hairs grow (and of course in the nat-
patients past the age of 40 years with ample donor reserve ural angle and direction of preexisting hair). The most common
and a minimal hair-to-scalp color contrast. For the majority of causes of inadequate density after hair transplantation include
patients, the front and midscalp have first priority and most of 1) excessive injury to the blood supply; 2) insufficient number
the donor hairs should be reserved for those regions. of grafts transplanted in the recipient area; 3) poor growth of
Transplantation procedures to reconstruct eyebrows were transplanted follicles due to injury sustained out of the body
among the first hair transplantation techniques to be described (during dissection, storage, or implantation); and 4) inappropri-
and this area of the face continues to gain popularity (approx- ate selection of donor hair from a region peripheral to the SDA.
imately two-thirds female and one-third male).32 The authors A recipient site can vary in size, shape, depth, width, angle,
encourage patients to try treatment with topical bimatoprost and direction. Angle and direction are distinct entities. Angle
ophthalmic solution 0.03% prior to considering hair trans- refers to the degree of hair elevation as it exits the scalp.
plantation, provided the hair loss is not cicatricial in nature. Direction refers to which way the hair points when leaving
Most patients know the shape of the eyebrow they desire and the scalp. Hair direction emanates from a whorl in the ver-
can outline the design themselves. The eyebrow is divided into tex, it is mainly posteriorly or anteriorly oriented within the
the head (medial one-fifth), the tail (lateral one-third), and the caudal scalp, and it is inferiorly and often inferoposteriorly
body (connecting the head and tail). The medial most aspect directed in the temporal and parietal regions. Although it has
of the eyebrow head should have FU directed somewhat ver- been demonstrated that more acute angles appear to increase
tically while the direction gradually becomes more horizon- perceived scalp coverage, it cannot be overemphasized that
tal while proceeding laterally as the head transitions into the both the direction and the angle of the recipient site incisions
body (Figure 52.12). Angles should be as acute as possible, should mimic the preexisting hair within the region of the
which may be facilitated by using counter-traction adjacent scalp that is being treated.33 Traditionally, surgeons have ori-
to the area where the recipient site is being created. The best ented recipient sites parallel to the direction of hair growth
donor harvest location (either via FUT or FUE) of the requi- (sagittally when within the caudal scalp). However, various
site 400 to 450 FU is an area of the scalp that most closely surgeons advocate for orienting multi-hair FU incisions per-
resembles the existing hair in the region. Often these are found pendicular to the direction of growth (coronally when within
in the mid-occipital region in which the necessarily fine hairs the caudal scalp). The surgeons who favor perpendicularly
are also the least likely to be or become gray and have the oriented sites believe that this results in a superior appear-
best texture and curl. Although both eyebrow and eyelash ance of density, while those favoring parallel sites feel that the
transplantation can be used for cosmetic enhancement as well increased vascular damage outweighs any benefits.34
as reconstruction, patients must be well informed regarding Multi-unit grafts (MUGs) may be utilized to create the illu-
the long-term need for routine trimming and curling of trans- sion of increased recipient area density. These grafts incorpo-
planted lashes. Scalp-to-beard and pubic hair transplantation rate 2 FUs that are chosen because their FUs are closer together
also provide marked cosmetic improvement but that discus- than most FUs are. Their benefit of providing increased den-
sion is beyond the scope of this chapter. sity is tempered by the increased challenge of ensuring their
B C
FIGURE 52.12. A. The eyebrow is divided into the head, body, and tail. It is slightly arched in females. The direction of hairs (white broken lines)
in the head is more vertical, while hairs in body cross hatch (cephalic hairs angle slightly down and caudal hairs angle slightly up). (a) Peak of
arch, finer hairs are chosen for the top border. (b) Slight narrowing on bottom aspect of body that helps creates the arch effect. (c) Medial border
of head, which is rounded or square. (B) Before and after at 8 months, after 250 grafts to each eyebrow of a 38-year-old Caucasian female whose
eyebrow loss was due to over-plucking as a teen: (B) before and (C) after. (Courtesy of J. Epstein, M.D. From Unger WP, Shapiro R, Unger R,
Unger M, eds. Hair Transplantation 5E. London and New York: Informa Healthcare; 2011.)

natural appearance. Therefore, they are only employed when as much as possible for the initial 72-hour postoperative period.
hair characteristics and donor/recipient zone features favor- The authors generally remove sutures between 8 and 10 days
able for MUG use in transplantation are present: 1) low hair- after surgery. However, sutures should be left in place for 10 to
to-scalp color contrast; 2) fine diameter and wavy or curly 14 days in patients with donor wound closing tension at either
hair (increases the shingling effect); 3) transplantation in the extreme (increased tension or excessive scalp laxity).
central forelock, midscalp, or anterior crown (zones where the Rare donor area complications include temporary localized
hair can be acutely angled to produce a shingling effect); and hyperesthesia, arteriovenous fistulas, and localized wound
4) the presence of surrounding hair (either existing or trans- dehiscence, as well as aesthetic complications of visible scar-
planted) so as not to expose the MUGs over time.35 ring, keloid or hypertrophic scarring, or temporary donor
When higher density is required and these four criteria are hair effluvium.41,42 Within the recipient area, the extremely
not met, high-density FUT or “dense packing” in targeted zones rare, but most serious complication of central recipient area
(defined as implantation of >30 FU/cm2) may be considered. necrosis results from vascular compromise and is more likely
When performed successfully, high-density FUT most closely in smokers, diabetics, and patients who have undergone prior
resembles natural hair distribution, increases patient satisfaction, scalp surgeries.42 Ingrown hairs and folliculitis are a more
and minimizes the likelihood that patients will require a follow- common but less severe complication (2% to 10% of patients)
up transplant to the same area.36 Disadvantages of this approach, that may be treated with either alcohol wipes or warm com-
in addition to increased vascular compromise, include the pro- presses three times per day or a course of a first-generation
longed out-of-body period due to increased time for denser recip- cephalosporin, such as Cephalexin, depending on the severity.
ient site creation, production of more “skeletonized” grafts, and Although patients may vary considerably, substantial cos-
more challenging graft insertion associated with a greater poten- metic improvement is present after 9 to 12 months, and the
tial for preexisting follicle transection, graft desiccation, and general timeline for hair growth after surgery is as follows:
traumatic graft insertion, respectively.37 Using the “stick-and- newly transplanted fine hairs begin to appear around the third
place” method of implantation in which the physician makes an or fourth postoperative month and the number and caliber of
incision and immediately places a graft into the site can mini- transplanted hairs continue to increase until full growth can
mize some of these hazards.38 Benefits of this technique include be appreciated approximately 18 to 24 months after a session.
minimal bleeding, decreased likelihood of empty sites or of those
inadvertently filled by more than 1 FU (i.e., “piggy backing”), Perioperative Adjunctive
smaller incisions due to a shortened time for scalp recoil prior
to graft insertion (resulting in less vascular trauma), the ability Therapy
to adjust the incision size based on the fit of the grafts, and a Finasteride 1 mg (a 5α reductase inhibitor) was approved
simpler procedure for the assistant due to the ease of identifying for the treatment of AGA in 1997. Since the Food and Drug
Aesthetic Surgery
the exact angle and direction of each recipient site. However, the Administration (FDA) approval, 6.7 million patient years of
greater demand for the physician’s time coupled with the limita- exposure have resulted in a roughly 87% efficacy in slowing
tions of only one pair being able to plant simultaneously discour- hair loss or increased hair counts, with a relative low adverse
age many practitioners from using this method. event profile ranging from 0.7% to 5.9% of patients.43,44 The
degree of hair growth is most noticeable in the vertex and less
Postoperative Period dramatic in more anterior regions of the scalp. According to
a 3,177 patient trial, the response rate improves during the
Once the transplanted FUs have all been placed, many phy- initial 3 years of therapy before diminishing in approximately
sicians place a postoperative bandage for one night over the 14% of patients after a decade of therapy.45
patients’ scalp. Despite the additional public attention it may Many surgeons encourage young patients to complete a
draw to the patient’s appearance, the postoperative bandage trial of oral finasteride therapy prior to proceeding with sur-
may promote wound healing by maintaining an appropriate gery, especially in those who are destined to develop a severe
moisture balance and prevent infection by providing a physi- pattern of MPB in the future and those in whom a thinning
cal barrier to microbial invasion.39 crown is of utmost concern. Alternatively, finasteride—as it is
Soaking the scalp after the bandage has been removed most effective in posterior scalp regions—may prove to be an
facilitates crust dissolution and helps prevent further crust ideal adjunctive therapy in a patient who opts for HRS in the
formation. Since it may cause inadvertent graft dislodgement, frontal and midscalp areas.
patients are generally discouraged from shampooing their This medication does not come without risk, however, and
scalp for the initial 48-hours postoperatively, but are then its image has recently been tarnished by accusations, including
encouraged to shampoo gently. For the same cautionary rea- increasing incidences of high-grade prostate cancer (Gleason
sons, showering the recipient area is also reserved until after grades 7 to 10), depression, male breast cancer, and permanent
5 to 7 days postoperatively. After moistening the scalp, oint- sexual adverse effects.44 Although it has not been proven that
ments, or gels are applied twice daily along the donor incision these side effects are caused by finasteride, the FDA concluded
and over the recipient area. The authors’ practice also encour- that bias alone could not account for the trend of increased
ages topical minoxidil application (3.5%) not only for its incidences of high-grade prostate cancer in patients taking fin-
vasodilatory effects that may enhance wound healing but also asteride 5 mg. Prescribing physicians should also inform their
because limited data suggest that minoxidil decreases postop- patients of finasteride’s influence on lowering prostate-specific
erative effluvium.40 Continued minoxidil use is encouraged antigen values. It has not been approved for use in women and
for 5 to 12 weeks postoperatively unless the patient develops should certainly not be taken by women who are pregnant.
scalp irritation, in which case it should be discontinued. Topical minoxidil, with its beneficial effects of increasing the
Postoperative pain is usually minimal and is limited to a feel- percentage of anagen hairs and enhancing local vascular per-
ing of tension along the donor wound. In addition to analge- fusion, may be used alone or in combination with finasteride
sic use (acetaminophen or narcotics), patients should ice a few to slow the progression of AGA.
times a day for 10- to 15-minute intervals along the nape of Autologous PRP administration is also an emerging adjunc-
the neck (only inferior to the wound) to help minimize local- tive therapy requiring further investigation. In limited studies,
ized edema, which may cause increased tension in the donor it has been anecdotally reported that PRP injected directly into
area. Tissue edema in the forehead and temporal areas usually the scalp can increase overall hair counts and hair diameter
becomes most evident 3 to 5 days postoperatively. Rarely, this while microscopic findings reveal thickened epithelium, pro-
edema can descend into the periorbital tissue. To minimize the liferation of collagen fibers and fibroblasts, as well as greater
possibility of these sequelae, patients are also encouraged to ice numbers of blood vessels around hair follicles in areas that
their forehead and temples bilaterally and lie in a supine position have been treated with PRP.46
MPB and is compounded by a young man’s expectation and

Transplanting In desire often for a low, thick hairline. The surgeon should
Hair-Bearing Areas virtually never comply with such a request because the lim-
ited donor supply will not be sufficient to create appropriate
Young Male Patients density in a natural distribution behind such a hairline. A
Young male patients in their mid-twenties or younger, who young man’s threshold for eligibility for HRS should remain
are frequently not yet completely alopecic but who request high after a careful evaluation of their projected donor-to-
surgical intervention for their hair loss, represent the great- recipient ratio. Medical adjuncts should then be presented
est challenge in terms of planning. This crucial time in a in detail and strongly encouraged. The authors do believe,
man’s life can be negatively impacted in a significant man- however, that—when performed prudently—young patients
ner by the stigma of hair loss. The difficulty in planning is may benefit greatly from HRS and not be arbitrarily
caused primarily by the uncertainty of the future pattern of excluded by age alone (Figure 52.13).47
A B
C D
E F
FIGURE 52.13. A. A 19-year-old man with severe hair loss in the frontal and midscalp areas before treatment. B. The area has been prepared
with betadine solution to reveal the true extent of hair loss in the frontal and midscalp areas. C. A photo taken 12 months after one session to the
frontal area and one to the midscalp area (a total of 4,244 FU) at a density of approximately 25 FU/cm2. The hair has been parted through the
frontal area for critical evaluation. D. A photo taken the same time as (C) but with the hair combed as normally worn. E. A photo taken 4 years
after the photos in (C) and (D) with the hair parted for critical evaluation. F. A photo taken 4 years after the photos shown in (D) with the hair
combed as normally worn. Note that the hair after 4 years is not quite as dense as in (C) and (D). This was because the donor area hair density
had decreased over that period of time, so the number of hairs per transplanted FU had, as expected, also decreased proportionately.31

In addition to the caveats addressed in the section
focused on hairline design, an ability to consistently pro- Female Patients
duce high hair survival rates at 25 to 30 FU/cm2 is impor- As with the younger male population, surgical technique for
tant in order to be able to cover larger areas than can be female patients emphasizes avoidance of existing follicle tran-
treated if the graft density is high (including areas of future section and temporary effluvium within the recipient area.
loss). This density and extent of coverage will help estab- However, because the donor area is often far more limited in
lish a relatively permanent pattern that will remain natural women than in men, it is wise to employ strategic transplan-
appearing when it exists on its own after the preexisting tation into the most cosmetically important areas of hair loss.
hair is gone. Avoiding transection of preexisting hairs is That approach, combined with more styling options than men
essential and, as noted earlier, the risk of temporary efflu- have, will ultimately provide the greatest illusion of overall scalp
vium should be minimized by creating the smallest recipient coverage. It is important to note that while some HRS find 20%
site incisions that will accept grafts without over-handling or fewer of the women they see in consultation to be candidates
and at as superficial a depth as possible. An extreme exam- for hair transplanting, a majority of experts polled on this sub-
ple of utilizing fewer grafts in order to create a natural ject felt 50% or more of those they saw were candidates.49
long-term pattern that is ideal for younger individuals with Surgical patterns previously described by the authors can
family histories of type VII MPB is a “Prospective” Isolated be selected for the aforementioned areas of strategic cover-
Frontal Forelock.48 age based on the patient’s particular presentation of FPHL
(Figure 52.14).50 In patterns focused along a “part” line, the
A
or
Frontal block T or L pattern Wedge Extended hairland
Aesthetic Surgery
“Male pattern” Type III Type IV
Hamilton pattern
Type V
“Frontal accentuation” Savin pattern Ludwig pattern
Olsen pattern
Before “L” pattern After

FIGURE 52.14. A. Four general categories of design utilized for female patients, which are then modified to cater to the exact needs of the
woman. B. The general designs address the various patterns of female pattern hair loss (FPHL) and (C) are ultimately applied to the individual
female patient.

patient must specify where she would like to ultimately part

her hair so that the improved density along that channel will Reconstructive and
yield the greatest cosmetic impact. Corrective Hair
Transplantation
Adjunct Treatment For The art of softening and camouflaging the “pluggy” appear-
Facelifting ance of a previous transplant involves not only the implan-
Face lifts may leave permanent signs, including discolor- tation of individual FU but also the removal of specific
ation of either the temporal or postauricular hairline. Even offending “plugs” (Figure 52.16). Partial excision of a plug
well-placed pretrichial incisions may widen or become hypo- using a 1.5- to 2-mm punch biopsy instrument removes a
chromic, revealing that a patient has undergone a cosmetic substantial amount of the plug hairs while leaving behind a
operation. Fortunately, HRS, when performed by an experi- crescent of a few remaining hairs that will appear softer and
enced surgical team, provides an excellent adjunct to conceal more natural, especially if surrounded by newly transplanted
undesirable discoloration, scarring, or displaced hairlines sec- FU. Determining the proper angle and direction of extraction
ondary to these procedures.51 is facilitated by trimming the offending plug hair to 3 mm in
An exposed temporal or preauricular scar is effectively length. This also gives a sense of the overall appearance once
concealed by re-creating a “sideburn” with fine caliber hair it is removed. Passing the punch deep enough to include 1 to
grafts. Regions of cicatricial alopecia in the postauricu- 2 mm of subpapillary adipose tissue not only minimizes the
lar region can also be camouflaged by transplanting both likelihood of regrowth of the offending hair but also enhances
within and around the scar (Figure 52.15). With all areas of viability of the excised portion of the plug as it is trimmed and
cicatricial alopecia, whether the skin surface has been previ- recycled for subsequent transplantation into a more appropri-
ously traumatized by a burn, reconstructed with a skin graft ate portion of the scalp. When individual FUs are transplanted
or flap, or rendered alopecic from mechanical trauma (such around a plug reduction site smaller than 2 mm, the biopsied
as trichotillomania, traction alopecia, and a dermatologic sites should not be sutured closed as this would reduce local
pathology), preserving the already-compromised underlying blood flow and increase localized scalp tension—both vari-
vascular perfusion is paramount. This may be aided by both ables detrimental to neighboring transplanted graft survival.53
avoidance of epinephrine use when anesthetizing the area
and transplanting at a graft density that is not high enough Future of Hair
to overwhelm the limited vascular supply. Repeatedly assess-
ing variations in perfusion while making incisions can help
Transplantation Surgery
determine if it is best to use either a 15 to 20 FU/cm2 density The advent of robotics in hair transplantation currently
in an area of low perfusion or up to a 30 FU/cm 2 pattern allows for automated harvesting of hair follicles using the FUE
where blood supply is sufficient.52 As dermal recoil and lax- method. Ultimately, the day will come when robots will auto-
ity are often limited in recipient areas of cicatricial alopecia, mate the entire hair restoration procedure, performing both
it is critical to optimize recipient site size to allow a “snug” retrieval and implantation. Even with robotic assistance, how-
fit of the grafts to ensure minimal graft handling by preven- ever, the drawbacks of FUE remain (potential decreased graft
tion of repeated “popping” or slipping out of grafts above viability secondary to denuded grafts, and noticeable punc-
the surrounding epidermis. tate scarring in the donor region if grafts are taken too closely
A B C
D E F
FIGURE 52.15. A. Browline and B. Postauricular regions of cicatricial alopecia of two different patients following a facelift procedure. These
areas made it difficult for the patient to wear her hair in any up-swept hairstyle which she favored in the summers. C. Preauricular area also
showing scars and regions of complete alopecia following the facelift. The patient wanted her hairline and “sideburn” re-created. D. Browline and
E. postauricular area following one hair transplant surgery. The area of cicatricial alopecia has good camouflage and the only remaining scar,
which is slightly visible is the hypo-pigmented incision scar. It is important to remind patients that although the hair will grow through the scar,
any skin discoloration may still be detectable upon close inspection. F. Preauricular area postoperatively. A natural hairline has been re-created
and the patient now can wear her hair tucked behind her ear as was her custom prior to the facelift procedure.

A B
FIGURE 52.16. A. A patient before repair of transplanting done in another office. The areas to be treated are outlined in black grease pencil and
the results after 1,973 FU can be viewed (B) 10 months later.
together or with too large a punch) and the artistry of surgical 15. Jimenez F, Izeta A, Poblet E. Morphometric analysis of the human scalp
hair follicle: practical implications for the hair transplant surgeon and hair
pattern creation may be limited. regeneration studies. Dermatol Surg. 2011;37:58-64.
Cell therapy in HRS remains on the horizon. Stem cell– 16. Epstein J. The efficacy of new technology: letter to the editor. Hair Transpl
rich regions of the hair follicle are believed to be the mesen- Forum Int. 2011;21(5):174-175.
chymal cells located at both the bulb region (dermal papilla) 17. Inaba M. Chapter 29.3. In: Inaba M, Inaba Y, eds. Androgenetic Alopecia:
and the bulge region. The concept of isolating hair follicle Modern Concepts of Pathogenesis and Treatment. Tokyo: Springer-Verlag;
1996:238-245.
stem cells and propagating them in vitro to generate new hair 18. Onda M, Igawa H, Inoue K, Tanino R. Novel technique of follicular
follicles was proposed over two decades ago. It was believed unit hair transplantation with a powered punch device. Dermatol Surg.
that autologous implantation of these replicated hair follicles 2008;34:1683-1688.
into the balding scalp would generate new hair follicles. The 19. Harris JA. New methodology and instrumentation for follicular unit extrac-
tion: lower follicle transection and expanded patient candidacy. Dermatol
promise of overcoming the shortcomings of current trans- Surg. 2006;32:56-62.
Aesthetic Surgery
plantation methods (a limited donor supply and scarring from 20. Harris JA. Follicular unit extraction (FUE): conventional FUE. In: Unger W,
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apy. Hair follicles have successfully been induced in rats and New York, NY: Marcel Dekker; 2011:291-296.
21. Gandelman M. Light and electron microscopic analysis of controlled injury
athymic mice using dermal papilla grown in culture media, to follicular unit grafts. Dermatol Surg. 2000;26(1):25-31.
and to a limited extent in their human donors.54,55 However, 22. Limmer R. Micrograft survival. In: Stough D, Haber R, eds. Hair
thus far, consistent growth of significant amounts of hair Replacement. St. Louis, MO: Mosby Press; 1996:147-149.
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45. Sato A, Takeda A. Evaluation of efficacy and safety of finasteride 1 mg in of cultured vibrissa dermal papilla cells in the adult rat. J Embryol Exp
3,177 Japanese men with androgenetic alopecia. J Dermatol. 2011;38:1-6. Morphol. 1986;97:111-124.
46. Takikawa M, Nakamura S, Nakamura S, Ishirara M, et al. Enhanced effect 55. Osada A, Iwabuchi T, Kishimoto J, et al. Long-term culture of mouse vibris-
of platelet-rich plasma containing a new carrier of hair growth. Dermatol sal dermal papilla cells and de novo hair follicle induction. Tissue Eng.
Surg. 2011;37:1721-1729. 2007;13(5):975-982.
47. Unger W. Hair transplanting in early stage male pattern baldness. Hair
Transpl Forum Int. 2011;21(5):148-152.

part VI
n BREAST
CHAPTER 53 n Augmentation Mammaplasty:

Principles, Techniques, Implant
Choices, and Complications
Steven Alan Teitelbaum
and final patient satisfaction is the cumulative result of all of

Introduction these steps. Most important of all is how perceptions of suc-
Breast implants have been FDA (Food and Drug cess after surgery were defined at the initial steps of education.
Administration) regulated since the Medical Device Act of Educating patients and having them sign off that their breasts
1976. The FDA uses the total reoperation rate as a criti- will not match, that some ptosis can be normal, that the only
cal index when evaluating these devices, which has directed truly natural breasts are non-augmented breasts, that implants
patients and surgeons to focus on the pivotal decisions can be felt, that no cup size can be promised, and that implant
that affect this rate. Reoperation rates at 3 years have con- edges or the implant shell may become visible over time can
sistently been in the 15% to 20% range, and the indica- actually increase satisfaction and reduce requests for reopera-
tions for reoperations have also been consistent over three tions. These issues must be made clear to patients as a part of
decades. These statistics suggest that it is not the devices informed consent.
themselves that are responsible for the high reoperation
rate. Rather, the problem is the way surgeons use them,
including patient education, device selection, surgical plan- Philosophical Approaches to
ning, and the conduct of the operation. The FDA regulates Breast Augmentation
the sale of implants by a manufacturer, but not the practice
There are two schools of thought in breast augmentation:
of medicine.
“Give the patient the size she requests” and “Give the patient
Focusing on the avoidance of complications is an ethical
Breast
the size that fits within her breast tissues.” The former assumes
imperative, especially for an elective procedure. The same
that augmentation is a purely cosmetic procedure initiated by
decisions and processes that reduce complications also pre-
the patient. The surgeon’s role is to safely deliver the result
dictably deliver superior aesthetic results. The modern breast
she requests, including issues such as the size and type of the
augmentation prioritizes avoiding complications, reducing
implant, incision, and so on.
reoperations, and minimizing iatrogenic damage to breast
The latter emphasizes that augmentation is real surgery
tissue.
and that the plastic surgeon must make medically prudent
The success of an operation can only be improved when
decisions. Patients do not understand which implant will fit
objective endpoints are defined before surgery. For onco-
within their breast tissues. They do not necessarily understand
logic surgeons and patients it may be local recurrence. For
the consequences of an excessively large implant on the shape
breast augmentation, the only valid quantifiable endpoint is
of the breast in the short term, nor the adverse effects of them
the reoperation rate (when such criteria are defined preop-
on breast tissues over time.
eratively). What local recurrence is to cancer surgeons and
Neither philosophy should totally trump the other. Both
patients, reoperation rate is to the aesthetic breast surgeons
must be considered concurrently and conflicts will arise.
and patients.
Patients may prefer one scar yet the surgeon realizes an objec-
tive benefit of another incision; a patient may want an implant
The Process of Breast of a certain size yet the surgeon may believe it is much too
large or small for her breast envelope.
Augmentation
Surgeons and patients tend to focus on the operation itself as
the event that determines the surgical outcome, with preopera-
The Causes of Reoperation
tive discussion and postoperative management considered to The only unequivocal endpoint assessing the quality of breast
be of secondary importance. This approach fails with breast augmentation is the revision rate. Fortunately, the steps that
augmentation where it has been demonstrated that reopera- reduce reoperations also create more beautiful breasts. The
tions can be reduced and patient satisfaction increased when a opposite of a malpositioned implant is an ideally situated
defined process is applied to breast augmentation.1-3 implant; the opposite of a contracted capsule is a soft capsule,
Each step of a breast augmentation is no better than the and so on.
one that preceded it: planning is dependent on patient educa- The plastic surgeon’s priority is to maximize preservation
tion; the operative procedure is dependent upon the opera- of tissue and prevent reoperation. This approach will simul-
tive plan; recovery is dependent on the surgical procedure; taneously reduce her chances of facing the risks, costs, and
565
566 Part VI: Breast
emotional distress of another operation and maximize the

likelihood of an optimal aesthetic result.
Capsular Contracture
Capsular contracture is and has always been a leading cause
of revisions. As scar tissue thickens and tightens around the
implant, the breast feels firmer, it looks becomes more spheri-
cal, the implant migrates superiorly, and the breast can be
painful. Though patients may say, “my implants got hard,” in
fact, the implants are soft but constrained within a tightening
envelope of their own tissue (see Figure 53.1).
The proximate cause of capsular contracture is inflamma-
tion, which in turn can be caused by silicone gel bleed, glove
talc, blood, tissue trauma, and bacteria. Current evidence
supports Staphylococcus epidermidis biofilm as a significant
cause of capsular contracture.4,5 Data include the association
of biofilm with contracted capsules, the experimental induc-
tion of capsular contracture through inoculation of breast Figure 53.2. These cloudy droplets emanated from the lactiferous
implants with Staph epidermidis, and reduction in capsular ducts during an inframammary augmentation. The ducts containing
contracture from the use of antibiotic irrigation. this fluid are divided during the periareolar approach and the implant
Breast augmentation is a “clean-contaminated” case surface becomes contaminated with the bacteria living within.
because there are bacteria within the breast, the concentration
of which is highest in the area of the periareolar (PA) inci-
sion. At least one study has shown a statistically significant
increase in the percentage of capsular contracture using the
PA approach.6 (see Figure 53.2).
Patients should be educated before surgery that it is normal
to feel the capsule around the implant (Baker grade II), that
the capsules on the two sides never develop equally, and that
revision should only be considered for a Baker grade III (firm
and distorted) or Baker grade IV (painful). Surgery is not indi-
cated for a Baker II capsule because there is little likelihood of
creating and maintaining a Baker I (no discernable capsule).
While saline implants had an advantage in reducing capsu-
lar contracture over older generation silicone gel implants, the
advantage no longer exists over today’s silicone implants perhaps
due to shells that reduce silicone diffusion or the use of a silicone
filler with fewer impurities.7,8 Meta-analyses demonstrate the
benefit of implant texturing in the subglandular position, but no
such advantage is seen in the submuscular position.
Malposition
Implant malposition creates some of the most severe deformi- Figure 53.3. Inferior malposition results in up-pointing nipples and
ties following breast augmentation (Figures 53.3–53.6). Breast an empty upper pole. Note the position of the inframammary scars
appearance is determined by the amount and distribution of above the current inframammary folds.
volume, which in turn is determined by the position of the
breast implant.
Figure 53.1. As scar tissue thickens and tightens around breast

implants, the shape becomes more spherical, frequently rises upward, Figure 53.4. Lateral malposition results in an underfilled medial
becomes firm, and often painful. meridian of the breast and a widened intermammary distance.

Chapter 53: Augmentation Mammaplasty: Principles, Techniques, Implant Choices, and Complications 567
is least effective in the situations where medial fullness is most
desirable: pectus carinatum, a wide intermammary distance,
or extreme tightness of the skin against the sternum. Implant
edge visibility and traction rippling caused by excessive medial
dissection or division of medial pectoralis attachments along
the sternum are largely uncorrectable deformities.
Even with a precise pocket, gradual migration from weight,
pressure, and gravity can occur, particularly with chest wall
deformities. For instance, a pectus excavatum will increase
the likelihood of medial migration (symmastia), and a cari-
natum shape will predispose a patient to lateral malposition
(Figures 53.7–53.9).
Whenever the musculocutaneous fibers that define the
perimeter of the breast are divided, then it is the tenacity of the
neighboring tissues that will either hold the implant in place
or allow it to passively migrate. In order to create an ideally
Figure 53.5. While other malpositions are related to some combi-
proportioned breast, the IMF may need to be lowered, but
nation of over-dissection, implant size, and irregularities in rib cage it must be done precisely; random and blunt lowering of the
contours, superior malposition is the result of inadequate division of IMF is unpredictable and uncontrolled.
pectoralis along the inframammary fold or capsular contracture. A surgeon should assess the strength of attachments
between the soft tissues and chest wall at the inferior edge of
the IMF incision. When these attachments are weak, the infe-
rior cut edge of scarpa’s fascia can be sewn to the muscle fas-
cia. Some surgeons will routinely place such sutures with the
Over-dissection allows an implant to move out from its inframammary incision.
ideal position and incomplete dissection prevents an implant
from settling in its ideal position. The use of pressure wraps,
circumferential bands, and special bras to push the implant
against undivided tissues or to prevent an implant from
migrating into an over-dissected space is ineffective. Accurate
dissection is more effective than any external influence.
Excessive lateral or inferior dissection allows implants
to malposition in those directions; division of the pectoralis
major muscle along the sternum risks symmastia and window-
shading of the muscle which reduces coverage and leads to
animation deformity; incomplete division of the pectoralis
major muscle along the medial inframammary fold (IMF)
predisposes to superior and lateral malposition; and failing to
divide accessory pinnate origins of the pectoralis just lateral
to its main trunk along the lateral sternal border may cause
lateral malposition (or restrict ideal medial position of the
Breast
implant and fill in that area).
Inferior and lateral over-dissection is most often inadver-
tent, medial over-dissection is often intentionally done to gain
more cleavage. Not only does this reduce muscle coverage
over the implant where tissue is thinnest, but also this method Figure 53.7. Worm’s eye view of patient with lateral implant
malposition on the left and capsular contracture on the right.
Figure 53.8. The pectus excavatum type of shape is now visible and
Figure 53.6. With medial malposition, the lateral breast is under- it is obvious how her implants would tend to migrate laterally. Note
filled and the nipple points outward. Presternal skin can be raised off also the depression of the ribs and parenchyma, particularly on the
of the sternum. right, corresponding to the position of the contracted implant.

568 Part VI: Breast
Ptosis
Ptosis recognized after breast augmentation either preceded
the augmentation or was created by it. Preexisting ptosis may
have been unrecognized or the patient may have declined
having a mastopexy. Either way, augmented ptotic breasts
are inevitably misshapen, and the weight and pressure of the
implants can make the ptosis worse. Implants in thin, ptotic,
and empty envelopes have a high tendency for palpable folds.
Breast augmentation is not a treatment for breast ptosis.
An implant can fill an empty breast, but it does not raise
nipples or shorten a long N:IMF (nipple to inframammary
fold) distance. If a patient has a preoperative N:IMF of
>9 cm, a mastopexy should be considered; when N:IMF > 10
it is required (Chapter 54).
Many patients with ptotic breasts do not want a masto-
pexy. In an effort to avoid the mastopexy, a very large implant
Figure 53.9. Medial rib cage depression (pectus excavatum) creates
passive forces that can lead to symmastia. This situation tempts sur- might be used, perhaps making the breasts larger than what
geons to divide enough pectoralis origins to fill the defect, but those the patient desires. In some cases, the bottom of the implant
fibers are critical to prevent a medial creep of the implant over time. remains at the IMF, and the breast tissue descends off the
front of the implant mound, creating a down-pointing nipple
and an upper bulge. In other cases, the implant falls to the
bottom of the breast envelope and creates even more lower
pole stretch, leading to more upper breast emptiness and an
Size Exchange upturned nipple (see Figures 53.10–53.13). If a ptotic patient
Reoperation to change the size of an implant should be rare. refuses mastopexy, then she should not have an augmenta-
Except for unusual changes in weight or lifestyle, reoperations tion. This is one of the most frequent avoidable errors in
for size exchange are usually the result of inadequate patient breast augmentation.
education and implant selection. If a breast has a large envelope by dimensions and a small
Determining implant size with bags of rice, water, and amount of existing parenchyma, (See “Size” on page 11), then
implants; filling a larger bra; prediction of a cup’s size; or look- it may take a large implant to fill the breast. Yet such skin may
ing at photos puts the patient into a mind-set that implant size stretch from the pressure and weight of the large implant.
is totally her choice. This allows the patient to reconsider size Post augmentation ptosis is invariably related to problem-
in the future. When patients are educated to choose the implant atic patient tissues. The N:IMF distance on maximal stretch
that ideally fills their breasts based upon their breasts’ dimen- is an indication of the amount of skin between the nipple and
sions, then future rationale for changing the size is limited. In the fold. When an implant is placed, the breast fills from the
addition, allowing a patient to expect to be a particular bra bottom up. If this distance is short, a given sized implant will
size is misleading because there is no standard for bra sizing. create more upper bulge; if this distance is long, then a simi-
When surgeons determine the implant size intraoperatively, larly sized implant will remain in the lower pole. Anterior
they may find themselves being criticized by a patient dissatis- pull skin stretch (APSS) is measured by pulling on the skin
fied with their size. This can be avoided when the implant size just medial to the areola and determining how far forward it
is agreed upon preoperatively. It is also apparent that sitting will move with gentle pressure. When it is short it indicates
a patient up during surgery with air around her implants as that the skin envelope has little stretch to accommodate an
swelling begins is not as accurate or predictive as preoperative implant, and when it is long it indicates that the skin will
objective tissue measurements (and prolongs operative time, not lay tight against the implant. Parenchymal contribu-
increases tissue trauma, bleeding, and raises the possibility of tion to stretched envelope fill (PCSEF) is a measurement of
contamination). how full a breast already is. If a given implant is put into a
There is a misunderstanding that using measurements
makes implant selection a surgeon’s choice. Implant size is
as much as patient’s choice when she chooses to tell the sur-
geon to select the size that is best for her tissues as when she
chooses to tell the surgeon a specific size. Optimal patient
education and informed consent teaches patients the evidence-
based benefits of published measuring systems, and the patient
then chooses to use those systems to determine implant size.
Patients are taught that breasts fill from the bottom up as if
sand were being poured in from a funnel. There is an ideal
volume to fill any particular breast. If the volume is excessive,
the upper pole will be too full, and if the volume is insuffi-
cient, the upper pole will remain underfilled.
There is also an adage to “go larger, because patients
always wished they were bigger.” This is false. Many patients
do request a second operation to receive smaller implants,
and the patients who think they are too big often have soft
tissue coverage and stretch problems as a result of those large
implants. Those who feel too big often suffer from anguish
or embarrassment, while those who contemplate being larger
are not distraught, but perhaps just want “more of a good Figure 53.10. Postpartum with a base width of 15 cm and an
thing.” But when the concept of “the right size” is taught N:IMF of 11 cm. Her breasts are heavy and ptotic, but she did not
to patients, then future requests for size exchange are nearly want a mastopexy.
eliminated.

Figure 53.11. Three months after subglandular augmentation with

a 550 cc implant.
breast that is already full, it will result in more upper full-

ness and definition of the implant, whereas an empty breast
will have more room to accommodate the implant. When
N:IMF > 9.5, APSS > 4, and PCSEF < 20%, the surgeon must
recognize that the patient is in a problematic situation and is
at risk for post augmentation ptosis that will require a revi-
sion surgery (see upcoming section and illustrations of these
measurements).
Shell Failure Figure 53.13. Top: two years after augmentation with subglandu-
Retrieval studies demonstrate that over half of all shell failures lar implants in a patient who declined mastopexy. Note severe dam-
are due to sharp instrument injury during implantation. Even age to the skin at periphery of implant and markings for a mastopexy.
a small scratch increases the chance of shell failure in stress
cycle testing.
The implant should be kept in its thermoform packaging
and touched only by the surgeon after changing into new abrasion to skin edges, damage to the implant shell, or “frac-
gloves. Saline implants can be rolled and placed through turing” of the fill in the case of some highly cohesive implants.
smaller incisions than silicone. Since they are filled after inser- Breast implants are most safely inserted through incisions with
Breast
tion, all sizes of saline implants can be placed through an inci- a minimal length of 4 to 4.5 cm, with longer incisions required
sion of the same length. Large, textured, or highly cohesive for implants with a base width over 13 cm or a volume over
breast implants require longer incisions. There is no consistent 350 cc. While IMF incisions can be lengthened, staying within
rule about incision length. Incisions should be of adequate a small areola or axilla can make it challenging to use those
length to assure atraumatic insertion of the implant, with no incisions for gentle implant insertion.
Cautery and needles must never be in proximity to the
implant. Pocket adjustment after implant placement must
be made with retractors designed for implants. The surgeon
should develop a system for closure that creates exposure and
protects the implant from the needle.
Underfilled saline or silicone implants are more subject
to collapse, shell folding, and possible failure along folds.
Surgeons should use implants with a fill that optimizes
shell folding, which is a consequence of both fill volume
and fill cohesivity. Intraluminal betadine in saline implants
can lead to shell delamination. Betadine irrigation into the
pocket for both saline and silicone gel implants is against
all manufacturers’ Directions For Use. But given its value
in reducing capsular contracture, this prohibition may be
reviewed.
Rippling
Rippling in the décolletage inhibits the ability to wear low-
cut clothing. Palpability reduces confidence and feels odd.
Figure 53.12. At 18 months post augmentation the lower pole skin
Rippling is probably the most distressing of all breast implant
has stretched and the upper pole emptied. A breast augmentation is issues for patients. It is the least likely of all secondary aug-
not a substitute for a mastopexy. Not only does she still need the mas- mentation deformities to be corrected (or even prevented) if
topexy, but her tissue is more stretched now than before her surgery. the breast tissue, muscle, or skin is thin, loose, or damaged
(Figures 53.14–53.17).

570 Part VI: Breast
Figure 53.14. Implant underfill rippling can be visible with the Figure 53.16. Severe underfill rippling in a nulliparous 26-year-old,
patient upright, but is exacerbated bending forward. Adequate tissue only 4 years after augmentation with high-profile saline implants.
coverage can conceal underfill rippling.
There are two types of rippling: implant underfill rippling Traction rippling occurs when an implant pulls on the cap-
and traction rippling. sule, which in turn pulls on the skin, much like a heavy object
Implant underfill rippling occurs when an implant shell is in a shirt pocket would create folds in the fabric.
filled to a volume that does not prevent upper shell collapse with Longstanding high-profile or contracted implants can cre-
the patient upright, allowing shell folding as the filler descends ate bowl-shaped deformation of the rib cage allowing the
to the dependent portion of the implant. Just as there is an ideal anterior surface of the implant to collapse and ripple.
fill volume for the breast, there is an ideal fill volume for the Breasts most prone to visible rippling are those with inad-
shell. The manufacturer (or surgeon filling a saline implant) must equate tissue coverage (e.g., when pinch thickness of the skin
balance the advantages of lower fill volume (less roundness and and subcutaneous tissue superior to the breast parenchyma is
more softness) versus higher fill (less rippling). Increased cross- less than 2 cm) or when pinch thickness at the IMF is less
linking of silicone polymers increases cohesivity, which may than 0.5 cm. Breasts with preexisting ptosis and those that
reduce rippling by decreasing the amount of inferior descent of are susceptible to postoperative ptosis (APSS > 4, NIMF > 9,
fill material within the shell. and PCSEF < 20%) are also prone to rippling. These situa-
Underfilled implant rippling can be camouflaged if tissue tions should be identified preoperatively. No type of breast
thickness over the implant is adequate, but the implant shell is implant can compensate for inadequate tissue coverage, and
nevertheless rippled. Even highly cohesive filler implants that are deformities that occur are largely uncorrectable. Surgeons
underfilled can cause rippling by pulling on thin overlying tissues. should consider refusing to augment breasts when such tissue
Some surgeons opine that textured implants ripple more problems are significant. The role of tissue coverage in pre-
than smooth implants. Textured shells are only slightly thicker venting rippling cannot be overstated. Therefore, the priority
than smooth shells. Perhaps this stiffens the shell enough so at primary augmentation is to maximize coverage and avoid
that folds less readily dissipate upon light palpation. tissue damage.
Figure 53.15. Same patient after using a higher cohesive implant.

Underfill rippling is eliminated, but traction rippling creates lines of Figure 53.17. But the implant is just one component of her defor-
tension. Just as with underfill rippling, thicker tissue coverage and mity; parenchymal atrophy, thinned skin, redundant skin, and a chest
better skin elasticity reduces its appearance. wall concavity will preclude her from ever having attractive breasts.

Asymmetry
Breast asymmetry is normal but if it is not documented pre-
operatively it may later be attributed to the surgery. Three-
dimensional breast photo analysis has revealed that 72% of
patients have significant nipple asymmetry and 94% have sig-
nificant breast-mound asymmetry.9 These should be demon-
strated to the patient preoperatively and the patient should be
made specifically aware that her breasts will not match.
Attempts to treat underlying asymmetries require trading
one asymmetry for another. When trying to equalize breasts
of different volumes, the larger breast would receive the
smaller implant and the smaller breast would receive a larger
implant. The smaller breast would appear more full and the
larger breast less full. These choices can be appropriate but
should be made only after careful consideration. The use of Figure 53.19. Thinning of skin, parenchymal atrophy, and rib cage
different size implants to create more volume symmetry fre- concavity are all present in this patient. There is always a question of
quently creates a shape mismatch that is more noticeable than the extent to which this was preexisting, an inevitability of time, or
the size mismatch. an effect of the implant. Notice how her tissue changes exactly cor-
The same planned N:IMF distance should be used on both respond to the position of her implant.
sides, even if one nipple is higher. This assures breasts of more
similar fill distribution, which is more aesthetically desirable
than IMFs at the same height. Patients must be aware preop-
eratively that this is intentional and implants placed in this breast envelope as much as would lactation can be anticipated
manner are not malpositioned. to permanently stretch and alter breast tissue.
Highly projecting implants place more pressure per area
Permanent Tissue Damage than a wider implant of the same volume. If width is held con-
stant, highly projecting implants can be nearly twice the vol-
Thin, weakened, stretched, and damaged tissues are responsi-
ume and weight, thereby placing substantially greater pressure
ble for the occurrence, severity, and difficulty in correction of
on the rib cage as well as the soft tissue. This causes parenchy-
many of the common reasons for reoperation. The same minor
mal atrophy, thinning of subcutaneous tissues, thinning and
malposition or capsular contracture which would not be vis-
stretching of skin, loss of skin elasticity, rib cage deformation,
ible under thick tissue and tight skin can be quite visible under
and loss of sensation. In any case, if an implant of the proper
damaged tissue. Rippling is rarely an issue with good tissue
volume is selected for a given breast, a high-profile implant
coverage but becomes one when tissue is thinned. Finally, any
would be excessively narrow for the breast and thereby create
problem that requires correction is more problematic to cor-
an imbalanced fill. If a high-profile implant is chosen of the
rect when tissues are thinner or weaker (Figures 53.18–53.27).
proper base width for the breast, the volume is almost inevita-
Both the surgical act of dissecting a pocket for a breast
bly too great for the breast.
implant and the longstanding presence of an implant can
These tissue changes can result in rippling, skin stretch
cause atrophy of breast tissue. Prudent implant selection and
requiring mastopexy, and bizarre animation deformities.
exacting surgical technique can help preserve tissue integrity
Such problems are often not correctable, and attempts to
and minimize long-term parenchymal atrophy. Longstanding
Breast
mask them with highly cohesive implants, an acellular der-
pressure against tissue causes remodeling: bras cause acro-
mal matrix, and fat injections all result in imperfect cor-
mial grooving, orthodontics move teeth, and tissue expand-
rections which are expensive and pose their own risks and
ers stretch and thin skin. A breast implant that stretches the
drawbacks. On the other hand, extremely damaged tissue
can almost rule out explantation alone as an option because
of the severe deformity that results (and explantation should
always be considered in recalcitrant post-augmentation
complications).
Preoperative decisions should make soft tissue cover-
age a priority and surgical technique should strive to protect
it. When the pinch of tissue overlying the IMF is less than
5 mm, consideration should be given to not dividing the
origins of the pectoralis major muscle along the medial IMF.
If the muscle is going to be divided along the IMF, it should
only be released to the junction of the IMF and the lateral
sternal border, but not even one interspace above that. To
do so permanently thins tissue along the sternum, which can
cause uncorrectable traction rippling and risks symmastia. It
also increases the degree of deformity when contracting the
pectoralis major muscles. It also allows the muscle to migrate
superiorly, further reducing critical tissue coverage.
Fibers between the pectoralis muscle and the overlying
parenchyma should be preserved because they hold the supe-
rior cut edge of the divided pectoralis inferiorly, thereby main-
Figure 53.18. Two years after augmentation with high-profile taining lower pole muscle coverage after division along the
implants. In addition to the inferior malposition, the pressure of the
implants remodeled the rib cage. This reduces projection, makes an
IMF (Figure 53.28). This is one major disadvantage of the
explantation option highly deforming, and increases the future likeli- subglandular approach: it destroys these fibers forever and
hood of underfill rippling (see “Rippling” section) because this forces should a dual-plane pocket ever be necessary in the future, the
redundancy of the anterior surface of the implant. absence of those fibers allows the muscle to slide superiorly,
reduce coverage, and contribute to animation deformities.

572 Part VI: Breast
Fig. 53.20. Fig. 53.21.
Fig. 53.23.
Fig. 53.22.
Figure 53.20–27. 53.20 Twenty-year-old preoperation for breast augmentation. 53.21. Intraoperation after placement of 380 cc high profile
saline implants filled with 440 cc of saline. 53.22. Severe deterioration of result at 2 years post operation. 53.23. Intraoperative view after masto-
pexy 2 years after primary augmentation. 53.24. One year after mastopexy with severe rippling. 53.25. One year after mastopexy with 3 mm of
coverage and damage to the skin at the junction of the implant and chest wall. 53.26. Compare the thickness of her breast tissue following these
large implants to what it was preoperatively, as shown in figure 53.20. 53.27. At revision of mastopexy with implants removed, compare appear-
ance of breast to her original preoperation: rib depression, skin stretch and texture changes, and loss of parenchyma. 53.28. Green arrow points
to serratus anterior muscle; red the origins of the pectoralis major muscle along the inframammary fold that will be divided; pale blue the origins
of the pectoralis major muscle along the sternum; black the transition between inframammary fold and sternum above which no muscle is divided.
While there is a high level of success treating ptosis, mal- The thoracoacromial artery and vein and lateral pectoral
position, and contracture, problems that result from damaged nerve enter the pectoralis major muscle through a fat pad on
and thinned tissues are frustrating for patients and plastic the muscle’s deep surface. Exposure of the bundle is not nec-
surgeons; solutions are often elusive and results are too often essary and visualization of it suggests that dissection may be
disappointing. more superolateral than necessary. The medial pectoral nerve
innervates the lateral oblique portion of the pectoralis major
Anatomy muscle after emerging either from within or lateral to the pec-
Standard descriptions of anatomy of the chest are available in toralis minor muscle. Unlike division of the lateral pectoral
medical school textbooks, but important nuances of surgical nerve, division of the medial pectoral nerve does not produce
anatomy are very relevant to breast augmentation surgery. symptomatic weakness.

Fig. 53.24.
Fig. 53.25.
Breast
Fig. 53.26. Fig. 53.27.
Figure 53.20–27. (Continued)
Inferior to the medial pectoral nerve are lateral cutane- Large perforating arteries and veins arise about 1.5 cm lat-
ous nerves arising at each interspace, the fourth intercos- eral to the midline. If the surgeon does not dissect more medi-
tal nerve providing primary sensation to the nipple. Larger ally, then injury to these vessels is usually avoided. These same
implants require more lateral dissection and put more nerves vessels usually enter the submammary plane about 5 mm more
in jeopardy. lateral than their entrance into the pectoralis. Dissection is too
superomedial if the large caliber vein at the second intercostal
space is visualized. It can be difficult to obtain hemostasis of
these vessels, particularly on the chest wall side. There is also
a risk of pneumothorax when trying to coagulate a vessel that
has withdrawn into an intercostal muscle. So if these vessels
are visualized and the decision is made to coagulate them, a
stalk should be left along the chest wall.
Smaller but important perforating vessels must also be rec-
ognized inferomedial to the areola and another approximately
midway from that vessel to the lateral sternal border. Several
lateral intercostal vessels can be encountered along the lateral
gutter of the pocket. When the lateral pocket appears tight
after implant insertion, an atraumatic spatula-like retractor
can be used to move the implant out of the way while the cau-
tery is used to incrementally enlarge the pocket. Blunt finger
dissection is less accurate and can result in lateral bruising and
notable post surgical discomfort in that area.
Figure 53.28. In retropectoral or dual-plane augmentation, division of
the pectoralis major origins along the medial IMF is necessary

574 Part VI: Breast
to establish an optimal relationship between the width of the

breast and the N:IMF distance, allowing optimal and pro-
portional fill of the lower pole of the breast. Division should
occur about 1 cm above the proposed IMF.
The medial pectoralis major origins along the lateral ster-
nal border provide necessary coverage over the medial edges
of the implant, help hold the superior cut edge of the pec-
toralis from sliding superiorly, and reduce the likelihood of
medial malposition (symmastia). Division of any of the main
body of pectoralis origins along the lateral sternal border also
increases the severity of animation deformities and can pro-
duce uncorrectable deformities, including window shading of
the pectoralis, visible implant edges, and traction rippling in
the cleavage area (Figures 53.29–53.33).
Lateral to the main trunk of the sternal head of the pec- Left Breast
toralis along the lateral sternal border, there are accessory
tendinous pinnate origins of the pectoralis. Left intact, the Figure 53.30. If muscle is divided along the sternum, the implant
will lose coverage and the muscle can scar to the deep surface of the
more lateral of these will keep the implant too lateral, thereby gland and create significant animation deformities.
reducing potential cleavage. So long as the main trunk of the
pectoralis major muscle originating from the lateral sternum is
clearly visible and distinct from these pinnate fibers, the pin-
nate fibers can be carefully divided.
is made into a substance that reduces microscopic gel “bleed”
The operative strategy should prioritize visualization of all
for silicone gel-filled shells.
structures, avoidance of contamination of the implant, and
Texturing is an additional step, and it is done with a vari-
precise and gentle handling of all tissues.
ety of ways. One method involves placing a thin and sticky
sheet of silicone over the implant and pressing against it with a
Selecting the Implant Shell, textured form. Another method involves placing salt or sugar
Fill, and Size crystals onto the surface of the implant after its last “dip,” and
then dissolving them away (“the salt-loss” method). There has
The fact that breast implant study data demonstrate consistent been a question about the association of implants made by
outcomes suggests that implant type is not the prime determi- the salt-loss technique with anaplastic large cell lymphoma
nant of results. Manufacturer-sponsored premarket approval (ALCL) of the breast, though the number of cases is too small
trials produce the best data because of independent monitor- to make a valid conclusion.
ing of the studies by a contract research organization and the The primary rationale for texturing implants is that it
rigorous follow-up. Yet each of these only evaluates a single reduces capsular contracture. Studies have shown inconsis-
product line and no comparisons between different implants tent results about whether texturing reduces contracture.
are performed. It is invalid to compare different outcome A meta-analysis did show that texturing reduced capsular
studies of the various implants because the cohorts are too contracture,10 but only in the subglandular and not in the sub-
different. So too are patient selection, surgical technique, par- muscular position.10 One type of texturing may be associated
ticipating doctors, and clinical endpoints. with late seromas.11,12
Most plastic surgeons have opinions about implants based All “anatomically” shaped or “teardrop” implants are tex-
upon their own experience. It is unlikely that there will ever tured to create friction or allow tissue ingrowth and minimize
be a study in which different implants are compared one to the risk of rotational malposition. Some surgeons use textured
another in a scientifically credible manner. implants when they are concerned that weak tissue or chest
wall irregularities will predispose the patient to malposition.
Implant Shell Others believe that textured implants improve the implant soft
Implant shells are made by sequentially dipping a solid mold tissue dynamic by reducing the sliding of breast tissue relative
of an implant form (a mandrel) into liquid silicone. One dip to the implant.
Left Breast
Figure 53.29. Release up to the black arrow places implant into a
dual plane I position (see section on “Operative sequence”). Further ver-
tical elevation movement of the muscle is the result of division between Figure 53.31. Muscle retracted far superiorly as a result of release along
the fibers interconnecting the muscle and the gland see the sternum. The muscle no longer can provide coverage to the implant.

became the most popular implants in the United States and
worldwide.
Breast implants filled with the most cohesive silicone gel
are often referred to as highly cohesive, colloquially referred
to by patients as “gummy bear.” There is no standardized
measurement or cutoff between a “regular” silicone gel and
a “highly cohesive” silicone gel implant. The intention of
the design of these implants is to maintain the distribution
of fill within the implant, which should allow greater pre-
dictability and control over breast shape. This also tends
to result in less shell collapse and folding, though these
implants are not immune to that problem. While some
uncontrolled data suggest they may have a lower rate of
shell failure, high cohesive fill implants also experience shell
failure. While highly cohesive implants maintain a more
constant shape than do conventional silicone implants, they
are not “form stable.” An implant that is truly form stable
Figure 53.32. Intraoperative view during breast reduction demon-
strates fibrous attachments between gland and superficial fascia of the would be too firm to be desirable.
pectoralis major muscle. Preservation of these in an augmentation is A variety of “alternative fill” implants have been tested in
important to prevent the muscle from “window-shading” superiorly. an effort to either avoid silicone or to be radiolucent, such as
hydrogel and soybean oil. None has yet achieved its objectives
and none has received the FDA approval.
Some surgeons believe that textured implants are more Implant Shape
prone to ripple even though the texturing adds negligible The most commonly used implants have always been round
thickness to the shell. implants. These implants are manufactured in various ratios
of width to projection, so that the same volume implant can be
Implant Fill Substance narrower or wider. Higher profile implants will project more
and be more spherical in shape than lower profile implants.
Implant filler materials include saline, silicone, and highly Shaped implants are sometimes referred to as anatomic or
cohesive silicone. Saline-filled implants were the only option teardrop implants. The shell in these implants is shaped like a
available during the US silicone moratorium from 1992 to wedge, being less projecting at the top and more projecting at
2006. They can be inserted through a small incision and the bottom.
inflated once in the pocket. The surgeon balances adding Implant shells cannot themselves maintain a filled implant
more fluid in order to reduce the chance of fluid waves and in a particular shape, and for that reason shaped implants
ripples with filling it less so that the implant is softer and need to be made out of a more highly cohesive gel. Similarly,
less round. if a round implant were made out of a highly cohesive gel,
Studies are underway in the United State to study a baf- it would stay round and not look like a breast. Therefore,
fled saline implant which aims to reduce the fluid wave and shaped implants are typically highly cohesive, and highly
thereby ostensibly feel more like a silicone gel-filled implant. cohesive implants are most often shaped.
Breast
Silicone gel has been the most venerable implant filer since
breast implants were first used in 1962. It is generally believed
to best mimic the feel of the human breast. Manufacturers can Size
control the amount of cohesivity of the silicone, and it is now There are two approaches to selecting the implant size. One
more gelatinous than it was in the 1970s. After the silicone is to pick the implant size that will create the breast size the
gel moratorium ended in 1996, these implants rapidly again patient requests and potentially force the tissue into a certain
Figure 53.33. Base width is a linear measurement of the width of the patient’s
existing breast parenchyma. Even when the breast mound extends to the midline,
the inner caliper should not go medial to an approximation of where the pectora-
lis origins on the lateral sternal border would be, since the muscle is never divided
along the sternum and it would therefore be misleading to assume any greater width.
(Courtesy of John B. Tebbetts MD).

576 Part VI: Breast
size and shape. The other is to pick the implant size that fills shape, and dimensions; (4) IMF position (N:IMF); and
but neither stretches nor distorts the breasts. (5) incision location15 (Figures 53.34–53.37).
There are a variety of personal styles to size by the first Thousands of patients sized with this methodology have
approach: entertaining patient requests for a particular cup been published in peer-reviewed journals; it is the most widely
size; placing sizers of silicone, water bags, or rice bags in a bra referenced and taught system of implant selection; it has been
she wishes to wear; selecting the size a friend received or was adopted by surgeons worldwide; and the objective nature of
used on her favorite Internet photo; using three-dimensional the system has allowed it to be easily adopted by surgeons of
computer simulations; surgeon empiric experience with sizing; all levels of experience.
or using intraoperative sizers to achieve a size that matches a
photograph the patient provided or that the surgeon and their
operating room staff believe looks most attractive.
Pocket Location
None of these methods has been validated. All are highly Options for pocket location are (1) total submuscular (subser-
subjective instead of being objective and scientific. They also ratus and subpectoral), (2) partial retropectoral (behind the
leave the door open to the patient changing her mind about the pectoralis with IMF origins intact), (3) subfascial (between
size and requesting another operation to change her implants. the pectoralis muscle fascia and the pectoralis muscle),
Some surgeons will start with the patient’s volume request (4) submammary or subglandular (between the breast
and will moderate their suggestion based upon their experi- and the pectoralis fascia) and (5) dual plane (controlled
ence. Such methods are highly personal and do not give the amounts of pectoralis major muscle over some parts of
young surgeon any practical guidance in implant selection. the implant and breast over other parts of the implant
A very important concept to recognize is that the breast (Table 53.1).
shape will change as a function of implant size, for example, a Total submuscular is more frequently a reconstructive
small implant in a given breast will look less round and have technique, less commonly done for augmentation owing to
less upper fill in a given breast than would a larger implant. a more painful and bloody dissection, a tendency for the
Patients may make requests that are inherently contradictory, device to rise superiorly, and difficulty in predictably cre-
such as a breast that is flat in the upper pole but of such a ating a deep and well-formed IMF, particularly laterally.
large size that there would inevitably be a significantly convex Subfascial has not been widely adopted due to an absence
upper pole. of satisfactorily controlled or long-term data. With only
The second approach is predicated on the hypothesis that 0.2 to 1 mm more coverage than a classic submammary dis-
each breast has an optimal fill volume. According to this section, this procedure is a variation of the submammary
method, quantitative measurements of the breast determine pocket and does not qualify as a distinct pocket type.
the implant size. Partial retropectoral and submammary have various
The BioDimensional™ System originated in a monograph trade-offs. The dual plane is the ideal compromise because it
published by Tebbetts for McGhan Medical and was popu- includes the benefits of each and minimizes the trade-offs of
larized in the mid-1990s.13 This system prioritized desired both. It allows the implant to be beneath the muscle where
size over the size that optimally filled the breast. It was also a coverage is needed and against the gland where expansion
two-dimensional system, not considering the important third is necessary, such as a constricted lower pole or a lax lower
dimension of tissue stretch (though it did encourage many pole. Though this approach is colloquially referred to as “half
surgeons to start measuring breasts as a part of preopera- over/half under,” in reality the implant should never be over
tive planning). And it did not take into account the effect of any part of the pectoralis major muscle. It is either behind
weight and pressure of the implant on adjacent tissues. pectoralis major muscle or it is behind gland. Some surgeons
In 2001, the TEPID™ System for implant size determina- will dissect superficial to the pectoralis muscle and transect
tion was published by Tebbetts.14 It was the first system that it in the direction of its fibers at the level they wish to have
specified an implant size based upon breast measurements. the muscle. But this permanently sacrifices any coverage ben-
It contained the crucial measurements of tissue thickness, efits from the more inferior portion of pectoralis and once
stretch, and breast fill. The High Five™ System published the muscle is divided the amount of coverage that remains is
by Tebbetts and Adams in 2005 took the implant sizing unpredictable.
methodology of TEPID™ and incorporated it into a system The submammary and partial retropectoral pockets are
for determining the five critical decisions in breast augmen- specific entities. However, the dual plane is a continuous
tation planning: (1) soft tissue coverage (pocket location); spectrum of options, occupying a continuous “gray-zone”
(2) implant size and weight (TEPID™); (3) implant type, between submammary and partial retropectoral. When the
Figure 53.34. Anterior pull skin stretch (APSS) is commonly referred

to as skin stretch. It is the measure of the distance the skin medially to
the areola can be pulled forward, Augmentation Mammaplasty, 2009
(Courtesy of John B. Tebbetts MD).13

Maximum
stretch
Figure 53.37. After the retropectoral pocket is made, the pectoralis

is divided 1 cm above the proposed inframammary fold to create a dual
plane I. The implant is variously submammary and subpectoral. There
is no more release of pectoralis origins on a dual plane II or III than I.
Figure 53.35. Nipple to inframammary fold distance is measured

from the medial nipple on maximum stretch with the arms out to the
sides on the operating table (Courtesy of John B. Tebbetts MD). amounts of this should be divided at a time; a mere several
millimeters of dissection along the superficial surface of the
muscle can yield a centimeter of vertical migration of the infe-
rior cut border of the pectoralis. By disrupting attachments of
pectoralis major muscle is left intact at the IMF, the implant is the muscle to the overlying gland, the muscle can be gradually
partial retropectoral; if the muscle is divided along the IMF up and incrementally raised, thereby reducing the proportion of
to the intersection of the IMF and the lateral sternal border, subpectoral pocket and increasing the proportion of submam-
the technique is termed as dual plane I. If the connections mary pocket (Figures 53.38–53.42).
between the muscle and the overlying parenchyma are released No matter the extent of the dual plane, the pectoralis major
so that the muscle slides up to about the lower border of the muscle is divided across the IMF, only to the point where
sternum, it is dual plane II; and if released to about the supe- the IMF joins the lateral sternum and never superior to that
rior areolar border it is dual plane III. point under any circumstances. The inferior muscle origins are
The dual-plane operation starts with the creation of a par- divided before the attachments between the muscle and the
tial retropectoral pocket (subpectoral pocket with no pectoralis gland are transected; otherwise, control of the muscle position
major muscle division). As pectoralis major muscle origins are would be lost.
divided along the IMF, the muscle will reposition just slightly
superiorly. If the muscle prevents expansion of the lower pole
Incision
Breast
or if gland scoring is necessary, then the fibers between the
muscle and the gland are incrementally transected. Very small Patients and surgeons often determine incision location by
where they wish the scar to be. But the scar is the least impor-
tant distinction between the incisions. Each incision exposes
different anatomy; has differing levels of endogenous bacterial
potentially seeding the implant, dissects through different tis-
sues, and allows different amounts of visualization. A recent
poll showed that about 62% of surgeons routinely use the
inframammary incision, 25% the PA incision, and about 8%
the transaxillary (TA) incision (Figures 53.42–53.44).
Though a dual-plane dissection can be performed from
all incisions, the inframammary incision allows the greatest
degree of control and precision. While this is certainly possible
from the PA incision, the IMF approach facilitates preserva-
tion of all the attachments between the muscle and the overly-
ing gland. Dissection from the PA incision down to the IMF or
the proposed level of transection of the muscle often results in
some degree of inadvertent disconnection of the muscle from
the overlying gland, thereby resulting in unintentional supe-
rior elevation of the muscle.
Patients are frequently encountered whose implants were
ostensibly retropectoral, yet in whom the muscle has retracted
so far superiorly that the implant is no longer behind any
muscle. The anatomy that influences muscle position is best
Figure 53.36. Parenchymal contribution to stretched envelope visualized through the IMF incision and the young surgeon
fill (PCSEF) is also referred to as just “fill.” It is an estimate of the
extent to which the potential space of the breast is full. It is the most
might delay considering the PA and TA incisions until after
imprecise of all of the measurements, but it only affects implant sizing facility is attained with the IMF incision. A ptotic breast with
in the extreme measurements, so exact measurement is unnecessary a long N:IMF distance can also result in an implant that was
(Courtesy of John B. Tebbetts MD). initially placed in a retropectoral pocket sliding inferiorly and
no longer being retropectoral.

578 Part VI: Breast
Tab l e 5 3 . 1
Pocket Comparisons
n Issue n Advantage n Advantage of n Dual-Plane

of Partial Subglandular Remedies
Retropectoral
Less pain X Best data to date
Better coverage X Large advantage vs SM;
ifference relative to PRP
d
dependent upon release
and up to determination of
surgeon
Access to lower pole X Yes
parenchyma
Expands constricted breasts x Yes
Fills ptotic breasts x Yes
Avoids muscle animation x Rarely clinically significant
Reduces tendency to “ride x Yes
high”
Reduces tendency to x Yes
“lateralize”
Faster recovery x Best data to date
Less capsular contracture x Best data to date
Better for mammograms x Appears to be
Reduce parenchymal atrophy x Best data to date
Reduces stretch deformities x Best data to date
Many surgeons release the muscle along the IMF and DP II or III, which would require retrograde dissection along
describe the procedure as “half over–half under,” or even the cut border of the pectoralis, remains beyond what current
“partial retropectoral,” which is exactly what is described as a instrumentation will allow.
dual plane type I. Muscle release can be performed via the PA
incision but this may have the disadvantage of greater bacte-
rial contamination and capsular contracture.16
Operative Sequence
A DP I, involving only the release of the pectoralis along For all incisions, the same operative principles apply: premea-
the IMF, can be undertaken from the TA incision. Unlike a sured implant size; predetermined N:IMF distance; precise mus-
blunt and blind TA approach which risks uneven release of cle release; preservation of the pectoralis along the lateral sternal
the muscle and imprecise level of the IMF, DP I TA should be border; preservation of the fibrous interface between parenchyma
performed with a bloodless, endoscopic technique. Creating a and pectoralis; all done with precise prospective hemostasis.
Figure 53.38. These fibers hold the muscle to the gland. They are
released incrementally to allow the muscle to move superiorly and Figure 53.39. This is taken seconds after the previous image;
thereby place a greater amount of implant in the subglandular space. dividing just a few fibers causes significant superior muscle movement.

Figure 53.42. So long as the incision is placed in the new inframa-

Figure 53.40. Restrictions are assessed and released when neces- mmary fold, a hyperpigmented and hypertrophic intramammary scar
sary, always prioritizing muscle preservation. is only visible when the breast is pulled upward.
Since the scar must be within the new IMF, that location the cautery is parallel to the chest minimizes the risks of inad-
must be accurately determined before surgery. It is measured vertent injury to the intercostal muscles. The tented pectoralis
from the nipple with the skin on maximum stretch. In general, muscle is divided 1 cm above the desired new IMF and 1 cm
the standard of 7 cm for a base width of 11 cm, 8 cm for a off the chest wall origin to enter the subpectoral space.
base width of 12 cm, and 9 cm for a base width of 13 cm holds The retractor blade is turned toward the sternum. The
true. The High Five System contains a table that defines optimal pectoralis is divided about 1 cm superior to the proposed
N:IMF for each implant volume or base dimension. If the IMF is IMF. Dissection stops at the lateral sternal border and never
already greater than that distance, it does not need to be altered. proceeds superiorly along the sternum.
Some surgeons place an adhesive dressing over the nipples The retractor is repositioned aiming to 12 o’clock, and the
to reduce bacteria in the surgical field. remaining areolar fibers are divided up to the superior extent of
An incision is made at the proposed IMF. Dissection is car- the pocket. It is very important at this stage of dissection to assure
ried straight down to the muscle fascia with the electrocau- that dissection does not damage the thoracoacromial pedicle.
tery, taking care to dissect slightly superiorly so as to preserve This dissection should be completed before dissecting laterally.
IMF fibers. It is all too easy to inadvertently dissect inferiorly The cautery then sweeps laterally raising the pectoralis
and so this must be done with great care. major muscle from the pectoralis minor muscle. The plane
A double-ended or army–navy retractor is placed with the between these muscles is more readily found when releasing
tip pointed toward the medial border of the areola. With no from medial to lateral.
dissection made over the surface of the muscle, there will be The dissection follows the lateral border of the pectoralis
Breast
little to hold the tissue on the blade of the retractor, so the minor down to the inferolateral IMF. What seems like very
ulnar fingers of the retractor hand are used to pull the tissue small enlargements of the inferolateral pocket results in very
onto the blade. Because it is loose on its deep surface, the pec- large increases in the pocket when the implant is placed, so
toralis will tent upward. lateral dissection is limited and expected to be enlarged after
Only the pectoralis major will rise off of the ribs. Serratus, implant placement if necessary.
intercostal, and rectus muscles are adherent and will not rise. A retractor is then directed superomedially and dissection
Lowering the cautery hand onto the upper abdomen so that proceeds from superior to inferior along the lateral sternal
Figure 53.41. While avoiding a scar on the breast, the TA incision Figure 53.43. The areola is the visual focus of attention and a peri-
produces the only scar visible outside of clothing. areolar scar can be very visible if not faint.

580 Part VI: Breast
over the incision is the only dressing that is used. With

bloodless dissection, no special bandages are necessary to
create compression, and early motion is not just allowed, it
is ordered. Patients move their arms over their head in the
recovery room in a slow jumping jack type of motion. They
may drive a car when they feel that they can safely make
unrestricted movements, which is usually in 2 to 3 days.
They are encouraged to perform all normal daily activities
that do not involve strain or exertion, such as opening and
closing car doors, putting on a seatbelt, lifting a baby, emp-
tying a dishwasher, or making dinner. They may return to
the gym after 3 weeks.
Most patients require only ibuprofen for analgesia once
they leave the recovery room, and no increase in bleeding
results from this practice.
Complications
Numerous factors contribute to complications and patient
Figure 53.44. When there is focus on avoiding complications such
as maximizing tissue coverage, avoiding malposition, contracture, and
dissatisfaction in breast augmentation. Unrealistic goals,
assuring adequate fill, the result is a beautiful and hopefully long-last- suboptimal implant selection, nonideal surgical plan,
ing result. This patient is shown 10 years after correction of capsular imprecise execution of surgery, healing problems, patient
contracture. noncompliance with instructions, changes in body habitus,
device inadequacies, and disorders of healing and patient
biology create a diverse set of causes for complications and
dissatisfaction.
border. This is often a very tight area and by leaving this as Bleeding and infection are reported to occur at an incidence
the final dissection there will thereby the best visualization of of 1% to 2%. Local complications are the most frequently
it. The main trunk or body of pectoralis fibers is always left encountered complications and their causes and avoidance
attached to the sternum, but lateral, tendinous pinnate fibers were discussed in section “The Causes of Reoperation.”
between the pectoralis major and the ribs are divided. A large Breast implants do not increase the incidence of breast
perforator at the second interspace is avoided, as well as per- cancer. One large registry showed a lower incidence of breast
forators at each interspace located approximately 1.5 cm from cancer.17-20 Breast implants are radiopaque and can interfere
the midline. with mammograms. Additional “displacement” views are nec-
The pocket is irrigated with antibiotic solution and essary in all of the standard mammogram views. Unless the
inspected for bleeding and accuracy. implants are firm, the entire breast can be visualized. If not,
The space thus created is dual plane I. To proceed to dual then ultrasound or magnetic resonance imaging may be neces-
plane II or III, the attachments between the pectoralis mus- sary to fully evaluate the breast. Proportionately, more breast
cle and the overlying parenchyma are incrementally divided, cancers are detected by physical exam rather than by mam-
allowing the muscle to thereby move superiorly. While dual mogram in women with breast implants when compared with
plane II denotes roughly the lower areolar border and dual women who do not have breast implants. This is perhaps a
plane III denotes a release to the superior areolar border, these consequence of the platform of the implant behind the breast
are not distinct entities and merely serve as reference points. making it easier to feel the breast tissue.
The surgeon should release only as much as is necessary to In recent years, a new entity has been recognized that can
remove restrictions or to expose parenchyma if scoring is arise within the capsular tissue. Brody’s disease (after Garry
indicated. Brody who described this entity) is a T-cell ALCL arising in
Gloves are changed, and the implants are gently inserted. the breast implant capsule. ALCL has been identified with
If the incision is too small to atraumatically place the implant, both saline and silicone-filled implants. In the cases where the
the incision is enlarged. implant shell was known, most or all were textured. Of those,
The patient is elevated to a sitting position for inspection of most or all were textured via a “lost salt” process, though
the breasts. Particular attention should be placed to the IMFs these observations are anecdotal and not of sufficient numbers
and the lateral breast pocket. If there are areas of flatness or to draw conclusions.
under-dissection, the pocket should be enlarged only under Several theories have been proposed for the cause of ALCL:
direct visualization with the implant retracted by a retractor mechanically induced inflammation, chronic biofilm, reaction
designated for breast implants. A very small amount of divi- to shards of silicone, or causes yet undetermined. In countries
sion can make a large increase in the pocket. A bulge in the with similar reporting there are widely different incidences
upper breast can represent under-dissection in that area or of this disorder, and the spectrum of the disease has a wide
180° from it. range. Racial and ethnic background, gluten intolerance, and
After repeating this process until the appearance is sat- other factors are being investigated at this time.
isfactory, the incisions are closed with attention at all times Less than 100 worldwide cases are known. While T-cell
directed to avoiding any contact between the needle and the lymphomas are very aggressive, only five of these patients
implant as even small shell injury may increase the chance of a presented with B-symptoms (fever, night sweats, and weight
subsequent shell failure. loss), four of whom died. The rest did not have metastatic
Skin closure should be meticulous and atraumatic to the disease and had benign clinical courses. Though primary
skin edges to achieve an optimal scar result. T-cell breast lymphomas occur (about 90 per year in the
United States), they involve breast tissue rather than capsule,
and they have aggressive courses. Most of Brody’s disease
Postoperative Care cases behave in a more benign manner, similar to cutaneous
With precise visualization of the pocket, no special bras or T-cell lymphoma. It would appear that most of these cases
straps are necessary to push the implant into position or pre- represent some form of benign lymphoid hyperplasia rather
vent it from moving out of position. Tape or a steri-strip than a true lymphoma.

10. Barnsley, GP, Sigurdson LJ, Barnsley SE. Textured surface breast implants
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Reconstr Surg. April 2011;127(4):1747-1748. Reconstr Surg. December 2005; 2005-2016.
6. Weiner T. Relationship of incision choice to capsular contracture. Aesth 16. Bartsich, S, Asherman, J, Whittier S, Yao, C, Rohde, C. The breast: a
Plast Surg. 2008;32:303-306. clean-contaminated surgical site. Aesthet Surg J. September 2011;31(7):
7. Haeck P, Glasberg S, Roth M, Schneider-Redden PR. The saline versus 802-806.
silicone breast implant debate: separating fact from opinion. Plast Reconstr 17. Deapen DM, Brody GS. Augmentation mammaplasty and breast cancer: a
Surg. May 2008;121(5):1847-1849. 5-year update of the Los Angeles study. Plast Reconstr Surg. 1992;89:660.
8. Wong CH, Samnuel M, Tan BK, Song C. Capsular contracture in subglan- 18. Breiting VB. Long-term health status of Danish women with silicone breast
dular breast augmentation with textured versus smooth breast implants: a implants. Plast Reconstr Surg. July 2004;114(1):217-223.
systematic review. Plast Reconstr Surg. 2006;118:1224. 19. Deapen DM, et al. Breast cancer stage at diagnosis and survival among
9. Liu C, Luan J, Mu L, Ji K. The role of three-dimensional scanning technique patients with prior breast implants. Plast Reconstr Surg. 2000;105:535.
in evaluation of breast asymmetry in breast augmentation: a 100-case study. 20. McCarthy CM, et al Breast cancer in the previously argumented breast.
Plast Reconstr Surg. December 2010;126(6):2125-2132. Plast Reconstr Surg. Jan 2007;119(1):50-58.
Breast

Chapter 54 n Mastopexy And Mastopexy/
Augmentation
W. Grant Stevens, Andrea E. Van Pelt, and Adrian M. Przybyla
length of the incisions, the amount of skin to be excised,

Introduction/History and whether the woman desires modification of breast size
According to ASAPS national statistical data, over 115,000 are considered. Decreasing the glandular mass with a small
mastopexies were performed in 2008, a 394% increase reduction can decrease the effects of gravity and recurrence
from 1997. Mastopexy currently ranks number eight on of ptosis. Augmentation may permit shorter incisions by
the list of the most commonly performed aesthetic surgical filling the skin envelope but may not satisfactorily address
procedures.1 nipple descent. 3,6 A flexible surgical plan takes all these
Although mastopexy techniques have evolved in tandem variables into account.
with innovations in breast reduction, mastopexy involves lift- Issues related to scar length and breast shape take on added
ing and shaping by redistributing the tissue without reducing importance in mastopexy compared with reduction. General
volume. The challenge lies in choosing the right technique to guidelines based on the degree of ptosis will help determine
maximize correction of ptosis, minimize scars, and slow the the best approach. When the nipple has descended 1 to 2
recurrence of ptosis over time.2 cm below the inframammary fold, surgical elevation of the
Most women seeking mastopexy have a relative deficiency nipple–areola complex is required for correction. When the
of breast parenchyma within a larger, ptotic skin envelope. nipple is pointing downward and the breast is low, correc-
Age, gravity, weight fluctuation, pregnancy, and lactation tion requires major reduction of skin and upward position of
all contribute to the development of breast ptosis and loss of the nipple–areolar complex. Glandular ptosis can be improved
a youthful shape. Loss of elasticity results in stretching and with augmentation or mastopexy, depending on the patient’s
lengthening of skin and glandular attachments. As glandular desired breast size.3
tissue settles, the upper pole of the breast loses its convexity When evaluating a patient for any type of breast surgery,
and appears deflated. Other reasons women seek mastopexy diligent cancer screening and baseline examinations are per-
include correction of congenital deformities such as tubular formed, including a review of previous mammograms, biop-
breasts, or to achieve symmetry of the contralateral breast in sies, breast scars, breast tissue, and family history of breast
post-ablative breast reconstruction.3 cancer. Baseline mammograms are obtained for patients older
In the setting of ptosis with considerable glandular than 35 years, or earlier in high risk patients. In regard to
atrophy or when the woman desires a larger breast size, future breast cancer detection, simple operations with less
mastopexy may be combined with implant augmentation. manipulation and internal repositioning of parenchyma are
In some cases, loss of upper pole fullness can be corrected preferable to limit internal scarring.3
with an implant only. The increased volume from implant
augmentation fills the ptotic skin envelope and decreases the Algorithm For Choosing The
amount of skin resection. Other situations such as congeni-
tal or acquired breast asymmetries and tuberous deformi- Right Procedure
ties may require combined augmentation and mastopexy for The senior author (WGS) uses an algorithm based on the
optimal aesthetic outcomes. degree of required nipple elevation and the woman’s desired
postoperative volume.
Definition and Classification Pseudoptosis
of Ptosis • For women who desire larger breasts, a biplanar aug-
mentation will provide superior fullness to match inferior
Several classification systems have been devised to better define fullness.
ptosis. Regnault’s classification is the most widely employed, • For women who desire the same breast size, a small resec-
establishing grades of ptosis based on nipple position in relation may be performed in conjunction with biplanar
tion to the inframammary fold and the skin envelope. She augmentation.
defines pseudoptosis, partial ptosis, and three degrees of true • Women who desire smaller breasts can undergo an infra-
ptosis4 (Table 54.1 and Figure 54.1). mammary wedge excision.
There have been a number of modifications to Regnault’s
classification that take into account components such as skin Grade I ptosis requiring no more than 2 cm nipple elevation
elasticity, glandular volume, and parenchymal distribution.3 • For women who desire larger breasts, an augmentation
Brink describes a ptotic breast that “pirouettes around its (preferably biplanar) can be performed with a circumareo-
adherent base,” as the nipple rotates inferiorly and descends lar mastopexy.
below the immobilized fold resulting in elongated distances • If the patient desires the same breast volume, a circumareo-
from clavicle to nipple, nipple to inframammary fold, and lar mastopexy is performed.
clavicle to inframammary fold. • For women who desire smaller breasts, a small reduction
may be performed.
Patient Selection Grade II ptosis requiring 3 to 4 cm of nipple elevation
Women are evaluated in terms of breast volume, the size • For women who desire larger breasts, an augmentation–
and quality of the skin envelope, nipple position, areo- mastopexy is performed. This may be performed in one or
lar size, the degree of ptosis, presence of asymmetry, and two operative stages depending on the surgeon’s preference
their expectations regarding shape and surgical scars.5 The and experience. Circumvertical mastopexy is preferred and
582
Chapter 54: Mastopexy and Mastopexy/Augmentation 583
TA B L E 5 4 . 1
Regnault’s Classification of Ptosis
Minor ptosis (first degree) Nipple at inframammary fold

Moderate ptosis (second degree) Nipple below inframammary fold, but above lower breast contour
Severe ptosis (third degree) Nipple below inframammary fold and at lower breast contour
Glandular ptosis Nipple above inframammary fold, but breast hangs below fold
Pseudoptosis Nipple above inframammary fold, but breast is hypoplastic and hangs below fold
should allow tightening both vertically and horizontally and

encourage reshaping into a more conical shape, while permit-
ting elevation of nipple–areolar complex.3
Although techniques are continuously evolving, three basic
scarring patterns remain, each with several variations: circum-
areolar, circumvertical, and inverted T.
Circumareolar
Circumareolar techniques can be either concentric or eccen-
A B C D E tric. Removal of a crescent of skin at the upper areolar
FIGURE 54.1. Breast ptosis classification. A. Normal. B. Minor or
border provides only minimal elevation of the nipple–are-
first degree. C. Moderate or second degree. D. Severe or third degree. ola. This is reserved for 1 cm lifts and eccentric areolae.
E. Glandular ptosis. Concentric periareolar mastopexies can be done with or
without remodeling of the gland and are usually limited to
small lifts. Circumareolar incisions offer the shortest pos-
sible scar pattern with the advantage of scar camouflage at
may require a horizontal wedge excision depending on the the areolar border. Most surgeons employ circumareolar
nipple-to-fold distance. Typical distances are 7 to 8 cm techniques for correction of grade I ptosis. Features com-
for a B cup, 9 to 10 cm for a C cup, and 10 to 11 cm for mon to all circumareolar techniques include the following:
a D cup breast. Skin and flap undermining are kept to a the new areola is circumscribed, points around the areola
minimum. The patient should be counseled preoperatively are connected to form a circle or oval pattern that is larger
that the resulting shape of the breast takes priority over the in diameter than the original areola; skin between the
presence or absence of a horizontal scar. inner and outer diameters is de-epithelialized. Temporary
• For women who want no change in volume, a vertical or wrinkling and pleating is common postoperatively, which
Wise pattern mastopexy is performed. improves over several months. A wider skin excision is asso-
• For women who desire smaller breasts, a small glandular ciated with a greater degree of skin pleating and flattening
reduction is performed. of the breast mound, as well as the potential for scar and
Grade III ptosis requiring >4 cm of nipple elevation areolar widening. Flattening can be advantageous in cor-
Breast
recting tuberous breast deformity. Spear proposed a series
• For women who desire larger breasts, a Wise pattern mas- of rules to minimize this tendency for periareolar tension,
topexy–augmentation is performed in one stage. Massive wrinkling, and complications. As a general guideline, the
weight loss patients often require a secondary procedure ratio of outer to inner diameter circumareolar markings
due to poor tissue quality. should ideally be less than or equal to 2:1, with a maximum
• For women who desire the same volume, a Wise pattern ratio of 3:1.13
mastopexy is utilized. For women who desire smaller Because of the criticisms associated with skin-only tech-
breasts, a Wise pattern reduction is performed.6 niques, several variations of the circumareolar mastopexy
were designed to improve breast projection, create upper pole
fullness, and prolong the correction of ptosis via parenchymal
Techniques remodeling. Circumareolar pursestring sutures were added to
The goal in mastopexy is to restore a firm and youth- prevent areolar distortion and scar widening.14-16
ful breast by reshaping the parenchyma and tightening Benelli developed the round block technique to increase
the ptotic skin envelope, while maintaining nipple–areolar projection and prevent areolar tension. One of two glandu-
vascularity and minimizing the extent of scarring. Many lar reshaping techniques is used, depending on the degree
authors have proposed algorithms to match a certain tech- of support needed. For simple ptosis in small breasts, the
nique with the degree of ptosis.3,5-7 There is no ideal tech- base of the breast is plicated and invaginated. He other-
nique and the shortest scar may not necessarily be the best wise performs a criss-cross glandular overlap of lateral and
one. Scar reduction at the expense of breast shape, position, medial flaps to increase projection and decrease the base
or longevity of correction is a poor trade-off; however, some width. Shape is maintained by fixating the glandular cone
women opt for this.2,8 to pectoralis fascia. Thick skin at the base of the breast is
Skin only mastopexies tend to lose shape over time and preserved so that it can maintain its supportive function.
accelerate secondary ptosis, particularly in large, heavy The round block involves a nonabsorbable pursestring cer-
breasts. Suturing the gland itself may result in a more durable clage around the areola. Benelli notes that this technique
shape.9,10 Some surgeons advocate suturing the superficial fas- is not suitable for all mastopexies and that patients must
cial system with permanent sutures.11 Others pass an inferiorly be willing to accept a less than perfect shape in favor of a
based flap under a pectoralis muscle loop to help maintain sus- reduced scar.14,16
pension.12 In general, smaller corrections require shorter scars, Goes developed another circumareolar method of reshap-
less skin excision, and tissue rearrangement. Skin excisions ing the breast parenchyma by implanting mesh as an internal

584 Part VI: Breast
brassiere. After creating skin flaps and reshaping the gland correct all grades of ptosis, but are predominantly employed
via rotation and plication techniques, a combination absorb- in mild to moderate ptosis (Figure 54.2). As an alternative to
able/nonabsorbable mesh is sandwiched between the de- the traditional inverted T approach, vertical techniques were
epithelialized periareolar dermis and the redraped skin flap. designed to decrease scarring, improve projection and upper
The periareolar pursestring suture is removed 6 to 9 months pole fullness, and maintain a long-lasting shape. Skin mark-
postoperatively.15 ings around the areola may be oval or dome shaped or resem-
ble an ice cream cone or parachute. “VOQ” is sometimes
used to describe a periareolar “O” atop a vertical “V” that
Vertical Techniques closes to resemble a “Q.”3 In glandular remodeling, the coni-
Vertical, or circumvertical, techniques add a vertical or cal shape is often overcorrected, allowing the breast to settle
oblique limb to the periareolar scar. They can be used to in its final position over several months. Vertical techniques
A B
C D
E F
FIGURE 54.2. Circumvertical mastopexy. A–C. Before circumvertical mastopexy. D–F. After circumvertical mastopexy.

have been criticized for being technically challenging and at a uniform 2 cm thickness. Medial and superior flaps are
frequently requiring revision, which has prompted various undermined for 2 to 3 cm along the pectoralis fascia. The
modifications to make them easier to learn. Lassus, Lejour, lower edge of the undermined superior flap is plicated to
Hall-Findlay, and Hammond are the pioneers of vertical scar pectoralis fascia to restore upper pole fullness. The edge of
techniques. the medially undermined flap is sutured to itself. The deep
Lassus first published his technique in 1969 and again in base of the inferior pedicle is then plicated to pectoralis
1970.17 Since his original design, Lassus has made modifica- fascia to secure an elevated position. The redundant infe-
tions to decrease vertical scar length and improve nipple– rior skin envelope is temporarily tailor tacked with staples
areolar blood flow. He prefers a superiorly based pedicle to create a smooth, rounded inferior contour. New exci-
for preservation of nipple sensation. In more ptotic breasts sion lines are marked along the staples, and the intervening
requiring greater than 10 cm of nipple–areolar elevation, a skin is de-epithelialized. The vertical incision is closed by
lateral or medial pedicle is used. The skin pattern resembles draping medial and lateral skin flaps over the inferior ped-
an oval, similar to that of a periareolar mastopexy. A glan- icle. A nonabsorbable interlocking periareolar pursestring
dular flap is dissected perpendicular to the chest wall medi- is cinched down to the desired areolar size. In patients who
ally and laterally, and inferiorly down to the inframammary do not need aggressive reshaping, Hammond uses a simple
fold. The inferior portion of the glandular flap is elevated, circumvertical skin resection without undermining skin
folded under, and anchored to pectoralis fascia to create or glandular flaps that can be accomplished under local
fullness and projection. A wedge of skin, with or without anesthesia.21-23
gland, is excised from the lower breast. The conical shape is
created by centrally coapting the medial and lateral glandu- Inverted T Technique
lar pillars. Lassus describes the postoperative breast shape as
The inverted T mastopexy (Chapter 55) may be used for
“the nose of a Concord,” noting it takes approximately 2 to
all grades of ptosis but is most useful for grade III, where
2.5 months for the breast to acquire a satisfactory appear-
the nipple–areolar complex requires more than 4 cm of
ance. Immediately post-op the vertical scar may be visible
elevation. It consists of periareolar, vertical, and horizon-
below the inframammary fold, but within 2 to 3 months
tal components. In general, longer horizontal and wider
with descent of the breast, the scar is usually no longer
vertical skin excisions allow for maximum correction of
apparent. Lassus would occasionally excise a small horizon-
ptosis (Figure 54.3). As with other techniques, there are
tal wedge, but later adjusted his technique by elevating the
many different incision patterns and glandular rearrange-
lower marking above the inframammary fold to avoid the
ments that produce an inverted T or anchor-shaped scar.
horizontal scar.17-19
The Wise pattern is the most commonly used, both for
Lejour further modified Lassus’ technique to shorten the
breast reduction and for mastopexy.8 Results are predict-
vertical scar. She described a superior pedicle and added
able but result in longer scars. Bottoming out, particularly
extensive inferior skin undermining with gathering of the
with inferior pedicles, is a long-term problem. There have
vertical scar to keep it above the inframammary fold. Any
been many attempts to shorten or eliminate the horizontal
necessary reduction is accomplished with liposuction imme-
component. Vertical techniques combined with short hori-
diately prior to the mastopexy. Thin, ½ cm skin flaps facili-
zontal elliptical excisions at the inframammary fold help
tate draping and gathering of excess skin on the inferior
keep the horizontal scar short. The lower ellipse tightens
pole and create a wider central glandular pedicle. Women
the skin envelope, shortens the nipple to fold distance, and
with particularly heavy or ptotic breasts may have persistent
diminishes skin pleating and dogears.2-3,8,24-27 If the horizon-
skin redundancy in the lower breast requiring subsequent
tal component is drawn as part of the original design, the
revision.10
pattern resembles an owl, where the periareolar and vertical
Hall-Findlay’s vertical technique (Chapter 56) begins
Breast
components represent the head and body, and the horizon-
with markings that resemble a modified Wise pattern with-
tal wedge represents the owl’s feet.28,29
out medial and lateral extensions. Markings curve toward
each other in the lower breast to meet 2 to 4 cm above
the inframammary fold. She prefers a medial pedicle, but Mastopexy Complications
may use a superior pedicle for small mastopexies. In gen-
eral, the pedicle is not undermined, but if needed, it may be
and Revisions
released from pectoralis fascia to facilitate upward rotation. Post-mastectomy complications include hematoma or seroma,
Skin flaps are beveled, but the inferior skin flap is kept uni- infection, asymmetry or nipple malposition, poor scarring,
formly thin. Medially based glandular flaps are mobilized loss of nipple sensation, necrosis of the areola, nipple or skin
and rotated up under the pedicle as an auto-augmentation flaps, and recurrent or persistent ptosis. Loss of sensation
to provide upper pole fullness. Medial and lateral pillars and necrosis are among the most devastating complications.
are sutured together inferiorly with deep sutures, narrow- Persistent ptosis implies inadequate correction of preop-
ing the base of the breast, elevating the inframammary fold, erative ptosis, whereas recurrent ptosis occurs later after an
and producing the conical shape. Skin is gathered to help it initially adequate correction. In a retrospective study of 150
retract during healing.9,20 consecutive patients undergoing mastopexy (298 breasts), the
Hammond developed the SPAIR technique (short scar most common reason for revision after primary mastopexy
periareolar inferior pedicle reduction mammoplasty), was poor scarring (6%). Other common complications were
which is easily adapted for mastopexy. Hammond designs seroma (2.7%), hematoma (3%), dogear formation (3%),
an 8 cm inferior pedicle centered on the breast meridian. and minor infections (2%). Persistent ptosis, asymmetry, and
On either side of the pedicle, marks are placed 8 to 10 radial nerve weakness were observed in 1% of the patient
cm up from the inframammary fold and connected with population. Nipple and flap necrosis did not occur in this
a curvilinear line. A variable distance of 4 to 6 cm above series, as flap undermining was minimized as much as pos-
the inframammary fold denotes the superior part of the sible. Seventy-five percent of the revision procedures were for
pattern and the top of the transposed areola. The breast is scar-related issues, which was statistically significant. Other
pushed up, medially, and laterally to mark medial and lat- revisions were for recurrent or persistent ptosis and asymme-
eral limits of dissection and form an elongated oval-shaped try. There was no significant difference in complication and
pattern. The inferior pedicle and a 5 mm rim of periareo- revision rates between inverted T and vertical pattern masto-
lar dermis are de-epithelialized. Medial and superior skin pexies, or between primary mastopexies and those with previ-
flaps are beveled, while the lateral skin flap is maintained ous breast surgery.30

586 Part VI: Breast
A B
C D
E F
FIGURE 54.3. T mastopexy. A–C. Before T mastopexy. D–F. After T mastopexy.
high risk of wound-healing complications, such as diabetics,

Mastopexy–Augmentation smokers, and immunocompromised patients, are not good
Combining skin envelope reduction with breast volume candidates for the one-stage procedure.13,31,35,36 When staged,
expansion requires careful planning. Some experts warn the mastopexy is typically performed first, although some
that the risk of the combined procedure is greater than the surgeons prefer the reverse—allowing the implant to stretch
risk of the individual procedures alone.31,32 However, plastic out the skin.37
surgeons have been safely utilizing the combined approach Breast augmentation may be performed in conjunc-
for decades.33,34,36,40,42 When compared with the option of a tion with any of the described mastopexy techniques:
staged breast augmentation and mastopexy that necessitates crescent, circumareolar, circumvertical, or inverted T
a second procedure in every case, many patients and sur- (Figures 54.4–54.6). Preoperative skin excision markings
geons desire a one-stage procedure that results in less time, are drawn conservatively and used as a guideline, keep-
cost, and recovery for the patient. The decision regarding ing in mind that skin envelope dimensions and nipple posi-
staging is based on the clinical scenario, surgeon’s experience tion will change after the implant is placed. Augmentation
and level of comfort, and the patient’s choice. Women with alone will elevate nipple position somewhat and increase

A B
C D
Breast
E F
FIGURE 54.4. Circumareolar mastopexy with augmentation. A–C. Before circumareolar mastopexy with augmentation. D–F. After circumareo-
lar mastopexy and placement of 300 cc cohesive gel implants.
the nipple-to-fold distance. Skin flap undermining is kept Secondary Mastopexy–

to a minimum to preserve perfusion to the nipple–areo-
lar complex and skin flaps. When possible, the parenchy- Augmentation
mal incision for implant placement should be oriented in Women often present to the surgeon’s office desiring aug-
a different direction than the overlying skin incision to mentation/mastopexy after having undergone previous breast
diffuse tension. Most recommend placing the implant in surgery such as augmentation (67% to 70%), lumpectomy
a submuscular pocket to minimize disruption of pectora- or biopsy (15%), mastopexy/augmentation (13%), reduc-
lis musculocutaneous perforators and reduce the risk of tion (5%), mastopexy (3%), and mastectomy with implant
capsular contracture. Glandular tissue is securely reap- reconstruction (2%). Indications for secondary surgery
proximated with one or two deep layers of suture to com- include recurrent ptosis, capsular contracture, and a desire
pletely cover the implant. Skin is frequently tacked around to change implant size, correct asymmetries, or revise poor
the implant before committing to the originally planned scarring.36,41,42
skin excision. If the nipple-to-fold distance is too long, a Secondary surgery may involve combinations of capsu-
transverse inferior wedge excision within the fold may be lar work, implant removal or exchange, and mastopexy.31,42
necessary.13,36,38-40 Technical complexity and risk of complications are greater

588 Part VI: Breast
A B
C D
E F
FIGURE 54.5. Circumvertical mastopexy with augmentation. A–C. Before circumvertical mastopexy with augmentation. D–F. After circumver-
tical mastopexy and placement of 330 cc cohesive gel implants.
with secondary augmentation/mastopexy. Preservation of There are several surgical options for augmented
blood supply to the nipple–areolar complex and skin enve- patients who present with ptosis. If the patient opts for
lope is of utmost importance. Previously augmented patients explantation alone, the breast typically resumes its pre-
have some degree of thinning of the tissues from the implant, augmentation degree of ptosis. There is debate over
and capsulotomy or capsulectomy may thin tissues even more. whether or not to perform an aggressive capsulectomy.
If the patient has undergone a prior mastopexy or reduction, Some fear that residual capsule leads to seroma and hin-
it is imperative to know the original pedicle orientation13 ders reattachment of breast tissue to the underlying chest
(Figure 54.7). wall.31 The senior author has not found this to be the case

A B
C D
E F Breast
FIGURE 54.6. T mastopexy with augmentation. A–C. Before T mastopexy with augmentation. D–F. After T mastopexy and placement of
200 cc cohesive gel implants.
when the implants are intact and the capsule is soft. If the result is preferred to avoid nipple ischemia. Initial skin
patient desires mastopexy following removal of implants, excision should be conservative—additional tissue may be
it may be performed simultaneously or delayed. In the resected after the implant is inserted. This reduces the risk
setting of tissue atrophy and thinning, it may be safer to of inadvertent skin shortage and diminishes the likelihood of
avoid capsulectomy to prevent devascularization of the excessive wound tension.31,42
nipple and skin. Ptosis of the implant itself in a previously augmented
A “snoopy deformity” is caused by descent of the nipple patient can create a “ball in sock” deformity, particularly
and breast tissue over an underlying implant. In this sce- with subglandular implants. Occasionally, the inframammary
nario, mastopexy may be performed with or without adjust- fold itself has descended, either because of overdissection at
ment of the implant or capsule. Most often, patients select the time of implant placement or disruption during transum-
re-augmentation in conjunction with mastopexy, where the bilical augmentation, causing the implant to sit too low on
implant is exchanged for a different size42 (Figure 54.8). The the chest wall. This may exacerbate the “double-bubble”
least aggressive mastopexy pattern to achieve the desired effect or give the appearance of pseudoptosis or bottoming

590 Part VI: Breast
A B
C D
E F
FIGURE 54.7. Correction of previous circumareolar mastopexy. A–C. Patient with widened areola after previous 400 cc textured silicone implants
and circumareolar mastopexy. D–F. After correction with a circumareolar mastopexy and replacement with 354 cc textured silicone implants.
out. Reconstructive options include pocket revision with cap- Complications are separated into either tissue-related or
sulorrhaphy, submuscular implant placement (in the setting implanted-related categories. Implant-related complica-
of existing subglandular implants), use of acellular dermal tions outnumber tissue-related complications and include
matrix, or creation of a neosubpectoral pocket.43 The implant deflation, capsular contracture, implant palpability,
capsule can also be used to create an internal autologous implant malposition, and a desire to change size. More
splint to reposition the implant and inframammary fold.44 serious complications involve infection, wound-healing
problems, and implant exposure or extrusion. Combined
Mastopexy–Augmentation secondary mastopexy–augmentation carries an increased
risk of infection because of more tissue rearrangement
Complications around the implant and risk of exposure. 42 Risk for loss
Although a single-stage procedure is technically diffi- of nipple sensation and ischemia or necrosis is increased
cult, complication, and revision rates compare favor- because of more extensive undermining and soft tissue
ably with rates seen in either procedure alone. 30,36,40,42 manipulation around the nipple. Skin flaps and incisions

A B
C D
Breast
E F
FIGURE 54.8. Secondary mastopexy with augmentation. A–C. Patient with “snoopy” deformity after a breast augmentation 5 years prior.
D–F. After secondary mastopexy with placement of 300 cc cohesive gel implants.
are at risk for the same reasons, particularly with added References
tension from an underlying implant. Poor scarring and 1. ASAPS. 2009 National Statistics Data. http://www.surgery.org/sites/default/
areolar widening may also be exacerbated by tension. files/2009stats.pdf
Nipple malposition can occur if the surgeon m isjudges its 2. Rohrich RJ, Thornton JF, Jakubietz RG, Jakubietz MG, Grunert
elevation following implant placement. Risks are dimin- JG. The limited scar mastopexy: current concepts and approaches to
correct breast ptosis. Plast Reconstr Surg. November 2004;114(6):
ished by proper patient selection and judicious plan- 1622-1630.
ning and technique. This is especially true for secondary 3. Bostwick JI. Aesthetic and Reconstructive Breast Surgery. St Louis, MO:
mastopexy–augmentations. 13,36,40,42 CV Mosby; 1983.

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2006;118(7):1631-1638. revisited: a review of 150 consecutive cases for complication and revision
9. Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin rates. Aesthet Surg J. March-April 2007;27(2):150-154.
Plast Surg. July 2002;29(3):379-391. 31. Handel N. Secondary mastopexy in the augmented patient: a recipe for
10. Lejour M. Vertical mammaplasty and liposuction of the breast. Plast disaster. Plast Reconstr Surg. Dec 2006;118(7 Suppl):152S-163S; discussion
Reconstr Surg. July 1994;94(1):100-114. 164S-165S, 166S-167S.
11. Lockwood T. Reduction mammaplasty and mastopexy with superficial fas- 32. Spear SL. Augmentation/mastopexy: “surgeon, beware”. Plast Reconstr
cial system suspension. Plast Reconstr Surg. April 1999;103(5):1411-1420. Surg. December 2006;118(7 Suppl):133S-134S; discussion 135S.
12. Graf R, Biggs TM. In search of better shape in mastopexy and reduction mam- 33. Gonzalez-Ulloa M. Correction of hypotrophy of the breast by means
moplasty. Plast Reconstr Surg. July 2002;110(1):309-317; discussion 318-322. of exogenous material. Plast Reconstr Surg Transplant Bull. January
13. Spear SL, Dayan JH, Clemens MW. Augmentation mastopexy. Clin Plast 1960;25:15-26.
Surg. January 2009;36(1):105-115, vii; discussion 117. 34. Regnault P. The hypoplastic and ptotic breast: a combined operation
14. Benelli L. A new periareolar mammaplasty: the “round block” technique. with prosthetic augmentation. Plast Reconstr Surg. January
Aesthetic Plast Surg. Spring 1990;14(2):93-100. 1966;37(1):31-37.
15. Goes JC. Periareolar mammaplasty: double skin technique with application of 35. Heden P. Mastopexy augmentation with form stable breast implants. Clin
polyglactin or mixed mesh. Plast Reconstr Surg. April 1996;97(5):959-968. Plast Surg. January 2009;36(1):91-104, vii.
16. Benelli LC. Periareolar Benelli mastopexy and reduction: the “round 36. Stevens WG, Freeman ME, Stoker DA, Quardt SM, Cohen R, Hirsch EM.
block”. In: Spear SL, ed. Surgery of the Breast: Principles and Art. 2nd ed. One-stage mastopexy with breast augmentation: a review of 321 patients.
Philadelphia, PA: Lippincott Williams & Wilkins; 2006:977-991. Plast Reconstr Surg. November 2007;120(6):1674-1679.
17. Lassus C. A technique for breast reduction. Int Surg. January 1970;53(1):69-72. 37. Nahai F, Fisher J, Maxwell PG, Mills DC 2nd. Augmentation mastopexy: to
18. Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr stage or not. Aesthet Surg J. May-June 2007;27(3):297-305.
Surg. February 1996;97(2):373-380. 38. Spear SL, Boehmler JH, Clemens MW. Augmentation/mastopexy:
19. Lassus C. Vertical scar breast reduction and mastopexy without undermin- a 3-year review of a single surgeon’s practice. Plast Reconstr Surg.
ing. In: Spear SL, ed. Surgery of the Breast: Principles and Art. 2nd ed. December 2006;118(7 Suppl):136S-147S; discussion 148S-149S,
Philadelphia, PA: Lippincott Williams & Wilkins; 2006:1021-1043. 150S-151S.
20. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening 39. Spear SL, Pelletiere CV, Menon N. One-stage augmentation combined with
the learning curve. Plast Reconstr Surg. September 1999;104(3):748-759; mastopexy: aesthetic results and patient satisfaction. Aesthetic Plast Surg.
discussion 760-743. September-October 2004;28(5):259-267.
21. Hammond DC. The SPAIR mammaplasty. Clin Plast Surg. July 40. Stevens WG, Stoker DA, Freeman ME, Quardt SM, Hirsch EM, Cohen
2002;29(3):411-421. R. Is one-stage breast augmentation with mastopexy safe and effective?
22. Hammond DC. Reduction mammaplasty and mastopexy: general A review of 186 primary cases. Aesthet Surg J. November-December
considerations. In: Spear SL, ed. Surgery of the Breast: Principles and Art. 2006;26(6):674-681.
2nd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:972-976. 41. Spear SL, Low M, Ducic I. Revision augmentation mastopexy:
23. Hammond DC, ed. Atlas of Aesthetic Breast Surgery. 1st ed. Philadelphia, indications, operations, and outcomes. Ann Plast Surg. December
PA: Saunders; 2009. 2003;51(6):540-546.
24. Chiari A Jr. The L short-scar mammaplasty. Clin Plast Surg. July 42. Stevens WG, Spring M, Stoker DA, et al. A review of 100 consecutive
2002;29(3):401-409, vi. secondary augmentation/mastopexies. Aesthet Surg J. September-October
25. Marchac D, de Olarte G. Reduction mammaplasty and correction of 2007;27(5):485-492.
ptosis with a short inframammary scar. Plast Reconstr Surg. January 43. Maxwell GP, Gabriel A. The neopectoral pocket in revisionary breast
1982;69(1):45-55. surgery. Aesthet Surg J. July-August 2008;28(4):463-467.
26. Marchac DA. Vertical mammaplasty with a short horizontal scar. In: Spear 44. Rowe NM, Freund R. The autologous internal breast splint: a novel
SL, ed. Surgery of the Breast: Principles and Art. 2nd ed. Philadelphia, PA: technique for the treatment of postaugmentation ptosis. Aesthet Surg J.
Lippincott Williams & Wilkins; 2006:1049-1059. November-December 2005;25(6):587-592.

Chapter 55 n Breast Reduction:
Inverted-t Technique
Scott L. Spear
Reduction mammoplasty is a clear example of the interface mammary, posterior intercostal, and axillary routes. Although
between reconstructive and aesthetic plastic surgery. The most lymph flow is through the axillary region, the internal
goals of the procedure are weight and volume reduction of the thoracic channels may carry 3% to 20% of the total.
breast, but aesthetic enhancement is also an important goal, Despite an extensive search for underlying metabolic
particularly in some women. Excellent procedures have been causes of breast hypertrophy and gigantomastia, these con-
described and emphasis has shifted to technical refinements ditions remain poorly understood phenomena, the products
for improved safety and predictable aesthetic results. At the of end-organ hormonal sensitivity, genetic background, and
same time, greater importance has been placed on preserva- overall body weight.
tion of both sensation and physiologic function. Although
there is a fundamental difference between reduction mammo-
plasty and mastopexy, both operations can follow the design
Reduction Mammoplasty
of the techniques to be described for reduction mammoplasty Indications
alone (Chapter 56).
Women seek to reduce the size of their breasts for both physi-
cal and psychological reasons. Heavy, pendulous breasts cause
Anatomy and Physiology neck and back pain as well as grooves from the pressure of
brassiere straps. The breasts themselves may be chronically
Sensory innervation to the superior portion of the breast is
painful, and the skin in the inframammary region is subject to
supplied by the supraclavicular nerves formed from the third
maceration, irritation, and rashes. From a psychological point
and fourth branches of the cervical plexus. The medial breast
of view, excessively large breasts can be a troublesome focus
skin is supplied by the anterior cutaneous divisions of the
of embarrassment for the teenager as well as the woman in her
second through seventh intercostal nerves. The dominant
senior years. Unilateral hypertrophy with asymmetry height-
innervation to the nipple is derived from the lateral cutaneous
ens embarrassment. At a minimum, excessively large breasts
branch of the fourth intercostal nerve, whereas lateral cutane-
can ultimately pose a liability for some women in terms of
ous branches of other intercostal nerves travel subcutaneously
comfort, wearing clothes, and daily functioning, including
to and beyond the midclavicular line. Independent confirma-
many forms of exercise.
tion of the importance of the lateral cutaneous branch of the
fourth intercostal nerve has led to greater acceptance of tech-
niques that include it in the vascular pedicle to the nipple. Inverted-T Techniques
There are three chief sources of blood supply to the breast. Two decisions confront the surgeon: (a) choice of incision
The internal mammary artery supplies the medial portion (scar) pattern and (b) choice of pedicle type. The inverted-T
through medial perforators near the sternal border. The vari- scar pattern can be applied to virtually any pedicle, including
able lateral thoracic artery supplies the lateral portion. The a superior pedicle, an inferior pedicle, a vertical bipedicle, a
Breast
anterior and lateral branches of the intercostal vessels supply central mound pedicle, and a superomedial pedicle. The scar
the remainder. Although there is a substantial degree of col- pattern and the pedicle type used in breast reduction are, for
lateralization among these vessels in the breast parenchyma, it the most part, independent variables. Furthermore, there is
has been estimated that the internal mammary artery provides no absolute cutoff regarding when an inverted-T scar pat-
approximately 60% of the total. The lateral thoracic artery is tern approach is appropriate instead of a vertical technique
thought to supply an additional 30%, primarily to the upper, that avoids or attempts to avoid a transverse inframammary
outer, and lateral portions. The anterior and lateral branches scar. At Georgetown University Hospital, we use both vertical
of the third, fourth, and fifth posterior intercostal arteries sup- techniques and inverted-T techniques, depending on the (a)
ply the remaining lower outer breast quadrant. The variability size of the breast, (b) degree of ptosis, and (c) patient’s goals.
and overlap between these vascular networks account for the Even when performing an inverted-T technique, we can virtu-
remarkable safety of nipple-bearing pedicles of diverse design ally always shorten the transverse scar component because of
based on different vascular supplies. our increasing experience with vertical scar techniques. The
The breast has two major venous drainage systems: one distinction, therefore, between vertical and inverted-T tech-
superficial and the other deep. The superficial drainage sys- niques has become less clear as surgeons add a short trans-
tem is divided into two types: transverse and longitudinal. The verse scar to vertical techniques or shorten the transverse scar
transverse veins run medially in the subcutaneous space and in inverted-T techniques.
empty into the internal mammary veins by multiple perforat- The majority of American plastic surgeons still use an
ing vessels. The longitudinal drainage ascends to the supra- inverted-T scar pattern, most commonly with an inferior ped-
sternal area to connect with the superficial veins of the lower icle. Informal polls at recent breast meetings suggest that this
neck. There are anastomotic connections across the midline, preference is evolving with more surgeons opting for supero-
but only between the superficial systems. The major portion medial or central pedicles. There are several major advantages
of the deep drainage is through perforating branches of the to the inferior pedicle with inverted-T scar technique. It is
internal mammary vein. Additional venous drainage is in the reproducible, straightforward, and easily taught. To a large
direction of the axillary vein. A remaining route of drainage extent, the skin incisions correspond to the underlying inci-
is posteriorly through perforators into the intercostal veins, sions that are made in the breast parenchyma itself. In this
which carry blood posteriorly to the vertebral veins. way, once the lines are drawn on the skin preoperatively,
The lymphatic pathways draining the breast parallel the cutting of the tissues and the closure of the wound pro-
closely the venous pathways and include cutaneous, internal ceed along the preoperatively planned lines. This has great
593
594 Part VI: Breast
advantage in terms of predictability and reliability. In contrast, of the new areolar window and inferiorly on the inframam-
vertical scar techniques often involve a significant disparity mary fold (IMF) and chest wall musculature. The flap carries
between the skin incisions and underlying glandular incisions. the nipple–areola and, although de-epithelialized, depends pri-
A significant amount of intraoperative judgment and adjust- marily on the parenchyma for blood supply.
ment is required in vertical scar procedures in terms of both With the patient erect, the markings are made in a fashion
removing tissue and reshaping tissue to obtain an acceptable similar to all breast reductions (Figure 55.1). The midline is
result. Finally, the closure of the skin may require adjustment drawn and the breast meridian is established by dropping a
to deal with the excess skin at the caudal end of the vertical line from the midclavicle through the nipple and continuing
incision (Chapter 56). inferiorly across the IMF. The IMF is marked, and a tangent
Once the decision has been made to perform a breast to the fold is drawn across the lower thorax and transposed
reduction, the surgeon must choose the orientation of the ped- to the anterior breast and marked on the breast meridian.
icle. This chapter describes the vertical bipedicle technique, Whereas the initial descriptions set the nipple some 2 cm
the inferior pedicle technique, a central mound technique, and higher, the best location for the new nipple position may be at
my preferred technique, the superomedial pedicle technique. the IMF level depending on where the patient’s breast paren-
chyma is situated. In patients with an empty upper breast,
it is important to keep the new nipple location centered or
Vertical Pedicle Technique near where the breast volume lies or is expected to lie at the
McKissock first described his vertical bipedicle technique for end of the procedure. The entire length of the IMF is mea-
nipple transposition during reduction mammoplasty in 1972. sured with a tape measure. In most cases, it is between 20 and
With this technique, the central breast is reduced to a vertically 24 cm long. Using a tape, a mark is made in the shape of a
oriented bipedicle flap based superiorly on the upper margin short arc on the surface of the breast that measures just over
TANGENT
MERIDIAN
A B
PER BORDE
UP R
9
8
7
6
AREOLA 5
EDGE
TAN
NIPPLE GE
NT
C
FIGURE 55.1. Preoperative markings. A. Drawing the basic landmarks, including the midline and breast meridian, for most breast procedures.
B. A tangent is drawn from the lower most portion of the IMF across the midline. C. This tangent is then superimposed onto the surface of the
breast. D. The length of the fold is then measured. It is often between 20 and 24 cm long. E. An arc that is just over one-half the length of the
fold is transposed onto the surface of the breast medially. F. A wire keyhole pattern (which is centered around the nipple site) can then be super-
imposed on the breast such that it crosses the arc line drawn in Figure 55.4. G. The keyhole pattern is completed by making the limbs the desired
length, anywhere from 5 to 8 cm long, depending on the size of the breast. It is important to double-check that the length of these proposed
superiorly based lateral and medial flaps along their cut, free, inferior edges matches the length of the fold to which they are to be approximated.

Chapter 55: Breast Reduction: Inverted-T Technique 595
1
2
4
5
7
8
9
F
PER BORDE
UP R

G
one-half the length of the fold (e.g., for a 22-cm fold, the dis- medial and lateral flaps are brought together over the pedicle,
tance would be 12 to 13 cm). Diverging lines are then drawn and closure is begun, working from the extremities toward
from the new nipple point; they pass as tangents to either side the center (Figure 55.4). Any central excess of skin is either
of the existing areola and meet the arc line drawn from the excised at the vertical closure, or “worked-in” to the closure.
Breast
ends of the IMF. A wire keyhole pattern is then adjusted to Specific strategies for fine-tuning the planned incisions and
a similar angle of divergence and superimposed on the lines, closure techniques apply to all the various pedicles and are
indicating the proper size and location of the new areolar win- addressed in detail when describing the author’s preferred
dow. The length of the limbs of the pattern is 5 to 8 cm. From technique later in this chapter.
these extremities, lines are directed medially and laterally to
intersect the IMF.
The new areola is circumscribed using a 42- to 48-mm
cookie cutter within the existing areola. The vertical pedicle is
outlined by extending the lines of the vertical limbs inferiorly
to the IMF as two parallel lines straddling the breast merid-
ian. The entire pedicle, except the reduced nipple–areola, is
de-epithelialized. The vertical pedicle is then incised along its
medial and lateral margins to the fascia of the underlying mus-
culature, and medial and lateral dermoglandular wedges are
resected (Figure 55.2). A thin layer of breast over the lateral
musculature is retained to favor preservation of sensation to
the nipple–areola complex. Additional breast tissue is resected
from the remaining medial and lateral elements: little to none
medially, but a considerable amount, including the axillary
tail, laterally. A window of breast tissue is removed from the
upper portion of the bipedicle flap, from the level of the nipple
to the height of the keyhole pattern, creating a bucket-handle
(Figure 55.3). This resection must not extend above the upper
limit of the areolar window to avoid the loss of superior breast
volume. The upper portion of this bipedicle flap should be
kept at least 2 cm if not 3 cm thick. The flap from the upper
edge of the now-reduced areola all the way to the IMF is left FIGURE 55.2. McKissock technique. Medial and lateral dermoglan-
full thickness. The flap is folded superiorly on itself, bring- dular resections.
ing the areola into position within the keyhole pattern. The

596 Part VI: Breast
A B
FIGURE 55.5. Inferior pedicle technique. A. Preoperative markings
with inferior pedicle de-epithelialized. B. Medial dermoglandular
resection.
FIGURE 55.3. McKissock technique. Central glandular resection

produces bucket-handle flap for infolding.
Central Mound Technique
The central mound technique is a further evolution of the
prior two designs. The pedicle is based on central chest wall
Inferior Pedicle Technique musculature alone and is not contiguous with any skin bound-
The inferior pedicle technique remains the most popular ary. Hence, it has no directional base in the sense of tradi-
technique among U.S. plastic surgeons today. The planning tional skin pedicles that may be classified as superior, inferior,
of the inferior pedicle technique is essentially the same as for or transverse.
the McKissock bipedicle procedure, with the desired nipple Preoperative marking is again performed as for the McKissock
location determined in the same manner. An inferiorly based technique. The skin is de-epithelialized within the entire key-
dermoglandular pedicle is planned with a base of 4 to 9 cm hole pattern, a process continued inferiorly to include the skin
at the IMF that gradually tapers as it ascends to encompass around the reduced nipple–areola complex (Figure 55.8). An
the nipple–areola complex. De-epithelialization with this tech-
nique is limited to the zone immediately about and inferior
to the nipple–areola (Figure 55.5). Skin and parenchymal
resections are performed not only medial and lateral to the
pedicle, as described above, but also superior to the nipple–
areola, up to the level of the keyhole pattern. These excisions
are performed leaving a beveled carpet of breast tissue over
the muscular fascia, especially laterally. Immediately superior
to the 1-cm de-epithelialized cuff about the nipple–areola, the
pedicle is terminated and incised down to muscle fascia, tak-
ing care not to undercut (Figure 55.6). A pyramidal pedicle of
dermis and parenchyma is thus left deep to and inferior to the
nipple–areola, based on the chest wall musculature and IMF.
In the vicinity of the areola, it measures 2 to 4 cm in thickness,
and near the base it is 4 to 10 cm. After completion of the
breast resection, the nipple–areola is brought to the desired
position in the keyhole pattern, and the medial and lateral
flaps are brought together as with the McKissock technique
FIGURE 55.6. Inferior pedicle technique. Pedicle developed.
(Figure 55.7).
A B
A B
FIGURE 55.4. McKissock technique. A. Vertical bipedicle flap folded FIGURE 55.7. Inferior pedicle technique. A. Nipple–areola positioned.
on itself as key sutures tied. B. Closure. B. Closure.

A B
FIGURE 55.8. Central mound technique. A. Preoperative markings.
B. Limited central de-epithelialization. A B
FIGURE 55.10. Central mound technique. A. Nipple–areola advanced
superiorly. B. Closure.
incision is placed in the inframammary crease and is carried
down perpendicularly to the pectoralis fascia. Incisions are now
made and beveled around the margins of the keyhole pattern setting. The markings are made as described above. I often
at its medial and lateral limbs. This incision is continued below mark the upper border of the existing breast parenchyma to
the level of the limbs to circumscribe the de-epithelialized pat- give some perspective as to where the breast will lie at the end
tern, including the nipple–areola, and is beveled in a caudal of the breast reduction procedure. This allows a better appre-
direction toward the IMF. The limb incisions, both medial and ciation of where the nipple might sit after the breast reduction.
lateral, are made in the standard fashion, developing flaps of While the IMF can be one useful landmark as to where to site
thickness similar to those in other techniques. Now the medial the nipple, it is also becoming increasingly clear that there needs
and lateral inferior quadrants of skin and breast, as well as the to be left some critical length of tissue/breast skin between the
central inferior tissue intervening between the nipple–areola and upper border of the breast and the upper border of the areola.
the IMF, are excised as a single curvilinear, ellipsoid unit that Depending on the overall breast size after breast reduction, this
includes the axillary tail (Figure 55.9). A skin incision at the can be anywhere from 7 to 9 cm or even more.
superior aspect of the keyhole is deepened only enough to allow The ideal length of the limbs of the keyhole pattern varies
comfortable transposition of the central mound pedicle with between 5 and 8 cm, depending on the size of the breast cur-
its nipple–areola into the keyhole position. The skin flaps are rently and the size of the planned breast after reduction. The
brought about the pedicle as in other techniques, and closure is larger the breast and the larger the breast that is to remain
performed (Figure 55.10). after the procedure, the longer these limbs should be. Five
centimeters is the minimum length of the vertical limb of the
Author’s Technique keyhole, and I will often go to 6, 7, or even 8 cm, depend-
ing on how big the breasts will be left postoperatively. I am
The patient is marked in the standing position in the exam well aware that when the breast is made too large for the skin
room or in the office the day prior to surgery. Over the years, I flaps, the skin flaps will often stretch, and that when the skin
have become increasingly fond of marking these procedures the flaps are larger than the breast, the skin flaps will often shrink
Breast
day before surgery and photographing the plan. This is espe- postoperatively. A fairly straight line is then initially drawn
cially helpful when the breast reduction is the first case of the from the lowest most point of the vertical limb of the keyhole
day or is scheduled on a particularly busy day where it may be to the medial most extent of the IMF mark. The same is done
more difficult to plan the surgery in an appropriately supportive laterally to the lateral most extent of the IMF.
At this point, the lengths of the transverse incisions are
reviewed to shorten the overall incision lengths and to equal-
ize the lengths of the medial and lateral fold incisions to the
upper transverse incisions that come off the vertical limbs of
the keyhole pattern. In the vast majority of cases, this results
in shortening the medial incisions by 2 to 4 cm and takes both
the medial and lateral IMF incisions out of the fold as they
move away from the breast meridian such that they join the
upper incisions 2 or 3 cm above the old fold. After drawing
the keyhole and the planned incisions, the pedicle is designed.
I am particularly impressed with the versatility and speed
of the superomedial pedicle and now use this approach in a
large majority of my breast reduction procedures, regardless
of whether they are inverted-T scar patterns or vertical scar
patterns. The design for the superomedial pedicle is drawn
so that it starts superiorly, along the arch of the previously
drawn keyhole, and ends either at or near the bottom of the
vertical limb of the keyhole (Figure 55.11). The planned are-
ola is circumscribed, leaving several centimeters around the
areolar margins as the pedicle is drawn. Some surgeons prefer
to use an inverted-V pattern rather than a keyhole pattern and
this procedure is conceptually compatible with that. The limbs
of the inverted-V need to be drawn at least 11 or 12 cm long
FIGURE 55.9. Central mound technique. Dermoglandular resection. and the areola window is created after the resection and pre-
liminary closure have been performed

598 Part VI: Breast
R
PE
UP
NO
T RESECTI
EC S T TANGEN
O
T
A
N
BR S
E
RE
FIGURE 55.11. Superomedial pedicle. The base of superomedial

pedicle should be drawn so that it connects to the keyhole pattern
somewhere along the areola window superiorly and along the vertical
limb inferiorly. The precise attachment is not critical, but it should be
drawn so as to facilitate rotation.
MERID
At this point, the plan is evaluated for symmetry. The
IAN
upper border of the planned areola, the location and length
of the vertical limb of the keyhole pattern, and the length and
location of the line joining the bottom of the keyhole pattern
B
to the medial IMF incision are key points to evaluate for sym-
metry. As mentioned earlier, because of preexisting asym- FIGURE 55.12. Even when performing an inverted-T–type reduc-
metry that is virtually always present, it is typical to place a tion, the planned incisions can be several centimeters shorter than the
larger resection on the larger breast. My preference is to try preexisting inframammary fold, so long as care is taken to resect the
to decrease the magnitude of the volume asymmetry without breast tissue that would otherwise remain in that area. The dashed lines
tipping the scales so much that the larger breast becomes the at the bottom of the breast represent a shortened inframammary incision.
smaller one.
I like to photograph the markings on the patient for later
reference both intraoperatively and postoperatively. With the and lateral glandular pillars are created and are approximated
advent of digital photography, it is relatively simple to print inferior to the nipple, thus coning and supporting the breast.
these photographs for use during the actual surgical procedure. In order to develop a lateral pillar, the lateral flap must be
I often have the patient lie down at this point and shorten left extra thick (3 to 5 cm) along the lateral keyhole limb and
the incisions both medially and laterally by at least 2 cm or must taper as it extends superiorly and laterally. The medial
double-check where I have already marked them to be short- and inferior incisions are made through the dermis down to
ened (Figure 55.12). This shortening is done in such a way or near the muscle fascia. Once all these incisions have been
that the medial most extent of the incision is brought lateral made, the pedicle is held using hooks or atraumatic clamps,
by 2 cm and this new end point is drawn midway between
the upper and lower previously planned incisions. The same is
done laterally, so that the scars or incisions that will be made
will curve somewhat off the IMF as compared with the origi-
nal plan. Thus, even preoperatively, the planned length of the
incision will be 4 cm or more shorter than the preoperative
length of the IMF.
To be certain that the lines that I have drawn are not lost
during the preparation of the patient, I lightly score these lines
just prior to surgery using an 18G or 21G needle.
One of the most remarkable advantages over the inferior
pedicle technique is the reduced time required for de-epitheli-
alizing. Because the pedicle is almost always quite small and
substantially smaller than with other techniques, de-epithelial-
ization is brief and is all within the keyhole pattern itself. The
incisions are then scored around the margins of the keyhole
and from the keyhole to the IMF and along the IMF. I prefer
to dissect the lateral flap first. The skin incision is deepened to
a depth of 1 to 2 cm of breast tissue. A laterally based flap is
created that extends to the axillary tail, leaving sufficient soft
tissue to ensure viability of the lateral skin flap (Figure 55.13). FIGURE 55.13. Lateral flap dissection. A laterally based flap of some
In recent years, I have focused more on parenchymal remod- safe thickness is dissected to allow access to the lateral breast tissue.
eling and support when performing this operation. Medial

FIGURE 55.14. Pedicle dissection. The superomedial pedicle is devel-

oped by cutting around the previously marked pedicle straight down
toward the chest wall, without undermining and with some feathering
laterally to protect the neurovascular supply.
and incisions are made straight down along the margins of the
pedicle superiorly, laterally, and inferiorly, taking care not to
undermine the pedicle (Figure 55.14). In particular, as the dis-
FIGURE 55.15. The resulting specimen is an inverted-C or C shape,
section is carried laterally away from the pedicle, some bevel-
depending on which breast.
ing is performed to leave soft tissue along the chest wall in the
anticipated path of the neurovascular supply to the nipple–
areolar complex. The breast tissue itself is removed in a C, or
inverted-C pattern from either breast (Figure 55.15). The key
technique. The creation of the pedicle is virtually the same.
elements of this resection are to leave adequate blood supply
The only difference is that the skin is tailored to the breast at
to the nipple–areola pedicle by not undermining the pedicle
the end of the operation and excess skin can be removed as
and leaving it fully attached to the chest wall. The breast tis-
necessary either in a vertical or a combined vertical and short
sue is aggressively removed in the medial wedge area, as well
T pattern (Figure 55.17).
as inferiorly and laterally. The area of greatest risk in this
Breast
operation is the circulation to the lateral skin flap and, there-
fore, that flap must not be made too thin or be traumatized in
the dissection. Breast Amputation With
I may then incise just the dermis of some of the pedicle Free Nipple Graft: Author’s
itself, where it joins the keyhole medially, to allow for easier
rotation of the dermoglandular pedicle. After rotation of the
Technique
nipple–areola, the areola is attached at the meridian of the An excellent, if often maligned, alternative to reduction
keyhole aperture. The keyhole pattern is then closed around mammoplasty with a nipple-bearing pedicle is breast ampu-
the pedicle at the 6 o’clock location of the areolar window, tation with free nipple graft. This technique consistently pro-
and the reduced breast is held up vertically at the top of the duces well-shaped breasts. In large women, in particular, an
keyhole with a strong hook. It is at this moment when paren- attractive breast contour is more easily accomplished with
chymal sutures are placed between the recently created lateral this technique than with conventional approaches. The dis-
pillar and the medial pillar and pedicle. This is typically a 2-0 advantage is the relatively unnatural appearance and func-
suture on a sturdy large needle. This usually includes three tion of the nipple–areola complex: Specialized sensation is
or four sutures including one placed on the backside of the lost, as well as some degree of nipple projection, especially
medial and lateral pillars as they are flipped over, taking care erectile nipple projection; lactation is similarly sacrificed;
not to tie any of these sutures too tight (Figure 55.16). Once and occasional spotty survival of the grafted areola produces
satisfied with the glandular reshaping and coning of the breast, areas of depigmentation that can be troublesome in dark-
the remaining skin can be stapled or sutured, including the skinned individuals.
6 o’clock position on the most inferior aspect of the vertical This rapid technique is especially indicated for women
limbs of the keyhole. Because the upper flap lengths have been with gigantomastia, who require a resection of 2,500 g or
measured preoperatively to approximate one-half of the IMF more of breast tissue per side, as well as for patients with
length, there are rarely any significant dog-ears to deal with. other complicating factors, such as increased age or systemic
A small 10-French suction drain is often placed along the IMF disease where significant reduction in blood loss and operat-
and brought out through the lateral extreme of the incision ing time is desired. It remains the preferred alternative for
or through a stab incision laterally to help facilitate drainage. many elderly patients who present for reduction mammo-
The final closure is accomplished and the staples are removed. plasty because of increasing symptoms involving a demin-
The technique is easy to perform and teach. The same pedi- eralized skeletal system. With respect to the patient with
cle can also be used as part of a vertical scar pattern reduction extremely large breasts, I consider this alternative whenever

600 Part VI: Breast
A B
FIGURE 55.16. Pillars. To provide a better breast shape with more

projection, the breast gland is closed by approximating medial and
lateral pillars of tissue which have been purposely left during the
resection. A. The first suture is placed just below the inferior edge of
the areola. B. The second and third sutures are placed successively
inferior toward the inframammary fold. C. A suture is often added on
the back side of the pillars as well.
C
A B
C D
FIGURE 55.17. Inverted-T, superomedial pedicle. A. Frontal view of plan for breast reduction using superomedial pedicle and inverted-T scar
pattern. B. Lateral view of plan. C and D. Before and 3 months after 575-g reduction using the author’s technique.

the nipple–areola complex is to be elevated more than 15
cm. This guideline is modified by other factors, especially Technique
the age of the patient. I am reluctant to use this alternative in The procedure is begun by rapidly removing the nipple–areola
young or unmarried patients, for example. Although concern complex as a full-thickness skin graft with attached subjacent
for ischemic injury to the retained nipple–areola complex ductal tissue at the site of the nipple papilla and setting it aside
in such greatly enlarged breasts remains a major indication in a moist saline sponge, clearly indicating the side of origin,
for this alternative, it may not be the sole reason to recom- right or left. I do not follow the skin markings as some have
mend it. Rather, the technical reality of breast reduction for suggested when performing the glandular resection, because
such large breasts may prove unwieldy when a pedicle is I find it too often results in inadequate central projection of
maintained. the breast. Far better is Rubin’s alternative of retaining an
inferior parenchyma pedicle at the inframammary line to be
covered by the superior skin flaps. I prefer, however, to retain
Preoperative Marking superiorly based parenchyma between the diverging limbs of
The breast markings remain similar to those for the previously the pattern, as well as an additional amount dropping below
described inverted-T techniques (Figure 55.18). The wire key- this area if needed. This retained tissue is designated with a
hole pattern is not used for this technique, however. Instead, single curvilinear line placed below the diverging arms, and
two diverging arms are drawn from the selected nipple point the enclosed area is rapidly deskinned. Clearly, the great-
at an angle approximating 90°. Limb length is measured at 10 est pitfall in this otherwise straightforward procedure is the
to 12 cm. The inframammary line is marked, and the medial amputation of excessive breast tissue, leaving only superior
and lateral extensions from the limbs are drawn as has already flaps with subcutaneous tissue and little breast. It is important
been described for the other pedicle techniques. The areola therefore to leave sufficient breast tissue across the extent of
is marked for reduction to 42 to 50 mm with the help of an the superior retained breast flap as one amputates the excess
areolar marker. tissue inferiorly.
Breast
A
FIGURE 55.18. Free nipple graft.

D Author’s breast amputation with free
nipple–areola graft, technique. A. Breast
meridian marked. B. Preoperative mark-
ings completed. C. Amputation com-
pleted. D. Central tissue coned and
rotated into retromammary space. E. Free
E nipple–areolar graft added at closure.

602 Part VI: Breast
The amputating incision is carried perpendicularly to the It needs to result in the bare minimum of serious complica-
chest wall musculature. The inframammary incision is similarly tions such as ischemic loss of the nipple and over-elevation of
carried perpendicularly to the musculature. The large interven- the nipple. It needs to fulfill the reconstructive goal of sufficient
ing wedge of gland is then dissected progressively from medial to weight reduction while doing a reasonable job of creating an
lateral away from the muscle fascia, maintaining exact hemosta- attractive breast, particularly for the younger and more slender
sis as the resection progresses. The central portion of the remain- patient. And, finally it needs to reduce the breast successfully
ing superior gland, including the deskinned portion between and in one operation with a minimal risk of revision which insur-
below the diverging limbs, is now dissected from the underlying ance carriers often view as cosmetic and will not cover.
muscle fascia superiorly to the apex of the inverted-V pattern.
The dermal edges of the inverted-V are incised and undermined Suggested Readings
just as much as needed to allow infolding of the superiorly based Balch C. The central mound technique for reduction mammoplasty. Plast
dermal flap. The most inferior points of the inverted-V are then Reconstr Surg. 1981;67:305.
approximated, thus effectively coning and infolding the breast. Courtiss E, Goldwyn RM. Reduction mammoplasty by the inferior pedicle tech-
Closure is completed in the standard fashion working both ver- nique. Plast Reconstr Surg. 1977;59:500.
Davison SP, Mesbahi AN, Ducic I, et al. The versatility of the superome-
tically and from the extremities centrally. dial pedicle with various skin reduction patterns. Plast Reconstr Surg.
Finally, the site for the nipple–areola complex is determined 2007;120(6):1466.
and measured upward from the IMF on either side. It may or Dex EA, Asplund O, Ardehali B, Eccles SJ. A method to select patients for
may not fall precisely at the superior extent of the vertical clo- vertical scar or inverted-T pattern breast reduction. J Plast Reconstr Aesthet
Surg. 2008;61(11):1294.
sure. The area is marked with the areolar marker and is de- Georgiade NG, et al. Reduction mammoplasty utilizing an inferior pedicle
epithelialized. The defatted nipple–areola complex is sutured nipple–areola flap. Ann Plast Surg. 1979;3:211.
in place and secured with a tie-over dressing. It is important to Hall-Findlay EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast
thin the areola graft sufficiently but not so thin that the areola Surg. 2002;29(3):379.
Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR) mam-
has an unnatural appearance. Similarly, a small amount of duc- maplasty. Plast Reconstr Surg. 1999;103(3):890.
tal tissue, a gram or so, is left within the papilla, to favor nipple Hammond DC. The SPAIR mammaplasty. Clin Plast Surg. 2002;29(3):411.
projection. A greasy dressing with wet cotton bolus is then tied Hidalgo DA. Improving safety and aesthetic results in inverted T scar breast
in place over the complex and is removed at 4 to 7 days. reduction. Plast Reconstr Surg. 1999;103(3):874.
Marchac D, de Olarte G. Reduction mammoplasty and correction of ptosis with
a short inframammary scar. Plast Reconstr Surg. 1982;69:45.
Conclusion McCulley SJ, Schaverien MV. Superior and superomedial pedicle wise-pattern
reduction mammaplasty: maximizing cosmesis and minimizing complica-
Despite the many recent advances in breast reduction surgery, tions. Ann Plast Surg. 2010;64(3):128.
McKissock PK. Reduction mammoplasty. Ann Plast Surg. 1979;2:321.
the inverted-T scar technique remains a comfortable and pre- McKissock PK. Reduction mammoplasty with a vertical dermal flap. Plast
dictable technique for the surgeon who performs breast sur- Reconstr Surg. 1972;49:245.
gery. Although there is appropriate increasing interest in short Nahabedian MY, McGibbon BM, Manson PN. Medial pedicle reduction
scar or vertical scar techniques, the inverted-T option has mammaplasty for severe mammary hypertrophy. Plast Reconstr Surg.
2000;105(3):896.
proven reliable and safe, which may be as important to the Nahabeian MY, Mofid MM. Viability and sensation of the nipple–areolar com-
patient as the length of the scar in the IMF. As our personal plex after reduction mammaplasty. Ann Plast Surg. 2002;49(1):24.
techniques of breast reduction surgery continue to evolve and Noone RB. An evidence-based approach to reduction mammaplasty. Plast
improve, certain concepts and principles have become increas- Reconstr Surg. 2010;126(6):2171.
Robbins TH. A reduction mammoplasty with the areola–nipple based on an
ingly clear. One’s preferred technique needs to be reliable, con- inferior dermal pedicle. Plast Reconstr Surg. 1977;59:64.
sistent, and reproducible. Because of the increasing pressures Spear SL, Howard MA. Evolution of the vertical reduction mammaplasty. Plast
of cost and time, it needs to be efficient and relatively quick. Reconstr Surg. 2003;112:855.

Chapter 56 n Vertical Reduction
Mammaplasty
Elizabeth J. Hall-Findlay
The key to a good breast reduction is in combining an complex can be dermal rather than dermoglandular, but care
aesthetic sense of an ideal breast with an understanding of must be taken to preserve the deep tissue around the periphery
the anatomy and science of tissue healing. Each surgeon must of the breast. Because the veins lie just under the dermis, it is
adapt different designs to different patient presentations. No important to maintain a dermal connection to most pedicles.
single technique is applied to all breasts. The artery to a superior pedicle originates at the second
The term “vertical” is misleading because it only applies to interspace. It travels laterally and is the same vessel that sup-
the final scars. Confusion is generated by equating the choice plies a deltopectoral flap. There is a large descending branch,
of the skin resection pattern with the choice of pedicle used to which curves over the breast and enters the areola about 1 cm
transfer the nipple–areolar complex. Different pedicles can be deep to the skin and close to the breast meridian.
combined with different parenchymal resection patterns and The artery to a medial pedicle originates at the third inter-
both can be combined with different skin resection patterns. space and curves up over the breast in the subcutaneous tissue.
Because the vertical skin resection pattern is often associ- A true superomedial pedicle will contain both the artery to
ated with a superior or superomedial pedicle and because the a superior pedicle and the artery to a medial pedicle. This is
inverted-T skin resection pattern tends to be associated with also an ideal pedicle because most of the venous drainage is
an inferior or central pedicle, the terms are often used without superomedial. The vessels are superficial at the level of the
clear distinction. This chapter outlines how to design and per- areola but deep close to the sternum.
form a medial or superomedial pedicle with a Wise parenchy- The artery to a lateral pedicle comes from the superficial
mal resection pattern and a vertical skin closure. branch of the lateral thoracic artery. It can enter the breast at
Although some skin types can be effective as a skin brassiere, a fairly low level and a lateral pedicle should be designed with
skin expansion techniques have taught us that skin and dermis a low base to ensure that the artery is included. This artery
stretch when tension is applied. The approach described in this is also deep at the periphery of the breast but becomes more
chapter does not rely on skin to hold the breast shape. The con- superficial closer to the areola. The arteries to both a superior
cept of the inferior vertical wedge resection combined with a and a lateral pedicle can be easily located with a Doppler.
tension-free parenchymal closure and a tension-free skin clo- The deep artery and vein from the fourth interspace sup-
sure will result in good healing and an enduring breast shape. ply an inferior or central pedicle. There are vessels that curve
around the inferior aspect of the breast from the fifth (and
possibly sixth) interspace and enter the breast at the level of
Anatomy the IMF. They have a deep origin and curve around to enter
The breast is a subcutaneous structure that originates at the the breast in the superficial subcutaneous tissue.
fourth interspace. It is attached to the skin at the nipple and
is only loosely connected to the pectoralis fascia. The breast Nerve Supply
is held in place by two zones of adherence: 1) the skin–fascial
Breast
attachments at the inframammary fold (IMF) and 2) The skin– Innervation to the nipple–areolar complex is said to be pro-
fascial attachments over the sternum (akin to the gluteal crease vided by the lateral branch of the fourth intercostal nerve
and the sacral skin attachments). The breast is not “attached” (Figure 56.1B). Although this is true, it does not constitute the
to the pectoralis fascia. The lateral and superior breast borders only nerve supply. The lateral branch divides into both a superfi-
are relatively mobile while the inferior and medial borders are cial branch and a deep branch that supply the nipple and areola.
held in place by skin adherence to deep fascia. The superficial branch is carried in a lateral pedicle. The deep
branch travels along the surface of the pectoralis fascia and then
Blood Supply turns upward toward the nipple at the breast meridian. This
is interesting because it means that any full-thickness pedicle
There is a deep artery (with venae comitantes) that emanates should be able to incorporate this deep branch. There are also
from the fourth branch of the internal mammary artery and per- medial branches of the intercostal system that run superficially
forates through the intercostals and the pectoralis muscle and and supply innervation to a medial pedicle. Supraclavicular
enters the breast just medial to breast meridian above the fifth branches run superficially and supply a superior pedicle.
rib (Figure 56.1A). This is the main blood supply to an inferior A study by the author of over 700 breast reduction patients
pedicle (and the inferior flap used in a mastopexy). As pointed who had either a full year follow-up or who had already
out by Ian Taylor, the rest of the breast blood supply is super- achieved full sensation were assessed. There were 58 breasts
ficial. This makes sense as one envisions breast growth from a with superior pedicles, 147 breasts with lateral pedicles, and
small subcutaneous fourth interspace structure which has a deep 1,206 breasts with medial pedicles. Patients were asked to
artery and vein. As it grows and develops, the breast pushes the compare their preoperative and postoperative sensation on a
arteries and veins contained in the subcutaneous tissue outward. visual analog scale. Sixty-seven percent of superior pedicles,
The main vascular supply of the breast (both deep and 77% of lateral pedicles, and 85% of medial pedicles recovered
superficial) originates from the internal mammary system. normal to near-normal sensitivity.
The veins and arteries in the superficial system do not travel
together. The veins are located just beneath the dermis and
they tend to drain superomedially. They can often be seen Ductal Preservation
through the skin. The arteries start out from a deep level at the There are approximately 20 to 25 ducts that enter the nipple.
periphery of the breast and then travel in the subcutaneous fat. Each duct is fed by glandular breast parenchyma. Although
Because the arteries are superficial around the curve of dermal pedicles may preserve arterial, venous, and nerve sup-
the breast, the design of the pedicle for the nipple–areolar ply, it is unlikely that dermal pedicles will retain much breast
603
604 Part VI: Breast
A B
FIGURE 56.1. Anatomy. A. Blood supply. The arterial supply is superficial (A, B, D) except for the deep perforator (C) that comes through the
pectoralis muscle. The deep perforator penetrates into the breast with its venae comitantes at the fourth interspace, while the other arteries curve
up in the subcutaneous tissue superficial to the breast mound. The veins lie just under the dermis and are quite separate from these superficial
arteries. B. Nerve supply. The main innervation to the nipple and areola is from the lateral fourth intercostal nerve. It should be noted that there
is a deep branch that courses just above the pectoralis fascia as well as the more superficial branch. This branch can provide sensitivity in several
full-thickness pedicles. There are also medial intercostal branches that supply innervation.
feeding potential. Ducts may reconnect to some degree but problems. On the other hand, the vertical patterns tend to use
dermoglandular pedicles will preserve more connections to the breast parenchyma to provide and maintain the shape.
glandular and ductal tissues. There is a good study by Norma Most inverted-T–type breast reduction patterns remove a
Cruz-Korchin that shows no difference in breast feeding in horizontal ellipse of skin and breast tissue and involve chas-
large-breasted patients with or without breast reduction. ing dog-ears medially and laterally. Most vertical-type breast
reduction patterns remove a vertical ellipse of skin and breast
tissue and involve chasing dog-ears superiorly and inferiorly.
Design Lateral and medial dog-ears can sometimes be difficult to pre-
There has been considerable reluctance to adopt the ver- vent and treat and the horizontal resection sometimes leaves a
tical skin resection patterns in breast reduction surgery boxy breast shape with a wide base.
(Figure 56.2). This is based on a fear that the shape takes a The vertical wedge resection allows better narrowing of the
long time to finalize and that there is a higher revision rate due breast base and increases breast projection, while the horizontal
to inframammary bunching. Neither is true. approaches tend to flatten the breast. To prevent pseudoptosis in
The key is to leave a Wise pattern of parenchyma behind the inverted-“T” approach, the vertical skin length from nipple
and to close both the pillars and the skin without tension. It to IMF is restricted to about 5 cm. Although some coning of the
makes more sense to remove the heavy inferior pole than it breast tissue occurs with the inverted-T patterns, the nature of
does to remove the upper pole. The inverted-T patterns tend the resection plays a minor role in shaping. The increased length
to use the skin brassiere to hold the breast shape. Placing the of the vertical scar is needed to accommodate the increased pro-
skin repair under tension inevitably leads to wound healing jection that results from the vertical wedge resection approach.
Inverted “T” skin/inferior pedicle Vertical skin/superior pedicle Circumvertical/superior pedicle Vertical skin/medical pedicle
Circumvertical skin/inferior pedicle Circumareolar/central pedicle
A B
FIGURE 56.2. Pedicles and skin resection patterns. The skin resection pattern and the pedicle used for the nipple–areolar complex are assessed
separately. Various combinations are available. A. Skin resection patterns. B. Pedicle choices.

Chapter 56: Vertical Reduction Mammaplasty 605
The choice of pedicle will also influence the resultant Superomedially based pedicle: A superior pedicle can be
breast shape. The superior, superolateral, and superomedial difficult to inset because it usually needs to be folded. It is
pedicles will rely less on the skin brassiere to hold the shape. often necessary (and safe) to thin the pedicle to allow for an
The inferior pedicle may give way to gravitational forces. The easier inset but this can lead to inferior hollowing of the breast
choice of pedicle will influence the parenchymal resection pat- with a concave lower breast pole at the end of the procedure.
tern. Any type of skin resection pattern can, however, be used Combining a superior and medial pedicle can include both of
with any type of pedicle. A “J,” “L,” or small or large “T” can the arteries from the second and third interspaces and there-
be added to remove any excess loose skin if needed. fore provide more dependable circulation. The superomedial
pedicle can be backcut laterally and if the pedicle is difficult
to inset, the deeper tissue (which has very little blood supply)
Vertical Breast Reduction can be removed to prevent kinking or compression. When cre-
Using The Medial or ating a pedicle, the surgeon will often note that the bleeding
Superomedially Based Pedicle occurs within the first centimeter of depth and there is very
little bleeding as the dissection progresses toward the pecto-
The following describes a vertical skin resection pattern using ralis fascia.
either a pure medially based pedicle or a superomedially based
pedicle for the nipple–areolar complex (Figure 56.3). Markings
Parenchymal resection: The parenchymal resection follows
the Wise pattern (not just the keyhole opening) with both a The key to marking a vertical breast reduction is to understand
vertical wedge resection and a horizontal resection of tissue what happens to the breast after reduction and where the ideal
below the pattern. The key is to leave a Wise pattern of paren- nipple position should be. The upper breast border and upper
chyma behind. When the Wise pattern (designed after a bras- pole of the breast will not change. Projection will improve, but
siere) is closed, the tissue is coned and the result is a breast the breast cannot be elevated higher on the chest wall.
with good projection and no tension on the pillar closure. It is It is important to understand (and point out to the patient)
believed that this resection pattern best resists the deforming that some patients are “high-breasted” and some patients are
forces of gravity over time. “low-breasted.” The breast footprint varies from patient to
Vertical skin resection pattern: The vertical skin excision is patient in both vertical and horizontal dimensions. The upper
a vertical ellipse. The skin is not used as a brassiere and is only breast border will not change but the IMF can rise with a
used to adapt to the new parenchymal shape. Because an ellip- medial pedicle, vertical breast reduction (and it can drop with
tical excision lengthens when closed and because the IMF rises an inverted-T, inferior pedicle reduction).
with this type of procedure, it is important to keep the skin It has been recommended by many surgeons (including the
resection pattern high on the inferior mound because some author) to use the IMF as a guide to the ideal nipple position.
breast skin will become chest wall skin. This is important to Although this can help, the upper breast border is a more accu-
prevent the scar from extending below the new IMF. rate landmark. There can be considerable variation in IMF
Medially based pedicle: A true medial pedicle is easy to level from patient to patient (and from breast to breast in the
inset. The inferior border of the medial pedicle becomes the same patient). The upper breast border is the junction of the
medial pillar and the pedicle rotates into position without any chest wall and the breast and it lies anterior to the depression
compression or kinking. The fact that the whole base of the just below the preaxillary fullness. The surgeon’s hand can be
pedicle rotates gives an elegant curve to the inferior aspect of used to push the breast up from below to better determine its
the breast. level. It is often marked by the upper extent of the striae.
Determination of New Nipple Position. The ideal
Breast
nipple position in an average “C” cup breast is about 10
cm below the upper breast border on the ideal breast merid-
ian—which is about 10 cm from the chest midline (as drawn
through the air and not around the breast). The breast merid-
ian should not be drawn through the existing nipple position
but it should be drawn through the ideal nipple position.
Although 10 cm is a good guide for a vertical breast reduc-
tion, somewhat more lateral will be better for an inverted-T
breast reduction because the breast base is narrowed more in
the vertical approaches.
The surgeon should be able to visualize the final result. The
upper pole of the breast will not change and the goal of the
breast reduction will be to remove the excess inferior and lat-
eral breast tissue. Measurements have shown that the nipple
position from the suprasternal notch will remain as marked. It
is a mistake to mark the nipple at an arbitrary distance from
the suprasternal notch. In high-breasted patients, the ideal
position might be 22 cm but in low-breasted patients it may
be at 26 cm. If the nipple is marked at 24 cm (for example)
from the suprasternal notch preoperatively with the patient
standing, the measurement will remain the same postopera-
FIGURE 56.3. Design of the skin resection pattern (outlined in red), tively. The upper breast border can be raised using an implant
the medially based pedicle (colored blue) and the parenchymal resec- by about 2 cm but it cannot be raised in a pure breast reduc-
tion pattern (crosshatched). The parenchymal resection follows a tion—even when breast tissue is sutured up to chest wall.
Wise pattern and the skin resection pattern looks like a snowman. It is best to err on the side of marking the new nipple posi-
The base of the pedicle can be carried up just lateral to the 12 o’clock
tion too lateral rather than too medial. An ideal nipple is best
position to create a true superomedial pedicle which then includes two
arterial supplies. Tissue deep to the pedicle (which does not contain placed to face slightly lateral and slightly inferior. Caution: it
the arteries) may need to be excised to allow easier inset of a true is almost impossible to lower a nipple that has been placed too
superomedial pedicle. high. It is much easier to raise a nipple that is too low. When
a patient lacks upper pole fullness, it is best to lower the new

606 Part VI: Breast
nipple position so that it is not placed on an upper concavity be either dermal or dermoglandular but it should be beveled
giving an appearance of glandular ptosis. out peripherally because the artery (from the third interspace
In cases of asymmetry, it is best to place the new nipple branch of the internal mammary artery) is deep when it comes
position slightly lower on the larger side. This takes into out from around the sternum. It then travels up around the
account the fact that closure of a wider elliptical resection will breast parenchyma into the superficial subcutaneous layer.
push the ends of the ellipse further. This is not something that A pure medial pedicle will appear to be superomedial when
happens with an inverted-T type of reduction. the patient is standing, but the blood supply is medial. A full-
The new nipple position should be placed at the most thickness medial pedicle is more likely to incorporate the deep
projecting part of the breast. The nipple should be “central- branch of the lateral fourth intercostal nerve and it will con-
ized” not “centered” on the breast mound. The nipple should tain more ducts than a dermal pedicle.
be one-third to one-half the way up the breast mound and it A full-thickness pedicle is also preferable because of the
should be slightly lateral to the breast meridian. thickness needed for the medial pillar. The inferior border
of the medial pedicle becomes the medial pillar as the pedi-
Skin Resection Pattern cle is rotated up into position. It is better if the pedicle is not
Areolar Opening. The new nipple and areola are best thinned.
marked with the patient standing. Although some intraop- A true superomedial pedicle has a design similar to a medial
erative adjustments can be made to make sure the areola is pedicle but the base extends superolaterally across the breast
circular, the landmarks are distorted in the supine position. meridian past the 12 o’clock position on the new areolar open-
The surgeon can stand back during the markings and visual- ing. This will include not only the medial pedicle artery but
ize the final result because the upper portion of the breast will also the significant descending branch of the internal mam-
not change. mary artery from the second interspace. Doppler examination
The areola is marked about 2 cm above the new nipple of 83 patients (160 breasts) by the author showed that this
position. An ideal areola is about 4 to 5 cm in diameter. The artery was very close to the new breast meridian with 59%
areola can be drawn freehand or with a template. It is not nec- just medial and 24% just lateral to the meridian. The remain-
essary to make the opening “mosque” shaped—it is actually ing 17% were at the meridian itself.
better to take more skin vertically rather than horizontally. A superomedial pedicle is more difficult to inset but it can
A good template is a large paper clip—folded out it measures be safely thinned because the artery lies at most 1 cm below
16 cm. A 16 cm circumference matches a 5 cm diameter are- the skin surface. Thinning the pedicle deeply will allow that
ola and a 14 cm circumference matches a 4.5 cm diameter. superior part to fold without compromising the second arte-
The actual design is not as important as making sure that rial input. This second artery adds a safety factor, especially in
the final shape is circular. It can be adjusted at the end of the long pedicles but it will be the longer pedicles that are more
procedure. difficult to inset.
The lateral pedicle design was initially chosen by the
Vertical Skin Resection Pattern. In this technique, the skin author because it was presumed to have better sensitivity (it
is not important in shaping the breast. Only enough skin is did not) and it is easy to inset, but the excess lateral breast
removed to prevent skin redundancy. The skin is not being used tissue that requires resection forms the base of the pedicle.
as a skin brassiere and it is unnecessary—and detrimental—to This prevents adequate lateral resection. Any attempt to pull
make the skin closure tight. the lateral breast tissue medially in order to correct the lateral
The vertical limbs can be drawn similar to that which fullness is unfortunately ineffective as the tissue tends to slide
would be drawn for an inverted-T or Wise pattern reduction. back, resulting in recurrent lateral fullness.
These can be determined by pushing (and slightly rotating) the It may be tempting to try to use the pedicle to push excess tissue
breast medially and then laterally to line up the vertical limbs superiorly in order to increase upper pole fullness. Unfortunately,
with the previously drawn meridians in the upper and lower the increase is temporary and bottoming-out always occurs.
chest wall areas.
Instead of extending the vertical limbs laterally and medi- Parenchymal Resection Design. The pedicle chosen
ally as would be done in an inverted-T–type Wise pattern, the will determine to some extent the pattern of the parenchymal
vertical limbs are joined to each other well above the IMF. resection. For example, using an inferior pedicle means that
The final shape of the skin resection pattern with both the the breast tissue is removed superiorly. For many of the verti-
areolar opening and the vertical skin resection is much like cal patterns, the breast tissue is removed inferiorly as a vertical
a child’s snowman. The body is round with a smaller round wedge.
head on top. Some surgeons have made the vertical resection The principle that the vertical limbs in an inverted-T
come down as a “V” in order to limit the skin dog-ear, but it should measure only 5 cm does not apply to the skin in the
is important when doing this to remove adequate subcutane- vertical techniques, but it is a useful concept for the paren-
ous tissue inferiorly. A postoperative pucker is more often a chyma. Keeping the pillar height at about 7 cm gives an ideal
result of excess subcutaneous tissue rather than excess skin. breast shape. To keep the pillars relatively short, the remain-
The skin resection pattern should terminate well above the ing parenchyma is removed horizontally below the pillars
existing IMF. There are two reasons for this. First, the paren- along a Wise pattern.
chyma and skin are excised as a vertical ellipse and closure Once the markings are complete, it helps to draw the
results in lengthening of the incision. The closure can then inverted-T or Wise pattern on the skin to guide the paren-
push the scar below the fold. Second, when the parenchyma chymal resection. The tissue above is maintained to shape the
is removed below the Wise pattern horizontally (in addition breast and create the breast pillars. The tissue below—both
to the resection along the vertical ellipse), the IMF will often vertically and horizontally—is removed. The vertical wedge
rise. If the fold rises, the scar can fall below the new IMF. If is excised directly. The horizontal areas are often removed by
these two factors are not taken into account, the scar might beveling out the resection and then tailoring the excision with
end up extending onto the chest wall skin that was previ- liposuction.
ously lower pole breast skin. On average, the incision should
stop at least 2 to 4 cm above the IMF in a small to medium
(300 to 600 g) reduction.
Operative Technique
Infiltration. Vasoconstriction is helpful. Infiltration along
Pedicle Design. A true medial pedicle has a base width of the inferior aspect and the base of the breast of about 40 mL
about 8 cm with half of the base up into the areolar opening per breast of lidocaine 0.5% with 1:400,000 epinephrine will
and half below onto the vertical limb. A medial pedicle can reduce bleeding during parenchymal resection. Unfortunately,
infiltration along the incision lines can result in small hemato- bleeding and preserve the nerves that run just above the fascia.
mas because of the numerous superficial veins just below the Some tissue cephalad can be left to leave a platform for the
dermis. pedicle, but it is important not to try to push that tissue up in
In obese patients, it is advisable to infiltrate about 500 to an attempt to increase upper pole fullness.
1,000 mL of a tumescent-type fluid on each side along the lat- As with the inferior pedicle, the medial pedicle will be quite
eral chest wall and the preaxillary areas. This reduces bleeding mobile and it is important that the assistant not pull exces-
when these areas are liposuctioned. Some of the tumescent- sively to avoid inadvertent undermining of the pedicle.
type fluid can be infiltrated around the base of the breast as
well. If too much is used, the breast will become quite “wet” Parenchymal Resection. Both scalpel and cutting cautery
and cautery will be less effective. can be used to remove breast tissue (Figures 56.4A and 56.5).
Care must be taken to secure accurate hemostasis when The resection is beveled out laterally and medially. The infe-
using vasoconstrictors for breast reduction. It is especially rior border of the medial pedicle becomes the medial pillar.
important to look for and cauterize the perforators that The whole base of the pedicle rotates as the nipple and areola
come through the pectoralis fascia. They may remain con- are inset into position and the pedicle itself gives an elegant
stricted and not bleed during surgery, but these are usually curve to the lower pole of the breast.
the vessels that will later open up and cause a postoperative The lateral resection will be more aggressive, but some
hematoma. tissue (about 2 cm thick) is left along the lateral vertical
limb to fashion a lateral pillar. There is often a considerable
Creation of the Pedicle. The skin of the pedicle is de-epi- excess of lateral breast tissue and direct excision is neces-
thelialized (Figure 56.4A). Putting the skin on tension by using sary because of its thick fibrous nature. Adipose tissue lat-
either a commercial device or a lap pad held around the base eral to the breast (which is actually on the lateral chest wall)
of the breast with a Kocher clamp helps the assistant keep the can be tailored with liposuction. Teenagers have very thick
skin taut. Care is taken to preserve the superficial veins that lie tissue laterally and this needs to be carefully carved out to
just beneath the dermis. prevent any ridges.
The pedicle is full thickness. It is incised directly down It is important to follow the preoperative plan for the
to the chest wall. Either a scalpel or a cutting cautery can be amount of tissue to be resected. Because it can be difficult to
used. Care is taken not to expose pectoralis fascia to avoid resect an adequate amount of breast parenchyma with this
Breast
A B
C D
FIGURE 56.4. Operative technique. A. Pedicle and skin resection pattern. B. Rotation of pedicle. Note that the inferior border of the medial
pedicle is now the medial pillar. C. Closure of the pillars. The pillar length is only about 5 to 7 cm. The pillar closure starts about half way up
the vertical opening because the parenchyma needs to be resected inferiorly as outlined (following the Wise pattern). D. Closure of the areola and
skin. Originally, it was thought that this vertical incision needed to be shortened to allow the skin to retract. It has become increasingly evident
that tightening the intracuticular suture not only interferes with healing but also delays resolution of the puckering.

608 Part VI: Breast
A B
C D
FIGURE 56.5. Wise pattern inferior resection principle. A, B. The

Wise pattern was adapted from a brassiere design and it is a good pat-
tern to use for the parenchyma that is left behind—and not for what
is removed. When the inferior wedge of tissue is removed and the
pattern is closed, a pleasing breast with good projection is achieved.
The Wise pattern is a better design for the parenchyma than it is for
the skin. C, D. The principle of the Wise pattern as applied to breast
reduction. Note that the tissue below the Wise pattern is the tissue
that is removed. The vertical limbs of the skin resection pattern are
not as wide as the pattern, but the tissue resection—both direct exci-
sion and liposuction tailoring—more closely follows the original pat-
tern. E. The most important markings are noting the level of the upper
breast border just below the preaxillary fullness and in this patient
at the upper border of the striae (and therefore the new nipple posi-
tion vertically about 10 cm below the upper breast border), the breast
and chest wall meridian (and therefore the new nipple position hori-
zontally) about 10 cm drawn straight from the chest meridian (not
around the breast), as well as the areolar opening, the skin resection
pattern, and the medial or superomedial (shown here) pedicle design.
E
technique, it may be tempting to remove tissue superiorly. If the superiorly when the patient has a significant amount of upper
patient has very little upper pole fullness, it is important not pole fullness.
to resect superior tissue for a few centimeters on either side of Some tissue is left superolaterally to provide a platform to
the breast meridian. On the other hand, tissue can be removed prevent inversion of the nipple–areolar complex. The pedicle
may be full thickness but it will appear to be undermined pillar. If the pedicle is long and heavy, it may be wise to suture
(much as an inferior pedicle) and a small platform can help some of the pedicle up onto the chest wall to help prevent
support the nipple and areola. bottoming-out.
The inferior breast tissue below the Wise pattern is removed
by direct excision and then liposuction is used to tailor the Closure of the Dermis. The dermis is closed so that the
resection inferiorly, both laterally and medially. Liposuction is resultant incision line is vertical (Figure 56.4D). Deep buried
not used for volume reduction, but it is used to correct asym- 3-0 Monocryl sutures are ideal because they absorb relatively
metry that remains during closure and it is used for cosmetic quickly and they are less likely to extrude than PDSs. There is
refinement. no need to suture the dermis up onto the breast parenchyma
The skin flaps remain attached to the breast tissue supe- (it will delay shape resolution postoperatively). Only enough
riorly and laterally, as well as superiorly and medially. The sutures are used to maintain approximation of the margins.
resection is beveled out laterally and medially and then fin-
ished with liposuction. The resection is actually undermined Liposuction. Before final closure of the skin, it is a good
inferiorly so that the inferior breast can now become chest idea to stand back and assess asymmetry and shape. The sur-
wall skin (and fat) as the IMF rises. The fold will only rise geon should be able to visualize the Wise pattern and leave
about 1 to 2 cm at the meridian, but it will curve up consider- that behind—with no tension on the pillars and no tension on
ably as it extends laterally and medially. the skin. Tissue beyond the Wise pattern needs to be removed
The IMF is not a ligament but it is a criss-crossing conden- by direct excision complemented by liposuction. Some sur-
sation of fibers between the skin and the deep fascia. It is not geons prefer to sit the patient up at this stage.
a breast structure but a skin–fascial zone of adherence much Unless the patient has very thick fibrous breast tissue
like the gluteal fold. The fold fibers can be easily seen and (which occurs in many of the normal-weight teenagers) lipo-
some of them are removed when the surgeon wishes to make suction can be used to correct asymmetry.
the IMF rise. The IMF fibers extend over a vertical distance The area that needs to be carefully checked is the area just
of about 2 cm. The fibers can be safely removed in this pro- above the existing IMF. There should be no excess subcuta-
cedure because the weight of the breast is left superiorly. If an neous tissue remaining that will result later in a pucker. The
implant is added, the surgeon should be careful to leave some tissue inferiorly at the level of the meridian will often need
of the IMF fibers intact. direct excision (there are definite transverse fibers at the level
The skin flaps are therefore full thickness superiorly with of the fold), especially if the surgeon wishes the fold to rise.
no undermining between the skin and the breast tissue. The Liposuction can be used medially and (especially) laterally to
lateral flap is beveled out laterally to remove any excess paren- tailor this region.
chyma. Inferiorly, the tissue is thinned (with still a layer of fat Liposuction is also used to reduce excess fat along the lat-
to prevent adhesions). Flap thickness is thinnest at the skin eral chest wall and in the preaxillary areas. If the patient is
margins (about 2 cm) and it gets thicker as one extends lat- obese, then tumescent-type infiltration is recommended for the
erally and medially. The pillars should be about 2 cm thick areas to be suctioned. Patients are warned preoperatively that
and have a vertical distance of about 7 cm. There will be these areas will bruise and that they are often the source of
an excess of skin remaining inferiorly compared with breast more discomfort postoperatively than the breasts themselves.
parenchyma. The inferior skin below the Wise pattern should
have a thickness of about 1 cm. Fat is needed on the dermis to Closure of the Skin. The vertical skin closure is best
prevent adherence and scar contracture. achieved by a running subcuticular 3-0 or 4-0 Monocryl
suture. It is important to close this skin relatively loosely.
Insetting the Pedicle. It is easier to inset the pedicle after Extra skin does not need to be excised in a lateral or medial
direction to hold the shape of the breast. Deep bites, tight
Breast
the base of the areola is closed (Figure 56.4B). A single 3-0
polydioxanone suture (PDS) or Monocryl suture is used. Some sutures, and skin tension will only delay wound healing.
dermis is incorporated with the first bite at the base of the The skin closure should not be gathered. It was originally
pedicle, but the dermis itself does not need to be undermined. thought that the skin should be gathered to shorten the length
Once this suture is tied, the nipple and areola rotate easily of the vertical scar. Not only does this skin stretch out (or it
into position. The amount of rotation will vary—only enough remains pleated requiring revision), it is actually important to
rotation is needed to allow a comfortable inset with minimal realize that a short vertical distance (which may be needed
compression. when the skin is used as a brassiere) tends to flatten and com-
Even though the pedicle is carried full thickness down to press the breast. A well-shaped “B” cup breast has a vertical
the chest meridian, it is very mobile and may appear to have distance from the bottom of the areola to the IMF of 7 cm. A
been undermined. well-shaped “C” cup breast has a vertical distance of 9 cm and
The medial and lateral pillars are then closed. Final inset a “D” cup has a vertical distance of 11 cm.
and closure of the areola is performed later. In fact, excess skin gathering will actually delay resolution
of any skin puckering inferiorly. Good quality skin will adapt
Closure of the Pillars. The inferior border of the medial very well to the new breast shape. With the procedure described
pedicle now becomes the medial pillar (Figure 56.4C). The in this chapter, the breast shape relies on the parenchyma left
pedicle needs to be pulled up so that the first pillar suture is behind (without any tension) and not on the skin brassiere.
placed just next to the inferior aspect of the base of the ped- It may be tempting to close the skin as an “L” or a “J”
icle. Closure of the pillars starts about half way up the skin or even a “T,” but this is usually not necessary. When there
opening—not at the bottom of the skin resection pattern and is a large amount of loose, inelastic skin (such as found in a
not at the IMF. post-bariatric patient) excision may be indicated. On the other
The sutures do not need to be deep. Some lateral pillar hand, this is rarely needed in most breast reductions up to
tissue at the same level on the other side is also incorporated 1,000 or more grams. It is not the amount of the parenchymal
into this first suture. There is no need to take large bites or resection that is important, but the quality of the redundant
to include fatty tissue. It is important to place the suture on skin that will make this determination.
either side into fibrous tissue. There is some fibrous tissue It is important not to suture the skin up onto the breast
in even the fattiest breasts. The pillars should come together parenchyma. This maneuver will only delay resolution. It is
without tension. also important not to suture the “pucker” at the lower end of
Only a few sutures are needed and it is important to pull the vertical skin down to the chest wall. If it actually remains
up on the pedicle as each suture is placed so that the infe- adherent, it will lead to an indentation that will later need to
rior border of the medial pedicle is positioned as the medial be corrected.
610 Part VI: Breast
The excess skin that remains inferiorly adapts surprisingly not necessary. The patient can shower the day after surgery,
well to the new breast shape. It is difficult for surgeons who wash over the tape, and then pat it dry. A brassiere is not used
have been trained to keep the vertical skin length at 5 cm to for compression, but can be used to hold gauze bandages (ini-
accept a long (sometimes more than 12 cm) vertical skin open- tially) and pantyliners (after a couple of days) in place.
ing. The temptation to excise this extra skin can be difficult Patients are encouraged to gradually increase their activi-
to resist. ties. Return to desk work may only take 1 to 2 weeks, whereas
return to heavy physical activity may take several weeks. The
Closure of the Areola. The skin opening for the areola pucker (dog-ear at the inferior end of the vertical incision)
should be round. In the past, when the vertical skin was gath- may take several weeks and months to settle. A seroma may
ered significantly, a teardrop shape resulted. This could take occur which makes the pucker look more ominous, but sero-
several months to settle postoperatively. Now that gathering mas will settle relatively quickly without intervention.
is not recommended, the problem of distortion of the areola is Patients should be warned about the time it takes for reso-
no longer a concern. lution of the shape, any asymmetries, or persistent puckers.
Because the upper breast border does not change postop- Surgeons are often concerned about the length of time for
eratively, it is not a good idea to change the nipple position this type of breast reduction to settle, but the postoperative
as marked preoperatively. The areolar skin opening can be course is very similar to an inverted-T, inferior pedicle. The
trimmed if needed to make sure that the opening is circular. postoperative discomfort is actually less and the shape at the
The skin opening will determine the final areolar diameter. end of the procedure does not need to look concave inferiorly.
Areolar skin stretches more than breast skin and it will stretch Patients have an acceptable shape within the first few weeks
out to fit the skin opening. A 16 cm skin opening circumfer- after surgery.
ence will result in a 5 cm diameter areola. A 14 cm skin open- They should know that revisions may be necessary in a lim-
ing circumference will result in a 4.5 cm diameter areola. ited number of patients, but that a full year should pass before
If there is a considerable discrepancy between the cir- considering any corrective surgery.
cumference of the skin opening and the circumference of the
areola (when it is stretched out properly), then consideration Complications
should be given to a permanent type of suture to prevent
widening. Usually, however, a few centimeter discrepancy is Complication rates reported in the literature can be confus-
easily tolerated and closure is best achieved by a few inter- ing. Care must be taken when comparing complications to
rupted 3-0 or 4-0 Monocryl sutures followed by a running determine whether these are “major” or “minor.” Revision
subcuticular suture. rates will also depend less on the procedure and more on
A true “circumvertical” pattern requires a permanent the threshold of a particular surgeon to perform a revision.
suture in an attempt to prevent areolar widening. The author All procedures in plastic surgery have a certain revision rate.
believes that it is better to match the areolar and skin circum- An inferior skin pucker is often more easily corrected than a
ferences and extend the length of the vertical scar. Surgeons medial or lateral breast pucker.
find it difficult to realize that a longer vertical scar is not only
acceptable—it is required to allow for the increased projection
Hematoma. Hematomas may develop postoperatively
if transected vessels are not apparent because they are con-
that is achieved with this approach.
stricted by epinephrine used for infiltration. The surgeon must
Drains and Antibiotics. The use of both drains and antibi- be aware of this problem and take care to search out such ves-
otics is controversial. Drains do not prevent a hematoma, but sels and cauterize them. Drains will not prevent hematomas
they may reduce the substrate for bacteria. When drains are and any significant hematoma will require re-operation.
used postoperatively, they are usually removed on the follow-
ing day, but some surgeons will leave them in place for sev- Seromas. Seromas can occur with or without the use of
eral days. Many surgeons do not use drains at all unless there drains. Even leaving the drains in for several days does
is considerable oozing present (as can occur when patients not prevent the development of seromas. Aspiration may
ignore advice to stop anti-inflammatory medications for 2 be indicated, but the seromas will tend to recur. They can
weeks preoperatively). Drains can be brought out through the be left to resolve on their own. Although surgeons may be
vertical incision or through a separate stab incision. concerned that a pseudobursa may develop, this does not
Seromas do occur but they are usually allowed to settle on appear to be a problem.
their own. Drains would need to be used for many days or
even weeks to prevent a seroma from collecting. The author’s
Nipple–Areolar Necrosis. Breast reduction surgery is also
a blood supply–reducing operation. Care must be taken while
preference is not to use drains at all and seromas are not aspi-
creating the pedicle to preserve as much blood supply as possi-
rated but allowed to resorb on their own.
ble. Although a clear understanding of anatomy is important,
Cephalosporins are the most commonly used antibiotics.
the actual blood supply in any particular patient is guesswork
There is controversy over whether they should be used at all,
at best.
whether they should be used only perioperatively, or whether
Nipple necrosis may be one of the best kept “secrets” in
they should be used for several days postoperatively. Breasts
plastic surgery but surgeons (and patients) should be aware
are not completely “clean” and breast ducts do harbor bacte-
that nipple necrosis is less likely to be a result of surgeon
ria such as Staphylococcus epidermidis.
error than it is a pattern of blood supply that cannot be deter-
The author found that antibiotics were integral to pre-
mined preoperatively. The incidence of nipple necrosis may
venting suture spitting. With the current recommendation
be as high as 0.5% in all types of pedicles and skin resection
of using only one preoperative antibiotic dose, the author
patterns.
has been able to reduce suture spitting by using Monocryl
Although it has been advised to take a nipple and areola
Plus which has an antibacterial (triclosan) incorporated into
that is compromised and convert it to a free nipple graft, this
the suture.
decision is extremely difficult. It is not uncommon for areo-
Representative cases are shown in Figures 56.6–56.8.
las to look dusky and pale at the end of the procedure. Most
Postoperative Course. Steristrips or Micropore paper tape surgeons are well aware that recovery is the rule. It would be
is applied to the incisions. The author prefers paper tape and inappropriate to convert these areolas to free grafts because
it can be left in place for about 3 weeks. A few horizontal grafting results in a lack of sensitivity and a lack of nipple pro-
strips can be applied inferiorly to help encourage the redun- jection. Breast feeding is not possible and grafts can heal with
dant inferior skin to contract. Taping of the whole breast is irregular pigmentation.

H
E
A
Breast
G
J
C
FIGURE 56.6. A 34-year-old 185 lb, 5′7″ patient who wore a 36F brassiere. A. Preoperative
frontal view moderate sized breast reduction. B. Preoperative lateral view. C. Preoperative view
with markings. The upper breast border is not marked but is at the upper level of the striae.
A purely medial pedicle is marked on this patient (many of these measurements are performed
for statistical analysis only). D. Intraoperative view at completion of the vertical approach using
the medial pedicle. The patient had 625 g of tissue removed from the right breast and 720 g from
the left breast. She also had 400 cc of fat removed from the lateral chest wall and preaxillary
areas with some contouring of the lower portion of the breasts. Surgery time was 90 minutes.
I now gather this incision far less than shown in this photograph. E. Frontal view at 10 days
post-op. F. Lateral view at 10 days post-op. G. Arms up view at 10 days. The results do not nec-
essarily take a long time to settle postoperatively. H. Frontal view at 15 months postoperatively.
I. Lateral view at 15 months postoperatively. J. Arms up view at 15 months postoperatively.
D

612 Part VI: Breast
A C
B D F
FIGURE 56.7. A 60-year-old patient who was 5′4″ tall, weighed 195 lb and wore a 38DD brassiere. She had 680 g of tissue removed from each
breast. A. Frontal preoperatively. B. Lateral preoperatively. C. Frontal 10 days postoperatively. D. Lateral 10 days postoperatively. E. Frontal
4.5 years postoperatively. F. Lateral 4.5 years postoperatively.
A C
B
Figure 56.8. A 24-year-old woman who had 295 g of tissue removed from her right breast and 315 g from her left breast. A. Frontal
preoperatively. B. Lateral preoperatively. C. Frontal markings preoperatively. D. Frontal 10 days postoperatively. E. Lateral 10 days post-
operatively. F. Frontal arms elevated 10 days postoperatively. This view is humbling in that it shows any residual puckering or deformity.
G. Frontal 18 months postoperatively. H. Lateral 18 months postoperatively. I. Frontal arms elevated 18 months postoperatively.

D
F
E I
If it is clear that a nipple and areola are suffering from also disappeared. When only one preoperative dose of antibi-
venous congestion postoperatively, then measures such as otics was later used, some suture spitting recurred. The best
Breast
removing sutures or taking the patient back to the operating approach in the author’s practice has been to use the one pre-
room for exploration may help. Many patients are now dis- operative dose combined with an antibacterial (not antibiotic)
charged on the same day as surgery and the opportunity for impregnated suture. This has reduced the infection rate and
this type of evaluation is not available. It would make sense controlled suture spitting while reducing the incidence of post-
to keep patients for observation if this evaluation was clear- operative diarrhea.
cut, but it is not. Necrosis is most likely a lack of arterial
input and this cannot be corrected. Necrosis from correct- Wound Healing. All types of breast reduction have prob-
able venous congestion is much less likely. The risk to benefit lems with wound healing. The inverted-“T” has more prob-
ratio is such that it is probably best to allow almost all ques- lems with necrosis at the “T” and the vertical types can have
tionable cases to declare themselves without intervention. more problems on the vertical incision line. Wound healing
Blistering and some loss may occur, but this is often prefer- problems can be prevented to a significant degree by avoid-
able to active intervention—which carries its own risks. ing undue tension on the incision lines. Avoiding tension can
Rarely, complete loss of the nipple and areola will occur. be harder with the inverted-“T” because the procedure relies
Intervening on the questionable cases is not likely to decrease more on the skin to hold the shape. The vertical approaches
this incidence. Each patient will need to be evaluated over time are more likely to run into problems if the surgeon causes
as to whether the necrotic tissue should be allowed to heal by constriction during closure by excising too much skin or by
secondary intention, in-office debridement, or intraoperative undue skin gathering. Antibiotics may be helpful in reducing
debridement. Some form of nipple and areolar reconstruction wound healing problems.
is then considered. It is important to avoid tension on both the parenchymal
and the skin closure.
Infection. Many surgeons believe that antibiotics are indi- Extensive flap necrosis is rare. It is more likely to occur when
cated because the breast ducts are open to the external envi- the skin is undermined and when excessive tension is applied to
ronment. Some surgeons use no antibiotics, some use peri- the flaps during closure. Debridement may be necessary. Skin
operative antibiotics, and some surgeons use a full course of grafting may close the wounds earlier, but the cosmetic result
antibiotics. The most commonly used antibiotics are first- or is often better if the open areas are allowed to heal secondarily.
second-generation cephalosporins.
The author initially did not use any antibiotics with breast Under–resection. It is far more difficult to remove enough
reduction surgery, but unfortunately, some patients developed breast tissue with the vertical techniques than it is with the
infections. A full course (a week) of cephalosporins reduced inverted-“T” techniques. At the end of the procedure, the
these infections. Interestingly, the problem of suture “spitting” breasts actually look smaller than they are. This can be a

614 Part VI: Breast
problem for surgeons who have been accustomed to assessing exception. Revisions do tend to be more common with the
size with the inverted-“T.” The extra projection can be mis- vertical approaches, especially during the learning curve. Each
leading. It is important to determine the amount of breast tis- surgeon will have a different threshold for revision, but a rate
sue to be removed preoperatively and to then follow that plan. of about 5% is not unexpected.
The excess breast tissue should be removed laterally from
under the lateral flap. Excess superior breast tissue should
only be removed when a patient has an overly full upper
Summary
pole preoperatively. All excess tissue below the Wise pattern It has been repeatedly documented that both physical and
should also be removed. Any attempt to pull in lateral tissue psychological outcomes are excellent after breast reduction
or push up inferior tissue will fail. Excess tissue that has been surgery. The challenge is to minimize scarring at the same
pulled into a new location will revert to its original position. time as giving the breast an aesthetically pleasing and endur-
It is important to remove the excess and then close the paren- ing shape.
chyma (and the skin) without tension. The surgeon should The vertical approaches are excellent for the small- to
leave the Wise pattern of parenchyma behind and then remove medium-sized reductions. With experience, surgeons also find
any excess tissue peripheral to that pattern. that the methods are applicable to larger and larger reductions.
At least 6 to 12 months should elapse before undertaking There is no question that there is an initial learning curve (as
any re-reduction. This can be achieved through liposuction-only there is with the inverted-“T”), but surgeons eventually feel
or by re-reducing tissue in the vertical plane. Most of the re- rewarded not only by the improved scarring that results but
reduction will involve parenchyma. It is important not to take also by the improved shape. The procedure takes less time to
too much skin in the re-reduction or a torpedo-type shape will perform; there is less blood loss and a faster patient recovery
result. An inferior wedge resection combined with further exci- time compared with inverted-“T” techniques.
sion under the lateral flap will be needed. Fortunately, the shape The concepts in the vertical techniques involve far more
will settle because the skin will inevitably stretch to some degree. than just a different vector in the skin and parenchymal resec-
tion patterns. This vector plus the more superiorly based
Asymmetry. Correction of asymmetry should follow simi- pedicles give a shape that resists gravity over time. In general,
lar guidelines to re-reduction. The problem may be solved by the vertical approaches use the breast parenchyma to shape
liposuction-only or it may require parenchymal excision, scar the skin, whereas the inverted-“T” approaches use the skin to
release, and shaping. Breasts can be asymmetrical in size and shape the breast.
shape (and IMF location) preoperatively and the surgeon can
better assess this asymmetry by having the patient raise her Suggested Readings
arms above her head. Asplund O, Davies DM. Vertical scar breast reduction with medial flap or
glandular transposition of the nipple-areola. Br J Plast Surg. 1996;49:
Puckers. The vertical skin pattern approach involves exci- 507-514.
sion of skin and parenchyma in a vertical ellipse. This means Corduff N, Taylor GI. Subglandular breast reduction: the evolution of a
that there are two dog-ears—one that is chased into the areolar minimal scar approach to breast reduction. Plast Reconstr Surg. 2004;113:
175-184.
opening and disappears and one that is chased inferiorly. The Cruz-Korchin N, Korchin, L. Breast-feeding after vertical mammaplasty with
skin excision should remain as a “U” and not be tapered into a medial pedicle. Plast Reconstr Surg. 2004;114(4):890-894.
“V,” especially if this would mean that the scar would extend Gray LN. Update on experience with liposuction breast reduction. Plast
below the IMF. The excess skin will tuck in under the breast as it Reconstr Surg. September 2001;108:1006.
Hall-Findlay EJ. A simplified vertical reduction mammaplasty: shortening the
settles. If a “V” is used, it is important to remove enough of the learning curve. Plast Reconstr Surg. September 1999;104:748.
underlying subcutaneous tissue on each side to prevent a pucker. Hall-Findlay EJ. Aesthetic Breast Surgery. St Louis, MO: Quality Medical
It is advisable to wait a full year before performing any Publishing; 2010.
revisions. At first glance, the pucker that remains may appear Hammond DC. Short scar periareolar inferior pedicle reduction (SPAIR)
mammaplasty. Plast Reconstr Surg. 1999;103:890.
to be a problem of excess skin. But usually the real problem Lassus C. A 30-year experience with vertical mammaplasty. Plast Reconstr
is excess subcutaneous tissue between the original and the Surg. 1996;97:373-380.
new IMF. If the pucker lies above the new IMF, it can be Lejour M. Vertical Mammaplasty and Liposuction of the Breast. St Louis, MO:
corrected with a vertical skin excision complemented by a Quality Medical Publishing; 1993.
Marchac D, de Olarte G. Reduction mammaplasty and correction of ptosis with
horizontal fat resection as needed. If the pucker lies below a short inframammary scar. Plast Reconstr Surg. 1982;69:45-55.
the new IMF it will require a horizontal excision but the McKissock PK. Reduction mammaplasty with a vertical dermal flap. Plast
horizontal excision will need to be designed to curve upward Reconstr Surg. 1972;49:245-252.
and will need to be long enough to prevent the creation of Ribeiro L. Creation and evolution of 30 years of the inferior pedicle in reduction
mammaplasties. Plast Reconstr Surg. September 2002;110(3);960-970.
two new dog-ears. Robbins TH. A reduction mammaplasty with the areola-nipple based on an
Adding a “T” at the initial procedure may obviate the inferior pedicle. Plast Reconstr Surg. 1977;59:64-67.
necessity to revise any puckers, but it has been shown that Schlenz I, Kuzbari R, Gruber H, Holle J. The sensitivity of the nipple-areola
performing a “T” resection did not alter the revision rate. complex: an anatomic study. Plast Reconstr Surg. 2000;105:905-909.
Spear SL, Howard MA. Evolution of the vertical reduction mammaplasty. Plast
Fortunately, many of these revisions can be performed in the Reconstr Surg. September 2003;112:855-868.
office under local anesthesia. The need for occasional revisions Wise RJ. A preliminary report on a method of planning the mammaplasty. Plast
is an integral part of plastic surgery, and breast reduction is no Reconstr Surg. 1956;17:367.

Chapter 57 n Gynecomastia
Nolan S. Karp
Gynecomastia is enlargement of the male breast and is caused Gynecomastia is said to occur in almost two-thirds of ado-
by an increase in ductal tissue, stroma, and/or fat. Most fre- lescent boys.3 This is thought to be due to an imbalance of
quently, the changes occur at the time of hormonal change: estradiol and testosterone. The adolescent gynecomastia also
infancy, adolescence, and old age. resolves in the vast majority of cases.2 In some cases, a degree
The term gynecomastia was introduced by Galen dur- of gynecomastia remains, but is not problematic enough to
ing the 2nd century AD and the surgical resection was first warrant medical attention. In the adolescent male, obesity
described by Paulis of Aegina1,2 in the 17th century AD. is frequently associated with enlarged breasts. This may be
due to the elevated levels of estrogen.4 The initial treatment
is weight loss, but if this is not successful, surgical correction
Etiology may be indicated.
The most common cause of gynecomastia is unknown (idio- The incidence of gynecomastia rises again in older men
pathic). The other common causes of gynecomastia are listed (age > 65 years). This is thought to be due to a decline
in Table 57.1. Gynecomastia often appears transiently at in testosterone and a shift in the ratio of testosterone to
birth. The process is thought to be related to an increased level estrogen.
of circulating maternal estrogens. After birth, the estrogen In all three age groups (neonatal, adolescent, and older
level decreases, the gynecomastia resolves, and treatment is men), gynecomastia appears to be related to either an increase
rarely necessary. in estrogens, a decrease in androgens, or a deficit in androgen
receptors.2 There are also numerous drugs and medications
that cause gynecomastia (Table 57.1). Systemic causes include
Table 57.1 adrenal diseases, liver diseases, pituitary tumors, thyroid dis-
ease, and renal failure. Tumors of adrenal, pituitary, lung, and
Common Causes of Gynecomastia
testis can be associated with hormonal imbalance resulting in
Idiopathic gynecomastia.
In any male patient with breast enlargement, breast cancer
Obesity must be considered since 1% of all breast cancers occur in
Physiologic men. There is no increased risk of breast cancer in patients
with gynecomastia when compared with the unaffected
Birth male population.5 The exception is patients with Klinefelter
Puberty syndrome. These patients have an approximately 60 times
increased risk of breast cancer.
Old age
Endocrine
Testis: hypogonadism, Klinefelter syndrome
Pathology
Breast
Three types of gynecomastia have been described: florid,
Adrenal: Cushing syndrome, congenital adrenal hyperplasia fibrous, and intermediate.6 The florid type is characterized
Thyroid: hypothyroid, hyperthyroid by an increase in ductal tissue and vascularity. A minimal
amount of fat is mixed with the ductal tissue. The fibrous
Pituitary: pituitary failure
type has more stromal fibrosis with few ducts. The interme-
Neoplasms diate type is a mixture of the two. The type of gynecomas-
Adrenal tia is usually related to the duration of the disorder. Florid
gynecomastia is usually seen when the breast enlargement is
Testis of new onset within 4 months. The fibrous type is found in
Pituitary cases where gynecomastia has been present for more than
1 year. The intermediate type is thought to be a progres-
Bronchogenic sion from florid to fibrous and is usually seen from 4 to
Systemic diseases 12 months.6,7
Renal failure
Diagnosis
Cirrhosis
A careful history and physical examination is the most impor-
Adrenal tant part of any workup for gynecomastia. The history notes
Malnutrition the time of onset of the gynecomastia, symptoms associated
with the gynecomastia, drug use (both medically prescribed
Drug-induced
and recreational), and careful review of systems. Organ
Hormones: estrogens, androgens system changes associated with gynecomastia include liver,
Antiandrogens: spironolactone, cimetidine, ketoconazole,
renal, adrenal, pulmonary, pituitary, testicular, thyroid, and/
ranitidine, flutamide
or prostate.
Physical examination includes assessment of the breast
Cardiovascular drugs: amiodarone, digoxin, nifedipine, gland and includes the nature of the tissue, isolated masses,
reserpine, verapamil and tenderness. The thyroid is evaluated for enlargement.
Abused drugs: Alcohol, heroin, marijuana The testes are examined for asymmetry, masses, enlargement,
or atrophy.
615
616 Part VI: Breast
Laboratory evaluation is based on the findings of the

istory and physical examination. Healthy adults with a
h Treatment of Gynecomastia
normal physical examination (other than gynecomastia) In patients with gynecomastia for more than 1 year and with
and longstanding gynecomastia do not require further a normal history and physical examination, surgery may be
workup. indicated. If there is a possible etiology noted in the patient’s
Patients with feminizing characteristics should undergo history, then an attempt should be made to either discontinue
endocrine testing. In addition, if marfanoid body habitus is the drug believed to be causing the gynecomastia or correct
associated with the feminization, Klinefelter syndrome must the systemic condition. If an abnormality is found on physi-
be ruled out. Any other new positive findings on physical cal examination, workup is indicated prior to surgical inter-
examination are evaluated in an appropriate manner. vention for the gynecomastia. If the underlying condition is
treated and the gynecomastia persists beyond a year, surgical
correction is indicated (Figure 57.1).
Classification The first surgical procedures used to treat gynecomas-
Simon, Hoffman, and Kahn8 divided gynecomastia into four tia were excisional in nature.11 Suction-assisted lipectomy
grades: grade 1: small enlargement, no skin excess; grade 2a: was first reported in the early 1980s,12 and more recently
moderate enlargement, no skin excess; grade 2b: moderate ultrasound-assisted liposuction has been used for certain
enlargement with extra skin; grade 3: marked enlargement types of gynecomastia.10 The physical deformity determines
with extra skin. In their opinion, grades 2b and 3 require some the appropriate surgical technique for the treatment of
skin resection. The need for skin excision also depends on gynecomastia.
the shape of the breast. Large breasts with wide bases may Most fibrous or solid Simon stage 1 or 2a lesions are treated
be treated without skin excision. On the other hand, smaller, with surgical excision or more recently, in selected cases, with
narrow breasts may require skin excision. ultrasonic liposuction. If surgical excision is c hosen, a peri-
Letterman and Schuster9 created a classification system areolar incision is performed as indicated in Figure 57.2A.
based on the type of correction: 1: intra-areolar incision with The skin incision is placed at the junction of the areola and
no excess skin; 2: intra-areolar incision with mild redundancy skin. If placed within the pigmented area, the scar may appear
corrected with excision of skin through a superior periareolar as a white line. If placed outside the areola, it may become
scar; and 3: excision of chest skin with or without shifting hypertrophic. The site of the incision should be marked prior
the nipple. to the distortion caused by injection of epinephrine-containing
Rohrich et al.,10 in a paper discussing the utility of ultra- solution. If placed properly, the ultimate scar is usually nearly
sound-assisted liposuction in the treatment of gynecomas- invisible. After the incision is made, a cuff of tissue 1 to 1.5
tia, developed the following classification: grade I: minimal cm in thickness is preserved directly deep to the nipple/areola
hypertrophy (<250 g of breast tissue) without ptosis; grade complex. This maneuver prevents postoperative nipple/areola
II: moderate hypertrophy (250 to 500 g of breast tissue) with- depression or adherence of the nipple/areola to the chest wall
out ptosis; grade III: severe hypertrophy (>500 g breast tissue) (Figure 57.2B). It is always better to leave more tissue under
with grade I ptosis; grade IV: severe hypertrophy with grade the nipple–areola than less. At the end of the case any excess
II or III ptosis. is trimmed. The chest skin flaps are developed in a plane
Detailed patient history and physical exam
Positive history
Negative history and normal

physical exam Abnormal physical exam
Drug history: discontinue drug

Systemic disease: correct underlying
disease
KIinefelter syndrome: karyotype,
bilateral mastectomy
Prepubertal, bilateral disease:
testicular ultrasound
Normal after workup Testicular mass: testicular US; serum testosterone, LH,
estradiol, and DHEAS; urology and endocrine consultation
Thyroid mass: thyroid function tests; endocrine consultation
Persistent gybnecomastia Breast mass: mammography, ultrasound, biopsy, surgical
oncology consultation
Hypogonadism: serum LH/FSH, estradiol, testosterone,
and DHEAS + karyotype; +/– adrenal CT scan; endocrine
>12 months <12 months consultation
Abdominal masses/hepatomegaly: liver function tests;
serum LH/FSH, estradiol, testosterone, and DHEAS; +/–
abdominal CT; endocrine consultation
Surgical management Observation
FIGURE 57.1. Algorithm for evaluation and treatment of gynecomastia. US, ultrasound; LH, luteinizing hormone; DHEAS, dihydroepian-
drosterone sulfate; FSH, follicle-stimulating hormone; CT, computed tomography. Adapted from Rohrich RJ, Ha RY, Kenkel JM, Adams WP.
Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plastic Reconstr Surg. 2003;111:909.

Chapter 57: Gynecomastia 617
A B
FIGURE 57.2. A. Periareolar incision. Medial and lateral extensions only used if necessary. B. Resection of gynecomastia through periareolar
incision. Note the cuff of tissue left deep to the areola.
between the subcutaneous fat and the breast tissue. To assure directions through both incisions (Figure 57.3B). The infra-
a smooth contour, the edges of the breast are trimmed with mammary fold is disrupted. The end point is a flat, smooth
either scissors or liposuction. contour with an absence of palpable tissue (Figure 57.4).
Patients with lesions that are glandular, fatty, or mixed in In cases of pure fatty gynecomastia, no further surgery is
nature and that are Simon grade 1 or 2a may be treated with necessary.
liposuction. Conventional liposuction with sharp tip cannulas, When liposuction is unsuccessful at removing all of the
power-assisted liposuction, or ultrasound-assisted liposuction tissue required to achieve a good result, the pull-through13,14
has been used successfully in this situation. technique is added. In this technique, either the lateral or
The patient is marked in the upright position. All areas of periareolar incision is opened slightly (about 1.5 cm) and the
tissue excess are marked as well as the inframammary fold. residual tissue is grasped. The tissue is pulled out through the
Sedation or general anesthesia is necessary. The area is infil- wound and removed with scissors or electrocautery. The pull-
trated with a tumescent solution that contains lactated ring- through resection is performed until the desired contour is
ers solution, 1 cc of 1:1,000 epinephrine solution, and 20 cc achieved. Again, over-resection of the subareolar area is assid-
of 2% lidocaine. The infiltration volume is about 1:1 with uously avoided (Figure 57.5). Drains are placed if the dead
the expected aspiration volume and covers a wide area of space is large. All patients are treated with compression gar-
Breast
the chest from the clavicle to below the inframammary fold. ments for at least 1 month.
Regardless of the type of liposuction chosen, special cannu- In patients with Simon grade 2b gynecomastia, the initial
las specifically designed for gynecomastia surgery are used. treatment is similar to that in patients with grade 1 and 2a
The typical incisions are shown in Figure 57.3A; typically, a gynecomastia. If the lesion is fatty, glandular, or mixed in
lateral incision at the level of the inframammary fold and a nature and some type of liposuction is the initial treatment
periareolar incision are made. Liposuction is performed in all modality, then no skin resection is performed at the first
A B
FIGURE 57.3. A. Location of incisions for suction-assisted lipectomy of gynecomastia. B. Direction of liposuction through both incisions.

618 Part VI: Breast
A B
C D
FIGURE 57.4. Patient with Simon 2a gynecomastia who underwent suction-assisted lipectomy of the chest (A–D). A, B. Pre-op appearance.
C, D. Post-op appearance.
surgical session. The patient is treated with a compression vest If the patient has a Simon grade 2b lesion that is very solid
and the chest wall tissue is given time to settle and contract. or fibrous in nature and an open approach is selected, then
The patient should wait at least 6 to 12 months before consid- skin resection may be incorporated into the initial procedure.
ering skin resection. In the majority of cases, no skin resection Alternatively, the tissue is resected via a minimalistic peri-
is required. When skin resection is performed, the amount of areolar incision and the patient treated with a compression
skin removed and the length of the incisions are less than if the garment. In many cases, no further skin resection is required.
resection had been performed at the time of the initial surgery. Ultrasonic liposuction with the pull-through technique
FIGURE 57.5. Pull-through resection of gynecomastia demonstrated.

Chapter 57: Gynecomastia 619
(if needed) has also been used in Simon 2b cases without skin Postoperative wound infection is uncommon. The use of
resection with good results. prophylactic antibiotics, particularly in liposuction cases, may
In patients with Simon grade 3 gynecomastia, skin resec- account for the low incidence of this complication.
tion is required. Numerous incisions and techniques have
been described to resect the skin and maintain nipple/areola References
viability, including superior and inferior periareolar incisions, 1. Goldwyn R. Plastic and Reconstructive Surgery of the Breast. Boston, MA:
omega incisions, nipple transpositions on a variety of pedicles, Little Brown; 1976;93:305.
concentric circle techniques, and any form of liposuction with 2. McGrath MH. Gynecomastia. In: Jurkiewicz MJ, Mathes SJ, Krizek TJ,
skin excision. The choice of technique is based on the prefer- Ariyan S, eds. Plastic Surgery: Principles and Practice. St. Louis, MO:
Mosby; 1990;1119.
ence of the surgeon. 3. Nydick M, Bustos J, Dale JH, Rawson RW. Gynecomastia in adolescent
boys. JAMA. 1961;178:449.
4. Hammond D. Surgical correction of gynecomastia. Plast Reconstr Surg.
Complications 2009;124:61e.
5. Cohen IK, Pozez AL, McKeown JE. Gynecomastia. In: Courtiss EH, ed.
The most common early complication after gynecomastia Male Aesthetic Surgery. St. Louis, MO: Mosby; 1991;373.
surgery is hematoma. In an open case, the hematoma should 6. Bannayan GA, Hajdu SI. Gynecomastia: clinicopathologic study of 351
cases. Am J Clin Pathol. 1972;57:431.
be evacuated if possible. This prevents excessive scarring and 7. Hands LJ, Greenall MJ. Gynecomastia. Br J Surg. 1991;78:907.
distortion of the breast. Postoperative closed suction drainage 8. Simon BE, Hoffman S, Kahn S. Classification and surgical correction of
decreases the incidence of this complication. In liposuction gynecomastia. Plast Reconstr Surg. 1973;51:48.
cases, evacuation may not be possible. 9. Letterman G, Schuster M. The surgical correction of gynecomastia. Am
Surg. 1969;35:322.
Under-resection of tissue is the most common long-term 10. Rohrich RJ, Ha RY, Kenkel JM, Adams WP. Classification and manage-
complication of gynecomastia surgery. This is particularly ment of gynecomastia: defining the role of ultrasound-assisted liposuction.
common in liposuction cases, when a residual mass of tissue Plast Reconstr Surg. 2003;111:909.
is not removed. This can usually be avoided using the pull- 11. Webster JP. Mastectomy for gynecomastia through a semi-circular incision.
Ann Surg. 1946;124:557.
through technique. Under-resection at the periphery of the 12. Courtiss EH. Gynecomastia: analysis of 159 patients and current recom-
breast can result from poor tapering and causes a noticeable mendations for treatment. Plast Reconstr Surg. 1987;79:740.
deformity. Over-resection in the nipple–areola can result in a 13. Hammond DC, Arnold JF, Simon AM, Cararo A. Combined use of ultra-
saucer-type deformity that is difficult to correct. Loose skin is sonic liposuction with the pull-through technique for the treatment of gyne-
comastia. Plast Reconstr Surg. 2003;112:892.
usually not considered a complication if it is part of the opera- 14. Bracaglia R, Fortunato R, Gentileschi S, Seccia A, Farallo E. Our experi-
tive plan. Occasionally, loose skin occurs unexpectedly, and ence with the so-called pull-through technique combined with liposuction
surgical excision is required. for management of gynecomastia. Ann Plast Surg. 2004;53:22.
Breast

Chapter 58 n
Breast Cancer: Current
Trends In Screening, Patient
Evaluation, and Treatment
Grant W. Carlson
Cancer of the breast is the most common cancer in women gene mutations. The genes are more common in women of
with the exception of skin cancer. It is the second lead- Ashkenazi ancestry, patients with bilateral breast cancer, can-
ing cause of cancer death after lung cancer. Approximately cer diagnosed before age 50, and patients with ovarian cancer.
200,000 new cases of breast cancer are diagnosed each year in The presence of a BRCA gene confers a 60% to 85% risk of
the United States. They account for over 40,000 deaths a year. developing breast cancer and a 10% to 40% risk of develop-
The incidence of breast cancer has decreased over the last ing ovarian cancer.
decade largely due to a discontinuation of hormone replace- Many epidemiological studies have linked early menarche,
ment therapy among postmenopausal women. late menopause, and late age at first full-term pregnancy to
The treatment of breast cancer has evolved because of the breast cancer. The total duration of menstrual cycles and the
results of large, prospective, randomized clinical trials orga- number of menstrual cycles before full-term pregnancy appear
nized by the National Surgical Adjunctive Breast and Bowel to be proportional to breast cancer risk. Premalignant his-
Project (NSABP) in the United States and the National Cancer tology on breast biopsy may increase breast cancer risk, as
Institute in Milan, Italy. The majority of women with breast discussed in the following section. A woman with unilateral
cancer are eligible for breast conservation therapy and receive breast cancer is at increased risk for developing cancer in the
some form of systemic adjuvant therapy. opposite breast. Studies have not shown that the development
of contralateral breast cancer impacts adversely on survival.
Risk Factors
One in nine women in the United States who reaches the age
Pathology
of 85 will develop breast cancer. The etiology is unknown but Screening mammography, by detecting early breast cancers,
is clearly multifactorial, with many exogenous and endoge- has increased our understanding of the malignant transforma-
nous risk factors being identified (Table 58.1). tion process. Most cancers arise from the ductal elements of
Aside from gender, age is the single most important factor the breast after passing, presumably, through a sequence of
in determining breast cancer risk. The probability that breast premalignant stages as depicted below.
cancer will develop increases throughout a woman’s life, with
half of all cases occurring in women older than age 65. Family Normal breast → hyperplasia → atypical hyperplasia →
history is also important since 20% of breast cancer patients will ductal carcinoma in situ → invasive cancer
have a relative with the disease. The magnitude of breast cancer This process can occur over a 10- to 20-year period,
risk is influenced by several factors pertaining to family history: and orderly progression through the various stages is not
number and proximity of affected relatives, their menstrual sta- obligatory. Ductal carcinoma in situ (DCIS), also known as
tus, age at diagnosis, and the presence of bilateral cancer. intraductal carcinoma, is cancer confined by the basement
Hereditary breast cancer accounts for 5% to 10% of breast membrane of the ducts. DCIS most commonly presents as
cancer cases and is caused largely by the presence of BRCA mammographic microcalcifications and currently comprises
30% of newly diagnosed cancers in populations following
screening mammography guidelines. DCIS occurs in several
Table 58.1
histological patterns with varying propensities to progress to
Breast Cancer Risk Factors invasive cancer. Comedo DCIS is characterized by pleomor-
phic cells, high-grade nuclei, and central areas of necrosis.
Gender Noncomedo DCIS occurs in several subtypes that are gener-
ally not as cytologically malignant as comedo DCIS. It may
Age
be difficult to distinguish noncomedo DCIS from atypical
Family history hyperplasia.
Reproductive history
Invasive ductal carcinoma accounts for the majority of
breast cancer cases. Grossly, it appears as a gray-white, irregu-
Early menarche lar, speculated mass that is hard and gritty on cut section. It
First birth after age 30 has no specific microscopic features but can be recognized his-
tologically as an invasive adenocarcinoma involving the ductal
Late menopause elements.
Benign breast disease A number of histological variants arise from ductal epi-
thelium. Medullary carcinoma is grossly soft and fleshy and
Atypical hyperplasia accounts for 6% of invasive cancers. It tends to grow to a
Lobular carcinoma in situ large size and is well circumscribed. Histologically, it is char-
acterized by poorly differentiated nuclei and infiltration by
Personal history lymphocytes. Medullary carcinoma has a favorable prognosis
Exogenous factors even in the presence of nodal metastases. Tubular carcinoma
is a rare histological variant in its pure form and accounts
Dietary factors
for 2% of breast cancer. It is characteristically small and is
620
Chapter 58: Breast Cancer: Current Trends in Screening, Patient Evaluation, and Treatment 621
usually found on mammography. It tends to be highly dif- ultrasound and histological information are used to guide
ferentiated and has an excellent prognosis. Mucinous or col- patient management. Breast MRI is used in patients with
loid carcinoma is another well-differentiated variant, which dense breasts and in those presenting with lobular carcinoma
tends to form a well-circumscribed soft, gelatinous mass. to define the extent of disease. The modality is also useful
Histologically, nests of tumor cells are surrounded by a muci- in the detection of contralateral disease and the assessment
nous matrix. of tumor response after neoadjuvant chemotherapy. There
Although most cancers arise from the ductal elements, are concerns that breast MRI may overestimate the extent
malignancies may also arise from the epithelium of the breast of disease, resulting in more patients being treated by total
lobules. Lobular carcinoma in situ (LCIS) has no radiologi- mastectomy.
cal or physical manifestations and has traditionally not been
regarded as a malignancy. LCIS is usually an incidental find-
ing after a biopsy of a mass or mammographic abnormality.
Locoregional Treatment
Current evidence suggests that the histological diagnosis of The goals of locoregional treatment are to provide optimal
LCIS confers a 20% risk of developing cancer in either breast local control, adequate disease staging, long-term survival,
at 20-year follow-up. and preservation or restoration of body form. Total mastec-
About 5% to 15% of infiltrating cancers arise from the tomy and axillary dissection were the standard treatment for
breast lobules. Once it has become invasive, lobular car- over 50 years, based on the Halsted mechanistic theory of can-
cinoma has a prognosis similar to the ductal type. It tends cer dissemination. Halsted believed that cancer was predomi-
to be extensively infiltrative without a distinct tumor mass. nantly a local disease that spreads by permeation of lymphatic
Histologically, the cells demonstrate a characteristic single file pathways. He proposed the radical mastectomy to remove
pattern. The tumor does not form microcalcifications, and the cancer and prevent systemic spread. Numerous prospec-
mammographic detection may be difficult. tive randomized trials have refuted this theory of tumor biol-
ogy. The bloodstream is an important pathway in early tumor
dissemination, and more conservative locoregional treatment
Screening combined with systemic therapy has proved to provide local
The American Cancer Society recommends that women at disease control with prolonged survival.
average risk should begin annual mammography at the age of
40 years.1 This has been shown to reduce the risk of dying of Breast Conservation
breast cancer. Early detection can also result in less aggressive
Breast conservation is the treatment of choice for the major-
surgery and adjuvant therapy to treat the cancer. The sensitiv-
ity of stage I and II breast cancers. Six prospective random-
ity of mammography is related to patient age, breast density,
ized trials of over 4,300 women have found breast-conserving
and breast cancer histology. False-positive exams may result in
treatment to result in survival rates similar to those achieved
additional breast biopsies, especially in young patients. There
by total mastectomy. Removal of the cancer with pathologi-
is no specific age to discontinue screening mammography.
cally negative margins is termed as lumpectomy or partial
Breast magnetic resonance imaging (MRI) is increasingly
mastectomy. The remaining breast is usually treated with
used for breast cancer screening. It has the greatest sensitivity
50 Gy of external breast radiation to improve local control.
of all imaging modalities for detecting breast cancer of a few
The NSABP B-06 trial compared total mastectomy, lumpec-
millimeters in diameter. MRI suffers from a low specificity,
tomy, and lumpectomy and radiation in 1,843 women.3 The
which can result in unnecessary biopsies as well as a high cost.
survival was the same for all three groups but the addition
The American Cancer Society recommends breast MRI in the
of breast irradiation to lumpectomy reduced the local recur-
management of women at high risk for developing breast can-
rence from 40% to 8%. Young patients and those with exten-
Breast
cer beginning at age 30.2 This includes women with known
sive intraductal cancer surrounding the invasive component
or suspected BRCA gene mutations and women who have
are at increased risk for local recurrence. Because of the pro-
undergone mantle radiation to the chest for the treatment
pensity for ductal carcinoma to spread upward toward the
of Hodgkin’s disease. Women felt to have a 20% to 25% or
nipple along the duct, a quadrantectomy has been proposed
greater lifetime risk of breast cancer based on risk estimation
to reduce local recurrence. Larger excisions result in slightly
models are also included in this high-risk category
improved local control rates at the expense of the cosmetic
result but have no impact on ultimate survival. Local recur-
Staging rences are generally treated by total mastectomy.
There are few absolute contraindications to breast conser-
The American Joint Committee on Cancer TNM staging
vation (Table 58.4). The cosmetic outcome of lumpectomy is
system is based on clinical as well as pathological informa-
dependent on both treatment-related factors and patient selec-
tion. The classification by primary tumor (T), status of axil-
tion and is judged to be excellent to good by 60% to 90% of
lary lymph nodes (N), and presence of distant metastases (M)
patients.
places patients in different prognostic groups (Tables 58.2 and
58.3). Stages I and II are considered early breast cancer for
which surgery plays a primary role in treatment. Stage III dis- Accelerated Partial Breast Irradiation
ease is also known as locally advanced breast cancer (LABC). Whole breast irradiation after lumpectomy or partial mas-
Despite the absence of metastatic disease, this stage has a poor tectomy is the standard of care to prevent local recurrences.
prognosis and is best treated with a combination of chemo- Studies have shown that most recurrences after breast con-
therapy, surgery, and radiation therapy. This stage includes servation occur near the original disease site. Recurrence
inflammatory breast cancer, a clinical entity characterized rates away from the tumor bed are similar after lumpectomy
by breast warmth, erythema, and edema. The orange peel whether adjuvant whole breast irradiation is administered or
appearance of the skin, peau d’orange, results from dermal not.4 This is the rationale for accelerated partial breast irra-
lymphatic invasion. diation (APBI). It concentrates radiation to a partial volume
of the breast over a 1- to 2-week period compared with a
6- to 7-week period for conventional whole breast irradiation.
Patient Evaluation Potential advantages of APBI include convenience and less
Most patients with breast cancer are diagnosed with image- toxicity with the potential for better cosmetic results.
guided core biopsy. Ultrasound of the axilla is routinely per- The most common method of delivering APBI is through
formed to screen for potential nodal spread. Mammography/ implantation of multiple interstitial catheters or a single

622 Part VI: Breast
Table 58.2
The American Joint Committee On Cancer TNM Staging System of Breast Cancer
Primary tumor (T)

TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ, intraductal carcinoma, lobular carcinoma in situ
T1 Tumor ≤2 cm in greatest dimension
T1mic Microinvasion ≤0.1 cm in greatest dimension
T1a Tumor >0.1 cm but ≤0.5 cm in greatest dimension
T1b Tumor >0.5 cm but ≤1 cm in greatest dimension
T1c Tumor >1 cm but ≤2 cm in greatest dimension
T2 Tumor >2 cm but ≤5 cm in greatest dimension
T3 Tumor >5 cm in greatest dimension
T4 Tumor of any size with direct extension to chest wall or skin only
T4a Extension to chest wall
T4b Edema (including peau d’orange) or ulceration of the skin of the breast or satellite skin nodules confined to the
same breast
T4c Both T4a and T4b
T4d Inflammatory carcinoma
Regional lymph nodes (N)
NX Regional lymph nodes cannot be assessed (e.g., were previously removed)
N0(i+) Malignant cells in lymph nodes not greater than 0.2 mm
N1 Micrometastases or metastases in one to three axillary lymph nodes and/or internal mammary nodes with
metastases detected by SLN biopsy
N1mi Micrometastases only, >0.2 cm but none greater than 2.0 mm
N1a Metastasis in one to three axillary lymph nodes, at least one metastasis greater than 2.0 mm
N1b Metastasis in internal mammary nodes detected by SLN biopsy
N1c Metastasis in one to three axillary lymph nodes and in internal mammary lymph nodes detected by SLN biopsy
N2 Metastasis in four to nine axillary lymph nodes or clinically detected, internal mammary lymph nodes in the
absence of axillary lymph node metastases
N3 Metastases in 10 or more axillary lymph nodes or infraclavicular lymph nodes
Distant metastasis (M)
MX Distant metastasis cannot be assessed
M1 Distant metastasis, including metastasis to ipsilateral supraclavicular lymph nodes
balloon catheter. This allows radiation to be delivered locally tumor volume removal are best treated by total mastectomy.
to the tissue at highest risk of recurrence. Randomized trials Breast reshaping is generally performed by replacing missing
comparing APBI with standard external beam radiation have tissue with various glandular flaps based on reduction mam-
yet to mature but the early results appear promising. moplasty techniques. The opposite breast is generally reduced
to achieve symmetry. If the defect is too large or in a medium-
Oncoplastic Surgery sized breast and cannot be corrected using local tissue, distant
flaps can be used.
Oncoplastic surgery combines the oncological principles of
tumor extirpation with plastic surgical techniques such as
breast parenchymal rearrangement and flap reconstruction. It Total Mastectomy
has the potential to increase surgical resection margins and Removal of the entire breast, nipple–areola, and skin overly-
improve cosmetic results after breast conservation. It is useful ing superficial tumors is still the most common local treatment
in patients with moderate- to large-sized breasts whenever a of breast cancer despite the proven results of breast conser-
partial mastectomy would result in noticeable breast defor- vation. In continuity removal of the axillary lymph nodes is
mity. This includes patients with medial and inferior pole termed as modified radical mastectomy. The pectoralis major
cancers and patients requiring removal of greater than 15% and minor muscles are usually preserved. A skin-sparing mas-
of the breast volume. Patients with small breasts and large tectomy preserves the inframammary fold and as much native

Chapter 58: Breast Cancer: Current Trends in Screening, Patient Evaluation, and Treatment 623
Table 58.3 found. They reported better arm mobility and less pain in the
SLND-alone group. At a median follow-up of 102 months,
Stage Grouping With The American Joint the regional failure rate in the SLND-alone group was 0.77%.
Committee On Cancer There was no significant difference in the disease-free survival
between the groups.
Stage 0 Tis N0 M0 ALND is the standard of care in patients found to have
Stage IA T0, T1 N0 M0 sentinel lymph node metastasis. Studies are emerging that
show that completion ALND can be omitted in patients
Stage IB T0, T1 N1mi M0 with early breast cancer treated by excision and whole breast
Stage IIA T0, T1 N1 M0 irradiation.6
T2 N0 M0 Treatment of DCIS
Stage IIB T2 N1 M0 The malignant potential of DCIS depends on the size, tumor
T3 N0 M0 grade, and the presence of comedo necrosis. If left untreated,
some but not all will progress to invasive cancer. Local recur-
Stage IIIA T0, T1, T2 N2 M0 rence after surgical excision alone occurs in up to 30% of
T3 N1, N2 M0 cases depending on tumor size and histology. One-half of
recurrences will be invasive carcinomas. Radiation therapy
Stage IIIB T4 Any N M0
has been shown to reduce local recurrences. The NSABP B-17
Any T N3 M0 trial studied 818 women with DCIS randomly assigned to
Stage IV Any T Any N M1 either lumpectomy alone or lumpectomy followed by breast
irradiation.7 With a median follow-up of 43 months, local
recurrences developed in 16% treated by lumpectomy alone
and 7% treated by lumpectomy plus irradiation. The role of
tamoxifen in the management of DCIS was addressed in the
skin as possible. It is used when immediate breast reconstruc-
NSABP B-24 trial, which studied 1,804 women treated with
tion is planned. Its oncological safety has been proven by
breast conservation therapy.8 After a median follow-up of
numerous studies.
74 months, tamoxifen was found to reduce the risk of ipsi-
Nipple-sparing mastectomy which preserves the entire
lateral breast tumors in women under age 50 by 38% and
breast skin envelope is being evaluated to further improve the
in those age 50 and older by 22%. There was also a 52%
aesthetic results of breast reconstruction. It is being used in
reduction in contralateral breast cancer events. This translates
women with small to moderate breast size and minimal breast
into an absolute reduction in breast cancer events from 13.4%
ptosis. Many centers are evaluating its use both in the prophy-
to 8.2%.
lactic setting and in the treatment of early breast cancer.
To correlate the risk of recurrence with pathological fea-
tures and treatment, Silverstein et al.9 devised an index depen-
Management of the Axilla dent on major risk factors for local recurrence: nuclear grade,
The removal of axillary lymph nodes provides pathologic size, comedo histology, and surgical margins based on ret-
staging as well as regional disease control. Lymph node rospective data analysis. The Van Nuys Prognostic Index is
involvement is an important prognostic factor in breast can- based on tumor size, tumor grade, and the presence of comedo
cer. The clinical examination of the axilla is inaccurate, with necrosis. Small, low-grade tumors without comedo necrosis
up to a quarter of clinically normal axillae harboring micro- have a low incidence of recurrence and may be treated with
Breast
metastatic disease. Sentinel lymph node dissection (SLND) excision alone in select patients.
has supplanted axillary lymph node dissection (ALND) as the
standard of care for staging the axilla in early breast cancer. Postmastectomy Radiotherapy
It has equivalent sensitivity and reduced morbidity in terms
Postmastectomy radiation therapy (PMRT) is increasingly
of arm stiffness, pain, paresthesia, and risk of lymphedema.
being administered in patients with early breast cancer. Studies
Blue dye and radioactive tracers are injected into the breast
have shown that it reduces the risk of locoregional recurrence
and are taken up by breast lymphatic system. This allows
(LRR) of breast cancer by approximately 67% but a survival
identification and removal of the lymph node(s) most likely to
benefit has been largely offset by an increase in cardiac deaths
contain metastases. Veronesi et al.5 performed a prospective
secondary to radiation. Indications of PMRT include patients
randomized trial of 516 breast cancer patients randomized to
at high risk for LRR: large tumors, four or more metastatic
SLND and ALND or SLND alone. A completion lymph node
lymph nodes, close or involved surgical margins, and LABC.
dissection was performed if sentinel node metastasis were
Two randomized trials have shown a survival benefit for post-
mastectomy radiotherapy in patients with one to three meta-
static lymph nodes.10,11 These studies have been criticized for
Table 58.4 having a high regional failure rate in the control nonirradiated
Contraindications To Breast Conservation groups. A meta-analysis by the Early Breast Cancer Trialists’
Collaborative Group has provided strong evidence supporting
Absolute the use of postmastectomy radiotherapy.12 The group stud-
ied the results of 8,500 women treated by total mastectomy
Multiple ipsilateral lesions and axillary clearance. They found a 20% absolute reduction
Diffuse suspicious microcalcifications in LRR in node-positive patients treated with PMRT. This
resulted in a 5% improvement in breast cancer survival at 15
Steroid-dependent collagen vascular disease years follow-up.
Relative The use of PMRT is based on the absolute risk of LRR.
Extrapolating the data from the meta-analysis of PMRT, every
Small breast/large tumor 5% reduction in LRR could result in a 1% improvement in
Radiation induced breast cancer survival. The benefits in low-risk patients must
be balanced against the potential cardiovascular morbidity of
Ongoing pregnancy
chest wall irradiation.

624 Part VI: Breast
with a pathological complete response rate of 12% to 50%

Systemic Therapy depending on tumor characteristics.15
Adjuvant chemotherapy, hormonal therapy, and biologic
therapy are used to eliminate occult metastases responsible References
for later recurrences. Clinical trials have shown that adjuvant 1. Smith RA, Saslow D, Sawyer KA, et al. American Cancer Society guidelines
therapy can reduce the odds of cancer recurrence up to 30%. for breast cancer screening: update 2003. CA Cancer J Clin. 2003;53(3):
The effect on disease-free interval is generally larger than the 141-169.
2. Saslow D, Boetes C, Burke W, et al. American Cancer Society guidelines for
effect on overall survival. Obviously, those at higher risk for breast screening with MRI as an adjunct to mammography. CA Cancer J
recurrence and death will obtain a greater benefit. Prognostic Clin. 2007;57(2):75-89.
factors, including tumor size and grade, nodal involvement, 3. Fisher B, Redmond C, Poisson R, et al. Eight-year results of a random-
hormone receptor status, and HER2 overexpression, are used ized clinical trial comparing total mastectomy and lumpectomy with
or without irradiation in the treatment of breast cancer. N Engl J Med.
to predict the risk of distant metastases. Gene expression 1989;320(13):822-828.
assays of individual breast cancers are used to provide tumor- 4. Veronesi U, Cascinelli N, Mariani L, et al. Twenty-year follow-up of a ran-
specific treatment based on the risk of recurrence. Commonly domized study comparing breast-conserving surgery with radical mastec-
used chemotherapy regimens include anthracyclines, cyclo- tomy for early breast cancer. N Engl J Med. 2002;347(16):1227-1232.
5. Veronesi U, Viale G, Paganelli G, et al. Sentinel lymph node biopsy in breast
phosphamide, and taxanes. In premenopausal women with cancer: ten-year results of a randomized controlled study. Ann Surg. 2010;
hormone responsive tumors, tamoxifen, a selective estrogen 251(4):595-600.
receptor modulator, is used. Aromatase inhibitors (anastro- 6. Giuliano AE, Hunt KK, Ballman KV, et al. Axillary dissection vs no axillary
zole and letrozole) block the peripheral conversion of adrenal dissection in women with invasive breast cancer and sentinel node metasta-
sis: a randomized clinical trial. JAMA. 2011;305(6):569-575.
steroids to estrogen and have been shown to be more effec- 7. Fisher B, Costantino J, Redmond C, et al. Lumpectomy compared with
tive than tamoxifen in postmenopausal women.13 Anti-HER2 lumpectomy and radiation therapy for the treatment of intraductal breast
targeted therapy is used in cancers that have HER2 oncogene cancer. N Engl J Med. 1993;328(22):1581-1586.
overexpression. 8. Fisher B, Dignam J, Wolmark N, et al. Tamoxifen in treatment of intra-
ductal breast cancer: National Surgical Adjuvant Breast and Bowel Project
The Early Breast Cancer Trialists’ Collaborative Group B-24 randomised controlled trial. Lancet. 1999;353(9169):1993-2000.
performed an overview of 69 randomized trials of adjuvant 9. Silverstein MJ, Lagios MD, Craig PH, et al. A prognostic index for ductal
combination chemotherapy.14 For recurrence, combination carcinoma in situ of the breast. Cancer. 1996;77(11):2267-2274.
chemotherapy produced significant proportional reductions 10. Ragaz J, Jackson SM, Le N, et al. Adjuvant radiotherapy and chemotherapy
in node-positive premenopausal women with breast cancer [see comments].
among women younger than 50 years of age (35% reduc- N Engl J Med. 1997;337(14):956-962.
tion) and those 50 to 69 years of age (20% reduction). For 11. Overgaard M, Hansen PS, Overgaard J, et al. Postoperative radiotherapy
mortality, the reductions for women younger than 50 years of in high-risk premenopausal women with breast cancer who receive adju-
age (27% reduction) and those 50 to 69 years of age (11%) vant chemotherapy. Danish Breast Cancer Cooperative Group 82b Trial
[see comments]. N Engl J Med. 1997;337(14):949-955.
were significant. Adjuvant tamoxifen administered for 5 years 12. Clarke M, Collins R, Darby S, et al. Effects of radiotherapy and of dif-
reduces the risk of recurrence at 10 years by 47% and the ferences in the extent of surgery for early breast cancer on local recur-
mortality at 10 years by 26% in estrogen receptor-positive rence and 15-year survival: an overview of the randomised trials. Lancet.
tumors. 2005;366(9503):2087-2106.
13. Baum M, Buzdar A, Cuzick J, et al. Anastrozole alone or in combination
with tamoxifen versus tamoxifen alone for adjuvant treatment of post-
Neoadjuvant Chemotherapy menopausal women with early-stage breast cancer: results of the ATAC
(Arimidex, Tamoxifen Alone or in Combination) trial efficacy and safety
Preoperative chemotherapy is indicated in patients with update analyses. Cancer. 2003;98(9):1802-1810.
LABC. It may be considered in patients with operable invasive 14. Polychemotherapy for early breast cancer: an overview of the randomised
cancers who would be candidates for adjuvant chemotherapy. trials. Early Breast Cancer Trialists’ Collaborative Group. Lancet.
1998;352(9132):930-942.
The goal would be tumor shrinkage to permit breast conserva- 15. Fisher B, Bryant J, Wolmark N, et al. Effect of preoperative chemother-
tion. Randomized trials of neoadjuvant chemotherapy in oper- apy on the outcome of women with operable breast cancer. J Clin Oncol.
able breast cancer have shown significant tumor downstaging 1998;16(8):2672-2685.

Chapter 59 n Breast Reconstruction:
Prosthetic Techniques
Joseph J. Disa and Nima P. Patel
The use of prosthetic devices for breast reconstruction began more than one operation and may require revisions over
in the early 1960s with silicone gel-filled implants. Over time. Additionally, if the patient has a chronic respiratory ill-
the years, implant technology and surgical techniques have ness, the pressure from the tissue expander on the chest wall
evolved, resulting in improvement in the quality of the recon- during the expansion process may exacerbate that underly-
structed breast. Currently, there are multiple methods of pros- ing condition. Finally, prosthetic-based breast reconstruction
thetic breast reconstruction and various types of implants often requires multiple steps and multiple visits to the office.
with different shapes, textures, and fill materials from which The patients must be reliable and stable enough from a psy-
the plastic surgeon can choose. chological standpoint that they can manage the reconstruc-
The popularity of one-stage implant reconstruction has tive process.
diminished over the years with the development of two- It is also important to explain to patients that prosthetic
stage, expander–implant reconstructions. Early experience breast reconstruction does not hinder detection of local or
with tissue expanders used smooth surface, round devices regional recurrence. There is no difference in the incidence
with remote fill ports. These devices were fraught with of locoregional recurrence in patients who have undergone
problems, including capsular contracture, poor expansion prosthetic reconstruction versus those who have not had
of the mastectomy pocket, and mechanical problems with reconstruction.4
the fill port. Current tissue expanders for breast reconstruc-
tion have textured surfaces, are anatomically shaped, and
have integrated valves. These devices have a semirigid back,
Timing
allowing for preferential expansion in the anterior dimen- Breast reconstruction using prosthetic techniques can be
sion. Device design also provides preferential expansion in accomplished either in the immediate or delayed setting. The
the lower pole of the reconstructed breast to create a better advantage of immediate reconstruction is that the first step in
match with a natural breast. Finally, the textured surface breast reconstruction is accomplished at the time of the mas-
on the expander reduces the incidence of capsular contrac- tectomy under the same anesthetic. In this setting, maximum
ture (Figure 59.1). These expanders are typically made in amounts of breast skin can be preserved as the prosthetic
varying heights, widths, degrees of projection, and shapes, device will occupy some of the mastectomy space. In the set-
so that the optimal device can be selected for the individual ting of a single-stage breast reconstruction using a permanent
patient’s needs.1,2 implant, immediate reconstruction allows for the placement
of an optimally sized device. Delayed breast reconstruction
using a prosthetic technique is also possible; however, tissue
Patient Selection expansion is almost always necessary. In this method, the
In general, most patients are candidates for prosthetic breast mastectomy skin flaps are re-elevated and expanded to re-cre-
reconstruction. There are, however, limitations with the ate a pocket for the ultimate placement of a permanent breast
Breast
overall shape of permanent breast implants that dictate the implant. In the setting of high-risk disease and patients who
quality of the final result. Factors to consider include uni- require chemotherapy and radiation therapy, a delayed recon-
lateral vs. bilateral, body habitus, associated comorbidities, struction may be appropriate as it will not delay the initiation
and the patient’s psychological profile. The ideal candidate of adjuvant treatment.
for breast reconstruction with prosthetic implants is a thin
patient with bilateral reconstruction, or a thin patient with a
normal, nonptotic breast who requires unilateral reconstruc-
tion. In this situation, symmetry is relatively straightforward.
As the patient’s breast size increases and the degree of ptosis
increases, the difficulty matching the opposite side with pros-
thetic reconstruction increases. In this situation, the patient
may be a candidate for a contralateral symmetry procedure
such as a mastopexy and a reduction mammoplasty. Even
with such procedures, however, exact symmetry out of cloth-
ing may not be possible. The patient is educated that the
goal is to achieve as much symmetry as possible, but that
this may only be accomplished when she is in her brassiere
and clothing.3 Although not an absolute contraindication,
obesity makes implant reconstruction difficult. In patients
with a broad chest wall and a large contralateral breast, the
expansion process may fail to achieve a pocket of appropri-
ate volume to obtain a meaningful and symmetric result.
In this situation, the addition of autologous tissue to an
implant-based reconstruction, or the use of autologous tissue
alone, may achieve a more pleasing result. For patients with FIGURE 59.1. Textured surface, integrated valve, biodimensional-
multiple medical problems, an implant-based reconstruction shaped tissue expander with Magna-Finder (Allergan, Irvine, CA) fill
may be more efficient than an autologous tissue reconstruc- port locating device.
tion. However, implant-based reconstructions may require
625
626 Part VI: Breast
Technique
With all types of breast reconstruction, the primary goal is
to achieve a breast mound that is as symmetrical as possible
with the other breast or to the contralateral reconstruction
in the setting of bilateral mastectomies. Coordination and
communication between the surgeon performing the mas-
tectomy and the reconstructive surgeon is required. Ideally,
mastectomy incisions are planned to minimize their impact
on subsequent tissue expansion and their visibility in conven-
tional clothing. Skin flaps should be of adequate thickness
to maintain blood supply, and the site of the inframammary
fold should be marked and preserved whenever possible
(Figure 59.2). The position of the point of maximum projec-
tion of the breast should also be noted. At the conclusion of
the mastectomy, if the inframammary fold has been detached,
it should be repaired. After obtaining hemostasis within the
mastectomy pockets, a submuscular pocket for the placement
of the tissue expander is prepared. The lateral border of the
pectoralis major muscle is elevated from the chest wall and
from the underlying pectoralis minor muscle. Care must be
taken to adequately coagulate perforating vessels to the mus-
cle to avoid hematoma formation. Expanders can be placed
in a complete submuscular or subfascial pocket by elevating
the medial border of the serratus anterior muscle and/or fas-
cia and elevating the pectoralis major from lateral to medial
and bringing both the subserratus and subpectoral pocket
into communication at the level of or slightly below the infra-
mammary fold (Figure 59.3). Final coverage of the expander
occurs by suturing the lateral border of the pectoralis major
muscle to the serratus anterior muscle. This technique com-
pletely separates the tissue expander from the mastectomy
space (Figure 59.4A, B).5 In the setting of a very thin mastec- FIGURE 59.3. Submuscular dissection of tissue expander pocket.
tomy skin flap, caution is recommended because there may Lateral border of pectoralis major muscle (black arrow) is retracted
be inadequate soft-tissue coverage over the inferior pole of medially while the medial boarder of serratus anterior muscle (white
the expander. Exposure of the expander either through the arrow) is retracted laterally.
skin flap or through a poorly healed mastectomy incision does
occur in some cases. In general, if soft-tissue coverage of the
expander is questionable, any mastectomy skin flap necrosis
should be treated aggressively with excision of devitalized is created for the expander, a sheet of acellular dermal matrix
tissue and closure of the wound. Occasionally, saline needs is tailored to the defect. It is placed in the inferior and lateral
to be temporarily removed from the expander to accomplish portions of the expander pocket and sutured to the pectoralis
closure. major muscle superiorly and to the chest wall or inframammary
An alternative to using the serratus anterior muscle and/or fold inferiorly (Figure 59.5). One to two closed suction drains
fascia for total submuscular coverage of the tissue expander are placed. Postoperative expansion starts in 10 to 14 days.
is to use acellular dermal matrix. Once a subpectoral pocket It has been suggested in many case series that the use of
acellular dermal matrix in tissue expander/implant recon-
struction allows for quicker expansion, decreased pain
caused by dissecting the serratus for submuscular coverage,
and improved cosmesis. However, this is based on anecdotal
reports. Initially, it was shown at our institution that there was
no difference in the mean rate of postoperative tissue expan-
sion with the use of acellular dermal matrix.6 More recently,
however, increased rates of expansion due to larger initial fill
volume in patients with acellular dermal matrix have been
observed. Additionally, a recent study evaluated 153 imme-
diate expanders placed using acellular dermal matrix versus
2,910 expanders placed without the acellular dermal matrix
over a 4-year period. The acellular dermal matrix group
had a higher incidence of overall complications, specifically
seroma (7.2%) and reconstructive failure (5.9%) mostly due
to infection.7
Choosing the appropriate expander is based on several
factors, including breast volume, breast dimensions (height,
width, and projection), breast shape, and the patient’s body
habitus. In general, an anatomically designed, textured surface,
integrated valve tissue expander is preferred (see Figure 59.1).
FIGURE 59.2. Intraoperative appearance of bilateral mastectomy The expander comes in various heights, widths, and amounts
defect. Original position of inframammary folds and planned lower of projection that either can be compared with the contralat-
position of the new inframammary fold are marked. eral breast or can be matched to another expander if a bilateral
procedure is performed. Final considerations in choosing an

Chapter 59: Breast Reconstruction: Prosthetic Techniques 627
A B
FIGURE 59.4. A. Tissue expander in place, covered by the pectoralis major muscle and serratus anterior muscle. B. Lateral border of pectoralis
major muscle is sutured to medial border of serratus anterior muscle to provide complete submuscular coverage of the tissue expander.
expander include the amount and quality of remaining breast elevated from the chest wall, or the muscle is split in the direc-
skin after the mastectomy and the impact of planned contra- tion of the muscle fibers and a subpectoralis major pocket
lateral symmetry procedures (augmentation, mastopexy, and is created. Similar to immediate expander placement, care is
reduction) on the shape of the opposite breast. The expander taken to avoid elevation of the pectoralis minor muscle. From
typically comes partially filled with air. The air is evacuated this point, dissection beyond the pectoralis can be extended
from the expander and a small amount of saline solution is either into the subcutaneous plane inferiorly and laterally, or
infiltrated into the expander to confirm the functioning of the into the submuscular/subfascial plane as noted in the descrip-
port. The expander is then placed into the pocket with the tion of placement of an immediate tissue expander. Similar
appropriate anatomic orientation. The expander can be filled to immediate tissue expander placement, the importance of
to match the available space in the submuscular/submastec- a careful dissection of the tissue expander pocket cannot be
tomy pocket. A closed suction drain is placed in the mastec- overemphasized. It is critical to free any scar tissue that will
tomy space, and the mastectomy wounds are closed. If there restrict expansion of the mastectomy flaps. The expander is
is redundant skin from the mastectomy, excision of this skin placed such that the zone of maximum expansion is located in
as much as possible prior to closure will improve the cosmetic the lower pole of the reconstructed breast, allowing for prefer-
result. ential expansion of the lower pole, for a more natural shape of
the reconstructed breast. Acellular dermal matrix may also be
used for delayed reconstruction.
Delayed Tissue Expanders
Breast
Delayed breast reconstruction with a tissue expander is similar Expansion
to immediate reconstruction. Typically, the mastectomy scar
is excised and the mastectomy flaps are re-elevated, although Intraoperatively, the tissue expander is filled to a volume that
not to the extent as was necessary during the original mas- optimally obliterates dead space, but does not impart exces-
tectomy. Once adequate pectoralis muscle is exposed, either sive pressure on the mastectomy skin flaps (Figure 59.6A–C).
the lateral border of the pectoralis muscle is identified and Because blood supply to the newly created mastectomy skin
flap may be tenuous, overfilling the expander intraoperatively
can impede circulation. Closed suction drainage tubes left at
the time of expander placement are removed when output is
≤30 mL per 24 hours, which typically occurs within 2 weeks.
Tissue expansion begins in the office approximately 10 to
14 days after surgery. A magnetic device is used to identify
the site of the integrated fill valve under the patient’s skin.
The area is cleansed with an antiseptic solution and a but-
terfly needle is used to gain access to the tissue expander.
Approximately 30 to 120 mL of saline is injected into the
expander during each expansion session. Expansion sessions
can occur as frequently as once per week or as infrequently
as once per month, although there is no set criterion to the
expansion schedule. The final goal of the expansion is to
achieve a volume that is approximately 25% to 30% greater
than the expander volume (Figure 59.7). This allows for extra
skin to be available at the exchange procedure, which can be
used to create maximum breast ptosis and inferior pole projec-
tion. Overexpansion also allows for the removal of unsightly
mastectomy scars, or scars that have resulted from delayed
or poor wound healing. If the patient is to receive postopera-
FIGURE 59.5. Tissue expander covered by the pectoralis major muscle tive chemotherapy, the onset of this typically coincides with
superiorly sutured to the acellular dermal matrix (black arrow) inferiorly. the expansion process. Patients can be safely expanded during
chemotherapy, although it may be necessary to coordinate

628 Part VI: Breast
A B
FIGURE 59.6. A. Magna-Finder (Allergan, Irvine, CA) device is used

to locate the port intraoperatively. B. Saline solution instilled into
tissue expander intraoperatively. The expander is filled to match the
available space in the submuscular pocket. C. Intraoperative appear-
ance of partially filled tissue expanders after wound closure.
C
the expansion schedule with their chemotherapy schedule. The type of implant is chosen preoperatively: saline ver-
Final replacement of the expander to a permanent implant sus silicone, smooth versus textured. Once the type of device
is deferred until the patient’s blood counts have returned is chosen, then the shape of the device is selected: anatomic
to normal after the conclusion of chemotherapy. Also after versus round. Round implants, whether they are silicone or
simulation for radiotherapy, it is important not to adjust the saline have varying projections: low, moderate, or high pro-
expander volume. In general, soft tissues are allowed to rest file. With smooth implants, the point of maximum projection
for at least 1 month between the time of the last expansion is in the center of the device. The smooth device is mobile
and the time of the exchange procedure.8 within the implant pocket, whereas textured implants are not
mobile within the pocket, as the textured surface adheres to
Exchange of Tissue Expander
For Permanent Implant
The second stage in breast reconstruction using a pros-
thetic device involves exchanging the tissue expander to a
permanent implant. This procedure can be accomplished at
any time after the tissue expansion is completed. Typically,
patients will wait at least 1 month following the last expan-
sion before undergoing the exchange procedure. If the
patient received chemotherapy as part of her management,
then at least 3 to 4 weeks after the last chemotherapy session
is allowed to pass so that bone marrow suppression induced
by chemotherapy can resolve before undergoing an elective
surgical procedure. The goals of the exchange procedure are
to create a breast mound that has similar shape, volume, and
position as the contralateral breast in a unilateral reconstruc-
tion, and to maximize symmetry and position in a bilateral
reconstruction. The patient is positioned in the operating
room such that the reconstruction can be accomplished in FIGURE 59.7. Unilateral right breast reconstruction with tissue
the sitting position, allowing for maximum ptosis of the nat- expander. The expander is intentionally overfilled to maximize pro-
ural breast. The permanent implant can then be placed with jection and inferior pole skin.
maximum symmetry.

the pocket. Anatomic shaped form stable cohesive gel devices Perhaps, the most important step in placement of the perma-
(Allergan/Inamed/McGhan 410, Irvine, CA, and Mentor CPG nent implant for breast reconstruction is accurate positioning
implant, Santa Barbara, CA) that were marketed in Europe in of the inframammary fold. The placement of the inframam-
1993 are not available in the United States at the time of this mary fold on the breast mound should be marked preopera-
writing except at centers that are IRB (Institutional Review tively with the patient in the upright position. This marking
Board) approved for FDA (Food and Drug Administration) then can be confirmed with the patient in the supine position.
investigations (Figure 59.8A–C). This implant will main- Depending on the degree of ptosis and whether a contralateral
tain its dimensions and form in any position. These devices symmetry procedure will be performed on the opposite breast,
are available in a matrix of sizes with varying base diam- the marking will help determine the final location of the infra-
eters, projections, and heights. The clinical implication of mammary fold. In general, the position of the inframammary
this implant compared with a round implant is that with the fold of the reconstruction should match the normal side or
shaped implant, careful dimensional planning is essential. the contralateral side in the setting of a bilateral reconstruc-
Also the pocket dissection must be precise and overdissection tion. If a contralateral symmetry procedure (augmentation,
is avoided.9 Patients should be educated on all implants and mastopexy, or reduction) is to be performed, care should be
informed consent should be obtained prior to surgery. taken to match the symmetry procedure to the reconstruction.
The selection of the proper final implant is aided by mea- In the setting of a more ptotic breast, where the breast gland
suring the dimensions of the normal breast. Specific measure- descends below the level of the inframammary fold, it may be
ments include base diameter, breast height, and projection. desirable to place the bottom of the implant at the level of the
The step in choosing the appropriate breast implant is match- bottom of the breast on the natural side. In this circumstance,
ing the volume of the contralateral breast. There are various the inframammary fold on the reconstructed side may be
techniques that can be used to facilitate this process. One slightly lower than it is on the contralateral side; however, the
involves comparing the weight of the breast removed at the overall position of the breast mounds is similar. Multiple tech-
time of mastectomy to the volume of the tissue expander. This niques for recreating the inframammary have been described:
technique will help in approximating the mass and volume internal placement of capsulorraphy sutures, external mari-
needed for the reconstruction. Another technique is to par- onette sutures as described by Spear,10 liposuction of the infra-
tially empty the expander (which typically is overexpanded mammary fold to allow the external skin to stick to the chest
so as to maximize inferior pole skin and projection) prior to wall, and advancement of the upper abdominal skin flap,
removing the expander (Figure 59.9A–D). The expander is suturing this internally to the chest wall to define the fold.
emptied to a point where its volume approximates the con- The combination of appropriate positioning and definition of
tralateral breast. The volume of the remaining fluid in the the inframammary fold, along with ample inferior pole skin
expander, the base dimension of the pocket from which the expansion, will create the desired pocket for prosthetic breast
expander came, and the height and projection of the contra- reconstruction. Maximizing projection of the reconstructed
lateral breast determine the appropriate size and shape of the breast can be further accomplished by performing internal
implant. Disposable sizers corresponding to particular per- capsulotomies positioned either circumferentially, radially, or
manent implants are also available and can aid in permanent both, or by performing a capsulectomy (Figure 59.11). Care
implant selection (Figure 59.10A, B). is taken to ensure adequate thickness of the mastectomy skin
Breast
A B
FIGURE 59.8. A. Anatomic shaped, form stable cohesive gel implant.

B. Cut anatomic shaped, form stable cohesive get implant. C. Round
silicone gel implant.
C

630 Part VI: Breast
A B
C D
FIGURE 59.9. Exchange of tissue expanders to permanent implant. A. Excision of mastectomy scar. B. Mastectomy skin flaps elevated off pecto-
ralis major muscle. C. Pectoralis muscle incised in the direction of its muscle fibers, exposing the tissue expander. D. Removal of fluid from tissue
expander to estimate planned volume of permanent implant.
A B
FIGURE 59.10. A. Disposable saline-filled sizers can be used to determine appropriate permanent implant. B. Intraoperative appearance of sizer
in implant pocket.

59.13). In the setting of a bilateral mastectomy and recon-
struction, the same principles are applied; however, the use
of capsulotomy, capsulectomy, and repositioning of the infra-
mammary fold is performed to maximize the symmetry of
the pockets and the overall symmetry of the reconstruction
(Figures 59.11 to 59.16).
Breast Reconstruction With

Immediate Placement of An
Implant
In select cases, immediate breast reconstruction can be accom-
plished with placement of an implant. The mastectomy skin
flaps must be completely healthy, the pocket must be of ade-
quate size so as to insert an implant of the appropriate size,
and the appropriate implant must be selected. If the pocket is
inadequate for a permanent implant of sufficient volume, then
an expandable implant, such as an expandable saline device
with a remote access port, can be used. The port is removed
FIGURE 59.11. Releasing an implant capsule aids in maximizing at a later stage. Alternatively, an expandable silicone/saline
projection and ptosis of permanent implant. device can be used. The advantage of an expandable device
is its adjustability during the postprocedure period prior to
final port removal, which generally can be accomplished in
the office setting. Acellular dermal matrix may be beneficial
flaps when performing these procedures. An inferior pole cap- in single-stage reconstruction. The disadvantage of immedi-
sulectomy or capsulotomy will allow for maximizing inferior ate reconstruction includes the risk of asymmetry with the
pole projection and ptosis in the reconstructed breast. contralateral breast, inadequate size and projection of the
If the patient desires a contralateral symmetry procedure, device, and the potential need for a revision to improve the
this is typically accomplished at the time of the exchange of the quality of the overall reconstruction. In general, use of a two-
tissue expander with the permanent implant (the second stage staged reconstruction with a tissue expander placed at the first
of breast reconstruction). Contralateral symmetry procedures stage, followed by a permanent implant at the second stage,
include augmentation mammoplasty, mastopexy, or reduc- maximizes the surgeon’s control. Whenever reconstruction in
tion mammoplasty. Performance of the symmetry procedure a single stage is performed with an implant, patients should be
at the second stage gives the surgeon maximum opportunity made aware that there may be a need for a revisionary proce-
to obtain symmetry with the normal breast (Figures 59.12 and dure to improve the overall result.11,12
A B
Breast
FIGURE 59.12. A. Unilateral right breast reconstruction with saline

implant and left mastopexy for symmetry. B,C. Oblique views.
C

632 Part VI: Breast
A B
FIGURE 59.13. A. Unilateral left breast reconstruction with ana-

tomic-shaped cohesive gel implant and right breast augmentation
with anatomic-shaped cohesive gel implant. B,C. oblique views.
C
Breast Reconstruction After disease was found in 5.2% of the nipples.13 In the same study,
after a nipple-sparing mastectomy and prosthetic reconstruc-
Nipple-Sparing Mastetomy tion, 3.5% of nipples were lost due to wound complications.
The goal of breast reconstruction is to create a natural appear- It is important to consider the incision placement for the
ing breast. An improved cosmetic result can be attained by mastectomy when planning a nipple-sparing mastectomy:
preserving the original nipple. Despite efforts to reconstruct periareolar, lateral, inframammary, omega type, or trans-
the nipple using various flaps, a reconstructed nipple cannot areolar. Our preferred incision is the periareolar with lateral
compete with the aesthetics of a normal nipple. Nipple-sparing extension. The lateral extension allows for lateral access to the
mastectomies, however, have raised questions about oncologic breast as well as to the axilla for either a sentinel node biopsy
safety even though the nipple–areola complex is an uncom- or axillary dissection. Multiple studies have shown increased
mon site for breast cancer development. In a retrospective patient satisfaction after preserving the original nipple.
review of 115 consecutive nipple-sparing mastectomies from However, proper patient selection is essential (Figures 59.17
Memorial Sloan Kettering Cancer Center (MSKCC), occult and 59.18).
A B
FIGURE 59.14. A. Unilateral right breast reconstruction with saline implant after nipple-areola reconstruction. The reconstructed inframam-
mary fold was intentionally lowered so that the lower pole of the reconstructed breast was symmetrical to the natural breast. B. Oblique views.

A B
FIGURE 59.15. A. Bilateral breast reconstruction with saline implants

after completion of nipple-areola reconstruction. B,C. Oblique views.
C
A B
Breast
FIGURE 59.16. A. A 6-year postoperative follow-up on bilateral breast

reconstruction with round silicone gel implants. B,C. Oblique views.
C

634 Part VI: Breast
FIGURE 59.17. Postoperative after exchange to bilateral anatomic- FIGURE 59.18. Bilateral two-stage breast reconstruction after
shaped cohesive gel implants. The patient had bilateral breast recon- nipple-sparing mastectomy with anatomic-shaped cohesive gel implants.
struction with acellular dermal matrix for tissue expander coverage
after a bilateral nipple-sparing mastectomy.
is in a complete submuscular location, thus having an inter-

face of normal healthy tissue between the device and the
area of skin necrosis. When the eschar resolves, the underly-
Postoperative Care ing tissue granulates and heals as a scar that can be revised
After placement of a tissue expander, or after exchange of an later. However, in the setting of larger areas of mastectomy
expander for a permanent implant, the patient is placed in a skin flap necrosis or questionable soft-tissue coverage of the
surgical bra, which helps to hold dressings in place and pro- implant, resection of necrotic skin with immediate wound clo-
vides a place for drains to be fastened. The use of oral antibi- sure is indicated. If a tissue expander that has been partially
otics after surgery is discretionary. The use of a conforming expanded is in place, fluid can be removed from the device,
breast binder to hold the implant position may be advanta- which might allow for tension-free closure of the remaining
geous. Patients are instructed to avoid the use of an underwire mastectomy skin flaps. If mastectomy skin flap closure is not
bra for several weeks after surgery and, depending on the type possible after resecting devitalized tissue, either the device can
of implant used, may be instructed to massage their implants. be removed and the skin subsequently closed, or a skin graft
Implant massage is usually reserved for patients with smooth can be applied, which later can be expanded along with the
implants rather than shaped, anatomic implants where mas- skin flaps and eventually resected to allow for closure.
sage may lead to implant malposition. Pain medication is pre- Late complications of prosthetic breast reconstruction
scribed as needed. include asymmetry, implant wrinkling, implant malposi-
tion, implant deflation, capsular contracture, and infection.
Infection is discussed above. In almost every case of unilateral
Complications breast reconstruction, and even in certain cases of bilateral
Complications specific to prosthetic breast reconstruction are breast reconstruction, some degree of asymmetry is expected.
similar to those associated with breast implant surgery in gen- The development of capsular contracture around a recon-
eral. Bleeding in the immediate postoperative period result- structed breast may lead to implant malposition, changes in
ing in hematoma warrants re-exploration. Hematomas under projection of the implant, and, occasionally, pain and discom-
the mastectomy skin flap and around the tissue expander or fort. All of these factors may lead to the patient’s desire for
permanent implant increase the risk of infection and predis- a revision.15 Implant wrinkling or ripple formation is a com-
pose to capsular contracture. Consequently, if a hematoma is mon sequela of breast reconstruction with implants. Unlike
recognized, it should be promptly evacuated. Infection of the the setting of an augmentation mammoplasty, where a breast
prosthetic device can occur early in the postsurgery period, or implant is covered by the skin, breast tissue, and often muscle,
late, occurring even years after the placement of the perma- the reconstructed breast is covered by the skin and muscle, or
nent implant. Infections typically present as cellulitis of the perhaps only the skin, subcutaneous tissue, and implant cap-
skin flaps over the implant. Occasionally, an abscess is identi- sule. Normal contour irregularities because of the compliance
fied. In a large series of tissue expanders placed at our insti- of the implant are transmitted through the skin and appear as
tution, the incidence of infection requiring expander removal a ripple on the reconstructed breast. As a consequence of grav-
was approximately 2%.8 Typically, if the patient presents with ity, these ripples tend to occur most commonly on the upper
cellulitis of the mastectomy skin flaps, a course of intravenous pole of the reconstruction, where they are most visible to the
antibiotics or, occasionally, oral antibiotics are initiated. If patient. Strategies to improve rippling include overfilling of
the cellulitis fails to resolve with antibiotic therapy, or a frank saline implants (although this will lead to a more firm-feeling
abscess develops, removal of the implant is indicated.14 In rare implant reconstruction) and the use of smooth wall devices.
circumstances, cellulitis of the skin flaps can be adequately Textured surface breast implants tend to be associated with
managed with antibiotics without implant removal. rippling more commonly than smooth surface devices. In the
Another early complication includes mastectomy skin flap current era of implant reconstruction and with current implant
necrosis. Factors such as the length of the mastectomy skin design, it is unknown whether the risk of capsular contracture
flap, the patient’s overall medical condition, the thickness of differs between smooth surface and textured surface implants.
the mastectomy skin flap, and whether or not the patient is However, the only types of devices that are available in the
a smoker can contribute to the development of mastectomy smooth surface are round devices either in a low, moderate,
skin flap necrosis. Superficial- or partial-thickness flap necro- or high profile.
sis is usually managed conservatively with local wound care. Fat grafting can be used to improve many of the contour
Occasionally, small areas of full-thickness necrosis can also be deformities that result from mastectomy and implant reconstruc-
managed with local wound care, particularly if the expander tion. Fat grafting is typically accomplished during the exchange

procedure and/or nipple areola reconstruction, but can be a sepa- the final pathology returns. If the tissue expander has been
rate procedure as well. The fat is injected in multiple different placed at the time of the mastectomy, then the protocol at
layers and feathered over the area that needs to be corrected. MSKCC includes expansion of the tissue expander during
Some authors have described the use of acellular dermal matrix chemotherapy, exchange of the tissue expander to the per-
to correct rippling as well as capsular contracture. manent implant as soon as possible after the conclusion of
the chemotherapy, and beginning radiation therapy several
weeks after the permanent implant is placed. In the setting
Impact of Radiation on where the surgeon and patient are aware that postoperative
Prosthetic Reconstruction radiation therapy will be required, a frank discussion must
be had regarding the increased complication rate associated
The indications and incidence of radiation therapy to the
with radiation and breast implants. A delayed reconstruction
chest wall after mastectomy have increased significantly in the
with autologous tissue, the use of autologous tissue primar-
past decade. As a result of studies demonstrating a reduction
ily, or the use of a prosthetic-based reconstruction must be
of local recurrence in certain subsets of patients with breast
considered.
cancer, radiation therapy is indicated after mastectomy for
patients with tumors that are ≥5 cm in maximum diameter,
four or more positive axillary lymph nodes, stage T3 or T4
References
disease, or positive margins. Additionally, the indications for 1. Spear SL, Majidian A. Immediate breast reconstruction in two stages using
textured, integrated-valve tissue expanders and breast implants: a retrospec-
radiotherapy seem to be expanding. Consequently, it is con- tive review of 171 consecutive breast reconstructions from 1989 to 1996.
troversial in plastic surgery as to whether or not to perform Plast Reconstr Surg. 1998;101(1):53-63.
immediate breast reconstruction in the setting of planned 2. Spear SL, Spittler CJ. Breast reconstruction with implants and expanders.
postoperative radiation therapy. Another controversial issue is Plast Reconstr Surg. 2001;107(1):177-187.
3. Losken A, Carlson GW, Bostwick J, et al. Trends in unilateral breast
management of the patient who has had a prior lumpectomy reconstruction and management of the contralateral breast: the Emory
and radiation therapy for breast cancer and now for either experience. Plast Reconstr Surg. 2002;110(1):89-97.
reasons of local recurrence or prophylaxis requires a salvage 4. McCarthy CM, Pusic AL, Sclafani L, et al. Breast cancer recurrence
mastectomy on the previously irradiated breast. Radiation following prosthetic, postmastectomy reconstruction: incidence, detection,
and treatment. Plast Reconstr Surg. February 2008;121(2):381-388.
therapy, whether it is delivered preoperatively or postopera- 5. Bacilious N, Cordeiro PG, Disa JJ, et al. Breast reconstruction using tissue
tively, complicates breast reconstruction. With respect to pre- expanders and implants in Hodgkin’s patients with prior mantle irradiation.
operative radiation therapy, placement of a tissue expander Plast Reconstr Surg. 2002;109(1):102-107.
at the time of the mastectomy may lead to failed expansion, 6. Preminger BA, McCarthy CM, Hu QY, Mehrara BJ, Disa JJ. The influ-
ence of Alloderm on expander dynamics and complications in the setting of
poor expansion with lack of projection, poor wound healing, immediate tissue expander/implant reconstruction: a matched-cohort study.
and an inability to achieve the desired result from this method Ann Plast Surg. May 2008;60(5):510-513.
of reconstruction. The rate of complications can be as high as 7. Antony AK, McCarthy CM, Cordeiro PG, et al. Acellular human dermis
60%.16 Careful patient selection is mandatory when attempt- implantation in 153 immediate two-stage tissue expander breast reconstruc-
tions: determining the incidence and significant predictors of complications.
ing to perform an expander-based reconstruction in a patient Plast Reconstr Surg. June 2010;125(6):1606-1614.
who has been irradiated. Ideally, the skin should show no evi- 8. Disa JJ, Ad-El DD, Cohen SM, et al. The premature removal of tissue expand-
dence of prior radiation therapy and there should be no fibro- ers in breast reconstruction. Plast Reconstr Surg. 1999;104(6):1662-1665.
sis within the pectoral muscle. A slow and careful expansion 9. Bengtson BP, Van Natta BW, Murphy DK, Slicton A, Maxwell GP. Style
410 U.S. Core Clinical Study Group. Style 410 highly cohesive silicone
should be performed and the patient and the surgeon should breast implant core study results at 3 years. Plast Reconstr Surg. December
be ready to convert to autologous tissue reconstruction if the 2007;120(7 Suppl 1):40S-48S.
expansion process fails. 10. Spear SL, Pelletiere CV. Immediate breast reconstruction in two stages
Another approach to the previously irradiated patient with the using textured, integrated-valve tissue expanders and breast implants. Plast
Breast
Reconstr Surg. 2004;113(7):2098-2103.
use of a tissue expander is immediate placement of a latissimus 11. Hunter-Smith DJ, Laurie SW. Breast reconstruction using permanent tissue
dorsi myocutaneous transposition flap over the expander. The expanders. Aust N Z J Surg. 1995;65(7):492-495.
latissimus flap will have not been previously irradiated and thus 12. Gui GP, Tan SM, Faliakou EC, et al. Immediate breast reconstruction using
is much more likely to expand without resistance. Additionally, biodimensional anatomical permanent expander implants: a prospective
analysis of outcome and patient satisfaction. Plast Reconstr Surg.
the autologous tissue provided by the latissimus flap will increase 2003;111(1):125-138.
the volume of skin for the breast reconstruction, thus enabling 13. Chen CM, Disa JJ, Sacchini V, et al. Nipple-sparing mastectomy and
the reconstruction to have more projection and ptosis. immediate tissue expander/implant breast reconstruction. Plast Reconstr
In patients who require postoperative radiation therapy, Surg. December 2009;124(6):1772-1780.
14. Nahabedian MY, Tsangaris T, Momen B, et al. Infectious complica-
radiating the permanent implant leads to a higher incidence tions following breast reconstruction with expanders and implants. Plast
of capsular contracture and need for revision. One study from Reconstr Surg. 2003;112(2):467-476.
MSKCC examined 81 irradiated patients. Sixty-eight percent 15. Spear SL, Baker JL Jr. Classification of capsular contracture after prosthetic
of the irradiated group had capsular contracture compared breast reconstruction. Plast Reconstr Surg. 1995;96(5):1119-1123.
16. Forman DL, Chiu J, Restifo RJ, et al. Breast reconstruction in previously
with 40% in the nonirradiated group.17 In another study, irradiated patients using tissue expanders and implants: a potentially unfa-
patient satisfaction was 70% with prosthetic reconstruction vorable result. Ann Plast Surg. 1998;40(4): 360-363.
after irradiation despite having a one grade higher capsular 17. Cordeiro PG, Pusic AL, Disa JJ, et al. Irradiation after immediate tis-
contracture on the irradiated breast compared with the non- sue expander/implant breast reconstruction: outcomes, complications,
aesthetic results, and satisfaction among 156 patients. Plast Reconstr Surg.
irradiated breast.18 On the other hand, a retrospective study 2004;113(3):877-881.
performed on 1,037 patients showed that the complication 18. McCarthy CM, Pusic AL, Disa JJ, McCormick BL, Montgomery LL,
rate increased from 21.2% to 45.4% with radiation. The most Cordeiro PG. Unilateral postoperative chest wall radiotherapy in bilateral
common radiation-related complications were implant extru- tissue expander/implant reconstruction patients: a prospective outcomes
analysis. Plast Reconstr Surg. November 2005;116(6):1642-1647.
sion and capsular contracture.19 19. Berry T, Brooks S, Sydow N, et al. Complication rates of radiation on tissue
In general, whether or not the patient needs postopera- expander and autologous tissue breast reconstruction. Ann Surg Oncol.
tive radiation therapy after mastectomy is not known until October 2010;17(Suppl 3):202-210.

Chapter 60 n Latissimus Dorsi Flap Breast
Reconstruction
Dennis C. Hammond and Michael A. Loffredo
Reconstruction with autologous tissue provides the patient

with a reconstructed breast created with her own tissues, Expander/Implant Choice
obviating the potential complications associated with a pros- Recent developments in expander and implant design
thesis. The disadvantage with this strategy is related to the have resulted in a wide array of devices available for use
creation of an additional donor site with scarring and poten- in reconstruction. Choosing between round and anatomi-
tial morbidity. Although reconstruction with tissue expand- cally shaped devices that are either textured or smooth
ers and implants eliminates the need for the additional donor and filled with either saline or silicone provides a variety
site, the potential complications associated with these devices of choices, which can be strategically exploited to solve
are a concern. The latissimus dorsi musculocutaneous flap individual reconstructive problems. For instance, a thin
(LDF) seems to offer no advantage as, most commonly, tissue patient with stark breast contours may be served best
expanders and implants are still required, and the additional by an anatomically shaped silicone gel textured implant.
donor site is created on the back. For this reason, the LDF By combining the volume-added latissimus flap with an
remains a distant third option for many reconstructive breast appropriately chosen expander or implant, excellent
surgeons. With the development of newer and more effective results are possible.
tissue expanders and implants, however, the advantages of
combining these devices with the well-vascularized LDF have
generated a resurgence of interest in the technique. This chap- Marking
ter focuses on the technical strategies for optimizing the use of
With the patient in the standing position, the borders of
the LDF with tissue expanders and implants.
the latissimus dorsi muscle are delineated. The midline of
the back is identified and the tip of the scapula is marked
Operative Strategy (Figure 60.1A). With the arm elevated, the anterior bor-
der of the muscle is drawn as it extends from the posterior
The LDF was originally described in 1906 by Iginio Tansini
border of the axilla downward toward the iliac crest. The
in Italy.1 It was used to reconstruct mastectomy wounds at
upper border of the muscle is drawn as it extends from the
the time, but soon fell from favor, to be rediscovered in the
axilla over the tip of the scapula to the midline of the back
late 1970s.2,3 Since its rediscovery, the flap has been used to
(Figure 60.1B). The origin of the muscle is marked inferi-
reconstruct nearly every part of the body, as both a pedicled
orly as it curves from the lower midline of the back to the
and a free flap. The LDF is a reliable and richly vascularized
anterior border of the muscle. The inferior segment of the
flap, and the proximity of the flap to the anterior chest wall
trapezius is drawn as it overlaps the upper medial border
makes it an ideal choice for providing the muscle, fat, and skin
of the latissimus as a reminder of this important anatomic
for use in reconstructing the breast after mastectomy. Sacrifice
relationship.
of the muscle creates a negligible functional deficit except in
Once the limits of the muscle have been identified, the
extremely athletic women.4–6 Transposition of the flap from
location and orientation of the skin island is identified. The
the back to the anterior chest wall provides a healthy layer of
skin island is positioned in the center of the muscle to ensure
soft tissue that can line the mastectomy defect, effectively soft-
equal soft-tissue coverage of the expander or implant in all
ening the edges of the wound and thus recreating the gentle
directions once the skin island is inset. When a small, circu-
curves of the normal female breast. By adding any one of the
lar skin island is required, as is commonly the case when a
numerous different styles of expanders and implants under
skin-sparing mastectomy strategy is used, the skin island is
the flap, the volume that is inherently lacking in the flap can
positioned directly in the center of the flap. The relaxed skin
be provided to restore the breast to its natural size and con-
tension line is identified as it passes through the center of
tour.7-10 Using this as a basic strategy, there are several vari-
the skin island, and this line guides the drawing of a gentle
ables both in flap design and elevation, as well as in expander
ellipse around the skin island (Figure 60.1C). By tapering
and implant choice, which can be manipulated to maximize
off around the skin island medially and laterally, adequate
the aesthetic quality of the result, while minimizing the donor-
exposure for flap dissection is provided, while allowing for
site morbidity and potential complications.
direct closure of the skin defect without dog-ear formation
at the medial or lateral ends of the incision. In this patient,
Flap Elevation the skin island also includes the addition of an immediate
Historically, use of the LDF has involved transposing only nipple–areola reconstruction using a skate flap purse-string
the muscle to the mastectomy defect with an isolated island technique (Figure 60.1D).11 Alternatively, the skin island
of skin and fat of varying size positioned on top of the muscle. can be left intact to reconstruct the nipple–areola at the sec-
Although this can effectively provide cutaneous cover for the ond stage.
breast, a more effective technique for providing volume is to When a larger skin island is required, as in cases
harvest the deep layer of subcutaneous fat with the muscle of delayed breast reconstruction, the same strategy is
beyond the skin island. The deep thoracic fascia provides a employed, attempting to place the elliptical skin island
readily recognizable anatomic landmark that guides dissection more or less in the center of the flap and orienting the long
and even allows the deep fatty layer below the fascia to be axis of the ellipse along the same relaxed skin tension line.
harvested beyond the borders of the muscle. By increasing the The advantage of orienting the long axis of the skin paddle
overall volume of the flap and creating a volume-added latis- in this fashion is that, despite the scar sweeping up to the
simus flap, the ability to fill in and soften the margins of the upper back, it heals in an acceptable fashion. This is in con-
mastectomy defect is enhanced. tradistinction to other scar orientations, which can be quite
636
Chapter 60: Latissimus Dorsi Flap Breast Reconstruction 637
A B
C D
FIGURE 60.1. Preoperative markings. A. The midline of the back is

marked along with the tip of the scapula. B. With the arm raised, the
sweep of the superior border of the latissimus muscle can be drawn
in as it courses over the tip of the scapula to the midline of the back.
The anterior border of the muscle is identified and marked as it runs
inferiorly from the posterior border of the axilla to the iliac crest.
C. The center of the muscle is identified and the relaxed skin ten-
Breast
sion line, which passes through this point, is drawn. This line gener-
ally sweeps from superomedial and curves anteriorly across the back
toward the abdomen. Placing the incision for the skin island in this line
results in the least visible postoperative scar. D. A gentle ellipse is drawn
around the circular skin island, tapering off medially and laterally so as
to provide a smooth postoperative scar. E. On the lateral view, the zone
of adherence marked by the X’s should be respected and these tissues
should not be elevated during flap transfer. Instead, the flap is optimally
passed through a tunnel created high in the axilla and dropped into the
mastectomy defect. This preserves the lateral breast contour, which is a
E landmark that can be difficult to create with internal sutures.
unsightly as the orientation of the skin island crosses the

relaxed skin tension lines of the back, resulting in widened Operative Technique
or hypertrophic scars.
Once the skin island is marked and the limits of the Stage 1
muscle identified, the zone of attachment between the After the mastectomy is completed, the viability of the skin
upper anterior border of the muscle and the lateral bor- flaps is assessed. If there is a question of mastectomy flap
der of the breast is marked. If at all possible, avoid dis- ischemia, fluorescein is infused to assess vascular perfu-
section in this area as this preserves the lateral border of sion. Debridement of all nonperfused areas is performed. It
the breast. This contour can be difficult to reconstruct is helpful at this point to predissect the high axillary tunnel
with suture plication if it is released during either the through the mastectomy defect in preparation for subsequent
mastectomy or in making the tunnel for passage of the flap transfer. This space is then easily entered during flap dis-
LDF. Finally, the tunnel through which the flap is to be section on the back, facilitating subsequent transposition of
passed anteriorly is drawn high in the axilla. This serves the flap once it is completely released, preventing inadver-
to preserve the lateral contour of the breast and limits any tent overdissection of the lateral chest wall during creation
potential lateral chest wall fullness or deformity that can of the tunnel.
occur as a result of overzealous tissue release in this area At this point, the wound is temporarily stapled closed and
(Figure 60.1E). covered with a sterile dressing. The patient is rotated into the

638 Part VI: Breast
prone position for both unilateral and bilateral reconstruc- enlarge the muscular soft-tissue envelope, allowing the now
tions. In the prone position, the anatomic landmarks are more upwardly retracted pectoralis muscle to cover the upper por-
easily identified than in the lateral decubitus position. tion of the defect, and using the LDF to cover the lower por-
The skin island is incised and the thoracic fascia is divided tion. Centrally, where these two muscles meet, the edges are
along the line of incision. With division of the fascia, the simply sutured together in a vest-over-pants fashion, with the
wound springs open as the loose, deep, fatty layer is exposed. latissimus secured on top of the pectoralis major. Whatever
Dissection then proceeds just under the fascia in all directions, strategy is used, it is important to close off the tunnel leading
keeping the deep layer of fat attached to the muscle. Once the to the back donor site to an opening of only 2 to 3 cm to pre-
limits of the muscle are reached, dissection proceeds through vent inadvertent slippage of the expander through the axilla
the deep layer of fat down to the margins of the latissimus into the back postoperatively.
muscle in all directions. The trapezius muscle is identified in At this point, the dimensions of the skin island are finalized
the upper medial corner of the dissection space and the latissi- and inset, discarding redundant skin as needed. In cases of
mus is released from under it. The upper border of the latissi- immediate reconstruction, often only a circular skin island is
mus muscle is then identified and released. The fibers of origin required to fit into the defect created by removal of the nipple
are then peeled away from the fascia of the back, extending and areola. In cases of immediate nipple–areola reconstruc-
from the upper medial corner of the dissection space toward tion, the skate flap purse-string technique is utilized prior to
the iliac crest. As the muscle is undermined, crossing perfora- suturing the skin island into place (Figure 60.2). In delayed
tors from the intercostal spaces are controlled. Inferiorly, the reconstruction, an ellipse is generally used to fill in the cutane-
muscle is divided from its attachments to the iliac crest. The ous defect created at the time of mastectomy. This ellipse of
muscle is released from its attachments to the serratus anterior skin can be positioned in one of two ways. Perhaps the most
and the anterior border is identified and released, care being straightforward inset strategy involves opening the mastec-
taken to avoid inadvertent elevation of the fibers of origin of tomy wound along the scar line and insetting the flap directly
the external oblique in the anterior-inferior corner of the dis- into the resulting wound. In this manner, no new scars are
section. The muscle is then elevated toward the axilla and any created on the breast, and the vascularity of the mastectomy
remaining attachments to the teres major muscle are divided. flaps is not compromised. In thin patients, or in patients with
Communication with the mastectomy wound is then made mastectomy scars positioned low on the chest, it is possible
high in the axilla and the muscle is passed anteriorly to the to resect nearly the entire lower mastectomy flap and replace
mastectomy defect. The pedicle is easily identified entering the it with the LDF skin island, placing the lower scar directly
underside of the muscle and care is taken to avoid tethering or in the inframammary fold. However, in patients with larger
injuring the vascular leash. With full release of the muscular breasts or high-riding mastectomy scars, not all of the lower
attachments, there is no need to divide the serratus branch, mastectomy flap can be removed, and the LDF skin island will
which can become important, as this vascular conduit can create an obvious patch effect once it is inset into the recon-
support the flap entirely if the main thoracodorsal pedicle was structed breast. To prevent this, many surgeons will ignore the
injured during the original mastectomy.12 previous mastectomy scar and open the mastectomy wound
The back wound is then closed over suction drainage. The by making an incision low and lateral along the proposed
placement of quilting sutures securing the upper and lower inframammary fold. Once the LDF skin island is then inset,
back flaps to the intercostal muscles may assist in preventing the lower scar will be hidden in the fold, and the shape of the
or limiting persistent postoperative drainage from the back ellipse will assist in creating a rounded ptotic appearance to
donor site.13 The patient is rotated back into the supine posi- the reconstructed breast. This approach can risk compromise
tion. The flap is fully withdrawn into the mastectomy wound of the vascularity of the remaining lower mastectomy flap as a
and the insertion of the muscle identified. I prefer to divide result of the crisscrossing scars; for this reason, some surgeons
this insertion completely, just above the entry point of the vas- will keep the remaining upper mastectomy flap attached to
cular pedicle, as this facilitates easy rotation of the LDF in any the pectoralis major muscle, positioning the expander under
direction required, depending on the dimensions of the mas- the muscle. The disadvantage is that the breast may have
tectomy defect. Alternatively, it is a reasonable compromise unwanted motion postoperatively because of the subpectoral
to divide the posterior 90% of the insertion, as the remaining placement.
attachments protect against inadvertent traction being placed After positioning the expander and insetting the flap and
on the pedicle, and yet full transfer of the flap into the mastec- the skin island, the skin incisions are closed over suction
tomy defect is greatly facilitated. drains. It should be noted that in cases where adjustment of
The vascular pedicle is readily identified. I prefer to divide the opposite breast is planned, that procedure (whether it is
the thoracodorsal nerve at this point. With division of the breast augmentation, reduction, or mastopexy) is performed
nerve, unwanted and distracting motion in the reconstructed at this initial stage. In this fashion, the breast is allowed to set-
breast is greatly diminished or eliminated, a finding that has tle until the stage 2 procedure is performed, which enhances
been a welcome addition to my results over the years. Such the accuracy of the second procedure, as the reconstructed
denervation has not resulted in enough volume loss in the breast is matched to a stable opposite breast size and shape.
flap to significantly detract from the aesthetic result of the Postoperative recovery is generally uneventful, with most
reconstruction. patients leaving the hospital within 2 to 3 days. Early motion
The flap is now prepared for insetting. In small- to of the arms and shoulders is encouraged to prevent stiffness.
medium-sized breasts, there is no need to elevate the pecto- Expander inflation is performed in the office setting as needed
ralis major muscle. The edges of the LDF are simply sutured to achieve the desired final volume, beginning as early as
into the medial, superior, and lateral margins of the mastec- 2 weeks postoperatively. Often only one or two expansions
tomy defect, and the tissue expander is placed under the flap. are necessary because of the adequacy of the dimensions of
The remaining edge of the LDF is then inset into the inferior the skin surface area created by adding the latissimus skin
margin of the mastectomy wound around the inferior border island. For this reason, it is also not necessary to overinflate
of the expander, providing complete muscle coverage for the the expander to a significant degree in most cases.
device.
In larger breasts, the surface area provided by the LDF may
not be enough to provide sufficient padding for the entire sur- Stage 2
face area of the mastectomy defect without tethering, and the After the recovery from the first stage is complete and all
skin envelope of the breast may not be sufficiently filled out. swelling has resolved, the final shaping of the breast is per-
In these cases, full release of the pectoralis major muscle can formed, usually 4 to 6 months later. The procedure is

A B
C D
Breast
FIGURE 60.2. Flap inset and immediate nipple–areola reconstruc-
tion. A. The flap has been passed anteriorly through the axilla and
the tissue expander positioned centrally within the mastectomy defect.
B. The muscle is then wrapped around the expander, suturing the
edges of the muscle into the margins of the mastectomy defect. This
maneuver softens the contours of the mastectomy wound, improv-
ing the overall quality of the reconstructive result. C. Full-thickness
incisions are made around the areolar hemiflaps and the skate flap.
The skate flap is then elevated and assembled keeping a uniform
thickness of fat on the underside of the flap. D. The two areolar hemi-
flaps are then sutured together and the entire nipple–areola construct
is then sutured into the defect using a periareolar purse-string suture.
E. After inset of the skin island in this case of a bilateral reconstruc-
tion performed in conjunction with a periareolar skin-sparing mas-
tectomy, an aesthetic result has been created, even at this early stage,
with the tissue expanders in place.
E
generally performed in the outpatient setting. At this stage, of several different techniques. It bears noting that, because
the tissue expander is removed, the breast is reshaped as the back dermis is quite thick, the appearance and longevity of
needed, and the nipple and areola are reconstructed if not per- nipples made with latissimus flap skin tend to be excellent. In
formed during the first stage. In cases of immediate nipple– selected cases, further modification of the reconstructed breast
areola reconstruction, this second-stage procedure can serve may be required to obtain the optimal result. These modifica-
as an opportunity to make any minor revisions as necessary tions may include contour reconfiguration with elevation or
to improve upon the previously reconstructed nipple and lowering of the inframammary fold, widening of the pocket,
areola. Additional adjustments to the opposite breast can or capsulectomy with removal of scar. Breast implant dimen-
also be made as needed. Under the best of circumstances, all sions, volume, and shape are chosen to give the best possible
that will be required to complete the reconstruction will be result. Liposuction of the lateral chest wall is occasionally
to remove the tissue expander, replacing it with a permanent required to treat excess fullness in this area. Using this staged
implant, and reconstruction of the nipple and areola using one approach, excellent results can be obtained in most cases.

640 Part VI: Breast
reconstruction, the bilateral latissimus flap option is an excel-

Expander Versus Implant lent choice. The LDF is also a useful flap for reconstruction
Many surgeons insert the primary implant at the same time of the partial mastectomy defect or for autogenous salvage
the latissimus flap is inset. This is an attractive option, as in cases of significant fat necrosis after TRAM flap recon-
the need for a second separate procedure to remove the tis- struction. At times, in patients with relatively small opposite
sue expander is avoided. It can be accomplished, particu- breasts, it can be used as a completely autogenous flap, obvi-
larly in cases of immediate breast reconstruction, because ating any need for an implant. In these latter circumstances,
generally there is no loss of skin envelope surface area to the “volume-added” strategy becomes a particularly attractive
the breast. Consequently, there is no need to “expand” the option for increasing the available soft-tissue bulk provided
skin. Despite this, I prefer to use a tissue expander during by the flap.
the stage 1 procedure. When true expansion is not required,
I consider the expander to be an intelligently chosen spacer, Complications
holding the soft-tissue envelope of the reconstructed breast
open while the soft tissues heal around it. This strategy The most recognized complication of latissimus flap harvest
facilitates more accurate implant selection at the stage 2 is donor-site seroma formation. It is not uncommon for the
procedure, allowing changes in implant base diameter, pro- drain to remain in the back donor site for as long as 6 weeks
jection, volume, and shape to be made based on how the postoperatively. Occasionally, outpatient aspiration of a per-
breast has recovered from the stage 1 procedure. As well, sistent seroma is required after drain removal. With time, fluid
a strategy for manipulation of the soft-tissue pocket at accumulation eventually stops, leaving behind an empty bursa
stage 2 is built into the operative plan, which only enhances of varying dimensions. Although isolated arm strength can
the ultimate result. be diminished after flap transfer, this is rarely a significant
finding, as the other muscles of the back compensate for the
absent muscle. The vascularity of the LDF itself is robust, and
Results only rarely is there any vascular compromise or fat necrosis
The LDF is an excellent option for almost any reconstructive noted after LDF transfer. However, marginal skin necrosis at
situation. It can be used with ease in cases of immediate or the donor site can occur particularly in smokers, which might
delayed reconstruction (Figure 60.3). It is a particularly attrac- suggest avoiding excessive undermining. After transfer of the
tive option for patients who require bilateral reconstruction flap with placement of a tissue expander or implant, capsular
(Figure 60.4). In patients who may not have enough volume contracture can occur. Treatment generally consists of com-
for a bilateral transverse rectus abdominis musculocutaneous plete capsulectomy, which alleviates the problem in the vast
(TRAM) flap and who want more of an expander/implant majority of cases.
A B
C D
FIGURE 60.3. Unilateral reconstruction. A, B. Preoperative appearance of a 54-year-old woman scheduled to undergo a left-sided modified radi-
cal mastectomy for adenocarcinoma of the breast. C, D. One-year postoperative appearance after eventual placement of a 400-cc smooth, round,
silicone gel implant on the left, and an augmentation of the right breast with a 375-cc smooth, round, silicone gel implant. The reconstructed
nipple and areola have been tattooed.

A B
C D
Breast
E F
FIGURE 60.4. A. Preoperative appearance of a 59-year-old woman

with lobular carcinoma in situ of the left breast. She had undergone
subcutaneous mastectomy with implant reconstruction in the remote
past. B. The preoperative marks outline a periareolar skin-sparing
mastectomy that includes a lateral extension for better access to the
breast. C. The back marks outline the circular skin island used to
replace the missing nipple and areola. The position of the ellipse is
oriented along the relaxed skin tension lines. D. Appearance 6 months
after her stage 1 procedure reveals good symmetry and a pleasing
overall aesthetic result. E. The preoperative marks for her stage 2 pro-
cedure outline her bilateral nipple and areola complex reconstruction
along with soft-tissue recontouring in the upper outer quadrant of the
breast. The tissue expanders will be replaced with silicone gel implants
at a second stage. F. Appearance 1 year after placement of a 600-cc
smooth, round, silicone gel implant on the right, and a 500-cc implant
on the left. G. Appearance of the back reveals no contour deformity
and a well-healed scar with no distortion or bunching.
G

642 Part VI: Breast
5. Russell RC, Pribaz J, Zook EG, et al. Functional evaluation of latissimus
Conclusion dorsi donor site. Plast Reconstr Surg. 1986;78:336.
6. Fraulin FOG, Louie G, Zorrilla L, et al. Functional evaluation of the shoulder
The LDF provides a readily available and reliable block of following latissimus dorsi muscle transfer. Ann Plast Surg. 1995;35:349.
tissue that can be used in breast reconstruction. Because it 7. Luce PA, Hammond DC. Latissimus dorsi musculocutaneous flaps and
dramatically enhances the ability of the plastic surgeon to artis- tissue expanders/implants in immediate breast reconstruction. Plast Surg
Forum. 1995;64:133.
tically reconstruct the contours of the breast in a wide variety 8. Fisher J, Hammond DC. The combination of expanders with autogenous
of clinical settings, it is recommended as an essential technique tissue in breast reconstruction. Clin Plast Surg. 1994;21:309.
in the armamentarium of the reconstructive breast surgeon. 9. Hammond DC. Postmastectomy reconstruction of the breast using the
latissimus dorsi musculocutaneous flap. Cancer J. 2008;14:248.
References 10. Hammond DC. Latissimus dorsi flap breast reconstruction. Plast Reconstr
Surg. 2009;124:1055.
1. Maxwell GP. Iginio Tansini and the origin of the latissimus dorsi 11. Hammond DC, Khuthaila D, Kim J. The skate flap purse-string technique for
musculocutaneous flap. Plast Reconstr Surg. 1980;65:686. nipple-areola complex reconstruction. Plast Reconstr Surg. 2007;120:399.
2. Olivari N. The latissimus flap. Br J Plast Surg. 1976;29:126. 12. Fisher J, Bostwick J III, Powell RW. Latissimus dorsi blood supply after
3. Schneider WJ, Hill HL, Brown RG. Latissimus dorsi myocutaneous flap for thoracodorsal vessel division: the serratus collateral. Plast Reconstr Surg.
breast reconstruction. Br J Plast Surg. 1977;30:277. 1983;72:502.
4. Laitung JKG, Peck F. Shoulder function following the loss of the latissimus 13. Rios J, Adams WP, Pollock T. Progressive tension sutures to decrease
dorsi muscle. Br J Plast Surg. 1985;38:375. latissimus donor site seroma. Plast Reconstr Surg. 2003;112:1779.

Tram Flap Techniques
James D. Namnoum
(Chapter 59) (Figure 61.2). This potential improvement in

Introduction softness and symmetry comes at the expense of a longer oper-
The transverse rectus abdominis myocutaneous (TRAM) ative time and hospital stay, and an abdominal donor site that
flap was introduced more than 30 years ago for breast can result in abdominal weakness, bulge, or hernia. Often the
reconstruction. Initially described by Holmstrom as a free resultant abdominal scar is positioned higher than would be
flap, it was later popularized by Hartrampf, who indepen- considered aesthetically ideal and is a potential drawback to
dently conceived of its use as an abdominal island flap for the procedure that should be discussed with the patient preop-
breast reconstruction.1,2 Drawing on the work of Esser, eratively (Figure 61.3). Many patients are erroneously led to
Hartrampf theorized that the lower abdominal skin and fat believe that the TRAM flap is synonymous with an aesthetic
could be transferred to the chest to create a breast mound abdominoplasty. While both may enhance the appearance of
based on circulation provided from the rectus abdominis the lower abdomen, they are in fact quite different procedures.
muscle.3 The successful outcome in a patient with a history The differences should be clearly explained to the patients pre-
of implant failure following radical mastectomy ushered in a operatively to avoid unrealistic expectations.
new era of breast reconstruction. The TRAM flap is unpar- While there are few absolute indications for one type of flap
alleled in its ability to provide a large volume of skin and fat over others, several relative indications merit consideration.
for breast reconstruction. It is especially valuable in patients Selection of one technique over the other as a general rule takes
presenting for delayed reconstruction following mastectomy into account the comfort level of the surgeon with the various
with post-mastectomy radiation. In these cases, the require- techniques. For the surgeon who infrequently performs micro-
ments for symmetry with the opposite breast often depend vascular surgery, the free TRAM or DIEP flap is best avoided.
on extensive amounts of skin replacement as well as volume Patients in high-risk categories such as those with a history of
(Figure 61.1). heavy cigarette use (greater than 10 pack/years smoking) and
those who are overweight or obese are more suitable for free
rather than pedicled TRAM reconstruction owing to improved
Types of Lower Abdominal flap perfusion and reduced rectus muscle sacrifice.8 This is
(TRAM) Flaps particularly true for those undergoing bilateral reconstruc-
tion. In contrast, patients without significant comorbidity,
Lower abdominal flaps can be grouped into two main cat- elevated BMI, or heavy smoking history show no difference
egories, pedicled TRAM and free flaps. The pedicled TRAM in incidence of flap or abdominal complications whether one
relies on perfusion from the superior epigastric system arbo- (unipedicle) or two (bilateral single pedicle or double pedicle)
rizing within the rectus muscle to provide perfusion to the pedicles are used, or whether a free TRAM flap is performed.9
lower abdominal tissues. In contrast, lower abdominal free Nahabedian has suggested an excellent algorithm for deci-
flaps make use of the deep inferior epigastric system (free sion making regarding DIEP versus free TRAM selection. For
Breast
TRAM, MS-0, MS-1, MS-2; DIEP [deep inferior epigastric patients requiring flaps less than 750 cc in volume in which a
perforator], MS-3) or superficial inferior epigastric system perforator of at least 1.5 mm can be identified, a DIEP flap
(SIEA [superficial inferior epigastric artery] flap, MS-4); can be safely selected; patients requiring larger flaps or having
these systems are generally the dominant blood supply to the inadequate perforators (less than 1.5 mm perforators) are bet-
lower abdominal skin and fat (Chapter 62). With regard to ter candidates for muscle-sparing free TRAM flaps.
muscle sacrifice and potential for donor-site weakness, bulge,
or hernia following free flap harvest, MS-0 flaps make use
of the entire rectus muscle while muscle-sparing MS-1 and Pedicled Tram
MS-2 flaps sacrifice decreasing amounts of rectus muscle. The pedicled TRAM is still the preferred technique for breast
MS-3 (DIEP) sacrifices no muscle but involves dissection reconstruction by most surgeons who perform the TRAM
and concomitant injury of a portion of rectus muscle and flap. However, microvascular procedures, particularly the
its intercostal innervation. MS-4 (SIEA) requires no muscu- DIEP flap, have gained significant popularity over the past
lar dissection or sacrifice. Not surprisingly, reduced mus- 10 years.10 Advocates for the pedicled TRAM cite its reliabil-
cular dissection and sacrifice is associated with decreased ity, predictable blood supply, ease and speed of harvest, safety
abdominal wall complications and improved abdominal wall in appropriately selected patients, and avoidance of a require-
strength.4-6 However, flap-related complications are higher in ment for microvascular skills and instrumentation. The relative
DIEP patients as opposed to non–muscle-sparing free TRAM simplicity of flap harvest may afford more time for insetting
patients (MS-0) owing to the reduced number of perforators and shaping, leading to superior aesthetic outcomes. The pop-
supplying the tissues.7 ularity of skin-sparing mastectomies has made this task con-
siderably easier. TRAM flap procedures are somewhat more
complex than the other options for breast reconstruction. As
Indications with other complex procedures, declining reimbursement has
The pedicled TRAM, free TRAM, and DIEP procedures may likely played a role in the popularity of simpler procedures for
be indicated for patients who desire immediate or delayed breast reconstruction such as expander/ implant reconstruc-
breast reconstruction and are ideal for matching a ptotic tion. It is interesting to note, though, that many surgeons who
opposite breast. Breast reconstruction utilizing tissues of prefer autologous reconstruction are increasingly opting for
the lower abdomen generally permits a softer, more natu- more technically sophisticated procedures such as the DIEP
ral reconstruction and tends to age in a similar fashion with flap for their patients. An analysis of the reasons behind this
the opposite breast as contrasted with device reconstructions change is of great interest but beyond the scope of this chapter.
643
644 Part VI: Breast
Figure 61.1. Preoperative and postoperative appearance of a 44-year-old woman who underwent delayed breast reconstruction after radiation
with TRAM flaps and Tissue expanders. At a second stage the expanders were exchanged for permanent breast implants and fat grafting
was performed. Under certain circumstances one needs large amounts of skin in conjunction with breast implants to achieve an aesthetically
pleasing result.

Chapter 61: Breast Reconstruction: Tram Flap Techniques 645
FIGURE 61.3. A 34-year-old following muscle-sparing free TRAM

reconstruction of left breast. Abdominal scar somewhat higher than
ideal from an aesthetic perspective although breast symmetry is achieved.
Breast
or hernia as a result. The pedicled TRAM can be based on an
FIGURE 61.2. Muscle-sparing free TRAM reconstruction in the right
breast of a 54-year-old with ptotic opposite breast. A. Preoparative
ipsilateral (relative to mastectomy) or contralateral pedicle; an
appearance. B. Postoperative appearance. The large volume of soft ipsilateral pedicle is chosen most often due to reduced bulk in
tissue permits symmetrical reconstruction in a patient who refuses the epigastrium. Flap orientation, either vertical or horizontal,
balancing of the opposite breast. is at the discretion of the surgeon. Adherence to Hartrampf’s
criteria for flap selection is associated with a low incidence of
fat necrosis and partial and total flap loss; abdominal bulge
and hernia are rarely encountered with the muscle-sparing
Technical Details (Figure 61.4) technique in normal-risk patients.13
The pedicled TRAM is based on the superior epigastric
vessels. A split muscle technique is used for flap harvest.
Controversy exists whether a whole muscle approach is supe-
Free Tram
rior, as the muscle-sparing approach may exclude some of the The free TRAM represents an evolution of technique from the
normal connections between the superior and inferior epigas- pedicle TRAM. First described by Holmstrom and later popu-
tric systems potentially affecting flap perfusion.11 This reduces larized by Grotting and others,14-16 it has undergone further
the incidence of abdominal contour deformities and permits refinement as surgeons have sought to optimize flap viabil-
a more secure immediate abdominal closure.12 Mesh is used ity while minimizing donor-site morbidity. This has led to
as an onlay only after the best possible primary fascial clo- the popularity of highly muscle-sparing free flaps such as the
sure. The indications for mesh include excessive tension on MS-1/MS-2 free TRAM and the DIEP (MS-3).17,18 Advocates
the repair and fascia that tears at closure or appears thin and for the free TRAM in its various degrees of muscle sparing
weak. Mesh is rarely required following single-pedicle TRAM cite its advantages of reduced abdominal dissection, muscle
flaps but is required more frequently in patients undergoing sacrifice and attendant weakness, enhanced flap vascularity,
bilateral or double-pedicle TRAM flaps. A continuous nonab- ease of flap inset, and avoidance of disturbance of the infra-
sorbable suture is used for the fascial repair. Care is taken to mammary fold. Patients undergoing free TRAM appear to
ensure that the internal oblique fascia is included in the repair. have less immediate postoperative pain and a quicker initial
This is especially important in the lower abdomen where it abdominal recovery (Chapter 62).
may retract underneath the external oblique fascia and be In contrast to the pedicled TRAM, patients with elevated
inadvertently excluded, with postoperative abdominal bulging BMI or history of heavy tobacco use undergoing free TRAM

646 Part VI: Breast
FIGURE 61.4. Pedicle TRAM flap technique—muscle-sparing flap is harvested preserving medial and lateral rectus muscle. Circulation is based
on superior epigastric vessels. Flap is tunneled to mastectomy defect. Fascia closed with a running nonabsorbable suture. Inset completed at
mastectomy defect.
did not differ in the incidence of flap or abdominal com-

plications, such as total flap loss, fat necrosis, hernia, and
bulge. Thus, the free TRAM is more appropriate for use in
these high-risk patients. Patients in high-risk categories are at
risk for abdominal or mastectomy skin loss, umbilical loss,
seroma, and infection, indicating that TRAM flap surgery in
general is not without increased morbidity in these patient
populations regardless of the technique utilized.19,20 Besides
requiring microvascular skills and longer operative times,
the main disadvantage of the free TRAM is the significantly
higher incidence of total flap failure when compared with
pedicle TRAM, where it is virtually nonexistent. Decision
making when selecting a technique should therefore take into
consideration a surgeon’s personal success rate with the free
flap breast reconstruction before committing a patient to a
procedure with a potentially higher rate of failure.
Technical Details (Figure 61.5)

A small segment of muscle and fascia from the lower abdo-
men is utilized for the harvest of the free TRAM flap, simpli-
fying the abdominal closure. In contrast, the DIEP flap spares
both the fascia and muscle though the dissection causes both
intramuscular scarring and denervation. The flap is based
on deep inferior epigastric vessels. The thoracodorsal ves-
sels or internal mammary vessels may be used as recipients,
depending on the ease of harvest. As more surgeons shift from
formal axillary dissections to sentinel node biopsies or lim-
ited axillary dissections, the internal mammary vessels have
gained in popularity. Use of these vessels permits more central
positioning of the flap, avoids the need for an axillary exten- FIGURE 61.5. Free TRAM flap technique—muscle-sparing flap
removes small central segment of rectus muscle and fascia from lower
sion of the skin-sparing incision, and avoids disturbance of
abdomen. Circulation is based on inferior epigastric vessels. Flap is
the axilla. This is balanced against the potential disadvantage transferred to the chest. Microvascular anastomoses are completed
of sacrificing the left internal mammary artery, which may end to end to the thoracodorsal or internal mammary vessels. Fascia
later be necessary for coronary artery revascularization. The is closed with running nonabsorbable suture. Flap is inset at the
increased flap vascularity permits a more flexible approach mastectomy defect.
to shaping.

Chapter 61: Breast Reconstruction: Tram Flap Techniques 647
technique but are seen from time to time whether a free or
Aesthetics pedicle technique is utilized.
Both the pedicled and free TRAM techniques can be used to Selection of a mastectomy skin pattern may generally be
create an attractive breast mound (Figure 61.6). Disturbance made without regard for the type of flap utilized. For free
of the inframammary fold due to tunneling may give the free flap reconstruction, a skin-sparing pattern requires use of the
flap technique an advantage in the short term. In most cases, internal mammary vessels as recipients unless a short axillary
the crease disturbance settles down after several months. As extension or vertical incision is added. For surgeons prefer-
long as all the intercostal nerves to the rectus muscle have ring the pedicled TRAM, the skin-sparing incision offers a
been divided, the muscle around the pedicle atrophies and great opportunity for near anatomic breast reconstruction.
does not distort the inframammary fold. Abdominal contour Reduction patterns for mastectomy are plagued by problems
disturbances may be minimized by the use of a muscle-sparing with mastectomy skin flap compromise particularly when
Breast
FIGURE 61.6. A 39-year-old 2 years following muscle-sparing free TRAM flap, right, and left breast reduction for balancing.

648 Part VI: Breast
coupled with pedicled TRAMs and may be best reserved for References
patients undergoing free TRAM reconstruction where tunnel-
ing is not required. In such instances, use of a vertical skin pat- 1. Holmstrom H. The free abdominoplasty flap and its use in breast recon-
struction: an experimental study and clinical case report. Scand J Plast
tern may reduce the risk of mastectomy skin loss; a transverse Reconstr Surg.1979;13:423.
incision may be added at the second stage of reconstruction 2. Hartrampf CR, Scheflan M, Black P. Breast reconstruction with a transverse
if needed. Intraoperative imaging with conventional fluores- abdominal island flap. Plast Reconstr Surg. 1982;96:216.
cein or laser-assisted indocyanine green fluorescent dye can 3. Esser JFS. Island flaps. N Y Med J. August 1917;264.
4. Nahabedian MY, Momen B, Galdino G, et al. Breast reconstruction with
help determine compromise of mastectomy skin flaps but may the free TRAM or DIEP flap: patient selection, choice of flap, and outcome.
overcall flap ischemia and lead to excessive debridement. Plast Reconstr Surg. 2002;110(2):466-475.
5. Selber JC, Nelson J, Fosnot J, et al. A prospective study comparing the
functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on
Donor-Site Morbidity the abdominal wall: part I. Unilateral reconstruction. Plast Reconstr Surg.
2010;126(4):1142-1153.
Donor-site issues such as abdominal bulge and hernia, weak- 6. Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing the
ness, and interference with activities of daily living have been functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on
debated over the decades since the introduction of the TRAM. the abdominal wall: part II bilateral reconstruction. Plast Reconstr Surg.
2010;126(5):1438-1453.
This debate continues today. There is a direct relationship 7. Man LX, Selber JC, Serletti JM. Abdominal wall following free TRAM or
between increased muscle sacrifice and improved flap perfu- DIEP flap reconstruction: a meta-analysis and critical review. Plast Reconstr
sion in pedicle and free flaps owing to the inclusion of addi- Surg. 2009;124(3):752-764.
tional perforators. On the other hand, in a comparison of free 8. Serletti JM. Breast reconstruction with the TRAM flap: pedicled and free.
Journal of. 2006;94:532-537.
TRAM and DIEP flaps, additional muscle sacrifice is associ- 9. Namnoum JD. An analysis of 920 pedicled and 286 free TRAM flap breast
ated with increased abdominal bulge, hernia, and diminished reconstructions. Presented at the Annual Meeting of the American Society
functional strength.5 The ability to perform sit-ups postopera- of Plastic Surgery, Orlando, Florida; November 2001.
tively is dependent on the amount of muscle harvested and is 10. Report of the 2010 Plastic Surgery Statistics: 2010 Reconstructive Breast
Procedures. American Society of Plastic Surgeons.
more likely to be preserved in patients undergoing free TRAM 11. Moon HK, Taylor GI. The vascular anatomy of rectus abdominis musculo-
compared with pedicled TRAM. Despite this finding, pedicled cutaneous flaps based on the deep superior epigastric system. Plast Reconstr
TRAM harvest rarely affects the activities of daily living and Surg. 1988;82(5):815-832.
most patients return to preoperative athletic pursuits. 21 A 12. Nahabedian MY, Dooley W, Singh N, et al. Contour abnormalities of
the abdomen after breast reconstruction with abdominal flaps: the role of
recent study directly comparing patients undergoing bilateral muscle preservation. Plast Reconstr Surg. 2002;109(1):91-101.
pedicle TRAM with bilateral DIEP flaps showed no difference 13. Hartrampf CR Jr, Bennett GK. Autogenous tissue reconstruction in the mas-
in abdominal hernia and bulge in these two groups attesting to tectomy patient. A critical review of 300 patients. Ann Surg. 1987;205:508.
its continued value in appropriately selected patients.22 14. Grotting JC, Urist MM, Maddox WA, et al. Conventional TRAM flap
versus free microsurgical TRAM flap for immediate breast reconstruction.
Flap Morbidity 15. Elliott LF, Eskenazi L, Beegle PH, et al. Immediate TRAM flap breast recon-
struction: 128 consecutive cases. Plast Reconstr Surg. 1993;92:217.
Fat necrosis and partial and total flap loss can occur with 16. Schusterman MA, Kroll SS, Weldon ME. Immediate breast reconstruction:
why the free TRAM over the conventional TRAM? Plast Reconstr Surg.
either pedicled or free TRAM techniques. Patients who are 1992;90:255.
heavy past smokers, actively smoking at the time of surgery, 17. Koshima I, Soda S. Inferior epigastric artery skin flaps without rectus
and obese or overweight may be at increased risk for flap muscle. Br J Plast Surg. 1989;42:645.
complications. Direct comparisons between pedicle and free 18. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast
reconstruction. Ann Plast Surg. 1994;32:32.
TRAM flaps have not yielded consistent results regarding the 19. Chang DW, Wang B, Robb GL, et al. Effect of obesity on flap and donor-site
incidence of fat necrosis. In general, increasing the numbers of complications in free transverse rectus abdominis myocutaneous flap breast
perforators included with the flaps reduces the incidence of fat reconstruction. Plast Reconstr Surg. 2000;105:1640-1648.
necrosis and partial and complete flap loss. Patients requiring 20. Chang DW, Reece GP, Wang B, et al. Effect of smoking on complications in
patients undergoing free TRAM flap breast reconstruction. Plast Reconstr
larger flaps, who smoke, and are obese are better candidates Surg. 2000;105:2374.
for less muscle conservation. 21. Mizgala CL, Hartrampf CR, Bennett GK. Assessment of the abdominal wall
after pedicled TRAM flap surgery: 5- to 7-year follow-up of 150 consecu-
tive patients. Plast Reconstr Surg. 1994;93:988.
Surgical Delay 22. Chun Y, Sinha I, Turko A, et al. Comparison of morbidity, functional
outcome, and satisfaction following bilateral TRAM versus bilateral DIEP
For patients in high-risk categories, surgical delay has been flap breast reconstruction. Plast Reconstr Surg. 2010;126(4):1133-1141.
suggested as a method to improve flap vascularity. To date, 23. Restifo RJ, Ward BA, Scoutt LM, et al. Timing, magnitude, and utility of
no study has shown a consistent reduction in the incidence surgical delay in the TRAM flap: II. Clinical studies. Plast Reconstr Surg.
1997;99:1217.
of flap complications in patients undergoing surgical delay of 24. Atisha D, Alderman AK, Janiga T, et al. The efficacy of the surgical
TRAM but experimental data suggest that flow is enhanced in delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg.
the superior epigastric vessels after surgical delay. 2009;63:383-388.

Free Flap Techniques
Maurice Y. Nahabedian
Women who are overweight or obese may not be candidates

Introduction for pedicled abdominal flaps but may be candidates for a free
The options for breast reconstruction following mastectomy TRAM or DIEP flap. The flap, however, must be tailored to
continue to expand. Prosthetic devices and pedicled musculo- sustain adequate perfusion and minimize fat necrosis.3,4 The
cutaneous flaps provide patients with good outcomes but have abdomen is usually not considered when a significant volume
limitations that preclude their use in patients with a history of is required and midline scars preclude incorporating the con-
cigarette smoking or prior radiation, or in patients who are tralateral zones.
overweight or obese. The primary limitations of pedicled mus- If the abdomen is not suitable, then the gluteal or thigh
culocutaneous flaps are that they usually require total sacrifice region is considered. The SGAP or IGAP is considered in
of the muscles, result in donor-site weakness, and sometimes patients who desire autologous reconstruction, lack sufficient
yield abnormal contour. The primary limitations of prosthetic abdominal fat, refuse prosthetic reconstruction, and prefer a
devices are that they are foreign materials and are subject to perforator flap.5,6 Most women will have sufficient donor fat
mechanical failure eventually. in the gluteal area. An alternative to the gluteal flaps is the
Free tissue transfer overcomes the limitations described TUG flap.7-9 The principal limitation with all of these alter-
above but is associated with morbidity related to technical nate flaps is that the volume is usually limited compared with
factors. Free flaps for breast reconstruction are generally con- the abdominal donor site. One advantage compared with the
sidered in women with increased body mass index (BMI), a abdomen, however, is that these flaps are available on both
history of tobacco use, prior radiation therapy, and also in sides of the body, permitting separate procedures if necessary.
women who desire preservation of the donor-site muscles. Patient age, in and of itself, is not an indication or con-
These flaps are derived from a variety of donor sites that traindication for any one operation. Advanced patient age
include the abdomen, gluteal region, and medial thigh. Free (>65 years) may be a relative contraindication for microvas-
flaps can be muscle or perforator based. cular breast reconstruction, but personal experience, and the
The principal abdominal free flaps include the free trans- existing literature, demonstrates that these techniques are safe
verse rectus abdominis musculocutaneous (TRAM), deep and effective in properly selected patients in this age range.10
inferior epigastric artery perforator (DIEP), and superficial Women of advanced age are required to obtain medical clear-
inferior epigastric artery (SIEA) flaps. Other donor sites for ance from their primary physicians. Women with multiple
free flap breast reconstruction include the gluteal and medial medical comorbidities are discouraged from pursuing com-
thigh regions. Although these latter sites can be considered as plex microvascular procedures and directed toward simpler
primary donor sites, most surgeons consider these when the methods, such as prosthetic reconstruction.
abdomen is not an option. The gluteal flaps include the inferior The decision to use a perforator flap or a musculocutane-
gluteal artery perforator (IGAP), superior gluteal artery per- ous flap can be difficult. This is especially true when consider-
forator (SGAP), and the gluteal musculocutaneous flaps. The ing the abdomen as the donor site. Some surgeons feel that all
Breast
thigh flap to be reviewed is the transverse upper gracilis (TUG) patients have a dominant abdominal wall perforator and that
flap or transverse musculocutaneous gracilis (TMG) flap. The a DIEP flap can be performed in anyone. Others are of the
anterolateral thigh and Reuben’s flap are seldom used for opinion that a dominant perforator is not always present and a
breast reconstruction and will not be reviewed in this chapter. musculocutaneous flap is sometimes necessary. Several studies
This chapter focuses on patient selection, anatomic consid- have described an algorithm for flap selection based on patient
erations, harvesting techniques, and clinical outcomes. Other characteristics.2 Our original algorithm was based on breast
relevant topics include a review of algorithms, monitoring volume, abdominal fat volume, perforator diameter, num-
techniques, and the current technological advancements that ber of perforators, patient age, tobacco use, and whether the
have facilitated these complex operations. reconstruction was unilateral or bilateral. In general, a DIEP
flap was preferentially performed when the volume require-
ment was less than 750 cc and the patient had mild to moder-
Patient Selection and ate excess abdominal fat. A free TRAM flap was preferentially
Flap Selection performed when the volume requirement exceeded 1,000 cc or
Patient and flap selection includes a thorough history and the patient had abundant abdominal fat. With increasing expe-
physical examination, review of the reconstructive options, rience, this algorithm has been modified (Table 62.1).
an understanding of patient expectations, and the surgeon’s The final component of the consultation includes a review
recommendations.1,2 Important details of the physical exami- of schematic illustrations and preoperative and postoperative
nation include body weight, patient height, BMI, and an photographs of other patients. Typically, the patient is shown
estimate of breast volume requirements. The possibility of a poor result, a good result, and an excellent result. Patients
secondary operations involving the ipsilateral and/or contra- are informed of the potential complications including flap
lateral breast is discussed. The variety of available donor sites failure (0.5% to 4%), abnormal donor-site contour (0% to
allows appropriate volume to be transferred in most patients. 20%), and return to the operating room (1% to 8%).
The abdomen is the preferred donor site for most surgeons
and patients if sufficient skin and fat are available given the
desired breast volume. Most patients have had children and
Preoperative Imaging
have some excess abdominal skin and fat. A slender woman With traditional musculocutaneous free flaps, there is little
with a paucity of abdominal fat may still be a candidate for need to assess the vascular architecture of the flap or donor
an abdominal flap if the reconstructive requirements are low. site. However, with the introduction of perforator flaps,
649
650 Part VI: Breast
TA B LE 6 2 . 1
An Algorithm For Selection of A Free Transverse Rectus
Abdominis Musculocutaneous, Deep Inferior Epigastric Artery
Perforator, or Superficial Inferior Epigastric Artery Flap
n Factor n Free Tram n Diep n Siea

Breast Volume Requirements
<800 g + ++ +
>800 g ++ + No
Abdominal Fat
Mild to moderate + ++ +
Severe ++ + No
Perforators >1.5 mm
0 + No
>1 + ++
Bilateral + ++ +
TRAM, transverse rectus abdominis musculocutaneous; DIEP, deep inferior epigastric artery
perforator; SIEA, superficial inferior epigastric artery.
preoperative imaging is useful. Over the past decade, there TRAM flap followed by the DIEP and SGAP flaps.11 Specific
have been a variety of technological advancements that facili- flow measurements in various vessels were obtained and
tate localization of perforators.11-18 Preoperative imaging included in the deep inferior epigastric artery (10.45 mL/min),
enables surgeons to identify suitable perforators and to deter- the superior gluteal artery (9.95 mL/min), and the internal
mine the patency of primary source vessels, namely the infe- mammary artery (IMA) (37.66 mL/min). The imaging could
rior epigastric and internal mammary vessels. The modalities differentiate between venous and arterial signals.11 The prin-
that are currently available include duplex and color duplex cipal limitation of the color duplex was that it could not pro-
ultrasound, computerized tomographic angiography (CTA), vide three-dimensional or architectural detail of the perforator
and magnetic resonance angiography (MRA) (Table 62.2). system. Giunta et al.19 reported a relatively high number of
false-positive results (46%) using the hand-held Doppler for
Duplex Ultrasound localization of perforators. In a comparative study evaluating
Doppler ultrasound and CTA, Rozen et al.12 found that CTA
The first tool used for preoperative mapping was the Doppler
was superior to Doppler based on visualization of the deep
ultrasound. Although there are many clinical applications for
inferior epigastric artery (DIEA), its branching pattern, and
the Doppler, plastic surgeons were interested in the Doppler
the perforators.
to map out perforating vessels throughout the cutaneous ter-
ritory of a flap.11,19,20 There were several early studies utiliz-
ing the color Doppler that provided useful information related Computerized Tomographic Angiography
to the location, caliber, and flow patterns of the perforators Computerized tomography may represent the gold standard
in the planning of the TRAM flap.20 Cluster analyses demon- for preoperative imaging and was the first of the highly accu-
strated that perforators were located throughout the anterior rate methods of perforator assessment.13,16,17,21 Its use is pri-
abdominal wall with the majority of dominant perforators marily directed toward abdominal flaps but it can also be used
being situated in the periumbilical area.20 Perforators exceed- in the gluteal and posterior thorax. Using multi-slice comput-
ing 2.2 mm were few in number but were identifiable in all erized tomography, axial and coronal images are obtained
four quadrants of the anterior abdominal wall. demonstrating the vascular architecture. The benefits of CTA
Other benefits using Doppler included information regard- include anatomic localization of the perforators, determina-
ing flow, direction, and velocity. In a study evaluating perfu- tion of the course of the perforator through the muscle, com-
sion of the TRAM, DIEP, and SGAP flaps, it was determined parative assessment of the right and left vascular anatomy,
that the highest blood flow and velocity was achieved in the and elucidation of anatomic detail of the medial and lateral
TA B LE 6 2 . 2
The Four Modalities For Preoperative Imaging of The Perforators are Listed
n Test n Xr n Contrast n Caliber n Location n Flow n Course n Accuracy
Doppler No No No Yes No No Low

Color duplex No No No Yes Yes No Moderate
CTA Yes Yes Yes Yes No Yes High
MRA No Yes Yes Yes No Yes High
CTA, computerized tomographic angiography; MRA, magnetic resonance angiography.

Chapter 62: Breast Reconstruction: Free Flap Techniques 651
TA B LE 6 2 . 3
The Various Abdominal Incisions and Their Consequences On The Superficial Inferior Epigastric
Artery, Deep Inferior Epigastric Artery Perforator, and Abdominal Perforators are Listed
n Scar n N n Siea Disruption n Diea Disruption n Perforator Disruption
Laparoscopy 20 None None None

Open appendectomy 20 All (ipsilateral) None (ipsilateral) Medial row of DIEA
Pfannenstiel 35 Medial branch (30/35) None NR
Paramedian 3 All (ipsilateral) All (ipsilateral) All (ipsilateral)
Open choly 1 None None None
Midline 17 None None Crossover
SIEA, superficial inferior epigastric artery; DIEA, deep inferior epigastric artery; NR, not reported.
From Rozen WH, et al. The effect of anterior wall scars on the vascular anatomy of the abdominal wall. Clin Anat. 2009;22:815-823.L
row perforators. CTA can also provide information that may source for 92 (57.5%) perforators, the inferior gluteal artery
discourage a surgeon from performing a perforator flap and was the source for 56 perforators (35%), and the deep femoral
choose instead to perform a muscle-sparing (MS) free TRAM. artery was the source for 11 (7.5%) perforators. The authors
Clinical trials using CTA have been useful. Casey et al.17 demonstrated that MRA imaging determined the location
have demonstrated that preoperative CTA has reduced oper- and course of the perforating vessels and can be useful when
ative times, increased the number of suitable perforators choosing an inferior or superior gluteal perforator flap.
included in a flap, and reduced the incidence of a postopera-
tive abdominal bulge. The latter is presumably related to the
selection of medial rather than lateral row perforators mini-
Free Flaps
mizing intercostal nerve injury. Unfortunately, CTA has not Free tissue transfer can be accomplished from virtually any-
reduced complications related to the anastomosis, flap failure where in the body. When reconstructing the breast, there are
rates, occurrence of fat necrosis, dehiscence, or delayed heal- certain criteria that make some flaps better suited than oth-
ing. CTA has also demonstrated benefit in the setting of prior ers. These criteria include adequate volume, ability to shape,
abdominal surgery. Rozen et al.16 studied 58 patients who had adequate donor vessels, and donor-site considerations. The
a total of 96 abdominal scars with CTA to determine if there flaps that are reviewed in this chapter include the free TRAM,
was any disruption to the perforators or the primary source DIEP, SIEA, SGAP, IGAP, and TUG.
vessels. Their findings were that paramedian incisions resulted Integral to the selection of the flap for microvascular
in most damage to the perforator, SIEA, and DIEA vessels. On reconstruction is the selection of the recipient vessels. The
the contrary, laparoscopic incisions caused the least damage most common recipient vessels are the internal mammary and
(Table 62.3). thoracodorsal artery and vein.24-28 The internal mammary ves-
sels are the vessels of choice in most cases because of ease of
Breast
Magnetic Resonance Angiography exposure, compatible size match, maximum freedom for flap
positioning, and excellent flow characteristics (Figure 62.1).
MRA represents the next generation in vascular imaging in
The diameter of the internal mammary vessels at the level of
part because the imaging quality is maintained or enhanced
the fourth rib ranges from 0.99 to 2.55 mm for the artery and
without ionizing radiation. 15,18,22,23 When compared with
0.64 to 4.45 mm for the vein. In contrast, the diameter of the
CTA, MRA has lower spatial resolution but greater contrast
thoracodorsal vessels ranges from 1.5 to 3.0 mm for the artery
resolution.22 This enables MRA to detect very small perfora-
tors that might otherwise be missed on CTA. MRA enables
surgeons to become aware of perforator location, size, and
distance from the umbilicus. Clinical studies have provided
useful information. Greenspun et al.18 reviewed the outcomes
in 31 women (50 flaps) scheduled for DIEP flaps. All perfo-
rators visualized on MRA using a gadolinium-based contrast
agent were found intraoperatively. In 100% of patients, the
intraoperative location of each perforator was within 1 cm
of that predicted using MRA. In three flaps, the DIEA perfo-
rators were small and the SIEA system was relatively large.
MRA successfully predicted the preferred use of an SIEA flap
instead of the DIEP flap in three out of three women (100%).
Other studies have demonstrated similar findings. Masia
et al.15 used MRA without contrast for abdominal perforators.
A dominant perforator was identified in 56 women having
DIEP flap reconstruction. They were able to determine the
location of the dominant perforator, define its intramuscu-
lar course, and reliably evaluate the SIEA. The intramuscular
perforators originated from the lateral row in 55% and from
the medial row in 31%.
Imaging of the gluteal and thigh perforators can also FIGURE 62.1. The internal mammary artery and vein are prepared
be performed. Vasile et al.23 used MRA in 32 buttocks and as recipient vessels for the microvascular anastomosis.
imaged 142 perforators. The superior gluteal artery was the

652 Part VI: Breast
TA B LE 6 2 . 4
The Muscle-Sparing Classification For Free Transverse Rectus Abdominis
Musculocutaneous and Deep Inferior Epigastric Artery Perforator Flaps Is Shown
n Muscle-Sparing Technique n Definition (Rectus Abdominis)
MS–0 Full width, partial length

MS–1 Preservation of lateral segment
MS–2 Preservation of lateral and medial segment
MS-3 (DIEP) Preservation of entire muscle
MS, muscle sparing; DIEP, deep inferior epigastric artery perforator.
and 2.5 to 4.5 mm for the vein.15,16 The blood flow rate of the flaps is perfused via the perforating branches of the inferior
IMA ranges from 15 to 35 mL/min (mean, 25 mL/min) and epigastric artery and vein.
the blood flow rate of the thoracodorsal artery ranges from The superficial system is less predictable, often absent, and less
2 to 8 mL/min (mean, 5 mL/min). commonly used. The limiting factors associated with the superfi-
In the author’s practice, the IMA vessels are preferred for cial vessels are that they are not present in all patients and when
all delayed reconstructions and most immediate reconstruc- present, they are usually smaller in caliber than the deep system.
tion. The vessels are exposed at either the third or fourth Thus, performing an SIEA flap is only possible in approximately
interspace. The cartilaginous segment of the rib is excised, the 30% of women and is best reserved for women of moderate body
perichondrium is incised, and the vessels are exposed. This habitus that require only a hemi-flap for the reconstruction.
is usually performed using loupe magnification. Given the
prevalence of sentinel lymph node dissection and the rarity Free TRAM
of axillary dissection, the thoracodorsal artery and vein are
The free TRAM was one of the first of the free tissue trans-
infrequently used. These vessels are preferred, however, in
fers for breast reconstruction. A primary goal of this flap was
the setting of a modified radical mastectomy where they have
to improve the perfusion and vascularity to the flap and to
been exposed.
minimize the amount of muscle removed relative to its ped-
icled counterpart. The free TRAM requires the removal of
Abdominal Free Flaps various amounts of the rectus abdominis muscle and anterior
In general, the abdomen is the preferred donor site for the rectus sheath. Inherent to understanding the free TRAM is an
majority of microvascular reconstruction procedures. The appreciation for the various types of muscle preservation tech-
abdomen is the source for the free TRAM, DIEP, and SIEA niques. Classification of MS is based on the amount of rectus
flaps. The blood supply to the intact anterior abdominal abdominis preserved.29,30 The rectus abdominis muscle can be
wall is derived from the deep inferior epigastric as well as the separated into three longitudinal segments: medial, lateral, and
superficial inferior epigastric systems. The deep system is usu- central. The MS-0 (muscle sparing—none) includes the full
ally dominant and is therefore preferred in the majority of width of the muscle; MS-1 includes preservation of the medial
cases. The free TRAM and DIEP flaps are based on the deep or lateral segment of the muscle; MS-2 includes the medial and
system, whereas the SIEA is based on the superficial system. lateral segment of the muscle; and the MS-3 includes preserva-
The adipocutaneous component of the free TRAM and DIEP tion of all three segments (Tables 62.4 and 62.5).
TA B LE 6 2 . 5
A Review Of Free Transverse Rectus Abdominis Musculocutaneous Flaps Is Shown
n Author n Year n Number n Type of n Muscle n Mesh (#) n Weak- n Sit-Ups n Bulge n Hernia
of Flap Sparing ness (#) (%) (%) (%)
Women (#)
Schusterman 1994 211 Free TRAM Yes (108) Yes (NR) NR NR 11 (5%)
Kroll 1995 123 Free TRAM Yes (NR) Yes (NR) Yes (NR) 63% 5 (4.1% 4 (3.3%)
(single pedicle)
45 Free TRAM Yes (NR) Yes (NR) Yes (NR) 46% 1 (2.2%) 0
(double pedicle)
Souminen 1996 27 Free TRAM Yes (27) No (27) Mild (NR) 100% 1 (4%) 0
Blondeel 1997 20 Free TRAM No (20) Yes (20) Yes (13) 35% 2 (10%) 1 (5%)
Nahabedian 2002 58 Free TRAM Yes (27) No (27) NR NR 1 (3.7%) 0
(unilateral)
No (31) No (31) NR NR 1 (3.2%) 0
13 Free TRAM Yes (9) Yes (7/13) NR NR 1 (11%) 0
(Bilateral)
No (4) NR NR 2 (50%) 0
TRAM, transverse rectus abdominis musculocutaneous; NR, not reported.

FIGURE 62.3. Elevation of adipocutaneous component of an abdom-

FIGURE 62.2. Preoperative abdominal markings in preparation for a inal flap starts from the lateral edge of the flap.
free TRAM, DIEP, or SIEA flap.
Given that there are three possible microvascular flaps (Figure 62.4). The anterior rectus sheath is elevated off the
within the donor site of the anterior abdominal wall, rectus abdominis muscle medially and laterally as indicated.
the question becomes how to decide which to choose. In The muscle is then undermined and the location of the infe-
patients with complex abdominal scars, imaging of the vas- rior epigastric artery is visualized and palpated (Figure 62.5).
cular architecture is recommended. The free TRAM flap is This maneuver will facilitate dissection of the free TRAM and
considered when the SIEA and superficial inferior epigas- minimize the chance of injury to the perforators or pedicle.
tric vein (SIEV) are not useable, the quality of perforators When the perforators are centrally located, an MS-2 free
is poor (< 1.5 mm in diameter), or in the event that the flap TRAM is performed (Figures 62.6 and 62.7). When the perfo-
volume requirements exceed 800 g. When a free TRAM is rators are medial or lateral, an MS-1 free TRAM is performed
selected, the MS free TRAM (MS-1 or MS-2) is usually per- (Figure 62.8). The rectus abdominis muscle is divided using a
formed. The MS-0 free TRAM is uncommonly performed; fine-tip mosquito clamp and an electrocautery device at a low
however, it is considered in the event of a narrow rectus setting. It is important to preserve the lateral intercostal motor
abdominis muscle. The limitation of the MS-0 free TRAM is innervation to maintain function of the rectus abdominis mus-
that it disrupts the continuity of the rectus abdominis muscle. An example of a woman following a bilateral MS-2 free
cle and results in functional outcomes similar to the pedi- TRAM flap is demonstrated (Figures 62.9 and 62.10).
cle TRAM. When the principal perforators are small and
localized in a segment of the rectus abdominis muscle or if Deep Inferior Epigastric Artery Perforator
the volume requirements are high, a small segment of the (Table 62.6)
muscle is harvested with the flap. The advantage of includ-
ing muscle is that multiple perforators can be included in In this author’s practice, the DIEP flap constitutes approxi-
mately 70% of all abdominal flaps followed by the MS-2 free
Breast
the flap that may minimize the incidence of fat necrosis and
venous congestion. TRAM and SIEA. When considering an abdominal perforator
flap, many surgeons will assess the vascular anatomy using
Operative Details. The preoperative markings include the methods previously described. Intraoperative assessment is
delineation of the anterior superior iliac spine (ASIS) as equally effective in identifying the abdominal wall perforating
well as the proposed upper and lower transverse incisions vessels. Reliance on only intraoperative assessment requires
(Figure 62.2). Following the initial incisions, the right and more experience because of the variability associated with
left flaps are elevated from a lateral to medial direction perforator location, caliber, and number. There are five types
(Figure 62.3). Once a network of perforators is visualized,
the anterior rectus sheath is outlined to encompass the perfo-
rators. The fascia is incised creating an island of perforators
FIGURE 62.4. Following identification of the relevant perforators, FIGURE 62.5. The rectus abdominis muscle is undermined to palpate
the anterior rectus sheath is incised in preparation for the free TRAM. the intramuscular course of the inferior epigastric artery.

654 Part VI: Breast
FIGURE 62.6. Typical appearance of the abdomen following MS-2

free TRAM flap. The central portion of the muscle is harvested.
FIGURE 62.9. Preoperative photograph of a woman with right

breast cancer.
FIGURE 62.7. Typical appearance of an MS-2 free TRAM that

includes the small central segment of the rectus abdominis muscle.
FIGURE 62.10. Postoperative photograph following right breast

reconstruction with a free TRAM flap.
of perforators that are typically encountered.31 These perfora-

tors are direct (does not perforate the muscle, e.g., SIEA) and
indirect (perforates the muscle). In general, for a perforator
flap to be successfully harvested and transferred, a single per-
forating artery and vein of at least 1.5 mm in diameter is rec-
ommended. These perforators typically have a palpable pulse
and are usually located in the periumbilical region. If a domi-
FIGURE 62.8. Typical appearance of the abdomen following an nant perforator arising from the deep system is not identified,
MS-1 free TRAM flap. The central and medial segments of the muscle it may be because the superficial inferior epigastric system is
have been harvested. dominant. In this situation, one can consider performing an
SIEA flap or an MS free TRAM.

TA B LE 6 2 . 6
A Review of Deep Inferior Epigastric Artery Perforator Flaps Is Shown
n Author n Year n Number n Sides n Weakness n Sit-UPS (%) n Bulge (%) n Hernia (%)
of Women (%)
Blondeel 1997 18 Unilateral NR NR 0 0
Hamdi 1999 34 Unilateral 0 1 (2%) 0
8 Bilateral 0 65% 1 (2%) 0
Keller 2001 85 Unilateral
40 Bilateral 4 (2.7%) NR 2 (1.4%)
Nahabedian 2002 14 Unilateral NR 16 (94%) 0 0
3 Bilateral NR 2 (67%) 0 0
Gill 2004 460 Unilateral
149 Bilateral NR NR NR 5 (0.7%
Guerra 2004 140 Bilateral NR NR 1 (0.7%) 2 (1.4%)
NR, not reported.
Operative Technique. The patient is marked preopera- to do so will likely result in abdominal weakness or bulge.
tively exactly as described with the free TRAM (Figure 62.2). Motor nerve branches that cross the perforator or the source
The initial operative sequence is similar to the free TRAM vessel can be sharply divided. Whether or not to coapt the
except that one or more perforators are selected and iso- severed nerve is controversial. Some advocate using a micro-
lated. The selected perforator should ideally be located near suture for coaptation; however, it is this author’s preference
the center of the flap in order to obtain equidistant perfusion. to allow the transected end to innervate the adjacent muscle
Perforator diameter should be in excess of 1.5 mm. When by neurotization. The intramuscular dissection proceeds to the
several perforators are available, sequential occlusion can point that the perforator or inferior epigastric vessel becomes
be performed to assist with the selection process. Multiple submuscular. At that point, the dissection progresses from the
perforators can be considered when they are aligned in series lateral edge of the muscle toward the iliac vessels. It is recom-
or in close proximity (Figure 62.11). An example of a three- mended to continue the dissection until the vessel diameter
perforator DIEP flap is demonstrated (Figure 62.12). Medial approaches 2.5 to 3 mm. Following the intramuscular dissec-
row perforators are preferred when the flap will include zone 3 tion, the anterior rectus sheath and continuity of the rectus
or zone 4. A personal observation in thin women is that perfo- abdominis muscle should be preserved and resemble that of a
rator diameter is usually less than 1.5 mm. An option in these myotomy and fasciotomy (Figure 62.15).
situations is to convert to a free TRAM. When initiating the Throughout the dissection, it is important to look for bleed-
dissection, it is recommended to include a small cuff of the ing from the edges of the flap to assess perfusion. One can also
Breast
anterior rectus sheath (1 to 2 mm) around the perforator, espe- use a hand-held Doppler probe to evaluate the arterial and
cially if the perforator is piercing the anterior rectus sheath at venous signals. When a unilateral reconstruction is planned,
a tendinous inscription (Figure 62.13). During the dissection it it is wise to preserve the contralateral perforators in the event
is imperative to preserve the lateral intercostal nerves as they that a “lifeboat” is necessary. When a bilateral reconstruction
pierce the rectus abdominis muscle at the junction of the latis planned, it is advised to proceed cautiously when isolating
eral and central longitudinal segments (Figure 62.14). Failure and dissecting the perforators because a contralateral lifeboat
FIGURE 62.11. A column of perforators are isolated in preparation

for a DIEP flap. FIGURE 62.12. A triple-perforator DIEP flap is shown.

656 Part VI: Breast
FIGURE 62.13. A single-perforator DIEP flap is shown in situ. FIGURE 62.16. Preoperative image of a woman with bilateral breast
implants scheduled for bilateral DIEP flaps.
FIGURE 62.14. Preservation of the lateral intercostal innervation is FIGURE 62.17. Postoperative image following bilateral DIEP flap
important and demonstrated in this photograph. breast reconstruction.
will not be available. When in doubt about the quality of the

perforators, an MS free TRAM flap is considered. An exam-
ple of a patient following bilateral DIEP flap is demonstrated
(Figures 62.16 and 62.17).
Superficial Inferior Epigastric Artery

The SIEA flap is based on the superficial inferior epigastric
artery and vein.32.33 The advantage of this flap over the other
abdominal free flaps is that it does not require a fasciotomy
or myotomy (Figure 62.18). The SIEA flap is technically eas-
ier to harvest than either the DIEP or MS free TRAM flap.
It is essentially an adipocutaneous flap that is perfused by a
direct perforator (does not course through the rectus abdomi-
nis muscle). The SIEA and SIEV cross the inguinal ligament
about one-third the distance from the pubic bone to the ASIS.
Vessels of suitable caliber are not present in all patients. In
patients with previous lower abdominal transverse incisions,
the vessels may have been previously divided. The angiosome
FIGURE 62.15. Typical appearance of the abdomen following territory of these vessels is restricted to zones 1 and 2.
bilateral DIEP flap harvest. The rectus abdominis and anterior rectus
sheath are incised and not removed. Operative Details. The patients are marked in a similar
fashion as the free TRAM patients. A recommended approach

with a flat abdomen, with or without scarring. Candidates
must have an excess of skin and fat in the medial thigh region.
Other indications include bilateral reconstructions in which
the mastectomy volume approximates the volume of the
medial thigh or meets the expectation of the patient. Schoeller
et al.7 have used this flap in 111 patients. These patients were
selected based on volume requirements, body habitus, and
their desire to proceed with autologous reconstruction. Mean
BMI was 23.7 (range, 19.4 to 28.5) and the mean volume of
the flap was 330 cc (range, 150 to 550 cc). The caliber of the
gracilis vascular pedicle ranged from 1.5 to 2.5 mm.
Operative Details. Patients are evaluated in the standing

position by pinching the medial thigh region to determine the
optimal height of the flap. In general, it ranges from 8 to 10 cm
and may be up to 12 cm in patients following massive weight
loss. The anterior and posterior limits of the flap are based on
the dimensions of the mastectomy defect. The skin paddle can
be delineated transversely or in a fleur-de-lis pattern. Patients
are placed in the lithotomy position. The skin territory is
incised and the dissection proceeds to the level of the muscle
fascia. Superficial nerves within the flap are usually transected.
The saphenous vein is included into the flap for additional
venous drainage if necessary. Typically, the gracilis artery is
associated with a vena comitans. The gracilis muscle is visual-
ized and divided at its origin and at its distal musculotendinous
insertion. The flap is transferred to the chest wall for the micro-
vascular anastomosis. Ideally, recipient vessels are selected that
will provide an optimal size match. The internal mammary ves-
sels or their perforating branches are typically used.
Gluteal Free Flaps

FIGURE 62.18. Typical appearance of the abdomen following harvest The gluteal region has proved to be a valuable alternative
of an SIEA flap. The anterior rectus sheath and muscle are not violated. for free flap breast reconstruction.6,35,36 It is generally recom-
mended for women who lack sufficient skin and fat in the
abdominal region. There are two general types of gluteal flaps
that include the musculocutaneous varieties and the perfora-
is to begin dissection with the contralateral SIEA and SIEV. If tor varieties. The perforator flaps include the SGAP and the
the vessels are of suitable caliber with a palpable pulse, then IGAP. These flaps are perfused on their respective vessels, the
the vessels are dissected to their origins and the SIEA flap is superior and inferior gluteal artery and vein. The gluteal flaps
planned. An important consideration is that the diameter of are considered to be among the more difficult flaps to harvest.
Breast
the SIEA be 1.5 mm as it enters the lateral edge of the flap.
Lesser diameters are associated with a higher failure rate. The
Operative Details. Preoperative identification of the ana-
tomic landmarks is essential in raising these flaps. These land-
length of the SIEA/SIEV pedicle ranges from 5 to 8 cm. If the
marks include the greater trochanter, the posterior superior
contralateral vessels are of suboptimal caliber without a palpa-
iliac crest, and the coccyx. The location of the perforators is
ble pulse, then the ipsilateral SIEA/SIEV are explored. If those
best determined via preoperative imaging as well as using a
vessels are not suitable, then the deep system of perforators are
hand-held Doppler probe with the patient in the prone posi-
explored. The contralateral and ipsilateral medial and lateral
tion on the operating table (Figure 62.19). Several Doppler
row of perforators are visualized and preferentially selected.
signals may be appreciated. It is this author’s preference to
Insetting the SIEA flap requires special considerations when
select a perforator that is based on the lateral aspect of the
compared with the free TRAM or DIEP flaps. The pedicle enters
flap and toward the periphery of the flap because the later-
the flap at the edge rather than the undersurface. Standard
ally based perforators will usually provide a pedicle length of
insetting will create a sharp 180° fold in the pedicle that can
6 to 8 cm; whereas the medially based perforators are usually
compromise flow. Zenn34 has described a technique that per-
4 to 6 cm in length (Figure 62.20). In contrast to the DIEP flap
mits a gradual folding of the pedicle that will not compromise
where a central perforator is preferred, a peripheral perforator
flow. The inferior 2 to 3 cm of the flap is de-epithelialized. The
is preferred for the SGAP flap in order to facilitate the tech-
dermis is released at the new epidermal edge. The flap is posi-
nical aspects of performing the microvascular anastomosis.
tioned with the pedicle oriented in the inferomedial direction.
With a central perforator, some of the useable length is under
This allows the pedicle to rotate superiorly without kinking.
the flap rather than outside the flap edge. With a peripheral
perforator, the added length can facilitate positioning of the
Gracilis Free Flaps flap during the anastomosis.
The medial thigh donor site has demonstrated success for Once the perforator is isolated, the dissection commences
breast reconstruction. Flaps such as the TUG and TMG have in the subfascial plane. In contrast to a DIEP flap in which
been described.7-9 Although the abdomen is the preferred the length of the myotomy is minimized, the length of the
donor site in the majority of women, alternative sites are myotomy is maximized with the SGAP dissection because
sometimes necessary. The gluteal flaps are another alternative the perforator dissection progresses perpendicular to the
but concerns about pedicle length and caliber make these flaps cutaneous surface. In the DIEP flap, the dissection is paral-
potentially undesirable. The medial thigh is an alternative that lel with the cutaneous surface. It is important to recognize
is gaining momentum. Candidates for this flap include women that the dissection continues deep to the gluteus maximus

658 Part VI: Breast
FIGURE 62.19. An acoustic hand-held Doppler is used to localize FIGURE 62.22. Preoperative image of a woman prior to left SGAP
the perforators in the upper gluteal region prior to SGAP flap harvest. reconstruction.
FIGURE 62.20. The dissection of an SGAP flap is depicted. FIGURE 62.23. Postoperative image following left SGAP reconstruction.
The IGAP flap is raised using the same gluteal landmarks.

The skin territory for this flap can be positioned to be “in the
crease” as described by Allen et al.36 In general, the adipocu-
taneous component of this flap is slightly less than that of the
SGAP.35 Other considerations are that the sciatic nerve is often
exposed during this dissection and may result in postopera-
tive discomfort. Because the incision is located in the ischial
region, sitting may be restricted for several days following the
operation and dehiscence of the incision is more common.
Intraoperative Monitoring
Tools
There are a variety of methods by which flap perfusion is
assessed intraoperatively. Traditionally, surgeons have evalu-
ated the color of the flap to determine if the perfusion is nor-
mal, congested, or pale. Surgeons have also employed the
FIGURE 62.21. The harvested SGAP is shown. Note that the pedicle hand-held acoustic Doppler and auscultated the signals of the
is relatively short. pedicle and the cutaneous perforators. Arteriovenous bleeding
from the cut edges of the flap is generally regarded a sign of
adequate perfusion. Zone 4 of the abdominal free flap is often
and medius muscles before penetrating the deep fibrous fas- poorly perfused and cannot be reliably transferred because of
cia (Figure 62.21). Once beyond this point, there are multiple the risk of fat necrosis. A fluorescent woods lamp can dem-
venous branches that must be carefully dissected and divided onstrate perfusion patterns within the flap. However, there
before choosing the end point of the perforator. An example has been no quantitative method to evaluate flap perfusion in
of a patient following a unilateral SGAP is shown (Figures the period immediately prior to or following a microvascular
62.22 and 62.23). anastomosis.
Fluorescent Angiography Near-Infrared Spectroscopy

Fluorescent angiography is a relatively new technology Near-infrared (NIR) spectroscopy is a continuous method of
that allows direct visualization of perfusion within a cuta- flap monitoring that measures oxygen saturation within the
neous territory.37-39 This application can be used on tissue cutaneous layer of the flap.41,42 A surface probe is placed on
that is elevated as a flap or on a cutaneous territory that the flap that emits NIR light and detects the hemoglobin con-
has not been elevated. The images are captured following tent in the surface vessels. The light has a maximum penetra-
the intravenous injection of indocyanine green (ICG). An tion depth of approximately 2 cm. The measure of hemoglobin
image-capturing laser is then positioned a few inches above saturation is relatively constant for a given flap unless there is
the cutaneous territory to be imaged. This device is linked an alteration of flow. These changes will manifest immediately
to a computer that analyzes the data and generates a real- on the electrical tracing before there are any clinical signs of
time image based on the fluorescence of the ICG. Images altered flap perfusion.
are obtained about 15 seconds after the ICG injection. In Clinical application of this technology has been encourag-
the setting of flap reconstruction, the images can be cap- ing. Keller has used NIR in 145 patients and 208 flaps. All
tured prior to, during, and following flap elevation, as well patients were monitored intraoperatively and for 36 hours
as postoperatively. postoperatively.42 Of the 208 flaps, five demonstrated abnor-
Evaluation of the reliable vascular territory of the cuta- malities in the spectroscopy measurements. All of these flaps
neous portion of an abdominal flap was one of the first were salvaged in part because of the early diagnosis of altered
applications of fluorescent angiography in the setting of perfusion. Colwell et al.41 applied the NIR system in seven
autologous reconstruction. It was demonstrated that clas- patients having free flap breast reconstruction using abdomi-
sic perfusion zones described by Hartrampf were not quite nal flaps. Baseline oxygen tension measurements ranged from
accurate in that the distal segment of the flap laterally 70% to 99% with a mean of 83%.
adjacent to zone 1 was better perfused than the medially
adjacent territory on the other side of the midline. Other
clinical applications have included assessing perfusion in
Outcomes
various free tissue transfer operations. Pestana et al.39 uti- Assessing outcomes following microvascular breast recon-
lized fluorescent angiography in 23 patients with a variety struction requires a complex set of parameters. It is not just
of soft tissue deformities. Flaps included the TRAM, DIEP, about flap success and failure. It also relates to patient sat-
SIEA, and SGAP. It was demonstrated that areas with rela- isfaction, donor-site morbidities, and flap-related morbidity
tive hypoperfusion went on to develop areas of necrosis or that in turn depends on surgeon experience. Some factors
eschar formation. They were also able to confirm patency of affecting outcome are within the surgeons control and oth-
the microvascular anastomoses based on arterial inflow and ers are not. Controllable factors include selection of the cor-
venous outflow. rect perforator, prevention of inadvertent perforator injury
Fluorescent angiography is also useful in evaluating via- (thermal injury and avulsion), ensuring adequate recipient ves-
bility of the mastectomy skin flaps in the setting of immedi- sels with a proper caliber match, and adequate postoperative
ate breast reconstruction. Fluorescent angiography is able monitoring of the free flap. Factors outside the control of the
to determine the perfusion thresholds of the skin follow- surgeon include architectural anomalies of the vascular system
ing mastectomy and predict whether the skin will remain within the flap or the recipient vessels, radiation damage, and
viable or not. Komorowska-Timek and Gurtner40 found the hypercoagulability.
technique to be beneficial especially in cases of mastectomy
with nipple–areolar preservation. Alterations in perfusion Abdominal Free Flaps
were noted in some women despite what appeared to be a
Breast
normal nipple–areolar complex. In patients with a history With the increasing interest in preserving the abdominal
of tobacco use or with connective disuse disorders, fluores- donor site, several studies have attempted to evaluate and
cent angiography can help determine if further debridement quantitate outcomes following the various types of free flaps.
is necessary. In an early study comparing the DIEP (MS-3) flap to the MS-2
free TRAM, Nahabedian et al.2,43,44 demonstrated improved
outcomes with regard to abdominal contour and strength
following DIEP flap reconstruction. In unilateral cases, an
Postoperative Monitoring abdominal bulge occurred in 4.6% and 1.5% of women fol-
Adequate flap monitoring is a critical component and pre- lowing free TRAM and DIEP flap reconstruction, respectively.
dictor of successful flap outcomes. Postoperative assess- The ability to perform sit-ups was demonstrated in 97% and
ment of flap circulation has traditionally required subjective 100% following free TRAM and DIEP flaps, respectively.
interpretation of objective data. Traditional methods of flap Following bilateral reconstruction, the differences were more
monitoring have included hand-held Doppler probes, surface pronounced. An abdominal bulge occurred in 21% and 4.5%
temperature assessment, flap turgor, capillary refill, and flap following free TRAM and DIEP flaps, respectively. The ability
color. Important components in the monitoring of free flaps to perform sit-ups was 83% and 95% following free TRAM
include differentiating the biphasic arterial and monophasic and DIEP flaps, respectively. For all MS-2 free TRAM flaps
venous signals using a hand-held Doppler and ensuring that (n = 113), outcome included fat necrosis in eight (7.1%),
both signals are present. With inflow problems, flaps will venous congestion in three (2.7%), and total necrosis in
become pale, cool, and soft with delayed or absent capillary two (1.8%) patients. For all DIEP flaps (n = 110), outcome
refill. With outflow problems, flaps will become tense, con- included fat necrosis in seven (6.4%), venous congestion
gested, and purple, with brisk capillary refill. Although these in five (4.5%), and total necrosis in three (2.7%) patients.
methods of flap monitoring are usually effective, they are not Although these differences in abdominal morbidity were not
continuous, are subject to interpretation, and are dependent statistically significant, a clear trend was evident.
on the experience of clinical personnel. There is a relatively Outcome analysis regarding bilateral microvascular breast
short window of opportunity in which a flap can be salvaged reconstruction has recently been evaluated. In a review of 342
in the event of altered flow. In muscle-based free flaps, the bilateral flaps, Rao et al.45 demonstrated failure or intraopera-
ischemia threshold is about 2 hours after which, irreversible tive termination of the procedure in 12 cases, yielding a failure
muscle damage will occur. With perforator flaps, there is no rate of 3.5%. Causes of flap failure included venous insuf-
muscle and the tolerated ischemic period is increased, ranging ficiency (6/12), lack of adequate perforator anatomy (3/12),
from 3 to 6 hours. and perforator injury during dissection (2/12). A review of
660 Part VI: Breast
386 unilateral cases over the same time period demonstrated a

failure rate of 2.1%. Gracilis Free Flaps
Regarding the abdominal wall, Nahabedian46 reviewed sec- The TUG and TMG flaps have demonstrated success in the
ondary operations following free TRAM and DIEP flap recon- setting of microvascular breast reconstruction. The benefits
struction. Secondary abdominal operations were performed in include the use of an expendable muscle and a donor site that
59 women (17.9%). The indications were considered neces- is relatively hidden. Donor-site morbidity in this region has
sary in 33 women (10%) and elective in 31 women (9.4%). been a bit higher than the other regions such as the abdomen
Lower abdominal bulge was the most common necessary and gluteal region; however, flap success has been high rang-
indication and was repaired in 9.3% of free TRAM flaps and ing from 97% to 100%. Vega et al.8 demonstrated donor-site
4.7% of DIEP flaps. Dog-ear scars were the most common infection in 3.7%, with delayed donor-site healing of 11%.
elective indication and were revised in 29 women (8.8%). The incidence of fat necrosis and donor-site contour abnor-
Neuromas of the anterior abdominal wall were diagnosed in mality was 7.4% and 3.7%, respectively. Operating times gen-
three women (0.9%). erally range from 4.5 to 5 hours for unilateral reconstruction
Wu et al.47 compared donor-site morbidity between the free and 6 to 7 hours for bilateral reconstructions. Patient satisfac-
TRAM, DIEP, and SIEA flaps. A questionnaire was used to tion was assessed by Fansa et al.9 who demonstrated that 94%
assess donor-site function, pain, and aesthetics in 179 women of patients (15/16) returned to normal work.
following microvascular breast reconstruction. The SIEA flap
scored highest in 10 of 12 categories following unilateral Conclusion
reconstruction. These categories included better postopera-
tive lifting (p < 0.02) and shorter duration of abdominal pain Microvascular breast reconstruction is rapidly acquiring
(p < 0.06). Of the bilateral patients, the ability to get out of momentum for women with breast cancer seeking autolo-
bed was significantly higher following the SIEA flaps com- gous reconstruction. The ability to transfer an adipocuta-
pared with MS free TRAM and DIEP flaps (p < 0.02). neous flap without removal of the donor-site muscle has
In an effort to better understand the risks and benefits been the driving force. Many women have learned of these
of the SIEA flap, Selber et al.48 compared flap and abdomi- perforator flap procedures and seek surgeons that perform
nal outcomes following microvascular breast reconstruction them. There are a variety of donor sites available, each with
with the MS free TRAM and the SIEA flap. It was demon- its own set of indications, benefits, and morbidities. The
strated that the incidence of hernia and bulge following the preoperative, intraoperative, and postoperative factors that
free TRAM flaps was 1.9% compared with 0% for the SIEA can influence the success of these operations have been out-
flaps. However, the incidence of thrombotic complications lined in this chapter.
and flap loss was significantly higher for the SIEA group com-
pared with the MS free TRAM group (p < 0.0005). Although References
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31. Blondeel PN, Van Landuyt KHI, Monstrey SJM, et al. The “gent” consensus the abdominal wall: part II. Bilateral reconstruction. Plast Reconstr Surg.
on perforator flap terminology: preliminary definitions. Plast Reconstr 2010;126:1438-1453.
Surg. 2003;112:1378-1383. 50. Selber JC, Fosnot J, Nelson J, et al. A prospective study comparing the
32. Spiegel AJ, Kahn FN. An intraoperative algorithm for use of the SIEA flap functional impact of SIEA, DIEP, and muscle-sparing free TRAM flaps on
for breast reconstruction. Plast Reconstr Surg. 2007;120(6):1450-1459. the abdominal wall: part I. Unilateral reconstruction. Plast Reconstr Surg.
33. Chevray PM. Breast reconstruction with superficial inferior epigastric artery 2010;126:1142-1153.
flaps. Plast Reconstr Surg. 2004;114(5):1077-1083. 51. Nahabedian MY, Momen B, Manson PN. Factors associated with
34. Zenn MR. Insetting of the superficial inferior epigastric artery flap in breast anastomotic failure following microvascular reconstruction of the breast.
Breast
reconstruction. Plast Reconstr Surg. 2006;117:1407-1411. Plast Reconstr Surg. 2004;114:74-82.

Chapter 63 n Nipple Reconstruction
Michael S. Beckenstein
Nipple reconstruction is an essential component in the cre- nipple. These procedures employ skin grafts or primary clo-
ation of an attractive breast. When viewing breasts, the eyes sure to close the donor defects. Examples of the commonly
are drawn to the nipple–areola complexes. A surgeon can cre- used pedicle flaps are the skate flap, modified skate flap, star
ate aesthetically pleasing breast mounds, but the improper flap, cervical visor (CV) flap, wrap flap, and fishtail flap. To
placement of the nipple–areola complexes will compromise be successful in creating nipples of sufficient projection and
the final result. In addition, errors in nipple–areolar placement dimension, the breast mound must provide well-vascularized
are challenging to correct. Nipple reconstruction techniques soft tissue of sufficient thickness. One must keep in mind
may seem minor in the overall scheme of breast reconstruc- that these are second-generation flaps; that is, they are cre-
tion; they are a major factor in the final result and demand ated from flaps of tissue that were themselves either mastec-
meticulous attention to achieve good aesthetic results. tomy flaps or autologous transferred flaps! These methods
The goal of nipple–areolar reconstruction is to create nip- may not be suitable for reconstructions in patients with thin
ples that are appropriately located on the breast mound and skin or irradiated tissue. Local flaps are best suited for breast
are of appropriate size, shape, color, and texture. Projection mounds composed of autologous tissue where these soft-tissue
is another key aspect of nipple reconstruction which can be requirements are met. These local flaps often lose volume and
varied to attain a patient’s goal. There are many techniques of contract substantially over time. Consequently, an initial over-
nipple–areolar reconstruction that can be employed to suit the correction is warranted. In unilateral reconstruction, the local
goals of both the patient and the surgeon. Some techniques are flap is made 50% to 75% larger than the contralateral nipple
better suited for autologous breast reconstruction where there size in anticipation of atrophy. If the final result is substan-
is more subcutaneous adipose tissue and others might be best tially larger than desired, a reduction is readily performed as
applied to prosthetic breast mounds with thinner subcutane- an office procedure. It is easier to reduce the size than to per-
ous tissue. form a secondary procedure to increase the size of a volume-
depleted, contracted nipple.
Marking Technique. All local flap procedures begin by designing the

flaps so that the base of the flap is located at the marked posi-
When performing unilateral breast reconstruction, simply tri-
tion of the nipple. The flap dimensions are drawn within the
angulating the distances from the contralateral nipple onto the
confines of a 38-, 42-, or 45-mm “cookie cutter.” The skin
reconstructed breast mound may not result in an appropri-
incisions are then made; the lateral flaps are raised as full- or
ate placement. Because there are usually breast mound asym-
partial-thickness skin grafts. The dermal fat pedicle is incised
metries, the surgeon uses aesthetic judgment to position the
into the subcutaneous adipose layer, raising the dermal-fat
nipple. One way to approximate the nipple–areola position is
pedicle 90° to the plane of the breast mound. Care is taken
to cover the contralateral breast and carefully study the recon-
to preserve the delicate blood vessels in the adipose tissue to
structed breast mound and place a mark where the nipple
minimize tissue atrophy postoperatively. The dermal fat ped-
location appears appropriate. The contralateral breast is then
icle must be of sufficient thickness to provide the necessary
uncovered and a careful comparison is made. Adjustments
bulk for the nipple. The donor site is closed in layers, approxi-
are made as deemed necessary. The patient is allowed to have
mating the deep dermis with an absorbable 4-0 suture. The
input into the nipple–areola location as well. A round adhe-
skin is closed with 5-0 absorbable simple mattress sutures.
sive bandage is placed on this location. The patient can relo-
The lateral skin flaps are then rotated around the dermal fat
cate the bandage to what she feels is an appropriate location.
pedicle and sutured with simple mattress sutures. All remain-
In bilateral reconstructions, there is more latitude in nip-
ing skin edges are closed in a similar manner. Figure 63.1A–C
ple location yet the marking methods are similar. Initially,
demonstrates these tenets, using Hartrampf’s Penny flap as
each breast is assessed separately. Careful inspection of both
the example. A dressing is applied, consisting of the base of
breasts is then performed and adjustments/compromises made
a 20-mL syringe, cushioned by an eye pad with the center cut
as necessary.
out. A 1-in. Xeroform strip is placed into the barrel of the
syringe after it is placed over the newly reconstructed nipple
and a Tegaderm dressing is applied. An alternative dressing
Methods consists of an arterial line protector, which is then injected
Ideally, the surgeon is familiar with a variety of techniques with antibiotic ointment, after it is placed over the nipple. The
and will choose one based on the goals of the patients and the dressings are removed 1 week postoperatively. The patient
amount of tissue available on the breast mound. The more wears the plastic nipple shields for an additional week, placing
common reconstruction methods consist of local flaps, grafts, them through the center of an adhesive bandage. These dress-
or a combination of both. Acellular dermal matrices (ACMs) ings are changed twice daily, applying antibiotic ointment to
used alone or in conjunction with local flaps are being utilized the nipple.
as well as injectable materials. Tattooing can also serve as the
sole form of nipple–areola construction in select patients.
Grafts
The use of grafts is another effective method of nipple–areola
Local Flaps reconstruction. Grafts are particularly useful in prosthetic
Local flaps are the most frequently performed methods of reconstructions as there is often a paucity of soft tissue to cre-
nipple reconstruction today. A central dermal fat pedicle is ate nipples with sufficient projection using the local flap tech-
wrapped by full- or partial-thickness skin flaps, creating a niques. The disadvantage of autografts is that they require a
662
Chapter 63: Nipple Reconstruction 663
A B
FIGURE 63.1. The “penny flap” demonstrates the basic tenets of dermal fat pedicle reconstruc-
tion of the nipple. A central dermal fat pedicle is elevated from the breast mound with partial- or
full-thickness lateral “wings” elevated in continuity. The lateral “wings” are wrapped around the
dermal fat pedicle and sutured into place. The base of the flap is sutured to the breast mound.
The donor defect can be closed primarily or reconstructed with a small skin graft. A. Flap design.
B. Flap elevation. C. Formation of the nipple.
Breast
C
donor site. Grafts of tongue, earlobe, toe, and labia have been a small, local skin flap 90° from the plane of the recipient
used, but these donor sites are undesirable and are of mostly breast mound. The nipple graft is sutured to the base of the
historical significance. recipient site and to the local flap edges creating a hybrid,
One of the best methods in unilateral breast reconstruction local flap–composite graft nipple reconstruction. Dressings,
is a composite nipple graft from the contralateral nipple. If similar to those used for local flaps, are employed. The donor
the patient has sufficient projection in the contralateral nipple site is dressed with antibiotic ointment and a bandage. The
and is willing to use it as a donor site, excellent nipple symme- graft dressings are changed 1 week postoperatively, and are
try can be attained. This is an easy technique to perform and dressed every other day with Xeroform for an additional
can readily be accomplished in the office. The patient must be week. Although the graft may appear dark and dusky after
informed that the donor nipple may suffer loss of sensibility 1 week, it is usually pink and viable within 2 to 3 weeks. Over
and erectile and ductile function. The graft can be harvested the next 2 to 3 months, the graft may grow approximately
in several ways, depending on the nipple size and projection. 20% to 30% larger, attaining the appearance of the contra-
If there is sufficient donor nipple projection, a simple transec- lateral nipple.
tion of the distal 30% to 50% of the nipple can be performed.
The donor nipple can be closed primarily with 4-0 chromic, Skin Grafts. Skin grafts can be used to create the nipple–
interrupted, vertical mattress sutures. Alternatively, a central areola complex, often using an ellipse of medial thigh skin.
vertical wedge can be excised closing the defect in a similar The graft is placed over the de-epithelialized, circular, donor
fashion. If the donor nipple does not have a significant pro- site and sutured with a tie-over dressing that is removed
jection to accommodate simple transection, a wedge can be 1 week postoperatively. A separate, central graft is placed
excised along the horizontal axis (analogous to a piece of pie), to simulate the nipple. Alternately, the skin graft is placed
closing the defect primarily. This will diminish the diameter of around a local flap or composite graft. Although skin grafting
the donor nipple but will not alter the projection. The appro- alone may not create significant projection, it may provide a
priate diameter of skin is excised to prepare the recipient site. more three-dimensional areola than areolar tattooing. These
The graft is then placed duct side down and sutured to the grafts, however, are poor color matches to “normal” areolae
skin with 4-0 chromic mattress sutures. Another method, and they do not take up the tattooed pigments readily. The
which increases both the nipple size and projection, raises medial thigh donor site is also undesirable to most patients.

664 Part VI: Breast
in these patients. The use of simple nipple–areola tattooing
Donated (Homograft) Cartilage may be the best option for these patients. The patient must
The use of cartilage is an excellent method of nipple recon- be aware, during the informed consent, that the cartilage is
struction, particularly in prosthetic reconstruction where from an organ donor and there is a theoretical risk of infec-
there might be a soft-tissue deficiency (Figure 63.2). The sur- tious diseases.
geon has complete control over the dimensions of the nipple.
The procedure is applicable to both unilateral and bilateral Technique. A pocket is created to accommodate the nip-
nipple reconstruction, is an easy procedure to perform, does ple graft, which is performed by making an incision approx-
not involve a donor site, and maintains long-lasting projec- imately 2 cm from the position of the nipple. After the skin
tion. A disadvantage of donated cartilage is that the resulting is incised, a double-hook retractor is placed and the sub-
nipple is firm with an unnatural feel. If the grafts are placed cutaneous tissue is carefully dissected down to the pectora-
too superficially and do not have a smooth contour, they lis major muscle or capsule. Gentle dissection is performed
can extrude through the skin, necessitating revision and/or to the location of the nipple position and then spread for
removal. Thin skin flaps or irradiated tissue also make extru- an additional 0.5 cm around the marked dimensions of the
sion more likely and extreme caution should be exercised nipple. Extreme care must be taken not to perforate the
A B
C D
E F
FIGURE 63.2. Nipple reconstruction using costal cartilage. A. The grafts are shaped into the patient-specific dimensions of diameter and
projection. B. The graft is made smooth with a rasp. C. After the skin incision is made, the pocket to accommodate the graft is created with
the gentle spreading of a tenotomy scissor in the plane between the skin and pectoralis major muscle. D. A horizontal mattress suture is placed
from the center of the nipple position, through the graft, and back through the same skin location. E. The graft is inserted into the pocket
employing traction on the suture to guide the graft into position. F. The incision is closed.

c apsule, as this structure is essential in providing the vascu- a two-dimensional entity and results in a flat areola, when com-
larized tissue for the base of the graft. If the skin flaps are of pared with a natural areola. This method will not achieve the
sufficient thickness, the dissection can proceed into the sub- true, three-dimensional appearance of a skin-grafted areola, but
cutaneous tissue avoiding the muscle or capsule, provided can create the illusion with good artwork! Tattooing should be
there is enough soft tissue for the underlying to overlying performed approximately 6 to 8 weeks after nipple reconstruc-
skin to “cushion” the graft. Hemostasis is achieved with a tion, to allow for wounds to heal. While this is an easy office
needle-tip cautery and the wound is irrigated with antibiotic procedure, insurance carriers no longer reimburse for this pro-
solution. cedure, as it is included into the global CPT (Current Procedural
The graft is carved carefully with a no. 10 scalpel to create Terminology) code for the nipple–areola reconstruction. As a
a nipple of the appropriate dimensions. The anterior aspect result, surgeons are now delegating this procedure to outside
(or tip) must be completely rounded and devoid of any sharp sources, including cosmetologists, salons, and other venues.
edges. A no. 5 rhinoplasty rasp can be used to soften and For selected patients, the entire nipple–areola complex can
smooth the anterior surface to prevent potential areas of pres- be created with tattooing. Using basic principles of light and
sure necrosis leading to graft extrusion. The base of the graft shadowing, a three-dimensional illusion can be created. This
should be slightly wider than the tip to create a more natural is particularly useful in patients with prosthetic reconstruc-
shape and 4-0 absorbable suture is placed at the center point tions who have thin, tenuous skin that would not support a
of the nipple location, through the skin, and into the pocket. local flap or graft. Some patients do not wish to undergo addi-
The suture is then placed through the tip of the graft, back tional surgical procedures and may simply opt for tattooing
through the pocket, and out through the center point of the alone. A nipple can be reconstructed at any time thereafter
nipple location (essentially a horizontal mattress suture). It is if the patient desires. Tattoos often fade and approximately
useful to place a forceps into the pocket to prevent inadvertent 60% of patients may require a secondary tattoo session.
puncture of the implant. Using the suture as a guide, gentle
traction is placed on it while the opposite hand pushes the
graft into the pocket and to the appropriate location. Traction
Secondary Cases
on the suture will assure the graft is upright and the suture In cases where a reconstructed nipple has insufficient dimen-
is then gently tied. The skin incision is then sutured with 4-0 sions and there is disparity with the contralateral nipple,
chromic horizontal mattress sutures. Four or five 5-0 chromic, secondary procedures can be performed. Small asymmetries
quilting sutures can be placed around the circumference of the can be rectified with the insertion of a small dermal graft,
graft to define the base of the reconstructed nipple. The avoid- ACM, or cartilage into the base of a local flap. A skin or
ance of overly tight sutures is essential as these can constrict composite graft can be placed on top or around a portion
the dermal blood supply, leading to graft extrusion. An eye of the flap or graft. Autologous fat can be injected into the
pad and adhesive are placed over the graft and left in place base of a local flap as well. For more significant disparities
for 3 to 5 days. The central guide structure is removed 1 week
postoperatively.
Acellular Dermal Matrices. Processed dermis can be used as

an adjunct to local flap reconstruction or as the primary mate-
rial for the nipple. A cylindrical roll of ACM can be created
and placed in front of the dermal fat pedicle of any local flap.
This creates a more rigid “strut” which is then wrapped by the
lateral skin flaps. The dimensions of this strut can be precisely
controlled to achieve the desired dimensions of the nipple. The
Breast
surgeon must pay careful attention when designing the dimen-
sions of the lateral flaps in order to accommodate the added
volume of the ACM strut.
A rectangular sheet of ACM, measuring 4 cm × 2 cm, can
be fashioned into a form of a nipple similar to what is created
from cartilage. It is placed just as was described with the car-
tilage grafts. A cylindrical shape can be created, which usually
creates adequate projection. The 4 cm × 2 cm sheet is rolled
along the long axis where the edges are secured with absorb-
able sutures. The length is then bisected creating congruent
halves. There are cases where more projection is desired or the
mammary skin flaps are “tight” requiring a larger ACM graft.
In these cases, the cylinder tends to collapse on itself losing
projection. A longer rolled graft is made that is sutured end
to end to create a donut shape. This form is more resistant
to the compressive forces, yielding a larger, more projecting
nipple. A disadvantage to ACM is the cost which dramati-
cally increases the overhead of a procedure that is currently
not highly reimbursed.
Nipple–Areola Tattooing
Nipple–areola tattooing is an excellent adjuvant treatment
(Figures 63.3 and 63.4). Because color choice is unlimited,
excellent symmetry is attainable in both unilateral and bilateral
reconstructions. With attention to detail, excellent three-dimen- FIGURE 63.3. A 2-year follow-up of a Penny flap with areolar tat-
sional appearance can be created with the use of basic light and tooing in a transverse rectus abdominis musculocutaneous (TRAM)
shading principles. The Montgomery glands can also be added flap reconstruction.
to achieve a more natural appearance. A nipple–areola tattoo is

666 Part VI: Breast
A B
FIGURE 63.4. A. Bilateral nipple reconstruction with acellular dermal matrix and tattooing. B. Right nipple reconstruction with cartilage and
left nipple reconstruction 10 months after injection with hydroxyapatite (a series of three injections over 9 months utilized).
involving local flaps, a second flap can be raised using the 0.3 to 0.5 cc per session and repeat it every 3 to 6 months
base of the previous flap as the new nipple location. A CV or to build s ufficient projection. Long-term results greater than
fishtail flap is particularly useful in this situation. The use of 1 year are not yet available and this is off-label use of the
long-term injectable fillers can be used to supplement smaller product. Further evaluation is warranted.
nipple deficits.
Conclusion
On The Horizon Although the techniques of nipple reconstruction seem sim-
The use of injectable fillers can be used to create a new nip- plistic compared with those employed in creation of the
ple as well as augment or improve the contours of an estab- breast mound, nipple reconstruction is extremely impor-
lished nipple (Figure 63.5). Dermal substitutes can also be tant. Inappropriate position of the nipple–areola com-
utilized for this as well. However, the costs of these methods plexes on the breast mound leads to an unacceptable result.
may exceed third-party reimbursement, thus limiting their Careful planning is required and the procedure relies on
use. Fillers are easily injected in the office. We raise a wheal the aesthetic judgment of the surgeon. Patient input is also
in the skin using the base of a 3 cc syringe that is spilt on the useful.
side to accommodate the needle. The syringe helps contain Several methods are available for nipple–areola recon-
the filler within the confines of the nipple location. We inject struction. It is important for the surgeon to become
A B
FIGURE 63.5. A. The technique of injecting a dermal filler for nipple reconstruction; the base of a 3 cc syringe, with a slit cut into the side,
accommodates the needle. This device assists in the containment of the material within the confines of the base. This allows for more precise fill-
ing as it diminishes wider dispersion of the material. B. The immediate appearance following injection of 0.3 cc of filler.

familiar with several techniques to meet the various Suggested Readings

challenges of breast reconstruction. Local flaps, with or Anton M, Eskenazi LB, Hartrampf CR. Nipple reconstruction with local flaps,
without skin grafts, are best suited for autologous recon- star and wrap flaps. Perspect Plast Surg. 1991;5(1):67.
struction as there is adequate subcutaneous fatty tissue to Gruber RP. Nipple–areola reconstruction: a review of techniques. Clin Plast
Surg. 1979;6:71.
provide sufficient volume and projection. These methods Jones G, Bostwick J. Nipple–areola reconstruction. Oper Tech Plast Surg.
may not be suited for prosthetic reconstructions where the 1994;1:35.
mammary flaps are thin. In these situations, the grafting Little JW. Nipple–areola reconstruction. In: Spears SL, ed. Surgery of the Breast:
techniques are indicated. The use of tattooing alone may Principles and Art. Philadelphia, PA: Lippincott-Raven; 1998:448.
Little JW, Spear SL. The finishing touches in nipple–areola reconstruction.
be an acceptable alternative in select patients. The use of Perspect Plast Surg. 1988;2:1.
injectable materials is being evaluated with ongoing trials Serafin D, Georgiade N. Nipple–areola reconstruction after mastectomy. Ann
and studies. Plast Surg. 1982;8:29.
Breast

Chapter 64 n Congenital Anomalies of
The Breast: Tuberous Breasts,
Poland’s Syndrome, and
Asymmetry
Kenneth C. Shestak, S. Alex Rottgers, Lorelei J. Grunwaldt, Derek Fletcher, and
Angela Song Landfair
(NAC) begins to form and is completed in the early postnatal

General Considerations— period. Branching and canalization continue after birth and
The Patient, The Family, through early childhood.1
Breast development is relatively quiescent throughout
and The Doctor childhood. Further growth and maturation is initiated at the
Breast appearance in the range of “normal” is of great impor- time of thelarche. With the increased growth at thelarche, the
tance for a young woman’s sexual identity and the percep- breast progresses through a series of morphological stages,
tion of her femininity.1 Deformities of the breast can cause as described by the Tanner classification.2 A Tanner stage 1
issues with clothing, psychological stress, depression, peer breast is prepubertal, with no appreciable breast parenchyma
rejection, and psychosexual dysfunction, particularly in ado- and slight nipple elevation. At thelarche, the breast progresses
lescent females. In the more mature woman, there is potential toward Tanner stage 2 with enlargement of the NAC and ele-
problem with breast feeding. Surgeons should be aware that vation of the breast/nipple as a small mound. Tanner stage 3
congenital breast deformities may be associated with abnor- describes a breast with further enlargement and a smooth
malities of other organ systems such as the genitourinary transition between the breast and areola without separation
system. of their contours. As the breast continues to enlarge toward
Many breast deformities lend themselves to correction or Tanner stage 4, the nipple and areola enlarge more and proj-
reconstruction during or after breast development is complete. ect as a secondary mound above the breast contour. Finally,
Since the breast evolves with time, and future revisions may at the final Tanner stage 5, the breast achieves its mature size
be required, the timing and method of reconstruction is deter- and form. The areola has receded and forms a continuous
mined only after a detailed discussion with the patient and her contour with the surrounding breast.2 Most females would
family. They must understand the realities and the limitations have achieved full breast maturity by 16 to 18 years of age;
of a proposed procedure. Honest communication is central to however, the evolution of the breast form continues as a life-
the process of informed consent and is the foundation of a long process.
healthy doctor–patient relationship.
Pediatric breast deformities are divided into hyperplas- Hypoplastic Disorders
tic, hypoplastic, and posttraumatic defects. Each repre-
sents various pathologic entities and a spectrum of disease Various conditions result in hypoplasia or aplasia of the
which warrants consideration on an individual case basis. breast. Hypoplasia in the form of mild asymmetry, constricted
Treatment goals focus on accurate diagnosis, appropriate breast deformities, and mild presentations of Poland syn-
timing, and technique selection in order to optimize the cos- drome is much more common than aplasia of the breast. Both
metic outcome and best satisfy the psychological needs of the constricted breast deformity and Poland syndrome will be
the patient. discussed in depth below.
Terms used to describe breast aplasia include athelia, iso-
lated absence of the NAC; amasia, absence of breast paren-
Embryology and Development chyma; and amastia, absence of both the breast tissue and
Breast development begins between the fifth and seventh the NAC.1 Though this nomenclature would suggest other-
weeks of uterine life. At this time, the mammary lines form wise, athelia and amasia do not seem to occur without each
as bilateral linear condensations of ectoderm extending from other. These conditions and their distinctions are delineated
the axillary areas to the inguinal regions. This ectoderm by Trier.3
comes to lie below the surface of the embryo and at this
point they are called the mammary ridges or milk lines which Hyperplastic Disorders
can potentially form the breast tissue (Figure 64.1A). In most Hyperplastic disorders include the excess development of
instances, however, only a small focus of mammary tissue mammary tissue in an otherwise normal anatomic location
overlying the thoracic region in the region of the fourth as well as the development of breast tissue or nipple–areolar
intercostal space (ICS) persists while those in the other areas structures in locations remote from the normal thoracic dis-
regress. The tissue aggregate in the fourth ICS continues tribution. Treatments require simple observation, excision, or
to divide and thicken, and by the eighth gestational week breast reduction techniques. Accurate diagnosis and assess-
ectoderm has invaded into the underlying mesenchyme in a ment of the severity of the deformity is essential, along with
branching pattern. At 16 weeks of gestation, 15 to 25 epithe- counseling the patient and the family.
lial branches have formed, but canalization has not begun. It
is during the third trimester, under the influence of placen-
tal sex hormones (mainly estrogen and progesterone), that Virginal Hypertrophy
these epithelial branches are canalized, and primitive breast Virginal hypertrophy of the breast is a rare condition that
ducts begin to form. At 32 weeks, differentiation of the results in excessive, rapid, and often non-yielding prolifera-
parenchyma into lobules begins. The nipple–areolar complex tion of breast tissue. The etiology is unclear, but pathologic
668
Chapter 64: Congenital Anomalies of the Breast: Tuberous Breasts, Poland’s Syndrome, and Asymmetry 669
FIGURE 64.1. The topography of polymastia. A. The milk line

extending from the axilla to the groin. B. A patient with bilateral
polymastia with breasts in the axilla and polythelia as demonstrated
Polythelia by nipple–areola complexes on them.
Breast
A Polymastia
evaluation seems to suggest an abnormal sensitivity of the The treatment is also surgical excision. This is accomplished
glandular tissue to the stimulatory effect of estrogen in the set- through breast reduction techniques with a pedicle design
ting of normal hormonal levels. The condition may be unilat- and excision pattern that incorporates the mass into the
eral or bilateral. Patients often exhibit a rapid onset of breast resection specimen and positions the pedicle in the loca-
hypertrophy only months after the initiation of breast growth tion of the greatest amount of normal breast tissue to pre-
that quickly becomes symptomatic with the typical signs of serve breast fullness.5 Concurrent matching procedures on
macromastia (shoulder and neck pain, bra strap grooving, and the contralateral breast or delayed mastopexy/augmentative
rashes) along with tender breast parenchyma, thinned skin, procedures may be required to achieve symmetry. Timing for
striae, and dilated veins. They will generally present because surgery is driven by the rate of tumor growth. Excision may
of the rapid progression.4 be necessitated prior to completion breast development to
Treatment is ultimately surgical. Breast reduction tech- limit the distortion of the breast and to optimize the aes-
niques are standard as a first-line therapy, and goals should thetic result.
be to first achieve an improved breast size and symptom relief. The differential diagnosis for fibroadenoma includes cys-
Improved symmetry in asymmetric cases of hypertrophy is also tosarcoma phyllodes, which can be difficult to differentiate
important. Some patients require additional breast reduction based on a biopsy. Since the incidence of phyllodes tumor is
operations, and mastectomy may be considered in refractory less than 1.3%, treatment should include simple excision of
cases.4 Pharmacologic therapy in the form of medroxyproges- the mass followed by consideration for mastectomy or adju-
terone acetate, dydrogesterone, tamoxifen, and bromocriptine vant therapy if the diagnosis of a malignant phyllodes tumor is
have been employed in the past but side effects have limited made.6 Consultation with surgical oncology or pediatric sur-
their use.1,4 gery is appropriate in this circumstance.
Giant Fibroadenoma Polythelia/Polymastia

Like virginal hypertrophy, giant fibroadenomas result from Polythelia, the presence of accessory nipples, is a common
abnormal sensitivity of the breast tissue to normal hormonal pediatric abnormality and has a reported incidence as high
levels. This entity is a discrete benign tumor that enlarges as 5.6%.1 Polymastia, the development of supernumerary
rapidly and causes asymmetric enlargement of the breast. 5 breast tissue, with or without a nipple or areola, is much less

670 Part VI: Breast
common. Both are presumed to arise from an incomplete authors’ preferred method. Severely redundant skin may be
regression of the mammary ridge during embryonic develop- excised primarily with a periareolar or vertical skin excision,
ment, leaving residual mammary tissue along the “milk line” but we believe that the significant elasticity of youthful skin
between the axilla and inguinal region. Supernumerary nip- often allows adequate retraction of skin excess such that pri-
ples typically occur caudal to the true nipple and can pres- mary skin excision is not warranted in most cases. If the skin
ent as a partial or complete nipple, partial or complete areola, redundancy persists beyond 6 to 12 months postoperatively,
or a combination. They may be isolated or multiple. While excision is undertaken.9 Care is taken during resection to
supernumerary nipples are often found during the neonatal avoid over-resection and the creation of a “dishing” or nip-
period or childhood, accessory breast tissue, either with or ple retraction. Regardless of the technique used, postopera-
without an accessory nipple, is often not identified until the tive care involves the use of closed suction drains following
tissue hypertrophies because of puberty, pregnancy, or lacta- excision, prolonged compressive garment application (for at
tion. Polymastia most often occurs with axillary breast tissue7 least 6 weeks), and twice-daily deep tissue massage instituted
(Figure 64.1B). Some authors differentiate the terms “poly- at 1 week postoperatively along with abstinence from heavy
mastia” and “ectopic breast tissue.” When used strictly, poly- exercise for 1 month. These adjuncts aid in tissue re-draping,
mastia refers to breast tissue occurring along the “milk line.” reduce edema, and limit formation of seroma and hematomas.
“Ectopic breast tissue” refers to the remarkably rare occur- The cited references8,9 provide an excellent overview of the
rence of breast tissue in other locations in the body. subject.
Supernumerary breast tissue may be removed surgically
with placement of closed suction drains. If left in situ, regu-
lar monitoring for breast pathology and malignancy must be Developmental Breast
performed, as this accessory mammary tissue is subject to an Asymmetry—Approaches
equal rate of breast malignancy as the normally positioned
gland. Treatment of a mass arising within this tissue must be
To Treatment
treated with the same oncologic principles as any breast mass.7 Both hypoplastic and hyperplastic breast disorders represent
a spectrum of disease. Patients often present with bilateral
manifestations of breast hypoplasia, breast constriction, and
Gynecomastia hyperplasia. Significant asymmetries can result due to variable
Though usually seen by plastic surgeons in its most severe expressions of these entities. The key to achieving an outcome
form, gynecomastia is by far the most common pediatric that pleases both the patient and the surgeon is to correct
breast deformity occurring in up to 65% of pubescent males.8 identification of abnormalities producing the asymmetry.
Gynecomastia is a clinical term denoting enlargement of the The breast morphology is examined to determine whether the
male breast such that it appears female. It is most often related problem is unilateral or bilateral. As discussed below, bilateral
to proliferation of ductal epithelium as no true acinar develop- correction is usually required.
ment occurs. Most often it is idiopathic in its etiology, but the An essential aspect in formulating a treatment approach is
proliferation can be a symptom of an underlying pathologic understanding what the patient perceives as abnormal, which
process. “Physiologic” gynecomastia is common during three breast she feels is preferable, and what her goals of treatment
periods of a male’s lifespan. Neonates often exhibit small are. Patient and family are educated that breast symmetry
enlargement of the breast bud and may secrete colostrum tran- and contour will be improved but perfection is not realistic.
siently as a response to maternal estrogens. As stated above, Perfection, the goal of every procedure, is rarely achieved.
the fluctuating hormonal milieu of early puberty p roduces If patients understand this before surgery, they are generally
gynecomastia in up to 65% of males between 14 and 16 years pleased with the result.
of age, and declining androgen production seen in later life In some instances, it is possible to operate on one breast,
can lead to a relative estrogen excess and to the development most often when a breast reduction alone will produce
of gynecomastia. If other signs of pubertal development are improved symmetry. In our experience, the best and most per-
present, a standard history and physical suffices for evalua- manent results are seen in cases of breast asymmetry where
tion, but in the absence of normal pubertal development, a a patient has a smaller, but aesthetically pleasing breast and
more extensive evaluation is required. In most males, pubertal wants the larger breast reduced to match the smaller breast. A
gynecomastia is mild and transient.1 breast reduction or mastopexy can improve symmetry, correct
While gynecomastia may be considered normal in these age ptosis in the larger breast, and avoid the potential problems
groups, a history and physical exam should be performed to of implant-based reconstruction/augmentation. A unilateral
rule out common causes such as testicular cancer, pituitary reduction mammoplasty limits the number of variables at
tumors, adrenal tumors, liver disease, paraneoplastic syn- play, increasing the predictability of the final outcome.
dromes, Klinefelter’s syndrome, thyroid disease, renal failure, In most cases, the clinical scenario is not so simple how-
myotonic dystrophy, human immunodeficiency virus, mari- ever. In our experience, most surgical procedures involve
juana use, alcohol, anabolic steroids, and medications known bilateral surgery. Differential reductions, mastopexies, aug-
to cause gynecomastia.1,8 The most common etiology of gyne- mentations, and most frequently combinations of these must
comastia in adolescents is idiopathic, while in patients over 40 be employed to achieve the most harmonious balance between
years of age it is most often drug induced. the breasts. Careful consideration is given to each breast and
When significant gynecomastia persists for 2 years beyond each breast abnormality within the context of the patient’s
puberty, surgery is often indicated to recreate a normal chest expectations. An explanation of surgical details such as inci-
contour and nipple location with limited scaring. The first pro- sion placement and a discussion of implant complications are
cedures described for gynecomastia focused on subcutaneous provided. In addition, the patient is informed that the breast
mastectomy through periareolar or various other incisions.1 appearance will most likely change with weight fluctuation,
This remains the best approach in cases of dense fibrous tissue pregnancy, and aging regardless of the procedures undertaken.
that is located in a subareolar plane. Others have advocated The important elements of an informed consent are explained
the use of ultrasound-assisted liposuction as the standard to both the patient and her parents.
first-line approach followed by secondary excision only for Timing for reconstruction is also addressed with the
a marked residual deformity.8 The ideal approach in most patient and her family. As the breast is constantly developing
cases is a combination of these, with direct periareolar exci- and evolving in form, it is usually best to delay treatment until
sion of the central, fibrous breast bud followed by liposuc- the patient has finished growing and her breasts are mature
tion to contour the peripheral breast area representing the (patients who are 16 years of age or older).

We employed this strategy in the patient shown in Case 2. this strategy when two postmastectomy patients were lost to
She was seen at age 15 with a combination of right breast follow-up after placement of their tissue expander and subse-
hypoplasia with breast constriction and left breast hypertro- quent expansion. The patients did not return for placement
phy (Figure 64.2A, B). The best approach was to wait until of their permanent prostheses until years later. In the interim,
the summer prior to her senior year in high school at which they had no complications and exhibited breast contours that
time she underwent a periareola augmentation/mastopexy were appealing. Placement of a tissue expander should not be
on the right side with the partial subpectoral placement of a considered definitive reconstruction, but it offers a means for
saline implant and a left vertical mastopexy. She is shown at a young patient to have her emotional and social concerns
4 months following surgery (Figure 64.2C, D) with improved centered around a significant breast asymmetry addressed in
symmetry. a timely manner and in a way that can be adjusted as she con-
Earlier intervention can be considered in cases of more severe tinues to grow. It also limits the risks of compromising her
deformities in a setting of a patient who appears to be mature ultimate outcome once she has reached maturity.
before age 16 years. When surgical procedures are undertaken
in these younger patients, future revisions are more common.
Another approach to this problem is placement of a breast Summary of Key Features
tissue expander followed by immediate expansion to correct of Congenital Breast
for the current asymmetry. If patients are young and likely
to have continued maturation of their breast, this expander
Asymmetry(IES)
can be left in place with subsequent adjustments made to Treat the patient and manage the family. Select the best
the volume over a period of months to years. The ultimate procedure(s) and optimal time for surgical intervention and
exchange for a permanent prosthetic can be made when the explain your recommendations to both the patient and the
patient has fully matured, and she desires the completion of family. Bilateral procedures are more common than unilateral
her reconstruction. The senior author (KCS) first encountered procedures. Short scar mammoplasty techniques—both breast
Breast
A B C
D E F
FIGURE 64.2. A. A 16-year-old patient with right breast hypoplasia and left breast hyperplasia. B. The plan for right dual lane breast augmentation
and left vertical breast reduction. C, D. Pre-op AP and oblique views of the breasts. E, F. Four-month postoperative breast appearance.

672 Part VI: Breast
reductions and mastopexies—are preferable. 10 The surgeon

must stress that the goal of the procedure is improvement Etiology
rather than perfection. Most often the patients and their fami- The definitive etiology of tuberous breast deformity is
lies are highly appreciative of the surgical outcome. unknown; however, the theory proposed by Grolleau et al.14
seems to most aptly fit the clinical picture. They proposed
anomalous superficial fascial adhesions between the dermis
The Spectrum of Breast and the underlying muscular plane. The adhesions restrict
Constriction or The Tuberous normal development of the breast parenchyma and overly-
Breast Deformity ing skin envelope in the lower pole. The restriction favors,
instead, growth of the breast away from the chest wall, lead-
Tuberous breast deformity describes a spectrum of aberrant ing to the formation of tuberous shape and enlargement of the
breast morphology first reported by Rees and Aston.11 The areola as the breast develops during adolescence.14 Mandrekas
term “tuberous breast” refers to the similarity in shape of et al.15 hypothesized that the deformity results from a combi-
affected breasts to a tuberous plant root. Since its original nation of an abnormal constricting fibrous ring surrounding
description in 1976, multiple authors have reported similar the periphery of the NAC and a normal superficial fascial win-
anomalous breast deformities under various names, includ- dow beneath the areola. Because the ring density is highest in
ing Snoopy breast, constricted breast, tubular breast defor- the lower pole, the developing adolescent breast is unable to
mity, lower pole hypoplastic breast, narrow-based breast, expand inferiorly and is forced to grow away from the chest
herniated areola complex, domed nipple, and nipple breast. wall, toward the superficial fascial window beneath the are-
The most commonly used term now is the “constricted ola. It is the degree of superficial fascial aberrancy that deter-
breast.” mines the degree of severity of the deformity.15
Clinical Features Classification

Tuberous breast deformity describes a broad spectrum of The broad spectrum of deformity and inconsistent nomencla-
aberrant breast shape that presents during adolescent breast ture used to describe tuberous breasts has led to the formation
development. The degree of deformity varies on a continuum of several classification systems. Von Heimburg13 stratified
from mild to severe.12 Affected breasts demonstrate a constel- tuberous deformities into four subtypes based on the degree of
lation of findings, each with variable degrees of contribution breast base constriction and subareolar skin deficiency:
to the deformity as a whole. These findings include:
Type I: hypoplasia of the lower medial quadrant
Constricted breast base or narrowed breast “foot print” Type II: hypoplasia of the lower medial and lateral
Contracted skin envelope in both vertical and horizontal quadrants with sufficient skin in the subareolar area
dimensions Type III: hypoplasia of the lower medial and lateral
Hypoplasia of the breast parenchyma quadrants with a deficiency of the subareolar skin
Elevated inframammary fold (IMF) Type IV: severe breast constriction with minimal breast
Short NAC-to-IMF distance (“high tight fold”) base
Herniation (or pseudo-herniation) of breast parenchyma
into the NAC Grolleau et al.14 simplified the Heimburg classification into
three types by combining types II and III:
The key features of tuberous deformity are lower pole skin
envelope deficiency in the vertical and horizontal dimensions, Type I: lower medial quadrant deficiency
parenchymal hypoplasia, and constriction of breast develop- Type II: lower medial and lateral quadrant deficiency
ment in the lower pole. Pseudo-herniation of the NAC is a Type III: deficiency of all four quadrants
common but not constant feature of tuberous breast defor- This latter classification is most commonly used by the
mity, occurring in 40% and 50% of cases. However, breasts authors (Figure 64.3).
that are more severely affected and/or asymmetric tend to
demonstrate greater degrees of NAC involvement, including Surgical Approach
enlargement of the areola and herniation of underlying paren-
chyma into the NAC.12-14 Aesthetic surgery of the tuberous breast poses a challenge to
There is no a consensus in the literature regarding what the plastic surgeon. The broad spectrum in aberrant breast
degree of deformity predominates. Grolleau et al.14 reported shapes requires a systematic approach to consistently achieve
a predominance of mild deformity (54%), Von Heimburg satisfactory outcomes. Once the diagnosis is established, every
reported a predominance of moderate/severe deformity effort must be made to accurately analyze the deformity.
(44%), and DeLuca-Pytell et al.12 reported a predominance of Careful consideration as to the severity of deformity, pres-
severe deformity (60.3%). Either unilateral or bilateral breast ence or absence of asymmetry, and the quantification of the
involvement may occur, though reports in the literature vary various morphological elements contributing to the deformity
as to which presentation is more common.12-14 should be measured and noted. This includes discrepancies in
IMF level, the nipple to fold distance, the suprasternal notch
to nipple distance, the breast and chest base width dimensions,
Incidence the patient’s torso dimensions, and an estimate of her native
The incidence of tuberous breast deformity among the general breast tissue and any asymmetries of the parenchyma. Once
population is not known. The incidence of tuberous breast the deformity has been accurately assessed and classified, the
deformity among patients with breast asymmetry seeking aes- patient (and her parents) should be engaged in a thorough dis-
thetic breast surgery has been reported. In their retrospective cussion regarding the various elements of her deformity, the
review of 375 women presenting for mammaplasty, DeLuca- proposed treatment, challenges and limitations of operative
Pytell et al.12 found a strong association between tuberous intervention, possible complications, and appropriate expec-
deformity and asymmetry. Of the 375 women included in the tations regarding outcome.
study, 81.1% were found to have asymmetric breasts. Of the The goals of surgery are to restore volume to the hypoplas-
women demonstrating asymmetry, 88.8% were found to have tic breast(s), expand the lower pole by releasing the tethering
some degree of tuberous breast deformity. Conversely, tuber- fibrous attachments or bands between the breast parenchyma
ous deformity was noted in only 7% of patients with symmet- and deep fascial and pectoralis muscle and also between the
ric breasts. breast parenchyma and skin, and where necessary reduce the

planned. Saline implants or silicone gel breast implants may be
used. Saline devices offer the advantage of mild adjustability
in this population where native breast volume asymmetry is
so prevalent. There must be an increase in the base dimensions
of the breast in terms of both width and height. In the vast
majority of cases, the procedure can be carried out in a single
stage. A two-stage procedure, which entails tissue expander
placement followed by implant insertion at a second stage, is
usually reserved for only the most severe cases.
A typical patient is illustrated in Figure 64.4A–F. This ado-
lescent female presented at age 17 with severe bilateral breast
hypoplasia and a Grolleau type III constriction of both breasts
(Figure 64.4A–F) with significant hypoplasia and pseudo-her-
niation of breast tissue through the areola. The surgical plan
entailed the partial retropectoral placement of 330 cc mod-
erate profile, smooth-surfaced, saline implants using a dual-
plane approach incorporating a circumareolar mastopexy
with Gortex suture. The 30-month postoperative follow-up
evaluation demonstrates (Figure 64.4D–F) improvement in
breast appearance from the standpoint of volume, contour,
and nipple–areola appearance.
In summary, the key features of treatment include an assess-
ment of the unique of features associated with each individual
deformity and restoring the mammary base dimension and
addressing the shortened nipple to fold distance by lowering
the IMF. This is accomplished by release of constricting bands
between the breast parenchyma and the deep fascial/muscle
tissue and placing a prosthetic implant in the dual plane posi-
tion. When pseudo-herniation of the NAC is present this is
reduced and the size of the areola is controlled through a cir-
cumareolar mastopexy approach. An important principle is to
address the breast asymmetry by altering procedures on each
breast accordingly. At this point in time, a prosthetic implant
is the mainstay in providing increased volume to the breast;
however, the injection of autologous adipose tissue17 if avail-
able is likely to play an increased role in these patients in the
near future.
Poland’s Syndrome
Poland syndrome (Poland anomaly) is a rare congenital
malformation.1,18 Although named after a medical student
Breast
and anatomist Alfred Poland, the condition was originally
described by Lallemand in 1826. These initial findings were
later reiterated by Poland in 1841 at Guys Hospital in London
who gave a precise description of the condition.18 Poland syn-
drome is associated with various degrees of thoracic and ipsi-
lateral upper extremity anomalies. Pathognomonic of Poland
syndrome is the agenesis of the sternocostal head of the pecto-
ralis major muscle.
The classic dysmorphogenesis of Poland’s syndrome
includes ipsilateral breast hypoplasia or aplasia, hypoplasia or
aplasia of other chest wall muscles, bony or cartilage abnor-
malities of rib and sternum, and ipsilateral upper limb anoma-
lies. The association with complex syndactyly was made by
Floriep in 1939.
The incidence of Poland’s syndrome is estimated at
1 in 30,000 to 1 in 100,000 live births, with the majority of
FIGURE 64.3. The Grolleau classification (types I–III) of breast cases being sporadic.1 The incidence is higher in men than for
constriction by anatomic location of the constriction on the breast women at 3:1, and the right side is often more affected than
mound. the left by 3:1.1,19 However, many men remain undiagnosed
unless they seek treatment for hand anomalies. The accom-
panying ipsilateral upper extremity deformity can manifest
as shortened upper arm, forearm, or fingers, termed brachy-
areola size and recess the herniated breast tissue. These are best symphalangism. Webbing of the ipsilateral fingers can occur.
accomplished with an infra-areolar incision which provides Fusion of the carpal bones, absence of the middle phalanges,
direct access for the release of the constricting fibrous bands and variable syndactyly are frequent presentations. The fre-
and for placement of an implant—most often in a dual plane16 quency of hand abnormalities in the Poland syndrome patient
(i.e., in the subpectoral space superiorly and the sub-glandu- is 13.5% to 56%. However, the diversity of the clinical
lar space inferiorly16). The incision can be easily converted expression most probably causes an underestimation of the
to a circumareolar incision if a circumareolar mastopexy is frequency of Poland syndrome.19

674 Part VI: Breast
A B C
D E F
FIGURE 64.4. A. Preoperative AP, (B) lateral, and (C) oblique views of an 18-year-old patient with a Grolleau type III constricted breast defor-
mity treated dual-plane saline breast augmentation and circumareolar mastopexy using 11.9 cm moderate profile implant with 320 cc saline and
interlocking Gortex mastopexy. At 2 years following surgery the (D) AP, (E) lateral, and (F) oblique appearances of the breasts are shown.
The most obvious deformities presenting to the clinician breast hypoplasia or aplasia leads to the most clinically signifi-
are limb anomalies in both females and males and ipsilateral cant deformity for which patients seek surgical correction. The
hypomastia in females. Foucros classification of Poland’s syndrome assigns a mor-
Breast deformity in the female is highly variable, ranging phologic grade according to the severity of the deformities.18
from mild hypoplasia to aplasia. The typical breast deformity
is marked by deficient parenchyma, high IMF, and a high and Etiology
underdeveloped NAC. About 14% of breast aplasia may be
The etiology of Poland syndrome is unknown. The most
accounted for by Poland’s syndrome.1 In 20% of cases, there
popular theory is the subclavian artery disruption sequence,
are associated skeletal deformities leading to contour and rota-
a vascular compromise event that occurs during critical sixth
tional anomalies of the chest wall. Ribs are typically deformed
and seventh weeks of gestation. Reduction in blood flow at
and hypoplastic, particularly second through fifth ribs.
crucial periods or hypoplasia of the internal thoracic artery
Poland’s syndrome is sometimes referred to as “acro-pecto-
could lead to disruption in pectoralis major development,
ral renal field defect” due to a high incidence of renal anomalies.
where hypoplasia of the branches of brachial artery during
The most common anomalies include duplication of the collect-
development could lead to symbrachydactyly.1
ing system of unilateral renal agenesis.1 Associations between
Poland syndrome and breast cancer and other malignancies
have been documented.21-23 Breast hypoplasia does not preclude Clinical Classification
development of breast carcinoma. The most commonly associ- The classification of Poland’s syndrome is a difficult task due
ated syndromes are Mobius and Klippel-Feil syndromes.22 to the variability of the clinical picture. The Foucras classifi-
In both men and women, agenesis of the sternoclavicular cation,20 which classifies the Poland’s syndrome patient into
head of pectoralis major causes a subclavicular hollowing as mild, moderate, and severe categories, adequately describes
well as the absence of the anterior axillary fold. In women, the clinical findings based on the degrees of thoracic deformity.20

Grade I: Minor deformity consisting of pectoralis major
hypoplasia and moderate breast hypoplasia resulting in breast Autologous Tissue Transfer
asymmetry in women but only slight chest wall asymmetry in Pedicled LD myocutaneous flap reconstruction, with or with-
men. Nipple areola is present, but often smaller and elevated. out an accompanying implant, has been considered a mainstay
No skeletal abnormalities should be found in a class I patient. of treatment in patients with moderate to severe chest wall
Grade II: Moderate deformity with marked pectoralis deficiency and breast agenesis or hypomastia. The potential
major aplasia, hypoplasia of other chest wall muscles, moder- benefits are ease of harvest, replacement of pectoralis major
ate rib deformity, and marked chest wall deformity in men and with similar tissue, and relative ease compared with microsur-
women. Breast tissue is severely hypoplastic or absent and the gical reconstruction.
nipple–areola is hypoplastic or absent. In men, grade II is best This strategy was used in the patient depicted in Figure
addressed with a customized chest wall implant, a latissimus 64.5A–D. She presented at age 18 with a right unilateral
dorsi (LD) or other free microvascular flap, with or without Poland’s syndrome with severe breast hypoplasia, including
autologous fat injections. In women, the LD flap with tissue a superiorly malpositioned NAC and absence of the antero-
expansion and implant may be affective. Adjunctive autolo- lateral axillary fold (Figure 64.5A). There was a deficiency
gous fat transfers can improve symmetry. Chest wall muscles of anterior chest wall and breast skin. The plan was for a
affected may include the muscles to the pectoralis major, two-stage reconstruction with the initial step being slow,
including the serratus anterior, LD, and external oblique. gradual expansion of the breast and chest wall skin (Figure
Grade III: Severe deformities demonstrate aplasia of breast 64.5B). Subsequent to this the patient underwent removal
and pectoralis major as well as aplasia of other chest wall of the expander along with harvest of the right LD muscle
muscles, major bone, and cartilage anomalies with rib aplasia flap through the limited back and high axillary incisions.
and sternal deformity, and major chest wall deformity in men The LD flap was inset (Figure 64.5C) to the parasternal area
and women. In both men and women, the treatment involves and to the inframammary region through the inframammary
several stages. Complicating the reconstructive ladder, grade incision used for the tissue expander placement. A 300 cc
III patients also often have absent or severely hypoplastic LD saline implant was placed beneath the LD flap. The patient
muscles. Free flaps may be the best options such as contralat- is shown 1 year following the second stage of the reconstruc-
eral free LD flap with an implant or a reconstruction based tion (Figure 64.5D) with an improvement in the appearance
on abdominal tissues. Primary skin expansion may often be of her breasts.
necessary. Outcomes are often less than satisfactory and serial The greatest limitation of this operation is that the LD
fat injections help balance the soft tissue defect. is often deficient and or absent in the more severe Poland’s
patients, leading to inadequate tissue bulk or deficient vascu-
Treatment lar supply. In addition, the harvest of LD flap may decrease
the function in an upper extremity that may already have
Surgical treatment of Poland’s syndrome focuses on improv-
decreased function compared with the contralateral extremity.
ing function of the affected limb and improving chest wall
TRAM flaps have been used frequently in Poland patients.
appearance. The chest deformities of Poland syndrome rarely
Pedicled TRAMs may encumber the young, active patient with
cause functional problems except in the most severe cases.
significant abdominal morbidity. Free microvascular TRAM
Indications for thoracic surgical intervention include sig-
flaps have been used successfully. Other free tissue transfer
nificant chest wall depression, inadequate protection of the
options include the deep inferior epigastric artery perforator
mediastinum, or paradoxical movement of chest wall dur-
(DIEP), the superior gluteal artery perforator, and superficial
ing respiration. Hand anomalies should be corrected prior to
inferior epigastric artery flap for the treatment of moderate
1 year of age to maximize functional outcomes.
to severe Poland syndrome with breast hypoplasia or apla-
In most women, surgery for Poland’s syndrome is for the
sia. Longaker et al.24 published a series of nine patients who
Breast
correction of breast aplasia or hypoplasia. In the absence
underwent free tissue transfer for Poland syndrome chest wall
of severe chest wall anomalies, waiting until after puberty
reconstruction. Gautam et al.25 reported a series of 12 patients
affords the best chance of maximizing symmetry. In the
who underwent free perforator flap reconstructions. Thirty
Poland’s patients with severely hypoplastic NAC or athelia,
percent of these patients required revision surgery, but there
nipple–areolar reconstruction is the appropriate final stage of
was no flap loss. Most recently, Blondeel (personal communi-
reconstruction. Contralateral breast procedures may be per-
cation) has combined the use of a DIEP with serial “lipofill-
formed for symmetry if desired, including reduction mamma-
ing” of the transferred tissue flap to produce excellent results
plasty, mastopexy, or augmentation mammaplasty.
(Figure 64.5). It should be noted that high rates of subclavian
The challenges to aesthetic breast reconstructions in the
arterial hypoplasia and anomalous venous return have been
Poland’s patient include the tight and unforgiving skin enve-
reported in Poland syndrome. Preoperative vascular imaging
lope, deficient subcutaneous tissue, high IMF, NAC malpo-
with a computed tomography angiogram or ultrasound may
sition or absence, and adequacy of recipient vessels if a free
aid in planning a free flap reconstruction.
flap reconstruction is desired. Often, a variety of treatment
modalities must be combined to produce optimal results.
Autologous Fat Injection
Expander and Implant Reconstruction Coleman’s technique of fat grafting is desirable due to low
Grade I patients and many grade II patients may be treated invasiveness and mobidity.17 Pinsolle and colleagues used
with implants alone. A single-stage correction with a submus- autologous fat injections in a series of eight patients (mean age
cular implant can produce suitable results. For implant recon- 25) with fat harvested from abdominal or trochanteric areas;
struction to be successful, the patient must have adequate soft fat necrosis occurred in one patient. They noted that fat injec-
tissue thickness on the affected side to cover and camouflage tion can be used in conjunction with other procedures and is
the implant. A tight skin envelope, high and tight IMF, and especially useful in filling the subclavicular hollowing seen in
soft tissue deficiency can prove challenging for reconstruction even the mildest cases of Poland’s patients.
with an implant alone and prompt tissue expander placement. At this particular time, serial fat transfer optimizes out-
With expansion of the upper chest skin, a malpositioned NAC come when used as an adjunct to postmastectomy breast
may descend to a more symmetric position (Figure 64.5). reconstruction. However, we would predict and anticipate
Implants are frequently utilized in Poland syndrome but as that autologous adipose transplantation via injections will
with their use in other locations, they are not without draw- play a substantially larger role in the breast reconstructions
backs and morbidity. performed in patients with breast hypoplasia accompanying

676 Part VI: Breast
B
A
FIGURE 64.5. A. A 19-year-old patient with Poland’s syndrome

exhibiting marked hypoplasia of the right breast and absent antero-
lateral breast fold and superiorly displaced nipple–areola complex
(NAC). B. Initial stage of reconstruction with placement of tissue
expander to modify skin envelope and achieve slight lowering of the
NAC. C. Reconstruction of the subcutaneous tissue and anterolateral
breast fold using a right latissimus dorsi muscle flap and placement of
260 cc saline implant beneath the flap. D. A 3-year postoperative AP
view demonstrates correction of the deformity. (This case courtesy of
Dr Julian J Pribaz.)
C
Poland’s syndrome and also in the correction of other congeni- implant, autologous, or combined implant–autologous recon-
tal and developmental breast deformities in the future.26 structions, with the patient and explain which option is best.
Autologous tissue techniques are becoming more common.
Finally, the work of Khouri26 strongly suggests that the trans-
Keys To Reconstruction of fer of free autologous fat grafts will increase in popularity,
Poland’s Syndrome especially if accompanied by external expansion (FN). This
technique of “lipo-filling” or larger volume fat transfer can be
In summary, the keys to reconstructing the breast in the patient
combined with the microvascular transfer of tissue from the
with Poland’s syndrome are to carefully assess the severity of
abdomen which can provide a recipient bed for the tissue.25
the patient’s breast deformity and accompanying soft tissue
and skeletal deformity(ies). Particular attention is paid to the
quantitative skin deficiency and also to the quality of the exist-
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Plast Reconstr Surg. 2003;111:909-923. series and thoracomammary reconstruction. Report of 27 cases. Ann Chir
9. Hammond DC. Surgical correction of gynecomastia. Plast Reconstr Surg. Plast Esthet. 2003;48:54-66.
2009;124(1s):61e-68e. 21. Havlik R-J, Sian K-U, Wagner J-D, Binford R, Broadie T-A. Breast cancer in
10. Hall-Findlay EJ. A simplified vertical reduction mammaplasty: Poland syndrome. Plast Reconstr Surg. 1999;104:180-182.
shortening the learning curve. Plast Reconstr Surg. September 1999; 22. Shaham N, Ramu N, Bar-Ziv J. Lieomyosarcoma in Poland syndrome. Acta
104(3);748-759. Radiol. 1992;33:444.
11. Rees T, Aston S. The tuberous breast. Clin Plast Surg. 1976;3:339. 23. Ahn MI, Park SH, Park YH. Poland syndrome with lung cancer. A case
12. DeLuca-Pytel DM, Piazza RC, Holding JC, Snyder N, Hunsicker LM, report. Acta Radiol. 2000;41:432.
Phillips LG. Plast Reconstr Surg. The incidence of tuberous breast deformity 24. Longaker MT, Glat PM, Colen LB. Reconstruction of breast asymmetry in
in asymmetric and symmetric mammaplasty patients. 2005;116:1894. Poland’s chest wall deformity using microvascular free flaps. Plast Reconstr
13. Von Heimburg HD. Refined version of tuberous breast classification. Plast Surg. 1997;99:429.
Reconstr Surg. 2000;105(6):2269. 25. Gautam AK, Allen RJ, LoTempio MM, Mountcastle TS, Levine JL, Chiu
14. Grolleau J, et al. Breast base anomalies: treatment strategy for tuberous MD. Congenital breast reconstruction using perforator flaps. Ann Plast
breast deformities and asymmetry. Plast Reconstr Surg. 1999;104:2042. Surg. 2007;58:353.
15. Mandrekas AD, Zambacos GJ, Anastasopoulos A, Hapsas D, Lambrinski 26. Khouri R, Del Vecchio D. Breast reconstruction and augmentation
N, Ioannidou-Mouzaka L. Aesthetic reconstruction of the tuberous breast using pre-expansion and autologous fat transplantation. Clin Plast Surg.
deformity. Plast Reconstr Surg. 2003;112:1099. 2009;36:269.
Breast

part VII
n Body Contouring
Chapter 65 n Liposuction

Mary K. Gingrass
Liposuction is the surgical aspiration of fat from the subcu- regimen for at least 6 to 12 months indicates the necessary
taneous plane leaving a more desirable body contour and a commitment to lifestyle change.
smooth transition between the suctioned and the nonsuc- Liposuction should not be offered as a treatment for obe-
tioned areas. Liposuction is one of the most popular cosmetic sity. In a perfect world, it is used to remove genetically dis-
procedures performed by board-certified plastic surgeons in tributed or diet-resistant fat. In practical terms, however, it is
the United States. Although liposuction is not a technically frequently used to remove fat that could be lessened with diet
difficult procedure to perform, it requires thoughtful planning and exercise. Ideal liposuction candidates are within 20% of
and careful patient selection to achieve consistently pleasing their ideal body weight or less than 50 lb above chart weight.
results. Poor planning or poor execution can result in uncor- Abnormally distributed bulges of fat or fat that resides outside
rectable deformities. the confines of the ideal body shape are the “target” areas that
are most commonly suctioned.
History Patient Evaluation

The aspiration of fat using blunt cannulas and negative-pressure A thorough physical examination is always performed. Although
suction was first popularized in Europe in the late 1970s.1 Three the focus of the examination should be on “problem areas,” it
French surgeons, Drs. Yves-Gerard Illouz, Pierre Fournier, is important to take the entire body shape into consideration.
and Francis Otteni, were the first to present their lipoaspira- An overall harmonious body contour is the desirable outcome.
tion experience at the 1982 American Society of Plastic and The patient is examined for areas of disproportionate fat, asym-
Reconstructive Surgeons annual meeting in Honolulu, Hawaii. metry between the two sides, dimpling/cellulite, varicosities,
The procedure was initially met with skepticism in the United and zones of adherence. Asymmetries are noted and, if they are
States. In late 1982, a “blue ribbon committee” was commis- significant, they are brought to the attention of the patient. If
sioned by the American Society of Plastic and Reconstructive the abdomen is being considered as a potential surgical site, it
Surgeons to visit Dr. Illouz in Paris and the committee returned should be carefully examined for hernias, significant abdominal
with a cautiously optimistic report. American surgeons’ inter- wall laxity, abdominal scars, history of abdominal radiation,
est in liposuction and public demand for minimally invasive and anything that might affect abdominal wall integrity.
body contouring have steadily risen since then. One of the most important physical findings, which will have
significant bearing on the final outcome, is the patient’s skin
tone, or dermal quality. It is important to pinch and palpate the
Patient Selection
Body Contouring
skin, assessing for the degree of laxity and dermal thickness. A
Patient selection is a critical determinant of a good surgical thicker dermis is more likely to retract after liposuction and give
result, especially in body contouring. Not all patients who a desirable result. Thin, stretched skin with striae (indicating
request liposuction are good candidates. The consultation dermal breakage) is unlikely to retract and may look worse after
begins with an assessment of the patient’s goals. What does liposuction. If it is determined that the skin quality is unsuitable
the patient wish to change about his or her body? What does for liposuction, alternative procedures are proposed, such as
the patient expect to accomplish with liposuction? The surgeon skin excision, if indicated. Liposuction does not treat cellulite;
then provides the patient with a realistic appraisal of what can thus one should not make promises to this effect.
and cannot be accomplished. Some patients may require alter- The quality of the fat should also be assessed because it
native procedures (such as an abdominoplasty) or liposuction may affect the outcome. The anatomy of the subcutaneous
combined with an open surgical procedure. An astute surgeon adipose tissue varies throughout the body. Some areas of the
is wary of patients who are particularly poor candidates for body have both a deep adipose compartment and a superfi-
liposuction such as (a) perfectionists with imperceptible “defor- cial adipose compartment, which are separated by a discrete
mities,” (b) those with underlying mental illness that prohibits subcutaneous fascia. The superficial fat in the trunk and thigh
realistic expectations (body dysmorphic disorder, or active eat- consists of smaller lobules, tightly organized within vertically
ing disorders), and (c) significantly overweight patients who are oriented, thin, fibrous septa. The deep fat consists of larger
incapable of weight reduction and/or weight maintenance after lobules arranged more loosely within widely spaced and more
liposuction. If a patient is steadily gaining weight before liposuc- irregularly arranged septa (Figure 65.1).2 In these areas, the
tion, he or she are likely to continue this trend after liposuction. deep layer of fat is the target for liposuction. The overlying
A detailed weight history is an important part of any lipo- superficial fat is (usually) relatively thin and will act as a pro-
suction consultation. Ideal candidates are at a stable weight tective layer to hide small contour deformities, especially for
with a working diet and exercise regimen in place. Patients the inexperienced liposuction surgeon. In contrast, other areas
who have a history of frequent or significant weight fluc- of the body that are commonly suctioned (arms and lower
tuations are at high risk for weight gain after liposuction. legs) have only one layer of fat. Suctioning these areas with
Maintaining a stable weight and practicing a diet and exercise smaller cannulas will help avoid contour irregularities.
679
680 Part VII: Body Contouring
Abdomen Superficial Anesthesia

layer (SL)
The appropriate type of anesthesia should be chosen based
Subcutaneous on surgeon preference, patient choice, estimated volume to
fascia (SQF) be removed, and whether other surgical procedures are being
Deep combined with liposuction. Liposuction can be performed
layer (DL) safely as an outpatient procedure in an office setting or in
an outpatient surgery facility as long as strict adherence to
Paralumbar Muscle layer patient safety is maintained. Local or regional anesthesia is
generally appropriate for aspiration of smaller volumes, and
general anesthesia is preferable when larger volumes are
SL removed. When large-volume liposuction (>5,000 mL of total
SQF aspirate) is performed, or when liposuction is combined with
a significant open surgical procedure(s), hospital admission or
DL 24-hour observation in a hospital setting is recommended.
Attention to perioperative fluid management is imperative
when significant volumes are suctioned. Approximately 70%
of the injected subcutaneous fluid will be absorbed and must
Gluteal–Thigh therefore be taken into account when calculating intraopera-
tive intravenous (IV) fluid. Anesthesiologists unfamiliar with
liposuction may not be aware of this fact and excessive fluids
SL may be administered. When the superwet technique is used
(see Wetting Solution below), the following guidelines for fluid
SQF resuscitation are recommended: (a) for volumes <5 L of total
DL aspirate, administer maintenance fluid plus subcutaneous wet-
ting solution; (b) for volumes ≥5 L total aspirate, administer
maintenance fluid plus subcutaneous wetting solution plus
0.25 mL of IV crystalloid per milliliter of aspirate above 5 L.3
Leg
Surgical Planning and
Instrumentation
SL There are a number of tools available to the liposuction sur-
SQF geon. Each tool has its advantages and disadvantages and some
surgeons simply prefer one tool or technique over another.
FIGURE 65.1. Superficial and deep fat layers. Markman and Barton The following discussion is only an introductory comparison,
studied the subcutaneous tissue of the trunk and lower extremity, not an in-depth analysis, of the available techniques.
finding that the fat lobules in the superficial layer (SL) are small and Traditional suction-assisted lipoplasty (SAL) became popu-
tightly packed within closely spaced septa, whereas those of the deep lar in the United States in the 1980s. The technique uses vary-
layer (DL) are larger, more irregular, and less organized. The arrange-
ing diameter, blunt-tip cannulas attached via large-bore tubing
ment becomes less obvious in the gluteal and thigh area, and disap-
pears as one proceeds from trochanter to knee. There is only one to a source of high vacuum, which effectively suctions fat
fat layer in the lower leg. (Adapted from Markman B, Barton F Jr. through a hole or holes in the tip of the cannula. Syringe SAL
Anatomy of the subcutaneous tissue of the trunk and lower extremity. is a variation whereby fat is aspirated with a cannula attached
Plast Reconstr Surg. 1987;80:252.) to a syringe. Suction is created when the plunger is withdrawn,
collecting the fat into the syringe. This technique is frequently
used if fat is being harvested for fat grafting.
SAL has a long track record and is considered the “gold
Superficial liposuction, a technique popularized by standard.” Traditional SAL cannulas are typically bendable
Marco Gasparotti and others, uses small cannulas to aspi- and come in many sizes and tip configurations, and most hos-
rate fat from the superficial planes (1 to 2 mm). Proponents pital operating rooms and surgery centers own this type of
of this technique contend that aspiration in the superficial equipment. SAL is an excellent technique for small- to medium-
plane leads to predictable contraction of the overlying skin. volume cases and removal of soft fat. The sheer simplicity of
Superficial liposuction leaves very little margin for error SAL makes it a valuable tool that is essential to have in any
and should not be attempted until the liposuction surgeon plastic surgeon’s armamentarium. It is a less efficient tool for
has gained considerable experience in the deep and interme- the removal of fat from more fibrous areas and requires a fair
diate planes. amount of physical effort on the part of the surgeon, which
becomes a disadvantage in larger volume cases. Bruising is
expected as a result of disruption of blood vessels by the shear-
ing and suction forces. Cross-tunneling is a necessary step with
Informed Consent SAL to avoid contour irregularity, which one study reported
Informed consent should be regarded by the surgeon not to be as high as 20%.4 The most frequently reported unsatis-
only as a legal responsibility but also as a mutually ben- factory results in this study were insufficient fat removal and
eficial transaction. The patient is informed of the risks, excessive waviness. Asymmetry, excessive fat removal, and
benefits, and available alternatives to the procedure being unacceptable scarring occurred with less frequency.
considered. A well-informed patient knows what to expect Ultrasound-assisted liposuction (UAL) was introduced in
in the postoperative period. In the event of a postoperative the United States in the mid-1990s to address some of the short-
complication, there is less likelihood of compromise of the comings of SAL. Ultrasonic energy is produced in a piezoelec-
doctor–patient relationship if the patient was well informed tric crystal within the UAL hand piece. The ultrasonic energy
initially. is transmitted down the attached probe or cannula to its tip,

Chapter 65: Liposuction 681
where it causes micromechanical, thermal, and cavitational trial.7 Studies by Brown et al. failed to show any adipocyte
effects on subcutaneous fat. The intervening fibroconnective disruption by histologic or scanning electron microscopy in
tissues remain relatively unharmed and available for postoper- porcine and human fat treated with laser-assisted lipoplasty
ative skin retraction. The emulsified fat is suctioned away with versus traditional SAL. This study also failed to show any clin-
low-power suction. UAL requires much less physical effort on ically significant differences in patients treated with internal
the part of the surgeon than does SAL because much of the or external laser-assisted lipoplasty.8
“work” is done by the ultrasonic energy. UAL is an extremely
efficient tool for the removal of fat in fibrous areas such as the
upper back, the hypogastrium, and the breast. UAL has been
Marking and Positioning
shown to cause less disruption of vasculature than SAL,5 which Preoperative markings provide an important “topographic
translates into less bruising in most cases. There is energy dis- map,” enabling the surgeon to visualize the targeted convexities,
sipation in all directions at the tip of the UAL probe or can- avoid concavities, and address asymmetries when the patient is
nula, which gives it a certain “airbrush” effect. Some surgeons lying on the operating table. Markings should be made imme-
believe it is a superior tool for sculpting and find there is less diately prior to surgery with the patient in a standing position.
need for cross-tunneling compared with SAL. A permanent marking pen is imperative so that the markings
There are also disadvantages to UAL. There is potential will not wash off when the patient is prepped. Asymmetries are
for frictional injury at the skin entry site, so constant irriga- carefully marked and brought to the attention of the patient.
tion at the incision or a skin protector must be used. Seroma Depressions and indentations can be marked with a different
rates can be high with prolonged ultrasound treatment times. color marker so that these areas can be avoided or treated to a
There is some elevation of tissue temperature with UAL and, lesser degree than surrounding areas (Figure 65.2).
if improper technique is used, thermal injury can occur. With Patient positioning is planned before the patient enters
proper training, these problems rarely occur. UAL is safe and the operating room and depends on which areas are being
effective when the surgeon is properly trained and the proce- suctioned. Although most body areas can be suctioned from
dure is performed properly.6 either the prone or supine positions, some surgeons prefer the
Power-assisted liposuction (PAL) was developed in the late lateral decubitus position for the hip rolls and lateral thighs.
1990s to address some of the concerns about UAL. PAL is When several body areas are to be suctioned, an intraopera-
basically traditional SAL powered by a reciprocating cannula. tive position change is necessary. Some surgeons prefer to prep
The main advantages of PAL over SAL are its efficiency in the patient circumferentially while standing and then have
fibrous areas and its ease of operation for the surgeon. There the patient lie down on a sterile drape. A locally anesthetized
is no particular salvage of fibroconnective tissue or neurovas- patient can rotate on the operating table as necessary through-
cular structures as there is with UAL. The main advantage of out the procedure. When the procedure is performed under
PAL over UAL is that there is no heat generation. PAL is an general anesthesia a position change is usually required. The
excellent tool for the surgeons who remain uncomfortable patient is first prepped in the prone position, which allows
with the potential for heat and the power of UAL. easy access to the back, flanks, buttocks, lateral thighs, and
The use of laser assistance to improve liposuction results the posterior aspect of the entire lower extremity. The patient
has recently been proposed. Proponents advocate that the is then turned to the supine position and reprepped and
application of laser energy, applied either externally or inter- draped. The abdomen, breasts, arms, and the anterior aspect
nally to the fatty layer, disrupts adipocyte cell membranes. of the lower extremity can be addressed from this position.
However, studies by Prado et al. failed to demonstrate clinical Patients are prepped with a 3-minute Betadine scrub, fol-
advantages with internally applied laser-assisted liposuction lowed by Betadine paint. Warming blankets are recommended
over traditional SAL in a double-blind, randomized, controlled on unexposed body parts and a Foley catheter should be
Body Contouring
FIGURE 65.2. Preoperative markings before circumferential thigh liposuction. Markings are similar to a topographic map. Lines and circles
represent surface features of the body showing the specific shape and size relationships between the component parts. In this case, progressively
smaller circles indicate a “higher” point (or more fat) in relation to the surrounding areas. Markings are extremely important to assist the surgeon
in getting smooth, even, and predictable results.

placed when aspirations >5 L are planned. When liposuction (see the discussion of lidocaine toxicity in the section Risks
is combined with an open surgical procedure, or when large- and Possible Complications).
volume liposuction is performed, compression hose and/or The actual infiltration technique is especially impor-
sequential compression device boots for deep vein thrombosis tant. An uneven infiltration of wetting solution increases the
prophylaxis are recommended. chances of an uneven final result. An electrical infiltration
pump which provides even flow rates while infusing is invalu-
Wetting Solution able. Infiltration is begun in the deepest plane of the area to
be suctioned and proceeds in a systematic fashion from deep
Liposuction was first practiced as a “dry” technique, meaning to superficial. Each level, or “plane,” should be evenly infil-
that nothing was done to prepare the fat prior to suctioning trated before slowly moving a bit more superficial. Palpation
it from the subcutaneous plane. As one might expect, hemor- over the area with the nondominant hand is used to guide this
rhagic complications were common. Illouz is credited for devel- process. The infiltrated fat should be evenly firm, and there
oping the “wet” technique, which he described as a “dissecting should be no disproportionate bulges in the skin at the end
hydrotomy,” wherein he instilled normal saline, water, and of the infiltration process. The wetting solution should be
hyaluronidase in the hope of creating a weak hypotonic solu- “feathered” at the edges of the target area, just like the suc-
tion to lyse the adipocyte cell wall.9 Hetter10 is credited with tioned fat is feathered.
adding lidocaine and dilute epinephrine to the wetting solution.
Jeffrey Klein, a dermatologist, developed and coined the term
tumescent technique, which is now used for the infiltration of Aspiration of Fat
large-volume, dilute lidocaine with epinephrine solution for the The wetting solution is allowed 7 to 10 minutes for maximal
purpose of performing liposuction with low blood loss.11 The vasoconstrictive effect. Aspiration is performed through vari-
importance of infiltration of wetting solution cannot be over- ous small incisions, the location of which depends on the area
stated. The superwet technique is defined as a 1:1 ratio of the being suctioned. Every attempt is made to hide incisions in
volume of wetting solution infused to the volume of aspirate. anatomic creases or Langer cleavage lines, when appropriate,
The term tumescent technique was classically described as a although most liposuction cannulas are small enough that the
ratio of 2 or 3:1. Technically, the tumescent and the superwet eventual scars are almost imperceptible. As a general rule, lipo-
techniques differ in the ratio of volume infused to volume of suction is performed using the dominant hand, making even
aspirate; however, both involve infusion of wetting solution to strokes in a systematic fashion. The cannula is inserted into
the point of tissue turgor or a “peau d’orange” of the overlying the deep plane first. Using even in-and-out strokes, the cannula
skin. Practically, the term tumescent liposuction is used as a is moved back and forth in a fanlike pattern, with the incision
generic term for liposuction using abundant wetting solution. as the fulcrum. The cannula is moved more superficially as
Injection of the wetting solution has a number of advan- fat is removed. The nondominant hand is kept over the area
tages. It provides a mechanism for delivery of anesthetic and being suctioned to provide tactile feedback as to the depth of
vasoconstricting agent, thereby providing a component of the underlying cannula and the distribution of remaining fat.
intraoperative anesthesia, decreasing blood loss and postop- Cross-tunneling (suctioning an area from a second incision at
erative bruising, and also providing postoperative analgesia. right angles from the first incision) is recommended for most
Administration of wetting solution eases the passage of the areas to avoid contour deformity (Figure 65.3).
cannula through the tissue and minimizes fluid requirements The end point of aspiration is determined by a number of
during and after surgery. Some surgeons believe that magni- factors. Contour of the patient is the most important factor, but
fication of the area to be suctioned is an advantage, whereas can be difficult to determine because of infused wetting solu-
others believe that distortion of the area is a disadvantage. It is tion and patient positioning. The aspirated volume should also
the author’s opinion that “final contour” is an end point that be carefully recorded and is especially helpful in achieving sym-
comes with experience, and infiltration of wetting solution is a metry when bilateral areas are suctioned. When UAL is used,
necessary part of the equation for the student to master. the amount of time that ultrasonic energy is applied should be
Table 65.1 describes the author’s standard wetting solution recorded and considered when determining the end point and
recipes. can be helpful when attempting to obtain symmetry between
It is the author’s preference to use lidocaine in the tumes- sides. The pinch test, another helpful guide, is performed by gen-
cent solution even when general anesthesia is used for the lipo- tly pinching the patient’s skin and subcutaneous fat between the
suction procedure. Although it is technically not necessary, it thumb and forefingers to assess the thickness and smoothness of
probably provides some intraoperative local anesthetic effect the underlying subcutaneous tissue and for comparing preopera-
which would theoretically decrease the amount of general tive with postoperative thickness. Simply pinching or rolling the
anesthetic and/or narcotic given by our anesthesia colleagues, tissue between one’s thumb and index finger helps in the assess-
both during the procedure and in the recover room. ment of irregularities. When all is said and done, it does not
The total amount of lidocaine infused per patient should matter it is removed; it matters what is left behind!
not exceed the maximum recommended subcutaneous dose Final contouring is routinely performed at the end of the
of 35 mg/kg (Chapter 12).12 The maximum dose for each liposuction procedure. The surgeon may use saline to wet the
patient should be calculated preoperatively and the case is skin and glide his or her hand over the surface to assist in find-
planned accordingly. If more infiltrate is needed once the ing small irregularities. Usually, smaller diameter cannulas
maximum dose has been reached, lidocaine can be omit- (2.5 or 3.0 mm) are chosen to do the final contouring and feath-
ted from the final bags as long as general anesthesia is used ering. The old adage “the enemy of good is better” should be
kept in mind. Over-resection is more difficult to fix than under-
TABLE 65.1 resection, so it is better to err on the side of under-resection.
Standard Wetting Solution
Body Areas Treatable With
n Local Anesthesia n General Anesthesia
Liposuction
1 L lactated Ringer solution 1 L lactated Ringer solution
Numerous body areas are amenable to liposuction given the
1 mL epinephrine (1:1,000) 1 mL epinephrine (1:1,000) plethora of equipment now available. Today’s patient can be
50 mL 1% Xylocaine 30 mL 1% Xylocaine treated from head to toe (Figures 65.4 to 65.7). The face and
neck can be successfully treated with liposuction, although fat

A B
FIGURE 65.3. Cross-tunneling. Cross-tunneling is a technique used to enhance smoothness and to decrease the risk of contour irregularity. The
patient is in the prone position with her head on the left side of the picture. A. The liposuction cannula is inserted into the gluteal crease incision
(black arrow) to suction the left lateral thigh, and into the parasacral area to suction the left posterior hip. B. A second incision is made and the
same areas are suctioned from a separate incision in the midaxillary line (at approximately a right angle from the first “line” of suction).
injection into the face instead of aspiration is increasingly pop- swelling subsides by 6 weeks postprocedure, and it takes a full
ular. The trunk, including the abdomen, back, breast, and pos- 4 to 6 months for 100% of the swelling to resolve, depending
terior hips (flanks), as well as the lower extremity, including on the extent of the procedure.
the knees, calves, and ankles, have all been successfully treated Patients begin ambulating on the day of surgery. Oral flu-
with liposuction. In the author’s experience, treatment of gyne- ids are encouraged. Physical activity should be low for the first
comastia is particularly amenable to UAL13 (Chapter 57). The week to discourage excessive edema, followed by a gradual
upper arm is also well suited for UAL or SAL when the skin increase in activity during the second week, depending on the
is not too loose. The buttocks can be successfully treated but amount of suction that was done. At the end of the first week,
should be approached with some degree of caution. Creation most patients can return to work and should be encouraged
of flat or ptotic buttocks is not only unsightly, but can require to begin light exercise, such as brisk walking on a treadmill
excisional measures to repair. (with compression garments on!). At 3 to 4 weeks, if edema
and bruising are resolving appropriately, the patient should
be advancing to full activity and may “wean” him- or herself
Postoperative Course out of the compression garment over the course of a week.
Incisions for cannulas larger than 3.0 mm are generally closed These are general guidelines for patients undergoing average
with a 5-0 nylon suture. Some surgeons recommend leaving volume liposuction (lipoaspirate 2,000 to 5,000 mL) and must
smaller incisions open to allow wetting solution to drain. be tailored to the individual patient. Large-volume liposuction
The patient is dressed in a compression garment that covers and circumferential thigh patients will need a more restrictive
the areas that have been suctioned. The author believe that postoperative regimen.
compression foam (e.g., Topi-Foam, Byron Medical, Tucson,
AZ) under a garment decreases early bruising and edema,
Body Contouring
which seems to speed recovery. An abdominal binder can be Risks and Possible
used when only the hips and/or abdomen are treated. If thigh
suction is also done, a girdle is preferable. The patient may
Complications
experience significant serosanguineous drainage from incision Any surgical procedure has risks. Fortunately, serious com-
sites for approximately 24 to 36 hours, which can be alarm- plications are rarely associated with liposuction procedures.
ing to family and friends if they are not informed in advance. The most common undesirable sequelae after liposuction
Showering is permissible on postoperative day 1 or 2. A vaso- are contour irregularities, which are related to inexperi-
vagal response is not uncommon the first time the postopera- ence and lack of attention to detail. Contour irregularities
tive garment is removed, so patients should be warned ahead generally fall into four categories: (a) overcorrection, (b)
of time to have someone with them the first time they remove undercorrection, (c) failure of skin retraction or abnormal
their garment. The patient is instructed to replace the compres- skin retraction, and (d) complex deformities consisting
sion foam over the suctioned areas until days 3 to 5 if tolerated. of combinations of a, b, and c. 14 Revisionary procedures
Drains are recommended for gynecomastia and when should be performed only after all the swelling has com-
>2,000 mL lipoaspirate is removed from the abdomen alone. pletely subsided. Generally, the treatment of undercorrec-
They are left in place until drainage is less than 25 to 30 mL tion is removal of more fat; the treatment of overcorrection
in a 24-hour period. Ideally, foam padding is left in place for is fat injection (Chapter 44); the treatment of loose skin is
3 to 5 days. Compression garments are generally encouraged skin excision; and the treatment of complex deformities is
24 hours per day for 4 weeks (6 weeks if circumferential thigh beyond the scope of this chapter. The best way to “treat”
suctioning is performed). Postoperative follow-up visits are contour irregularities is to avoid them.
scheduled at 5 to 7 days to remove sutures; at 2 weeks to make Other risks, including unusual bleeding, which could result
sure that bruising is subsiding normally and to advance the in unusual ecchymosis or permanent skin discoloration, hema-
patient’s activity; at 8 to 12 weeks to make sure that edema toma, seroma, infection, dysesthesia, fat embolism, thrombo-
is subsiding normally and to assess the early result. The final embolism, fluid imbalance, lidocaine toxicity, skin necrosis,
postoperative contour will not be evident for approximately 6 perforation of viscera, and death, fortunately, are rare.
months. Maximal swelling can be expected at postoperative Lidocaine toxicity deserves special mention because
days 3 to 5. In the author’s experience, 60% to 80% of the according to the Physicians’ Desk Reference, the maximal

A B
C D
FIGURE 65.4. Ultrasound-assisted liposuction of a 27-year-old woman shown before (A, C) and 12 months after (B, D) UAL of the abdomen,
posterior hips, and circumferential thighs. A total of 4,700 mL of wetting solution was infiltrated and a total of 4,775 mL of lipoaspirate (fluid and
fat) was removed: 575 mL from the abdomen, 475 mL from each posterior hip, and 1,625 mL from each thigh which was treated circumferentially.

A B
Body Contouring
C D
FIGURE 65.5. Ultrasound-assisted liposuction of a 50-year-old woman. She was treated with UAL to the abdomen, posterior hips, and lateral
thighs. A total of 1,250 mL, 600 mL, and 700 mL of wetting solution was infiltrated into the abdomen, hips and lateral thighs, respectively.
A total of 1,300 mL, 900 mL, and 925 mL of lipoaspirate, respectively, was removed from each area. The total infiltrated was 3,850 mL, and the
total aspirated was 4,950 mL. Preoperative views A and C, Postoperative views B and D.
recommended dose of subcutaneous lidocaine HCl when

used in combination with epinephrine is 7 mg/kg in an adult,
Conclusion
yet numerous studies have documented the safety and effi- Liposuction is an extremely popular cosmetic procedure in
cacy of larger doses (greater than 35 mg/kg) of lidocaine for today’s body-conscious society. Technically, it is a relatively
the purposes of liposuction11 (Chapter 12). Table 65.2 lists easy procedure to perform adequately; however, it requires
the signs and symptoms of lidocaine toxicity. If lidocaine strict attention to detail and a keen aesthetic eye to perfect
toxicity is suspected, the injection of lidocaine is stopped the art of liposuction. Sucking fat is easy, whereas sculpting
immediately. Benzodiazepines are the drug of choice for the the body by removal of the right amount of fat, and leaving
treatment of seizures. behind a more optimal body contour, is an art.

A B
C D
FIGURE 65.6. Ultrasound-assisted liposuction of the breast in a 47-year-old man with gynecomastia. The patient is shown before (A, C) and
4 months after (B, D) UAL of the breast. A total of 650 mL of wetting solution was infiltrated into each breast and 575 mL of lipoaspirate (fluid
and fat) was removed from each breast.
A B C
FIGURE 65.7. Suction-assisted lipoplasty of the neck in a 53-year-old woman shown before (A, B) and after (C) SAL of the neck. Superior results
can generally be obtained with liposuction of the neck in the younger population; however, this woman had very good skin retraction for her age.
Careful preoperative assessment of skin quality and thorough preoperative counseling with this type of patient is imperative. In this case, incisions
were made in the submental area and behind each ear in order to allow contouring along the jawline.

TABLE 65.2
Lidocaine Toxicity
n Early signs n Later signs n Late signs
Plasma concentrations 3 to 6 μg/mL Plasma concentrations 5 to 9 μg/mL Plasma concentration >10 μg/mL
Lightheadedness Shivering Convulsions
Restlessness Muscle twitching CNS depression
Drowsiness Tremors Coma
Tinnitus
Slurred speech
Metallic taste in mouth
Numbness of lips and tongue
CNS, central nervous system.
laser-assisted lipoplasty with suction assisted lipoplasty. Plast Reconstr

References Surg. 2006;118:1032.
8. Brown S, Rohrich R, Kenkel J, Young V, Hoopman J, Coimbra M. Effect
1. Fournier P. Popularization of the technique. In: Hetter GP, ed. Lipoplasty:
of low-level laser therapy on abdominal adipocytes before lipoplasty proce-
The Theory and Practice of Blunt Suction Lipectomy. 2nd ed. Boston, MA: dures. Plast Reconstr Surg. 2004;113:1796.
Little Brown; 1990:35-38. 9. The wet technique. In: Illouz YG, DeVillers YT, eds. Body Sculpturing by
2. Markman B, Barton FE. Anatomy of the subcutaneous tissue of the trunk Lipoplasty. New York, NY: Livingstone Churchill; 1989:124.
and lower extremity. Plast Reconstr Surg. 1987;80:248. 10. Hetter GP. The effect of low dose epinephrine on the hematocrit drop fol-
3. Rohrich RJ, Kenkel JM, Janis JE, et al. An update on the role of subcutaneous lowing lipolysis. Aesthetic Plast Surg. 1984;8(1):19.
infiltration in suction-assisted lipoplasty. Plast Reconstr Surg. 2003;111:926. 11. Klein JA. The tumescent technique for liposuction surgery. Am J Cosmetic
4. Pitman GH, Teimourian B. Suction lipectomy: complications and result by Surg. 1987;4:263.
survey. Plast Reconstr Surg. 1985;76:65. 12. Klein JA. Tumescent technique for regional anesthesia permits lidocaine
5. Kenkel JM, Robinson J, Beran SJ, et al. The tissue effects of ultrasound doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16:248.
assisted lipoplasty. Plast Reconstr Surg. 1998;102:213. 13. Gingrass MK, Shermak, MA. The treatment of gynecomastia with ultrasound-
6. Ablaza VJ, Gingrass MK, Perry LC, et al. Tissue temperatures during ultra- assisted lipoplasty. Perspect Plast Surg. 1999;12:101-112.
sound assisted lipoplasty. Plast Reconstr Surg. 1998;102:534. 14. Gingrass MK, Hensel JM. Secondary liposuction. In: Mathes SJ, Hentz VR,
7. Prado A, Andrades P, Danilla S, Leniz P, Castillo P, Gaeto F. A pro- eds. Plastic Surgery. 2nd ed. Philadelphia, PA: Saunders/Elsevier. Volume VI.
spective, randomized, double-blind, controlled clinical trial comparing 381-388. Specifically 382.
Body Contouring

Chapter 66 n Abdominoplasty and
Belt Lipectomy
Al S. Aly and Emil J. Kohan
may present with abdominal skin laxity and stretch marks.

Introduction The skin in those patients is stretched beyond its ability to
Body contouring of the lower trunk region is an integral part of rebound back to its original elasticity. A similar process occurs
the plastic surgeon’s armamentarium. The lower trunk is a cir- with massive weight gain and subsequent weight loss in which
cumferential structure that begins at the inferior border of the the skin is overexpanded, leading to a skin–fat envelope that
breasts and ends at the pelvic rim. Although this is a convenient is loose and inelastic.
unit, it is difficult to separate from surrounding structures such
as the thighs and the thorax. Deformities in the lower truncal
region are variable in nature and require different approaches
History of Body Contouring
for their treatment. Recent advances in bariatric surgery have Body contouring procedures early in the twentieth century
resulted in a large population of weight loss patients, which has consisted of dermatolipectomies of hanging abdominal pan-
led to an emphasis on the evaluation and treatment of lower niculi. In these procedures, excess skin and underlying fat were
truncal contour deformities. This chapter will focus on exci- removed to rid the patient of hanging tissues with minimal
sional procedures, with or without liposuction, in the treatment attention to aesthetic principles. In the second half of the cen-
of lower truncal deformities. Problems that can be ameliorated tury, advances in abdominoplasty techniques led to improved
by liposuction techniques alone are covered in Chapter 65. scar placement, abdominal wall plication, and umbilical trans-
position. In the 1980s, liposuction was introduced, and it
became a tremendous tool in the armamentarium of the plas-
Patient Presentation tic surgeon for affecting body contour, replacing a number of
Patients with lower truncal complaints demonstrate a variety excisional procedures. Currently, plastic surgeons routinely
of deformities on a continuum from minimal excess fat to cir- use both excisional and liposuction techniques, alone and in
cumferential fat and skin excess accompanied by abdominal combination, to improve abdominal contour.
laxity of the fascia1 (Table 66.1).
Weight is the first important factor that affects the pre-
sentation of patients with lower truncal deformities. Because Relevant Anatomy
absolute weights can be misleading, body mass index (BMI), Fat in the lower trunk is organized into superficial and deep
which relates weight to height, is the most commonly used layers separated by the superficial fascial system, which per-
parameter. It is calculated in the following manner: vades the entire body. Anteriorly the superficial fascial system
Body mass index = weight in kilograms/(height in meters)2 is referred to as Scarpa’s fascia (Figure 66.1).
The blood supply of the abdominal skin and fat is impor-
Body mass index = weight in pounds/(height in inches)2
tant to understand. The skin overlying the rectus muscles is
× 703
primarily supplied by arteries that originate from the superior
Patients who present for lower truncal contouring span the and inferior epigastric vessels that run within the rectus mus-
range of BMI from normal to obese. cles. Branches from these vessels perforate the overlying rectus
The upper limit of normal BMI is 25; 26 to 30 is consid- fascia and traverse through the two layers of abdominal fat,
ered overweight; and 30 and above is considered obese. A finally reaching the skin. This direct blood supply of abdomi-
variety of surgical approaches are required to treat patients in nal skin is interrupted during the elevation of the abdominal
different BMI ranges. flap in a traditional abdominoplasty. A secondary blood sup-
A second factor that affects the presentation of patients ply is derived from lateral intercostal, subcostal, and lumbar
is the fat deposition pattern, which is genetically controlled. vessels that course anteriorly in the fat superficial to Scarpa’s
Women typically deposit fat in the infraumbilical abdomen, fascia (Figure 66.2). These vessels are the only remaining
lateral thighs, hips, and medial thighs. Men tend to deposit fat blood supply of central abdominal skin after traditional flap
in the flanks, the infraumbilical abdomen, and intra-abdomi- elevation. Interruption of these vessels by scars, such as cho-
nally.2 Although these patterns are common, dramatically dif- lecystectomy, or chevron scars, can lead to necrosis of tissues
ferent patterns of fat deposition are often present even within inferomedial to the scar. The superficial epigastric vessels
the same gender. supply blood to the skin of the lower abdomen but are also
The quality of the skin–fat envelope is a third factor to divided during abdominoplasty procedures.
evaluate. Some women who have had one or more pregnancies The lower trunk has fascial attachments between the skin
and the underlying muscle fascia that act as anchoring points
or zones of adherence3 (Figure 66.3). These zones of adher-
T A BLE 6 6 . 1 ence restrict the overlying skin from moving during the pro-
Factors That Affect The Presentation of cesses of aging and/or weight fluctuations. Posteriorly, the
The Patient Requesting Lower Truncal midline has a zone of adherence that overlies the spine. The
Contouring anterior midline of the abdomen has a less well-defined zone
of adherence. Three horizontal zones of adherence are located
Body mass index at presentation
in the inferior aspects of the lower trunk; one is located at
the inguinal region bilaterally and extends toward the anterior
Fat deposition pattern superior iliac spine (ASIS). Another is located just above the
Quality of the skin–fat envelope mons pubis and is variable in its adherence properties. The
third is located bilaterally between the hip and lateral thigh fat
688
Chapter 66: Abdominoplasty and Belt Lipectomy 689
Skin
Superficial fat layer
Superficial fascial system

(Scarpa fascia anteriorly)
Deep muscular fascia

FIGURE 66.1. Organization of fat and fascia
Muscle in the anterior abdomen.
Superior epigastric a. wall laxity and minimal abdominal skin excess limited to the
infraumbilical region are good candidates for mini-abdomi-
noplasty. Patients who present with abdominal wall laxity
Intercostal a. of both the infra- and supraumbilical regions and general-
ized skin excess limited to the anterior aspects of the lower
Subcostal a.
trunk are good candidates for a full abdominoplasty. As the
Lumbar branches deformities increase in magnitude and involve the lateral and
posterior aspects of the lower trunk, circumferential truncal
liposuction and/or dermatolipectomies become necessary. The
Ascending branch of indications, goals, and a general description of each procedure
deep circumflex a. are given below.
Lower truncal body contouring procedures are often long
Inferior epigastric a. and extensive in nature. Medical problems such as heart dis-
Superficial epigastric a. ease, diabetes, and lung disease must be under control before
surgery is contemplated. Cigarette smoking also has a delete-
rious effect on blood supply and, when combined with the
already compromised vascular supply of the abdominal skin,
can lead to significant tissue necrosis. Many plastic surgeons
avoid performing abdominoplasty on active smokers.
FIGURE 66.2. The abdominal wall vasculature. a, artery.
Mini-Abdominoplasty
Women who present with abdominal wall laxity restricted
to the infraumbilical region that is associated with minimal
infraumbilical skin and fat excess are candidates for a mini-
abdominoplasty. Physical examination of the abdomen in the
supine position will demonstrate infraumbilical rectus diasta-
sis, which can be confirmed by the “diver’s test” (Figure 66.4).
Body Contouring
Strong zones
Variable zones
FIGURE 66.3. Fascial zones of adherence. The zones of adherence
control the movement of tissue associated with aging and/or massive
weight loss. These fascial attachments result in lateral descent of trun-
cal tissues, which rotate toward the midline.
deposits. Truncal tissues become lax due to aging, pregnancy,

and/or massive weight loss. They descend the greatest distance
laterally, caused by a combination of tissue laxity and central
tethering of the midline zones of adherence. As tissues descend
around the pelvis they also migrate centrally (see Figure 66.3).
The inguinal and mons pubis zones of adherence are respon-
sible for holding the final position of abdominoplasty scars in
the lower truncal region. Without their effect, the scars would
migrate cephalad, possibly above natural underwear lines.
Patient Selection
Patients who have minimal to moderate subcutaneous fat FIGURE 66.4. The classic “diver’s test” demonstrates how a bend at
excess and no abdominal wall laxity are good candidates the waist will reveal the true extent of abdominal wall laxity.
for liposuction alone. Patients who present with abdominal

These patients are usually young women who have had enough to allow for the desired supraumbilical plication. In
one or two pregnancies, have good skin elasticity, and are not any of the mini-abdominoplasty techniques discussed, liposuc-
overweight. They may or may not have localized fat depos- tion can be used to decrease the thickness of any part of the
its in other areas of the trunk and lower extremity such as abdominal flap that has not been elevated.
the hips and lateral thighs. The goal of surgery in this patient One of the most difficult aspects of mini-abdominoplasty is
population is to eliminate the infraumbilical abdominal wall avoiding dog-ears because of the short incision.
laxity and the minimal skin and fat excess.
Technique (Mini-Abdominoplasty) Abdominoplasty

An incision is marked in the patient’s natural suprapubic Generally, abdominoplasty is indicated in patients whose lax-
crease and angled toward the ASIS. Often the incision can be ity involves the supra- and infraumbilical regions, limited to
limited to the width of the pubic hair or just beyond its lateral the anterior aspects of the lower trunk. The goals of abdomi-
edges. Intraoperatively, the proposed incision is made and the noplasty depend on the presenting deformities. They include
dissection extended to the muscle fascia. An abdominal flap is creating a flat abdominal contour, eliminating abdominal wall
elevated superiorly to the level of the umbilicus. The infraum- laxity, enhancing waist definition in some patients, and eradi-
bilical rectus muscle diastasis is identified, and rectus fascia cating mons pubis ptosis if present.
plication is performed. Some surgeons prefer a single layer, Stretch marks are common and may be limited to the infra-
whereas others favor a two-layer plication (Figure 66.5). The umbilical region or may include both the infra- and supraum-
abdominal flap is advanced inferiorly and tailored to remove bilical skin. Rectus diastasis of the entire vertical extent of the
the excess skin and underlying fat. This advancement will usu- abdomen is present in these patients, with the infraumbilical
ally pull the umbilicus down 1 to 3 cm. diastasis usually more extensive because of the position of the
The closure of this incision, as in all subsequent incisions dis- uterus during pregnancy. Preoperatively abdominal wall laxity
cussed in this chapter, is performed in multiple layers, with the can again be detected by the “diver’s test” and physical exami-
most important layer being the reapproximation of the superfi- nation. Massive-weight-loss patients who reach a near-normal
cial fascial system, or Scarpa’s fascia.4 Permanent or long-lasting BMI may also present with lower truncal excess limited to the
sutures are used in this layer in an attempt to limit widening of anterior abdomen. However, most often they present with cir-
the scar in the long run. The authors prefer to use interrupted cumferential deformities that require more extensive circum-
monofilament absorbable sutures in the subcuticular layer to ferential excisions.
perfectly approximate the skin with an overlying layer of medi- Patients who present with excess intra-abdominal fat that
cal-grade skin glue. Drains are inserted and a compression gar- would prevent flattening of the abdominal wall by plication
ment is used in the postoperative period by most surgeons. are not good candidates for abdominoplasty. The outer skin/
A variation of this technique can be used in patients who fat envelope of the belly always conforms to the shape of an
have minimal lower abdominal skin excess, no upper abdomi- inner balloon whose anterior wall is made up of the abdomi-
nal skin excess, and both infra- and supraumbilical rectus nal muscle wall. If that wall is rendered convex in profile by
diastasis. To allow access to the supraumbilical rectus diasta- virtue of overly abundant intra-abdominal contents, then the
sis, the base of the umbilicus can be amputated. The abdomi- final profile of the belly will also be convex. Because abdomi-
nal flap is then elevated on either side of the midline in the nal contour flattening is one of the major goals of surgery,
supraumbilical region, and a supraumbilical rectus plication these patients are better served by weight loss prior to contem-
and an infraumbilical plication are performed. The umbilical plating abdominoplasty-type procedures.
stalk is then resutured to the plication at the appropriate level, By the nature of an abdominoplasty, where an ellipse of
and the lower aspect of the abdominal flap is tailored appro- tissue is removed from the lower abdomen, dog-ears can be
priately. It is also possible to use a minimal-incision approach created at the edges of the ellipse, especially in patients who
to the supraumbilical plication by making an incision in the already have lateral excess. Patients who present with defor-
superior aspect of the umbilicus and using an endoscope to mities that extend beyond the anterior aspects of the lower
perform a dissection superior to the umbilicus that is wide trunk may require 1) extending the abdominoplasty excision
laterally, 2) liposuction of the lateral and posterior trunk, and/
or 3) circumferential dermatolipectomy to attain the best pos-
sible contour.
Some authors advocate the use of fleur-de-lis or “T”-type
excisions in which an anterior vertical wedge of tissue is
resected, as discussed later in this chapter. Generally, as cir-
cumferential lower truncal dermatolipectomy has become
more mainstream in plastic surgery because of the massive-
weight-loss population, the indications for isolated abdomino-
plasty have narrowed.
Technique (Abdominoplasty)
The markings for an abdominoplasty are performed prior to
surgery. The proposed excision is marked in the lower abdo-
men. Centrally, the inferior incision line is often marked in
the natural suprapubic crease and then carried laterally. Some
surgeons utilize a “French bikini/thong pattern” in which the
lateral aspects of the proposed inferior incision are angled
toward the ASIS, while others prefer a flatter pattern, with
many variations described in the literature.5 An attempt is
made to avoid the incision beyond the ASIS, but it is more
important to avoid dog-ears. With the inferior mark in place
FIGURE 66.5. The abdominal flap elevation and rectus fascia placa- the patient is slightly flexed at the waist, and the pinch tech-
tion in a mini-abdominoplasty. nique is used to approximate the superior extent of the exci-
sion. Ideally, the patient should have enough excess abdominal

skin to allow excision of the skin from just above the umbili- plication, in one or two layers, is most common. The patient
cus to the suprapubic crease centrally. is then flexed at the waist, and the abdominal flap is advanced
In the operating room, a circumumbilical incision is made inferiorly to facilitate the process of flap tailoring. As the
and the umbilical stalk is dissected to the deep fascia. The infe- abdominal flap is advanced, the surgeon can control where
rior mark of the proposed abdominal skin excision is incised. the greatest tension will be at closure—centrally or laterally.
An abdominal flap is elevated superiorly, around the umbilicus, Creating the greatest amount of tension centrally is advanta-
and up to the xiphoid and costal margins (Figure 66.6). The geous in limiting the lateral extent of the final scar but may
flap is classically elevated at the level of the underlying muscle lead to excessive mons pubis elevation and less waist defini-
fascia but many plastic surgeons prefer to elevate the flap at tion. Lockwood, in his “high-lateral-tension” approach to
Scarpa’s fascia level. It is felt that this may reduce the rate of abdominoplasty, espoused placing the greatest tension on the
seroma formation. Two theories have been invoked as to the lateral aspects of the abdominal closure.6 This is based on the
etiology of this reduction. The most popular is that the remain- fact that the greatest laxity in the lower trunk occurs laterally.
ing subscarpal fat contains intact lymphatic vessels, which help However, the increased lateral tension often necessitates exten-
absorb fluid in the wound. The other possibility is that the fat- sions of the scar laterally to eliminate dog-ears. This approach
to-fat interface leads to better adhesion between the abdominal can lead to better waist definition and an improvement in ante-
flap and the underlying tissues. Neither theory has been tested rior thigh contour, but often necessitates leaving behind the
experimentally; thus, it is not currently known why this type of original umbilical defect as a closed vertical scar. Thus, place-
elevation seems to reduce seroma formation. Wide undermin- ment of tension, centrally or laterally, in abdominoplasty sur-
ing allows the greatest amount of abdominal flap advancement gery should depend on the patients’ differing needs and desires.
at the time of flap tailoring, but it also leads to the division With the tailored abdominal flap approximated to the lower
of the greatest number of superior epigastric muscle perfora- incision, the position of the umbilicus is noted on the flap and a
tor vessels, leaving only the lateral intercostal, subcostal, and neo-umbilicus is created. The stalk of the umbilicus is brought
lumbar vessels as the only viable blood supply of the flap. Some through the abdominal flap using one of various incisions advo-
surgeons prefer a more limited dissection above the umbilicus, cated by different authors. The authors prefer a simple vertical
just to the medial edges of the rectus muscle fascia, to allow for incision, no defating of the underlying soft tissues, and “three-
supraumbilical rectus fascia plication up to the xiphoid. The point fixation” sutures at 3, 6, and 9 o’clock. Whatever method
benefit of the limited dissection is the increased number of the the surgeon chooses, the umbilicus should be fairly small, verti-
perforator vessels left intact to support the blood supply of the cally oriented, superiorly hooded, have a slight hollow around
tailored abdominal flap. In some patients, however, the limited it, and contain the scar on the inside of the cylindrical structure.
dissection will not allow the appropriate advancement of the The closure of the abdominal incision is accomplished in
abdominal flap and may reduce the amount of tissue that may multiple layers, with the most important layer being the super-
need to be resected to create the best contour. As a general rule, ficial fascial system, or the Scarpa fascia.4 This is accomplished
flap elevation should be restricted to just what will allow appro- with permanent or long-lasting suture, which, it is hoped,
priate rectus fascia plication and appropriate flap advancement. reduces the significant tension that can be generated at closure,
Often it is best to limit the initial elevation and then release the prevents acute wound dehiscence, and reduces scar widening in
tissues incrementally to allow for appropriate contour. the long run. The authors prefer to use interrupted monofila-
After flap elevation, rectus fascia plication is performed. ment absorbable suture in the subcuticular layer to perfectly
Many patterns have been proposed for plication, but a vertical approximate skin. An overlying layer of medical-grade skin glue
is then applied. Drains are placed. A compression garment is
used in the postoperative period by most surgeons. Figure 66.7
Body Contouring
FIGURE 66.7. Traditional abdominoplasty. A young woman who

presented after two pregnancies desiring an improvement in her
abdominal contour. She complained of loose abdominal skin and pro-
trusion of her belly, despite a regular exercise program. Her abdomi-
nal wall laxity was more prominent in the infraumbilical region,
consistent with her pregnancies. She underwent an abdominoplasty
using a French bikini pattern of excision and is shown 6 months after
surgery. Because her deformities were limited to the anterior abdomen
FIGURE 66.6. The extent of abdominal flap elevation and fascial and she was within the normal weight range, there was no need to
plication in a traditional abdominoplasty. combine other procedures with her traditional abdominoplasty.

shows an example of abdominoplasty in an ideal patient. Many

surgeons, including the authors, use quilting sutures in an
attempt to decrease the rate of seromas by reducing dead space
between the flap and the underlying muscle wall.7
Combining liposuction with traditional abdominoplasty
techniques is controversial and is often left to the surgeon’s
experience and philosophy.8 Liposuction of the abdominal
flap in nonundermined areas is generally considered safe.
Liposuction of undermined regions of the flap can potentially
lead to flap necrosis because of the compounding effect of lipo-
suction on the already compromised blood supply. Certainly,
liposuction of areas outside the bounds of the undermined
abdominal flap, such as the hip region and the lateral thighs,
can be performed without concern for flap compromise.
Studies have demonstrated that combining liposuction with
abdominoplasty, whether the liposuction is performed on the
elevated flap or the non-flap contiguous areas, may lead to
FIGURE 66.8. Belt lipectomy and lower body lift. Two patients who
increased risk of seroma formation.9 underwent a belt lipectomy above and a lower body lift below. In a
belt lipectomy the scar is placed at the junction between the buttocks
Circumferential Lower and lower back, which helps to frame the natural buttocks contour
and accentuate waist narrowing. In a lower body lift the scar is onto
Truncal Dermatolipectomy the buttocks proper and is overall more inferiorly placed, especially in
its lateral and posterior aspects. The combination of eliminating the
or Cirumferential Lipectomy pelvic zones of adherence and the lower position of the excised wedge
As a basic principle of plastic surgery, it is always better to allows the lower body lift to elevate the thighs more effectively than
reconstruct an anatomic unit in its entirety when possible. in a belt lipectomy.
Abdominoplasty treats deformities limited to the anterior
lower trunk. When deformities involve more than the anterior
created by this technique. This is often desired in women but
abdomen, other procedures are required to adequately treat
may be less desirable in men. Pelvic rim zones of adherence
all the deformities. If the surrounding areas such as the thighs,
help to prevent the descent of lower truncal tissues as well as
buttocks, hips, and lower back regions contain excess fat
inhibit elevation of lower extremity tissues (see Figure 66.4).
without ptosis, liposuction can be added to abdominoplasty
These fascial attachments are interrupted but not completely
to create a better overall lower truncal contour. However, for
eliminated during a belt lipectomy, and they prevent exten-
patients who present with generalized laxity and/or ptosis of
sive lifting of lower thigh tissues. Thus, overall, a belt lipec-
those areas, circumferential lipectomies are required. Massive-
tomy is capable of creating excellent lower truncal contour by
weight-loss patients make up the largest group of such patients
accentuating waist definition, delineating the buttocks from
who require circumferential excisional procedures. They will
the lower back, and lifting the lateral thighs, but it has limited
continue to grow in numbers, given that obesity has been rec-
capability in lifting the distal thighs.
ognized as a major health-care issue in the United States and
A lower body lift treats the lower trunk and thighs as a unit.
the world. In addition, women who gain moderate weight,
The pelvic rim zones of adherence are intentionally interrupted
30 to 40 lb, usually with childbirth and/or aging, and are not
as completely as possible, which allows inferior thigh tissues,
able to lose the weight through normal means of exercise and
down to knee level, to be lifted. This leads to a significant
nutritional changes may be candidates. They often present
reduction in anterior and lateral thigh laxity. The final scar
with a desire to eliminate anterior abdominal excess, but care-
is located within the buttocks proper, which can blunt waist
ful examination will demonstrate circumferential excess that is
definition (see Figure 66.8). This is often desirable in men but
best treated with a circumferential lipectomy. Finally, normal-
may be less so in women. The resultant scar is easily covered
weight-range patients who desire remarkable improvements in
by normal undergarments, and the thighs are dramatically
their lower truncal contour may be candidates as well.
improved down to the knee level. However, a lower body lift
There is a variety of names used to describe circumferential
is less efficient in creating waist definition and can result in less
lower truncal dermatolipectomies: extended or circumferen-
than ideal buttocks definition because the scar does not respect
tial abdominoplasty, central body lift, torsoplasty, and body
the natural junction between the lower back and buttocks.
lift. The authors prefer to divide these different variations into
The majority of patients undergoing a circumferential
two general categories based on what they treat and what they
lipectomy are massive-weight-loss patients. Often they present
accomplish. The first category is made up of centrally based
with a hanging panniculus, mons pubis ptosis, an ill-defined
procedures that mainly treat the lower truncal unit, which
waist, lower back rolls, hip-fat excess, lateral thigh ptosis,
will be referred to as belt lipectomies, as espoused by Aly and
and varying types of buttocks deformity. The goals of surgery
Cram.10,11 The second category includes procedures that treat
include elimination of the hanging panniculus, mons pubis
the lower trunk and thighs as a unit, which will be referred
elevation, creation of waist definition (especially in women),
to as lower body lifts, as espoused by Lockwood.12,13 Each
decrease or elimination of lower back rolls, lifting of the outer
procedure has its benefits and drawbacks. Both should be in
thighs, and increase in buttocks definition.
the armamentarium of the plastic surgeon who performs body
contouring surgery. The choice of procedure is based on the
patient’s desires and presenting deformities. Techniques (Truncal Dermatolipectomy)
Both procedures eliminate a circumferential wedge of tis- Although a circumferential lipectomy is a combination of an
sue from the lower trunk. A belt lipectomy removes a wedge abdominoplasty, a lateral thigh lift, and a buttocks lift, the
that is more superiorly located than that removed in a lower procedure is more complex than simply combining them. The
body lift (Figure 66.8). The final scar after belt lipectomy is lower trunk of patients who present with circumferential excess
located above the widest aspect of the bony pelvic rim, at has the shape of an inverted cone (Figure 66.9). A wedge of tis-
the junction between the lower back and buttocks, which sue is marked for proposed excision around the lower trunk.
may be visible outside of brief undergarments. Because this The wedge brings a narrower part of the cone down to the
allows cinching at waist level, more waist definition can be level of a wider part of the cone located at, or near, the pelvic

FIGURE 66.9. Truncal deformity in weight loss patients. In the massive-weight-loss patient, the presenting lower truncal deformity is in the
shape of an inverted cone. In a circumferential lipectomy a wedge of tissue is removed. The diameter of the wedge at its superior edge is smaller
than its diameter at the inferior edge.
rim (see Figure 66.9). As previously noted, the wedge to be Because of the circumferential nature of the procedure,
excised is generally located in a more superior position in belt more than one position is necessary to accomplish the resec-
lipectomy when compared with the wedge to be excised in a tion in the operating room. No matter what sequence is pre-
lower body lift. In either method, the anterior aspect of the ferred by a particular surgeon, the abdominal part of the
wedge is wider (in vertical distance) than the lateral or poste- procedure is performed in the supine position. Surgeons who
rior aspects. The lateral resection is the next widest aspect so advocate prone/supine or supine/prone positioning cite the
as to reverse the lateral truncal descent (Figure 66.10). single turn required in the operating room and the ability to
control buttock symmetry as their reasons for choosing the
“two-position” sequences. The supine/lateral/lateral or lat-
eral/lateral/supine proponents prefer these “three-position”
sequences because they allow for easier lateral thigh liposuc-
Body Contouring
tion and hip abduction in the lateral decubitus position, which
facilitates maximal lateral resections. All body positions have
potential complications associated with them, especially if the
patient is to be maintained in those positions for extended
periods of time. The surgeon should be familiar with those
complications and how to prevent them.
The extent of anterior flap elevation in the abdominoplasty
portion of the circumferential procedure is based on surgeon
preference. The lateral elevation is usually more extensive
than in an abdominoplasty, which compromises the remaining
blood supply to the abdominal flap to a greater extent. Thus,
it is important that an effort is made to preserve as many lat-
eral feeding vessels as possible. The plication of the rectus fas-
cia is similar to abdominoplasty plication except that it may
sometimes require plication distances that far exceed the usual
5 to 7 cm encountered with routine abdominoplasty. Closure
FIGURE 66.10. A 31-year-old woman presented after an 80-lb of the circumferential wound should include reapproximation
weight loss to reach a body mass index of 27.31. (Above) Shown with of the superficial fascial system with permanent and/or long-
preoperative markings for a circumferential belt lipectomy. Note that lasting suture.
the excision laterally is generally aggressive to counteract the lateral During the lateral and posterior resection, some surgeons
descent that occurs with massive weight loss and/or aging. Vertical prefer to incise the superior marks first and dissect an inferior
marks are placed along the circumference of the proposed resection
to help alignment at closure. Surrounding areas of the thigh are also
skin–fat flap, whereas others prefer the opposite. Some sur-
marked for liposuction. (Below) The patient 6 months after surgery, geons incise both the superior and inferior extents and excise
demonstrating dramatic waist narrowing, elimination of the pannicu- a predetermined marked amount. The authors prefer to incise
lus and lower back rolls, and improved buttocks definition. the superior side first and tailor the inferior-based flap based
on tension and creation of the appropriate contour.

Some surgeons choose to combine extensive liposuction of Patients who present in the high BMI ranges are more likely
the surrounding regions, such as the lower back, the upper to develop seromas. Measures that are used to reduce their
back, and thighs, whereas others limit their liposuction to the occurrence include the use of suction drains, compression gar-
lateral thighs. A major difference between belt lipectomy and ments, reduction of activity, and use of quilting sutures. When
a lower body lift is in the treatment of the pelvic rim’s zones of they do occur, they can most often be treated with serial aspi-
adherence. In belt lipectomy, these attachments are disrupted rations. For persistent seromas, sclerosing agents and seroma
by liposuction of the lateral thighs, but they are not completely catheter insertions may be utilized.
eliminated. In a lower body lift, discontinuous undermining of Seromas are the most common source of infection after
the anterior and lateral thighs, down to knee level, intention- lower truncal procedures. Simple cellulitis is fairly uncommon
ally destroys the pelvic rim zones of adherence. This allows and is usually treated by appropriate antibiotic coverage and
significant thigh elevation.12 close follow-up. Seroma pockets that become infected usually
The results attained from circumferential lipectomies present with overlying cellulitis, fluid collections that may or
depend, to a great extent, on the presentation of the patient may not spontaneously drain, fever, and generalized malaise.
and the type of procedure chosen (see Figure 66.10). As a gen- A diligent effort should be made to find seromas and treat
eral rule, the lower BMIs at presentation lead to better aes- them whenever suspected. Once seromas become infected,
thetic results and lower rates of complications.10,11 aggressive intravenous therapy and appropriate surgical
drainage should be instituted.
Toxic shock syndrome can occur with any body contour-
Complications ing procedure. Postoperatively, patients who appear toxic
Table 66.2 lists complications that can occur with lower trun- with fever, chills, generalized malaise, and elevated white
cal contouring procedures.14 Circumferential procedures are blood cell counts should be investigated. Although there is
associated with more complications, but they are often per- often no evidence of frank pus or large fluid collection in the
formed on patients with higher BMIs. When complications wounds, aggressive surgical drainage is urgently required in
are stratified by BMI, noncircumferential and circumferential this group of patients.
procedures have similar rates. Vascular compromise can occur with lower truncal body
Superficial wound healing problems are the most com- contouring procedures, leading to tissue necrosis. Most com-
mon complication that occurs with any body contouring monly the necrosis occurs in the inferomedial aspect of the
excisional procedure because of the high tension created abdominal flap. A number of factors can contribute to this
at the wound edges. Conservative wound care will usually problem, which include excessive tension on the abdominal
allow healing to occur, with the possible need for subse- closure, aggressive thinning of the abdominal flap, overly
quent scar revisions. Wound dehiscences, defined as sepa- aggressive liposuction, and anything that may lead to com-
ration of the wound at the level of the superficial fascial promising the lateral feeding vessels of the abdominal flap
system, are possible with any of the procedures discussed such as open cholecystectomy incisions. If necrosis occurs,
in this chapter but tend to occur more frequently with cir- the wound is treated conservatively and eventually allowed to
cumferential procedures. In procedures limited to anterior heal by secondary intention. Eventually, a scar revision may
resections, mini-abdominoplasty, and abdominoplasty, be required.
dehiscences can be prevented by keeping patients flexed Bleeding after lower truncal contouring procedures can be
at the waist for 5 to 7 days after surgery and educating extensive because of the surface area within which blood can
patients on a slow return to the full upright position over accumulate prior to detection. Although drains do not prevent
the second week after surgery. Circumferential procedures hematomas, they can often warn the surgeon of a develop-
create competing anterior and posterior tensions, making ing hematoma. Small hematomas that are well evacuated by
it difficult to place patients in positions that do not stress drains in place can be managed expectantly. Large hematomas
at least one aspect of the closure. Avoidance of dehiscences should be treated by surgical drainage.
in this patient population entails adjustments of the com- Procedures that tighten the abdominal wall are theorized
peting resections to account for opposing tensions, care- to increase intra-abdominal pressure, leading to a decrease
ful ambulation of the patients in the early postoperative in venous return from the lower extremities. The possible
period, and education of patients on how to help prevent resultant stasis of blood in the deep venous system may
dehiscences.15 cause deep venous thrombosis and/or pulmonary emboli.
Seromas are common complications with lower truncal Measures that are commonly used in the prevention of
contouring procedures. They are due to large dissection sur- thrombotic events include early ambulation and sequential
face areas and can develop anywhere in the surgical field but compression garments. Some surgeons feel that chemopro-
tend to be located posteriorly in circumferential procedures. phylaxis, low molecular weight heparin (enoxaparin pro-
phylaxis), is indicated in the perioperative period. At the
time of the writing of this chapter it is not clear what the
proper course of action should be in this arena. The authors
T A BLE 6 6 . 2
prefer to utilize epidural catheter infusions, which help
COMPLICATIONS ASSOCIATED WITH LOWER reduce pain, but have been found to reduce the risk of deep
TRUNCAL BODY CONTOURING PROCEDURES vein thrombosis/pulmonary embolism as well, and avoid the
use of chemoprophylaxis.16
Seroma Patients who undergo large excisional procedures of the
lower trunk, especially massive-weight-loss patients, can
Wound-healing problems/dehiscence have psychiatric difficulties in the postoperative period that
Infections may interfere with their recovery. Although this can occur
with any surgery, the long recovery period that is required
Tissue necrosis
after circumferential procedures makes it wise for the plastic
Bleeding/hematoma surgeon to actively investigate a patient’s psychiatric reserves
and consider obtaining psychiatric clearance prior to sur-
Thrombotic events (deep venous thrombosis pulmonary emboli)
gery. The tendency of massive-weight-loss patients to have
Psychiatric difficulties lifelong psychiatric problems that are not solved by weight
Scar and contour asymmetry loss alone also contributes to the relatively high incidence of
these problems.

Although careful marking techniques can help reduce scar References
and contour asymmetry, it is not possible to eliminate these
problems in many patients because of intrinsic skeletal and 1. Aly AS. Approach to the massive weight loss patient. In: Aly AS, ed. Body
Contouring After Massive Weight Loss. St. Louis, MO: Quality Medical
soft tissue asymmetry. It is best for the surgeon to recognize Publishing; 2006:49.
these natural asymmetries and point them out to patients 2. La Trenta GS. Suction-assisted lipectomy. In: Rees TD, La Trenta GS,
prior to surgery. eds. Aesthetic Plastic Surgery. 2nd ed. Philadelphia, PA: WB Saunders;
1994:1180.
3. Aly AS. Options in lower truncal surgery. In: Aly AS, ed. Body Contouring
Fleur-de-lis or T-Type After Massive Weight Loss. St. Louis, MO: Quality Medical Publishing;
2006:59.
Procedures 4. Lockwood T. Superficial fascial system (SFS) of the trunk and extremities: a
new concept. Plast Reconstr Surg. 1991;87:1009.
A fleur-de-lis or T-shaped excision, whether used as an 5. La Trenta GS. Abdominoplasty. In Rees TD, La Trenta GS eds. Aesthetic
Plastic Surgery. 2nd ed. Philadelphia, PA: WB Saunders; 1994: 126.
abdominoplasty pattern or in combination with a circum- 6. Lockwood T. High-lateral-tension abdominoplasty with superficial fascial
ferential lipectomy, is advocated by some authors. The system suspension. Plast Reconstr Surg. 1995;96:603.
advantage of the vertical wedge is to eliminate horizontal 7. Pollock TA, Pollock H. No-drain abdominoplasty with progressive tension
excess, create more waist definition, and decrease lateral sutures. Clin Plast Surg. July 2010;37(3):515-524. [Epub 2010 May 23].
8. Matarasso A. Abdominoplasty: a system of classification and treatment for
fullness. Traditionally, this pattern has not been frequently combined abdominoplasty and suction-assisted lipectomy. Aesthetic Plast
used because it is difficult to justify a vertical midline inci- Surg. 1991;15:111.
sion without a preexisting vertical scar. Recently, however, 9. Najera RM, Asheld W, Sayeed SM, Glickman LT. Comparison of seroma
it has found more use because many massive-weight-loss formation following abdominoplasty with or without liposuction. Plast
Reconstr Surg. January 2011; 127(1):417-422.
patients have midline incisions and/or deformities that super- 10. Aly AS, Cram AF. Body lift: belt lipectomy. In: Nahai F, ed. The Art of
sede the created vertical scar in unattractiveness. Even with Aesthetic Surgery. Principles and Techniques. St. Louis, MO: Quality
a preexisting scar, however, there are major disadvantages Medical Publishing; 2005:2302.
to the vertical aspect of the T pattern. There is an increased 11. Aly A, Cram A, Chao M, et al. Belt lipectomy for circumferential trun-
cal excess: the University of Iowa experience. Plast Reconstr Surg.
chance of flap necrosis at the T intersection. When used to 2003;111:398.
treat circumferential excess, a fleur-de-lis resection pattern 12. Lockwood TE. Thigh and buttock lift. In: Nahai F, ed. The Art of Aesthetic
does not eliminate all lateral excess and does not affect lateral Surgery. Principles and Techniques. St. Louis, MO: Quality Medical
thigh descent or buttocks ptosis. When the pattern is used Publishing; 2005:2424.
13. Lockwood T. Lower body lift. Oper Tech Plast Reconstr Surg. 1996;3:132.
in conjunction with a circumferential lipectomy, it can create 14. Grazer FM, Goldwyn RM. Abdominoplasty assessed by survey, with
a greater mismatch between the upper and lower circumfer- emphasis on complication. Plast Reconstr Surg. 1977;59:513.
ences of the inverted cone-shaped edges to be reapproximated 15. Aly AS. Belt lipectomy. In: Aly AS, ed. Body Contouring After Massive
(see Figure 66.9). Finally, the vertical wedge excised can often Weight Loss. St. Louis, MO: Quality Medical Publishing; 2006.
16. Rimler JC, Scholz T, Shbeeb A, Chua W, Wirth GA, Paydar K. The inci-
lead to epigastric fullness secondary to the dog-ear effect cre- dence of venous thromboembolism in postoperative plastic and reconstruc-
ated by the excision. Due to these disadvantages the authors tive surgery patients with chronic spinal cord injury. Plast Reconstr Surg.
do not utilize this pattern of excision.14 2010;126:40.
Body Contouring

Chapter 67 n Lower Body Lift and Thighplasty
Joseph P. Hunstad and Remus Repta
issues may also be prohibitive. Patients who have a significant

Lower Body Lifts amount of excess fat and only a mild or moderate amount of
skin laxity should be educated regarding the benefit of weight
Key Points loss through diet and exercise or through bariatric surgery.
The lower body lift is recommended for patients with circum- The lower body lift is ideally suited to correct skin and soft-
ferential body laxity who have achieved significant weight tissue laxity and not as a fat reduction procedure.
loss through surgical bariatric intervention or diet and exer-
cise regimens (see Chapter 66). The procedure is performed Preoperative History and Preparation
in both prone and supine positions requiring patient reposi-
tioning intraoperatively. The circumferential component of Patients who have achieved massive weight loss may be mal-
the procedure allows for the treatment of buttocks ptosis, lat- nourished and/or suffer from other metabolic abnormalities.4
eral and anterior thigh laxity, abdominal tissue redundancy, Laboratory blood work including complete blood count, basic
as well as mons ptosis. The lower body lift procedure can be metabolic panel, coagulation profile, pregnancy test, and total
combined with various ancillary procedures such as autolo- protein/albumin levels is recommended. Abnormal laboratory
gous buttocks augmentation, fleur-de-lis abdominal contour- values warrant additional nutritional analysis and intervention
ing, thigh lift, and mons reduction. There is overlap between to avoid postoperative wound healing problems. A history
this chapter and Chapter 66 on abdominoplasty. We encour- is obtained regarding VTE (Chapter 11). A factor V Leiden
age the reader to study both chapters. analysis can be performed to rule out this unusual form of
coagulopathy. Hormone replacement therapy and birth con-
trol medications are discontinued for several weeks prior to
Introduction surgery if possible. Patients are encouraged to stop smoking
The lower body lift serves as the “keystone” procedure upon for 6 weeks before surgery and not to resume until 3 weeks
which all subsequent body contouring procedures are based.1-3 post-op. Sequential compression devices are used on the lower
It is important for patients to understand that there is no exer- extremities throughout the surgical procedure and until dis-
cise for skin! This is frustrating for patients who exercise regu- charge. The use of proper intraoperative positioning with the
larly but have skin laxity of the trunk secondary to genetics. The knees partially flexed, perioperative prophylactic medication
lower body lift procedure is far more than a “belt lipectomy” such as Lovenox, and early postoperative ambulation are also
where circumferential excess skin is removed from the mid- employed.5
waist area of the trunk (Chapter 66). By placing the resection Existing abdominal scars are evaluated since they can
lower, near the trunk–lower body junction, more powerful lift- adversely impact the blood supply to the abdominal apron.1
ing of the buttocks and thighs is accomplished. Circumferential A lower body lift procedure usually eliminates the inferior
resection allows for maximum tissue resection without concern and central blood supply to the abdominal soft tissue, basing
for dog-ears. Ancillary procedures including vertical thigh- the remaining vascular supply on the intercostal perforators
plasty, mons resection, and autologous buttock augmentation (Chapter 66). Preexisting scars can also impact the final aes-
can be included. thetic result of the lower body lift procedure if they cannot
be included in the resection. The presence of scars may alter
Patient Selection the tissue pliability in that region and the surgical markings
should take this into consideration.
Patients who present in consultation for a lower body lift
usually seek improvement primarily in the appearance of the
abdomen and buttocks. Patients must be educated regarding Operative Approach
the resulting scar and should be at or near their goal weight. It Preoperative photographs are obtained. Existing scars are
is necessary that the patient be well informed and compliant. marked and included, whenever possible, in the proposed
This is a big operation and cooperation in the postoperative skin resection. When the patient desires the final incision
period can impact the risk of complications, such as deep vein within the boundary of a specific undergarment or swim-
thrombosis (DVT), and the final result. wear, we mark the outline of the garment and position the
incision accordingly. With the patient lifting the abdomi-
Indications nal skin superiorly, the lower transverse mark is made at
the level of the pubic symphysis (Figure 67.2). The patient
During consultation, patients frequently demonstrate their
then releases the abdominal soft tissue and the incision is
desired surgical outcome by lifting the excessive tissue lax-
lengthened laterally to the level of the iliac crest following a
ity of the lower abdomen, buttocks, and thighs (Figure 67.1).
natural skinfold. The desired final location of the posterior
Massive weight loss patients who have reached a normal
incision is marked along the upper portion of the buttocks
BMI (they do not require additional liposuction) and normal
(Figure 67.3A). If autologous buttocks augmentation is
weight individuals are the ideal candidates for this procedure.
anticipated, the final incision line over the buttocks should
be a continuation of a line from the pubic symphysis to the
Contraindications greater trochanter and extended to the posterior midline
Relative contraindications for lower body lift surgery include (Figure 67.3B). This line will indicate the area of maximum
smoking, diabetes, malnutrition, wound healing issues, and projection of the buttocks.1,6 Starting in the midaxillary
immunodeficiency. The use of anticoagulant medications, line with the patient bent slightly away from the surgeon
lower extremity venous insufficiency, lymphedema, a previous to prevent over-resection the extent of the resection is esti-
history of venous thromboembolism (VTE), and other medi- mated bilaterally (Figure 67.4A). The posterior resection is
cal issues such as renal insufficiency, anemia, and pulmonary marked, noting that the amount of resection is conservative
696
Chapter 67: Lower Body Lift and Thighplasty 697
A B
Figure 67.1. Patient’s concerns relative to lower body contouring. A and B. Patients often demonstrate their desired outcome by strongly lifting
the abdominal skin, thigh skin, and the buttocks areas.
in the midline because of the strong zone of adherence (Figure 67.5). All markings are rechecked to ensure symmetry
and reduced laxity. When autologous buttocks augmenta- and to avoid over-resection.
tion is planned, the amount of resection of the posterior General anesthesia is initiated, antibiotics and steroids are
segment is reduced to accommodate the volume that will given (Ancef 1 g and Decadron 4 mg), and a Foley catheter is
be added. From the upper marking in the midaxillary line inserted. When concurrent liposuction is planned, thorough
a dotted line is continued anteriorly across the abdomen, tumescent infiltration of all areas to be suctioned is performed.
representing the estimated amount of resection. The exact The patient is carefully rolled in the prone position on the
amount of the resection will be determined intraoperatively operating room table that has been arranged with padded
(Figure 67.3A). Areas for concurrent liposuction are then chest rolls, kneepads, and a roll or pillow beneath the ankles.
marked as well. The patient is surgically prepped and draped taking care to
A V–Y mark is made within the planned resection amount include the most anterior point of the planned V–Y closure in
at the midaxillary line which will allow temporary closure the midaxillary line bilaterally.
of this area when the patient is repositioned from prone to Once prepped and draped, the markings are checked for
supine (Figure 67.4B). For patients with significant transverse tension and symmetry. The posterior resection is performed
as well as vertical tissue laxity, a concurrent vertical resection, without undermining, forming a “V”-shaped resection. This
commonly referred to as a fleur-de-lis resection can be utilized inward beveling allows closure to occur without dead space.
(Figure 67.5). Most massive weight loss patients are willing When autologous buttocks augmentation is performed, the
to accept a vertical midline scar in return for correction of intervening tissue between the upper and lower incisions is de-
laxity.1 The final shape of the fleur-de-lis resection should be epithelialized. This flap of tissue can be molded with suture
closer to an ellipse than a triangle, to prevent excessive ten- in a purse-string method or partially elevated and rotated as
sion at the junction of the vertical and horizontal closure a flap.4,7,8
Body Contouring
Laterally, the resection continues to the midaxillary line
where the temporary V–Y resection and closure is performed
(Figure 67.6). Undermining is suggested at this point over the
trochanter to release the retaining elements in this area of
adherence. The posterior drain is placed and the end is coiled
and inserted beneath the skin of the V–Y closure to be brought
out anteriorly when the patient is turned supine. Hemostasis
is obtained and a three-layer closure is performed. The most
important layer of the closure, the superficial fascia, is closed
with either a number 1 or 0 Vicryl or equivalent suture.
Repair of the superficial fascial layer is performed under ten-
sion. Doing so allows the dermis to be approximated under
minimal tension which increases the chance of obtaining a
thin, inconspicuous scar. Size 2-0 or 3-0 Vicryl or equivalent
suture is used in an interrupted buried fashion to approximate
the dermis at each vertical oriented/tattoo mark and then at
approximately 1 cm intervals. Finally, a running intradermal
number 4-0 Monocryl or equivalent suture is used to approxi-
mate the skin edges. The patient is carefully repositioned into
the supine position. Foam rolls are placed beneath the knees
and the heels are padded. The arms are abducted and placed
Figure 67.2. The lower abdominal incision. The first transverse line
on padded arm boards. Warm air blankets are placed over the
is placed at the level of the pubic symphysis with the patient strongly
elevating the abdominal skin. This is the ideal final location for the lower extremities. A standard surgical prep and drape of the
incision which is placed in a pleasingly low location. Notice that the anterior body surface is performed. When indicated, liposuc-
upper third of the hair-bearing mons is routinely resected. tion is performed throughout the areas that were previously
infiltrated.

A B
Figure 67.3. Lower body lift markings (A and B). Preoperative markings are demonstrated with the patient relaxed. A. Note how low the
anterior incision is in the midline, removing a significant portion of the hypertrophied mons. B. Realignment marks are added. In this case, a
buttocks augmentation using a purse-string gluteoplasty will be performed and the markings for this are evident.
The temporary sutures placed at the midaxillary V–Y clo- The width of the plication can be modified as needed during
sure are removed and the end of the V–Y incision is contin- the plication process (Figure 67.7B). We utilize a number 0,
ued anteriorly connecting to the lower abdominal incision. looped nylon suture with a large tapered needle to perform a
The superficial inferior epigastric vessels are identified and running single layer myofascial plication, bringing together
controlled. Dissection continues in the cephalic direction to the lateral borders of the marked plication boundary. This
the level of the umbilicus where perforating vessels are identi- double-stranded suture has proven to be highly effective and
fied and controlled. Massive weight loss patients often have durable and has replaced our previous use of interrupted
perforators of significant caliber requiring suture ligature sutures and a two-layer closure. We have not identified a
or vascular clipping. The umbilical skin is circumferentially single instance of suture failure and premature release of the
incised at its junction with the abdominal skin, and scissor myofascial plication utilizing the looped nylon method over
dissection is performed to the abdominal wall. Frequently, the last 10 years. At the level of the umbilicus the suture is
this dissection naturally finds the natural plane between the placed only on one side of the plication, allowing an appro-
umbilical stalk and the subcutaneous tissue. The abdominal priate amount of fascial laxity around the umbilical stalk.
flap that has been elevated up to the umbilicus is then usu- The looped nylon is tied at the level of the pubic symphysis
ally split vertically in the midline which facilitates further and the knot is buried. The use of the looped nylon allows
cephalic dissection (Figure 67.7A). Dissection is continued complete myofascial plication in a continuous fashion with
in the cephalic direction to the level of the costal margins the creation of only one knot. A second layer of suture can
and xiphoid. Myofascial plication is performed with the help be placed to reinforce the first but we have rarely found this
of muscle relaxation provided by the anesthesiologist. The to be necessary.
medial borders of the rectus diastasis and the anticipated Marcaine 0.5% is injected throughout the entire area
borders of the plication are marked with methylene blue. of undermining and into the rectus sheath to decrease
A B
Figure 67.4. Lateral markings in lower body lift (A and B). The most important marking is in the midaxillary line where the risk of over-
resection is the greatest. A. The final desired incision line is marked and then strong bimanual palpation is used to identify the redundancy. The
patient leans away from the surgeon to avoid over-resection. B. An anteriorly pointing V–Y marking is made, which signifies the transition from
the prone to the supine portions of the operation.

Figure 67.5. Fleur-de-lis markings. The vertical resection is in the Figure 67.6. Closure of the superficial fascia. The superficial fascia
shape of an ellipse. It is not a triangle because a triangle resection will is marked in methylene blue and this is the line at which the high
result in excessive tension at the final closure point. With an existing tension closure is performed. Strong tension on the superficial fas-
subcostal scar, the vertical ellipse is shifted to the right which allows cia decreases the tension across the final incision line which lessons
for the inclusion of this scar and its removal in the fleur-de-lis resection. scar widening.
A B
Body Contouring
C D
Figure 67.7. Supine portion of lower body lift (A–D). A. The flap is divided at the umbilicus and some subcutaneous tissues are left sur-
rounding the umbilicus to preserve its vascularity. B. Dissection is continued to the level of the xiphoid and markings are made for rectus
plication. The medial borders of the rectus are first marked and then an estimated line of plication is marked lateral to this in methylene blue.
C. After the plication has been completed, a final drain and the pain pump catheter are placed. D. Tissue to be resected is determined with the
Pitanguy demarcator.

postoperative pain. We place a lidocaine pain pump as a

continuous infusion device and suture this catheter over Postoperative Care
the rectus plication. We usually leave the pain pump cath- We frequently have the patients stay in our overnight care
eter in place and refill it as needed for a total of 6 days facility. The decision for overnight care is based on patient
(Figure 67.7C). health as well as the specifics of the surgical procedure. If they
At this point the final abdominal skin resection is are kept overnight, the suction drains are connected to high
determined by using the tissue demarcator. The patient is vacuum wall suction to assist with drain function. A warm air
placed into a semi-Fowler position with the waist flexed. blanket is placed and continued until the patient is appropri-
Appropriate tension is placed in the midline as the abdomi- ately warm and comfortable. The urine output is monitored
nal soft-tissue apron is pulled caudally and the level of the throughout the postoperative stay.
lower incision in the midline is translocated and marked on The patient is assisted in walking at least twice on the
the overlapping abdominal flap. The abdominal soft-tissue evening of surgery, taking care to maintain a partially flexed
apron is divided in the midline up to the level marked and waist position. Incentive spirometry is begun on awakening
a temporary closure with a towel clip or dermal stapler in and continued throughout the postoperative course. We have
the midline is performed. Markings are made and the pro- begun a program of routine DVT chemoprophylaxis and
posed resection amounts on the left and right are compared administer Lovenox 40 mg 12 h postoperatively. We recog-
to ensure symmetry (Figure 67.7D). If subscarpal fat resec- nize that there is no universal agreement as to the use, dosage,
tion is not planned, the excess tissue marked is resected and method of administration of DVT chemoprophylaxis and
using a scalpel to make a full-thickness incision through the care should be individually tailored to each patient’s needs
skin and soft tissue. The tumescent infiltration placed at the and risk factors.
beginning of the procedure can make this a nearly blood- Following discharge from the overnight facility, patients
less maneuver. Electrocautery is used as needed for hemo- continue their oral antibiotics and pain medications as pre-
stasis. If subscarpal fat resection is planned, resection of the scribed. Patients are seen in follow-up within a few days after
abdominal tissue should proceed in a controlled fashion until their procedure. We take this opportunity to review with the
the superficial fascial layer is transected. The fat below this patient their instructions for drain care, incision dressing, and
layer is the subscarpal fat and is visually distinct from the limitations of activity. A binder is recommended if there is
subcutaneous fat. Resection of the subscarpal fat proceeds no ischemia of the abdominal flap. We recommend frequent
to the appropriate extent for the individual patient. The new ambulation, proper fluid intake, and leg movement while
site for the umbilicus is identified with the tissue demarca- recumbent to help reduce the risk of DVT. We suggest that
tor (Figure 67.8A). A vertical elliptical incision is made to the patient maintain a flexed waist position for approximately
accommodate the new umbilicus and the subcutaneous tissue 1 week postoperatively. Drains are removed when output has
beneath is resected (Figure 67.8B).12 reached an appropriate level, usually less than 30 ml in 24 h,
The umbilicus is inset with interrupted 4-0 Monocryl and which may take 2 weeks.
running intracuticular Monocryl for final closure. Closure of The results with a lower body lift can be dramatic. Overall
the abdominoplasty flap is performed in a similar fashion to this procedure completely contours the entire circumference
the posterior closure utilizing number 1 or 0 Vicryl for the of the body and is effective in reducing abdominal laxity,
superficial fascia, 2-0 or 3-0 Vicryl or equivalent for the deep abdominal striae, buttocks ptosis, and anti-laxity. Although
dermis, and 4-0 Monocryl intracuticular for final skin closure. minor incision line suture abscesses are common, major com-
The incision is either taped or glued with cyanoacrylate tissue plications are remarkably rare considering the magnitude of
adhesive. The patient is then transferred to the hospital bed, the procedure. Figures 67.9 and 67.10 attest to the results that
where they are maintained in the semi-Fowler, partial waist can be achieved with lower body lifting. When a circumferen-
flexed position, to prevent excessive tension on the abdominal tial deformity exists, a circumferential surgical procedure reju-
skin and soft tissue. venates the body circumferentially. Not only is the abdominal
A B
Figure 67.8. Umbilicus creation and abdominal closure. A. Abdominal closure is performed with either staples or sutures leaving space to use
the Pitanguy demarcator to identify the new umbilical location. B. A narrow elliptical skin excision is performed which automatically expands
because of normal skin tension. Care should be taken not to make this too large.

A B
C D
Body Contouring
E F
G H
Figure 67.9. A 37-year-old, 128 lb female before and after lower body lift (A–H). Each pre-op image is shown adjacent to the corresponding
post-op image taken 1 year later.

A B
C D
E F
G H
Figure 67.10. A 57-year-old, 172 lb female who underwent a significant weight loss with gastric bypass, shown before and after lower body
lift (A–H). Each pre-op image is shown adjacent to the corresponding post-op image.

contour made ideally thin, tight, and flat but also the thighs in combination with a lower body lift, can dramatically cor-
are elevated and buttocks ptosis corrected. Patient satisfaction rect excessive laxity and provide improved shape and contour
is high with this procedure. to the thigh. The vertical thigh lift is the thigh lift of choice for
the majority of massive weight loss patients.
Thighplasty
Patient Selection
Key Points A patient who presents in consultation for a thigh lift procedure
Medial thigh laxity can be addressed through either a proxi- may be a candidate for either a thigh lift procedure alone, a
mal inner thigh lift or a vertical thigh lift procedure. The inner lower body lift, liposuction alone, or any combination of these
thigh lift addresses the laxity of the proximal medial thigh procedures. Dissatisfaction with the appearance of the but-
and is most useful in the normal weight individual with mild tocks, hips, and thighs is common and a more global discussion
to moderate inner thigh laxity. This can occur with normal about excess fat, soft-tissue laxity, and scars associated with any
weight fluctuations during life or as sequelae of liposuction. potential surgery is required to identify the patients’ preferences.
This procedure places the incision in the pubic–thigh crease. Patients who undergo the inner thigh lift should understand
Because of the specific anatomic restriction of the pubic area, the limited benefits of this procedure and the potential adverse
the inner thigh lift has a high incidence of caudal scar migra- effects including caudal scar descent and vulvar distortion.
tion. The scar tends to descend from the pubic–thigh crease Patients who undergo the vertical thigh lift should understand
because the pull is not balanced as in other body lifting pro- that a long and visible inner thigh incision will be present post-
cedures where equal tension is applied across the incision line. operatively. This has been very well tolerated in our patients.
The inner thigh lift has limited impact on the shape and con-
tour of the lower half of the thigh. Indications
The vertical thigh lift is useful for massive weight loss
patients with significant medial and circumferential thigh The best candidates for an inner thigh lifting are those with
laxity. This procedure can be performed by itself or in isolated inner thigh laxity of the proximal thigh. This proce-
combination with thigh liposuction. When performed with dure usually benefits patients of normal weight and is useful
concurrent liposuction, intraoperative swelling may result in treating proximal medial thigh skin that has lost its elastic-
in suboptimal correction. The final desired tightness of the ity due to weight fluctuations, changes with aging, or changes
thigh may be less than ideal and may require revision. The that occur following significant lifetime sun damage. The
resection of tissue results in a vertical scar from the inner result that can be obtained with this operation can be demon-
pubic area extending inferiorly and usually ending at the strated to the patient by lifting the inner thigh skin up into the
medial aspect of the knee. The exact length of the incision pubic thigh crease in front of a full-length mirror. No lifting of
is ultimately based on patient preference and the amount of the anterior thighs should be done because this demonstrates
soft-tissue laxity and excess fat present. This procedure can an unrealistic outcome. This will help the patient reasonably
be continued down below the knee if laxity is present and see what outcome can be expected.
the patient desires full correction of the excess laxity. When The best candidates for undergoing a vertical thigh lift are
crossing below the knee, the linear scar should be broken up those with circumferential thigh laxity. They may have con-
to avoid a scar band contracture. The final scar below the current excess fatty tissue amenable to liposuction which can
knee tends to heal remarkably well. be dealt with as a separate staged procedure or as a combined
operation with the vertical thigh lift. The degree of correction
Introduction can be demonstrated to the patient using a full-length mirror
while the surgeon bimanually gathers thigh tissue medially,
The proximal inner thigh lift procedure was first proposed in thereby tightening the skin of the thigh circumferentially.
the 1970s, but it lost popularity as a result of unsightly scars
and vulvar disfigurement.9 With Lockwood’s description of
the superficial fascial system (SFS) and specific attention to
Contraindications
Body Contouring
anchoring the SFS of the thigh tissue to immobile structures Relative contraindications for either thigh lift procedure
such as the pubic tubercle, ischio-pubic rami, and Cooper’s includes smoking, poorly controlled diabetes, malnutri-
ligament, renewed attention to this procedure occurred.10,11 tion, and wound healing issues or immunodeficiency.
Modifications to limit the incision visibility posteriorly as well Anticoagulants, lower extremity venous insufficiency, lymph-
as incision migration caudally have improved outcomes and edema, or a history of VTE also warrants careful consider-
are responsible for the renewed popularity of this operation. ation and may preclude these procedures.
This procedure still has significant limitations, however, with
respect to the extent of medial thigh laxity correction. The Preoperative History and Preparation
inner thigh lift is designed ideally to address only the proxi-
Standard preoperative laboratory analysis is recommended.
mal medial thigh. Although a small amount of improvement
Massive weight loss patients undergoing a vertical thigh lift
can be seen in the distal medial thigh, at times to the knee,
may require nutritional assessment if this has not been done
the effect is minor and not enough to market the procedure
previously or they have not already undergone a lower body
beyond its role as a proximal thigh lift. Because of moisture
lift. We do not routinely employ VTE chemoprophylaxis for
in the inner thigh crease area, an increased incidence of super-
patients undergoing a thigh lift unless their medical history indi-
ficial wound dehiscence can be encountered in the postopera-
cate otherwise or they are having a concurrent lower body lift.
tive period. This, as well as potential scar descent, should be
discussed preoperatively.
The vertical thigh lift procedure is a much more useful and Operative Approach
powerful tool in tightening and shaping the thighs compared
with the inner thigh lift. This procedure can circumferentially Inner Thigh Lift. The markings for the inner thigh lift are
tighten and address circumferential thigh laxity from the made by marking the pubic thigh (inguinal) crease. Posteriorly,
pubic area to and inferior to the knee . Although lower body the markings end before they become visible in posterior view.
lifting can improve the laxity of the anterior, lateral, and pos- Anteriorly, the markings extend approximately to the level
terior thigh, it does not offer any improvement to the medial of the pubic tubercle. When performed in combination with
thigh.10 When significant thigh laxity exists, such as that seen lower body lifting, this incision will course along the mons
following massive weight loss, the vertical thigh lift, alone or and join the transverse abdominal incision (Figure 67.11).

be shortened or extended based on the amount of laxity pres-

ent and on patient preference (Figure 67.12). Bimanual pal-
pation gathers the redundant tissue centered on the planned
final location of the incision. The amount of laxity estimated
is marked the entire length of the proposed final incision,
usually from the groin crease to just above the knee. If there
is a significant amount of fat present, the markings should
take this into account to prevent excess tension on closure.
Transverse realignment marks are made, which can facilitate
accurate closure intraoperatively.
Under general anesthesia, a penetrating towel clip can
be used to gather the redundant skin previously marked at
multiple locations to verify that this amount of resection is
appropriate. Markings are adjusted accordingly. Tumescent
infiltration is performed. Additional tumescent infiltration is
done if concurrent circumferential thigh liposuction is per-
formed. If circumferential liposuction is planned, the poste-
rior thigh liposuction is completed in the prone position. The
patient is then turned supine for the remainder of the liposuc-
Figure 67.11. Inner thigh lift and concurrent lower body lifting
resulting in the operation frequently referred to as a complete lower
tion and the vertical thigh lift procedure.
body lift. The inner thigh incision extends vertically up along the hair- In the planned resection area, a thorough and complete
bearing mons to join the transverse abdominal portion of the body liposuction is performed first to remove virtually all of the
lift incision. subcutaneous fat. The goal is to remove most or all of the sub-
cutaneous fat from the planned resection area, leaving behind
only the skin and the subcutaneous neural, venous/lym-
phatic network. Liposuction should be performed thoroughly
The amount of soft-tissue resection is estimated at this point throughout the resection area and specifically beneath the
but should rarely exceed 4 to 6 cm. Limiting the resection will incision markings to facilitate skin release from the underly-
significantly reduce the chance of scar descent postoperatively. ing subcutaneous fat (Figure 67.13). A penetrating towel clip
General anesthesia is employed. The patient is placed in the is again used for final verification that the amount of planned
supine position with the legs in the “frog leg” position. The tissue resection is appropriate and not excessive. Often these
incisions are infiltrated with lidocaine containing adrenaline. marks have to be adjusted at this point somewhat inside the
The incision is made into the dermis and then electrocautery original markings.
is used to complete the incision into the subcutaneous tis- The most proximal portion of the skin removal is strongly
sue. Dissection is performed rather superficially: deep to the grasped and then using a folded towel as a stabilizer is avulsed
superficial fascia but not into the investing muscular fascia. from proximal to distal keeping all of the soft tissue connected
Dissection is performed inferiorly to the level marked or until to the underlying musculature. Caudal traction on the thigh
the redundant tissue has been undermined. At this point, the skin results in a natural separation of the circumscribed thigh
amount of skin and soft tissue to be removed is reevaluated, skin from the surrounding tissue (Figure 67.14). Facilitated by
marked, and resected. The Freeman rake is used to retract the the liposuction performed at the beginning of the procedure,
skin in the pubic thigh crease, and gauze dissection is used to removal of the thigh tissue occurs with remarkable preserva-
identify Cooper’s ligament, the pubic tubercle, and the ischio- tion of the venous and lymphatic network. Electrocautery is
pubic rami. Additional inferior discontinuous undermining used to achieve meticulous hemostasis and the wound edges
can be performed if indicated using the Lockwood dissector are promptly stapled together. This is done efficiently to allow
or a large liposuction cannula. This dissection, if performed,
is done immediately on top of the investing muscle fascia deep
to the superficial fascia. This additional dissection can be per-
formed to the level of the knee. Closure is begun posteriorly
with number 0 permanent or long-lasting absorbable sutures
are placed in interrupted buried fashion strongly advancing
the inferior skin flap anteriorly to avoid a posterior dog-ear.
The most posterior sutures are placed into the fibrofatty tis-
sues of the buttocks area. Sutures are placed incrementally
approximately every 1 cm anchoring the thigh SFS. Sutures
should be anchored such that tension on the sutures does not
produce vulvar distortion. As the anchoring advances anteri-
orly, sutures are anchored from the SFS of the thigh flap to
the periosteum of the ischio-pubic rami, pubic tubercle, and
Cooper’s ligament. Tissue adjustment is performed as needed
to minimize the formation of a dog-ear. Number 2-0 Vicryl
or equivalent suture is used for deep dermal closure and can
again advance the inferior thigh skin anteriorly and num-
ber 4-0 Monocryl or equivalent suture is used for running
intracuticular as a final wound closure. The final closure is
usually made waterproof with the use of cyanoacrylate tissue Figure 67.12. Significant laxity of the thighs, knees, and calves. In
adhesive. these patients, the vertical thigh lift can be extended down below the
knee. Care is taken to avoid a linear scar across the knee joint and this
Vertical Thigh Lift. The markings for the vertical thigh is where we place an anteriorly pointing notch. This notch allows for
lift begin at the insertion of the gracilis muscle in the pubic proper tension to be determined at the time of surgery and avoids the
area. The vertical thigh lift incision extends to the inferior need for a Z-plasty or other modifications.
level of the deformity usually ending near the knee and may

Figure 67.13. Pre-excision liposuction. During the vertical thigh Figure 67.14. Skin removal by avulsion. The proximal part of the
lift, a complete evacuation of all subcutaneous tissue is performed skin to be removed is strongly grasped with a Kocher clamp. A lap
with liposuction. This evacuation protects the important neural vascu- sponge is placed to stabilize the remaining thigh tissue as the skin is
lar structures and the release, at the proper level, of the overlying skin. avulsed from proximal to distal.
the skin and soft-tissue approximation to be completed before

excess swelling occurs, making closure more difficult. Closure
is usually performed with 3-0 polydioxanone suture in the
deep dermal layer and final intracuticular layer of number 4-0
Monocryl. Drains are used only when circumferential thigh
liposuction and vertical thigh lifting are combined. The inci-
sions are either glued with cyanoacrylate tissue adhesive or
taped with multiple layers of paper tape that is split every 4 to
5 cm to allow for postoperative swelling.
Postoperative Care
While still on the operating table, 4 inch wraps are used to
wrap the feet from the base of the toes to the knees. Absorbent
gauze is placed over the final incision lines and 6 inch wraps
gently compress the thighs from the knee to the groin.
Sequential compression devices are maintained throughout
the first postoperative evening. Patients are encouraged to
A
avoid standing or sitting but may ambulate for short periods.
Body Contouring
When not walking, we recommend the patients recline with
the feet at a level higher than the heart.
We see the patients very soon postoperatively and fre-
quently following surgery. Dressings are changed as needed
and within 4 or 5 days the taping, when applied, is removed
and scar cream containing silicone, mild steroid, and vitamin
E is applied. Should a dehiscence occur, steri-strips are placed
proximally and distally to prevent its propagation. Saline
dressings are used until this wound is closed.
Summary
The inner thigh lifting is best suited for patients of normal
weight who have experienced inner thigh laxity and dissent.
Minimizing the incision so that it is not visible posteriorly
and limiting the resection width to approximately 4 to 6 cm
usually ensure an acceptable outcome. The medial aspect
can be extended as needed and can be integrated into the
abdominal incision when performed in combination with B
a lower body lift (Figure 67.15). The most common com- Figure 67.15. Inner thigh lift. A. Preoperative view. B. The final
plication is dissent of the scar from the medial thigh crease scar is in good position in the pubic thigh crease and easily concealed.
(Figure 67.16).

A
Figure 67.16. Scar descent after inner thigh lift. This can occur even
if the amount of skin resection is not excessive and proper anchoring
has been performed to the immobile structures of ischio-pubic rami,
pubic tubercle, and Cooper’s ligament.
The vertical thigh lift is a completely separate entity

and is reserved for patients who have experienced massive
weight loss. For patients with complete weight loss, it is a
completion procedure that eliminates laxity of the thighs
from the groin to the knee. For patients with residual excess
fat it can be performed as the second stage of a two-stage
procedure or in combination with circumferential thigh
liposuction. The incision length is determined by the clinical
findings and patient request, but usually extends from the
origin of the gracilis to the level of the knee. Thorough com-
plete liposuction of the marked area for resection, frequent
checking of the resection width to avoid over-resection, and B
skin avulsion from proximal to distal preserving the neu-
rovascular and lymphatic structures ensure a predictable Figure 67.17. Vertical thigh lift after massive weight loss following
gastric bypass (A–B). A. Preoperative view. B. Note the length of the
outcome. This procedure provides circumferential thigh incision. The notch at the level of the knee avoids a linear scar across
tightening which is simply unachievable with other thigh- this joint and possible scar contracture.
plasty methods (Figure 67.17). Apart from some issues of
scar widening or suture line separation which respond to
scar revision, the formation of a lymphocele in the region of
the knee can occasionally be seen but is less common with
the avulsion technique described. Treatment requires surgi- prophylaxis in excisional body contouring surgery. Plast Reconstr Surg.
cal exploration and space obliteration or secondary healing, July 2008;122(1):269-279.
followed by scar revision. 6. Roberts TL 3rd, Weinfeld AB, Bruner TW, Nguyen K. “Universal” and
ethnic ideals of beautiful buttocks are best obtained by autologous
References micro fat grafting and liposuction. Clin Plast Surg. July 2006;33(3):
371-394.
1. Hunstad JP, Repta R. Atlas of Abdominoplasty. London: Elsevier; 2008. 7. Hunstad JP, Repta R. Purse-string gluteoplasty. Plast Reconstr Surg. March
2. Hunstad JP. Advanced abdominoplasty concepts. Perspect Plast Surg. 2009;123(3):123e-125e.
1999;12(2):13-38. 8. Le Louarn C, Pascal JF. Autologous gluteal augmentation after massive
3. Hunstad JP, Aitken ME. Circumferential body contouring. In: Aly A, weight loss. Plast Reconstr Surg. April 2008;121(4):1515-1516.
ed. Body Contouring after Massive Weight Loss. St. Louis, MO: Quality 9. Schultz RC, Feinberg LA. Medial thigh lift. Ann Plast Surg. May
Medical Publishing, Inc.; 2006:110-119. 1979;2(5):404-410.
4. Naghshineh N, O’Brien Coon D, McTigue K, Courcoulas AP, Fernstrom 10. Lockwood, TE. Fascial anchoring technique in medial thigh lifts. Plast
M, Rubin JP. Nutritional assessment of bariatric surgery patients presenting Reconstr Surg. August 1988;82(2):299-304.
for plastic surgery: a prospective analysis. Plast Reconstr Surg. August 11. Mathes, DW, Kenkel JM. Current concepts in medial thighplasty. Clin Plast
2010;126(2):602-610. Surg. 2008;35:151.
5. Hatef DA, Kenkel JM, Nguyen MQ, Farkas JP, Abtahi F, Rohrich RJ, 12. Craig SB, Faller MS, Puckett CL. In search of the ideal female umbilicus.
Brown SA. Thromboembolic risk assessment and the efficacy of enoxaparin Plast Reconstr Surg. January 2000;105(1):389-392.

Chapter 68 n Brachioplasty and Upper
Trunk Contouring
Susan E. Downey
Aesthetic brachioplasty was first described by Correa- the subaxillary upper lateral chest wall. Baroudi divides
Inturrasape and Fernandez in 1954. Since this first descrip- patients undergoing brachioplasty into three groups. Group
tion, modifications have been proposed to vary the placement 1 includes patients with moderate to firm skin and volumi-
of the scar, improve the contour of the upper trunk concomi- nous upper arm fat deposits. Group 2 includes patients with
tantly, and minimize scarring. flabby skin and fat deposits. Group 3 includes patients with
A major advance came with the description by Lockwood flaccid skin and no fat deposits. Appelt has described a clas-
in 1995 of brachioplasty with fixation of the superficial fas- sification that takes into account the amount of residual fat
cial system suspension. Lockwood postulated that loosening as well as the skin laxity to stratify the patients and deter-
of the connections between superficial fascial system and the mine which procedure is best in a given situation. Appelt’s
axillary fascia and loosening of the axillary fascia itself with classification system describes three different types of skin
age, weight changes, and gravitational pull yield a “loose excess as well as fat excess. Type I patients have a relative
hammock” effect, resulting in ptosis of the poster medial arm. excess of fatty deposits in the upper arm but have good
Lockwood’s technique involves anchoring the arm flap to the skin tone and minimal laxity. These patients are good can-
axillary fascia. didates for liposuction alone. Type II patients have moder-
Despite Lockwood’s advances many plastic surgeons did ate skin laxity with minimal excess fat. Type II is further
not routinely perform brachioplasties until the late 1990s broken down into IIA, IIB, and IIC. Type IIA patients have
when the obesity epidemic and the takeoff of bariatric proce- only proximal upper arm redundancy. This group of patient
dures produced an influx of patients with laxity of all parts of can also be broken down again into two groups: those with
their bodies. The majority of patients who present for brachio- isolated horizontal laxity and those with both vertical and
plasty have undergone massive weight loss which is reflected horizontal laxities. Patients with only isolated horizontal
in the numbers reported by the American Society of Aesthetic laxity can be treated with excision of a vertical ellipse with
Surgery. In 1997, there were 2,516 brachioplasties performed the scar in the axilla. Those with both longitudinal and hori-
and in 2011 the number of brachioplasties had increased to zontal excess can be treated with a T-shaped excision along
14,998. the proximal anterior aspect of the upper arm. Type IIB
The arm and upper chest, like all other parts of the patients have redundancy of their entire upper arm. These
body, demonstrates great variation after massive weight patients are candidates for a traditional brachioplasty with a
loss. Attempts have been made to classify these deformi- scar from the elbow to axilla (Figures 68.1–68.4). Type IIC
ties. Objective measurements such as the coefficient of patients have laxity of the entire length of the arm and also
Hoyer or the ratio of the height of the hanging skin have along the chest wall. These patients are candidates for an
been described. Sacks described a technique pinching the extended brachioplasty, including excision not only of the
excess skin between the fingers and measuring the length of excess arm skin but also along the lateral chest wall. Type
excess skin. Strauch broke down the upper extremity into III patients have both excess fat and redundant skin of the
four zones to help define the deformities seen after massive arm. These patients are counseled that a brachioplasty alone
weight loss. The zones are as follows: (1) zone 1 extends will not give them an aesthetically pleasing result. For these
from the wrist to the medial epicondyle; (2) zone 2 extends patients, staged liposuction and brachioplasty procedures or
Body Contouring
from the medial epicondyle to the proximal axilla; (3) zone a combined single-stage liposuction and resection can be rec-
3 is the anatomical borders of the axilla; and (4) zone 4 is ommended (Figures 68.5–68.7).
FIGURE 68.1. Preoperative arm before brachioplasty. FIGURE 68.2. Postoperative arm after brachioplasty.
707
FIGURE 68.6. Deflated arm after liposuction.
FIGURE 68.3. Preoperative arm before brachioplasty.
FIGURE 68.7. Postoperative arm after two procedures: liposuction

followed by brachioplasty.
Patients with good skin tone and minimal laxity (Applets

FIGURE 68.4. Postoperative arm after brachioplasty. I) may undergo liposuction alone but care in patient selec-
tion is critical. The majority of patients with excess fatty
deposits in the upper arm do not have good skin tone and
will not be good candidates for liposuction alone. Grazer
estimates that only 25% of patients presenting for upper
extremity plastic surgery fall into this category. Only
patients with a circumferential increase in fat volume but
adequate skin turgor and elasticity will be happy after lipo-
suction alone. Evaluation of the skin tone with the pinch
test will provide information about whether the skin will
shrink adequately.
The most significant drawback to brachioplasty is the
long scar extending from the axilla to elbow. Limited inci-
sion brachioplasty or mini brachioplasty with the scars lim-
ited to the axillary region has been described. Ideal patients
for this procedure have moderate amounts of skin and fat
excess in the proximal third of the upper arm. This proce-
dure can be combined with some liposuction to contour the
upper arm. The excision is limited to the anterior and pos-
terior limits of the axilla to hide the scars in this area with
the arms at rest. This excision only removes the skin in one
dimension (Figure 68.8). Patients with excess skin usually
have two-dimensional excess and care must be taken before
promising a scar that is isolated to the axilla. Skin qual-
ity and tone must be excellent. The limited brachioplasty
only addresses skin excess in the longitudinal direction,
whereas the full brachioplasty, with an incision extending to
FIGURE 68.5. Non-deflated arm despite massive weight loss. the elbow, addresses both longitudinal and transverse skin
excess. In some cases, a small dart may be incorporated.
Chapter 68: Brachioplasty and Upper Trunk Contouring 709
FIGURE 68.8. Result after limited brachioplasty—note the residual

looseness of upper arm skin.
FIGURE 68.10. Poor scarring after brachioplasty—note the better

appearance of scar near axilla.
FIGURE 68.9. Poor scarring after brachioplasty—note the better

appearance of scar near axilla. FIGURE 68.11. Visible scarring after posterior placement of incision
and scar.
Body Contouring
Although this will add a “T” incision to the procedure,
doing so may refine the outcome for patients with focal hor-
izontal excess.
The scars from brachioplasty are notorious for being best
in the hidden areas (the upper inner arm and axilla) and
less acceptable in the more exposed areas (near the elbow)
(Figures 68.9 and 68.10). An ongoing unresolved issue is the
placement of the scar. Some surgeons advocate a scar on the
most posterior portion of the arm, whereas others prefer a
scar medially in the bicipital groove. A survey was done of the
general public, plastic surgeons, and patients with examples
of the various scar placements. The majority of participants
felt that the medial placement of the scar was more acceptable
(Figure 68.11).
Candidates for a full brachioplasty have vertical and
horizontal skin excess and are willing to accept a high rate
of unfavorable scarring along the medial arm in exchange
for a contour improvement. If the patient also has sub- FIGURE 68.12. Markings for extended brachioplasty.
stantial fat excess throughout the arm they may require
a staged procedure with liposuction as a first stage. The
marking for a brachioplasty is best done in the standing
position, with the shoulder abducted to 90° and the elbow skin and fat to be resected is drawn but will be adjusted in
flexed to 90°. The first marking is the bicipital groove the operating room. Aly has proposed a marking technique
which represents the desired final position of the incision described as the two-ellipse technique. The final excision
(Figure 68.12). The proximal extent of the incision is set is drawn before the patient goes to the operating room.
high in the axilla. A second line estimating the amount of An ellipse is marked after pinching the skin and fat of the

made. The partially resected ellipse can partially be rein-

troduced into the wound to reduce tension and the subse-
quent line of resection can be adjusted.
The more traditional brachioplasty techniques resect the
excess skin and fat of the arm by incising along the pro-
posed incision line and then undermining the skin and fat
to be resected. The undermined flaps are overlapped over
the proposed incision line and the excess resected. It can be
helpful for an assistant to hold the proposed incision line
so the desired scar position does not migrate. Markings are
made at the proposed level of resection. As the resection
progresses, towel clips can be used to approximate the tis-
sues as the resection continues toward the axilla. Rotation
of the skin and fat not just across the proposed incision line
but toward the axilla helps with residual excess near the
elbow.
Brachioplasty is usually performed with the arms
extended on arm boards (Figure 68.13). Preoperative discus-
sion with the anesthesiologist regarding the blood pressure
monitors and IV access is important. There is controversy
FIGURE 68.13. OR positioning for brachioplasty. about the need for a Z-plasty across the axilla. Most of the
patients who present for brachioplasty are massive weight
loss patients with universal excess and laxity of skin, and
arm. A second (inner) ellipse is marked which represents hence a Z-plasty is not necessary (Figure 68.14). The ini-
the proposed final excision. The second ellipse (inner) is tial tightness across the axilla will loosen with recruitment
marked after the amount of pinched skin is measured. of adjacent loose skin. Female patients are generally happy
This technique was designed to standardize the process having the scar placed high in the axilla and having as
of a brachioplasty but great care has to be taken while much hair-bearing skin removed as possible. Male patients
the markings are being done to adjust for the thickness tend to be the opposite. American men in general prefer to
of the tissues. When the resection commences, the resec- have hair in their axillae and the scar is placed more pos-
tion should progress from distal to proximal so that if the teriorly preserving the normal male pattern of axillary hair
surgeon encounters too much tension an adjustment can be (Figure 68.15).
FIGURE 68.15. Position of brachioplasty scar to maintain normal

FIGURE 68.14. Full extension after brachioplasty without a Z-plasty. male pattern of axillary hair.

Chapter 68: Brachioplasty and Upper Trunk Contouring 711
Push excess
tissue forward
A B C
FIGURE 68.16. A–C. Markings for lateral thoracic excision.
Most patients presenting for brachioplasty also have For patients in whom the upper chest laxity is more
excess of their lateral chest wall. This excess may not be extensive a transverse excision may be considered. These
appreciated unless the patient is examined wearing a bra. transverse excisions can be combined with a brachioplasty
This excess of the upper chest is quite bothersome to women or mastopexy to fully contour the upper body. Staging of the
and is often as limiting to their clothing choices as the excess procedures may be necessary to avoid a confluence of scars.
skin and fat of their arms. For this reason, many surgeons Transverse excision may be carried out as far as the excess
now include contouring of the lateral chest when performing occurs even to the extent of completely across the back. If
a brachioplasty. For patients who do not have arm excess the excision crosses the entire back it may be referred to as
have already undergone a brachioplasty or do not wish an upper body lift (UBL). The line of excision is dictated
to have scars on their arms, the contouring of the lateral somewhat by the position of the skin and fat rolls but if pos-
chest can be performed as a stand-alone procedure. It is sible the pattern of resection can be planned to place the
important to avoid pulling the nipple in a lateral direction. scar under the brassiere line. Patients who have multiple skin
Preoperative marking is critical because once the patient is rolls of the back and lateral chest are good candidates for a
supine on the operating table it is impossible to judge the UBL. As with all massive weight loss patients, there are con-
amount to be removed without pulling the breasts laterally. siderable variations in the presentations, size of rolls, and
With the patient in the standing position, the loose or excess position of the rolls so a surgical plan must be individual-
skin and fat of the upper chest is pulled anteriorly. A verti- ized. The main goal of a UBL is to correct the horizontal skin
cal line is drawn at this point from the axilla to the infra- excess which exists on the posterior trunk and lateral chest
mammary fold. This represents the line of the final incision wall. This procedure is reserved for patients with favorable
and resultant scar. The excess skin and fat is then pulled body mass indices. UBLs are most commonly performed
back and an ellipse is drawn to represent the line of excision. concurrently with other body contouring procedures during
Body Contouring
During this process, the breast is observed to ensure that it a second stage. Complications of direct excision and UBL
is not deformed in the process. The skin and fat within the surgeries have been reported as minor with seromas being
ellipse is then directly excised (Figure 68.16). the most common.
If drains are used patients may find it more comfortable if
the drains exit through the chest wall incision rather than the
arm incision. Compressive garments may be used, especially if
liposuction has been added, but many surgeons have abandoned
compressive garments due to bunching and pinching of the skin.
Complications with brachioplasty occur less frequently
than with other body contouring procedures, even in the
massive weight loss population. 22 Complications include
seromas, paresthesias, and wound dehiscence (Figure 68.17).
The medial antebrachial cutaneous nerve becomes a superfi-
cial structure at about 14 cm proximal to the medial epicon-
dyle and is therefore at risk during brachioplasty surgery.
The medial brachial cutaneous nerve sends two or three
branches to the skin 7 cm proximal to the medial epicon-
dyle. Another three or four branches pierce the fascia to
innervate the skin 15 cm proximal to the medial epicondyle.
Knowledge of this anatomy can help prevent damage to
these nerves and their branches. The most common problems
after brachioplasty are ugly scars. As has been mentioned,
this is most common near the elbow. The scars tend to be
narrower and less unattractive as the axilla is approached.
This is an important consideration and is discussed with the FIGURE 68.17. Wound dehiscence following brachioplasty.
patient preoperatively.

Lockwood T. Brachioplasty with superficial fascial system suspension. Plast
Suggested Readings Reconstr Surg. 1995;96:912-920.
Abramson DL. Minibrachioplasty: minimizing scars while maximizing results. Rohrich RJ, Beran SJ, Kenkel JM. Back and arms. In: Rohrich RJ, Beran SJ,
Plast Reconstr Surg. November 2004;114(6):1631-1634. Kenkel JM, eds. Ultrasound—Assisted Liposuction. 1st ed. St Louis, MO:
Aly A, Cram A. Brachioplasty. In: Aly AS, ed. Body Contouring after Massive Quality Medical Publishing; 1998.
eight Loss. St Louis, MO: Quality Medical Publishing; 2006:304-333. Rubin J, Eaves F. Approaches to upper body rolls. In: Rubin J, Matarasso A,
Chowdhry S, Elston JB, Lefkowitz T. Avoiding the medial brachial nerve in bra- eds. Aesthetic Surgery after Massive Weight Loss. Philadelphia, PA: Elsevier;
chioplasty: an anatomical study. Plast Reconstr Surg. June 2010;(suppl):136. 2007:101-112.
Correa-Inturrasape M, Fernandez JC. Dermolipectomia braquial. Prensa Med Rubin J, Michels J. Correction of arm ptosis with a medial bicipital scar. In:
Argent. 1954;34:24-32. Strauch B, Herman C, eds. Encyclopedia of Body Sculpting after Massive
Downey S. Approach to excess trunk rolls with vertical excision. In: Strauch B, Weight Loss. New York, NY: Thieme; 2011a:163-171.
Herman CK, eds. Encyclopedia of Body Sculpting after Massive Weight Rubin J, Michaels J. Upper body lift for the correction of back rolls.
Loss. New York, NY: Thieme; 2011:216-223. In: Strauch B, Herman C, eds. The Encyclopedia of Body
Glanz S, Gonzalez-Ulloa M. Aesthetic surgery of the arm: part I. Aesthetic Plast Sculpting after Massive Weight Loss. New York, NY: Thieme; 2011b:
Surg. 1981;5:1. 224-229.
Goddio AS. A new technique for brachioplasty. Plast Reconstr Surg. Sacks AC. Grading system simplifies brachioplasty decisions cosmetic surgery.
1989;84(1):84-85. Times. March 2003:8.
Grazer F. Rejuvenation of the upper arm. Plast Reconstr Surg. August Samra S, Sawh-Martinez R, Liu YJ, et al. Optimal placement of brachio-
1998;102(2):552-553. plasty scar: a survey evaluation. Plast Reconstr Surg. October 2010;
Gusenoff JA, Coon D, Rubin JP. Brachioplasty and concomitant procedures 126(3):77.
after massive weight loss: a statistical analysis from a prospective registry. Strauch B, Greenspun D, Levine J, et al. A technique of brachioplasty. Plast
Plast Reconstr Surg. 2008;122(2):595-603. Reconstr Surg. 2004;113(3):1044-1048.
Hurwitz DJ. Brachioplasty. In: Borud LJ, ed. Atlas of Body Contouring after Teimourian B, Malekzadeh S. Rejuvenation of the upper arm. Plast Reconstr
Weight Loss. Woodbury, CT: Cine-Med; 2008:210-229. Surg. August 1998;102(2):545-551.
Illouz Y, DeVillers Y. Body sculpting by lipoplasty. 1st ed. Edinburgh: Churchill Trussler AP, Rohrich RJ. Limited incision medial brachioplasty: techni-
Livingstone; 1989. cal refinements in upper arm contouring. Plast Reconstr Surg. January
Knoetgen J, Moran S. Long-term outcomes and complications associated with 2008;121(1):305-307.
brachioplasty: a retrospective review and cadaveric study. Plast Reconstr Vogt PA, Baroudi R. Brachioplasty, axilloplasty and pre-axilloplasty. Aesthetic
Surg. 2006;117(7):2219-2223. Plast Surg. 1983;7:31.

Chapter 69 n Principles Of Plastic Surgery
After Massive Weight Loss
J. Peter Rubin
bariatric surgery patients. Nearly every region of the body

Introduction can be affected, resulting in redundant, loose, hanging rolls
Plastic surgery following massive weight loss (MWL) is a rela- of skin and fat often in patterns that had not previously been
tively new subspecialty of plastic surgery, fueled by the obe- described in the plastic surgery literature.7 These deformities
sity epidemic and successful outcomes from bariatric surgery. lead to intertriginous rashes, chronic fungal infections, skin
MWL patients represent a unique cohort that differs from breakdown, soft tissue sepsis, and social embarrassment.
typical body contouring patients. Evaluation must take into Patients frequently seek consultation with a plastic surgeon to
account complex medical and psychosocial issues associated address these deformities, and often consider body contour-
with obesity and operative planning requires unique strategies. ing as the “final phase of their weight loss journey.” With
The goal of this chapter is to provide a safe and comprehen- the increased number of bariatric procedures, body contour-
sive approach to management of the MWL patient. Technical ing has been a tremendous area of growth in plastic surgery,
details of specific operative procedures appear in Chapters 65 and many plastic surgeons are now exposed to the weight loss
to 68. The key topics covered here are 1) the medical impact of population in their training and practices.8
obesity and the rise of bariatric surgery as an effective therapy,
2) critical factors for consideration in the preoperative evalu-
ation of the MWL patient presenting for plastic surgery, and
Preoperative Evaluation
3) a framework for designing a safe operative plan, including The surgeon must bear in mind that these are truly elective
when to combine multiple procedures and when to perform cases on complex patients and deferring surgery to modify risk
them in separate stages. factors is never a bad option. Indeed, in the Life After Weight
Loss post-bariatric center at the University of Pittsburgh,
patients are often engaged in a collaborative effort to further
Obesity, Associated Medical reduce BMI or improve nutritional status over a period of
Comorbidities, and Impact of many months before surgery is offered.9
Bariatric Surgery We have identified six key assessment points in a compre-
hensive preoperative evaluation of the MWL patient: 1) tim-
Obesity has a major impact on the health of our patients, ing of body contouring surgery relative to gastric bypass; 2)
and an appreciation for the medical problems associated with BMI at presentation; 3) nutritional assessment; 4) evaluation
overweight and obese patients is vital. The key metric, body for medical comorbidities of obesity; 5) evaluation of psycho-
mass index (BMI), obtained by dividing weight in kilograms social issues, and 6) assessment of the physical deformities.
by height in meters squared (kg/m2), is used to define “over- Table 69.1 outlines pitfalls at each step, along with pitfalls in
weight” as a BMI of 25.0 to 29.9 kg/m,2 obesity as a BMI operative planning and management.
> 30 kg/m2, severe obesity as a BMI > 35 kg/m2, and mor- The surgeon and office staff must recognize that an MWL
bid obesity as a BMI > 40 kg/m2. Obesity rates in the United patient has made a major life transformation through great
States, based on 2010 Centers for Disease Control data, reveal dedication and should be congratulated on this accomplish-
that no state has a prevalence of obesity less than 20%. In ment. Importantly, since these patients are constantly strug-
Body Contouring
contrast, 1995 data indicated not a single US state had an obe- gling with self-esteem issues, appropriate compassion helps
sity prevalence rate exceeding 20%.1 A striking statistic is that them feel more comfortable.
33.8% of adults over age 20 are classified as obese, and nearly
5% are morbidly obese with a BMI > 40 kg/m2.2 Worldwide, Weight Loss History and Timing of Plastic
the International Obesity Task Force estimates that over 1 bil-
lion individuals are overweight and 475 million are obese.3 Surgery Relative to Bariatric Surgery
Medical comorbid conditions associated with obesity are A history of the age of onset of obesity, family history of obe-
numerous. Diabetes, hyperlipidemia, hypertension, obstruc- sity, and course of obesity over the patient’s life leading up to
tive sleep apnea (OSA), gastroesophageal reflux disease, and bariatric surgery is obtained. A detailed history of the type of
osteoarthritis are common. These conditions are all greatly bariatric procedure performed includes the type of procedure,
improved by weight loss, but may still be present at the time date of procedure, any complications and/or additional proce-
of plastic surgery consultation and are specifically considered dures, and course of weight loss since the procedure. An accu-
and addressed. rate weight is obtained in the office, and inquiry made about
The most effective treatment for morbid obesity is bariatric goal weight. The highest BMI prior to bariatric surgery, the
surgery, and a 1991 National Institutes of Health Consensus lowest BMI since bariatric surgery, and the BMI at the time
Conference recommended the procedure for patients with a of presentation are calculated and recorded. Additionally,
BMI > 40 kg/m2 or a BMI > 35 kg/m2 with significant comor- we find it helpful to document weight loss over the previous
bid conditions.4 month and 3 months prior to presentation. We require weight
Since that time, rates of bariatric procedures performed stability, defined by not more than 5 lb of weight change per
have increased steadily, with over 200,000 people undergoing month in the previous 3 months.
various weight loss procedures annually. The improvement of Timing of plastic surgery following MWL is an impor-
obesity-related medical disorders following bariatric surgery tant factor and patients must be at a stable weight before
has been a major health benefit.5,6 undergoing body contouring. Patients typically experience a
Deflation of the skin envelope after successful weight significant and rapid weight loss during the first year after
loss results in a varied constellation of deformities in many bariatric surgery. In general, a minimum of 12 months
713
Table 69.1
Key Steps In Evaluation and Management, and Potential Pitfalls
n Key Step In Evaluation And Management n Pitfalls

Timing of body contouring surgery relative to GBP Patients less than 12 months from GBP may still be actively losing
weight and in a catabolic state
BMI at presentation High BMI can impact patient safety and aesthetic outcomes;
attempts should be made to optimize BMI before body contouring
surgery
Nutritional assessment Oral protein intake often low in post-GBP patients. Low serum
protein measures cannot be ruled out by history alone. Iron
deficiency and associated anemia is common in the GBP population
Evaluation for residual medical comorbidities of Unrecognized cardiac disease may be exacerbated by stress of body
obesity contouring surgery
Evaluation of psychosocial issues Low self-esteem is a persistent issue faced by weight loss patients
and can affect satisfaction. Additionally, body dysmorphic disorder
and other body image issues can be found even in patients with
significant deformities
Evaluation of anatomic deformities Suggesting operations based on apparent severity deformities
present, rather than first asking the patient to prioritize areas of
concern, can result in an operative plan that is not well tailored to
the patient’s goals
Planning operative procedure Patient desire for correction of multiple body regions can lead to
an overly aggressive operative plan, given such factors as surgical
setting and composition of OR team
Postoperative management Patients may not be fully aware of the magnitude of recovery from
major body contouring procedures and high incidence of wound
healing problems
GBP, gastric bypass; BMI, body mass index; OR, operating room.
should elapse following weight loss surgery to enable the initial panniculectomy or reduction mammaplasty can greatly
patient to reach this plateau, and often a plateau is not improve comfort and ability to exercise as the patient strives
observed until 18 months post-op. A patient still undergo- for further weight loss. Surgery is usually deferred for patients
ing rapid weight loss may not have achieved metabolic and with a BMI > 40 kg/m2 until they achieve further weight loss,
nutritional homeostasis and could be at risk for subopti- unless symptoms are unusually severe (e.g., acute or recurrent
mal wound healing. Protein intake is usually improved for soft tissue sepsis on the pannus).
patients after 12 months following bariatric surgery. In addi- When a patient with a higher than optimal BMI is encoun-
tion, the aesthetic results may be compromised if a patient tered, the surgeon should consider deferring surgery and
loses a significant amount of weight after body contouring referring the patient back to the bariatric surgeon and/or
surgery. Patients still actively losing weight are deferred and nutritionist for further weight loss. Follow-up visits with the
reassessed in 3 months.10 plastic surgeon at 3-month intervals will keep the patients
engaged and motivated toward their goals of being good can-
Role of BMI didates for body contouring surgery.
Regarding risk and BMI, a prospective analysis of 511 post-
Once weight stability is verified, BMI at presentation is care-
bariatric cases at our center demonstrated that both higher
fully considered. There is no absolute threshold for BMI prior
pre-bariatric maximum BMI and BMI at presentation were
to surgery, but the best candidates for extensive body contour-
associated with increased complications in patients undergo-
ing surgery typically have a BMI less than 30 kg/m2 and can be
ing a single body contouring procedure. The same study found
considered for a wide range of procedures including multiple
that the change in BMI (maximum to BMI at presentation)
procedures, if their medical and psychological conditions are
was directly related to overall complications in patients under-
favorable.12 While a BMI lower than 25 kg/m2 is optimal, that
going multiple procedures.11 These BMI parameters and their
value is not commonly seen after MWL and many success-
association with complications have been corroborated by
ful bariatric patients will present in the BMI range of 25 to
other investigations.12 Others have found that the frequency of
30 kg/m2. At higher BMIs between 30 and 35 kg/m2, one must
both major and minor complications were higher in the mor-
be more selective and evaluate individual patterns of body fat
bidly obese and severely morbidly obese groups.13
distribution to guide surgical planning. For example, a patient
with an android body type might have a large intra-abdomi-
nal adipose burden at a BMI of 35 kg/m2 that limits effective Search for Residual Medical Comorbidities
abdominal contouring. Patients with a BMI between 35 and Weight loss induced by bariatric surgery improves health and
40 kg/m2 tend to have findings that limit effective aesthetic alleviates active disease, with effects noted often within the
contouring, including a thicker subcutaneous adipose layer first 2 to 5 months postoperatively.14 It is gratifying to hear
and a large intra-abdominal fat compartment. In this patient patients talk about going from handful of medications to
group, we focus on single procedure, functional operations barely any prescription drugs. However, the plastic surgeon
to relieve symptoms and encourage further weight loss. An must actively inquire about the most common comorbidities

Chapter 69: Principles of Plastic Surgery After Massive Weight Loss 715
of obesity and search for unresolved issues. While Pories optimizing their own outcomes by ceasing their smoking
et al.15 demonstrated that 82% of obese patients with type II habit. Often, a surgery date is not scheduled until the patient
diabetes mellitus had resolution of their disease following has stopped tobacco use.
weight loss, patients with persistent insulin resistance will still One other factor to consider is a potential higher risk of
present to the plastic surgeon. Hemoglobin A1C is checked perioperative pulmonary aspiration in patients with a gastric
as an indicator of glucose control. Oral hypoglycemic agents band. It is advisable to consult with the patient’s bariatric
are held on the morning of surgery, and insulin dose, if appli- surgeon to see if they advise deflating the band prior to plastic
cable, is reduced on the morning of surgery consistent with surgery.
the fasting state. For all diabetic patients, glucose is monitored
every 6 hours postoperatively and treated with an insulin slid-
ing scale for tight glycemic control. The plastic surgeon may
Nutritional Evaluation
opt for assistance from an internist in the management of Nutritional evaluation begins with an inquiry about persis-
these issues but the ultimate responsibility is his/hers and the tent nausea and vomiting. These symptoms could suggest a
surgeon should be familiar with the dose of every medication mechanical stricture necessitating referral to the bariatric sur-
given to his/her patient. geon. Nausea and vomiting also raises suspicion for thiamine
Obstructive sleep apnea (OSA) is another common comor- deficiency (see below). Inquiries are also made about symp-
bidity of obesity and may still be present in patients presenting toms of dumping, which, when present, raise particular con-
for plastic surgery. Risks and complications associated with cern for protein malnutrition.21
OSA include myocardial infarction, stroke, arrhythmia, and The type of weight loss procedure that the patient under-
sudden death. Patients should be questioned about recent went is also relevant. Purely restrictive operations, such as
sleep studies and recommendations for perioperative manage- gastric banding and vertical banded gastroplasty, have a low
ment obtained from the treating pulmonologist or internist. risk of nutritional deficiencies. Roux-en-Y gastric bypass, a
If patients use continuous positive airway pressure (CPAP) common bariatric procedure performed in the United States,
devices at home, they should be instructed to bring their own is both restrictive and malabsorptive and is associated with
CPAP machine and mask for use after surgery, as their device a higher incidence of nutritional deficiencies compared with
will be well tolerated and will increase compliance during the restrictive procedures. The plastic surgeon must be aware of
inpatient stay. older malabsorptive procedures such as the duodenal switch
Hypertension is highly prevalent in the obese population, and biliopancreatic diversion, as these have the highest risk of
and bariatric surgery is very effective at reducing hypertension, nutritional derangements.
with 50% to 60% of patients becoming normotensive.16,17 It is, Protein intake is a key factor for the post-bariatric patient.
however, imperative to question the patient about symptoms Food aversions and difficulty tolerating red meat and other
of active cardiovascular disease during the interview, including animal protein sources are often noted after gastric bypass.
exertional dyspnea and chest pain. Inactive patients, especially This may not be a problem in the unstressed state, but major
in higher age ranges, raise concern for underlying cardiac dis- elective surgery will require an increased calorie and protein
ease that could be unmasked by the stress of a major surgical consumption of up to 25%.22 A formal interview and assess-
procedure. Exercise tolerance is a useful topic to explore dur- ment by a nutritionist is helpful to obtain an estimation of
ing the interview, as patients who routinely tolerate 45 minutes daily protein intake. Even without the use of a nutritionist,
of vigorous exercise are likely to tolerate the stress of surgery however, the plastic surgeon can certainly get a rough esti-
(Chapter 11). Given the magnitude of major body contouring mate of a patient’s daily protein intake by having the patient
procedures, we are quick to refer patients for a preoperative list the foods consumed during the previous 2 days and calcu-
stress test and other appropriate cardiovascular studies. lating nutrient value from standard food composition tables.
Risk factors for venous thromboembolism (VTE) are A good source is the online U.S. Department of Agriculture
assessed, including current obesity state, immobility, increasing Food and Nutrient Database for Dietary Studies 4.1., http://
age, and venous varicosities.18 Additionally, the potential for www.ars.usda.gov/Services/docs.htm?docid=12089.23 Patients
hereditary coagulopathies is considered. A history of multiple are counseled on how to read food package labels and advised
Body Contouring
spontaneous abortions, in particular, should arouse suspicion to increase their daily protein intake to at least 70 to 100 gm/
of an underlying thrombophilia.19 Moreover, all patients with day and focus on lean, protein rich foods. This may require
a documented history of VTE are tested for hypercoagulable specific protein supplements, such as whey sources, that
disorders and referred where indicated to a hematologist for they are able to tolerate. The challenge is identifying protein
perioperative risk assessment and recommendations. For par- sources that are low in fat and carbohydrate content. Gastric
ticularly high-risk patients, placement of a temporary inferior bypass patients may have a high daily protein intake and still
vena cava filter is considered. Shermak and colleagues investi- be at risk for protein malnutrition. In our prospective study of
gated the incidence of VTE in the post-bariatric body contour- gastric bypass patients, we found a 13.8% incidence of low
ing population. They showed an overall risk for VTE of 2.9% albumin and a 6.5% incidence of low prealbumin, with no
for all patients undergoing body contouring surgery. This correlation found between measured serum protein levels and
rate increased to 8.9% for patients with a BMI of 35 kg/m2 reported daily protein intake. Therefore, protein malnutri-
or greater.20 While clear evidence-based guidelines for the use tion cannot be effectively ruled out by history alone in the
of chemoprophylaxis have not been established for plastic post-bariatric patient and serum protein measures should be
surgery, all patients should have intermittent pneumatic com- obtained in the preoperative workup.21
pression devices applied prior to the induction of general anes- A host of micronutrient deficiencies are also seen in this
thesia. Early ambulation is critical and must be stressed during patient population.24-26 Iron deficiency is common, especially
hospitalization and at the time of discharge. in women, and is frequently associated with anemia27 requir-
Risk of platelet dysfunction from medications, including ing treatment with daily iron supplements. In the author’s
aspirin and nonsteroidal anti-inflammatory agents, is consid- prospective evaluation of patients presenting for plastic sur-
ered, especially given the prevalence of osteoarthritis in this gery after weight loss, iron deficiency was the most common
population, and the medications are discontinued for at least nutritional derangement with an incidence of 39.7%.21
2 weeks before surgery. Inquiries are also made about herbal Calcium deficiencies are observed after malabsorptive pro-
medications and these agents held preoperatively. cedures, and supplementation with 1,200 to 1,500 mg of cal-
Tobacco use is another modifiable risk factor for postop- cium citrate daily is employed. Vitamin B12 deficiency may be
erative complications. In our center, we are aggressive about present and is supplemented with 500 to 600 μg daily to avoid
educating patients and hopefully getting them to partner in megaloblastic anemia and potential peripheral neuropathy.

Folate deficiency is less commonly seen, but may also result motivations for undertaking body contouring procedures are
in megaloblastic anemia.24-26 Thiamine deficiency may be much more likely to be disappointed or dissatisfied; surgery
encountered and symptoms can be potentiated during surgery should be deferred pending a psychiatric evaluation.32-34
by intravenous solutions containing dextrose. If postoperative
neurological symptoms are noted, thiamine is likely deficient Evaluating the Anatomic Deformities
and if left untreated may result in Wernicke-Korsakoff enceph-
The MWL patient is unique in that nearly every part of the
alopathy, progressive paralysis, coma, and even death. We have
body can be affected. A thorough evaluation considers not
had occasion to observe this phenomenon in our center and
just the loose skin, but relative body type (android versus
fortunately the neurologic symptoms were reversed with intra-
gynoid), overall body fat distribution, skin tone in different
venous thiamine, starting with an initial bolus of 100 mg.28
regions, skin folds/rolls, and regional adiposity. The locations
of tethering points that define a skin roll are noted, as well
Psychological Considerations as the presence of multiple rolls. The Pittsburgh Rating Scale
and Managing Patient is a point-based rating system for severity of deformities in
the MWL patient by anatomic region7 and correlates severity
Expectations to the type of treatment. Challenging cases require that both
Body image issues and low self-esteem are prevalent in the bar- loose skin and excess adipose deposits are addressed, and this
iatric population even after successful weight loss, and abun- may entail a combination of excisional surgery and liposuc-
dant, excess, loose-hanging skin may be one cause.24 Beyond tion. Additionally, an important surgical concept is that not
the loose skin, however, many bariatric patients describe dif- all excess adipose tissue is best treated by excision; some adi-
ficulty shedding their former body image even after weight loss pose tissue can be transposed to a new location adding volume
and describe seeing themselves as still being “obese.” The psy- and shape to the breast or buttock region.
chological issues are complex, and the risk of major depression
is nearly five times higher in individuals with a BMI > 40 kg/m2 Special Considerations in Preoperative
when compared with individuals of average weight.29 Unlike Counseling
diabetes and hypertension, which often disappear after weight
Most MWL patients, with proper counseling, are very satis-
loss, the mood and personality disorders, destructive eating
fied with their surgery. Important concepts to emphasize are
patterns, and poor body image issues seen in obese patients
scarring, lack of effect on regions outside those being treated,
often do not resolve.30-32 The common finding of controlled
potential for recurrence of skin laxity, magnitude of recovery,
depression in the weight loss patient is not, in itself, a con-
and risk of wound healing complications.10 It is essential that
traindication to body contouring surgery. However, patients
the patient recognize the trade-off between removing excess
with a diagnosis of bipolar disorder or schizophrenia require
skin accepting scars. For MWL surgery, the phrase holds true
an evaluation and clearance from their mental health provider
that “minimal access scars equals minimal results.” It is often
before body contouring surgery.33
useful to draw the anticipated scar position on the patient with
A supportive social network is vital during the recovery
a marker in front of a full-length mirror. These marks can also
period from major body contouring procedures. First of all,
be photographed to document the discussion. The best way
MWL itself may drastically alter a patient’s interpersonal rela-
to simulate the effect of surgery during the consultation is by
tionship. Some relationships may be strengthened but many
pinching together the tissues to be manipulated and demon-
patients report separations, divorces, and new relationships.
strating the pull on the adjacent tissues. Just as important as
Before undertaking major procedures, the plastic surgeon
explaining what the operation will accomplish is describing
should make sure adequate support systems are in place.
what the operation will not do. Patients often have the misper-
Setting expectations begins with an understanding of moti-
ception that an operation, such as an abdominoplasty, with
vations and priorities. The patient must identify the anatomic
correct upper back rolls or buttock ptosis through tissue pull.
regions of greatest concern to them. Most patients have a
The surgeon must explain where the impact of a given opera-
positive tone, express pride in their accomplishments, and
tion ends anatomically. Another important concept to com-
articulate what they expect from the body contouring opera-
municate is that recurrent skin laxity may occur after body
tion. Patients must accept the scars and significant recovery
contouring, no matter how tight the tissues are pulled in the
period, and embrace the concept that they will be significantly
operating room and that recurrent laxity may warrant surgi-
improved but not “perfect.”
cal revision.33 Patients must be properly informed about the
Even with a good outcome, patients tend to forget their pre-
magnitude of recovery. Given the popularity of laparoscopic
operative appearance. Occasional review of the preoperative
bariatric surgery, patients should be educated that body con-
photos during postoperative visits helps remind the patients
touring procedures are much more invasive and not “simple
how far they have progressed and keeps them motivated.34
skin tucks.” Patients must also understand the high incidence
Despite the fact that MWL patients have significant defor-
of wound healing complications in MWL body contouring
mities, they can still have body dysmorphic disorder or simi-
procedures, including wound dehiscence and seroma.35
lar severe body image derangements that preclude satisfactory
outcome. This is a serious pitfall. During the consultation, it
is vital to observe the patient’s affect and mood while they COMBINING AND Staging
describe their lifestyle and the impact of the hanging skin.
Patients who are morose, overly preoccupied with their defor-
PROCEDURES
mities, and spend an inordinate amount of time thinking Patients will often present with multiple regions of concern
about their loose skin (especially if these thoughts are highly and satisfaction will be maximized if these areas are addressed
disruptive) are likely poor candidates. Importantly, patients in order of priority. Certain procedures can be combined in a
who inappropriately attribute problems with job perfor- single operative procedure (Table 69.2). The decision to per-
mance, career advancement, relationships, and general self- form multiple procedures takes into consideration the medi-
esteem to the loose skin are to be avoided. When patients are cal condition of the patient, the composition of the operative
scar-averse and use terms such as “normal” for the expected team, the surgeon’s experience with body contouring surgery,
outcome, the surgeon is wise to defer intervention. In such the facility in which these procedures are performed, and finan-
circumstances, it is nearly impossible to meet expectations no cial burden for the patient (Table 69.3). Single procedures and
matter how skillfully the surgery is performed. Those indi- combinations of procedures can be organized into a staged
viduals who express unrealistic expectations or questionable plan. Reducing concurrent procedures and opting for staging is

Table 69.2
Guidelines For Selecting Procedure Combinations
n Generally Favorable Combinations

of Procedures n Caveats and Pitfalls
Abdominoplasty and mastopexy (a) (a) A loose inframammary fold may be displaced
Abdominoplasty and brachioplasty (b) during abdominoplasty and impact planned
Circumferential lower body lift and brachioplasty markings for mastopexy
Circumferential lower body lift and mastopexy (b) Brachioplasty concurrent with another procedure
Transverse upper body lift/torsoplasty and mastopexy may limit a patient’s ability to get out of bed
Mastopexy and brachioplasty independently in the early postoperative period
Mastopexy and vertical thigh lift
Brachioplasty and vertical thigh lift
n Combinations that Require Caution
in Planning n Caveats and Pitfalls
Circumferential lower body lift and vertical thigh lift (c) (c) There is a high magnitude of recovery for this
Circumferential lower body lift and transverse upper body lift (d) combination, as well as opposing vectors of
Transverse upper body lift/torsoplasty and brachioplasty (e) tension
(d) Opposing vectors of tension may result in
displacement of scar position
(e) Extension of brachioplasty scar inferiorly onto
lateral chest may result in confluence of scars
(“T” point) that is prone to breakdown
always the default plan in higher risk cases. Table 69.4 shows Table 69.4
the relative advantages and disadvantages of combining and
staging procedures. A clear advantage of a staged approach Pros and Cons of Staging and Combining
is that it provides a planned opportunity to revise recurrent Procedures
skin laxity after previous procedures. We prefer a minimum of
3 months between stages with no firm upper limit on intraop- n Advantages to n Advantages
erative time for each operative episode.35 We attempt to avoid staging the to combining
combining procedures that would result in opposing vectors operative plan procedures
of tension. In our practice, most patients requesting total body • Decreases operative time • Decreases number of
reshaping will require a minimum of two stages, not including for each surgical episode operations
facial rejuvenation. Figure 69.1 shows an example of a staged • Easier recovery from each • Decreases overall recov-
approach to total body reshaping in which the circumferen- stage ery time
tial lower body lift, the cornerstone operation for lower trunk • Decrease surgeon fatigue • May have less financial
contouring (Chapters 66 and 67), is combined with one upper • Planned opportunity to burden for patient due to
body procedure (brachioplasty) (Chapter 68) in the first stage. return to operating room cost-effective operating
and correct any issues room utilization with
remaining from first surgery, team approach and less
Body Contouring
Table 69.3 including tissue relaxation time out of work
• Staged plan can avoid
Considerations In Deciding To Combine opposing vectors of pull
Procedures • Overall safety may be
maximized
• Operative setting
n Disadvantages n Disadvantages
– Outpatient center to staging the to combining
– Hospital operative plan procedures
• Patient medical status • Increases number of • Longer operative times
operations • Greater recovery
– Known medical problems
• Greater cumulative • Opposing vectors of
– Cardiac risk recovery time and time tension from adjacent
out of work for patient operative regions may be
• Surgeon comfort with long case
• Overall financial burden problematic
• Interplay of adjacent procedures for patient may be higher • Increased risk of surgeon
– Are there opposing vectors of pull? fatigue
• Higher potential for
– Impact on blood supply blood loss and need for
– Displacement of intended scar positions transfusion
• Revisions may need to be
• Operative team addressed in an unplanned
– Second surgeon procedure, rather than
during a planned pro-
– Residents cedure within a staged
– Extenders sequence of operations

A, B C
D, E F
G, H I
FIGURE 69.1. A 38-year-old woman desired total body contouring after a weight loss of 209 lb. A–C. Preoperative views. D–F. Postoperative
views 5 months after stage 1, consisting of fleur-de-lis abdominoplasty, lateral thigh/buttock lift, and brachioplasty. G–I. Postoperative views
9 months after stage 2, consisting of dermal suspension and parenchymal reshaping mastopexy, upper back lift, and vertical medial thigh lift.
Reprinted, with permission, from Coon D, Michaels J, Gusenoff JA, Purnell C, Friedman T, Rubin JP. Multiple procedures and staging in the
massive weight loss population. Plast Reconstr Surg. 2010;125(2):691-698.

The vertical thigh lift (Chapter 67) and a second upper body 13. Au K, Hazard S, Dyer A, et al. Correlation of complications of body
contouring surgery with increasing body mass index. Aesthetic Surg J.
procedure (transverse upper body lift and mastopexy) are per- 2008;28:425-429.
formed in the second stage. This plan avoids the simultaneous 14. Buchwald H. Consensus conference statement bariatric surgery for morbid
opposing vectors of tension from the upper and lower body obesity: health implications for patients, health professionals and third-
lift, separates the vertical thigh lift from the circumferential party payers. Surg Obes Relat Dis. 2005;1(3):371-381
15. Pories W, Swanson M, MacDonald K, et al. Who would have thought it?
lower body lift, and avoids a fresh “T” point at the junction An operation proves to be the most effect therapy for adult-onset diabetes
between the chest extension of the brachioplasty scar and the mellitus. Ann Surg. 1995;222:339-350.
upper body lift. As previously reported, combining body con- 16. Carson J, Ruddy M, Duff A, et al. The effect of gastric bypass surgery
touring procedures is safe in well-selected patients. Aggregate on hypertension in morbidly obese patients. Arch Intern Med. 1994;154:
193-200.
minor complication rates are higher than in single-stage cases, 17. Benotti P, Bistrain B, Benotti J, et al. Heart disease and hyperten-
but there is no increase in complications on a per-procedure sion in severe obesity: the benefits of weight reduction. Am J Clin Nutr.
basis (i.e., the total complication rate is the sum of the 1992;55:586S-590S.
expected complication rate for each individual procedure).36 18. Geerts W, Pineo G, Heit J, et al. Prevention of venous thromboembolism.
Chest. 2004;126:338S.
To maintain patient safety during multiple procedures, fluid 19. Friedman T, Coon D, Michaels J, et al. Hereditary coagulopathies: practi-
balance, blood loss, and body temperature are carefully moni- cal diagnosis and management for the plastic surgeon. Plast Reconstr Surg.
tored during the procedure. The patient is advised preopera- 2010;125(5):1545-1552.
tively that the surgeon will truncate the operation if there is 20. Shermak M, Chang D, Heller J. Factors impacting thromboembolism
after bariatric body contouring surgery. Plast Reconstr Surg. 2007;119:
evidence of increased risk. 1590-1596.
21. Naghshineh N, Coon D, McTigue K, et al. Nutritional assessment of bar-
Conclusion iatric surgery patients presenting for plastic surgery: a prospective analysis.
22. Van Way C. Nutritional support in the injured patient. Surg Clin North
Plastic surgery after MWL has a tremendously positive impact Am. 1991;71:537-548.
on the lives of many patients. With the worldwide increase in 23. U.S. Department of Agriculture, Agricultural Research Service. 2012. Food
obesity rates and success of bariatric surgery, plastic surgeons and Nutrient Database for Dietary Studies 4.1. http://www.ars.usda.gov/
will continue to encounter MWL patients requesting body Services/docs.htm?docid=12089. Accessed December 31, 2011.
24. Song A, Fernstrom M. Nutritional and psychological considerations after
contouring procedures. A methodical approach and careful bariatric surgery. Aesthetic Surg J. 2008;28:195-199.
operative planning maximizes patient safety and outcomes. 25. Sebastian J. Bariatric surgery and work-up of the massive weight loss
patient. Clin Plastic Surg. 2008;35:11-26.
References 26. Agha-Mohammadi S, Hurwitz D. Potential impacts of nutritional deficiency
of postbariatric patients on body contouring surgery. Plast Reconstr Surg.
1. Centers for Disease Control. U.S. Obesity Trends. Online. http://www.cdc. 2008;122:1901-1914.
gov/obesity/data/trends.html. Accessed December 30, 2011. 27. Brolin RE, Gorman JH, Gorman RC, et al. Prophylactic iron supplementa-
2. Flegal K, Carroll M, Ogden C, et al. Prevalence and trends in obesity among tion after Roux-en-Y gastric bypass: a prospective, double-blind, random-
US adults, 1999-2008. JAMA. 2010;303:235-241. ized study. Arch Surg. 1998;133(7):740-744.
3. International Obesity Task Force. About obesity. Online. http://www.iotf.org. 28. Sebastian J, Michaels J, Tang L, et al. Thiamine deficiency in a gastric bypass
Accessed December 20, 2011. patient leading to acute neurological compromise after plastic surgery. Surg
4. National Institutes of Health. Gastrointestinal surgery for severe obesity. Obes Relat Disord. 2010;6:105-106.
NIH Consensus Statement Online. 1991;9:1-20. 29. Onyike C, Crum R, Lee H, et al. Is obesity associated with major depres-
5. Belle S, Berk P, Courcoulas A, et al. Safety and efficacy of bariatric sur- sion? Results from the Third National Health and Nutrition Examination
gery: longitudinal assessment of bariatric surgery. Surg Obes Relat Dis. Survey. Am J Epidemiol. 2003;158(12):1139-1147.
2007;3:116-126. 30. Sarwer D, Thompson J, Cash T. Body image and obesity in adulthood.
6. Sjostrom L, Lindroos AK, Peltonen M, et al. Lifestyle, diabetes, and car- Psychiatr Clin North Am. 2005;28(1):69-87.
diovascular risk factors 10 years after bariatric surgery. N Engl J Med. 31. Sarwer D, Thompson J, Mitchell J, et al. Psychological considerations of
2004;351:2683-2693. the bariatric surgery patient undergoing body contouring surgery. Plast
7. Song A, Jean R, Hurwitz D, et al. A classification of weight loss deformities: Reconstr Surg. 2008;121:423e-434e.
the Pittsburgh rating scale. Plast Reconstr Surg. 2005;116:1535-1554 32. Sarwer D, Fabricatore A. Psychiatric considerations of the massive weight
8. American Society of Plastic Surgeons. 2010 Statistics. Online. http://www. loss patient. Clin Plastic Surg. 2008;35:1-10.
plasticsurgery.org/Media/Statistics.html. Accessed December 20, 2011. 33. Rubin JP, O’Toole JP. Evaluation of the massive weight loss patient
9. Tang L, Song AY, Choi SJ, Fernstrom M, Rubin JP. Completing the meta- who presents for body contouring surgery. In: Rubin JP, Matarasso A,
Body Contouring
morphosis: building a center of excellence in postbariatric plastic surgery. eds. Aesthetic Surgery After Massive Weight Loss. London: Elsevier;
Ann Plast Surg. 2007;58:54-56. 2007;13-20.
10. Rubin JP, Nguyen V, Schwntker A. Perioperative management of the 34. Song AY, Rubin JP, Thomas V, Dudas J, Marra KG, Fernstrom MH.
post-gastric-bypass patient presenting for body contour surgery. Clin Plastic Body image and quality of life in post massive weight loss body contouring
Surg. 2004;31:601-610. patients. Obesity. 2006;14:1626-1636.
11. Coon D, Gusenoff J, Kannan N, et al. Body mass and surgical complications 35. Michaels J, Coon D, Rubin JP. Complications in postbariatric body con-
in the postbariatric reconstructive patient: analysis of 511 cases. Ann Surg. touring: strategies for assessment and prevention. Plast Reconstr Surg.
2009; 249:397-401. 2011;127(3):1352-1357.
12. Nemerofsky R, Oliak D, Capella J. Body lift: an account of 200 consecutive 36. Coon D, Michaels J, Gusenoff J, et al. Multiple procedures and staging
cases in the massive weight loss patient. Plast Reconstr Surg. 2006;117(2): in the massive weight loss population. Plast Reconstr Surg. 2010;125:
414-430. 691-698.

part VIII
n Hand
Chapter 70 n Functional Anatomy

and Principles of Upper
Extremity Surgery
Kate W. Nellans and Kevin C. Chung
musculature of the hand (muscles that arise in the hand),

Introduction which includes the thenar and hypothenar muscle groups, the
This chapter presents the common elements in the evaluation adductor pollicis, lumbrical, and interosseous muscles. More
and conduct of hand surgery. distal nerve lacerations or compressive pathologies affect these
intrinsic muscles without deficits in the other flexors and
extensors (Chapters 74 and 77).
Functional Anatomy
Hand and Digits Wrist
The thumb is a unique and specialized digit with tremendous The wrist consists of eight carpal bones grouped in two rows
mobility and strength, essential for power and precision grips. with restricted motion between them and is the most complex
Painful arthritis at the carpometacarpal (CMC) joint can be joint in the body. The term “wrist” is used to include any
crippling, and laxity at the metacarpophalangeal (MCP) joint of these numerous articulations. Normal flexion/extension
of the thumb can prevent a strong oppositional grip because motion is 90°/70°, but an 80° arc provides good function.1
of joint instability. The mobility of the CMC joints of the Reduction in hand pronation is well tolerated if one has a
index through small fingers increases toward the ulnar aspect functional shoulder to compensate, whereas loss of supination
of the hand. Angulated fractures are generally better tolerated, is not as easily tolerated.
therefore, in the ulnar digits because of compensatory motion. The distal radioulnar joint is unique in that the ulna makes
The MCP joints of the index through the little fingers have no direct contact to the carpal bones and is connected to the
little tolerance for stiffness because the arc of motion for the radius through the triangular fibrocartilage complex (TFCC).
fingers starts at the MCP joints. Motion at the proximal inter- Eighty percent of the forces through the arm are dispersed by
phalangeal (PIP) and distal interphalangeal (DIP) joints also the carpal articulation with the radius. Static restraints to the
contributes to making a fist, but stiffness is better tolerated movements at the radiocarpal joint include the tough, strong
in these joints, particularly the DIP joints because stability, volar capsular ligaments, as well as less stout dorsal capsular
rather than mobility, is more important in the terminal joints. ligaments. Incising the volar capsular ligaments to assess artic-
Rotational or angular deformities are not tolerated because ular congruity when performing an ORIF (open reduction and
they may lead to scissoring of the fingers by interfering with internal fixation) of a distal radius fracture is discouraged,
the motion of the adjacent normal finger, or catching on pock- because this can lead to instability.
ets and clothing. Movements between the carpal rows are biomechanically
The forces acting across these joints include both static complex. The lunate is an intercalated segment sandwiched
constraints (collateral ligaments, joint capsules, and volar between the scaphoid and the triquetrum which follows the
plates) and tendons that create dynamic compression through bone to which it is still attached. Dorsal tilt occurs when the
movements. The volar plate of the MCP, PIP, and DIP may be scapholunate ligament is torn because the scaphoid flexes and
involved in dislocations, both prior to and following reduc- the lunate must extend with the triquetrum (resulting in a
tion (Chapter 81). For dorsal MCP dislocations, if the defor- dorsal intercalated segment instability) (Figure 70.3). A more
Hand
mity is accentuated in an attempted reduction, the volar plate rare condition occurs when the lunotriquetral ligament is dis-
may have become interposed in the joint, necessitating open rupted, leaving the scapholunate ligament is intact, resulting
reduction in the operating room. If the volar plate is disrupted in flexion of the lunate with the scaphoid (resulting in a volar
during dorsal dislocation of the PIP joint, the lateral bands intercalated segment instability) (Chapter 81).
may subluxate dorsally over time, causing hyperextension Wrist and finger motions are the result of combined actions
at the PIP and flexion at the DIP, known as a “swan-neck” and firing of multiple muscle groups. For example, wrist
deformity (Figure 70.1). Another common finger deformity flexion requires a balanced flexion of both the flexor carpi
is the boutonniere deformity. This occurs when the insertion ulnaris and flexor carpi radialis to prevent deviation in one
of the central slip on the dorsal middle phalanx and the tri- direction or the other. The finger flexors and the median nerve
angular ligament are disrupted, causing the lateral bands to run through the carpal tunnel, which is covered by the trans-
subluxate volarly. The PIP joint becomes flexed, and the DIP verse carpal ligament connecting the hamate and the pisiform
hyperextends (Figure 70.2). ulnarly to the scaphoid and trapezium radially (Chapter 77).
Most flexion and extension of the fingers and wrist results The median nerve is susceptible to compression in carpal tun-
from forearm-based muscle groups, innervated far proxi- nel syndrome and when dorsally displaced distal radius frac-
mally. Finely controlled movements, however, use the intrinsic tures increase the pressure at the carpal tunnel. The extensors
721
722 Part VIII: Hand
FIGURE 70.1. A swan-neck deformity of the middle and ring fingers,

resulting from dorsal subluxation of the lateral bands, and leading to
a fixed hyperextension at the PIP joint and flexion at the DIP joint.
FIGURE 70.2. A boutonniere deformity of the right ring and little
fingers has resulted from a volar subluxation of the lateral bands,
leading to fixed flexion at the PIP joint and hyperextension at the
DIP joint.
of the wrist and hand are grouped into six tightly bound fibro-
osseous compartments (Chapter 78). Stenosis or tenosynovitis
can develop due to the restricted spaces and movements, com-
monly resulting in De Quervain syndrome at the first dorsal Most displaced fractures should be reduced into a more
compartment, or intersection syndrome at the crossover of the anatomic position in the emergency room prior to splinting
first on the second compartment tendons (Chapter 79). to decrease tension on the soft tissues or to achieve defini-
tive reduction if the fracture is to be treated nonoperatively.
Closed reduction requires an understanding of the bony anat-
Principles of Upper Extremity omy and the muscular and tendinous attachments that serve
Surgery as the deforming forces. A knowledge of the intact ligaments,
soft tissues, and bony anatomy for a particular fracture will
Acute Injuries help in the realignment of any displaced fracture fragments
Emergency room management of patients with hand injuries into an improved position using ligamentotaxis (Figure 70.4).
includes an assessment of other, life-threatening injuries. One Splinting options are discussed later in this chapter.
should always remember the expression “life over limb.” A Whether in the emergency department or in the office,
severely mangled hand may attract attention, but the patient a proper history should include hand dominance, the time
must be assessed in sequence to verify that all life-threatening course of the problem (acute injury versus gradual onset), and
conditions are treated first. Attempting to “tie off” a bleeding a patient’s level of functioning and difficulty with activities of
vessel in the emergency room is not recommended, because daily living. A pianist with a tendon laceration may have dif-
hemorrhage can usually be controlled with elevation and ferent needs and expectations than an elderly patient with a
direct pressure. A blood pressure cuff may be inflated above distal radius fracture.
the systolic blood pressure to control bleeding, but should not Physical Examination. The physical examination of the
be left in place for longer than necessary, 90 minutes at most, hand begins with general inspection for edema, bruising or
to prevent ischemic reperfusion injuries. discoloration, deformities of the digits, or previous scars.
Injuries that require urgent operative intervention include Wounds are inspected for infection, surrounding skin viability,
limb-threatening ischemia, most open fractures, pressure and proximity to major neurovascular structures. Nerve lac-
injection injuries, or active bleeding in the setting of a coagu- eration may not always be evident in the initial survey. Range
lopathy. For amputated digits, hypothermia (wrapped in moist of motion (ROM) of the digits and wrist helps guide further
gauze inside a plastic bag and placed on ice) will reduce the evaluation. When assessing motion, a concurrent evaluation
metabolic by-products that damage the tissue and improve the of rotational deformities, gross instability, or laxity may be
likelihood of a successful replant (see Chapter 83). Pressure completed. Occasionally, a full assessment of ROM is limited
injection injuries may appear innocuous on presentation, but by pain, and local blocks may help further assess injuries, but
in cases of caustic materials such as paint or cleaning solutions these should not be performed before a full sensory exami-
can lead to tissue necrosis and possible loss of the digit if not nation is conducted, including two-point discrimination. A
recognized and appropriately debrided. strength assessment should be comprehensive, and areas

Chapter 70: Functional Anatomy and Principles of Upper Extremity Surgery 723
A B
FIGURE 70.3. AP and lateral wrist x-rays of dorsal intercalated segment instability (DISI). A. Scapholunate widening is shown in the AP view
with an arrow. B. The dorsally tipped lunate is outlined with white dots in the lateral view.
of concern carefully evaluated to, for example, distinguish fingertip), and ulnar nerve (volar tip of the small fingertip).
mechanical weakness (i.e., torn or lacerated tendon) from a For injuries in the palm or fingers, two-point discrimination
more proximal nerve injury resulting in muscle denervation. distal to the laceration can be tested with a paperclip bent into
Radial and ulnar pulses at the wrist are typically palpable a 5 mm gap. A Tinel sign may indicate an injured nerve with
when systolic blood pressures are above 80 mmHg. The pulses regenerating axons.
of individual digital arteries are assessed with a Doppler probe,
Hand
although the finger is usually adequately perfused if one digital Radiographic Evaluation. Most acute hand injuries
artery is patent. In most individuals, the ulnar artery provides require radiographic assessment. Imaging generally begins
most of the blood flow to the fingers via the superficial palmar with standard x-ray evaluation. Specifically, an injury to a
branch, forming a connection with the superficial branch of single digit requires a true anterior–posterior view of the fin-
the radial artery. The Allen test assesses the competency of the ger, including the MCP, PIP, and DIP joints. A lateral film
ulnar artery to perfuse the hand by occluding both arteries, must include the condyles of the distal, proximal, and middle
exsanguinating the hand with a tight fist, and then releasing phalanx, without other fingers obscuring the digit in ques-
the ulnar artery and looking for full perfusion to the fingers. tion. The thumb has a unique orientation and requires oblique
The radial artery terminates in the deep palmar arch after cir- views to obtain adequate views of the interphalangeal (IP),
cling around the dorsal aspect of the CMC joint of the thumb, MCP, and CMC joints. A hand series is most useful for sus-
supplying blood flow to the thumb and index finger via the pected metacarpal injuries, whereas a wrist series is required
princeps pollicis. to assess distal radius fractures.
Adequate sensation of the digits is necessary for practical Part of the art of assessing hand injuries is a concise and
use of the hand. Proximal denervation may be assessed by accurate description of the fracture pattern seen on the x-rays
knowing the autonomous sensory zones of the radial nerve (Chapter 75). Eponyms help describe common fracture patterns,
(first dorsal web space), median nerve (volar aspect of index but should not be used if there is an abnormal component to the

724 Part VIII: Hand
e Force
c
for
FIGURE 70.4. A technique for closed reduction of a metacarpal neck FIGURE 70.5. A sugar-tong splint can be useful for distal forearm
fracture using knowledge of the important anatomical structures to and wrist injuries, especially when it is important to control prona-
successfully reduce the malalignment using ligamentotaxis. tion, supination, flexion, and extension.
fracture, because this leads to confusion and misunderstanding. immobilization of fractures above and below the joint is rec-
The bone and location of the fracture is stated (e.g., base of ommended, and immobilization following a soft-tissue injury
the thumb metacarpal or midshaft proximal phalanx of the ring can prevent excessive tension on the repair. Intrinsic position-
finger) and specific mention is made if it extends into the joint ing for the hand reduces stiffness by fully extending the joint
(e.g., intra-articular distal radius fracture). The angulation of capsules of the wrist in slight extension, the MCPs in near full
the fracture apex (dorsal or volar), as well as the fracture pat- flexion, and the IPs in full extension.
tern (transverse versus oblique), with comment on the commi- Two basic types of splints are used to immobilize inju-
nution or displacement of the fragments should be described ries based on their locations. A cast or other circumferential
because this aids in assessing whether nonoperative treatment immobilization is used with caution in acute injuries because
is possible. For example, describing a fracture as a “Colles frac- swelling could result in a compartment syndrome. A sugar-
ture” is less helpful than saying, “apex volar, intra-articular, tong splint is most useful for distal forearm and wrist inju-
distal radius fracture with dorsal comminution and 30° of dor- ries where both flexion/extension and pronation/supination
sal tilt, significant shortening and loss of inclination, with an need to be controlled (Figure 70.5). Three-point cast molding
associated ulnar styloid fracture.” Such a description immedi- with pressure at the apex of the fracture, as well as molding
ately conveys that this is an unstable fracture unlikely to hold proximal and distal to the fracture opposite of the fracture
the reduction and requires operative reduction and fixation. apex, can be used to help maintain a reduction. An ulnar gut-
Advanced imaging, such as computerized tomographic ter splint can immobilize metacarpal and phalangeal fractures,
(CT) scans, magnetic resonance imaging (MRI), and magnetic while leaving the thumb and two other fingers free to allow
resonance (MR) arthrograms, are helpful to better define cer- for pinch-type movements (Figure 70.6).
tain conditions and injuries (CT for suspected carpal fractures
or intra-articular distal radius fracture, MRI for soft-tissue Preoperative Planning
tumors, or MR arthrograms for suspected TFCC injuries), but For elective surgical cases, the operating room staff should
should not replace X-rays as the first line of imaging. have preference cards listing the specific preferences of the
surgeon, including positioning and draping, instrument trays,
special implants for fractures, and dressing and immobiliza-
Immobilization Techniques tion materials. For more complex fractures and combined-
For mobile structures such as the hand and wrist, splint- type injuries where multiple major structures are damaged,
ing and immobilization following injury or surgery is often the reconstructive principles serve as a framework for guiding
a difficult balance between healing and stiffness. In general, operative steps (Table 70.1).

Chapter 70: Functional Anatomy and Principles of Upper Extremity Surgery 725
to be seated around the table. The hand can be pronated and
supinated in this position, giving access to both the dorsal
and volar aspects of the hand and wrist. The use of periop-
erative antibiotic coverage administered prior to the incision
remains controversial for short (<2 hour) soft-tissue proce-
dures because there is no evidence that the benefits outweigh
the risks. Generally, for procedures involving implants or
bony work and for those lasting more than 2 hours, antibiot-
ics are used and redosed throughout the course of the surgery
as needed based on the drug’s half-life properties.2
Anesthesia. Local blocks are covered in Chapter 71, but
are extremely useful for hand surgery to prevent the need for
general anesthesia. For most routine hand cases, a local block
with a small amount of sedation is adequate. Regional anes-
thesia, such as interscalene blocks, with or without general
anesthesia, provides complete muscle relaxation and is help-
ful to reduce initial pain pathways. However, in trauma cases
where monitoring for compartment syndrome is required
postoperatively, a long-acting block may mask the symptoms
and prove dangerous.
Tourniquet. Hand and wrist procedures are facilitated by
a tourniquet. Essentially a blood pressure cuff, the tourniquet
prevents arterial flow in the arm, leaving the operative field
nearly bloodless. An upper arm tourniquet (either sterile or
non-sterile) should be used for the elbow, forearm, and wrist
work. It is important to exsanguinate the arm before inflation
to empty the compliant venous system. Generally, a tourni-
quet 100 mmHg greater than the patient’s systolic pressure is
sufficient to prevent surgical field bleeding. One must be care-
ful to monitor the time a tourniquet has been in place, because
FIGURE 70.6. The ulnar gutter splint works to immobilize metacar-

pal and phalangeal fractures, while leaving the thumb and two other
fingers free for pinch movements.
The equipment necessary for upper extremity surgery,

especially if bony work is required, must be addressed in
advance of the case. Intraoperative imaging with a mini C-arm
is indispensable for fracture work, especially for fractures that
may be amenable to closed reduction and fixation. If vascu-
lar repair is anticipated, use of the microscope is required.
Depending on the fracture and injury, the options for plates
and screw are numerous and should be considered in advance.
Additional equipment beyond a basic hand tray may include
drills, Kirschner wires (K-wires), or bone reduction clamps.
Operative Principles
Nearly all routine hand surgery cases require an arm table
Hand
with the patient’s arm abducted 90°, allowing the surgeons
Table 70.1
Reconstructive Principles In The Upper Limb
1. Restore circulation

2. Obtain soft-tissue coverage
3. Align and stabilize bony anatomy
4. Restore nerve function
FIGURE 70.7. A Bruner incision of the finger into the palm. This
5. Mobilize joints incision technique is useful to decrease the likelihood of contracture
6. Restore tendon function formation.

726 Part VIII: Hand
anything over 90 to 120 minutes increases the risk for a reper- a non-occlusive yet adherent dressing, such as petroleum-
fusion injury, resulting from the buildup of toxic metabolites impregnated gauze, is placed. Layers of dry gauze or “fluffs”
in the arm.3 For hand and finger work, a forearm tourniquet may be used to cushion the incision and absorb any bleeding
may be used that is more comfortable for the patient. In the from the surgical site. Most importantly, any circumferential
emergency room setting, a finger tourniquet may be used, but dressings are placed loosely to prevent a tourniquet effect.
requires vigilance to remove it before the dressing is placed Splint immobilization for most operatively repaired fractures
because the patient will not detect an ischemic finger when the is advised and may be useful for soft-tissue procedures to pre-
finger is anesthetized. We typically place a clamp on the finger vent tension on the incision with movement, especially if the
tourniquet to remind us to remove it. incision crosses a joint.
Incisions. When considering incisions in the hand, care Perhaps most important is the benefit of elevation on swell-
should be taken not to cut across flexion creases to prevent ing, a point that cannot be overemphasized with the patient.
the development of scars which will contract and limit motion. Careful attention to elevation while sleeping and in a sling
The dorsal aspect of the hand has thinner, more mobile skin can minimize swelling that leads to pain, wound problems,
and longitudinal incisions can generally be used. Zigzag inci- finger stiffness, and longer recovery times. The role of post-
sions allow access to structures in the volar finger and palm. operative oral antibiotics in routine elective soft-tissue proce-
The common incision techniques, known as Bruner incisions, dures (i.e., carpal tunnel release, trigger finger release, etc.)
are diagonal incisions between flexion creases that serve to cre- remains controversial with no clear benefit. Injuries or sur-
ate a series of short broad-based opposing flaps (Figure 70.7). geries involving open fractures or other bony work warrant
Closure of hand incisions and wounds is generally accom- 24 hours of perioperative IV antibiotic coverage.
plished with a single layer of interrupted nylon sutures. Vertical
mattress sutures help evert the skin edges. If a laceration crosses References
a skin crease, a Z-plasty is considered to prevent contractures.
1. Ryu J, Cooney WP III, Askew LJ, An KN, Chao E. Functional ranges of
motion of the wrist joint. J Hand Surg. 1991;16(3):409-419.
Postoperative Principles 2. Rizvi M, Bille B, Holtom P, Schnall SB. The role of prophylactic antibiotics
in elective hand surgery. J Hand Surg. 2008;33(3):413-420.
Dressings following surgical procedures are highly depen- 3. Wilgis E. Observations on the effects of tourniquet ischemia. J Bone Joint
dent on surgeon preference. Directly over the surgical site, Surg Am Vol. 1971;53(7):1343.

Chapter 71 n Anesthesia Techniques
Warren C. Hammert
Introduction Preservatives
A variety of anesthetic techniques can be used effectively for Antimicrobial preservatives, such as methylparaben and ethyl-
upper extremity surgery. Most upper extremity surgical cases paraben, are often added to multidose vials. Anesthetics with
can be performed using regional anesthesia, monitored anes- these additives can be used for local infiltration, but should
thesia care (MAC) and/or local. These anesthetic choices have not be used for IV regional (bier block) anesthesia or spinal/
advantages over general anesthesia, such as decreased incidence epidural anesthesia. Antioxidants such as sodium ethylenedi-
of postoperative nausea and vomiting, better pain control, and aminetetraacetic acid can be added to prevent oxidation and
greater cardiovascular stability, and earlier discharge. General slow their degradation.1
anesthesia for upper extremity surgery is the same as for other
anatomical regions and will not be discussed in this chapter. Epinephrine
The choice of anesthesia is dependent on the duration Epinephrine is commonly added to local anesthetics. It
and type of procedure, anatomical location, and surgeon and functions by increasing the time of onset, limits the systemic
patient preference. Although the surgeon will not perform all absorption, and thus increasing the maximum dose, and
regional blocks, he/she should be familiar with the techniques increases the duration of action (Chapter 12). It is commonly
and advantages/disadvantages of different techniques and the used in concentrations of 1:200,000 (range 1:100,000 to
anatomy of peripheral nerves. 1:400,000).2
A description of the various local anesthetics and their Historically, it was taught that epinephrine should not be
pharmacology is found in Chapter 12. used in the hand or finger for fear of vasoconstriction and fin-
ger necrosis. A critical look at the evidence indicates that case
Toxicity reports are mostly prior to the 1950s and associated with pro-
caine and cocaine injections with epinephrine.3 The current
Local Reactions evidence clearly demonstrates that epinephrine can be safely
The perineurium acts as a barrier, preventing high concentra- used in the fingers.3-9 If reperfusion is delayed, 0.5% phen-
tions of anesthetics from reaching the intraneural structures. tolamine mesylate can be used to reverse the effects of epi-
This protective perineurium makes direct toxicity rare with- nephrine. It is injected locally, reversibly blocking the alpha-1
out an intraneural injection. Injection directly into the nerve receptors, and causing vasodilation.10,11 Phentolamine has a
produces an intense pain response and must be avoided. Care short half-life, so repeat injection may be necessary.
must be taken when injecting around peripheral nerves in
patients under general, deep sedation, or with proximal nerve Regional Anesthesia
blockade as they will not elicit the pain response and inadver-
tent intraneural injection could occur. Brachial plexus blocks can be used for most procedures
in the upper extremity. These can be used as the sole anes-
thetic agent, or combined with sedation or general anesthesia,
Systemic Reactions depending on the patient, surgeon, and anesthesiologist pref-
Central nervous system (CNS) and cardiovascular system toxic- erence. Chan et al. compared infraclavicular block anesthesia
ity are dose and time dependent; most severe reactions are a with general anesthesia and demonstrated an increase in time
result of intravascular injection. The quicker the plasma levels to begin the surgical portion of the case. The block took 5 to
rise, the greater the chance systemic problems will occur. Initial 10 minutes to perform and 15 to 25 minutes to reach a level
CNS symptoms are tinnitus, metallic taste, light-headedness, and for surgical stimulation.12 The trade-off for this increased time
perioral numbness. With higher levels, muscle twitching, trem- to begin the procedure is decreased recovery time, leading to
ors, tonic–clonic seizures, loss of consciousness, and respiratory faster discharge, elimination of anesthetic gases, and thus, less
arrest may occur. Benzodiazepines will raise the CNS threshold potential for nausea and vomiting, and better early postopera-
and can be used to terminate seizure activity. Protection of the tive pain relief. Of course, the onset of pain will occur as the
airway with intubation and ventilation to ensure oxygenation is block wears off and this may be in the middle of the night,
paramount in caring for patients with CNS toxicity.1 making it important to instruct the patient on use of postop-
Cardiovascular toxicity is less common than CNS toxic- erative pain medications. The most efficient use of regional
Hand
ity, but occurs as a result of decrease in myocardial peripheral anesthesia is a system where the anesthesiologists can perform
smooth muscle conduction. There is prolongation of conduction, the block about 30 minutes prior to starting the procedure
increasing the PR and QRS intervals, along with suppression of to allow adequate time for the block to take effect. This can
the sinoatrial and atrioventricular nodes, causing bradycardia, be performed in a designated area, such as a “block area or
conduction block, and cardiac arrest. Bupivacaine has greater room,” to allow the most efficient use of the operating room.
cardiotoxicity than lidocaine. Similar to CNS toxicity, intubation Brachial plexus blocks can be performed at four anatomi-
and mechanical ventilation, followed by Advanced Cardiac Life cal sites: two above the clavicle (interscalene and supraclavicu-
Support (ACLS) protocol for resuscitation, should be instituted.1 lar), one below (infraclavicular), and one in the arm (axillary).
Ultrasound or nerve stimulation is commonly used to assist
Additives with localization of the needle, increasing safety and effective-
ness of the block.2
Sodium Bicarbonate
Sodium bicarbonate can be added to local anesthetic solu- Interscalene
tions to increase the rate of onset and decrease the pain at the The interscalene block allows for anesthesia at a proximal
injection site.1 level, away from the lung, making this location good for
727
728 Part VIII: Hand
shoulder surgery with a low incidence of pneumothorax.

Anesthesia of the inferior trunk (C7-T1) may be incomplete,
necessitating ulnar nerve block for procedures involving the
elbow, wrist, and hand.13
Supraclavicular
Supraclavicular block allows for complete block with rapid
onset due to the anatomical position of the trunks of the bra-
chial plexus at this level, but the incidence of pneumothorax
ranges between 0.5% and 6%. This technique is less desirable
in obese patients as it is more challenging to identify anatomic
landmarks and in tall thin patients, who often have a high
lung apex. The phrenic, recurrent laryngeal nerves and cervi-
cal sympathetic chain are in close proximity, making it likely
one or more of these nerves will also be anesthetized with a
block at this level.13
Infraclavicular
Figure 71.1. Ulnar nerve block at the level of the elbow (MED EPI,
Infraclavicular block provides ideal anesthesia for procedures medial epicpondyle; OLE, olecranon).
at the elbow and distal as incomplete blocks are less common.
The brachial plexus is deeper at this level, making the pro-
cedure more challenging for the anesthesiologist and poten-
tially more uncomfortable for the patient. The axillary artery
and vein are in close proximity and their relationships to the Elbow
clavicle make it more difficult to diagnose bleeding/hematoma Ulnar Nerve. The ulnar nerve passes through the groove
or provide direct compression in the event of bleeding.13 between the medial epicondyle of the humerus and the
olecranon and can be blocked in this area (Figure 71.1).
Axillary Injection should be in the subcutaneous tissue and not directly
The axillary block can be completed with a transarterial in the groove because this is a tight space and inadvertent
approach, where the needle is passed through the artery and injection into the nerve could occur.
local anesthetic deposited directly behind the artery and ante- Median Nerve. The median nerve at the level of the elbow
rior to the artery upon removal of the needle. The brachial is located medial (ulnar) and superficial to the brachial artery,
plexus is well compartmentalized at this level, so incomplete which is medial to the biceps tendon (Figure 71.2). Anesthetic
blocks are more common. The musculocutaneous nerve is injected subcutaneously medial to the brachial artery. Care
exits the sheath higher, so a separate injection must be com- should be taken to prevent intra-arterial injection by aspirat-
pleted, or the upper arm tourniquet will not be well tolerated. ing prior to injection. If the artery is inadvertently entered,
Complications are rare and when they occur are usually the firm pressure should be a help for several minutes.
result of an intravascular injection.13
Radial Nerve. The radial nerve can be blocked at the level
Intravenous Regional Anesthesia (Bier Block) of the distal humerus or at the level of the antecubital fossa
IV regional anesthesia can be used for procedures of short (Figure 71.3). There is variability in the branching of the radial
duration (typically 60 minutes or less), due to tourniquet nerve (i.e., the branches to the extensor carpi radialis longus,
pain. Using a double tourniquet can prolong procedure time extensor carpi radialis brevis, and the sensory branch), mak-
to approximately 90 minutes. The technique is relatively ing the proximal block more predictable.14 The nerve wraps
straightforward to perform, but tourniquet malfunction around the humerus from posterior to lateral approximately
can be disastrous, as the entire volume of anesthetic may be 4 cm proximal to the lateral epicondyle. The needle is inserted
released into the CNS. The mechanism of action is felt to be
due to retrograde flow of local anesthetic through the vaso-
venosum to peripheral nerves and diffusion through venous
channels to peripheral nerve endings. The tourniquet should
remain inflated for 30 minutes to allow for anesthetic binding
to the tissues and preventing rapid rise in systemic levels of
anesthetic after deflation. The tourniquet should be “cycled
down” with release and rapid reinflation to allow slow release
of anesthetic into the circulation. Three cycles are sufficient,
but the patient should be monitored during deflation for signs
of CNS toxicity (tinnitus, metallic taste, and perioral numb-
ness) and treated if present.13
Peripheral Nerve Blocks

Peripheral nerve blocks can be used in conjunction with MAC/
IV sedation or performed for procedures under straight local
anesthesia. For procedures in the forearm, the nerve block is
performed at the level of the elbow. The ulnar, median, and
radial nerves can be blocked at this level, but the forearm also
receives innervation from the medial and lateral brachial and Figure 71.2. Median nerve block at the elbow (BR ART, brachial
antebrachial cutaneous nerves, so local infiltration in the sur- artery).
gical area is required in addition to the nerve block.

Chapter 71: Anesthesia Techniques 729
A
Figure 71.4. Ulnar nerve block at the wrist (FCR, flexor
carpi radialis tendon; PL, palmaris longus tendon; FCU, flexor carpi
ulnaris tendon).
the nerve proximally and runs in the subcutaneous tissue at this

level, so subcutaneous injection should also be performed.
Radial Nerve. The sensory branch of the radial nerve

(SBRN) exits from the brachioradialis tendon and runs sub-
cutaneously along the radial aspect of the wrist (Figure 71.6).
Subcutaneous infiltration at this level will block the SBRN
and branches of the lateral antebrachial cutaneous nerve, pro-
viding anesthesia to the dorsal radial aspect of the hand.
Hand
The common and proper digital nerves can be blocked in the
B palm and this approach can be used to block multiple digits.
The dorsal innervation proximal to the distal interphalangeal
Figure 71.3. Radial nerve block at the elbow. A. One alternative
is injection approximately 4 cm proximal to lateral epicondyle along (DIP) joint requires a dorsal subcutaneous injection as the
the course of the radial nerve from the posterior to lateral aspect of dorsal aspect of the digits proximal to the DIP joint is from
the humerus in the spiral groove. B. A second alternative is injection the SBRN in the thumb, index, middle, and radial half of the
lateral to the biceps tendon at the level of antecubital crease. ring finger and the dorsal sensory branch of the ulnar nerve
in the ulnar half of the ring and small fingers. The individual
digits can be blocked from the volar aspect by injecting along
the radial and ulnar aspects of the digits until the anesthetic
flows in the subcutaneous region across the dorsal aspect of
until the humerus is contacted, then slightly withdrawn, and
the digit.
the anesthetic is injected.
Alternatively, the nerve can be blocked at the level of the
antecubital fossa. The radial nerve is located lateral and deep
to the biceps tendon and is blocked by injecting the anes-
thetic in this area. An incomplete block due to the anatomical
variability of the sensory branch may occur.
Wrist
Hand
Ulnar Nerve. The ulnar nerve at the level of the wrist is

located deep to the flexor carpi ulnaris (FCU) tendon and ulnar
to the ulnar artery (Figure 71.4). The nerve can be blocked
from the radial or ulnar aspect of the FCU by injecting deep to
the tendon; the ulnar approach avoids the ulnar artery. Care is
taken to avoid injecting into the artery by aspirating prior to
injection. The dorsal sensory branch of the ulnar nerve typi-
cally branches 6 to 8 cm proximal to the ulnar head, so this
nerve is blocked along the ulnar subcutaneous border of the
wrist or hand.14
Median Nerve. The median nerve is blocked at the wrist by

injecting anesthetic just ulnar to the palmaris longus (PL) ten- Figure 71.5. Median nerve block at the wrist (FCR, flexor
don (Figure 71.5). When the PL is absent, the injection can be carpi radialis tendon; PL, palmaris longus tendon; FCU, flexor carpi
given along the axis of the ring finger. The injection is just deep ulnaris tendon).
to the antebrachial fascia. The palmar cutaneous branch exits

730 Part VIII: Hand
2. Brown DL, Rosenquist RW, Sites BD, Spence BC. Local anesthetics and
regional anesthesia equipment. In: Brown DL, ed. Atlas of Regional
Anesthesia. 4th ed. Philadelphia, PA: Saunders Elsevier; 2010:3-16.
3. Thomson CJ, Lalonde DH, Denkler KA, Feicht AJ. A critical look at
the evidence for and against elective epinephrine use in the finger. Plast
Reconstr Surg. January 2007;119(1):260-266.
4. Chowdhry S, Seidenstricker L, Cooney DS, Hazani R, Wilhelmi BJ. Do
not use epinephrine in digital blocks: myth or truth? Part II. A retrospec-
tive review of 1111 cases. Plast Reconstr Surg. December 2010;126(6):
2031-2034.
5. Fitzcharles-Bowe C, Denkler K, Lalonde D. Finger injection with high-dose
(1:1,000) epinephrine: does it cause finger necrosis and should it be treated?
Hand (N Y). March 2007;2(1):5-11.
6. Lalonde DH, Lalonde JF. Discussion: do not use epinephrine in digital
blocks: myth or truth? Part II. A retrospective review of 1111 cases. Plast
Reconstr Surg. December 2010;126(6):2035-2036.
7. Lalonde D, Bell M, Benoit P, Sparkes G, Denkler K, Chang P. A multicenter
prospective study of 3,110 consecutive cases of elective epinephrine use in
the fingers and hand: the Dalhousie Project clinical phase. J Hand Surg Am.
September 2005;30(5):1061-1067.
8. Wilhelmi BJ, Blackwell SJ, Miller JH, et al. Do not use epinephrine in digital
blocks: myth or truth? Plast Reconstr Surg. February 2001;107(2):393-397.
9. Wilhelmi BJ, Blackwell SJ, Miller J, Mancoll JS, Phillips LG. Epinephrine in
Figure 71.6. Radial sensory nerve block at the wrist (RSN, radial digital blocks: revisited. Ann Plast Surg. October 1998;41(4):410-414.
10. Markovchick V, Burkhart KK. The reversal of the ischemic effects of
sensory nerve branches; FCR, flexor carpi radialis tendon; PL,
epinephrine on a finger with local injections of phentolamine. J Emerg Med.
palmaris longus tendon). September-October 1991;9(5):323-324.
11. Hinterberger JW, Kintzi HE. Phentolamine reversal of epinephrine-induced
digital vasospasm. How to save an ischemic finger. Arch Fam Med. February
1994;3(2):193-195.
12. Chan VW, Peng PW, Kaszas Z, et al. A comparative study of general anes-
Fingers thesia, intravenous regional anesthesia, and axillary block for outpatient
hand surgery: clinical outcome and cost analysis. Anesth Analg. November
Several studies have looked at injection techniques for digital 2001;93(5):1181-1184.
anesthesia.15-20 Accepted techniques include traditional digi- 13. Brown DL, Sites BD, Spence BC. Section II: upper extremity blocks.
tal block (TDB) technique, injecting from the dorsal aspect In: Brown DL, Boezaart AP, Galway UA, et al., eds. Atlas of Regional
between the web space along each side of the digit; transthe- Anesthesia. Philadelphia, PA: Saunders Elsevier; 2010:31-88.
14. Botte MJ. Nerve anatomy. In: Doyle, Botte, eds. Surgical Anatomy of the
cal block (TTB), where the injection is from the volar aspect Hand and Upper Extremity. Philadelphia, PA: Lippincott Williams and
and the injection is within the flexor sheath, and subcutane- Wilkins; 2003:185-236.
ous infiltration from the volar aspect. The volar blocks do not 15. Hill RG Jr, Patterson JW, Parker JC, Bauer J, Wright E, Heller MB.
anesthetize the dorsal branches from the radial or ulnar dorsal Comparison of transthecal digital block and traditional digital block for
anesthesia of the finger. Ann Emerg Med. May 1995;25(5):604-607.
sensory nerves, so either a separate dorsal injection or advanc- 16. Keramidas EG, Rodopoulou SG, Tsoutsos D, Miller G, Ioannovich
ing the needle between the metacarpals from the volar surface J. Comparison of transthecal digital block and traditional digital block for
to deposit anesthetic in the dorsal subcutaneous tissue must be anesthesia of the finger. Plast Reconstr Surg. October 2004;114(5):1131-
completed. All of these techniques can provide adequate anes- 1134; discussion 1135-1136.
17. Low CK, Vartany A, Diao E. Comparison of transthecal and subcutaneous
thesia, so it becomes a matter of surgeon preference. single-injection digital block techniques in cadaver hands. J Hand Surg Am.
The best current evidence suggests that the single sub- September 1997;22(5):897-900.
cutaneous injection provides rapid onset of anesthesia and 18. Low CK, Vartany A, Engstrom JW, Poncelet A, Diao E. Comparison of
less pain than the TTB.20,21 The TDB technique requires two transthecal and subcutaneous single-injection digital block techniques.
J Hand Surg Am. September 1997;22(5):901-905.
injections and has been shown to have slower onset20 and the 19. Low CK, Wong HP, Low YP. Comparison between single injection
research subjects preferred the single subcutaneous injection. transthecal and subcutaneous digital blocks. J Hand Surg Br. October
1997;22(5):582-584.
References 20. Hung VS, Bodavula VK, Dubin NH. Digital anaesthesia: comparison of
the efficacy and pain associated with three digital nerve block techniques.
1. Kent C. Regional anesthesia for the upper extremity. In: Trumble T, J Hand Surg Br. December 2005;30(6):581-584.
Rayan G, Budoff J, Baratz M, eds. Principles of Hand Surgery and Therapy. 21. Harness NG. Digital block anesthesia. J Hand Surg Am. January
2nd ed. Philadelphia, PA: Saunders Elsevier; 2010:23-34. 2009;34(1):142-145.

Chapter 72 n Treatment of Hand Infections
Benjamin Chang and Suhail K. Kanchwala
Initial management of paronychial infections includes

General Principles warm soaks and oral antibiotics. When paronychial infec-
Infections of the hand result in pain, disability, as well as lost tions progress to abscess formation within the eponychial fold
time and productivity at work. Prompt, accurate diagnosis or under the nail plate, surgical drainage is necessary. When
minimizes disability and facilitates rapid recovery. In addition, performing an incision and drainage of a paronychia, it is
infections in the hand are the presenting symptom in a number important to angle the blade away from the nail bed to avoid
of systemic illnesses. inadvertent damage to the nail bed and subsequent ridging of
Evaluation of a hand infection includes an assessment of the nail. When the abscess extends under the nail plate, the
the extent of erythema, depth of infection, presence of an nail is removed (Figure 72.2).
abscess, and range of motion of the affected digits. In addi-
tion, a medical history is obtained with emphasis on factors Herpetic Whitlow
that affect immune response (diabetes, human immunodefi-
ciency virus, and immunosuppression). Commonly confused with paronychial infections, herpetic
The anatomy of the hand, with numerous fascial compart- infections of the hand typically involve the fingertip and soft
ments, allows the inflammatory response to infection itself to tissues surrounding the nail plate. While herpetic infections
become pathogenic. For example, excessive swelling in the may mimic bacterial infections of the hand, they can usually
hand can result in increased pressure on tendons in the fingers be distinguished by an adequate history and exam.
and palm, leading to ischemia and tendon necrosis. Potential Herpetic infections in children and healthcare work-
spaces, such as flexor tendon sheaths and the deep palmar ers (dentists, respiratory therapists, etc.) are most often the
space, can serve as conduits for infection. result of viral inoculation from the oropharynx by the her-
Early infections in the hand, regardless of location, are man- pes simplex type 1 virus (HSV-1). In adults, however, HSV-2
aged initially by rest, elevation, antibiotics, close observation, predominates and is most often due to inoculation from geni-
and splinting in the intrinsic plus position. For those infections tal herpes. Herpetic infections typically have an incubation
that have progressed or whose initial presentation indicates the period of 2 weeks after which patients experience pain and
presence of an abscess (i.e., fluctuance and drainage), the treat- mild swelling in the affected digit. Small 1 to 2 mm vesicles
ment includes surgical drainage and debridement of devitalized then erupt in the affected digits and coalesce to form large
tissues. When a delay in operative treatment is unavoidable, bullae. A Tzanck smear is diagnostic.2
the abscess cavity should be aspirated to reduce compart- The management of herpetic hand infections does not
ment pressures and the risk of tendon and neurovascular involve surgery unless there is bacterial superinfection. In fact,
injury. surgical intervention in cases of herpetic whitlow can lead to
Antibiotics covering the most likely pathogens for each systemic spread.3 Viral infection can lie dormant in the ner-
type of infection are started after wound cultures have been vous system for many years and then reactivate (Figure 72.3).
obtained. Antibiotics, however, are not a substitute for ade-
quate surgical drainage and debridement. Infections in the
hand are often polymicrobial—a critical consideration when
Chronic Paronychia
making a selection of empiric antibiotic therapy (Table 72.1).1 Chronic paronychia is a distinct clinical entity from acute
All wounds that are a result of exposure to soil, animals, paronychia. Chronic inflammation of the soft tissues sur-
or the oral cavity (i.e., human bite wounds) require tetanus rounding the nail plate can lead to repeated episodes of ery-
prophylaxis. thema, pain, and drainage from the infected region. Patients
Drainage of hand infections can often be performed who have repeated exposure to water (waiters, dishwashers,
using regional anesthetic techniques (Chapter 71). etc.) are at highest risk for developing chronic inflammation.
However, the infiltration of local anesthesia directly into Staphylococcus pyogenes, Staphylococcus epidermidis, and
an area of cellulitis or infection is ill-advised and may Candida are the most common causes of chronic paronychia.
spread the infection. For example, fingertip infections can The treatment of chronic paronychia involves the excision
be managed with digital blocks, but deep space infections of a minimum 3 mm wide crescent of skin and subcutane-
of the hand should be drained under either axillary block ous tissue parallel to the eponychial fold running the entire
or general anesthesia. A pneumatic tourniquet is used to width of the finger. This procedure is referred to as eponychial
Hand
avoiding excessive bleeding that can impair visualization. marsupialization. The wound is then left open for drainage
When using the tourniquet in the presence of infection, the and the patient is placed on a regimen of hand soaks in a vari-
extremity is exsanguinated by elevation and gravity, rather ety of solutions such as dilute povidone–iodine solution. The
than compression to avoid the spread of the infection warm soaks are continued until the inflammation/drainage
(Figure 72.1). has ceased. Nail irregularities caused by chronic paronychia
can be treated by the removal of the entire nail.4 As long as
the eponychial fold is appropriately stented, the nail usually
Acute Paronychia regrows without abnormalities.
Paronychia or runaround infections of the fingertip are
infections of the soft tissue fold surrounding the nail
plate, typically with staphylococcal species. Risk factors
Felon
for paronychial infection include hangnails, nail biting, A felon is an infection in the soft tissue pulp on the volar aspect
manicures, and poor hand hygiene. Hallmarks of paro- of the fingertip. The distal finger pad is an anatomically dis-
nychial infection include pain, swelling, and erythema in tinct structure from the rest of the finger. Numerous fibrous
the perionychium. septae attach the dermis of the distal finger pad directly to the
731
732 Part VIII: Hand
TABLE 72.1
Common Hand Infections, Most Common Infecting Organisms, and Recommended Empiric Antibiotics
n Most Common n Recommended

n Condition Infecting Organisms Antibiotics n Comments
Paronychia, felon, pyogenic Usually Staphylococcus First-generation cephalospo- Incision and drainage
flexor tenosynovitis aureus or streptococci; rin or anti-staphylococcal should be performed
Pseudomonas, Gram- penicillin; if anaerobes if infection is well
negative bacilli, and or Escherichia coli are established. If infection is
anaerobes may be present, suspected, oral clindamycin chronic, suspect Candida
especially in patients with (Cleocin) or amoxicillin– albicans. Early infections
exposure to oral flora clavulanate potassium without cellulitis may
(Augmentin) or ampicillin– respond to antibiotics
sulbactam (Unasyn); alone.
if MRSA is endemic in
community, consider
trimethoprim/sulfamethoxa-
zole (Bactrim)
Herpetic whitlow Herpes simplex virus types Supportive therapy Consider antibiotics if
1 and 2 Antiviral therapy may be pre- secondarily infected.
scribed if infection has been Incision and drainage are
present for less than 48 h contraindicated
Human bite, clenched-fist S. aureus, streptococci, Intravenous first-generation Oral antibiotics should be
injury Eikenella corrodens, gram- cephalosporin or used if outpatient therapy
negative bacilli, anaerobes anti-staphylococcal is chosen. Wounds should
penicillin and penicillin G be explored, irrigated, and
or ampicillin–sulbactam debrided
or amoxicillin–clavulanate
potassium or Second-
generation cephalosporin
such as cefoxitin (Mefoxin)
Adapted from Wright PE II: Hand infections. In: Canale ST, ed. Cambell’s Operative Orthopedics. 9th ed. St Louis, MO: Mosby 1998.
A B
FIGURE 72.1. Subcutaneous abscess of the first web space (A) appearance on presentation and (B) after wide surgical debridement.

Chapter 72: Treatment of Hand Infections 733
A B
FIGURE 72.2. Acute paronychia (A) as seen in the emergency room and (B) incision is made through the most fluctuant region.
underlying bone, allowing the fingertip to be used for essential interphalangeal or distal interphalangeal joint on the volar
functions such as grasp. If a significant number of these septae surface. The flexor tendon sheath can be penetrated by for-
are disrupted during drainage of a felon, a mobile, nonfunc- eign bodies or teeth (as in the case of a human or animal
tional fingertip can result.5 bite). Rarely, pyogenic tenosynovitis is spread to the fingers
Surgical management of the felon requires antibiotics and from a distant source, such as disseminated gonorrheal infec-
adequate incision and drainage directly over the point of max- tion. The most common organisms cultured from patients
imal fluctuance. Incisions should not be carried over the joint with pyogenic tenosynovitis are Staphylococcus aureas and
flexion crease to prevent postoperative contracture (Figure 72.4). β-hemolytic streptococcus species.
Pyogenic tenosynovitis can be extremely disabling because
infections in the tendon sheath impair the normal gliding
Pyogenic Tenosynovitis mechanism of the flexor tendons. Late recognition and treat-
Pyogenic tenosynovitis is a closed space infection of the flexor ment of this disorder can result in fibrosis, or tendon necrosis
tendon sheath of the fingers or thumb. The most common and permanent loss of function.
cause of this infection is penetrating injury to the proximal Hallmarks of this infection include the following clinical
signs that were initially described by Kanavel6:
1. Semi-flexed finger position
2. Symmetrical enlargement of the whole digit
3. Excessive tenderness over the course of the flexor tendon
sheath
Hand
4. Pain on passive extension of the finger

The management of pyogenic tenosynovitis involves ade-
quate drainage and irrigation of the tendon sheath. A vari-
ety of drainage procedures have been advocated. There is a
consensus that copious irrigation of the tendon sheath with
minimized exposure of the tendon itself through carefully
placed incisions leads to fewer postoperative complications
secondary to adhesion formation within the flexor sheath 7
(Figure 72.5).
Deep Space Infections

Deep space infections of the hand can be broken down into
FIGURE 72.3. Herpetic whitlow. three general regions, the palmar, thenar, and Parona’s spaces.
The thenar eminence is the most common region for deep

734 Part VIII: Hand
A B
FIGURE 72.4. Felon: (A) Typical appearance and (B) all necrotic tissue is excised.
space infections to occur. These occur most commonly as

direct puncture wounds to the region or from nearby infec-
tion of the tendon sheath. Management includes incision and
drainage of the region. Placement of the incision depends on
the location of the abscess: (1) palmar—curvilinear from dis-
tal palmar crease to hypothenar eminence and (2) thenar—
curvilinear along thenar crease (avoid recurrent branch of the
median nerve).
Collar Button Abscess

Collar button or web space abscesses form beneath palmar
calluses and penetrate through one of the three web spaces
and are common in laborers. Since the dorsal skin is more
compliant than the palmar skin, swelling and fluctuance from
collar button abscesses are often greater dorsally. Complete
drainage of these abscesses often requires incisions on both the
dorsal and palmar surfaces. The failure to recognize the extent
of the infection on the palmar surface can lead to incomplete
drainage and spread of the infection to the deep palmar space.
It is important to avoid damage to the web itself to avoid con-
tractures postoperatively.
Radial, Ulnar Bursa Infections

Knowledge of the anatomy of the radial and ulnar bursae of
the hand allows understanding of bacterial infections in this
region. The radial bursa is the proximal extent of the flexor
sheath of the thumb, while the ulnar bursa includes the flexor
sheath of the little finger and palmar portions of the second,
third, and fourth flexor tendon sheaths. Parona’s space (the
potential space between the pronator quadratus and the flexor
FIGURE 72.5. Pyogenic flexor tenosynovitis. tendons) serves as a bridge between the radial and ulnar bur-
sae and allows the formation of “horseshoe” abscesses. When

Chapter 72: Treatment of Hand Infections 735
draining abscesses in Parona’s space it is particularly impor-
tant to avoid injuring the median nerve and its palmar cutane-
ous branch.
Human Bites
Human bite injuries lead to some of the most complex of all
the common hand infections. Typically, human bite injuries
occur through clenched-fist injuries where the patient’s fist
strikes an opponent’s tooth, piercing the metacarpophalangeal
joint. The initial puncture wound may appear innocuous but
leads to a septic joint in a few days. Most of these infections
are polymicrobial and include a wide range of possible patho-
gens due to the high number of bacterial species present in the
human mouth.8 Skin flora and Eikenella species are the most
common organisms isolated. Additionally, these patients are
often noncompliant and there is frequently a significant delay
in seeking medical care.9 A
The management of human bite injuries includes admis-
sion, x-rays to evaluate foreign bodies and fractures, culture,
and empiric antibiotics. Superficial abrasions and infections
are managed with antibiotics and close observation. If the
extensor mechanism has been penetrated, or the depth of pen-
etration cannot be determined, the wound is explored in the
operating room.
The management of animal bites (i.e., dog and cat) is quite
similar to that of human bites. Tetanus prophylaxis is required.
Dog and cat bites are more likely unimicrobial with cat bites
having a high likelihood of Pasteurella multocida infection. Of
the two, cat bites are more likely to become infected because
the puncture wounds are small and seal quickly.
Septic Arthritis
Finger joint infections are typically the result of infection
from adjacent tissues and less commonly the result of hema-
togenous spread. Symptoms of a septic joint include swelling,
fluctuance, and warmth. The finger is usually held in slight B
flexion pain on even slight passive movement. Joint aspira- FIGURE 72.6. Osteomyelitis from untreated paronychia: (A) Clinical
tion is an important diagnostic tool and will typically pro- appearance and (B) radiograph showing resorbed distal phalanx epiphysis.
duce purulent/cloudy fluid that contains (1) >50,000 white
blood cells, (2) >75% polymorphonuclear neutrophils, and
(3) glucose <40 mg.
Once pus is identified in the joint, rapid and adequate
irrigation and debridement is necessary to minimize cartilage
Necrotizing Fasciitis
and joint destruction. Cultures are obtained prior to starting Necrotizing fasciitis is a limb- and potentially life-threatening
antibiotics, which are chosen according to the gram stain infection that is often caused by minor trauma. Hallmarks
results. of necrotizing fasciitis in the upper extremity include bright
shiny skin, nonpitting edema, poorly demarcated redness,
violaceous discoloration, and skin necrosis. Patients who are
Osteomyelitis diabetic or immunocompromised are at much higher risk.
Osteomyelitis of the hand is typically the result of penetrating A single organism is found as the causative agent in nearly
trauma or open fractures. The degree of damage to the soft tis- 50% of cases, most often group A β-hemolytic streptococcus
sues overlying the affected bone plays a significant role in the (occasionally Staph. aureas).11
pathogenesis of osteomyelitis. Direct spread from a soft tis- Because the mortality of necrotizing fasciitis is as high as
Hand
sue infection such as pyogenic tenosynovitis is a rare cause of 40%, early and aggressive surgical debridement of all infected
osteomyelitis. The diagnosis can be made by identifying risk tissues is mandatory. Early empiric treatment with broad-
factors as well as plain radiographs, nuclear medicine imaging spectrum antibiotics, even before cultures have been obtained,
(bone scan and tagged white blood cell scan), and magnetic can significantly decrease morbidity. Depending on the degree
resonance. of infection and soft tissue damage, serial debridements and
The management of osteomyelitis depends on the sever- even amputation may be necessary.
ity of the presenting complaint/disability and the duration
of infection. Early infections with minimal complaints may
be cautiously managed with intravenous antibiotics alone.
Intravenous Drug Abuse
However, surgical debridement is necessary in most cases The direct inoculation of bacteria into the subcutaneous
to achieve adequate resolution of the infection. 10 When a tissues by intravenous drug use can lead to the rapid forma-
sequestrum is present, curettage of all necrotic bone is tion of abscesses. In addition to the introduction of bacteria,
essential and the wound should be packed open. Should a the injected material itself can cause local tissue necrosis.
bone defect be present after debridement, reconstruction The most common causative agents are staphylococcal and
is only considered after definitive clearance of infection streptococcal species. These infections are polymicrobial and
(Figure 72.6). present many challenges to treatment.

736 Part VIII: Hand
A B
FIGURE 72.7. Subcutaneous abscess from intravenous drug abuse: (A) Clinical presentation and (B) the use of multiple small incisions and
penrose drains to manage a large loculated abscess.
Appropriate management involves rapid and adequate

debridement and antibiotic therapy. Repeated debridements Conclusion
may be necessary. Despite adequate drainage, recurrent Successful treatment of hand infections requires early diagnosis,
abscesses are common. Large abscesses can be effectively appropriate antibiotic therapy, and prompt adequate drainage
drained through the area of maximal fluctuance and multi- of abscesses. When possible, cultures are obtained prior to ini-
ple small incisions along the periphery of the cavity. Penrose tiating antibiotic therapy. Abscesses should be widely drained,
drains are threaded through these incisions, across the cavity, all necrotic tissues debrided, and wounds left open for drainage.
to maintain drainage until purulence resolves (2 to 3 days)
(Figure 72.7).11 References
1. Cannon DL, Beatty JH. Hand infections. In: Canale ST, Beatty JH, eds.
Nosocomial Infections Campbell’s Operative Orthopedics. 12th ed. Philadelphia, PA: Elsevier;
2013:3694.
Postoperative infections in the hand are quite rare. The rou- 2. Louis, DS, Silva J Jr. Herpetic whitlow: herpetic infections of the digits.
tine use of prophylactic antibiotics in clean, routine hand J Hand Surg (Am). 1979;4(1):90-94.
3. Clark DC. Common acute hand infections. Am Fam Physician. December
cases is not recommended. Perioperative antibiotics are 2003;68(11):2167-2176.
recommended for operations involving implants, bone or 4. Grover C, Bansal S, Nanda S, Reddy BS, Kumar V. En bloc excision of
joint spaces, or exceeding 2 hours in length. The most com- proximal nail fold for treatment of chronic paronychia. Dermatol Surg.
mon causative organism for hand infections after surgery is March 2006;32(3):393-398; discussion 398-399.
5. Connolly B, Johnstone F, Gerlinger T, Puttler E. Methicillin-resistant
Staph. aureus. Staphylococcus aureus in a finger felon. J Hand Surgery (Am). January
2000;25(1):173-175.
Treatment of Resistant 6. Kanavel, AB: Infections of the Hand—A guide to the Surgical Treatment
of Acute and Chronic Suppurative Processes in the Fingers, Hand and
Organism Infection Forearm. 7th ed. Philadelphia, PA: Lea & Febiger; 1939:241-242.
7. Boles SD, Schmidt CC. Pyogenic flexor tenosynovitis. Hand Clin.
There has been a dramatic increase in the number of inpa- 1998;14:567-578.
8. Chuinard RG, D’ambrosia RD. Human bite infections of the hand. J Bone
tients with nosocomial methicillin-resistant Staph. aureus Joint Surg. 1977;59a(3):416-418.
(MRSA) wound infections in the last decade. This trend has 9. Zubowicz VN, Gravier M. Management of early human bites of the hand: a
been seen in the outpatient setting as well. Recently, Karanas prospective randomized study. Plast Reconstr Surg. 1991;88:111-114.
et al.12 reported a case series of four patients with community- 10. Dormans JP. Hand Infections in Pediatric Orthopaedics and Sports
Medicine. St Louis, MO: Mosby;2004:101.
acquired MRSA hand infections who had no previous risk fac- 11. Bisno AL, Stevens DL. Streptococcal infections of skin and soft tissues.
tors for MRSA infection. The increase in resistant infections N Engl J Med. January 1996;334:240-245.
underscores the importance of routine wound culture prior 12. Karanas YL, Bogdan MA, Chang J. Community acquired methicillin-
to initiating antibiotic therapy, whenever possible, to guide resistant Staphylococcus aureus hand infections: case reports and clinical
implications. J Hand Surg (Am). July 2000;25(4):760-763.
antibiotic therapy. Many institutions publish hospital-specific 13. Moran GJ, Krishnadasan A, Gorwitz RJ, et al. Methicillin-resistant S.
guidelines for empiric antibiotic coverage, which account for aureus infections among patients in the emergency department. N Engl
individual drug resistance patterns.13 J Med. August 2006;355:666-674.

Chapter 73 n Soft Tissue Reconstruction of
the Upper Extremity
Scott L. Hansen, Patrick Lang, and Hani Sbitany
structures are exposed. Thus, negative pressure dressings serve

Introduction as a bridge to definitive coverage. In addition to the conve-
Soft tissue reconstruction of the upper extremity requires nience and cleanliness of the dressings, negative pressure has
strict adherence to standard surgical principles. In keeping been shown to promote wound contraction, improve local
with the reconstructive ladder, options for coverage include tissue perfusion, and promote the formation of granulation
primary closure, skin grafting, local flaps, regional flaps, and tissue—effects that make definitive reconstruction easier to
free tissue transfer. Goals include restoration of a functional, achieve.2
sensate, and aesthetically acceptable hand. In addition, stable
coverage of vessels, nerves, tendons, and joints throughout Healing by Secondary
the forearm and arm is required. Primary wound healing is
also a fundamental goal as it reduces scar formation and joint Intention
stiffness. Among the considerations involved in selecting the The goal of upper extremity soft tissue reconstruction is pri-
proper techniques are the components involved, the size of mary wound healing. Healing by secondary intention is
the defect, the mechanism of injury, and the cleanliness of the occasionally appropriate such as in certain fingertip injuries.
wound. Patient factors including handedness, occupation, age, As one of the main goals of fingertip reconstruction is the resto-
sex, and overall health are also considered. ration of protective sensibility, this method is helpful in small,
Classic teaching dictates that soft tissue reconstruction fol- superficial tip defects. In such defects, sensation is maintained
lows skeletal stabilization in the traumatized extremity. After in the healed tissue as sensate skin is drawn into the defect.3
bony fixation, stable soft coverage facilitates wound healing, This is especially helpful for defects in both children and
reduces contracture, decreases infection, and improves out- the elderly. Wounds heal more rapidly in children than in
comes for secondary skeletal operations such as bone grafting adults because of enhanced wound contraction. In the elderly,
or distraction. The attempt to achieve a stable soft tissue enve- healing by secondary intention avoids some of the pitfalls of
lope begins immediately following injury, as Godina espoused sensate local flaps: prolonged postoperative immobility and
for lower extremity injuries.1 Although definitive soft tissue resultant joint stiffness, and the avoidance of necessary corti-
coverage may not be immediately possible, wound debride- cal reinnervation.
ment is always performed initially. Early debridement of non- Apart from these defects, healing by secondary intention is
viable tissue reduces the opportunity for local inflammatory of little use for soft tissue resurfacing elsewhere in the upper
response and infection. Serial debridement is performed as extremity because of the functional limitations from the resul-
many times as necessary to ensure viability of all remaining tant contracture.
tissues. Definitive coverage is then performed once the wound
is adequately debrided.
When planning definitive coverage, local tissue options are
Amputation
considered. Uninvolved soft tissue of the upper extremity is Similar to healing by secondary intention, revision amputation
often superior to more distant tissue, as it offers similar sensi- is best suited for specific cases of fingertip injuries in select
bility and tissue match. Unfortunately, there is often a paucity patients. This is often advantageous in those patients eager to
of donor tissue in the upper extremity, especially following return to work, and those with multiple comorbidities or clini-
significant injuries or extirpative surgery. In such cases, dis- cally unstable pictures.
tant tissue options are explored. Although those injuries of the remainder of the extremity
Basic wound care principles are as essential as the various with large amounts of devitalized tissue may also benefit from
grafts and flaps available. These principles allow the craft- some degree of select amputation, it is rarely indicated as the pri-
ing of a safe and effective reconstructive plan for the upper mary method for definitive treatment of upper extremity injuries.
extremity. This chapter outlines reconstructive options rang-
ing from simple skin grafts to complex free tissue transfer. Skin Grafts
There are many instances in upper extremity soft tissue recon-
struction where “less is more”—an example being the healing Stable skin and soft tissue coverage of the hand is essential for
Hand
of a fingertip injury by secondary intention, when more com- hand function. Volar and dorsal surfaces should be considered
plex solutions would prolong impairment. The surgeon must separate entities when considering coverage. The dorsal hand
be comfortable with all rungs of the reconstructive ladder if skin is thin, mobile, and has the primary function of allowing
the appropriate reconstruction is to be performed in a wide flexion, while maintaining nonadherent coverage of tendons
range of clinical scenarios. and joints. Split-thickness skin grafts are appropriate for large
defects of the upper extremity that have no vital structures
exposed. In addition to improved “take” relative to full-thick-
Negative Pressure Dressing ness skin grafts, split grafts also offer the advantage of greater
The use of negative pressure dressings has revolutionized the secondary contraction of the wound, and resultant reduction
care of complex wounds. Although some controversy exists in the size of the grafted area. The presence of paratenon
regarding its effect on time to heal, there is no debate over greatly enhances the survival of the graft and improves post-
the degree of convenience that it has introduced for both operative tendon gliding. The ideal thickness for skin grafts to
the patient and the surgeon. Wounds of the upper extrem- the hand ranges between 0.012 and 0.014 inches. Meshing of
ity requiring serial debridement do well with negative pres- the graft can be performed to increase graft surface area, and
sure dressings between procedures provided no neurovascular allow egress of underlying fluid.
737
738 Part VIII: Hand
B
FIGURE 73.1. A. Exposed extensor tendons after IV infiltration and serial debridements. B. Reconstruction with Integra followed by delayed
coverage with a skin graft.
When resurfacing the dorsal surface of the hand, tendon division of the vertical fibrous septa is crucial to obtain
adhesion to the overlying skin graft may occur, and subse- adequate advancement. The terminal branches of the neu-
quent tenolysis is often required. The authors have found that rovascular bundles lie in the lateral pulp tissue of the flap,
large dorsal defects with exposed tendon do well with cover- and thus, careful attention must be taken to avoid their injury
age by Integra Dermal Regeneration Template, followed by during undermining. In cases where complete closure can-
split-thickness skin grafting (Figure 73.1). Other biologic not be achieved due to inadequacy of advancement, the flaps
templates may also be comparable and should provide the can be advanced maximally, and the remaining wound can
benefits of improved coverage and reduced adherence to be allowed to heal by secondary intention. Due to the limited
underlying gliding tendons. Though not appropriate for all mobility of these flaps, use of the V-Y advancement flaps is
wounds, elderly patients or those with significant comorbidi- usually reserved for defects distal to the midnail level.
ties precluding free tissue transfer can be reconstructed using
this method. Volar V-Y Advancement Flap
The glabrous skin on the volar surface of the hand carries
Closure of transverse or dorsally angulated fingertip injuries
a highly specialized tactile sensory function. Because of the
can often be achieved with the use of a volar V-Y advance-
mechanical demand placed on the working palm, the volar
ment flap (Figure 73.3). Described by Atasoy and Kleinert,
skin is thick and densely adherent to the underlying fascial
this is a V-shaped flap with the tip at the distal interphalan-
system, through a series of vertical ligaments. For defects
geal crease which is advanced distally, to achieve tension-
involving the volar hand, primary options for resurfacing
free closure. 5 Like the bilateral V-Y advancement flaps,
include full-thickness glabrous skin grafts from either the
the volar advancement flap requires division of the fibrous
hypothenar eminence or the non–weight-bearing region of
septa from the distal phalanx to achieve adequate advance-
the plantar foot. This offers the advantage of also provid-
ment. Expected advancement, when incision is entirely
ing specialized nerve endings, similar to those encapsulated
distal to the DIP flexion crease, is 1 cm. When properly
nerve endings in the injured volar skin, and donor sites that
planned, the entire donor defect can be closed primarily
may be closed primarily. If necessary, full-thickness grafts
with little tension.
for such defects may also be obtained from other areas of the
upper extremity. Given that the native volar skin is devoid of
pilosebaceous structures, every effort should be taken to har-
vest the grafts from similarly hairless areas, such as the volar
wrist, or the skin just proximal to the medial epicondyle of
the elbow.
Skin grafting of forearm and proximal arm defects follows
a similar algorithm to dorsal hand grafting. The majority of
defects can be adequately covered with meshed split-thickness
grafts. Skin grafting is also an option for fingertip defects.
While full-thickness skin grafts are sometimes useful for tip
coverage, they are rarely a preferred primary method due to
poor recovery of sensibility. In most cases, a sensate flap is a
better option, as it retains the important protective sensibility
of the fingertip.
Local Flaps
Bilateral V-Y Advancement Flap
Transverse and volar fingertip injuries can be treated with
bilateral V-Y advancement flaps (Figure 73.2). As described FIGURE 73.2. Kutler flap. Bilateral triangular advancement flap for
by Kutler, these flaps are elevated from the sides of the injured patients with transverse or volar oblique amputations.
digit and advanced distally. 4 Because mobility is limited,

Chapter 73: Soft Tissue Reconstruction of the Upper Extremity 739
B
FIGURE 73.4. A. Moberg flap. Design of the homodigital advance-
ment flap to cover defects of the thumb pulp. B. Advancement of
Moberg flap to cover thumb pulp defect.
(Figure 73.5). The pedicle can be designed laterally, proxi-

mally, or distally. The donor site is skin grafted (full-thick-
ness graft) and both digits are immobilized. Because this flap
acts as a vascularized full-thickness flap of skin, it may be
safely divided within 2 weeks; thus, stiffness of the immobi-
FIGURE 73.3. Atasoy flap. Volar V-Y advancement flap. lized digits is minimized.
Complications associated with the cross finger flap include
poor aesthetics at the donor site, stiffness due to prolonged immo-
bilization, and cold intolerance of the donor digit. In addition,
Volar Neurovascular Advancement Flap the recipient digit will always have relatively poor sensibility.
(Moberg Flap)
Fingertip amputations can be covered with distal advance-
Reverse Cross Finger Flap
ment of the entire volar finger skin as a single neurovascular Dorsal digital wounds can be covered with use of the reverse
flap (Figure 73.4). The volar digital neurovascular advance- cross finger flap (Figure 73.6). This flap consists of subcu-
ment flap has been described for use in all digits, but Moberg taneous tissue elevated from the dorsum of the middle pha-
popularized its use for transverse amputations of the thumb, lanx of the adjacent finger. This is exposed by first elevating
a procedure that persists today as the most common applica- the skin of the donor digit in this region, maintaining a base
tion of this flap.6 Two parallel longitudinal incisions are made laterally, on the side opposite the injured digit. The flap is
dorsal to the neurovascular bundles, followed by elevation of turned over to cover the dorsal defect of the injured finger.
the flap off of the flexor tendon sheath. The flap is designed The elevated skin from the donor digit is then sutured back
with its base at the metacarpal phalangeal crease and advanced into its native position and the flap on the injured digit is
distally with its neurovascular bundles intact. The true Moberg skin grafted. Delayed division of the pedicle is generally per-
flap requires splinting with some degree of flexion to allow for formed at 2 weeks.
tension-free healing of the advanced flap. This can create prob-
lems with stiffness, particularly in older patients. Modifications Thenar Flap
include the creation of a true island flap with skin grafting of
The thenar flap is an excellent and reliable choice for recon-
the resulting proximal defect, which may increase advance-
struction of distal phalanx soft tissue defects and amputations
Hand
ment to 1.5 cm. Alternatively, flap design into the web space
(Figure 73.7). This flap stands in contrast to the historically
proximally may increase advancement to 3.0 cm.7
complication-ridden palmar flap, described by Gatewood,
This flap should be avoided in non-thumb digits due to ten-
which resulted in frequent proximal interphalangeal (PIP)
uous dorsal skin perfusion following the required longitudinal
joint contracture.9 Beasley established four guidelines for
incisions. It is the unique dorsal and volar blood supply of the
proper execution of the thenar flap in an attempt to limit
thumb that allows for safe elevation of this flap.
complications associated with the related palmar flap: (1)
the metacarpal phalangeal joint of the recipient finger is fully
Cross Finger Flap flexed in an attempt to limit required flexion of the PIP joint;
Volar fingertip pulp amputations can be treated with the (2) the thumb is placed in full palmar abduction or opposi-
cross finger flap. Gurdin and Pangman first described the use tion; (3) the flap is designed with a proximal pedicle high on
of dorsal skin and subcutaneous tissue from an adjacent fin- the thenar eminence so that its lateral margin is at the meta-
ger for volar defect coverage.8 The flap is designed over the carpophalangeal skin crease; and (4) the pedicle is divided
dorsum of the middle phalanx and elevated off the underly- after 10 to 14 days.10
ing extensor paratenon. Preservation of the paratenon over In addition to these principles, the flap should generally be
the extensor apparatus is critical. The flap is then turned 1.5 times the diameter of the injured fingertip. This enables
over to resurface the volar tip of the adjacent (injured) finger preservation of the rounded contour of a normal fingertip.

740 Part VIII: Hand
B
FIGURE 73.5. A. Cross-finger flap. Elevation of cross finger flap to reconstruct a defect on an adjacent digit. B. Cross-finger flap. Inset of the
cross finger flap on the adjacent thumb pulp defect with coverage of the donor site with a split-thickness skin graft.
The donor site can often be closed primarily, but will occa-
sionally require placement of a skin graft. Neurovascular Island (Littler) Flaps
Following pedicle division, active and aggressive rehabilita- In 1960, Littler described transfer of vascularized, sensate tis-
tion of the finger must be commenced to prevent finger stiff- sue from the ulnar border of the long or ring finger for recon-
ness and joint contracture. Although there may be a higher struction of volar thumb pulp.12 These neurovascular island
risk of joint contracture in those patients older than 40 years flaps are based on the digital artery and proper digital nerve
following a thenar flap, they have been used in patients of all of the donor finger. The artery is dissected proximally to
ages with reports of minimal morbidity.11 the level of the palmar arch, and the nerve is freed from its
A B
FIGURE 73.6. A. Reverse cross-finger flap. Elevation of the epidermis. B. Elevation of retic-
ular dermis and subcutaneous tissue flap and rotation to the adjacent dorsal finger defect.
C. Inset of the flap over the exposed DIP joint of the dorsal index finger and coverage of the
donor site with the previously elevated epidermis.
C

A B
FIGURE 73.7. A. Thenar flap. Transverse index finger defect with exposed bone. Preparing to design the proximally based thenar flap. B. Inset
of the index finger tip into the thenar flap prior to division at 2 weeks.
adjacent digital nerve at the level of the common digital nerve. ipsilateral distal digital nerve. Following flap mobilization, the
The flap is transferred to the volar thumb on its pedicle in a resultant defect on the donor digit is skin grafted.
single-stage fashion (Figure 73.8).
Having adequate sensation in the volar thumb is associated
with better functional outcomes. Unfortunately, this requires First Dorsal Metacarpal Artery Flap
cortical reeducation which is reported to occur in only 40% The first dorsal metacarpal artery (FDMA) flap is a sensate,
of cases.13 Another drawback of this flap is the donor finger fasciocutaneous flap, harvested from the skin of the dorsal sur-
sensory deficit, secondary to the necessary division of the face of the hand, index finger, and thumb. It is used primarily in
Hand
FIGURE 73.8. A. Littler flap. Design of the neurovascular island

pedicle flap. B. The neurovascular island flap tunneled to volar thumb
defect with coverage of the donor site with a split-thickness skin graft.
A

742 Part VIII: Hand
reconstruction of ulnar side defects of the volar thumb pad.14,15 The distally based reverse radial forearm flap is a useful
It is also indicated for severe first web space contractures with modification for distal defects. This flap is based on the radial
irregular surfaces and exposed neurovascular structures. The artery and its accompanying venae comitantes, which drain
skin of the FDMA flap is particularly durable and flap sen- the flap in a retrograde manner. For this modification of the
sibility is comparable to that of the Littler flap. Though the flap, arterial inflow is supplied through the ulnar artery, and
reversed-flow flap has been described for coverage of skin the superficial palmar arch. A preoperative Allen test is essen-
defects up to the distal phalanx of the index finger, this should tial prior to any radial forearm flap harvest in order to ensure
not be used as a first choice, due to unreliable perfusion. that the hand will remain perfused following radial artery har-
The branches of the FDMA run close to the first metacar- vest (Figure 73.11).
pal bone, in the middle of the first interosseous space. Two Whether using a standard or retrograde approach, care
venae comitantes are present around the artery, and drain into should be taken to avoid injury to the superficial radial sen-
the superficial venous system. sory nerve. Injury of this nerve or its branches may lead to
During dissection of this flap, it is important not to include significant paresthesias and postoperative pain. In addition,
the skin over the index finger metacarpal neck. This helps to when raising the proximally based radial forearm flap, the
avoid web space contracture. If the skin in this area is necessary cephalic vein may be maintained within the flap such that
to cover the skin defect, the flap is extended ulnarly toward the venous drainage will be augmented. In order to include the
long finger metacarpal. Following flap elevation and transfer, cephalic vein, the flap must extend on to the dorsal aspect of
the donor site is covered with a skin graft (Figure 73.9). the radial side of the arm.
The FDMA flap, taken in antegrade fashion, offers a reli-
able option for sensate thumb reconstruction. With a constant Posterior Interosseous Flap
anatomy and expendable artery, its use in hand reconstruction
The posterior interosseous flap has a range of applications
can reduce the need for many of the distant pedicled flaps cov-
similar to that of the radial forearm flap. With its dorsal donor
ered later in this chapter.
site skin paddle supplied by septocutaneous perforators from
the posterior interosseous artery, this fasciocutaneous flap can
Regional Flaps cover a wide range of defects of the elbow, forearm, wrist,
dorsal hand, first web space, and thumb.16
Radial Forearm Flap The primary contraindication to use of this flap is in cases
of significant wrist or forearm injury, as there is an increased
The radial forearm flap is a versatile fasciocutaneous flap that
risk of PIA thrombosis. The flap can also be harvested with
can be used to reconstruct a wide range of upper extremity
functional muscle or vascularized tendon. Like the radial fore-
defects (Figure 73.10). As a pedicled flap it may be used in a
arm flap, a distally based reverse flap is useful for coverage of
standard or reversed fashion to provide reliable coverage of
distal defects.
the forearm, elbow, wrist, hand, and thumb. As a free flap,
it is even more versatile. Robust septocutaneous perforators
from the radial artery allow for a wide range of skin paddle Medial Arm Flap
shapes and sizes. The donor site can be skin grafted with mini- The medial arm flap is a reliable coverage option for fascio-
mal morbidity, provided the paratenon of the underlying ten- cutaneous defects of the axilla and antecubital fossa. Based on
dons is preserved. Even with adequate skin grafting, however, branches of the superior ulnar collateral artery, the standard
the donor sites are aesthetically problematic. flap design allows rotation into the axilla. Antecubital defects
B
A
FIGURE 73.9. A. First dorsal metacarpal artery flap. Flap design over the proximal phalanx of the dorsal index finger and rotation to a volar
thumb defect. B. Inset of the flap with split-thickness skin graft coverage of the donor site.

A C
FIGURE 73.10. A. Radial forearm flap to elbow. Degloving injury of the upper extremity with open elbow joint. B. Elevation of flap and rota-
tion to defect. C. Stable soft-tissue coverage of elbow.
can be covered with a reverse flap pedicled on the posterior In addition to harvest of the muscle as a pedicle flap, harvest
ulnar collateral vessels. A relatively smaller skin paddle can as a myocutaneous flap is common. In order to reach distal
be elevated as a free flap for transfer throughout the body, arm defects, it is necessary to ligate the vascular branch to
including the upper extremity. The medial arm donor site can the serratus muscle. In addition, it is necessary to separate
often be closed primarily, although skin grafting is necessary the muscle from its insertion on the humerus, as well as tran-
for larger flaps. sect the thoracodorsal nerve. Harvesting this muscle often is
not associated with functional problem and the donor scar is
Lateral Arm Flap less conspicuous and more acceptable when compared to the
The lateral arm flap is another regional fasciocutaneous flap radial forearm flap.
that provides good coverage for upper extremity defects. Transfer of the muscle with preservation of the thora-
The standard flap, based on the radial collateral artery, can codorsal nerve and humeral insertion can also be performed
provide an adequate arc of rotation for coverage of axillary for use of the muscle as a neurotized flap. This is often used
and shoulder wounds. The reverse flap, based on the radial for restoration of shoulder and elbow function.
Hand
recurrent artery, can be used as a pedicled flap for elbow cov-

erage. Additionally, a segment of vascularized humerus or tri-
ceps tendon can be taken with the standard flap design for
Distant Flaps
reconstruction of composite defects. Like the medial arm flap, Distant flaps are based on anatomically defined pedicles.
the lateral arm flap can be harvested as a free flap for cover- As such, they are performed in a two-stage procedure, with
age of more distant upper extremity defects, such as those of pedicle division and flap inset occurring at the second stage.
the hand. As they are supplied by a named arterial, they offer a robust
Obesity and the presence of epicondylitis or other inflam- and reliable blood supply. These flaps are especially useful for
matory elbow diseases generally preclude the use of this flap. coverage of large defects of the hand.
Latissimus Dorsi Flap Superficial Inferior Epigastric Artery Flap

The latissimus dorsi muscle can be used to reconstruct soft- Based on the superficial inferior epigastric artery (SIEA),
tissue defects of the shoulder, upper arm, elbow, and fore- which ascends onto the abdomen from its origin at the femo-
arm.17,18 It carries the advantage of being a large, expendable ral artery, this flap was first described as an inferiorly based
muscle with a significant arc of rotation. This is due to the tubed flap for hand coverage.20 Given its vertical orientation,
significant length of its thoracodorsal vascular pedicle. donor sites up to 10 cm width can be closed primarily. Flap

744 Part VIII: Hand
A B
C D
FIGURE 73.11. A. Reverse radial forearm flap. Degloving injury of dorsal hand with unstable soft-tissue coverage and contracted first web
space. B. Debridement of unstable tissue and release of the first web-space contracture with resulting defect. C. Design of the reverse radial
forearm flap. D. Stable soft-tissue coverage of the dorsal hand defect.
harvesting from the side contralateral to the injured hand Another source of random pattern cutaneous flaps for
allows the involved upper extremity to sit more comfortably upper extremity reconstruction is the contralateral arm. The
during the 2- to 3-week period of immobilization prior to ped- medial surface of the contralateral upper extremity is often
icle division (Figure 73.12). a supple, well-vascularized source of tissue. As with random
abdominal pattern flaps, these flaps should be made small.
Superficial Circumflex Iliac Artery Flap However, contralateral arm flaps provide a better color and
tissue match, with less hair-bearing potential.
Known also as the groin flap, the superficial circumflex iliac
artery flap is based on the superficial circumflex iliac branch Microvascular Free Tissue Transfer. Free tissue trans-
of the femoral artery.19 These flaps may be designed widely in fer provides robust, vascularized tissue for coverage of a
the inguinal region, and donor sites up to 14 cm can be closed wide variety of upper extremity defects, including composite
primarily. It is based medially, usually on the side ipsilateral to defects. Specific indications for use of this method in upper
the injured hand. This results in more difficult and uncomfort- extremity reconstruction include an inadequacy of donor tis-
able immobilization than the contralateral SIEA flap, as the sue around the zone of injury, large defect size, exposed hard-
shoulder must be rotated externally. However, relative to the ware, and anticipated postoperative radiation therapy.
SIEA, the groin flap usually can be designed in an area with In light of the end-organ arterial anatomy of the upper
minimal hair growth. extremity, end-to-side anastomoses for tissue transfer may be
Contraindications to using the groin flap include patients required in many cases. However, provided superficial palmar
with chronic groin infections (e.g., intertrigo), and those with arch patency is confirmed (Allen test), radial or ulnar artery
lower extremity or upper extremity edema (relative contra- ligation may be feasible for completion of an end-to-end anas-
indication). In addition, preservation of the lateral femoral tomosis. For venous outflow, either the venae comitantes of the
cutaneous nerve is critical to avoiding prolonged pain and arteries or the superficial veins (cephalic, basilic) can be used.
dysesthesia postoperatively.
Random Pattern Flaps. The so-called random pattern Latissimus Dorsi Flap
flaps are those based on smaller, unnamed vascular pedicles. The latissimus dorsi muscle can be harvested in full or in
As such, they must be smaller. When derived from the part as a free flap for coverage of upper extremity defects.21
abdomen, they may be based in any direction. A large, reliable skin paddle can be included. Advantages of

A B
C D
FIGURE 73.12. A. Superficial inferior epigastric artery flap. Chronic forearm wound with exposed ulna and osteomyelitis. Design of flap.
B. Elevation of the flap. C. Inset of the flap into the defect with primary closure of the donor site. D. Stable soft-tissue coverage after flap division.
the latissimus flap for upper extremity coverage include its rel-
ative thinness, making it ideal for achieving an aesthetic con- Gracilis Flap
tour in the upper extremity, and its consistently long pedicle The gracilis flap, based on the medial circumflex femoral ves-
(up to 15 cm). sels, is another muscle or musculocutaneous flap with wide
Although the latissimus should always be harvested based application to the upper extremity. Advantages include its
on the thoracodorsal vessels, it is possible to preserve a leash relatively concealed donor site with little donor site functional
of the serratus branch during dissection. This branch can be deficit. In addition, the close proximity of the obturator motor
utilized as a secondary source for anastomosis if necessary nerve to the vascular pedicle makes the harvest of the entire
(Figure 73.13). neurovascular pedicle efficient. In cases involving significant
neuromuscular deficits, the gracilis can be harvested as a func-
Rectus Abdominis Flap tional muscle for reestablishment of basic upper extremity
motion such as wrist or elbow flexion. Accordingly, the flap has
The rectus abdominis muscle or musculocutaneous flap is a
gained popularity for correction of motor deficits due to bra-
Hand
reliable flap for use in a variety of upper extremity recon-

chial plexus palsy, and treatment of Volkmann contracture.22
structive scenarios. Based on the deep inferior epigastric
artery, the muscle can be transplanted to provide vascularized
bulk for coverage of large soft tissue defects (Figure 73.14). Anterolateral Thigh Flap
The rectus flap is particularly useful in instances of hardware Since Song first described the use of the anterolateral thigh
exposure or previous underlying osteomyelitis. Free muscle (ALT) flap in 1984, perforator-based fasciocutaneous flaps
without the overlying skin paddle is covered with a split- have come to play an increasingly important role in soft tissue
thickness skin graft. Disadvantages of the rectus abdomi- reconstruction of the upper extremity (Figure 73.15). Their
nis flap include a large visible scar in the abdomen, and the versatility and low donor site morbidity have led many sur-
potential for abdominal wall morbidity, including bulge or geons to abandon traditional musculocutaneous flaps in a
hernia formation. variety of upper extremity defects. We have found the ALT
Although this flap can be based on either the superior or flap to be particularly useful in the upper extremity as the
inferior epigastric vessels, the inferior vessels are generally flap can be harvested reliably, and the donor site can often
preferred. When taken just beyond their origin from the exter- be closed primarily. Flap sizes up to 8 × 25 cm are reliable,
nal iliac vessels, they offer a much larger caliber than the supe- but may require skin grafting at the donor site.23 The primary
rior epigastric vessels. disadvantage of the ALT flap for upper extremity coverage is

746 Part VIII: Hand
A B
C D
FIGURE 73.13. A. Latissimus dorsi flap. Mutilating trauma to the upper extremity. B. Wound after serial debridements. C. Microsurgical
transfer of the latissimus dorsi muscle. D. Long-term follow-up showing stable wound coverage.
contour irregularity related to the flap’s relative bulk, particu- the overlying skin. However, this flap can be perfused reliably
larly in western populations. In these circumstances, a second- based on one perforator. Should additional soft tissue bulk be
ary flap debulking is often required. necessary, the vastus lateralis muscle can be included in the
The descending branch of the lateral circumflex femoral flap on the continuation of the descending vascular pedicle,
pedicle generally yields one to three significant perforators to thus creating a chimeric flap.
C B
FIGURE 73.14. A. Rectus abdominis flap. Degloving injury of dorsal hand with open metacarpal fractures. B. Elevation of the rectus abdominis
flap through a paramedian incison. C. Long-term follow-up showing stable soft-tissue coverage.

C D
FIGURE 73.15. A. Anterolateral thigh flap. Traumatic avulsion of

thumb with large soft-tissue deficit. B. Design of the anterolateral
thigh flap. C. Stable flap coverage of volar hand in preparation for
delayed toe transfer. D. Harvest of second toe in preparation for
thumb reconstruction. E. Long-term follow-up.
E
flap, it is skin grafted for coverage. The main advantages of

Deep Inferior Epigastric Artery Perforator Flap this flap is its pliability which provides appropriate contour
The abdominal wall is a large potential source of free donor and shape without the need for debulking often attendant
tissue. Perforator flaps based on the deep inferior epigas- with other flaps.
tric artery (DIEP) have traditionally been described for use
in breast reconstruction, but may also be applied to upper Microneurovascular Partial Toe Transfer
extremity reconstruction. The true DIEP flap spares the rec-
tus muscle and thus results in no functional deficit at the Partial toe transfer is a useful option in select cases of trau-
donor site. Muscle dissection can be avoided altogether with matic or surgical loss of finger pad, or to resurface an insen-
a fasciocutaneous flap based on the superficial inferior epi- sitive or atrophic pulp. The use of the free pulp transfer in
Hand
gastric vessels. Both flaps can be considered in the algorithm such cases is reserved for situations where the use of a local
for reconstruction of large upper extremity soft tissue defects heterodigital or distant flap is not possible. These situations
requiring significant bulk. may occur in cases with extensive tissue loss, or when it is not
possible to obtain usable skin cover of the thumb or index
finger.24 One advantage of these flaps is avoidance of the cold
Temporoparietal Fascia Flap intolerance at the donor site frequently noted following har-
In cases where a thin, pliable flap is needed to provide a vascu- vest of a heterodigital island flap.
larized bed onto which a skin graft may be placed, the tempo- This procedure allows transfer of pulp from the big toe
roparietal fascia flap is an excellent option. This is especially with the digital neurovascular bundle. The larger plantar
useful on dorsal hand defects with exposed tendon. It is also nerve for the big toe is more suitable than the second toe to
useful for secondary tendon and nerve reconstructions, as well match the size of the nerves in the fingers. Most commonly,
as small three-dimensional defects in the hand (e.g. after first the ipsilateral foot is used for thumb reconstruction, and the
web space release). contralateral foot’s big toe for index reconstruction. Transfer
The flap is harvested based on the superficial temporal ves- of the pulp from the big toe yields a two-point discrimination
sels that run just deep to this fascia above the zygomatic arch. from 7 to 18 mm, assuming a strict sensory reeducation pro-
The donor site is closed primarily, and following inset of this gram is followed postoperatively.25

748 Part VIII: Hand
vessels in the hand. In addition, they result in minimal donor

Other Flaps site morbidity. Common donor sites include the volar fore-
There are a number of other free flaps that we view as second- arm, the dorsal digits or hand, and the dorsal foot. These flaps
ary options for upper extremity reconstruction. These include are especially useful in difficult replantations with vessel dam-
the scapular and parascapular flaps, serratus anterior muscle age, and in fingertip resurfacing.27
flap, the first web space flap, and the dorsalis pedis flap.26 Most commonly, the venous flow-through flap is con-
While all are useful, they have been replaced by more ana- structed as an arterialized venous conduit flap between two
tomically reliable flaps with a more efficient harvest. arteries (functionally reconstructing the artery). Additionally,
Also useful for coverage of fingertip injuries or small they may be designed between an artery and a vein (as is
defects of the hand are venous flow-through flaps. These offer typical for an A-V fistula). Less commonly, they may also be
the advantage of small, pliable skin islands that conform well interposed between two veins as a total venous perfusion flap.
to the surface of the hand. In addition, they offer a very high Such a design, however, leads to greater size restriction than
success rate regarding flap survival. These flaps are easily har- an arterialized flap, due to the low oxygen delivery from the
vested, and the veins offer an excellent size match to recipient venous inflow (Figure 73.16).
A B
C D
FIGURE 73.16. A. Venous flap to thumb. Chronic dorsal thumb

wound with exposed extensor tendon. B. Debridement of dorsal
thumb wound and creation of defect template. C. Template of
defect drawn on volar forearm based on superficial venous system.
D. Immediate result after microsurgical anastomoses. E. Long-term
follow-up showing stable wound coverage and excellent extension
of thumb.
E

14. Sherif MM. First dorsal metacarpal artery flap in hand reconstruction.
References I. Anatomical study. J Hand Surg. 1994;19:26-31.
1. Godina M. Early microsurgical reconstruction of complex trauma of the 15. Sherif MM. First dorsal metacarpal artery flap in hand reconstruction.
extremities. Plast Reconstr Surg. 1986;78:285-292. II. Clinical application. J Hand Surg. 1994;19:32-38.
2. Orgill DP, Bayer LR. Update on negative-pressure wound therapy. Plast 16. Zancolli EA, Angrigiani C. Posterior interosseous island forearm flap.
Reconstr Surg. 2011;127:105S-115S. J Hand Surg [Br]. 1988;13:130-135.
3. Louis DS, Palmer AK, Burney RE. Open treatment of digital tip injuries. 17. Ching-Hou M, Yuan-kun T, Chin-Hsien W, Cheng-Yo Y, Shang-Won Y,
J Am Med Assoc. 1980;244:697-698. Feng-Chen K. Reconstruction of upper extremity large soft-tissue defects
4. Kutler W. A new method for finger tip amputation. J Am Med Assoc. using pedicled latissimus dorsi muscle flaps – technique illustration and
1947;133:29. clinical outcomes. Inj Int J Care Inj. 2008;39:S67-S74.
5. Atasoy E, Loakimidis E, Kasdan ML, et al. Reconstruction of the amputated 18. Pierce TD, Tomaino MM. Use of the pedicled latissimus muscle flap for
fingertip with a triangular volar flap. A new surgical procedure. J Bone Joint upper-extremity reconstruction. J Am Acad Orthop Surg. 2000;8:324-331.
Surg. 1970;52A:921. 19. Shaw DT, Payne RL. One-stage tubed abdominal flaps. Surgl Gynecol
6. Moberg E. Aspects for sensation in reconstructive surgery of the upper Obstet. 1946;83:205.
extremity. J Bone Joint Surg. 1964;46A:817. 20. McGregor IA, Jackson IT. The groin flap. Br J Plast Surg. 1972;25:3.
7. Rohrich RJ, Antrobus SD. Volar advancement flaps. In: Blair WF, ed. 21. Upton J, Havlik RJ, Khouri RK. Refinements in hand coverage with micro-
Techniques in Hand Surgery. Baltimore, MD: Williams & Wilkins; vascular free flaps. Clin Plast Surg. 1992;19:841-857.
1996:39-47. 22. Chung DC, Carver N, Wei FC. Results of functioning free muscle transplan-
8. Gurdin M, Pangman WI. The repair of surface defects of fingers by tation for elbow flexion. J Hand Surg. 1996;21:1071-1077.
trans-digital flaps. Plast Reconstr Surg. 1950;5:368. 23. Wang HT, Erdmann D, Fletcher JW, Levin LS. Anterolateral thigh flap
9. Gatewood M. A plastic repair of finger defects without hospitalization. technique in hand and upper extremity reconstruction. Tech Hand Up
J Am Med Assoc. 1926;87:1479. Extrem Surg. December 2004;8(4):257-261.
10. Melone CP, Beasley RW, Carstens JH. The thenar flap: an analysis of its use 24. May JW, Chait LA, Cohen BE, O’Brien BM. Free neurovascular flap from
in 150 cases. J Hand Surg. 1982;7:291. the first web of the foot in hand reconstruction. J Hand Surg. 1977;2:387.
11. Barbato BD, Guelmi K, Romano SJ, et al. Thenar flap rehabilitated: 25. May JW, Daniel RK. Great toe-to-hand free tissue transfer. Clinl Orthop.
a review of 20 cases. Ann Plast Surg. 1996;37:135-139. 1978;133:140.
12. Littler JW. Neurovascular skin island transfer in reconstructive hand 26. Zuker RM, Mantkelow RT. The dorsalis pedis free flap: Technique for
surgery. In: Wallace AB, ed. Transactions of the Second Congress of the elevation, foot closure, and flap application. Plast Reconstr Surg. 1986;77:
International Society of Plastic Surgeons. London: Livingstone; 1960;175. 93-104.
13. Oka Y. Sensory function of the neurovascular island flap in thumb recon- 27. Parrett BM, Bou-Merhi JS, Buntic RF, Safa B, Buncke GM, Brooks D.
struction: comparison of original and modified procedures. J Hand Surg. Reining outcomes in dorsal hand coverage: consideration of aesthetics and
2000;25:637-643. donor-site morbidity. Plast Reconstr Surg. 2010;126:1630-1638.
Hand

CHAPTER 74 n MANAGEMENT OF NERVE
INJURIES AND COMPRESSIVE
NEUROPATHIES OF THE UPPER
EXTREMITY
SCOTT A. MITCHELL AND Kodi Azari
This process clears the endoneurial tubes of axonal and

PERIPHERAL NERVE INJURY myelin debris in preparation for axonal regeneration. Axonal
The peripheral nerve is a hierarchical structure in which the regrowth begins near the site of injury and progresses under
axon is the basic subunit. The endonerium surrounds indi- ideal conditions at a rate of 1 mm/day. As the endoneurial
vidual myelinated axons or groups of unmyelinated axons. tubes remain intact to guide regeneration, prognosis for recov-
Collections of axons are gathered into fascicles by a layer of ery is favorable and functional recovery is anticipated.
perineurium. The fascicle is the smallest subunit of peripheral Neurotmesis implies complete nerve transection with dis-
nerve that can be surgically dissected. Within most periph- ruption of axons and all layers of investing connective tissue.
eral nerves, fascicles are grouped together by condensations There is degeneration of all axons distal to the site of injury
of internal epineurium. For instance, as the ulnar nerve as well as a physical separation of the nerve ends. Scar tissue
approaches the wrist, distinct fascicular groups bound for the formation within the intervening gap blocks advancement of
dorsal sensory, deep motor, and superficial sensory branches the regenerating axons and results in a neuroma. Recovery
may be identified. The outermost layer of connective tissue, will not occur unless the transected stumps are surgically
the external epineurium, encases the fascicular groups to coapted.
form the peripheral nerve. The epineurium is typically sur- Sunderland expanded Seddon’s classification to delin-
rounded by loose areolar tissue permitting nerve excursion eate five degrees of nerve injury.2 First- and second-degree
with joint motion. injuries are analogous to Seddon’s neurapraxia and axonot-
Common etiologies of peripheral nerve injury include pen- mesis, respectively. With third-degree injury, there is loss
etrating trauma, traction, compression, electrical, and thermal of continuity of the axons as well as the endoneurial tubes.
injuries. Many injuries reflect a combination of these mecha- The fascicular architecture and investing perineurium remain
nisms. A variety of secondary processes, including infection, intact. Axonal regeneration will occur; however, specificity
ischemia, and fibrosis, may contribute to further damage. of reinnervation is compromised due to endoneurial disrup-
Although the peripheral nerve may be injured in a variety of tion and prognosis is less favorable than with second-degree
manners, it has a limited arsenal of responses. There are two injuries. Fourth-degree injury refers to loss of continuity of
basic pathophysiologic responses to trauma—demyelination the axons, endoneurial tubes, and perineurium, with only the
and axonal degeneration. This primary distinction forms the outer epineurium remaining intact. This degree of injury often
basis for most classifications of nerve injuries. Mild injuries produces a neuroma in continuity due to intra-neural scaring
result in local demyelination along otherwise intact axons. that precludes significant spontaneous recovery. Fifth-degree
Repair of the myelin sheath by residing Schwann cells typi- injury, analogous to Seddon’s neurotmesis, refers to complete
cally restores function. More severe injuries affect the axons nerve transection.
themselves, resulting in degeneration of the axons distal to the During the early clinical evaluation of patients with trau-
site of injury through the process of Wallerian degeneration. matic peripheral nerve injuries, it is not possible to distinguish
Regeneration of injured axons and re-innervation of distal tar- among these subtypes. The mechanism of injury may provide
gets are required to restore function. some guidance. Penetrating trauma tends to produce neurot-
mesis injuries. The zone of injury is typically small with sharp
Classification of Nerve Injury lacerations but may be more extensive with dull lacerations
as stretching and tearing of tissues become more prominent.
There are two commonly used classification schemes for Traction tends to produce axonotmesis with a relatively exten-
peripheral nerve injuries (see chapter 36). Seddon divided sive zone of injury. Acute compression generally produces
peripheral nerve injuries into three subtypes: neurapraxia, neurapraxia due to local contusion. The surrounding inflam-
axonotmesis, and neurotmesis.1 Neurapraxia refers to a con- matory response, however, can contribute to subsequent scar-
duction block in which axons remain in continuity. In its ring, chronic compression, and eventual axonal injury.
mildest form, temporary neural ischemia produces a reversible
physiologic conduction block. More severe forms result from Electrodiagnostic Studies. Electrodiagnostic studies are use-
focal demyelination at the site of injury. Axons remain ana- ful objective tests to classify nerve injuries and identify early stages
tomically intact but are unable to conduct across the injured of recovery. Testing consists of two components: nerve conduc-
segment. Prognosis for spontaneous recovery is typically tion studies (NCSs) and electromyography (EMG). NCSs measure
good, although with more significant injuries remyelination signal transmission along large myelinated axons, whereas EMG
may require several weeks. In the absence of secondary injury, measures spontaneous and induced electrical activity within target
full functional recovery can be expected within 2 to 3 months. muscles.
Axonotmesis refers to the loss of continuity of the axons With neurapraxic or demyelinating lesions, NCSs dem-
within a peripheral nerve; however, all layers of the con- onstrate a conduction block across the zone of injury. With
nective tissue architecture, including the endoneurial tubes, complete injuries, when the nerve is stimulated proximal to
remain intact. Wallerian degeneration, a programmed invo- the lesion, distal potentials are absent. With incomplete inju-
lution of axonal segments, occurs distal to the site of injury. ries, a characteristic feature of demyelination is slowing of
750
Chapter 74: Management of Nerve Injuries and Compressive Neuropathies of the Upper Extremity 751
conduction across the lesion. When stimulated below the site chronic nerve injuries presenting beyond the 12- to 18-month
of injury, however, conduction along the distal nerve segments window, tendon transfers should be considered.
remains normal. EMG demonstrates decreased voluntary Two common clinical scenarios deserve special mention.
motor unit action potentials. A defining feature of neura- Gunshot wounds are considered apart from other penetrat-
praxic lesions on EMG is that no fibrillations or denervation ing traumas. Most deficits are secondary to concussive effects
changes develop regardless of the time since injury. rather than direct laceration. The potential for spontaneous
With axonal injury, including axonotmesis and neurotme- recovery is favorable and a period of observation as with
sis, conduction both above and below the site of injury is dis- closed injuries is recommended. Nerve deficits occurring in
rupted due to axonal damage. Conduction abnormalities in association with fractures are managed primarily based on
the distal segment are not present acutely but develop over the the fracture. With closed fractures, 70% to 80% of nerve
first 1 to 2 weeks as axonal degeneration ensues. A character- deficits are neuropraxic and may be managed nonoperatively.
istic feature of axonal damage on NCS in cases of incomplete However, if internal fixation is indicated, nerve exploration
lesions is decreased amplitude of distal potentials with normal may be reasonably performed during fracture exposure. The
conduction velocity. EMG demonstrates denervation poten- incidence of nerve laceration increases with open fractures.
tials and fibrillations in affected muscles 3 to 4 weeks follow- Early nerve exploration at the time of wound debridement is
ing injury. Their presence identifies axonal injury but does not recommended. Definitive reconstruction should await fracture
discriminate between axonotmesis and neurotmesis lesions. repair and stable wound coverage.
Clinical Management. Initial treatment decisions are

based primarily upon injury mechanism and presumptive clas- COMPRESSIVE NEUROPATHIES OF
sification of the nerve lesion. Neurologic deficits in the con- THE UPPER LIMB
text of penetrating trauma, even if incomplete, are assumed
to represent neurotmesis injuries. Early surgical exploration Compressive neuropathies are among the most common clini-
is recommended. Primary repair is ideally performed within cal problems encountered in the upper limb. Each of the major
72 hours of injury. For sharp, clean lacerations with minimal peripheral nerves demonstrates a predilection for entrapment
contusion of the nerve ends, primary repair may be performed in specific anatomic regions. Although presentations vary
at the time of initial exploration. If significant crush or avul- based on the affected nerve and site of entrapment, the com-
sion is identified or in cases with unstable wounds, the nerve mon pathophysiologic pathway reflects the mechanical and
ends should be grossly approximated to prevent retraction. ischemic effects of chronic compression. In their early phases,
Definitive reconstruction should be delayed for 2 to 3 weeks compressive neuropathies resemble focal neurapraxias. With
to allow demarcation of the extent of nerve injury. Nerve short-term compressive pressures of 30 mm Hg, there is dis-
grafts or conduits are typically required to span the resultant ruption of intra-neural blood flow and loss of slow axonal
nerve gap. transport.3 This manifests clinically as temporary paresthesias
For closed injuries in which nerve continuity is uncertain, an and muscle weakness. Increased vessel permeability follow-
initial period of observation is recommended. Treatment deci- ing an episode of compression also causes intra-neural edema,
sions are based on the assumption that neurapraxic and axo- which leaves the nerve more susceptible to further insults.3
notmetic lesions will recover spontaneously and these lesions More prolonged compression affects the myelin sheath, lead-
are best treated nonoperatively. As early as 1 to 2 weeks following to focal demyelination beginning with large diameter sen-
ing injury, electrodiagnostic studies can distinguish neurapraxic sory and motor fibers. In their chronic forms, compressive
from axonal injuries. With neurapraxia, conduction distal to neuropathies are characterized by a mixture of demyelination
the site of injury remains intact, whereas with axonal injury, and axonal loss. It is thought that the inflammatory reaction
distal conduction is impaired due to axonal degeneration. to compressive episodes, in conjunction with chronic ischemia
Early studies may also determine whether a lesion is complete and impaired axonal transport, ultimately lead to progressive
or incomplete. The presence of even a small number of motor fibrosis and axonal damage. The critical pressure or duration
units under voluntary control defines an incomplete lesion. This of compression required to produce axonal injury remains
indicates that the nerve has not been completely transected and unknown.
that surgery is less likely to be required.
Electrodiagnostic studies are traditionally repeated 4 to
6 weeks following traumatic injury. EMG evidence of target
COMPRESSIVE NEUROPATHIES OF
muscle denervation identifies the presence of axonal injury. THE MEDIAN NERVE
However, the only way to differentiate axonotmesis from neu-
rotmesis injuries, aside from surgical exploration, is to moni- Carpal Tunnel Syndrome
tor the patient for signs of recovery. This critical distinction The carpal tunnel refers to the fibro-osseous canal bounded
relies on the return of motor unit potentials following axo- by the concave bony arch of the carpus and the transverse
nal regeneration, confirming the presence of an axonotmesis carpal ligament (TCL). Although the tunnel is open-ended
Hand
lesion. However, this is a retrospective diagnosis and inter- both proximally and distally, it behaves much like a closed
vention cannot be delayed indefinitely. There are a number of compartment physiologically. Contents of the carpal canal
temporal factors to consider in determining the optimal timing include the median nerve and tendons of the flexor digitorum
of intervention for non-recovering deficits. With neurapraxic superficialis (FDS) and flexor digitorum profundus (FDP), and
injuries, remyelination may require up to 8 to 12 weeks. With the flexor pollicis longus (FPL). The median nerve typically
axonotmesis injuries, axonal regeneration proceeds at a rate runs in a superficial and radial position (Figure 74.1). Near
of 1 mm/day under ideal conditions. Depending on the site of the distal aspect of the carpal tunnel, the median nerve divides
injury and distance to the nearest target muscle, evidence of into sensory branches to the thumb, index, middle, and radial
early re-innervation will often become apparent within 3 to ring fingers and the recurrent motor branch to the thenar mus-
6 months. However, a competing process occurs during this culature. Anatomic variations in the course of the recurrent
time that must also be considered. Irreversible atrophy grad- motor branch are classified as extraligamentous, subligamen-
ually occurs in denervated muscle (estimated rate of loss of tous, and transligamentous patterns, the latter being most
1% per week) such that significant motor recovery is unlikely vulnerable to injury during carpal tunnel release. The palmar
beyond 12 to 18 months. For this reason, if there is no clinical cutaneous nerve arises 5 cm proximal to the wrist crease.
or electrodiagnostic recovery evident by 3 to 6 months after It passes superficial to the TCL to supply the skin over the
injury, surgical exploration is generally recommended. For thenar eminence.

752 Part VIII: Hand
Recurrent
Ulnar motor
artery branch
and
Transverse
nerve PCN
carpal
Radial Ulnar nerve
ligament
Transverse artery
carpal
ligament
Volar carpal Median Median nerve

ligament nerve
A B
FIGURE 74.1. The median nerve in the carpal tunnel. (A) Note the superficial and radial position of the median nerve beneath the transverse car-
pal ligament. (B) The nearby ulnar neurovascular bundle passes superficial to the transverse carpal ligament as it courses through Guyon’s canal.
Carpal tunnel syndrome (CTS) represents the most the reference standard. The hallmark findings of compressive
common compressive neuropathy encountered clinically. neuropathies on NCSs are an increase in distal latency and a
Common comorbid conditions associated with increased decrease in conduction velocity. Although standards vary, dis-
risk of developing CTS include advanced age, female gen- tal motor latencies of greater than 4.5 ms and/or distal sensory
der, obesity, diabetes, and pregnancy. A variety of addi- latencies of more than 3.5 ms are generally considered diag-
tional etiologic conditions have been implicated, including nostic. A decrease in amplitude of distal potentials, indicative
hypothyroidism, rheumatologic and autoimmune diseases, of axonal loss, may be seen in more severe cases. EMG may
alcoholism, and renal failure. Compression may also result also demonstrate increased insertional activity, fibrillations,
from space-occupying lesions within the canal such as prolif- and denervation potentials in the thenar musculature with
erative tenosynovitis, hematoma, tumors, or ganglion cysts. advanced disease.
Displaced distal radius or carpal injuries may also diminish Treatment decisions are based upon the duration and severity
canal volume. Although CTS is often viewed as an occu- of symptoms, etiology, and patient preference. Nonsurgical mea-
pational disorder, a causative relationship underlying the sures include night splinting and corticosteroid injection. Both
commonly cited association with cumulative or repetitive are more likely to be successful in patients with mild or recent-
work activity such as keyboarding has not been objectively onset symptoms. Corticosteroid injection offers transient relief in
demonstrated. 80% of patients; however, only 20% are expected to be symp-
The history and physical examination are cornerstones tom free 1 year later.4 Injections may also be used diagnostically
for diagnosis. Patients classically report intermittent numb- when alternative etiologies are being considered. A favorable
ness and paresthesias in the radial digits. Symptoms may be response confirms the diagnosis and predicts successful outcome
exacerbated with activities involving prolonged wrist flexion with surgical release. Nonoperative measures are less likely to
or extension and are characteristically relieved by shaking the benefit patients with prolonged symptoms or advanced disease
hand. Nocturnal symptoms are considered a hallmark of CTS, with evidence of median nerve denervation. Surgical release
and their absence should invite suspicion for alternate causes. should be considered in these cases.
In more severe cases, numbness and/or paresthesias become Surgical release of the TCL is the most effective treatment
constant. Frequent dropping of objects and loss of coordina- for CTS.5 Release may be performed through either open or
tion in the hand may be reported and likely reflect the com- endoscopic approaches. Open release involves placement of
bination of thenar weakness and impaired sensibility in the a 2 to 4 cm incision in the base of the palm. The palmar fas-
radial digits. cia and TCL are incised longitudinally to expose the median
Examination may demonstrate decreased light touch sensa- nerve. Division is performed along the ulnar margin of the
tion in the median innervated digits. Objective threshold tests TCL to avoid injury to the motor branch. Release is carried
including Semmes-Weinstein monofilament testing are more distally to the superficial arch. Proximally, the deep ante-
sensitive to detect early sensory loss compared with innervation brachial fascia is divided for a variable distance above the
density tests such as two-point discrimination. With advanced wrist crease. Adjunctive procedures including epineurotomy,
disease, weakness and atrophy of the thenar musculature internal neurolysis, routine tenosynovectomy, and reconstruc-
develop. Several examination maneuvers have been described tion of the TCL have not been found to improve outcomes.
to aid in the diagnosis of CTS. Tinel’s nerve percussion test, Endoscopic techniques aim to minimize the problems of scar
Phalen’s wrist flexion test, and Durkan’s nerve compression tenderness, pillar pain, and prolonged recovery that may be
test are among the most common tests. Provocative tests should observed following open releases. Endoscopic procedures
reproduce paresthesias in the median nerve distribution. have been associated with shorter recovery time and a more
Electrodiagnostic studies remain the primary objective test rapid return to work.6 However, long-term outcomes are not
to diagnose CTS and are considered by many to represent substantially different from open decompression.

syndrome. Tenderness to palpation in the antecubital fossa
Pronator Syndrome and a Tinel sign over the course of the nerve in this region fur-
In the distal arm, the median nerve and brachial artery course ther differentiate pronator syndrome from CTS. The pronator
between the biceps and brachialis muscles. The median nerve compression test involves manually compressing the median
enters the forearm between the superficial humeral and deep nerve at the proximal aspect of the pronator muscle for 30
ulnar heads of the pronator teres (Figure 74.2). It then passes seconds. Other provocative tests include resisted forearm supi-
beneath the proximal arch of the FDS to travel between the nation, resisted forearm pronation with the elbow extended,
FDS and FDP muscles through the forearm. The anterior and resisted middle finger proximal interphalangeal flexion.
interosseous nerve (AIN) branches from the median nerve in Positive tests should reproduce paresthesias in the median
the antecubital fossa roughly 4 cm distal to the medial epicon- distribution. Electrodiagnostic tests are obtained primarily
dyle. The AIN typically arises from the radial aspect of the to exclude CTS or more proximal compression. However,
nerve and passes beneath both the deep head of the pronator abnormalities are present in only 30% to 50% of patients.
teres and the FDS arch to course along the interosseous mem- Nonoperative treatment measures are recommended. The
brane in the forearm. combination of rest, activity modification, anti-inflammatory
Proximal compressive neuropathies of the median nerve medication, and temporary splinting relieves symptoms in
are very uncommon relative to CTS. Pronator syndrome approximately 50% of patients. In refractory cases, release is
refers to a constellation of signs and symptoms resulting from performed through a curvilinear incision across the antecubital
compression of the median nerve around the elbow. This syn- fossa. All potential sites of compression from the ligament of
drome was initially attributed to entrapment by the pronator Struthers through the pronator and FDS arcades are released.
teres muscle. Several additional potential sites of compres- The AIN is also identified and decompressed through its pas-
sion have been identified, including the ligament of Struthers sage beneath the deep head of the pronator and FDS arch.
(a fibrous band extending from an anomalous supracondylar
process of the distal humerus to the medial epicondyle), the
proximal fibrous arch of the pronator teres, intramuscular
Anterior Interosseous Nerve Syndrome
aponeurotic bands within the pronator, the proximal arch of The AIN innervates the FPL, FDP to the index and middle
the FDS, and by the leading edge of the bicipital aponeurosis.7 fingers, and pronator quadratus. Patients with AIN syndrome
Clinically, patients with pronator syndrome present with present with loss of motor function in these muscle groups. FPL
aching pain in the proximal forearm and antecubital fossa weakness and difficulty with pinch are often the most notice-
accompanied by numbness and paresthesias radiating into the able. Pain in the antecubital fossa may be present. However,
radial digits. These sensory complaints may be mistaken for because the AIN is a motor nerve, the paresthesias and distal
CTS. Unlike CTS, however, symptoms primarily occur during sensory loss typical of carpal tunnel and pronator syndrome
activity and are rare at night. Distal sensibility may be dimin- are absent. Patients have difficulty flexing the thumb interpha-
ished in the radial digits and over the thenar eminence in the langeal (IP) joint and index finger distal interphalangeal (DIP)
palmar cutaneous nerve distribution. The latter is spared with joint when asked to make an “OK” sign. Weakness of the
CTS. Characteristically, motor weakness is absent in pronator long finger DIP joint flexion is typically less severe than in the
index finger. Pronator quadratus weakness will not be appar-
ent if tested with the elbow extended due to the strength of the
pronator teres but may be unmasked if tested with the elbow
in full flexion to relax the pronator teres.
Brachial Debate continues as to whether this rare entity represents
artery a compression neuropathy or a peripheral neuritis akin to
Biceps brachii Parsonage-Turner syndrome. The latter should be considered
Median if symptom onset was sudden and accompanied by severe
nerve antecedent pain. Attritional ruptures of the FPL and FDP ten-
dons as seen with rheumatoid arthritis may also mimic the
motor deficits of AIN syndrome. The presence of intact thumb
Bicipital
aponeurosis
and index finger tenodesis with wrist motion confirms tendon
(cut) integrity.
Pronator
Most patients with AIN syndrome improve without sur-
teres (cut)
gical intervention.8 An extended period of observation (3 to
6 months) has been recommended given this favorable natural
Radial artery history. The surgical approach for patients who have not dem-
onstrated improvement during this period is similar to that
described for pronator syndrome. The median nerve is identi-
fied proximally, and all potential constrictive sites across both
Hand
the median nerve and AIN are released through the pronator
muscle and FDS arcade.
FDS arch
COMPRESSIVE NEUROPATHIES OF
THE ULNAR NERVE
Cubital Tunnel Syndrome
The ulnar nerve is a terminal branch of the medial cord of
the brachial plexus. In the proximal arm, the nerve courses
medial to the axillary artery in the anterior compartment.
At the level of the mid-humerus, the nerve pierces the medial
FIGURE 74.2. The course of the median nerve through the ante-
cubital fossa. Common sites of compression include the bicipital intramuscular septum and enters the posterior compartment.
aponeurosis, pronator teres, and fibrous proximal arch of the flexor It then passes posterior to the medial epicondyle of the distal
digitorum superficialis (FDS). humerus and enters the cubital tunnel, bounded by the medial
epicondyle, olecranon process of the proximal ulna, and the

754 Part VIII: Hand
overlying arcuate ligament (Osborne’s ligament). The nerve fingers. Symptoms are exacerbated by prolonged elbow flex-
then enters the forearm between the two heads of the flexor ion or direct pressure on the posteromedial elbow. Because the
carpi ulnaris (FCU) and courses distally between the FCU and ulnar nerve has a relatively high proportion of motor fibers,
FDP muscle bellies. motor dysfunction will predominate in more severe cases. The
Ulnar nerve compression at the elbow is the second most hand intrinsic muscles tend to be most affected. Early fatigue
frequently encountered compressive neuropathy in the upper with repetitive activities, weakness of grip and pinch, and loss
limb. Although multiple potential sites of compression across of dexterity may be noted.
the elbow have been identified, the cubital tunnel proper is Examination characteristically reveals diminished light
the most common. The floor of this fibro-osseous tunnel is touch sensation in the small and ulnar ring fingers. Sensory
formed by the medial epicondyle of the humerus and the olec- loss over the dorsoulnar hand in the distribution of the dorsal
ranon process of the ulna. The roof is formed by Osborne’s sensory branch of the ulnar nerve distinguishes ulnar nerve
ligament. Distally, this ligament is confluent with the proxi- compression at the elbow versus the wrist. The bulk and
mal aponeurotic arcade spanning the two heads of the FCU strength of the first dorsal interosseous should be compared
origin. Within this tunnel, the ulnar nerve is subject to both with the contralateral side. Wartenberg sign, an abducted
longitudinal traction and direct compression. Due to the posture of the small finger most notable with finger exten-
course of the nerve posterior to the axis of elbow motion, sion, may be an early presenting sign of motor weakness.
the nerve itself stretches 5 mm with full elbow flexion.9 The With more advanced disease, weakness of thumb pinch (due
shape of the tunnel also changes dramatically with elbow to both adductor pollicis and first dorsal interosseous dys-
motion. It transitions from a round contour in elbow exten- function) may result in Froment’s sign (flexion of the thumb
sion to a flattened triangle with elbow flexion, reducing its IP joint) or Jeanne’s sign (hyperextension of the thumb meta-
cross-sectional area by over 50%.9 carpophalangeal [MP] joint) with attempted forceful pinch.
Multiple additional sites of compression of the nerve across Extrinsic weakness may be apparent in the FDP to the small
the medial elbow have been identified and must be considered finger, though FCU weakness is seldom encountered. With
during surgical release (Figure 74.3). The most proximal site chronic severe compression, weakness and atrophy of the
of potential compression is the arcade of Struthers, located on intrinsic musculature may produce clawing of the ring and
average 8 cm proximal to the medial epicondyle. This arcade small fingers.
is formed by an aponeurotic band extending obliquely from The elbow is assessed for tenderness, deformity, crepitus,
the medial head of the triceps fascia to the medial intermuscu- or loss of motion suggestive of bony or articular pathology.
lar septum. Hypertrophy of the medial triceps may exacerbate Instability of the nerve, defined as either subluxation or
compression in this region. The intermuscular septum thickens frank dislocation of the nerve from the epicondylar groove
and flares distally as it inserts onto the medial epicondyle and with elbow flexion, is assessed. Provocative tests include the
may be a site of potential compression. Most commonly, this presence of a Tinel sign over the course of the ulnar nerve
is iatrogenic due to kinking of the nerve over its edge follow- and the elbow flexion test in which the elbow is placed in
ing anterior transposition. Compression at the medial epicon- maximal flexion for up to 60 seconds. A combined elbow
dyle or retrocondylar groove may occur as a consequence of flexion-compression test, in which direct pressure is applied
bony trauma, elbow arthritis, or valgus deformity. Instability to the cubital tunnel proper during elbow flexion, enhances
of the ulnar nerve allowing subluxation out of the groove or sensitivity of this maneuver. These maneuvers are considered
frank dislocation over the epicondyle with elbow flexion may positive if they reproduce paresthesias in the ulnar distribu-
also cause neuritis. The most distal site of potential compres- tion. These provocative tests may cause paresthesias in 10%
sion occurs 4 to 5 cm distal to the medial epicondyle as the to 15% of normal individuals, and correlation with clinical
ulnar nerve penetrates the deep flexor-pronator aponeurosis symptoms is necessary.
to course between the FDP and FDS muscles. Electrodiagnostic studies are helpful to confirm the diag-
Patients with cubital tunnel syndrome present with inter- nosis when symptoms or clinical findings are equivocal or
mittent numbness and paresthesias in the small and ring if the site of compression is uncertain. Results are typically
reported as conduction velocities rather than distal latencies
as are standard in carpal tunnel testing. Motor conduction
velocity of less than 50 m/second represents absolute slow-
Triceps ing. Relative slowing by more than 10 m/second across the
Brachialis elbow compared with conduction through the forearm is also
considered diagnostic. A drop in amplitude of compound
Biceps
muscle action potentials in the hypothenar and first dorsal
Flexor- Flexor carpi interosseous muscles with stimulation of the nerve indicates
pronator ulnaris axonal damage. EMG studies may demonstrate fibrillations,
group denervation potentials, and increased insertional activity in
the ulnar innervated intrinsics with advanced disease.
For the majority of patients with mild, intermittent symp-
toms, nonoperative measures are appropriate. In many
Arcade of cases, avoiding provocative activities such as prolonged
Struthers elbow flexion or resting the elbow on firm surfaces relieves
symptoms. Night-time splinting of the elbow in a position
Medial
intermuscular
of relative extension is commonly recommended. As many
Deep as 50% of cases in which symptoms have been present for
septum flexor-pronator
Medial Ulnar 6 months or less will improve spontaneously.10 Surgical indi-
Osborne’s apneurosis
epicondyle nerve cations are based on the duration and severity of compression.
ligament
In patients without objective muscle weakness, nonoperative
management for at least 6 to 12 weeks is attempted. Surgery
FIGURE 74.3. The course of the ulnar nerve across the elbow. Note may be considered in patients with refractory symptoms. The
the five common sites of compression: arcade of Struthers, medial development of weakness or atrophy of the intrinsic muscula-
intermuscular septum, medial epicondyle, Osborne’s ligament, and ture should prompt surgical release.
deep flexor-pronator aponeurosis. A variety of procedures have been advocated includ-
ing simple decompression (in situ decompression), medial

epicondylectomy, and decompression with anterior subcuta- Ulnar nerve Transverse
neous, intramuscular, or submuscular transposition. Choice Volar carpal carpal
and artery
of surgical technique remains an intensely debated subject. ligament ligament Median
In situ decompression involves incising Osborne’s ligament nerve
Pisiform
and releasing the fascial tunnel between the two heads of
the FCU. The nerve is retained in its native bed following
release. Advantages of this technique include limited dissec-
tion of the nerve and preservation of the surrounding vascu-
lar network. With the refinement of endoscopic techniques
in recent years, in situ decompression has gained popularity.
Relative contraindications include nerve instability or dis-
torted tunnel anatomy such as with bony trauma and elbow
arthritis.
Medial epicondylectomy combines decompression of the
ulnar nerve with resection of the bony prominence of the FIGURE 74.4. Schematic cross section of the wrist through Guyon’s
medial epicondyle. Often described as a “mini-transposition” canal. Note the superficial position of the ulnar neurovascular bundle
this technique allows the nerve to shift anteriorly to a path of relative to the carpal tunnel. The transverse carpal ligament forms the
least resistance while avoiding the more extensive dissection roof of the carpal tunnel and the floor of Guyon’s canal.
required for formal transposition. The medial collateral liga-
ment of the elbow originates from the inferior margin of the
epicondyle and may be injured with excessive bony resection,
potentially resulting in elbow instability.
Anterior transposition addresses both direct compression with direct nerve injury, hook of hamate fractures, and throm-
and the longitudinal traction on the nerve that occurs with bosis or pseudoaneurysms of the ulnar artery.
elbow flexion. All potential sites of compression are released Presenting symptoms depend on the zone of compression
from the arcade of Struthers through the deep flexor-pronator within Guyon’s canal. Lesions in zone I typically cause both
aponeurosis. The nerve is moved anterior to the medial epi- motor and sensory symptoms. Compression in zone II results
condyle to run in a subcutaneous, intramuscular, or submus- in primarily motor symptoms and within zone III results in
cular position relative to the flexor-pronator musculature. By primarily sensory symptoms. When sensory involvement is
transposing the nerve anterior to the axis of motion, tension present, a Tinel sign over the affected region will be present.
is decreased with elbow flexion. Disadvantages include more Unlike cubital tunnel syndrome, sensation is spared in the dis-
extensive surgical dissection and potential compromise of the tribution of the dorsal sensory branch of the ulnar nerve due
nerve’s blood supply. Submuscular transposition also requires to its takeoff proximal to Guyon canal. Motor involvement
release and repair of the flexor-pronator muscular origin. mimics that of cubital tunnel syndrome, with weakness of the
Despite the frequency of cubital tunnel syndrome, there intrinsic musculature. Examination should assess for tender-
remains considerable controversy regarding choice of surgical ness over the hook of the hamate, an abnormal Allen test, or
technique. A common theme in the literature is that results are a pulsatile mass over the ulnar artery. Electrodiagnostic tests
influenced heavily by the duration and severity of compres- help distinguish ulnar tunnel syndrome from more proximal
sion. A review of historical series found that all techniques compression. Imaging studies include plain radiographs or
provide similar favorable outcomes for patients with mild computed tomography to assess for the hook of hamate frac-
compression, but anterior submuscular transposition yielded ture and magnetic resonance imaging (MRI) to assess for soft
the most satisfactory results with moderate or severe com- tissue anomalies. Ulnar artery thrombosis or pseudoaneurysm
pression.10 More recent studies, however, suggest that in situ may be confirmed with Duplex ultrasound or angiography.
decompression provides similar if not improved outcomes Nonoperative treatment should be considered in the absence
compared to transposition with fewer complications.11 of an identifiable cause of compression. Provocative activi-
ties should be identified and avoided. Wrist splints may also
be helpful. Decompression is indicated in patients with refrac-
Ulnar Tunnel Syndrome tory symptoms or space-occupying lesions. The ulnar nerve
At the level of the wrist, the ulnar nerve and artery enter the and artery are typically identified proximal to the wrist crease.
ulnar tunnel, also referred to as Guyon’s canal (Figure 74.1). The volar carpal ligament is divided over neurovascular bundle
The roof of this canal is formed by the volar carpal ligament and the bifurcation of the nerve is identified. The motor branch
and the floor by the TCL (Figure 74.4). The ulnar border is arises from the deep surface of the nerve and passes beneath the
formed by the pisiform and the radial border by the hook of the proximal arcade of the hypothenar musculature. This fibrous
hamate. Within the canal, the nerve divides into a superficial arch is divided and the floor of the canal around the hook of
sensory branch, supplying the palmar surfaces of the small and hamate inspected for ganglions or other masses. The ulnar
artery is assessed for thrombosis or aneurysm. If present, liga-
Hand
ring fingers, and a deep motor branch supplying the intrinsic

musculature of the hand. The ulnar tunnel is typically divided tion or graft reconstruction is performed depending on the sta-
into three zones based on this branching. Zone I is located tus of collateral circulation.
proximal to the bifurcation. Zone II follows the deep motor
branch as it dives deep beneath the fibrous arch of the hypothe- COMPRESSIVE NEUROPATHIES OF
nar muscles and around the hook of the hamate. Zone I follows
the superficial sensory branch as it courses along the fascia of
THE RADIAL NERVE
the hypothenar musculature. The radial nerve begins as a terminal branch of the posterior
Compression of the ulnar nerve at the wrist is much less cord of the brachial plexus. The nerve passes from medial to lat-
frequent than at the elbow. Ulnar tunnel syndrome most com- eral along the spiral groove of the posterior humerus. The nerve
monly results from either direct trauma or the presence of pierces the lateral intramuscular septum 10 to 12 cm proximal
a space-occupying lesion. The latter are identified in almost to the lateral epicondyle and travels between the brachialis and
half of the cases and include ganglia, anomalous muscle bel- brachioradialis muscles. At the elbow, the nerve lies just anterior
lies, and benign tumors such as lipomas and neurilemmomas. to the radiocapitellar joint. In the antecubital fossa, the radial
Repetitive blunt trauma to the ulnar aspect of the palm, the nerve divides into the posterior interosseous (PIN) and superficial
so-called hypothenar hammer syndrome, has been associated radial sensory (RSN) nerves. The RSN continues distally under

756 Part VIII: Hand
the cover of the brachioradialis muscle. The PIN, however, dives There are two distinct conditions that may result from
deep into the radial tunnel just distal to the bifurcation. It courses compression of the PIN through the radial tunnel—radial tun-
beneath the proximal fibrous edge of the supinator as it wraps nel syndrome (RTS) and PIN syndrome. PIN syndrome refers
around the proximal radius to enter the posterior compartment to a loss of motor function only without pain or sensory loss,
of the forearm (Figure 74.5). As it exits the radial tunnel, the whereas RTS refers to a pain-only syndrome without motor
PIN divides into multiple motor branches to supply the extensor loss. Why two divergent syndromes may result from compres-
compartment musculature.

sion of the same nerve in the same anatomic region remains a
subject of debate.
Compression Syndromes of the Posterior
Interosseous Nerve Radial Tunnel Syndrome. RTS is characterized by pain
in the proximal/lateral forearm. Discomfort worsens with
The radial tunnel refers to the anatomic surroundings of the repetitive activity. Unlike most compression neuropathies,
PIN as it courses from the anterior to posterior compartment distal motor function and sensory function remain intact.
of the proximal forearm. Five potential sites of compression This disorder shares many features of tennis elbow and dis-
of the PIN within this tunnel are described. From proximal tinguishing between the two disorders may be difficult. The
to distal, these sites include (1) fibrous or compressive bands characteristic pain and tenderness of RTS is located beneath
anterior to the radiocapitellar joint between the brachialis and the mobile wad 3 to 4 cm distal to that of lateral epicondy-
brachioradialis, (2) transverse crossing radial recurrent vessels litis. Provocative exam maneuvers include pain with resisted
at the level of the radial neck (the vascular leash of Henry), forearm supination and pain with resisted middle finger MP
(3) fibrous bands along the proximal edge of the extensor carpi joint extension. Electrodiagnostic studies are typically unre-
radialis brevis (ECRB), (4) the fibrous arcade formed by the vealing in the absence of PIN syndrome. Because RTS is
leading edge of the supinator muscle (the arcade of Fröhse), largely a clinical diagnosis without consistent objective find-
and (5) the distal fibrous edge of the supinator fascia. The ings, it remains a controversial diagnosis. Diagnostic injection
arcade of Fröhse is most commonly identified as the primary of short-acting local anesthetic into the radial tunnel remains
site of compression. This fibrous arch lies roughly 1 cm distal a useful test. A properly placed injection should produce
to the leading edge of the ECRB and is formed by a thickened a temporary PIN palsy. The relief of pain in conjunction with
aponeurotic band extending across the proximal edge of the PIN palsy confirms RTS.
superficial (humeral) head of the supinator muscle. Nonoperative treatment is the standard for RTS and
includes activity modification, splinting, stretching, and anti-
inflammatory medications. Patients must avoid provocative
activities involving prolonged elbow extension, forearm pro-
nation, and wrist flexion. Little has been reported regarding
the natural history of RTS or the efficacy of nonsurgical treat-
ment. At least 3 months of nonoperative management is rec-
ommended prior to surgical intervention.
Radial nerve Decompression may be performed through either volar
or dorsal exposures. All potential sites of compression are
addressed. The volar approach utilizes the interval between
the brachioradialis and FCR in the antecubital fossa. The dor-
sal approach uses the interval between the extensor carpi radi-
alis longus (ECRL) and ECRB or between the brachioradialis
and ECRL. The volar approach provides improved access to
the proximal sites of compression; however, the distal aspect
of the supinator may be difficult to reach. Conversely, the dor-
Brachioradialis sal exposure provides excellent access to the PIN through the
supinator muscle; however, access to the proximal most sites
Extensor carpi of compression may be limited. A combined approach work-
radialis longus ing along both margins of the brachioradialis through a single
Arcade of incision may also be used.
Frohse
Superficial Posterior Interosseous Syndrome. The PIN is the motor
radial nerve nerve to the extensor musculature of the dorsal forearm. PIN
syndrome results from a compressive lesion causing motor
weakness. This functional loss is painless, and sensory dis-
Supinator turbances are absent. Patients present with difficulty extend-
ing the fingers and thumb. Wrist extension is spared due to
Posterior
Extensor carpi more proximal innervation of the ECRL from the radial nerve
interosseous
nerve radialis brevis proper, though radial deviation with wrist extension may be
noted due to ECRB and extensor carpi ulnaris weakness. The
classic differential diagnosis in a patient presenting with an
inability to extend the digits and/or thumb includes attritional
extensor tendon ruptures as seen in rheumatoid arthritis. The
presence of intact tenodesis (passive MP joint extension with
wrist flexion) confirms tendon integrity. Ruptures of the sagit-
tal bands of the extensor mechanism with subluxation of the
FIGURE 74.5. Dorsal approach to the posterior interosseous nerve extensor tendons must also be considered.
(PIN) through the radial tunnel. The course of the PIN through the In contrast to radial tunnel syndrome, electrodiagnostic
supinator is exposed deep to interval between the extensor digitorum
abnormalities, including fibrillations and denervation poten-
communis (EDC) and ECRB muscles in the proximal forearm. Note
the arcade of Fröhse at the proximal margin of the supinator, a com- tials in the extensor musculature, are commonly identified.
mon site of PIN compression. ECRL, extensor carpi radialis longus. Imaging studies should also be obtained, including either
ultrasound or MRI, as compressive soft tissue masses are

often identified. Management in the absence of a space-occu- management is recommended. Because external compression
pying lesion begins with nonoperative measures for a period is a common inciting and/or exacerbating factor, removal of
of up to 3 months. Supervised therapy and intermittent exten- any constrictive wear is essential. Corticosteroid injection may
sion splinting of the MP joints are helpful to maintain pas- be attempted although efficacy is unpredictable. In refractory
sive mobility. If no recovery is evident by 3 months, surgical cases, surgical decompression may be achieved by division of
decompression is recommended. The surgical technique fol- the fibrous dorsal margin of the brachioradialis tendon.
lows that of radial tunnel syndrome. Tendon transfers may
be considered in chronic cases or those who fail to improve
following decompression. References
1. Seddon HJ. A classification of nerve injuries. Br Med J. 1942;2:237-239.
Wartenberg Syndrome. The superficial radial nerve 2. Sunderland S. A classification of peripheral nerve injuries producing loss of
leaves the cover of the brachioradialis in the distal forearm function. Brain. 1951;74:491-516.
3. Rydevik B, Lundborg G, Bagge U. Effects of graded compression on intra-
roughly 9 cm above the radial styloid. It passes through neural blood blow. An in vivo study on rabbit tibial nerve. J Hand Surg Am.
a narrow interval between the ECRL and brachioradialis 1981;6:3-12.
tendons, as it enters the subcutaneous plane. Although the 4. Gelberman RH, Aronson D, Weisman MH. Carpal-tunnel syndrome.
RSN may be compressed at any point along its course, it is Results of a prospective trial of steroid injection and splinting. J Bone Joint
Surg Am. 1980;62:1181-1184.
most vulnerable as it passes along the sharp dorsal border 5. Hui AC, Wong S, Leung CH, et al. A randomized controlled trial of surgery
of the brachioradialis tendon. Trauma is a common incit- vs steroid injection for carpal tunnel syndrome. Neurology. 2005;64:
ing factor for RSN compression. Direct blows, handcuffs, 2074-2078.
or tight wristbands have been implicated. Along its sub- 6. Trumble TE, Diao E, Abrams RA, Gilbert-Anderson MM. Single-portal
endoscopic carpal tunnel release compared with open release: a prospective,
cutaneous course, the RSN is also particularly sensitive to randomized trial. J Bone Joint Surg Am. 2002;84-A:1107-1115.
injury from surgical dissection or percutaneous hardware. 7. Johnson RK, Spinner M, Shrewsbury MM. Median nerve entrapment syn-
Compression due to scarring around the nerve may contrib- drome in the proximal forearm. J Hand Surg Am. 1979;4:48-51.
ute to refractory symptoms. Patients typically present with 8. Miller-Breslow A, Terrono A, Millender LH. Nonoperative treatment of
anterior interosseous nerve paralysis. J Hand Surg Am. 1990;15:493-496.
painful dysesthesias along the dorsum of the hand radiating 9. Apfelberg DB, Larson SJ. Dynamic anatomy of the ulnar nerve at the elbow.
into the thumb index and middle fingers. A Tinel sign local- Plast Reconstr Surg. 1973;51:79-81.
izes the site of c ompression. Because the RSN is a purely 10. Dellon AL. Review of treatment results for ulnar nerve entrapment at the
sensory nerve, any motor deficits should draw attention to elbow. J Hand Surg Am. 1989;14:688-700.
11. Zlowodzki M, Chan S, Bhandari M, Kalliainen L, Schubert W. Anterior
more proximal sites of compression. transposition compared with simple decompression for treatment of cubital
Spontaneous resolution of symptoms is common with tunnel syndrome. A meta-analysis of randomized, controlled trials. J Bone
Wartenberg syndrome and an extended course of nonoperative Joint Surg Am. 2007;89:2591-2598.
Hand

Chapter 75 n Management of Hand
Fractures
MATTHEW S.S. CHOI AND JAMES CHANG
Irreducible fractures are candidates for open reduction

Introduction and internal fixation (ORIF). Even when performed with
Fractures of the metacarpals and phalanges are frequent inju- precise technique, a surgical procedure creates additional
ries, representing 41% of all upper extremity fractures in the trauma to the damaged area; therefore, the surgeon must care-
United States.1 Each patient and fracture is unique, but com- fully ascertain if an indication for operative treatment exists:
mon principles apply. The goals of hand fracture treatment malrotation, instability, or multiple contiguous fractures.
are restoration of articular congruity, reduction of malrotation Furthermore, if ORIF will ultimately speed up motion and
and angulation, maintenance of reduction with minimal surgi- recovery, then an operative procedure may be preferable.2
cal intervention, and rapid mobilization. This chapter focuses For open fractures, the wound is irrigated and debrided
on the most common types of hand fractures with an empha- urgently in the operating room. The fracture is treated by
sis on the principles related to optimal fracture treatment. internal fixation or Kirschner wire (K-wire) fixation during
the same session if the wounds are clean. Soft tissue defects
are reconstructed prior to or at the time as definitive fracture
Focused Examination of treatment. Most skin defects can be closed with local tissue.
the Hand The dorsum of the fingers requires special consideration. Due
Physical examination of the patient with a hand fracture fol- to its thin soft tissue cover, this area is vulnerable to full-
lows a thorough history. The type of trauma provides valuable thickness skin loss. Coverage with local flaps, however, is lim-
information. When inspecting the injured hand, the contralat- ited because of the shortage of adjacent tissue. In these cases,
eral hand serves as an excellent reference. Swelling, tenderness,
or open wounds are assessed. Gentle palpation locates tender
points. Circulation and sensation of the hand and the integrity
of tendons and ligaments are assessed. The patient is asked to
maximally extend and flex the fingers to detect malalignment
or rotational changes of the digits (Figure 75.1). It may be use-
ful to block the fracture site with local anesthesia to facilitate
motion, which may otherwise be impossible due to pain.
In the presence of an open fracture, the wound is inspected
after cleansing and disinfection of the hand. Deep probing of
the fracture through the wound in an emergency setting is not
recommended, as this may propagate bacterial contamination
from the skin edges into the fracture site.
Plain radiographs in three planes—posteroanterior, lateral,
and oblique—are obtained. It is of great importance that pro-
jections are accurately directed with the central beam aimed
at the area of interest. Special views will be discussed as indi-
vidual fractures are presented below.
Principles of Fracture
Treatment
The majority of closed hand fractures can be effectively
treated by closed reduction and splinting. Fractures can be
identified as transverse, oblique, or spiral. Each fracture has
its own “personality,” depending on the time from injury to
presentation, the fracture pattern, the amount of cortical ver-
sus cancellous bone at the fracture site, and the muscle/ten-
don forces acting on the fractured parts. Stable, non-displaced
fractures can usually be treated by splinting and/or buddy tap-
ing (taping to the adjacent digit) alone. Initially unstable frac-
tures may be reduced, converting them to a stable position for
splinting. If the reduction is not stable in post-reduction radio-
graphs, then the position should be secured by percutaneous
pinning or other means of fixation (Figure 75.2).
Once stabilized, the patient is encouraged to move all
uninvolved digits and to elevate the hand to minimize edema.
A follow-up radiograph is obtained after 7 to 10 days to check
alignment and to rule out displacement. Metacarpal and pha- FIGURE 75.1. In this sculpture by Auguste Rodin, the long finger
langeal fractures usually require 3 to 4 weeks for clinical union. scissors over the ring finger while all the other fingers correctly point
Clinical union, which is defined as a state of stability and pain- toward the scaphoid tubercle.
lessness, may precede radiographic evidence of bone healing.
758
Chapter 75: Management of Hand Fractures 759
Algorithm for Fracture Treatment Table 75.1
Practical Tips for Optimal K-Wire Placement
Fracture
1. Use fluoroscopy for proper placement.
2. View the operative field without surgical loupes to
assess proper anteroposterior and lateral orientation.
(Surgical loupes are helpful for delicate dissection, but for
Closed Open K-wire application, the reduced field can lead to spatial
disorientation.)
3. Gain a “toehold” onto the bone before drilling. Even
though the soft tissue envelope of the hand is thin, the tip
Wound closure of the K-wire can easily be displaced when drilling before it
reaches its actual starting point on the bone. Therefore, it is
important to first drill through the skin until the K-wire tip
can be anchored at the desired site on the bone cortex.
4. Direct passage of the pin precisely. Once the wire has made
Undisplaced Displaced a track in the bone, the direction of the K-wire cannot be
readjusted.
In order to measure the length of wire advancement or retrieval, place
Closed the driver head of the drill at the level of the skin to use the skin as a
reduction reference point.
compressive force. K-wires of 0.035 or 0.045 inch diameter

are driven across the fracture line. Care is taken not to posi-
Stable Unstable tion the wire ends directly underneath a tendon. A 24G or
26G monofilament steel wire is guided in a figure of eight
fashion and tightened dorsally, counteracting the natural pull
of the flexor tendons. This technique provides adequate fixa-
K-wire tion for early motion (Figure 75.3).
ORIF
FIGURE 75.2. Algorithm for fracture treatment. K-wire, Kirschner

Interosseous Wiring
wire; ORIF, open reduction and internal fixation. The 90° to 90° interosseous wire fixation can also provide sta-
bility and compression with minimal soft tissue dissection. It is
mainly used for transverse fractures of the phalanges, for joint
island flaps from the metacarpal skin that can reach the digi- fusion, and for osteosynthesis in replantation. The technique
tal area such as reversed metacarpal artery flaps can be used.3 requires 0.045 inch K-wires, an 18G needle, and 24G or 26G
Distant or free flaps are rarely needed. Adequate soft tissue dental wire. Drill holes are made using a 0.045 inch K-wire
cover is essential for proper bone healing. Prophylactic intra- through both bone fragments, dorsal to palmar, and radial
venous antibiotics are administered.4 There is evidence that a to ulnar. An 18G needle is inserted through the drill holes to
single dose of intravenous antibiotic can reduce the incidence serve as a temporary guide for the insertion of a 24G or 26G
of infection in open fractures.5 Antibiotic administration is dental wire. After circumferential engagement of the wire, it
continued for up to 72 hours in type II injuries according to is tightened carefully to avoid wire breakage (Figure 75.4).
the modified Gustilo classification by Duncan et al.4 Alternatively, instead of using interosseous wires in antero-
posterior and lateral planes, both loops can be positioned in a
dorsal to volar direction.
Techniques of Bone Fixation
K-Wires (Kirschner Wires)
K-wires are the most versatile and the most frequently used
fixation method. To minimize trauma, the wires can be intro-
duced percutaneously under fluoroscopic guidance after
Hand
closed reduction of the fracture. If closed reduction is not

possible, the fracture can be reduced via an open approach
and then stabilized with K-wires. One K-wire alone cannot
provide rotational stability; therefore, at least two wires in
different planes are necessary to prevent rotation. K-wires do
not add a compressive component on the fracture. The dis-
advantages of this technique are lack of rigidity, possible pin
loosening, pin tract infection, and the necessity for additional
immobilization (Table 75.1).
Tension Band Wiring

The principle of this technique is to maintain the alignment
of the fracture fragments with K-wires and to apply inter- FIGURE 75.3. Tension band wiring: K-wires provide stabilization
fragmentary compression with wire loops around the K-wire. and wire loops exert compression across the fracture line.
The forces of the strong flexor tendons also contribute to the

760 Part VIII: Hand
A
A
B
FIGURE 75.5. Intra medullary fixation of a metacarpal fracture
B with anterograde insertion of prebent K-wires. A. During placement.
FIGURE 75.4. Interosseous wiring: A. Two-wire loops at 90° angles B. Wires are trimmed after placement.
to each other (90° to 90°) or (B) parallel wires provide both stabiliza-
tion and compression.
Compression Screws
Compression can be applied between the fracture fragments
using the lag screw principle. This is done by using screws with
Intramedullary Fixation a small length of thread at the tip and a smooth shank between
The use of intramedullary fixation may be suitable for trans- the threaded portion and the tip. Fully threaded screws can
verse fractures. Steinmann pins or multiple K-wires are used also act as lag screws if the proximal cortex is over-drilled
(Figure 75.5).6 The devices are completely intraosseous and so that the proximal hole acts as a glide hole (Figure 75.6).
their removal is not necessary. Potential disadvantages are Compression of two bone fragments with lag screws can be
rotational instability and pin migration. They are difficult to applied in long oblique and spiral fractures, where the frac-
apply in spiral or long oblique fractures. ture length is at least twice the bone width. Proper holding of
A B
D
C
E F
FIGURE 75.6. Lag screw principle (compression screw): A. Drilling of hole across both fragments. B. Countersinking. C. Screw length determi-
nation. D. Drilling of glide hole with larger drill bit. E. Tightening the lag screw. F. Two or three lag screws assure stability.

the accurately reduced fragments with appropriate clamps is with severe soft tissue damage and/or contamination may be
essential for successful lag screw osteosynthesis. best treated by external fixation. The external fixator bridges
across the fracture, thus stabilizing the bone fragments and
Plate Fixation maintaining length until soft tissue healing occurs. As the
manipulation of the fracture site is minimal, preservation of
The main benefits of osteosynthesis with plates and screws
the vascular supply is possible. The high stability of external
are rigid fixation and maintenance of bone length. The tech-
fixator systems permits early mobilization.
nique is indicated in metacarpal fractures, especially with
multiple fractures, and for the reconstruction of malunion
and nonunion. Compression plates are designed to provide Metacarpal Fractures in
compression across the fracture line. Tightening the screw in
an eccentrically placed drill hole creates a force vector in the
the Fingers
longitudinal direction. The screw head progressively pulls Metacarpal Neck Fractures
the plate along with already fixed fracture portion toward
the other fragment (Figure 75.7). Due to the need for exten- The most common location of metacarpal fractures is the
sive dissection, plate fixation is associated with a higher rate neck. These fractures are referred to as boxer’s fractures
of extensor tendon adhesion formation, often necessitating because they often result from a fist striking an unyield-
tenolysis. Despite the development of thinner plates, some ing target, quite often a human face or a wall. They occur
bulkiness remains and plates may require removal. most frequently in the fourth and fifth metacarpals. Due
to the pull of the intrinsic muscles, metacarpal neck frac-
tures are angulated with their apex dorsally (Figure 75.8).
External Fixation For closed reduction, proper anesthesia is very helpful. An
External fixation is used in complex fractures where anatomic ulnar nerve block at the wrist in addition to fracture site
reconstruction is not feasible. For example, highly commi- anesthesia facilitates fracture manipulation by paralyz-
nuted fractures with bone loss, gunshot wounds, and fractures ing the intrinsic muscles. When reducing metacarpal neck
fractures, a modification of the Jahss maneuver is applied
(Figure 75.9). With the metacarpophalangeal joint of the
fractured digit flexed at 90°, the middle phalanx is pressed
dorsally with one hand. At the same time, the other hand
creates counter pressure by pushing the metacarpal body
volarly. The middle phalanx is used as a crank to reduce the
displaced metacarpal head. Flexion of the interphalangeal
joints as recommended in the original Jahss maneuver actu-
ally encumbers the reduction by unnecessarily tightening
the intrinsic muscles.
The majority of metacarpal neck fractures can be treated
A B by closed reduction, followed by cast immobilization in 70° to
90° flexion of the metacarpophalangeal joint. Most patients
regain satisfactory flexion and extension despite some resid-
ual angulation. However, severe angulation can be associated
with prominence of the metacarpal head in the palm, which
can be troublesome for laborers and athletes. The loss of
knuckle prominence on the dorsum when making a fist may
also be an aesthetic problem.
The degree of acceptable residual angulation is controver-
sial and varies between the metacarpals. Angulation of up to
30° after reduction can be treated conservatively without sig-
nificant functional loss for the ring and small fingers. Flexor
tendon function may decrease significantly when the angula-
tion is greater than 30° and the finger is shortened.7 Index and
C D
long fingers tolerate less angulation because their carpometa-
carpal joints are less mobile.
If a metacarpal neck fracture is unstable after closed reduc-
tion, percutaneous K-wire fixation, either in a retrograde fash-
ion or in a transverse manner to the adjacent metacarpal, may
be necessary. The latter method has the advantage of allow-
Hand
ing active exercise 1 week after reduction, and reports show

excellent outcomes.8 An alternative to percutaneous K-wiring
is intramedullary nailing (Figure 75.5).6
E
FIGURE 75.7. Principle of compression plates. A. The distal holes
are drilled in a neutral position. B. After fixation of the LC-DC 2.0
plate to the distal bone with adequate screws, the first proximal hole
is drilled eccentrically (away from the fracture). C. Insertion of the
first proximal screw. D. The screw head pulls the plate proximally
along with the distal fragment providing compression. E. The final FIGURE 75.8. The dorsal angulation of metacarpal head fractures is
screw is inserted in a neutral position. a result of the pulling force of the intrinsic muscles.

762 Part VIII: Hand
Table 75.2
Indications for Operative Fixation of
Metacarpal and Phalangeal Fractures
1. Irreducible fractures
2. Malrotation
3. Intra-articular fractures
4. Open fractures
5. Segmental bone loss
6. Polytrauma with hand fractures
7. Multiple hand or wrist fractures
8. Fractures with significant soft tissue defects
interosseus spaces is considered. Two longitudinal incisions

are made over the second and fourth metacarpal bases. Each
of these incisions allows fasciotomy of two adjacent interos-
seous spaces.
Metacarpal Base Fractures

These fractures are usually the result of high-energy trauma
and may involve dislocation of the carpometacarpal joints.
Therefore, thorough evaluation of carpal involvement is
necessary. If reduction cannot be accomplished with closed
reduction alone, K-wire fixation or open reduction and plate
fixation is required.
FIGURE 75.9. Modified Jahss maneuver for reduction of metacarpal

head fractures: The digit is pressed dorsally in flexed position of the
metacarpophalangeal joint with volarly directed counterpressure on
the metacarpal bone.
Metacarpal Shaft Fractures

The stability and healing of metacarpal shaft fractures depends
on the fracture pattern. Transverse fractures may be unstable
and slow to heal because of the small amount of cortical bone
at the fracture site. Oblique and spiral fractures of the meta-
carpal shaft have more bony surface area for stability and
healing, but malrotation needs to be corrected.
Non-displaced and stable fractures after closed reduc-
tion are treated with a short arm cast for 3 to 4 weeks. If
the reduced fracture is unstable, percutaneous K-wires can
be used to hold the reduction. Loss of metacarpal length can
compromise extensor tendon balance. Cases of comminution,
bone loss, or fractures of multiple metacarpals favor open
reduction and plate fixation (Table 75.2). When performing
osteosynthesis with plates, incisions should be placed off the
axis of the extensor tendons to minimize postoperative adhe-
sions. Division of the junctura tendinum may be necessary to
retract the extensor tendons. After longitudinal splitting and
dissection of the periosteum, the fracture is reduced utilizing
bone clamps. Plates are contoured precisely, and the reduc-
tion is confirmed both fluoroscopically and by clinical evalu-
ation of possible malrotation, before they are stabilized with
screws.9 Alternatively, long oblique fractures can be stabilized
with lag screws (Figure 75.10).
FIGURE 75.10. Multiple metacarpal fractures may require ORIF.
Multiple metacarpal fractures can lead to a critical rise of The index metacarpal was stabilized with plates and screws. For the
pressure in the muscle compartments. If evaluation reveals long finger, a T-plate was used, and the comminuted fragments were
evidence of compartment syndrome such as persistent unre- held together with a cerclage wire. The spiral fracture of the ring fin-
lieved pain disproportionate to the trauma, or pain with ger was stabilized with two lag screws.
passive extension of the affected muscles, fasciotomy of the

A B
FIGURE 75.12. First metacarpal base fractures: A. Bennett frac-
ture: the abductor pollicis longus tendon pulls the main portion of
the metacarpal bone dorsoradially while the fracture fragment stays
aligned. B. Rolando fracture with comminuted base, here Y-shaped.
reduction and casting because the plaster can be effectively

molded around this solitary metacarpal. Upto 30° of angula-
tion is acceptable because of the great mobility of the carpo-
metacarpal joint. Greater angulations require reduction, and
usually closed pinning.10
Metacarpal base fractures are much more common than shaft
fractures. The intra-articular types are referred to as Bennett and
Rolando fractures (Figure 75.12). Base fractures are a result of
an axial load through the metacarpal shaft in contrast to shaft
fractures, which are commonly caused by a direct blow.
The most common fracture of the thumb metacarpal base
FIGURE 75.11. Multiple carpometacarpal fracture dislocations: note
the significant soft tissue swelling. is the Bennett fracture, an intra-articular fracture through the
volar–ulnar aspect of the metacarpal base. In these fractures,
the main metacarpal bone is displaced dorsoradially by the
pull of the abductor pollicis longus tendon, while the smaller
fracture fragment is held in position by the volar oblique liga-
Intra-articular base fractures of the fifth metacarpal are ment. Closed reduction after traction and pronation of the
referred to as “reverse Bennett” fractures and are unstable due thumb with percutaneous pinning is the first choice of treat-
to the pull of the extensor carpi ulnaris tendon, which inserts ment. The focus should be on realigning the main metacar-
onto the base of the fifth metacarpal. The dislocation of the pal bone. The K-wire is anchored in the trapezium and/or the
fifth metacarpal is reduced and pinned to the fourth metacar- base of the second metacarpal. Then, the fracture fragment is
pal and the hamate. If possible, the fracture fragment itself is reduced as best as possible. If the resulting articular step-off is
reduced to the fifth metacarpal as anatomically as possible. more than 1 mm, open reduction may be necessary to reduce
These principles for treatment are the same as for the true the severity of arthritic changes. Fixation can be obtained with
Bennett fracture of the thumb (discussed later). K-wires, lag screws, or plates. The fracture is immobilized for
Fracture dislocations of the other carpometacarpal joints 4 to 6 weeks in a thumb spica cast.11
of the fingers may be multiple and represent high-energy inju-
Resulting mostly from high-energy trauma, Rolando frac-
ries. It is critical to consider compartment syndrome in these
tures are frequently comminuted and difficult to treat. They
cases (Figure 75.11). Accurate reduction and fixation, either
consist of at least three fragments. The typical fracture line is
closed or open, is performed. For patients with severe joint
T- or Y-shaped. The goal is to restore both height and articu-
destruction, primary arthrodeses may be considered.
lar congruency. The treatment of choice is open reduction
with fixation using condylar plates or K-wires. External fixa-
Metacarpal Fractures of tion should be considered for severe cases. Even with excel-
Hand
lent surgical technique, posttraumatic arthritis of the thumb

the Thumb carpometacarpal joint may result over time.
Fractures of the thumb metacarpal are mostly divided into
shaft and base fractures because thumb metacarpal head
fractures are extremely rare. Energy directed toward the Proximal and Middle
head usually results in rupture of the collateral ligaments.
Although thumb metacarpal shaft fractures are usually eas-
Phalangeal Fractures
ily detected by routine radiographs, full visualization of the Proximal and middle phalangeal fractures have similar prop-
base of the thumb metacarpal and the trapeziometacarpal erties. Both can be transverse, oblique, spiral, or comminuted.
joint is obtained with the Robert’s view (PA view with hand As a result of the intrinsic muscles and the extensor tendons,
30° short of full pronation and maximal ulnar deviation of transverse fractures of the proximal phalanx tend to angulate
the wrist). volarly (Figure 75.13). Stable proximal phalangeal fractures
Thumb metacarpal shaft fractures are usually transverse are ideal candidates for dorsal splinting with flexion of the
and are dorsally angulated due to the volar pull of the thenar metacarpophalangeal joint. This position causes the exten-
muscles and the dorsal pull of the abductor pollicis longus tensor apparatus to serve as a tension band across the trans-
don proximally. Most shaft fractures can be treated by closed verse fracture line. This effect, which is increased when the

764 Part VIII: Hand
lateral bands. Stabilization is achieved by K-wires, screws, or

T-plates. Plating is avoided when possible because it often
results in stiffness due to extensive dissection and frequently
necessitates tenolysis after plate removal.
Non-displaced shaft fractures can be buddy taped to an
adjacent uninjured finger. Any fracture showing rotational
deformity requires operation. Whereas short oblique fractures
can be treated with crossed K-wires, spiral fractures should be
FIGURE 75.13. Volar angulation of proximal phalangeal bone frac- stabilized with interfragmentary screws. When using crossed
tures: The intrinsic muscles pull the proximal fragment volarly and K-wires, the level of crossing should not be at the fracture site.
the extensor tendon pulls the distal fragment dorsally. Extra-articular base fractures can be treated with conser-
vative treatment with 70° flexion of the metacarpophalangeal
joints. Rotational deformities need to be treated by ORIF.
Intra-articular fractures are amenable to closed treatment, if
undisplaced. Cortical screws or K-wires are used for displaced
proximal interphalangeal (PIP) and the distal interphalangeal
fractures. Loss of motion may result after phalangeal fractures,
(DIP) joints are flexed, can be used to reduce a proximal pha-
especially after long immobilization, and joint and crush injury.
langeal fracture. After 3 weeks, the patient is encouraged to
Therefore, early immobilization is of utmost importance.
move the finger supported by buddy taping.
PIP joint fracture dislocations are complex and often result
The chance of secondary displacement of primarily stable
in a stiff, painful, arthritic PIP joint (Figure 75.15). The treat-
fractures is low.12 Reduced fractures, which were originally
ment is based on the size of the volar middle phalanx base
displaced, however, have a high chance of redisplacement. If
fragment and the amount of subluxation or dislocation of
a secondary displacement is seen in weekly follow-up radio-
the middle phalanx. Treatment options range from fragment
graphs, stabilization with K-wires is considered.
screw fixation, dorsal block pinning, and dynamic external
Condylar fractures that are not amenable to closed treat-
fixator placement to salvage operations, such as volar plate
ment require an open approach. Care must be taken not to
arthroplasty and hemi-hamate arthroplasty. Full discussion is
injure the collateral ligaments, as much of the blood supply
beyond the scope of this chapter.
to the condyle is derived from this structure. Unicondylar
fractures can be reduced by a midaxial approach. Screws of
1.0 to 1.2 mm diameter are used for fixation. The goal is to Fractures of the Distal
achieve rigid fixation and allow early movement of the joint
(Figures 75.14 A and B).
Phalanx
Bicondylar fractures are usually unstable and require Distal phalangeal fractures are the most common fractures in
an open approach, which is best done via a dorsal incision the hand. They can be classified into tuft, shaft, and base frac-
splitting the extensor tendon between the central slip and the tures. Tuft fractures are usually the result of direct trauma,
A B
Figure 75.14. Unicondylar proximal phalanx fracture treated with screw and supplemental K-wire. A. Lateral view. B. Posteroanterior view.

of unstable phalangeal fractures treated by plates and/or
screws achieved excellent outcomes (at least 210° arc of
motion). 14 Two factors may have caused the poorer out-
come in this particular study: inclusion of unstable frac-
tures only and the high percentage of unfavorable factors,
such as open fractures, soft tissue damage, and comminu-
tion. Another group reported that only 52% of metacarpal
and phalangeal fractures repaired with plates and screws
obtained ≥220° total range of motion.15 These studies high-
light the high incidence of tendon scarring after ORIF.
Complications
Given the wide range of fracture treatment techniques, the
key to success for maximizing functional outcome while mini-
mizing complications is the selection of the best treatment
modality for each given case. Choosing a conservative method
will avoid hardware-associated complications such as tendon
adhesions and rupture and infection at the cost of nonrigid
fixation, which may lead to malunion and joint stiffness from
prolonged immobilization. The surgeon must therefore be
aware of the possible complications associated with the dif-
ferent modalities. Despite early exercise after plate fixation
of metacarpal and phalangeal fractures, Page and Stern15
encountered major complications in 36% of injuries, includ-
ing stiffness, plate prominence, nonunion, infection, and ten-
don rupture. Complications were observed more frequently in
open fractures and phalangeal fractures. Similar observations
were made by Pun et al.14
The primary factors influencing stiffness are soft tissue
damage14,16 and the age of the patient.16 Infection is also highly
associated with soft tissue injury. Whereas the infection rate in
closed fractures is less than 0.5%, open fractures of the hand
FIGURE 75.15. PIP joint fracture dislocation of the ring finger with showed deep infections in 2% to 10% of patients. The most
disruption of 50% of the middle phalanx joint surface and resultant
common bacteria isolated from open hand fractures were
dorsal dislocation.
staphylococci and streptococci.17
Malunion is more likely to occur after closed reduc-
tion and splinting or internal fixation with one longitudi-
and comminution is frequent. Due to the close proximity of nal pin. Transverse metacarpal fractures result in dorsally
distal phalangeal bone and the nail bed, they are frequently angulated malunion, which may cause pseudoclawing, pain
accompanied by nail bed injury and subungual hematoma. with gripping due to palmar prominence of the head, and
The hematoma is evacuated by wide fenestration of the nail dissatisfaction with the final appearance. When correct-
using electrocautery in its proximal portion, distal to the ing dorsal angulation, a corrective osteotomy with a clos-
lunula. Damage to the nail bed by this maneuver is unlikely, as ing wedge may be sufficient in many cases, as the loss of
the nail is separated from it by the hematoma. To avoid irreg- bone length is compensated for by the angle correction. 18
ularities of the new nail, meticulous repair and splinting of the Rotational malunion leads to overlapping of the digits.
nail bed is required. An extension splint is used to immobilize Correction is performed by osteotomy either at the previ-
the DIP joint for 2 to 3 weeks. Non-displaced shaft fractures ous fracture site or more proximally. 17 Nonunion is rare
can be treated in the same way. Displacement of transverse after hand fractures.
fractures is mostly accompanied by laceration of the overly- The hardware used for osteosynthesis can lead to several
ing nail matrix, which requires repair. Bone fixation is usu- complications. The most common is pin tract infection after
ally performed with a K-wire. Epiphyseal disruption may percutaneous pinning. In the presence of early signs of infec-
present as a mallet deformity. This appearance is produced by tion, a course of antibiotics is administered. If no improve-
the pull of the flexor tendon on the distal fragment, whereas ment is observed, removal is the only reasonable treatment
the extensors act on the proximal fragment. Closed reduc- to avoid deep infection. Despite the development of thinner
Hand
tion is mostly sufficient with repair of the nail bed, if present. and smaller material, plates and screws can cause irritation
Distal phalangeal fractures may result in nonunion but they of the overlying tissues due to their prominence, necessitat-
are rarely symptomatic. Distal phalangeal “mallet” fractures ing their removal. Postoperative scarring may result in tendon
with detachment of the terminal extensor are discussed in the adhesions after internal fixation. The indication for extensor
extensor tendon chapter (Chapter 78). tenolysis and dorsal capsulotomy is judged cautiously and
should be performed after an interval of at least 3 months to
allow for softening of the tissues.17
Outcomes
Treatment outcomes after hand fractures are variable
because of the wide range in presentation and treat-
Conclusions
ment. Excellent results are reported after screw and/ In order to achieve a functionally and aesthetically satisfac-
or plate fixation of metacarpal and phalangeal fractures tory outcome, it is important to understand not only the ana-
with 92% displaying more than 220° range of motion.13 tomical and pathomechanical basis of the injury but also the
Favorable outcomes also follow fixation of metacarpal three-dimensional pattern of the fracture. Recent improve-
and phalangeal fractures with K-wires and intramedullary ments in the development of osteosynthesis techniques have
rods. 9 Some researchers, however, found that only 27% led to an increase in open approaches to hand fractures. It is

766 Part VIII: Hand
in this context that the surgeon must critically compare the 8. Galanakis I, Aligizakis A, Katonis P, et al. Treatment of closed unstable
metacarpal fractures using percutaneous transverse fixation with Kirschner
advantages of rigid fixation and the potential complications wires. J Trauma. 2003;55:509-513.
of this method for each specific case. In most cases, the sim- 9. Kozin SH, Thoder JJ, Lieberman G. Operative treatment of metacarpal and
plest method that will allow adequate reduction and immobi- phalangeal shaft fractures. J Am Acad Orthop Surg. 2010;8:111-121.
lization will have the best outcome. In addition, the period of 10. Carlsen BT, Moran SL. Thumb trauma: Bennett fractures, Rolando fractures
and ulnar collateral ligament injuries. J Hand Surg. 2009;34A:945-952.
immobilization should be kept to the minimum so that motion 11. Soyer AD. Fractures of the base of the first metacarpal: current treatment
can be restored in a timely fashion. options. J Am Acad Orthop Surg. 1999;7:403-412.
12. Wright TA. Early mobilization in fractures of the metacarpals and phalan-
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2. Ip WY, Ng KH, Chow SP. A prospective study of 924 digital fractures of the 14. Pun WK, Chow SP, So YC, et al. Unstable phalangeal fractures: treatment
hand. Injury. 1996;27:279-285. by AO screw and plate fixation. J Hand Surg. 1991;16A:113-117.
3. Foucher G, Khouri RK. Digital reconstruction with island flaps. Clin Plast 15. Page SM, Stern PJ. Complications and range of motion following plate
Surg. 1997;24:1-32. fixation of metacarpal and phalangeal fractures. J Hand Surg. 1998;
4. Gonzales MH, Bach HG, Bassem TE, et al. Management of open hand 23A:827-832.
fractures. J Am Soc Surg Hand. 2003;3:208-218. 16. Bannasch H, Heermann AK, Iblher N, et al. Ten years stable internal
5. Hoffman RD, Adams BD. Antimicrobial treatment of mutilating hand fixation of metacarpal and phalangeal hand fractures—risk factor and out-
injuries. Hand Clin. 2003;19:33-39. come analysis show no increase of complications in the treatment of open
6. Foucher G. “Bouquet” osteosynthesis in metacarpal neck fractures: a series compared with closed fractures. J Trauma. 2010;68:624-628.
of 66 patients. J Hand Surg. 1995;20A:S86-S90. 17. Balaram AK, Bednar MS. Complications after the fractures of metacarpal
7. Birndorf MS, Daley R, Greenwald DP. Metacarpal fracture angulation and phalanges. Hand Clin. 2010;26:169-177.
decreases flexor mechanical efficiency in human hands. Plast Reconstr Surg. 18. Green DP. Complications of phalangeal and metacarpal fractures. Hand
1997;99:1079-1083. Clin. 1986;2:307-328.

Chapter 76 n Management of Wrist
Fractures
Sandeep Jacob Sebastin and Kevin C. Chung
The wrist is one of the most complex joints in the body and links younger group, whereas there is a preponderance of females
the forearm to the hand. Anatomically the wrist consists of eight in the elderly group due to osteoporosis. In the United States,
carpal bones, but functionally it extends from the distal forearm approximately 280,000 fractures occur in working-age per-
to the base of the metacarpals and includes the distal ends of sons and the economic impact of these injuries is considerable,
the radius and the ulna, eight carpal bones, and the bases of the as patients take an average of 12–16 weeks to return to work.
metacarpals (Figure 76.1). The distal radius and ulna refer to Approximately 10% of 65-year-old white women will experi-
the distal 2 to 3 cm metaphyseal (cancellous) portion of these ence a distal radius fracture in their lifetime and the annual inci-
two bones.1 The carpal bones are arranged in two rows. The dence of distal radius fractures in the US population over the
proximal row includes the scaphoid, lunate, and the triquetrum age of 65 has been reported to be 57–100 per 100,000. These
and the distal row includes the trapezium, trapezoid, capitate, numbers will rise in the future because the “Baby Boomers”
and the hamate. The pisiform is a sesamoid bone in the tendon are aging and individuals are living longer and lead healthier
of the flexor carpi ulnaris (FCU) and lies palmar to the trique- and more active lives compared to previous generations.6
trum.2 This complex architecture of the wrist is maintained by
the inherent geometry of the bones that are held together by Anatomy
numerous extrinsic and intrinsic ligaments (Chapter 81). This
The ulna articulates proximally with the humerus and rep-
joint configuration maintains stability and allows for transfer
resents the stable unit of the forearm. The radius (with the
of loads from the hand, while providing tremendous mobility.
associated carpus and hand) rotates around the ulna at the
This chapter discusses the management of fractures of the wrist
proximal and distal radioulnar articulations.3 The volar surface
with emphasis on the distal radius and the scaphoid with brief
of the distal radius is relatively flat, whereas the dorsal surface
mention of avascular necrosis of the lunate (Kienbock disease).
is convex and closely related to the overlying extensor tendons.
The volar cortex of the distal radius is also considerably thicker
Distal Radius Fractures than the dorsal cortex. The distal ends of the radius and ulna
A fracture of the distal radius and/or ulna is the most common articulate with the proximal carpal row. The distal end of the
fracture seen by physicians accounting for 15% to 20% of all radius has three articular fossae (Figure 76.2). The most radial is
fractures. There is a bimodal age distribution, with peaks of the triangular scaphoid fossa with the radial styloid at its apex.
incidence occurring in the youth and in the elderly.3,4 In the An anteroposterior ridge (interfacet ridge) separates the scaphoid
younger population, these fractures are most often the result fossa from the lunate fossa. The sigmoid fossa is located along the
of high-energy trauma such as motor vehicle accidents or distal ulnar surface of the radius and articulates with the ulnar
falls from a height. In the elderly population, however, these head.7 It has a poorly defined proximal margin, but well-defined
fractures frequently result from falls from a standing height distal, volar, and dorsal margins.8 The carpus is separated from
and other low-energy trauma.5 Although the overall gender the distal end of the ulna by the triangular fibrocartilage complex
rates are similar, the fractures in men tend to occur in the (TFCC). The TFCC originates on the ulnar border of the lunate
fossa and inserts onto the base of the ulnar styloid.9
Metacarpals
Biomechanics
Approximately 80% of the axial load across the wrist is trans-
mitted through the distal end of the radius and 20% across
the TFCC and the distal end of the ulna.3 Most fractures of
the radius occur at the metaphysis because it is mostly spongy
Lister tubercle
Styloid process
IV III II Radius of ulna
V
I Styloid process
Hand
Hamate Trapeziod
of radius
Triquetrum Trapezium
Pisiform Capitate
Scaphoid
Lunate
Styloid Styloid process
process of radius
of ulna
Scaphoid fossa
Lunate fossa Lunate fossa Ulna

Ulna Radius Scaphoid fossa
FIGURE 76.1. The bones of the wrist as seen from the volar surface. FIGURE 76.2. The distal articular surface of the radius and ulna.
767
768 Part VIII: Hand
cancellous bone. Fractures may be either extra-articular or volar and dorsal lunate fossa fragments.1 Occasionally the
intra-articular involving the radiocarpal and/or distal radio- articular surface is sheared off to produce a fracture sublux-
ulnar joint/s (DRUJ). Extra-articular fractures often follow ation of the wrist. Other deforming forces around the distal
a fall on an outstretched, extended hand. Because the dorsal radius include the insertion of the brachioradialis on the radial
cortex is thinner compared to the volar cortex, it is frequently styloid, associated injuries to the ulnar styloid or the TFCC
comminuted and results in the classic dinner fork deformity
(dorsal displacement with dorsal tilt [loss of normal volar tilt],
radial tilt [loss of radial inclination], and shortening [loss of
height]).10 Intra-articular fractures usually result from higher
energy trauma and the fracture pattern depends on the mag-
nitude and direction of force and the quality of bone and soft
tissues. The lunate can exert pressure on its fossa causing a
die-punch fracture. A multifragmentary intra-articular frac-
ture pattern with four large fracture fragments is often seen.
These fragments are the radial styloid, the radial shaft, and
Groove for
ECU tendon
B
B
FIGURE 76.4. Standard lateral radiograph of wrist. A. Positioning
FIGURE 76.3. Standard PA radiograph of wrist. A. Positioning for a for a wrist lateral radiograph. B. A correctly positioned lateral view
wrist PA radiograph. B. A correctly positioned PA view showing the showing the pisiform (white dotted lines) overlying the distal scaph-
ECU groove radial to the ulnar styloid. oid (green dotted lines) and the capitate (red dotted lines).

Chapter 76: Management of Wrist Fractures 769
that can lead to DRUJ instability, and intercarpal injuries that elbow in 90° flexion, and the hand positioned in the same plane
can lead to carpal instability.11 as the humerus (Figure 76.4A). In a true lateral view, the pal-
mar cortex of the pisiform should overlie the central third of the
History and Physical Examination interval between the palmar cortices of the distal scaphoid and
the head of the capitate (Figure 76.4B).
The key elements in the history are the mechanism of injury
Three radiographic measurements on standard PA and lat-
to determine the energy involved and the direction of force
eral views correlate with patient outcome: radial height, radial
transmission. This information is useful in assessing sever-
inclination, and volar tilt (Figure 76.5).9,11,13 The radial height
ity of injury and likelihood of associated ligament and nerve
is measured on a PA radiograph as the distance between a line
injuries.7 The patient should be questioned about pain in the
perpendicular to the long axis of the radius passing through
hand, elbow, and shoulder and sensation in the median nerve
the distal tip of the sigmoid notch at the distal ulnar articu-
distribution. The patient should also be questioned about
lar surface of the radius and a second perpendicular line at
handedness, occupation, medical history, social history, and
the tip of the radial styloid. Normal radial height averages
recreational activities to determine the functional demands on
10 to 14 mm. The articular surface of the radius has a radial
the injured wrist.2,3
to ulnar slope (radial inclination) and a dorsal to volar slope
The involved wrist as well as the elbow and the contralat-
(volar tilt).
eral upper limb are examined. Focal tenderness in the anatomic
The radial inclination is also measured on a PA radiograph
snuffbox suggests a scaphoid fracture. Tenderness 1 cm distal
and represents the angle between one line connecting the tip
to the Lister tubercle suggests a scapholunate ligament injury.
of the radial styloid and the ulnar aspect of the distal radius
Median nerve function is evaluated by assessing sensibility at
and the second line perpendicular to the longitudinal axis of the
the fingertips. We use the ‘ten test’ to perform a quick assess-
radius. The normal radial inclination ranges between 20° and
ment.12 A decrease in sensibility compared with the normal
25°. The volar tilt is measured on a lateral radiograph and rep-
side may indicate the need for median nerve decompression.
resents the angle between the line along the distal articular sur-
face of the radius and a line perpendicular to the longitudinal
Radiographic Evaluation axis of the radius. The normal volar tilt averages 11° and has a
The posteroanterior (PA) and lateral radiographs are routine. range of 5° to 15°. An additional radiographic parameter that
The PA view is obtained with the shoulder in 90° abduction, the is useful is ulnar variance. Ulnar variance refers to the distance
elbow in 90° flexion, and the wrist and forearm in neutral rota- between the articular surface of the ulnar head and the ulnar
tion (Figure 76.3A).13 In a true standard PA view, the groove border of the lunate fossa. It is described as neutral when both
for the tendon of the extensor carpi ulnaris should be at the are at the same level: ulnar plus, when the ulna is longer; and
level or radial to the base of the ulnar styloid (Figure 76.3B).9 ulnar minus, when the ulna is shorter (Figure 76.6). Normal
The lateral view is obtained with the shoulder in 90° adduction, ulnar variance can range from 0 ± 2 mm.
Hand
FIGURE 76.5. Measurement of radiographic parameters of the distal end of the radius [Radial height (red dotted lines), radial inclination (white
dotted lines), and volar tilt (green dotted lines)].

770 Part VIII: Hand
Mayo Clinic,17 and the AO18 (Association for the Study of

Internal Fixation) classifications. The Frykman, Melone,
Mayo clinic, and the AO classifications focus on the frac-
ture pattern, whereas the Fernandez classification is based
on the mechanism of injury. We use the AO classification in
our practice. It divides the fractures into three broad groups
(A. Extra-articular; B. Partial involvement of articular sur-
face; and C. Involvement of entire articular surface). These
are then subdivided into 9 subtypes or 27 distinct fracture
Ulna positive Ulna neutral Ulna negative patterns (Figure 76.9).
FIGURE 76.6. Measurement of ulnar variance.
Treatment
The aim of treatment of distal radius fractures is to restore
normal anatomy (radial height, volar tilt, and articular con-
Plain radiography may be insufficient in the assessment of gruity) because this is believed to correlate with functional
the comminuted, grossly displaced, and complex intra-articular outcome.1,13,19 Based on the radiographic findings, fractures
fractures. Computed tomography (CT) is performed in such may be classified as stable or unstable. Stable fractures do not
cases (Figure 76.7). CT should also be considered when a displace at presentation or following manipulative reduction.20
detailed evaluation of an articular step or gap is required. They present with minimal displacement, have dorsal angu-
Magnetic resonance imaging (MRI) is useful when con- lation less than 5°, and radial shortening less than 2 mm.21
comitant ligamentous injuries are suspected or fractures Stable fractures can be managed with cast immobilization. In
are suspected but not visualized on routine radiographs contrast, unstable fractures cannot be reduced or the reduc-
(Chapter 81). A dynamic fluoroscopic examination is also tion cannot be maintained. The factors that have been associ-
useful for detecting carpal instability. ated with instability following closed reduction are listed in
Table 76.1.22,23 Age of the patient, dorsal comminution, and
increased ulnar variance (>3 mm) are the most important pre-
Classification dictors of collapse with cast treatment.24 Unstable distal radius
Many eponyms and classification systems have been used to fractures require surgical intervention to maintain reduction.
describe distal radius fractures. A list of common eponyms Multiple surgical options are available that include percu-
has been provided because they are frequently used in clini- taneous pin fixation, external fixation, open reduction and
cal practice (Figure 76.8). The commonly used classifica- plate fixation, intramedullary fixation, and arthroscopically
tion systems include the Frykman,14 Melone,15 Fernandez,16 assisted fixation.
FIGURE 76.7. CT images of a comminuted intra-articular distal radius fracture demonstrate the comminuted and impacted “die-punched”
articular fragments.

Dorsal Dorsal
Colles fracture Smith (reverse Colles) Lunate die-punch fracture

fracture palmer
dorsal dorsal
Volar Barton fracture Dorsal Barton fracture Chauffeur’s fracture

palmer
FIGURE 76.8. Common eponyms used to describe distal radius fractures.
While there is no consensus, the current trend is toward (3) Application of force opposite to the direction of deformity
internal fixation of unstable fractures.3 Insufficient data exist to reduce the fracture (Figure 76.10).25
to support any particular treatment method. Although age is We tend not to use the traditional maneuver to reduce
not a contraindication to surgical treatment, one must take Colles fractures as it requires extreme hyperextension and
into account the functional demands of the patient. Available flexion. Instead we apply strong longitudinal traction by pull-
evidence shows no difference between casting and surgical fix- ing on the thumb, index, and the long finger, while an assistant
ation of unstable distal radius fractures in the elderly, defined provides counter-traction at the distal arm just proximal to
by age (>55 years), low functional demand, and poor bone the elbow. Sustained traction is maintained for 5 to 7 minutes.
quality with low-energy injuries.6 Thereafter pressure is applied in a palmar direction on the
dorsum of the distal radius (the distal fracture fragment) along
Closed Reduction and Plaster Immobilization. This with slight pronation and ulnar deviation to reduce the frac-
is the initial treatment for most distal radius fractures. ture (Figure 76.11).26,27
It relies on ligamentotaxis to pull the fracture out to length, Once reduction is complete, it must be maintained by keep-
uses the intact soft tissues to reduce the displaced fragments, ing the dorsal soft tissue hinge under tension. This is done
and requires a three-point pressure splint to maintain the by using a three-point pressure splint. Two points of pressure
reduction. Closed reduction needs relaxation of the local are on the dorsum of the forearm proximal and distal to the
Hand
musculature with adequate analgesia. It can be performed fracture site and one point is on the volar side correspond-
under general anesthesia, axillary, or intravenous regional ing to the fracture (Figure 76.12). Three-point pressure cannot
anesthesia, but usually it is performed under a hematoma be given by a simple dorsal splint or a volar splint. It needs
block by infiltrating 5 to 7 mL of local anesthetic into the a dorsoradial splint or a sugar-tong splint.28 We prefer the
fracture site. use of a sugar tong splint because forearm rotation can be
There are a number of ligaments that extend from the dis- controlled and it immobilizes the DRUJ.27 It is important to
tal radius to the carpal bones. By putting longitudinal trac- avoid extremes of wrist flexion and ulnar deviation (Cotton-
tion on the hand, these ligaments are stretched and pull the Loder position) that can result in iatrogenic median nerve
impacted distal radius fragments with them. In the common compression, extensor tendon tightness, and weaken flexion
Colles fracture, the volar periosteum is torn, however the dor- from decreased excursion of flexors. The splint should also
sal soft tissue (periosteum and the extensor tendon sheath) is not extend beyond the proximal palmar crease to allow full
intact. This dorsal soft tissue hinge is the key to the reduc- flexion of the metacarpophalangeal joint.
tion. The traditional reduction maneuver consists of three A cast is generally not applied after the initial reduction in
steps: (1) Longitudinal traction for a few minutes to assist the emergency room because subsequent swelling may lead
in muscle relaxation; (2) Application of a force in the direc- to skin breakdown or compartment syndrome. Radiographs
tion of the deformity to disimpact the fracture fragments; and are repeated to evaluate restoration of the radiographic

772 Part VIII: Hand
Type A: Extra-articular fractures
Dorsal Dorsal
A1 A2 A3
Ulna only Simple impacted Comminuted
Type B: Partial articular fractures
Dorsal Dorsal
B1 B2 B3
Sagittal fragment Dorsal fragment Volar fragment
Type C: Intra-articular fractures
C1 C2 C3
Simple articular and Simple articular and Comminuted articular and
simple metaphyseal comminuted metaphyseal comminuted metaphyseal
FIGURE 76.9. The AO classification of distal radius fractures.
Table 76.1 parameters, to evaluate articular congruity, and assess sever-

ity of comminution. Patients are seen within 1 week after
Factors Associated with Instability Following reduction for repeat radiography. If the reduction is main-
Closed Reduction of Distal Radius Fractures tained, the splint is exchanged for a cast. Patients are typi-
cally seen again 1 week after cast placement to ensure that
Injury Factors (Radiographic Findings) fracture reduction is not lost. Surgical intervention may be
More than 5 mm shortening needed if there is loss of reduction.9
Dorsal tilt greater than 20°
Percutaneous Pinning. This technique is suitable for
Articular displacement greater than 2 mm unstable fractures that can be reduced but the reduc-
Displacement more than two-third of the width of the shaft tion cannot be maintained using plaster. Pinning by itself
in any direction is inadequate for fractures with significant metaphyseal
Dorsal metaphyseal comminution comminution and/or articular instability. The use of intra-
operative fluoroscopy has greatly enhanced the accu-
Associated ulnar fracture racy of pin placement and allows confirmation of fracture
Patient Factors reduction. 1.6 mm (0.062 inches) Kirschner wires (K-wires)
Age greater than 60 y (osteoporosis) are usually used. After reduction, the K-wire is passed in
a distal to proximal direction entering the tip of the radial

Volar
surface
Intact
dorsal soft
tissue hinge
B
FIGURE 76.10. The traditional maneuver for reduction of a Colles frac-
ture. A. Fracture disimpaction by longitudinal traction and dorsiflexion.
B. Fracture reduction by continued traction, flexion and ulnar deviation. B
FIGURE 76.12. The three point pressure splint. A. Producing and
holding the reduction by maintaining the dorsal tissue hinge under
tension and compressing the volar cortex (small red arrows). Note the
styloid, across the fracture to the proximal ulnar cortex three points of pressure (large red arrows). Two on the dorsum (distal
of the diaphysis. One or two additional K-wires can be and proximal to the fracture) and one on the volar aspect (at the level
placed in a crossed fashion. Another technique popular- of the fracture). B. Maintaining the three points of pressure by using
ized by Kapandji is “intrafocal pinning.” Here the K-wire a dorsoradial plaster slab.
is used to achieve reduction as well as maintain the reduc-
tion (Figure 76.13). The initial wire is introduced through
the fracture site in a radial to ulnar direction. Once the wire

reaches the ulnar cortex, it is used as a lever to elevate the
radial fragment to restore radial height and inclination.
The wire is then driven through the ulnar cortex to hold the
reduction. Another wire is introduced through the fracture
site at 90° to the first in a dorsal to volar direction and in a
similar manner used to restore volar tilt. A third wire may be
passed through the radial styloid across the fracture site for
additional stability.29
Pinning is usually combined with a short arm splint. The
K-wires are removed 4 to 6 weeks later and the patient is
Hand
A started on range of motion exercises coupled with a protective

splint until the fracture is clinically healed. Pinning is asso-
ciated with the risk of pin tract infection and impaling the
superficial radial nerve that may lead to chronic regional pain
syndrome (CRPS). It is important to make a sufficiently long
skin incision at proposed pin insertion sites and dissect the
soft tissue so that the pin can be placed safely (open pin place-
ment versus percutaneous pin placement).
External Fixation. External fixators work by holding the

B fracture out to length and neutralizing compressive, bending,
FIGURE 76.11. Maneuver preferred by the authors for reduction of
and torsional forces across the fracture site. External fixation is
a Colles fracture. A. Fracture disimpaction by sustained longitudinal useful in patients with highly unstable fractures with s ignificant
traction. B. Fracture reduction by palmar directed pressure on dorsum metaphyseal comminution as they allow alignment of the artic-
with slight flexion and ulnar deviation. ular surface with the shaft of the radius (Figure 76.14). They
cannot, however, be used to reduce displaced intra-articular

774 Part VIII: Hand
FIGURE 76.13. Result of Kapandji technique of “intrafocal pin- FIGURE 76.14. External fixation combined with percutaneous pin-
ning” in an extra-articular distal radius fracture in an elderly patient ning in a poly-trauma patient with a comminuted intra-articular distal
(AO A2 type). radius fracture (AO C3 type).
fractures. This technique is also useful in cases where the risk pin loosening and loss of reduction. Other complications asso-
of infection is high or significant edema precludes safe open ciated with external fixator frames include pin tract infection,
reduction and internal fixation (ORIF). It is usually used in superficial radial nerve injury, and CRPS.31
conjunction with other forms of fixation most often with
K-wires. Many different types of external fixator frames are Open Reduction and Internal Fixation. Open reduc-
available that differ in variation of pin placement, rigidity tion and plate fixation allows direct reduction of the frac-
in different planes, ability to adjust fracture reduction, and ture, maintains the reduction rigidly, and is associated with
whether the fixator frame spans the radiocarpal joint (bridg- a decreased period of immobilization and an earlier return
ing versus non-bridging). In bridging external fixator, a set of of wrist function. Dorsal and volar approaches to the distal
pins are placed in the second metacarpal and another set in radius have been described. The dorsal approach uses a lon-
the proximal radial shaft, thus spanning the radiocarpal joint. gitudinal incision in line with the Lister tubercle. The 3rd
In a non-bridging external fixator, the distal group of pins is extensor compartment is opened and the extensor pollicis
placed in the articular fragment of the distal radius. This design longus (EPL) transposed subcutaneously. The second and
prevents stiffness resulting from excessive ligamentotaxis and fourth compartments are elevated off the distal radius to
immobilization of the wrist. However a large and stable distal expose the fracture. The volar approach uses the standard
fragment is necessary for pin placement.10,19 A variation of the Henry approach between the radial artery and the flexor carpi
external fixator frame is a percutaneously placed dorsal fix- radialis (FCR) protecting the palmar cutaneous branch of the
ator plate (bridge plating) that extends from the diaphysis of median nerve on the ulnar aspect of the FCR. The flexor pol-
the radius to the second or third metacarpal. This “fixator- licis longus (FPL) is retracted ulnarly, the pronator quadratus
internal” is especially useful in polytrauma patients, where (PQ) incised along the radial border of the radius, and elevated
external fixation makes nursing care difficult.30 as an ulnarly based flap to expose the fracture.32
The interval for safe passage of the proximal external fix- Traditionally a dorsal approach was used, because this
ator pins is between the tendons of the extensor carpi radialis allowed the plate to buttress the dorsally displaced fracture.
longus and the extensor carpi radialis brevis approximately The dorsal approach permits direct visualization of the articu-
10 to 15 cm proximal to the radial styloid. The distal pins lar surface, allows concomitant treatment of intercarpal liga-
are inserted along the dorsal lateral aspect of the index meta- ment injuries, and is indispensable in dorsal shearing fractures.
carpal. It is important to ensure that the pins are bicortical It is also easier to bone graft from the dorsum as the metaph-
to prevent subsequent pin loosening.7 The use of external fix- yseal bone is thinner and frequently comminuted. However
ators in osteoporotic bone can be challenging due to risk of dorsal plating fell out of favor in the late 1990s and early

2000s as earlier generations of dorsal plates were associated
with soft tissue complications resulting from the close proxim-
ity of the extensor tendons to the distal radius. This resulted
in tendon irritation or ruptures and often required routine
removal of the plate or other procedures. In addition, early
motion following the use of nonlocked dorsal plates could
result in loosening of the distal screws, especially in osteopo-
rotic patients with metaphyseal comminution. The newer gen-
eration low-profile dorsal locking plates, however, has been
shown to be as equally effective in maintaining reduction fol-
lowing fracture fixation without increased risks of complica-
tions when compared with volar plates (Figure 76.15).33
Currently, most hand surgeons prefer the volar approach
for the majority of distal radius fractures (Figure 76.16).
The PQ forms a barrier between the implant and the flexor
tendons minimizing the tendon complication rate. The fixed
angle plate with locked screws maintains reduction more
effectively, providing subchondral support, and resisting sec-
ondary displacement even in the presence of osteoporotic
bone. The need for bone grafting is reduced compared to dor-
sal plating. A direct visualization of the articular surface is
not possible from the volar approach and one must be careful
not to elevate the volar carpal ligaments off the volar rim of
the distal radius. Volar plating is not without complications.
Improperly placed plates can result in irritation and rupture
of the FPL at the distal border of the plate. Overpenetrated
screw tips can result in rupture of extensor tendons. There is
also risk of the distal subchondral screws penetrating the joint.
FIGURE 76.16. The use of a low profile volar locking plate to

address a partial articular distal radius fracture (AO B3 type).
This is difficult to assess on standard PA and lateral views and

a 22° elevated lateral view or a 45° pronated oblique view is
often required to rule out joint penetration (Figure 76.17).19
Fragment-specific fixation, which uses small contoured
plates on specific components of the fracture, is another. The
smaller size of the implants decreases tendon irritation and
allows the use of smaller volar and/or dorsal incisions mini-
mizing soft tissue disruption. The distal unstable fragment
is reduced and fixed to the proximal shaft. Stable fixation is
achieved by smaller implants because they are aligned in an
orthogonal fashion.34 Recently, a new class of implants has
been introduced that uses a fixed angle subchondral support
fixed to an intramedullary stem and locked by metaphyseal
screws. Less dissection is required to place the implant and
Hand
there is no tendon irritation as the device is intramedullary.35

A combined dorsal and volar approach may be occasionally
required to achieve reduction and fixation in complex high-
energy intra-articular fractures. In such cases it is preferable
to stabilize the volar rim first by a volar approach. The volar
wound is then closed and a dorsal approach used to reduce
and fix intra-articular fracture fragments or place bone
grafts. Rarely a bridging external fixator may be required.
Arthroscopic Assisted Fixation. Wrist arthroscopy

allows direct visualization of the articular surface, manip-
ulation of individual articular fragments using small
FIGURE 76.15. The use of a low profile dorsal locking plate in a pointed probes, and fixation of the fragments with K-wires.
patient with a comminuted intra-articular distal radius fracture Arthroscopy is also valuable in the diagnosis and treat-
(AO C3 type). ment of concomitant ligament injuries of the wrist espe-
cially the scapholunate and lunotriquetral interosseous

776 Part VIII: Hand
FIGURE 76.17. The use of a 22° elevated lateral view to rule out joint penetration by the distal screws. The radiograph on
the left represents the fixation in Figure 76.15 (dorsal locking plate) and the radiograph on the right represents the fixation in
Figure 76.16 (volar locking plate).
ligaments and the triangular fibrocartilage complex. The in full supination, one can consider immobilizing the forearm
use of arthroscopy has not been associated definitively with in supination for 3 weeks, neutral position for the following
superior outcomes. There is a substantial learning curve and 3 weeks, and then start mobilization. If the DRUJ is stable
it increases the operative time.19,36 only in full pronation, the forearm should not be immobilized
in pronation as it is difficult to regain supination postopera-
Associated Injuries tively. In these cases it is preferable to reduce the DRUJ in
neutral (mid-prone) position and maintain the reduction using
It is important to evaluate the entire upper extremity to
two parallel 0.062 inch (1.6 mm) K-wires passed below the
identify any associated musculoskeletal or neurovascu-
ulnar head into the radius.7 If the DRUJ is unstable in all posi-
lar injuries such as shoulder dislocation, elbow fracture/
tions, one must consider a tear of the radioulnar ligaments
dislocations, brachial plexus injuries, or vascular injuries.
(RUL), which is usually an avulsion of the RUL from their
The following wrist injuries are frequently associated with
foveal insertion. Direct bone anchor repair of the RUL is
distal radius fractures.
required with pinning of the radius and ulna for 4 to 6 weeks.
Ulnar Styloid Fractures. A concomitant ulnar styloid
fracture is seen in more than 50% of distal radius fractures Carpal Ligamentous Injuries. They are frequently asso-
but not all ulnar styloid fractures require repair. Operative ciated with high-energy trauma especially those resulting in
intervention depends on the stability of the DRUJ. Basal radiocarpal fracture–dislocations and avulsion of the radial
fractures of the ulnar styloid and those with greater than styloid. Arthroscopic studies have shown a 30% incidence of
2 mm of displacement were found to affect DRUJ stabil- scapholunate ligament injury and 15% incidence of lunotri-
ity.37,38 When there is suspicion of DRUJ instability based quetral ligament injury following a distal radius fracture.39 All
on radiographic appearance, the opposite normal wrist is patients with a distal radius fracture should be assessed for
examined for translational laxity of the DRUJ in neutral, associated ligament injuries. This can be done after fixation
full supination, and full pronation. Once the distal radius of the radius by doing a fluoroscopic assessment of the c arpus
fracture has been repaired, the surgeon should examine the in radial and ulnar deviation and flexion and extension. An
injured wrist and compare it with the normal side. If the arthroscopic assessment is ideal when injury to these liga-
DRUJ is lax, especially in full supination, the ulnar styloid ments is suspected. Complete interosseous ligament injuries in
is repaired. K-wires, tension band wire, or a cannulated young and active individuals will need exploration and bone
headless screw can be used (Figure 76.18). The forearm anchor repair, whereas partial ligament injuries can be man-
should be immobilized in neutral rotation for 4 to 6 weeks aged by pinning the respective joints under fluoroscopy. The
using a sugar tong or Munster type splint. pins are cut under the skin to prevent pin tract infection and
maintained for 4 to 6 weeks.
Distal Radial Ulnar Joint Instability. In addition to an
ulnar styloid/neck/head fracture, DRUJ instability may result Median Nerve Dysfunction. The median nerve can be
from an intra-articular fracture involving the sigmoid fossa injured by blunt contusion during the injury, by stretch of
or a tear of the TFCC. The stability of the DRUJ should be the nerve over the angulated fracture fragment, or from frac-
reassessed after fixation of the fractures. If the DRUJ is stable ture hematoma within the carpal tunnel. It is important to

undisplaced or minimally displaced extra-articular fracture
when the increased intracompartmental pressure within the
third extensor compartment is not released with the surgical
procedure. The treatment of choice is a transfer of the exten-
sor indicis proprius to restore thumb extension (Chapter 80).
The other cause of tendon rupture is irritation by a plate or
screw tip.
Malunion of the distal radius is common and may be extra-
articular, intra-articular, or both. Only symptomatic mal-
union requires operative intervention. Elderly low-demand
patients who are pain free and function well despite significant
radiographic deformity require no intervention. However,
malunion in young adults with higher functional demands
can result in pain, loss of motion, and deformity. If there is
greater than 25° to 30° of dorsal tilt or 6 mm of discrepancy
between the radius and ulna, surgical intervention is required.
This may include a corrective osteotomy (lengthening) of the
A distal radius or a shortening osteotomy of the ulna.9 The distal
radius osteotomy aims to restore radial height, volar tilt, and
radial inclination and improves the flexion/extension arc of
motion (Figure 76.19). The ulnar osteotomy is indicated for
ulnar impingement and ulnar-sided wrist pain. The Darrach
procedure (resection of the ulnar head) is the procedure of
choice in elderly patients with ulnar-sided wrist pain. Limited
or total wrist fusion or a Sauve-Kapandji procedure may be
indicated in symptomatic patients with radiocarpal and radio-
ulnar arthritis, respectively.
B
FIGURE 76.18. Delayed presentation of DRUJ instability with non-
union of the ulnar styloid. A. Pre-op radiograph demonstrating dorsal
subluxation of the radius relative to the ulna, with displaced ulnar
styloid shown by arrow. B. Late postoperative radiograph showing
tension band wiring of the ulnar styloid with TFCC re-insertion using
a bone anchor.
obtain history of preexisting carpal tunnel symptoms and

do a quick ‘ten test’ to assess sensibility in the fingertips.
If the nerve symptoms (paresthesias, numbness, etc.) do not A
improve or worsen within 24 to 48 hours after satisfac-
tory closed reduction, one must perform early carpal tunnel
release and surgical stabilization of the fracture. However,
there is no evidence to support routine release of the carpal
tunnel at the time of operative fixation in patients without
preoperative evidence of median nerve dysfunction.40
Complications
Hand
The long-term complications reported after distal radius

fractures include stiffness of the fingers and wrist, CRPS, attri-
tional rupture of tendons, malunion, ulnar-sided wrist pain,
and degenerative arthritis involving the radiocarpal and radio-
ulnar joints.5 Mild forms of CRPS are common with distal
radius fractures especially those treated with casting and/or
percutaneous pins. Patients with increasing pain, joint stiff-
ness, and paresthesias will need early attention and refer-
ral to a pain management service. The use of supplemental B
vitamin C after distal radius fractures was found to signifi-
FIGURE 76.19. Osteotomy of the radius for correction of a malunited
cantly reduce the incidence of CRPS.40 Spontaneous rupture distal radius fracture. A. Pre-op radiographs showing loss of radial
of the EPL is an uncommon complication after distal radius height and inclination and significant dorsal tilt with an ulnar positive
fractures. It is believed to result from ischemia of tendon as variance. B. Early postoperative radiograph demonstrating correction
a result of compression by fracture hematoma within the of radiographic parameters after a corrective osteotomy of the radius.
third extensor compartment. It is usually associated with an

778 Part VIII: Hand
Radiographic Evaluation. In addition to the standard

Carpal Fractures PA and lateral views of the wrist, one should obtain 45° pro-
Carpal fractures account for 6% to 7% of all carpal injuries nated and supinated oblique views, and a PA clenched fist
and 18% of hand fractures. The scaphoid and triquetrum view in ulnar deviation (Figure 76.20). Ulnar deviation places
are the most frequently fractured accounting for 79% and the scaphoid in an extended posture and brings it more com-
14% of all carpal fractures. The incidence of isolated fractures pletely in view. The clenched fist will accentuate any scaphol-
of any of the remaining carpal bones is 1%.41 Carpal frac- unate widening and distract any unstable fracture fragments.
tures are often associated with fractures of other carpal bones, Approximately 8% to 20% of scaphoid fractures are not evi-
fracture of the distal radius, and ligamentous instability of the dent on initial X-ray. If there is a high clinical suspicion, but
carpus. These fractures are a diagnostic challenge because of no radiographic evidence of a fracture, a thumb spica cast is
their infrequency and the difficulty in detecting them on initial applied and follow-up radiographs done 10 to 14 days later.
conventional radiographs. Missed carpal fractures have a high This may show bone resorption at the fracture site.41 If the
risk of developing degenerative arthritis resulting in a chroni- plain radiographs are still negative, one can consider bone
cally painful wrist. scintigraphy, CT scan, or an MRI. Although bone scintigra-
phy is sensitive, it is nonspecific and increased uptake may
Scaphoid Fractures indicate arthrosis or synovitis. A CT scan is better for assess-
Scaphoid fracture occurs most often in young men as a result ing bony anatomy; 2 mm sagittal cuts parallel to the long
of a fall on an outstretched hand. In the United States, approx- axis of the scaphoid are ideal. An MRI is useful in detecting
imately 345,000 scaphoid fractures occur per year.42 These occult scaphoid fractures, assessing the vascularity, especially
fractures are rare in children because the carpal bones have in delayed union or nonunion, and ruling out any associated
not completely ossified and the distal radius physis tends to ligamentous injuries. An acute scaphoid fracture shows a low
fracture first. signal intensity at the fracture line and high signal intensity
on the surrounding bone marrow on T2 images. AVN of the
Anatomy. The scaphoid is boat shaped (scaphos proximal pole is evident as dark signal intensity on T1 and
[Greek] = skiff) and concave in both the ulnar and palmar T2 images.42 Gadolinium enhancement can improve the MR
directions. It is anatomically divided into three parts, namely evaluation of proximal pole vascularity.
the distal pole, waist, and the proximal pole. The tubercle
is the distal and palmar protuberance of the scaphoid. Over Classification. Scaphoid fractures have been classified
80% of the scaphoid is covered with articular cartilage. based on fracture location, plane of the fracture, and stabil-
Approximately 70% to 80% of the blood supply of the scaph- ity. Russe classified scaphoid fractures based on the plane of
oid arises from dorsal branches of the radial artery that enter the fracture into horizontal oblique, transverse, and vertical
at the level of the waist. The remaining 20% to 30% of the oblique. He felt that vertical oblique fractures were unstable,
blood supply is via palmar braches of the radial artery that difficult to control with immobilization, and had a higher risk
enter via the distal tubercle. The proximal pole of the scaph- of nonunion.44 Herbert and Fisher classified fractures based
oid is vascularized by retrograde flow and explains the slower on their stability into stable acute (type A), unstable acute
union and increased tendency for proximal pole fractures to (type B), delayed union (type C), and nonunion (type D)
go into avascular necrosis (AVN).41 (Figure 76.21). In their opinion all complete fractures of the
waist and proximal pole were unstable (type B). The only sta-
Biomechanics. The scaphoid links the proximal and ble fracture patterns were tubercle fracture (type A1) and an
distal carpal rows. It assumes a flexed foreshortened posture incomplete waist fracture (type A2).45 However neither clas-
in radial deviation and wrist flexion and an extended and sification predicts fracture union. We agree with Herbert’s
elongated posture on ulnar deviation and wrist extension. concept of scaphoid fractures and fix all unstable fracture
A fall on the outstretched hand causes the proximal aspect of patterns (fracture line traverses the entire scaphoid).
the scaphoid to impact on the dorsal rim of the distal radius
resulting in palmar tensile and dorsal compressive forces caus- Treatment. A scaphoid fracture with greater than 1 mm
ing a fracture through the scaphoid waist. Another mechanism displacement, comminution, angulation (intrascaphoid angle
of injury is a pure compressive force like in an automobile greater than 35°; height to length ratio greater than 0.65), open
accident. Approximately 75% to 80% of scaphoid fractures fracture, and/or associated carpal instability (scapholunate
occur at the waist, 10% to 15% occur at the proximal pole, angle greater than 60°; radiolunate angle greater than 15°) is
and 5% to 10% occur at the distal pole including the tuberos- considered as an unstable fracture pattern and surgical treatment
ity.43 The displacement of a scaphoid fracture depends on the is indicated.42 In addition surgery is recommended in patients
direction and degree of force and the plane of the fracture. with a proximal pole fracture or where the diagnosis and treat-
Scaphoid fractures heal by intramembranous ossification. ment have been delayed. The proximal pole fracture may heal
There is no fracture callus to provide initial stability. If the with prolonged casting (up to 6 months). Complications from
wrist is loaded before union occurs, it can lead to progressive disuse of the arm are high with such a long period of immobil-
flexion and pronation of the distal scaphoid, especially in ity, which supports surgical fixation of proximal pole fractures.
unstable or displaced fractures. The distal scaphoid fragment The indications for conservative treatment with a cast include
has a tendency to flex and the proximal fragment extends by stable, undisplaced waist and tuberosity fractures that are diag-
virtue of its attachment to the lunate. This combined with nosed soon after injury. We recommend internal fixation for
the resorption of bone on the volar aspect will lead to a undisplaced scaphoid waist fractures in the young and active
“humpback” or flexion deformity of the scaphoid.9 patients in preference to casting. Early internal fixation reduces
the problems associated with the long period of cast immobili-
History and Physical Examination. There will be his- zation such as stiffness of the wrist, decreased grip strength, and
tory of fall on an extended wrist and pain over the scaphoid. delayed return to work.46
There will be swelling and loss of the normal concavity of the
anatomical snuffbox and pain on moving the wrist and the Conservative Treatment. A thumb spica cast is applied for
thumb. Tenderness can be elicited on deep palpation in the 8 to 12 weeks until radiographic union is evident. There is
snuffbox or over the scaphoid tuberosity or on axial loading no consensus whether the cast should include the elbow or
of the first metacarpal thus compressing the scaphoid. Patients the thumb interphalangeal joint. Our preference is to give
presenting subacutely may complain of vague ache in the wrist a short arm cast that excludes the thumb interphalangeal
with loss of motion or strength. joint and the elbow. A union rate of over 95% has been

Clenched fist postero-anterior

Postero-anterior in ulnar deviation
45°supinated oblique
45° pronated oblique Lateral
FIGURE 76.20. Scaphoid views showing a displaced scaphoid wrist fracture.
shown in undisplaced scaphoid waist fractures and 70% Surgical Treatment. The headless compression screw intro-
in undisplaced proximal pole fractures, when treatment duced by Herbert and Fisher in 1984 has become the accepted
is started within 3 weeks of injury. If fracture union is in standard surgical treatment of scaphoid fractures. The greatest
doubt, healing should be monitored with serial radiographs advantage of this technique is that the screw can be recessed
or CT scans. below the articular cartilage. Technological advances using
Type A : Stable acute fractures Type B : Unstable acute fractures
A1 A1 B1 B2 B3 B4
Fracture of tubercle Incomplete fracture Distal oblique Complete fracture Proximal pole Trans-scaphoid
through waist fracture of waist fracture perilunate
Hand
fracture–dislocation
of carpus
Type C : Delayed union Type D : Established nonunion
C D1 D2
Delayed union Fibrous union Pseudarthrosis
FIGURE 76.21. Herbert classification of scaphoid fractures.

780 Part VIII: Hand
cannulated headless screws and better instrumentation com- ligaments. It has been combined with wrist arthroscopy to
bined with improved intraoperative fluoroscopy have made ensure anatomic reduction and detect any concomitant liga-
placement of the screw easier. ment injuries. Irrespective of the approach, the important
The screw can be placed through dorsal or palmar aspect of screw fixation of the scaphoid is to place the screw
approaches either by an open technique or a percutaneous in the long axis of the scaphoid. Recognizing that the long axis
technique (Figure 76.22). The dorsal open approach provides of the scaphoid tilts approximately 45° palmarly and 45° radi-
better exposure of the proximal pole and allows easier screw ally is important when the screw is inserted.47
placement, but has a risk of disrupting the tenuous dorsal
blood supply. The palmar open approach preserves the blood Complications. The most important complication of a scaph-
supply, but disrupts the radiocarpal ligaments and provides oid fracture is nonunion. Other complications include malunion
poor exposure of the proximal pole. The palmar approach and radiocarpal arthritis. Nonunion results from a delay in diag-
is needed to reduce humpback deformity by prying open the nosis or treatment allowing the two fracture fragments to move
collapsed scaphoid and inserting a cortical bone graft strut independent of each other creating a fibrous interphase between
to restore scaphoid length. The percutaneous technique is the distal and proximal scaphoid. Other factors that can lead
useful in patients with undisplaced or minimally displaced to nonunion include insufficient immobilization, fracture com-
fractures and avoids damaging the blood supply or the minution, fracture displacement, and poor patient compliance.
Scaphoid nonunion can also occur following operative treat-
ment due to inadequate screw length, eccentric screw placement,
or failure to achieve compression across the fracture site. If left
untreated, scaphoid nonunion will lead to a predictable pattern
of arthritic change beginning at the radial styloid articulation
with the distal scaphoid pole, the radioscaphoid articulation,
followed by the midcarpal joint, and ultimately by pancarpal
arthritis. This sequence of changes has been termed as scaphoid
nonunion advanced collapse (SNAC).
The treatment of nonunion depends on the location of the
fracture, degree of collapse, vascularity of the proximal pole,
and presence of any arthritic change. If there is no collapse
or humpback deformity, screw fixation with cancellous bone
graft is adequate. Bone graft may be obtained either from the
distal radius, the olecranon, or the iliac crest. Iliac crest bone
harvested using a trephine is ideal. The use of distal radius
bone graft may compromise the use of vascularized bone grafts
needed for later reconstruction. If there is associated collapse
or a humpback deformity, the fracture should be approached
volarly and a corticocancellous wedge-shaped bone graft used
to correct the deformity and a screw or K-wires used to immo-
bilize the scaphoid until union is complete.
Scaphoid nonunions with avascular necrosis of the proxi-
A mal pole require vascularized bone grafting. Many different
vascularized bone grafts have been described.48,49 The most
widely used is a bone graft from the dorsoradial aspect of
the distal radius that is vascularized by the 1, 2-intercom-
partmental supraretinacular artery (1, 2-ICSRA). Other
vascularized bone grafts include the 2, 3-ICSRA and the
4, 5-extracompartmental artery (ECA) from the dorsum of the
distal radius and the PQ-based graft from the volar aspect of
the distal radius. The use of a vascularized bone graft from
the medial femoral condyle as a free flap is becoming increas-
ingly popular. This requires microsurgical anastomosis of the
donor vessels to the radial artery and its venae commitantes.
The main advantage of this graft is that it can be placed on
the volar side and corrects the humpback deformity in addi-
tion to revascularizing the proximal pole. A rare cause of
AVN of the scaphoid is Preiser disease or idiopathic AVN.
There is no history of previous fracture and it is believed to
be caused by repetitive microtrauma. Other suggested factors
include alcoholism, corticosteroids, chemotherapy, and sys-
temic lupus erythematosus. It is seen more often in women
(3:1) and patents present with dorsoradial wrist pain. MRI is
the investigation of choice and the treatment options are simi-
lar to scaphoid nonunion with an avascular proximal pole.
Patients with arthritic change will need a salvage proce-
dure depending on the extent of the arthritic change and the
functional demands of the patient. If the arthritis involves only
the radial styloid, radial styloidectomy combined with bone
B grafting of the scaphoid may be attempted in the young active
FIGURE 76.22. Scaphoid fracture. A. Preoperative radiograph show- patient. In the older patient and in patients with more exten-
ing scaphoid fracture (arrow). B. Open reduction internal fixation of sive arthritis, the options include scaphoid excision and four-
scaphoid fracture with a headless cannulated screw. corner fusion (fusion of the lunate-triquetrum-hamate-capitate)
or proximal row carpectomy (excision of the scaphoid, lunate,

and triquetrum such that the capitate articulates with the lunate Revascularization procedures include use of pedicled vascular-
fossa of the radius). Proximal row carpectomy (PRC) is useful ized bone grafts from the base of the 2nd or 3rd metacarpal or
when the arthritic changes are restricted to the radioscaphoid from the dorsum of the distal radius. The selection of unload-
joint. If there is arthritic change of the capitate, a four-corner ing procedures depends on the ulnar variance. If the patient
fusion is indicated. In advanced SNAC with involvement of the has positive ulnar variance, a capitate shortening or capito-
radiolunate joint, the treatment of choice is a wrist arthrodesis. hamate fusion can be considered. If the patient has a n egative
or neutral ulnar variance, a radial shortening osteotomy is
Lunate Fracture carried out (Figure 76.23).
In patients with stage IIIB disease, one can consider sca-
Fractures of the lunate are quite rare except in association with photrapeziotrapezoid (STT) fusion or scaphocapitate fusion
Kienbock disease (idiopathic avascular necrosis of the lunate dis- to unload the radiolunate and restore carpal height. If there
cussed in the next section). Dorsal chip fractures of the lunate is significant synovitis associated with collapsed lunate, the
may be confused with dorsal fractures of the triquetrum on lunate can be excised. In stage IV disease, the options are lim-
plain radiographs. Patients with lunate fractures have tenderness ited to PRC and wrist fusion. The radiolunate joint must be
immediately distal to the Lister tubercle. The suggested treatment evaluated before considering a PRC. If it is grossly arthritic,
is cast immobilization for 4 to 6 weeks for undisplaced and chip the only option is a wrist fusion.
fractures and ORIF for large displaced fractures.50
Kienbock Disease. Kienbock disease (avascular necrosis of Triquetrum Fracture

the lunate) is common in men between the ages of 20 and This is the second most common carpal bone to be fractured
40 years. The etiology is unknown and possible causes include after the scaphoid. Fractures of the triquetrum may occur
abnormalities in blood supply of the lunate and repetitive in isolation or be part of a more complex injury like a peri-
trauma. Negative ulnar variance, flatter than normal radial lunate fracture–dislocation. Isolated triquetral fractures can
inclination, and the geometry of the lunate itself are believed either be a dorsal rim chip fracture or involve the body. 53
to predispose an individual to Kienbock disease.51 Chip fracture usually represents an avulsion of the dorsal
radiotriquetral ligament. Body fractures represent a high-
History and Physical Examination. Patients may present energy injury and one must be suspicious for other associ-
with remote history of trauma and complain of wrist pain ated injuries. Patients present with dorsal hand and wrist
with limitation of motion. This may range from mild discom- edema and restricted range of flexion. They also have tender-
fort to constant debilitating pain depending on the stage of ness on palpation just distal to the ulnar styloid. The fracture
the disease. There may be history of fall on an extended wrist. can usually be visualized on an oblique or lateral view radio-
Physical examination may show a swelling suggestive of reac- graph. Occasionally, a CT scan may be necessary to confirm
tive synovitis over the dorsum of the wrist with weakness of the diagnosis. Dorsal chip fractures and undisplaced body
grip and pain on motion. There is also tenderness over the fractures can be managed with 4 to 6 weeks of cast immo-
lunate. bilization. The exception to this is the instance where a dor-
Radiographic Evaluation. Standard PA and lateral views of sal chip fracture is associated with flexion of the lunate as a
the wrist are obtained. In a young patient with unexplained result of complete lunotriquetral dissociation following fail-
mid-dorsal wrist pain and normal radiographs, further evalua- ure of the lunotriquetral and dorsal radiotriquetral ligamen-
tion with an MRI is indicated. The MRI will be able to pick up tous restraints. Symptomatic nonunited avulsion fragments
early AVN before radiographs show positive findings. There may need excision. Displaced body fractures and those asso-
will be evidence of bone marrow edema initially followed by ciated with carpal instability will need ORIF.
decreased vascularity of the lunate (decreased signal inten-
sity on T1 weighted images limited to the lunate). With pro- Pisiform Fracture
gressive disease, the radiographs will demonstrate fractures, Pisiform fractures result from a direct blow like a fall on the
sclerosis, collapse, loss of carpal alignment, and progressive palm of the hand. Patients present with tenderness over the
degenerative changes of the radiocarpal and midcarpal joints. base of the hypothenar eminence. A carpal tunnel view or
Lichtman has modified the Stahl classification of Kienbock a supinated oblique view may be necessary to visualize the
disease (Table 76.2)52 and this is useful in treatment planning. fracture. Cast immobilization for 4 to 6 weeks is the treat-
ment of choice. Malunion can lead to pisotriquetral arthri-
Treatment. Patients with stage I disease are managed con-
tis that may require excision of the pisiform at a later date.
servatively with immobilization (cast) and activity modifica-
Excision usually does not compromise the strength of wrist
tion. The treatment of patients with stage II and stage IIIA
flexion.
disease is directed toward improving the vascularity of the
lunate by revascularization procedures or by decreasing the
axial load on the lunate or a combination of both procedures. Hamate Fracture
Hand
A hamate fracture may involve the body, the dorsal rim, or

the hook of the hamate. Body fractures are rare and usually
Table 76.2 follow a direct injury to the ulnar aspect of the wrist or a dor-
sopalmar crush. Dorsal rim coronal fractures occur following
Lichtman Modification of the Stahl
an axial force, as in a fist fight.54 These injuries are frequently
Classification for Kienbock Disease
associated with fracture–dislocation/subluxation of the fourth
and fifth carpometacarpal joints. The hook of the hamate
Stage I Normal radiographs (lunate edema on magnetic fracture classically occurs following a stick-handling sport like
resonance imaging) golf or hockey or following repetitive trauma from holding a
Stage II Lunate sclerosis without collapse handle too tightly. These patients usually do not recall a spe-
Stage III Lunate fragmentation and collapse cific traumatic incident and present with pain and weakness
of grip especially of the small and ring fingers. Late cases may
IIIA Without carpal collapse even present with attritional rupture of the flexor tendons to
IIIB With carpal collapse the small and ring finger and ulnar nerve dysfunction. It is
Stage IV Arthritic change in radiocarpal/midcarpal joints difficult to pick up this injury on standard radiographs. A car-
pal tunnel view and a 30° palmar tilted lateral projection are

782 Part VIII: Hand
useful in visualizing fractures of the hook of the hamate. The

most reliable diagnostic study is a CT scan. Hook of hamate
fractures are frequently recognized late, after it has progressed
to nonunion. In these cases the treatment is subperiosteal exci-
sion of the hook, taking care to protect the motor branch of
the ulnar nerve. ORIF with a screw can be attempted if the
diagnosis is made acutely.
Capitate Fracture
Isolated capitate fractures are rare and usually occur along
with a perilunate injury. This injury is known as a scapho-
capitate fracture syndrome and results in waist fractures of
the scaphoid and the capitate. The proximal capitate fragment
may end up rotated 180° with the fracture surface pointed
proximally. The injury can easily be missed on a routine radio-
graph and a CT scan is necessary for an accurate diagnosis.
Anatomic reduction is required to restore carpal kinematics.
ORIF with a cannulated, headless screw is optimal. Fractures
of the capitate waist may progress to AVN; however nonsur-
gical treatment is preferred for AVN of the capitate as patients
often remain asymptomatic.55
Trapezoid Fracture
Isolated trapezoid fractures are extremely rare and usually
seen along with an injury to the index finger carpometacarpal
joint (CMCJ). It is important to achieve anatomic reduction
to prevent arthrosis of the CMCJ. Malunited fractures may
necessitate arthrodesis at a later date.
Trapezium Fracture
A Isolated trapezium fractures are also uncommon and occur
in association with first metacarpal or distal radius fractures.
The Robert view (hyperpronated AP view) or the Bett view
(semipronated hand with ulnar palm resting on the X-ray
plate and X-ray beam centered on the scaphotrapeziotrap-
ezoid joint) allow visualization of the injury.9,55 Undisplaced
fractures are treated with cast immobilization for 4 weeks.
Unstable fractures or those with articular incongruity will
need ORIF. Patients with median nerve symptoms will need
carpal tunnel release.
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Course Lect. 1993;42:73-88. 37. May MM, Lawton JN, Blazar PE. Ulnar styloid fractures associated with
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and internal fixation for distal radius fractures. J Hand Surg. 1992;17A: instability. J Hand Surg. 2002;27A:965-971.
745-755. 38. Sammer DM, Shah HM, Shauver MJ, Chung KC. The effect of ulnar sty-
18. Muller ME, Nazarian S, Koch P. AO Classification of Fractures. Berlin: loid fractures on patient-rated outcomes after volar locking plating of distal
Springer; 1987. radius fractures. J Hand Surg. 2009;34A:1595-1602.
19. Henry MH. Distal radius fractures: current concepts. J Hand Surg. 39. Shih JT, Lee HM, Hou YT, Tan CM. Arthroscopically-assisted reduction of
2008;33:1215-1227. intra-articular fractures and soft tissue management of distal radius. Hand
20. Fernandez DL, Jupiter JB. Fractures of the Distal Radius: A Practical Surg. 2001;6:127-135.
Approach to Management. New York, NY: Springer-Verlag; 1996. 40. Lichtman DM, Bindra RR, Boyer MI, et al. Treatment of distal radius frac-
21. Abbaszadegan H, Jonsson U, von Sivers K. Prediction of instability of tures. J Am Acad Orthop Surg. 2010;18:180-189.
Colles’ fractures. Acta Orthop Scand. 1989;60:646-650. 41. Kawamura K, Chung KC. Wrist fractures. In: Chung KC, Disa JJ, Gosain
22. Lafontaine M, Hardy D, Delince P. Stability assessment of distal radius frac- AK, Kinney BM, Rubin JP, eds. Plastic Surgery: Indications and Practice.
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23. Leone J, Bhandari M, Adili A, McKenzie S, Moro JK, Dunlop RB. Predictors 42. Knoll VD. Scaphoid fractures and nonunions In: Trumble TE, Budoff
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Philadelphia, PA: Elsevier; 2012. 49. Kakar S, Bishop AT, Shin AY. Role of vascularized bone grafts in the treat-
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248-252. 50. Seng KR, Blazar PE. Carpal bone fractures excluding the scaphoid In:
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the volar locking plating system. Surgical technique. J Bone Joint Surg. 52. Lichtman DM, Lesley NE, Simmons SP. The classification and treatment of
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Complications of low-profile dorsal versus volar locking plates in the distal 53. De Beer JD, Hudson DA. Fractures of the triquetrum. J Hand Surg.
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Hand

Chapter 77 n Flexor Tendon Repair
Bradon J. Wilhelmi
The flexor tendons originate in the forearm with muscles

Introduction arranged in three different layers: superficial, intermediate,
Flexor tendon injuries have long been considered one of the and deep. The superficial layer consists of the pronator teres,
most challenging problems for hand surgeons. Poor results fol- flexor carpi radialis, palmaris longus, and flexor carpi ulnaris.
lowing flexor tendon repair in the fingers led one expert hand The pronator teres, palmaris longus, and flexor carpi radialis
surgeon, Boyes, to state “Here in a small area we have two are innervated by the median nerve, whereas the flexor carpi
flexor tendons, one passing through the other in a close fitting ulnaris receives stimulus from the ulnar nerve. The interme-
sheath and snugly held to the proximal phalanx by a pulley diate layer includes only the flexor digitorum superficialis,
which is unyielding so that either trauma or infection squeezes innervated by the median nerve. The deep layer consists of the
out the blood supply and the tendon dies of ischemia. Suturing flexor digitorum profundus, flexor pollicis longus, and prona-
of a divided tendon usually results in some thickening and this tor quadratus. The median nerve innervates the flexor pollicis
enlarged area cannot pass the constricting pulley and motion is longus, pronator quadratus, and index/middle finger flexor
prevented.”1 Furthermore, Bunnell coined the term “no man’s digitorum profundus. The small and ring flexor digitorum
land” to emphasize the difficulties associated with injuries in muscles are innervated by the ulnar nerve.
this area of the digital sheath.2 If we exclude flexor tendon inju- Within the carpal tunnel, nine tendons pass to their respec-
ries within the digital sheath, however, the remaining flexor tive digits. The flexor pollicis longus is the most radial struc-
tendon injuries are not a problem. For injuries in no man’s land, ture, inserting onto the thumb distal phalanx. The flexor
adherence to certain surgical techniques and postoperative ther- digitorum profundus tendons are found along the base of
apy programs can optimize results and finger motion. Harold the carpal tunnel, aligned in order to insert into the base of
Kleinert revolutionized the primary repair of acute flexor ten- the distal phalanx of the index through the small fingers. The
don injuries in the digital sheath, after others had treated them flexor superficialis tendons course under the carpal tunnel in
for decades in a staged fashion with grafts for years.3 a stacked array with the middle and ring tendon volar to the
index and small finger tendons, which insert into the middle of
the middle phalanx of each respective finger. In the palm, the
Anatomy flexor superficialis tendons are initially volar to the flexor digi-
Accordingly, Verdan classified flexor tendon injuries by the torum profundus tendons. The flexor digitorum superficialis
location of transection relative to the extremity and their tendon decussates at the level of Camper’s chiasm, to allow
prognosis4 (Figure 77.1A). For simplicity, injuries are classi- the flexor digitorum profundus to become more volar in the
fied based on zones: distal to the flexor superficialis insertion finger. The flexor digitorum superficialis and flexor digitorum
(zone 1), within the digital sheath of the flexor superficialis profundus tendons course in the finger in a fibro-osseous canal
and profundus (zone 2), palm (zone 3), within carpal tunnel that is lined by synovium and reinforced by a pulley system.
(zone 4), and in the forearm proximal to the carpal tunnel The fibro-osseous canal is comprised of pulleys with
(zone 5). In general, flexor tendons repaired in zones 1, 3, 4, variable anatomy depending on their function. There are
and 5 have a better prognosis than those in zone 2. annular pulleys, labeled A1 to A5, and cruciate pulleys,
labeled C0 to C4 (Figure 77.2). The A1, A3, and A5 pul-
leys prevent bowstringing of the flexor tendon across the
Zone 1
Finger
tip flexion
Zone 2 A4
Tendon Distal
C2 phalanx
excursion A3
Zone 3 C1
A1 C0 A2
Moment Middle
arm phalanx
Zone 4
Proximal
Zone 5 phalanx
Metacarpal
A B
Figure 77.2. Pulley system. The A2 and A4 pulleys are the most
Figure 77.1. Zones of flexor tendon injury. A. Distal to the flexor critical. When a certain amount of either of these pulleys is missing
superficialis insertion (zone 1), within the digital sheath of the flexor the flexor is not held down to the bone which increases the moment
superficialis and profundus (zone 2), palm (zone 3), within carpal of the system. Widening of the moment arm causes less motion of the
tunnel (zone 4), and in the forearm proximal to the carpal tunnel fingertip with a given tendon excursion, resulting in bowstringing of
(zone 5). In general, flexor tendons repaired in zones 1, 3, 4, and 5 the finger and loss of fingertip flexion. Redrawn from Wilhelmi BJ,
have a better prognosis than those in zone 2, known as “no man’s Snyder N, Verbesey JE, Ganchi PA, Lee WPA. Trigger finger release
land.” B. Brunner’s zigzag extensions to optimize exposure of the with hand surface landmark ratios: an anatomic and clinical study.
proximal and distal ends of the flexor tendon. Plast Reconstr Surg. 2001;108(4):908-915.
784
Chapter 77: Flexor Tendon Repair 785
metacarpophalangeal joint, proximal interphalangeal (PIP) tendons within 24 to 72 hours minimizes adhesions, tendon
joint, and distal interphalangeal joint, respectively. The A2 retraction, and repair tension, along with gapping at the
and A4 pulleys prevent bowstringing of the flexor tendon repair site and joint stiffness. Full exposure of the proximal
across the proximal phalanx and middle phalanx, respec- and distal tendons usually requires extending the laceration in
tively. The A2 and A4 pulleys are known as the critical pul- a zigzag (Bruner) or mid-longitudinal fashion (Figure 77.1B).
leys because they are thicker, longer and in a more critical The distal end of the tendon will be found more distally when
area than other annular pulleys, allowing them to aid in the the injury occurred with the finger in flexion. If the finger
prevention of bowstringing. A deficiency of 25% of either was extended at the time of injury, the proximal and dis-
of these critical pulleys has the potential to result in the con- tal tendon ends are found at the laceration level. Excessive
dition of bowstringing. Found between the annular pulleys, manipulation of the flexor tendons should be avoided to mini-
the cruciate pulleys (C0 and C3) are of less biomechanical mize adhesion formation. Flexor tendons should be grasped in
and functional significance. the core of the severed end to avoid epitenon injury that could
Digital flexor tendons receive nutrition from both intrinsic be nidus for adhesion formation. In general, the technique of
and extrinsic sources. The synovial fluid provides extrinsic flexor tendon repair is dictated by the zone of flexor injury.
nutrition with pumping action facilitated by flexion and exten-
sion of the fingers. Flexor tendons receive intrinsic nutrition Repair Techniques
by three sources, including longitudinal vessels entering the
Several techniques of flexor tendon repair have been described
palm in the endotendinous channels, vessels that enter at the
over the years. Tendon repair strength has been shown to be
osseous insertion, and vincula (two short and two long). Most
proportional to the number of strands of suture placed across
of the internal nutrition is delivered on the dorsal side of the
the repair site. There are multiple different types of suture
tendon.
material that can be used for flexor repairs, including Ticron,
Flexor tendon function depends on many factors, including
nylon, Ethilon, Mersilene, Prolene, and stainless steel wire.
tendon excursion, intact pulley system, joint motion, and the
The ideal suture material is nonreactive, of small caliber, is
presence of lubricating synovial fluid. Flexor excursion can
strong, and with excellent knot-holding characteristics. The
be limited by adhesions among tendons, bones, and the syno-
suture techniques have different grasping qualities depend-
vial sheath. If bowstringing is present, greater amplitude of
ing on the cruciate, mattress, and cross-stitch configuration.
muscle contraction and greater amount of tendon excursion is
Knots tied within the repair site may consume space and delay
required to close the fingertip to the palm.
healing, whereas knots placed outside the repair may increase
friction and adhesion formation. Suture placement may be
Diagnosis better on the volar surface to avoid hindering blood delivery
to the tendon, which is along the dorsal surface. Use of an
Clinical exam provides the most accurate means of detect-
epitendinous suture in addition to the core suture adds 20%
ing flexor tendon injuries. When the flexor tendon is tran-
to the strength of the repair.
sected, the finger will have impaired flexion. Pain may limit
Recently, the modified Becker technique (MGH,
the utility of this exercise and other examination maneuvers
Massachusetts General Hospital) has gained popularity
are required. Flexor tendon lacerations can be identified by
for its strength, resistance to gap formation, and endurance
observing a loss of normal finger cascade. Injuries to the flexor
with active range of motion therapy. 6-12 The MGH tech-
tendons can also be suggested by loss of tenodesis effect with
nique is like the Becker repair as it involves placement of
passive wrist extension and flexion. Another useful technique
four strands through the core in a criss-cross configuration13
to evaluate integrity of the flexor tendons can be compressing
(Figures 77.3A–B). However, the MGH is different in that the
the distal forearm that normally brings the fingers into the
core sutures are 3-0 instead of 6-0 and includes augmentation
flexed posture.
with an epitenon suture and avoids the step-cut bevel.
Diagnostic studies are occasionally helpful. Plain radio-
graphs, magnetic resonance imaging, or ultrasound may
help detect the location of the proximal tendon after closed
zone 1 injuries (jersey finger injury). Knowing the location of
the proximal tendon also assists in management. When the
Flexor Digitorum Profundis (FDP) retracts to the palm (Leddy
type 1), the tendon must be repaired within 2 weeks. When
retracted to the PIP joint, the repair must be performed within
6 weeks (Leddy type 2). When caught at A4 pulley (Leddy
type 3), the repair can be performed at any time.5 Fullness and
tenderness at these locations, if present, direct management of A
jersey finger injuries making diagnostic studies unnecessary.
The presence of neurovascular injuries should also be assessed
Hand
for open lacerations at any level.

Partial tendon injuries are suggested in patients with pain
on resisted flexion. On exploration, if the injury is more than
60% of the tendon in diameter, it should be repaired. If the
injury is less than 60% of tendon diameter, the free edges are
debrided to prevent catching on the pulleys.6
Treatment
B
Ideal flexor tendon repairs are strong and smooth. Strength
Figure 77.3. The MGH flexor tendon repair technique. (A) This tech-
allows for early active motion to prevent adhesion forma-
nique is like the Becker repair as it involves placement of four strands
tion. Repairs should be strong enough to resist gap forma- through the core in a criss-cross configuration. (B). However, the modi-
tion, which can be a site for adhesion formation or repair fied Becker technique (MGH) is different in that the core sutures are 3-0
rupture. Repair techniques should also be smooth and not instead of 6-0, and it includes augmentation with an epitenon suture,
bunched to facilitate gliding of the tendons around adjacent avoiding the step-cut bevel. © Bradon J. Wilhelmi, MD.
structures such as pulleys or other tendons. Repairing flexor

786 Part VIII: Hand
Specifically, the MGH involves approximation of the epi- Zone 2 Injuries. Zone 2 injuries occur within the digital
tenon with 6-0 nylon suture in a continuous fashion. Then sheath from the distal palmar crease to the middle of the mid-
two double-armed 3-0 sutures (Prolene) are used to place dle phalanx where the flexor digitorum superficialis inserts.
four criss-cross sutures through the core. The criss-crosses of Flexor repairs are more challenging in this area because of the
two of the four core sutures are placed on each side of the pulley system, and coursing of the flexor digitorum profundus
tendon. These sutures are initiated by placing the 3-0 suture through the chiasm of the flexor digitorum superficialis. A zig-
(Prolene) transversely through the lateral aspect of the tendon zag Bruner type incision or mid-longitudinal incision is used
at least 1.5 cm from the tendon end (Figure 77.4A). Then one for exposure of the pulley system and tendon to avoid flex-
of the needles is driven in the oblique direction through the ion contracture formation. In exposing the tendon ends, it is
tendon (Figure 77.4B). This is repeated two more times in important to preserve the critical A2 and A4 pulleys. The cut
a spiral fashion and brought out the core, creating oblique profundus should also be carefully pulled through the super-
suture lines parallel to each other on the external surface of ficialis if it is proximal to the chiasm. The retracted proximal
the tendon (Figure 77.4B). The other needle of the first 3-0 tendons can be retrieved as described above by the forearm
suture (Prolene) is then used to place sutures perpendicular milking with wrist and finger flexion. Once retrieved, the
to the previous spiral of sutures (Figure 77.4C). These criss- proximal tendon can be stabilized with a hypodermic needle.
crosses are created by taking the second needle in the oblique Repair of both tendons is performed for optimal strength and
direction through the tendon between the parallel lines of the reduced risk of injury. The same technique should be utilized
suture on the external surface in the proximal to distal direc- in repairing both tendons to allow for appropriate described
tion to exit the core. This technique is repeated on the distal therapy. In other words, if a technique that allows for early
end of the tendon (Figure 77.4D). active motion is used for the flexor digitorum profundus, the
The second double-arm 3-0 suture (Prolene) is used to same technique should be used on the flexor digitorum super-
complete the criss-cross cores on the contralateral side. In ficialis. Even though the risk of adhesion formation is theo-
performing this technique, three criss-crosses are placed on retically increased with repair of both tendons, the best results
either end of the tendon. The sutures should be pulled taut occur when both are repaired. In addition, repair of both pre-
to facilitate tendon compression and preload the repair to vents hyperextension of the PIP joint. Selection of a strong
prevent gapping. Furthermore, before tying the knot the repair for injuries in this zone allows for early active motion
suture is carefully see-sawed to take the slack out and com- and better postoperative range of motion (Figures 77.5A–C).
press the tendon ends, preloading the repair to prevent gap
formation. Zone 3, 4, and 5 Injuries. Most research has focused on
A monofilament suture (such as Prolene) slides through the the treatment of flexor tendon injuries in zones 1 and 2.
tendon substance better and is preferred for preloading and Many studies have shown that flexor repairs for injuries
minimizing gapping. However, the disadvantage of a monofil- in these zones 3, 4, and 5 do well if basic surgical princi-
ament is the need for multiple knots, which can increase resis- ples are followed. Wide exposure and carpal tunnel release
tance to glide. A modification of the MGH technique involves is generally required to facilitate identification of not only
laying this stack of knots longitudinally along the tendon with the injured tendons but other neurovascular structures that
another purchase as far from the stack as the height of the require repair. It may be necessary to tag and align structures
stack (Figure 77.4E). Then, three more ties can be performed to ensure appropriate coaptation with the respective tendons
to lay the stack of knots along the tendon (Figure 77.4F). A when multiple tendon injuries are encountered such as in a
taper needle is preferred. Furthermore, the MGH technique spaghetti wrist injury. Remember that the stacked array of
should be avoided in patients who require cast immobiliza- the middle and ring flexor digitorum superficialis volar to the
tion, replants, or combined injuries that cannot be enlisted in index and small flexor digitorum superficialis assists in iden-
early active motion therapy, because of the increased resis- tifying the proximal flexor tendons. The distal tendons can
tance to gliding as shown by biomechanical studies. be localized by pulling on the tendon end to observe its func-
tion. In general, composite grip is recovered in these patients
Zone 1 Injuries. Zone 1 flexor injuries occur at the level with the flexor tendons moving en masse. However, recovery
distal to the flexor digitorum superficialis insertion and by of independent tendon glide for injuries at this level is vari-
definition can only involve the flexor digitorum profundus. An able and optimized by the use of early active motion proto-
attempt should always be made to repair the profundus ten- cols. Reduced active and passive motion after zone 5 injuries
don. If the patient presents too late for repair and the Flexor can result from adherence of all the tendons en bloc to the
Digitorum Superficialis (FDS) is intact, a distal interphalangeal pronator quadratus, necessitating a later tenolysis procedure
joint arthrodesis can be considered. Grip strength, however, (Figures 77.6A–C).
will be decreased. The finger is opened with a Bruner incision
to expose the proximal and distal tendon ends. If the proximal
end has retracted, wrist and finger flexion with forearm com-
Therapy
pression can help milk the tendon distally to the opening in Without good hand therapy, flexor tendon repairs are
the sheath where it can be carefully grasped with a small mos- doomed. Several flexor therapy regimens have been described.
quito or Jacobson and repaired to the distal stump. Usually, Each protocol places different tensile stress demands on the
the long vincula prevent retraction of the profundus past the tendons at the repair site. Techniques that allow for more
A2 pulley. As much of the A4 pulley as possible should be aggressive therapy are preferable because stressed tendons
preserved in exposing the proximal tendon end. A hypodermic heal faster, gain strength more rapidly, have fewer adhesions,
needle can be used through the proximal tendon and proxi- and result in better excursion and function.
mal pulley to hold it during the repair. Because early active There are two types of protocols: passive motion and
motion is not as critical for repairs at this level, the repair active range of motion protocols. Passive range of motion
technique is the surgeon’s choice. If there is less than 1 cm of programs include the Duran and Kleinert protocols. The
distal flexor digitorum profundus stump, the proximal tendon Kleinert protocol involves the use of nail plate hooks with
can be advanced to the decorticated distal phalanx with Keith elastic bands attached proximally to the palm and wrist to
needles and repaired dorsally over the sterile matrix of the nail passively draw the fingers into flexion. The Duran protocol
with a button. Repair over the sterile matrix minimizes the requires the patient to passively move the fingers into flex-
risk of nail deformity. For avulsion injuries of the flexor digi- ion. In both cases, patients actively extend their fingers into
torum profundus, the Leddy classification provides guidance the dorsal blocking splint. Both protocols include the use of
for the timing of repair. dorsal blocking splints with the wrist in 20° to 30° of flexion,

A B
Hand
E
Figure 77.4. Modified Becker technique. These first two cores are started by placing the first bite with 3-0 suture (Prolene) transversely
through the lateral aspect of the tendon at least 1.5 cm from the tendon end (A). Then one of the needles is driven in the oblique direction through
the tendon (B). This is repeated two more times in a spiral fashion and brought out the core, creating oblique suture lines parallel to each other on
the external surface of the tendon (B). The other needle of the first 3-0 suture (Prolene) is used to place sutures perpendicular to the previous spiral
of sutures (C). These criss-crosses are created by taking the second needle in the oblique direction through the tendon between the parallel lines
of the suture on the external surface in the proximal to distal direction to exit the core. This technique is repeated on the distal end of the tendon
to complete the criss-cross on both ends of the tendon (D). The second double-arm 3-0 suture (Prolene) is used to complete the criss-cross cores
on the contralateral side. In performing this technique three criss-crosses are placed on either end of the tendon. The sutures should be pulled
taut at each suture purchase to facilitate tendon compression and preload the repair to prevent gapping. Furthermore, before tying the knot the
suture carefully is see-sawed to take the slack out and compress the tendon ends, preloading the repair to prevent gap formation. A monofilament
suture (such as Prolene) slides through the tendon substance better and is preferred for preloading and minimizing gapping. However, the disad-
vantage of a monofilament is the need for multiple knots, which can increase resistance to glide. A modification of the MGH technique involves
laying this stack of knots longitudinally along the tendon with another purchase as far from the stack as the height of the stack. (E) Then, three
more ties can be performed to lay the stack of knots along the tendon (F). © Bradon J. Wilhelmi, MD.

788 Part VIII: Hand
A B
Figure 77.5. Zone 2 repair of both the flexor digitorum superficia-

lis and profundus. A. The ring finger has lost cascade from flexor digi-
torum superficialis and profundus transaction. B. This demonstrates
repair of both the profundus and superficialis with the modified
Becker MGH tenorrhaphy. C. Postoperative photos of the patient to
have recovering normal flexion with composite grip and differential
gliding and near-normal extension. ©Bradon J. Wilhelmi, MD.
C
Figure 77.6. Zone V multiple flexor tendon repair (A) with recovery
of normal composite grip and extension (B), as well as differential flexor
gliding of the superficialis index, middle, ring, and small fingers (C).
© Bradon J. Wilhelmi, MD.
C
metacarpophalangeal joints at 70° to 80° of flexion, and the 3 weeks, gentle tenodesis exercises are begun out of the splint.
interphalangeal joint straight. All the fingers are placed in Active composite flexion exercises without the splint are initi-
the splint and permitted to actively extend to splint. Passive ated at 4 weeks as well as differential tendon gliding exercises.
proximal and distal interphalangeal joint motion within the The splint is discontinued at 6 weeks with initiation of passive
restrains of the dorsal blocking splint is encouraged four times extension exercises. At 7 weeks, composite passive extension
a day. At 4 weeks, active composite flexion and extension are is started. Light strengthening is allowed at 8 weeks and nor-
performed outside the splint, while dorsal blocking splint is mal activities at 12 weeks.
continued between exercises. At the fifth week, the dorsal Cast immobilization is necessary in children younger
blocking splint is discontinued. Blocking exercises may be ini- than 10 years of age due to lack of compliance with motion
tiated at 6 weeks. Gentle passive extension is initiated and a protocols.
static extension splint may be used if extrinsic flexor tightness
is encountered. At 8 weeks, light strengthening is started and
resisted exercises are begun at 10 weeks. By 12 weeks normal Outcomes
activities are performed.
Several outcome assessment tools have been described to ana-
An example of an active range of motion program, the
lyze flexor repair results. The first was the Boyes outcome
MGH protocol, involves the use of a splint similar to the pas-
scale that judged results based on finger tip flexion measure-
sive regimens (Table 77.1). However, in addition to passive
ment from palm with poor being >6 cm, fair 4 to 6 cm, good
flexion and active extension within the splint, this protocol
2.5 to 4 cm, and excellent 0 to 2.5 cm. Then, the American
also involves the patient passively flexing and actively hold the
Society for Surgery of the Hand (ASSH) flexor outcome was
fingers in the palm by gently contracting the muscles to hold
popularized, which defined outcome based on total active
the digits in the fist position and for differential gliding of the
motion minus extension deficit. In the ASSH outcome, mea-
digit’s individual PIP passive placement and active holding. At
surement of less than 50% (130°) is considered poor, greater
than 50% (130°) fair, greater than 75% (195°), and good and
excellent as normal or 260°. But probably the most accurate
assessment tool is the Strickland Modification of the ASSH
T A B LE 7 7 . 1 which only considers motion of the distal interphalangeal
Early Active Motion Protocol motion and PIP motion as the digital flexors are not the pri-
mary metacarpophalangeal flexor. In the Strickland Modified
Day 1 outcome assessment scale poor is 0% to 24% motion (<44°),
fair is 25% to 49% motion (44° to 87°), good is 50% to 74%
Dorsal blocking splint with wrist neutral, metacarpophalan- motion (88° to 131°), and excellent is 75% to 100% motion
geal joint 70°, and interphalangeal joints straight (>132°).
Digits strapped to splint

Modified Duran passive flexion with active extension
to splint
Complications
Place and hold exercises passively flex digits and allow patient Adhesions
to actively contract muscles to hold digits in fist, composite, and Dissection is minimized to prevent long segments of ten-
differential. don ischemia that could result in adhesions. Early motion is
3 wk instituted as soon as possible to reduce the risk of adhesion
development. Also, cast immobilization can increase the risk
Gentle tenodesis exercises out of splint of adhesion formation. Tenolysis procedures can be con-
No active composite flexion sidered for compliant patients who can follow early active
motion therapy programs at 22 weeks post-repair. This
Continue place and hold exercises allows for plateau of function with therapy and minimizes
4 wk the risk of repair site rupture with the tenolysis procedure.
Moreover, if patients have stiff joints, these are addressed by
Active composite flexion exercises out of splint passive range of motion exercises before the tenolysis pro-
Differential tendon gliding exercises cedure. Post tenolysis patients have significant pain and can
benefit from indwelling catheter or regional blocks to permit
No passive extension, no blocking
therapy.
Continue dorsal blocking splint between exercises
5 wk Rupture
Hand
Initiate blocking exercises Failure of the repair is often due to suture or knot rup-
ture. Flexor pollicis tendons are the most likely to rupture.
Splint at night and for protection only during the day
Therefore, it is critical to use strong suture and secure knots.
6 wk Furthermore, use of a grasping technique like the MGH may
Discontinue splint resist rupture even if the knots slip. The strength of the repair
decreases up to 50% between the first and third weeks after
Initiate passive extension repair if the tendon is not stressed. Less decrease in strength
7 wk is noted after early stress to the repaired tendon. Tendon rup-
turing may be lessened with early therapy and loading of the
Start composite passive extension repair. Also, rupture can be from noncompliance with splint
8 wk and therapy. If the repair ruptures early, the tendon can often
be re-repaired. If the patient presents late, grafting may be
May start light strengthening (putty) required.
12 wk Rupture can also complicate tenolysis procedures, which
necessitates grafting and must be discussed with the patient
Normal activities
preoperatively.

790 Part VIII: Hand
on the length requirement and the number of tendons requir-

Treatment of Late Flexor ing graft reconstruction. The palmaris longus provides 16 cm,
Tendon Injuries or sufficient length to graft from the palm to the fingertip. If
more graft is needed, lower extremity donors can provide
Flexor tendon grafting may be required in the late treatment 30 to 35 cm. The palmaris is generally the preferred graft
of flexor tendon injuries, including after late rupture of the because it is in the same operative field and provides sufficient
flexor tendon repair, rupture after tenolysis, or delay in treat- length. The technique of harvesting a tendon involves dividing
ment after flexor tendon injury. Flexor tendon grafting can be the tendon distally and pulling the tendon through a tendon
performed in a single stage or in two stages in which the first stripper (Brand), which releases the tendon from the muscle
stage involves placement of a silicone rod, pulley reconstruc- substance. The palmaris longus is absent in 15% to 25% of
tion, and joint contracture release. Single-stage tendon graft- patients. Presence of the palmaris longus can be determined by
ing can be considered for tendon deficits in zones 3, 4, and 5. asking the patient to oppose and flex the wrist against resis-
For coaptation of the tendon graft to the proximal and distance. Another potential upper extremity donor is the injured
tal ends of the tendon, the interweave technique is preferred flexor digitorum superficialis. When multiple tendon grafts or
because it has been shown to be the strongest in biomechani- one long tendon graft from the wrist to the fingertip is required,
cal studies. Two-stage tendon grafting is recommended when the longer lower extremity donors are useful. The plantaris pro-
patients require tendon grafting in conjunction with pulley vides 35 cm of tendon but is absent in 7% to 20% of patients.
reconstruction or joint contracture release. Two-stage graft- The plantaris is located anterior and medial to the Achilles
ing is also recommended if collapse of the sheath or excessive tendon. If the plantaris and palmaris are absent, the extensor
scarring is encountered at the time of tendon grafting or if soft digitorum longus from the second, third, and fourth toes can
tissue reconstruction is required over the graft. provide multiple segments of the tendon 30 cm in length. The
Several donor tendon site options are available: the palmaris, extensor digitorum longus is harvested through an incision over
plantaris, extensor digitorum longus, extensor indicis proprius, the metatarsophalangeal joint. These tendons, however, can be
and extensor digiti minimi. Selection of a tendon graft is based fused at the ankle level, thus necessitating a second incision.
A B C
D E
Figure 77.7. Two-stage tendon graft procedure with initial pulley reconstruction over a silicone rod (A). At the second stage, the silicone rod is
replaced with a tendon graft (B, C). After completion of the distal juncture repair over a button, the proximal tendon is repaired with interweave
technique to set the proper tension across the graft (D). Postoperative photos demonstrate the recovery of full composite grip, differential flexion,
and full extension (E). © Bradon J. Wilhelmi, MD.

At the first stage of two-stage tendon grafting for zone II too short, quadriga and weakened grip can result. If the tendon
reconstruction, the sheath is exposed with mid-longitudinal graft is too long, a lumbrical-plus posture results with para-
incisions to minimize the risk of silicone rod exposure. The doxical hyperextension of the PIP joint on attempted finger
flexor digitorum profundus can be used as the motor unit and flexion. These potential complications can be avoided by using
is generally identified just proximal to the A1 pulley because the proximal flexor digitorum superficialis as the motor unit
it is held there by the origin of the lumbrical. The distal part to avoid quadriga and lumbrical-plus posture. Immediately
of the flexor digitorum profundus is preserved to suture to after the second-stage operation, early active motion can be
the silicone rod and the tendon graft in the first and second initiated with passive flexion and active hold exercises. Patients
stages, respectively. Alternatively, the flexor digitorum super- can begin active flexion exercises at 4 weeks postoperatively.
ficialis can be used as the motor unit to avoid the potential At 6 weeks, the dorsal blocking splint can be discontinued.
risk of tendon imbalance with quadriga or a lumbrical-plus The patient is allowed to participate in regular activities at
posture. The distal end of the flexor digitorum superficialis 12 weeks (Figures 77.7A–E).
is preserved to adhere to the flexor canal to prevent PIP joint Possible complications of tendon grafting include adhe-
hyperextension. If the PIP joint already hyperextends, the sions, infection, rod exposure, synovitis, and rupture and
flexor superficialis tail can be tenodesed to the flexor canal to tendon imbalance.
treat the hyperextension. Joint contractures should be released
at the first stage. The distal portion of the silicone rod should References
be secured distally and left free proximally to prevent the rod 1. Boyes JH. Immediate versus delayed repair of the digital flexor tendons Ann
from being pulled or migrating from the appropriate position. West Med Surg. 1947;1:145-152.
Pulley reconstruction should be performed at the first stage 2. Bunnell S. Surgery of the Hand. Philadelphia, PA: Lippincott; 1944:434.
3. Kleinert HE, Kutz JE, Ashbell TS, et al. Primary repair of lacerated flexor
over the silicone rod. Of the various techniques described, tendons in No Man’s land”. J Bone Joint Surg. 1967;49A:577.
the encircling repair technique with a tendon graft has been 4. Verdan C. Primary repair of flexor tendons. J Bone Joint Surg. 1960;42:617-657.
shown to be the strongest. In this technique, the tendon graft 5. Leddy JP. Avulsions of the flexor digitorum profundus. Hand Clin. 1985;1:77-83.
is passed circumferentially around the silicone rod and proxi- 6. Neumeister MW, Wilhelmi BJ. Flexor tendon repair. In: McCarthy JG,
Galiano RD, Boutros S, eds. Current Therapy in Plastic Surgery.
mal phalanx volar to the extensor for the A2 pulley, and dor- Philadelphia, PA: Elsevier Science; 2005:535-540.
sal to the extensor for the A4 pulley. For reconstruction of the 7. Greenwald DP, Hong HZ, May JW Jr. Mechanical analysis of tendon
pulley system of the thumb, the oblique pulley has been shown suture techniques. J Hand Surg. 1994;19A:641.
to be the most critical. 8. Greenwald DP, Randolph MA, Hong HZ, et al. Augmented Becker versus
modified Kessler tenorrhaphy in monkeys: dynamic mechanical analysis.
The second stage should be performed at 3 months to J Hand Surg. 1995;20A:267.
allow for development of a pseudosheath. Radiographs can 9. Greenwald D, Shumway S, Allen C, et al. Dynamic analysis of profundus
be obtained to confirm appropriate positioning of the rod. tendon function. J Hand Surg. 1994;19A:626.
After limited proximal and distal incisions, the tendon graft 10. Wasserman RJ, Howard R, Markee B, et al. Optimization of the MGH repair using
an algorithm for tenorrhaphy evaluation. Plast Reconstr Surg. 1997;99:1688.
is sutured to the rod proximally and pulled distally, and the 11. Yang C, Zhao C, Amadio PC, et al. Total and intrasynovial work of flex-
graft is left in the pseudosheath. Of the various distal junc- ion of human cadaver flexor digitorum profundus tendons after modified
ture techniques, repairing a tendon directly to another tendon Kessler and MGH repair techniques. J Hand Surg. 2005;30A(3):466.
has been shown to heal most reliably. The distal juncture can 12. Moriya T, Zhao C, Yamashita T, An KN, Amadio PC. Effect of core suture
technique and type on the gliding resistance during cyclic motion following
also be repaired with a pull-through suture through the sterile flexor tendon repair: a cadaveric study. J Orthop Res. 2010;28(11):1475.
matrix of the nail bed and nail plate over a button. The proxi- 13. Becker H, Orak F, Duponselle E. Early active motion following a beveled
mal end of the tendon graft is repaired to the motor unit with technique of flexor tendon repair: report on fifty cases. J Hand Surg Am.
the interweave technique, which allows for size discrepancy September 1979;4(5):454-460.
14. Wilhelmi BJ, Kang RH, Wages D, May JW Jr, Lee WPA. Optimizing inde-
and tendon balancing 1 cm tighter than cascade to allow for pendent finger flexion with zone v flexor repairs using the Massachusetts
tendon stretching. This technique also allows for setting the General Hospital flexor tenorrhaphy and early protected active motion.
appropriate length of the tendon graft. If the tendon graft is J Hand Surg. 2005;30A(2):230-236.
Hand

Chapter 78 n Extensor Tendon Surgery
Mark E. Puhaindran
proximal phalanx where the EDC tendon trifurcates, with

Introduction the central portion becoming the central slip that inserts into
The extensor system is complex and intricate. A fine balance the base of the middle phalanx, and the lateral portions join-
exists between the long extensors, innervated by the radial ing the tendons of the interosseous muscles and lumbricals
nerve, and the intrinsic muscles of the hand, innervated by to form the lateral bands (Figure 78.2). These lateral bands
the median and ulnar nerves. The superficial location on the come together over the middle phalanx and form the most
dorsum of the hand makes the extensor system vulnerable to distal part of the extensor tendon that inserts into the base
injury. Because small variations in tendon length and tension of the distal phalanx.6 The lateral bands translate in a pal-
result in significant functional deficits, outcomes of treatment mar–dorsal direction relative to the axis of rotation during
may be suboptimal. proximal interphalangeal joint (PIPJ) flexion and extension
The purpose of this chapter is to review the anatomy of the and are prevented from subluxation in a dorsal direction
extensor system and the surgical management and rehabili- by the transverse retinacular ligament (TRL), or in a volar
tation of commonly encountered injuries and conditions that direction by the triangular ligament, found over the dorsum
affect the extensor system. of the middle phalanx. The oblique retinacular ligaments,
originally described by Landsmeer,7 originate from the distal
aspect of the second annular pulley and travel obliquely and
Anatomy insert into the extensor tendon over the middle of the distal
There are 12 extensor muscles, all of which are innervated phalanx. They are not easily identified in all digits and help
by the radial nerve directly or its terminal motor branch, coordinate extension in between the PIPJ and DIPJ (distal
the posterior interosseous nerve (PIN). The brachioradia- interphalangeal joint).
lis, anconeus, and extensor carpi radialis longus (ECRL) are Many variations to the classic anatomy of the extensor
innervated by the radial nerve. The extensor carpi radialis system are found.8 Examples include the presence of acces-
brevis (ECRB) innervation may arise from the radial nerve sory muscles like the extensor carpi radialis intermedius
or the PIN. All other extensor muscles are innervated by and extensor medii proprius, which are present in 10% of
the PIN. The most distally innervated muscle is the exten- hands.9 Variations exist in the number of EDC slips to the
sor indicis proprius (EIP).1 The brachioradialis, ECRL, and digits and anatomy of the juncturae tendinae over the dor-
ECRB muscles originate from the lateral supracondylar ridge sum of the hand.8 There is also variation within the EDC
and epicondyle of the distal humerus, and from the mobile muscle, which has been described to have a common muscle
wad of muscles in the proximal forearm. The extensor digi-
torum communis (EDC), extensor digiti minimi (EDM),
extensor carpi ulnaris (ECU), and anconeus originate from
the common extensor origin at the lateral epicondyle of the
humerus, and the other muscles originate more distally in
the forearm. The extensor muscles are arranged in two lay-
ers, superficial and deep, within the forearm—the anconeus,
ECRL, ECRB, EDC, EDM, and ECU form the superficial
layer. The deep layer consists of the supinator, abductor pol-
licis longus (APL), extensor pollicis brevis (EPB), extensor
pollicis longus (EPL), and EIP.2
At the wrist, the tendons of the extensor muscles run
under the extensor retinaculum and are separated into six
compartments (five fibro-osseous and one fibrous). The first
compartment contains the APL and EPB tendons and the sec-
ond contains the ECRL and ECRB tendons. The EPL winds
around Lister tubercle and occupies the third extensor com-
partment. The EDC and EIP tendons run in the fourth com-
partment, the EDM runs in the fifth compartment—the only
fibrous compartment—and the ECU runs in the sixth com-
partment (Figure 78.1).3
Over the dorsum of the hand, there are bands, the junctu-
rae tendinae, that connect the ring EDC tendon to the EDC
of the middle and small fingers, as well as from the middle to
the index finger.4 The EIP and EDM tendons lie ulnar to their
respective EDC tendons and insert at the level of the metacar-
pophalangeal joint (MCPJ).
At the MCPJ, the extensor tendon is held in position
FIGURE 78.1. Dorsal wrist compartments. APL, abductor pollicis lon-
by the sagittal bands, a sling that arises from the volar gus; EPB, extensor pollicis brevis; ECRL, extensor carpi radialis longus;
plate of the MCPJ and intermetacarpal ligaments.5 These ECRB, extensor carpi radialis brevis; EPL, extensor pollicis longus; EIP,
bands facilitate extension of the MCPJ through a lasso extensor indicis proprius; EDC, extensor digitorum communis; EDM,
effect around the base of the proximal phalanx. The exten- extensor digiti minimi; ECU, extensor carpi ulnaris.
sor tendon becomes broad and thin over the dorsum of the
792
Chapter 78: Extensor Tendon Surgery 793
I DIP joint
II Middle phalanx
III PIP joint
IV Proximal phalanx
V MP joint
VI Metacarpal
VII Extensor
retinaculum
VIII Distal forearm
FIGURE 78.2. Extensor tendon complex over the dorsum of a digit.

EDC, extensor digitorum communis.
belly. Intramuscular branching of the nerve in the muscle may IX Musculotendinous

occur,10 and this allows independent index finger extension junction
following EIP harvest for tendon transfer.
FIGURE 78.3. Zones of injury for the extensor system. DIP, distal inter-
Extensor Tendon Injuries phalangeal; PIP, proximal interphalangeal; MP, metacarpophalangeal.
Finger extension is achieved through a balance of two sepa-
rate systems—the radial nerve innervated extrinsic exten-
sors and the intrinsic muscles, innervated predominantly by
the ulnar nerve, with some contribution from the median
the variable interconnections between the EDC tendons
nerve. Distal to the MCPJ, the extensor tendon is thin,
over zone 6.8 This has to be taken into account when
making core repairs difficult. Furthermore, there is a pre-
assessing patients with dorsal hand lacerations. Surgical
cise balance between the various components of the tendon
exploration is frequently the best way to determine if the
during movement, which is difficult to restore following
EDC tendon has been cut.
injury.6 Although there is more excursion of the tendon at
II. Testing for the EPL—The EPL tendon functions mainly
the level of the wrist, there is minimal excursion at the level
to extend the IPJ of the thumb. It also extends the
of the PIPJ and DIPJ, with 0.6 mm of excursion for every
Hand
MCPJ (together with the EPB) and the carpometacarpal

10° of movement at the DIPJ; hence, tendon shortening at
joint (together with the APL), and it adducts the thumb
this level from tendon repair will result in significant loss of
toward the palm when the thumb is in full extension.
movement.11
However, the EPB, APB, and FPB can also cause IPJ
Extensor tendon injuries are classified based on eight
extension due to their insertion on the extensor appara-
anatomical zones described by Kleinert and Verdan.12 Odd
tus. Hence, the best way to assess for EPL function to ask
numbered zones are located over the joints, whereas even
the patient to lift the thumb up while the palm placed flat
numbered zones are found in between (i.e., zone 1 lies over
on a table (Figure 78.4).
the DIPJ, zone 3 over the PIPJ, zone 5 over the MCPJ, etc.)
III. Testing for a closed central slip rupture—This test was
(Figure 78.3). In the thumb, the interphalangeal joint (IPJ) is
first described by Elson.13 The PIPJ of the patient is maxi-
zone 1 and MCPJ is zone 3.
mally flexed by the examiner and the patient asked to
Several difficulties and pitfalls in the clinical assess-
extend the PIPJ while the examiner resists (Figure 78.5).
ment of patients with acute extensor tendon injuries are
Should the central slip be ruptured, minimal extension
highlighted:
power is felt at the PIPJ while more power is felt at the
I. Juncturae tendinae—Digit extension at the MCPJ may DIPJ because of the force generated through the intact
still be possible after complete EDC laceration because of lateral bands.

794 Part VIII: Hand
Table 78.1
Classification of Mallet Finger Deformities
Type I Closed injury, with or without a small avulsion

fracture
Type II Open injury, tendon laceration
Type III Open injury, with loss of skin and tendon
substance
Type IV Mallet fractures
A Transphyseal fractures in children
B Hyperflexion injury with fracture involving
20–50% of the articular surface
C Hyperflexion injury with fracture of the articular
surface of greater than 50% and with early or late
volar subluxation of the distal phalanx
FIGURE 78.4. Testing of EPL function by asking the patient to place
the palm flat on the table and lift the thumb.
the joint can be splinted internally using a Kirschner wire for
patients who cannot tolerate an external splint or for patients
who must continue working, such as a surgeon. Patients are
Management of Acute advised to continue moving the PIPJ while the DIPJ is splinted.
Long-term, slight extensor lag of 10° is to be expected follow-
Extensor Tendon Injuries ing conservative treatment, and patients are counseled about
this limitation at the start of treatment.16 A similar splinting
Zone 1 Injuries protocol can also be used for patients with closed thumb mal-
Injuries over the DIPJ (zone 1 injuries) have been classified let injuries.17
into four types by Doyle (Table 78.1).14 Type I or closed inju- Type II injuries are lacerations that involve the tendon and
ries are the most common and can be treated by splinting the can be treated with wound debridement and repair of the skin
DIPJ in extension for 6 to 8 weeks, followed by night splinting and tendon. The sutures can be used to catch and oppose
for another 6 weeks. Patients presenting a few months after both the skin and the tendon at the same time, or they can
injury can still be treated using this technique.15 Alternatively, be repaired separately. This is followed by splinting just as in
type I injuries.
Type III injuries are those with loss of skin and tendon and
may require skin coverage and/or tendon grafts. Postoperative
splinting of the DIPJ is required for 6 weeks and is more eas-
ily accomplished using a Kirschner wire to avoid the need for
splint removal during dressing changes, and with it the risk of
jeopardizing the tendon repair.
Type IV injuries include fractures of the distal phalanx.
Type IVA injuries, also known as Seymour’s fractures, are
fractures through the physis in children.18 Open fractures must
be sought under the eponychial fold where they can be hid-
den by the overlying nail plate. Open wounds are debrided,
irrigated, and the fracture treated with an axial Kirschner
wire that spans the DIPJ. Type IVB fractures involve between
20% and 50% of the joint surface and type IVC fractures
involve more than 50% of the joint surface and have volar
subluxation of the distal phalanx. Both operative treatment
with extension block pinning and nonoperative treatment
with splints are acceptable, with no technique of interven-
tion clearly superior to the other.19 Surgical fixation is gener-
ally preferred, especially for patients with type IVC injuries,
because surgical intervention allows accurate restoration of
the articular surface and possibly reduces the risk of osteoar-
thritis developing in the future.
Zone 2 Injuries
Repair of a laceration involving less than 50% of the exten-
sor tendon in zone 2 is not required, and active mobilization
can be commenced once the wound has healed. A laceration
involving more than 50% of the tendon is repaired with a run-
ning suture using a 5-0 nonabsorbable suture. It is not pos-
sible to place core sutures in the tendon in zone 2 because the
tendon is too thin. After repair, the DIPJ should be splinted
or pinned in extension for 6 weeks while the PIPJ is actively
FIGURE 78.5. Elson’s test for central slip integrity. mobilized. Zone 2 injuries of the thumb are treated in a
similar way.

(Figure 78.6). A thorough debridement and washout of
Zone 3 Injuries the joint should be done, and tendon repair deferred till the
The treatment for injuries in zone 3 depends on which com- wound is considered clean. Failure to recognize and treat these
ponent (central slip or lateral band) is injured, as well as the human bite injuries can result in septic arthritis and destruc-
extent of injury. Closed central slip injuries can be treated by tion of the MCPJ and tendon.21 Tendon lacerations in zone
pinning or splinting the PIPJ in extension for 6 weeks while 5 can be repaired with strong core 3-0 or 4-0 sutures supple-
the DIPJ is actively mobilized. If the central slip is avulsed mented with an epitendinous suture using 5-0 prolene.
with a large bone fragment, then fixation with a Kirschner Injuries involving the sagittal band of the extensor tendon
wire or screw is required. can result in subluxation of the tendon to the side opposite
Open zone 3 injuries frequently breach the joint capsule to the injury. Closed ruptures are seen more frequently than
and involve the PIPJ, so a proper debridement is performed open lacerations, and subluxation takes place after more
prior to tendon repair. Lacerations involving just one lateral than two-thirds of the proximal band is cut. Open injuries
band do not require repair, though lacerations that involve are treated by simple mattress sutures followed by buddy
more than 50% of the central slip should be repaired with splinting to the adjacent finger while allowing gentle mobi-
core sutures, if possible, or attached to the bone using bone lization. Closed sagittal band injuries can occur following
tunnels or a suture anchor if there is insufficient tendon sub- blunt trauma or resisted extension of the digit and often
stance distally. The PIPJ is pinned or splinted in extension. involve the radial side of the middle and ring fingers. The
Chronic central slip injuries can result in boutonniere defor- patient may complain of a snapping sensation on flexion
mities, and the management is discussed later in this chapter due to the tendon subluxing, and the finger may be adducted
and in Chapter 91. ulnarly. In addition, the patient may have difficulty initiat-
ing extension when the MCPJ is in full flexion even though
Zone 4 Injuries the tendon is in a central position during full extension.22
When assessing these injuries, the opposite hand should be
The extensor tendon is draped over much of the dorsal and examined as patients with hyperlaxity have nonpathologic
lateral surfaces of the proximal phalanx; hence, lacerations tendon subluxation. Patients with closed sagittal band inju-
over the dorsum or open fractures often result in injuries to ries seen within 3 weeks of injury can be treated with flex-
the extensor tendon. Lacerations involving more than 50% ion block splints that limit flexion of the MCPJ and allow
of the tendon can be repaired using core sutures through the the tendon to heal in the reduced position. Active MCPJ and
thicker central slip and lateral bands using 4-0 prolene, supple- PIPJ movement is allowed within the splint, which should be
mented with a continuous running repair using 5-0 prolene.20 worn continuously for up to 8 weeks.23 Patients seen after
Postoperatively, early motion can be started with dynamic 3 weeks, and those who have failed conservative treatment
extension splint in order to minimize adhesions. Alternatively, with splinting, are treated surgically. Several techniques of
static splinting is instituted for 4 weeks before mobilization is surgical repair have been described for reconstruction of sag-
commenced. ittal band injuries, and these include direct repair or the use
Thumb zone 4 injuries occur over the metacarpal, where of slips of the EDC or juncturae tendinae as slings to central-
the tendons are thick enough to perform standard repairs with ize the tendon.
core sutures using 3-0 or 4-0 sutures supplemented by epiten- Zone 5 of the thumb lies over the wrist. Injuries to the
dinous repairs using 5-0 prolene. This is followed by protected extensor tendon here can be treated with core suture repairs
early motion postoperatively. supplemented with epitendinous sutures, followed by splint-
ing and protected active mobilization.
Zone 5 Injuries
Lacerations over the MCPJ are approached with caution
because they are often human bites, resulting from a “punch” Zone 6 Injuries
to the mouth, with the teeth causing a penetrating injury. Complete laceration of an EDC tendon in zone 6 may not
Patients often omit the history of a fight, and the external result in an extensor lag at the MCPJ because of the juncturae
wound may appear small and innocuous. Most bite wounds tendinae that interconnect the EDC tendons. It is advisable,
involve the MCPJ, and a careful wound exploration is per- therefore, to surgically explore lacerations on the dorsum
formed to look for breach in the dorsal capsule of the joint of the hand. Because the extensor tendons are thick in zone 6,
Hand
A B
FIGURE 78.6. Human bite injury after a fight with breach of the joint capsule (arrow). A. Pre-op appearance. B. Intraoperative appearance.

796 Part VIII: Hand
core suture repair followed by an epitendinous suture are per- PIPJ. Synovitis at the PIPJ can cause attenuation of the
formed. Good outcomes can be expected for zone 6 tendon volar plate and TRL, which allows dorsal translation of
repairs because strong repairs can be performed, allowing the lateral band, as well as destruction of the flexor digi-
aggressive rehabilitation, and there is also adequate soft tissue torum superficialis insertion. This allows hyperextension
coverage. of the PIPJ, which in turn results in increased tension in
the flexor digitorum profundus tendon, as well as loss
Zone 7 Injuries of tension in the lateral bands, resulting in DIPJ flexion.
To perform tendon repairs in zone 7, the extensor retinacu- Over time, adhesions develop and convert this into a fixed
lum is opened to gain access to the extensor tendons. A “Z” deformity.
or oblique incision is used to facilitate repair of the extensor MCPJ. Synovitis at the MCPJ can lead to weakening of the
retinaculum following repair. Tendon repair can be performed insertion of the long extensors into the base of the proximal
using similar techniques as in zone 6, though the surgeon must phalanx, causing the force to be transmitted to the base of the
be prepared to extend the wound to the forearm in order to middle phalanx, resulting in PIPJ hyperextension. The syno-
retrieve retracted tendons. The EPL tendon should be trans- vitis can also cause weakening of the volar plate, resulting in
posed subcutaneously following repair of the ECRL/ECRB to subluxation of the MCPJ, allowing adhesion and later short-
protect it from the suture knots of the tendon repair as this ening of the intrinsic muscles, further contributing to the PIPJ
can result in tendon rupture. hyperextension and SND.
Zone 8 Injuries DIPJ. Rupture of the terminal extensor tendon, which can
Injuries at the level of the musculotendinous junction or in occur following trauma or due to synovitis, allows proxi-
the muscle are difficult due to the poor suture holding in mus- mal migration and relaxation of the lateral bands. Extensor
cles.24 Repair of the intramuscular tendon can be performed power is then concentrated on the central slip, resulting in
and augmented by a repair of the muscle belly, followed by PIPJ hyperextension and SND as the volar restraints weaken
static splints postoperatively. In addition, the PIN should be over time.
explored and the intra- and extra-muscular portions repaired,
especially for proximal injuries, because this will help preserve
Wrist. Synovitis at the wrist can result in carpal collapse,
carpal supination, and ulnar translation. Carpal collapse
function of the distal muscles (EPL, EIP, APL, and EPB).25
causes relative lengthening of both long flexors and extensors,
allowing the intrinsic muscles to overpower their action and
Rehabilitation Following cause MCPJ flexion and PIPJ extension, which in time can
Tendon Repair lead to an SND.
SNDs have been classified by Feldon et al. into four types,
Unlike flexor tendons, the extensor tendon in zones 1 and 2 is depending on PIPJ mobility and the condition of the joint sur-
thin, making strong tendon repairs with core sutures difficult. faces, that determine surgical treatment28 (Table 78.2). The
Furthermore, core sutures will also cause tendon shortening main objective is to restore active flexion at the PIPJ if pos-
and excessive bulk of the repair. Hence, static splinting for sible, or to fuse the joint in a functional position should this
6 to 8 weeks is normally required following tendon repair in not be possible.
zones 1 and 2.25 The tendon in zones 4 to 8 is thicker and ame-
nable to strong tendon repairs; hence, early protected mobili-
zation with dynamic splinting or controlled active movement Boutonniere Deformities
is possible.26 Complications encountered following extensor Boutonniere deformities are characterized by a flexion defor-
tendon repair include extensor lag, which can be due to failure mity of the PIPJ, with reciprocal extension at the MCPJ and
of the tendon repair, stretching of the tendon, or tendon adhe- DIPJ. It is more an aesthetic than a functional problem, because
sions. Conversely, there can be loss of flexion, which can be patients can still make fists and grasp objects. Boutonniere
due to adhesions or excessive tensioning of the tendon repair. deformities develop due to pathology at the PIPJ alone, unlike
Tenolysis can be considered 6 months after surgery if there is SND. Initially, the central slip becomes dysfunctional, due to
no further improvement with therapy. either an injury or attenuation secondary to synovitis from
inflammatory disorders like rheumatoid arthritis. Second, the
triangular ligament stretches and allows the lateral bands to
Chronic Extensor Tendon sublux in a volar direction, maintaining persistent PIPJ flex-
Problems ion. The ruptured central slip also allows the force from the
lumbricals and interosseous muscles to be transmitted directly
Four chronic conditions that affect the extensor tendon sys- to the distal phalanx, resulting in DIPJ extension. Over time,
tem are addressed in this section: a chronic boutonniere deformity with fixed joint contractures
1. Swan neck deformity (SND) develops.
2. Boutonniere deformity Boutonniere deformities can be classified into four
3. Tendon loss and tendon grafts stages 29 (Table 78.3). Stages I and II can be treated with
4. Attritional tendon rupture and tendon transfers splinting, 30 to achieve full PIPJ extension while DIPJ pas-
sive flexion exercises are done. Splinting should be con-
tinued for at least 2 to 3 months to gain the maximum
Swan Neck Deformities (Chapter 91) possible correction, and surgical release of the joint consid-
SNDs are characterized by PIPJ hyperextension, with recipro- ered only if splinting fails, especially for stage III disease.
cal flexion at the DIPJ and MCPJ, and it can be caused by Any tendon surgery should be delayed until good passive
a variety of conditions, from rheumatoid arthritis to cerebral motion of the joint is restored. Options include central
palsy. A patient with SND has impaired function due to an slip reconstruction, distal extensor tenotomy, and lateral
inability to make a full fist due to loss of PIPJ flexion. band mobilization. Care must be taken not to jeopardize
SNDs can develop due to pathology at the PIPJ, DIPJ, MCPJ, flexor function in an effort to restore PIPJ extension, since
or the wrist. Hence, it is important to understand how pathol- this will result in a greater functional deficit than the
ogy at each of these joints can contribute to the deformity.27 Boutonniere deformity.

Table 78.2
Classification for Swan Neck Deformities
n Type n MCPJ n PIPJ n DIPJ

I Dermadesis Fusion
(PIPJ flexible in all positions) FDS sling
Littler ORL reconstruction
II Intrinsic release As for type I As for type I
(PIPJ flexion limited in certain positions)
III s for type I
A s for type I
A As for type I
(Limited PIPJ flexion in all positions) Plus Plus
MCPJ reconstruction as needed PIPJ manipulation Skin release
Check flexor tendons
IV As for type III s for type III
A As for type I
(Stiff PIPJ with poor radiographic Plus
appearance) Arthroplasty or fusion
MCPJ, metacarpophalangeal joint; DIPJ, distal interphalangeal joint; PIPJ, proximal interphalangeal joint; FDS, flexor digitorum superficialis; ORL,
oblique retinacular ligament.
In chronic zone 6 tendon injuries, tendon transfers may

Extensor Tendon Loss and Tendon Grafts not be required, with side-to-side repairs of the EDC sufficient
Tendon grafts are indicated in cases where there is loss of ten- to restore function. At times, surgical repair may not even be
don substance but there remains a functional neuromuscular necessary if the function has been adequately substituted by
unit. The most commonly used tendon graft is the palmaris lon- adjacent tendons via the juncturae.
gus, due to its ease of harvest and minimal donor-site morbid-
ity. Tendon grafting should be performed in a well-vascularized
and noninfected bed, with good passive range of movement of References
the joints that the tendon crosses. Frequently, tendon loss in 1. Abrams RA, Ziets RJ, Liever RL, et al. Anatomy of the radial nerve motor
dorsal hand injuries is accompanied by soft tissue loss and soft branches in the forearm. J Hand Surg (Am). 1997;22:232-237.
2. Botte MJ. Muscle anatomy. In: Doyle JR, Botte MJ, eds. Surgical Anatomy
tissue reconstruction is required before tendon grafting. of the Hand and Upper Extremity. Philadelphia, PA: Lippincott Williams &
Wilkins; 2002:92-184.
Attritional Tendon Rupture and 3. Palmer AK, Skahen JR, Werner FW, et al. The extensor retinaculum
of the wrist: an anatomical and biomechanical study. J Hand Surg (Br).
Tendon Transfers 1985;10:11-16.
4. Von Shroeder HP, Botte MJ. The functional significance of the long
The most common tendon transfers for extensor function extensors and juncturae tendinum in finger extension. J Hand Surg (Am).
include those done to restore thumb, digit, and wrist exten- 1993;18L:641-647.
sion following radial nerve injuries or following attrition rup- 5. Young CM, Rayan GM. The sagittal band: anatomic and biomechanical
tures due to rheumatoid arthritis or following distal radius study. J Hand Surg (Am). 2000;25:1107-1113.
6. Harris C Jr, Ruteledge GL Jr. The functional anatomy of the extensor mech-
fractures. Attrition ruptures following distal radius fractures anism of the finger. J Bone Joint Surg Am. 1972;54:713-726.
can occur whether the fractures are treated with a cast or with 7. Landsmeer JMF. The anatomy of the dorsal aponeurosis of the human fin-
internal fixation, whether with volar or dorsal plates.31 Often, ger and its functional significance. Anat Rec. 1949;104:31-44.
direct repair of the ruptured tendons cannot be performed due 8. Von Shroeder HP, Botte MJ. Anatomy of the extensor tendons of the
fingers: variations and multiplicity. J Hand Surg (Am). 1995;20:27-34.
to the excessive fraying of the tendon, and tendon transfers 9. Von Shroeder HP, Botte MJ. The extensor medii propius and anoma-
are required. Donor musculotendinous units for tendon trans- lous extensor tendons to the long finger. J Hand Surg (Am). 1991;16:
fer should have a low donor morbidity, synergistic functions, 1141-1145.
and similar excursion and force generation as the recipient. 10. Lim AY, Pereira BP, Kumar VP, et al. Intramuscular innervation of upper-
limb skeletal muscles. Muscle Nerve. April 2004;29(4):523-530.
The EIP tendon is an ideal donor to the EPL to restore thumb 11. Elliot D, McGrouther DA. The excursions of the long extensor tendons of
extension, because it has a synergistic action, is easily har- the hand. J Hand Surg Br. 1986 February;11(1):77-80.
vested, and has minimal donor morbidity. Independent index 12. Kleinert HE, Verdan C. Report of the committee on tendon injuries
finger extension is still possible after this transfer.32 (International Federation of Societies for Surgery of the Hand). J Hand Surg
(Am). 1983;8:794-798.
Hand
13. Elson RA. Rupture of the central of the extensor hood of the finger: a test
for early diagnosis. J Bone Joint Surg Br. 1986;68:229-231.
Table 78.3 14. Doyle JR. Extensor tendon – acute injuries. In: Greed D, ed. Operative
Hand Surgery. 4th ed. New York, NY: Churchill Livingstone; 1999:
Stages of Boutonniere Deformity 195-198.
15. Garberman SF, Diao E, Peimer CA. Mallet finger: results of early versus
Stage I Supple, passively correctable deformity delayed closed treatment. J Hand Surg (Am). 1993;19:850-852.
16. Okafor B, Mbubaegbu C, Munshi I, et al. Mallet deformity of the fin-
Stage II Fixed contracture with contracted lateral ger: five-year follow-up of conservative treatment. J Bone Joint Surg Br.
bands 1997;79:544-547.
17. Patel MR, Lipson LB, Desai SS. Conservative treatment of mallet thumb.
Stage III Fixed contracture with joint fibrosis, J Hand Surg (Am). 1989;14:674-678.
18. Seymour N. Juxta-epiphyseal fracture of the terminal phalanx of the finger.
collateral ligament, and volar plate J Bone Joint Surg Br. 1966;48:347-349.
contractures 19. Handoll HH, Vaghela MV. Interventions for treating mallet finger injuries.
Cochrane Database Syst Rev. 2004;(3):CD004574.
Stage IV Stage III plus PIPJ arthritis 20. Strauch RJ. Extensor tendon injury. In: Wolfe SW, Hotchkiss RN,
PIPJ, proximal interphalangeal joint. Pederson WC, Kozin SH, eds. Greens Operative Hand Surgery. 6th ed.
New York, NY: Elsevier Churchill Livingstone; 2011:159-188.

798 Part VIII: Hand
21. Chadaev AP, Jukhtin VI, Butkevich AT, et al. Treatment of infected clench- dynamic splint in the rehabilitation of repaired extensor tendons. J Hand
fist human bite wounds in the area of the metacarpophalangeal joint. Surg (Br). 2002;27:283-288.
J Hand Surg (Am). 1996;21:299-303. 28. Sebastin SJ, Chung KC. Reconstruction of digital deformities in rheumatoid
22. Rayan GM, Murray D. Classification and treatment of closed sagittal band arthritis. Hand Clin. 2011;27(1):87-104.
injuries. J Hand Surg (Am). 1994;19:590-594. 29. Feldon P, Terrono AL, Nalebuff EA, et al. Rheumatoid arthritis and other
23. Catalano LW 3rd, Gupta S, Ragland R 3rd, et al. Closed treatment of non- connective tissue diseases. In: Green DP, ed. Operative Hand Surgery. 4th
rheumatoid extensor tendon dislocations at the metacarpophalangeal joint. ed. New York, NY: Churchill Livingstone; 1999:1651-1739.
J Hand Surg (Am). 2006;31:242-245. 30. Burton RI. Extensor tendon – late reconstruction. In: Green DP, ed.
24. Takami H, Takahashi S, Ando M, et al. Traumatic rupture of the exten- Operative Hand Surgery. New York, NY: Churchill Livingstone; 1988:
sor tendons at the musculotendinous junction. J Hand Surg (Am). 2073-2116.
1995;20(3):474-477. 31. Littler JW, Eaton RG. Redistribution of forces in the correction of bouton-
25. Lim AY, Lahiri A, Pereira BP, et al. The role of intramuscular nerve niere deformity. J Bone Joint Surg (Am). 1967;49:1267-1274.
repair in the recovery of lacerated skeletal muscles. Muscle Nerve. March 32. Benson EC, DeCarvalho A, Mikola EA, Veitch JM, Moneim MS. Two
2006;33(3):377-383. potential causes of EPL rupture after distal radius volar plate fixation. Clin
26. Purcell T, Eadie PA, Murugan S, et al. Static splinting of extensor tendon Orthop Relat Res. 2006;451:218-222.
repairs. J Hand Surg (Br). 2000;25:180-182. 33. Moore JR, Weiland AJ, Valdata L. Independent index extension and
27. Chester DL, Beale S, Beveridge L, et al. A prospective, controlled, random- strength after extensor indicis propius transfer. J Hand Surg (Am).
ized trial comparing early active extension with passive extension using a 1987;12:232-236.

Chapter 79 n Tenosynovitis Disorders of
The Upper Extremity
Mary C. Burns And Michael W. Neumeister
Tendonopathies of the upper extremity are extremely com- cumulative injury, and strain of the common extensor ori-
mon disorders encompassing a large variety of conditions gin at the lateral epicondyle. Continued use of the upper
from tendon strains to ruptures or lacerations. The most extremity results in continued strain and re-injury to the
common tendinopathy is tenosynovitis or inflammation of muscle origins. 4,5 This can lead to degeneration and pos-
the tendon sheaths. Inflammation may arise from a num- sible avascularity at the muscle origin, which in turn, theo-
ber of causes as categorized in Table 79.1. It is important retically, leads to chronic inflammation causing the injured
to understand that inflammation is a continuous process areas to remain weak and painful. Ironically, however,
that involves a cascade of events leading to variable clinical inflammation is not a characteristic histologic finding of lat-
symptoms and signs. Acute inflammation involves a vascular eral epicondylitis, but fibrosis and mucinoid degeneration of
response, fluid exudate and swelling, cellular exudate with the origin of the extensor muscles have been documented.6
phagocytosis, and alterations in tissue composition. The exu- Table 79.2 highlights the histologic changes observed at the
dates associated with inflammation differ from normal inter- origin of the extensor muscles of the forearm.
stitial fluid by having a greater protein content and higher Patients generally present with pain and localized ten-
specific gravity (over 1.020).1 derness of the extensor origin and lateral epicondyle of the
The fate of acute inflammatory conditions, however, humerus (Figure 79.1). The onset may be acute or insidious,
depends upon the treatment and cessation of the inciting and it is more common in males between 40 and 50 years of
caustic agent or activity. Upon cessation, the inflamma- age. Generally, there is increased pain with wrist extension or
tion may resolve completely leaving normal tissues behind. with gripping. Activities requiring full elbow extension and
Alternatively, the acute inflammatory response may result in a forearm pronation aggravate the discomfort that may radi-
number of pathologic states, including (A) organization of the ate down the posterior forearm or proximally over the lateral
exudate leading to fibrosis, (B) tissue destruction and second- upper arm above the elbow. The pain may also be accentuated
ary healing by repair/scarring, (C) chronic inflammation, and by extreme wrist flexion from the passive stretch of the ECRB
(D) in the case of infection, suppuration. muscle or by active contraction of the wrist extensors.
During the initial examination of the patient, the surgeon
should also evaluate the range of motion (ROM) of the elbow,
Lateral EPicondylitis assess crepitus of the radiohumeral joint, observe for bursitis
Lateral epicondylitis, or tennis elbow, is a common condi- and osteochondritis of the capitellum, and rule out radial tun-
tion of the lateral elbow. First described in 1873 by Runge, nel or posterior interosseous nerve entrapment.
lateral epicondylitis is the direct result of strain at the fascia There is limited value in obtaining further diagnos-
and origin of the extensor muscles of the forearm.2 Active tic studies for lateral epicondylitis. One may consider plain
extension against resistance, such as occurs when one hits radiographs if degenerative elbow changes are considered or
a tennis ball with a back hand shot (hence the term “tennis identified on physical exam. Similarly, magnetic resonance
elbow”), presumably results in microtrauma to the origin imaging scans may identify articular pathology or masses, but
of the extensor carpi radialis brevis (ECRB), the extensor generally these tests are not indicated for clinically confirmed
digitorum communis (EDC), and the extensor carpi ulnaris. lateral epicondylitis. Nerve conduction and electromyogram
Although the specific etiology is unknown, 3 it is postu- studies may be useful if radial tunnel or posterior interosseous
lated that this disease results from micro-tears at the origin nerve entrapment is suspected. These nerve entrapments are
of the common extensor muscle mass. Many reports believe not uncommonly found in patients with lateral epicondylitis.
that these small tears are caused by overuse, repetitive or Injecting a local anesthetic agent around the extensor origin
and lateral epicondyle confirms the diagnosis but the diagno-
sis is usually made at physical exam. The lateral epicondyle
TABLE 79.1 and the proximal radius are the origins of the extensor mus-
Etiology Of Inflammation Of Tendons Or cles of the forearm. The extensor carpi radialis longus (ECRL)
Tendon Sheaths
Hand
Mechanical TABLE 79.2

Acute trauma Histologic Features At The Lateral Epicondyle In
Repetitive trauma Patients With Lateral Epicondylitis
Reactive Hyaline degeneration (Reference Goldby, Reagan)

Chemical Angiofibroblastic hyperplasia (Reference Goldby, Nirschl)
Radiation Collagen disarray
Tissue necrosis Neovascularization/angiogenesis
Thermal Microscopic tears
Infectious Fibrosis
Immunologic Mucoid degeneration
799
800 Part VIII: Hand
amount of pressure. Maximum contraction of the wrist exten-

sors is avoided. A brace that is applied too tightly may result
in swelling of the distal forearm and hand, compression of
the posterior interosseous nerve, and pain. When lateral epi-
condylitis is severe, complete immobilization may be neces-
sary. A wrist cock-up splint or even a long-arm splint with
the elbow at 90° of flexion may be warranted. The Richard
wrist cock-up splint maintains the wrist in extension to off-
load the extensors. Orthoses have been described in various
positions ranging from neutral to 45° of wrist extension. The
rigid wrist orthosis, however, is fraught with noncompliance
and is therefore limited to only the more severe cases of lateral
epicondylitis.
Steroid injections have been utilized for the treatment for
lateral epicondylitis. The duration of the effects of the ste-
roid injection, however, is variable.7 Most patients respond
favorably within the first 6 weeks but recurrence of the pain
Figure 79.1. Location of pain in “tennis elbow.” Lateral epicondy-
litis is characterized by point tenderness over the lateral epicondyle.
is common. The steroid is injected at the site of the maxi-
The patients often complain of weakness, pain on wrist extension, mum tenderness at the lateral epicondyle. Typically, 1 cc
and lateral elbow pain. of dexamethasone or Kenalog is injected into this area. No
significant difference has been demonstrated between differ-
ent steroid preparations. Most surgeons wait for a period
of 2 to 3 months before re-injection at this site and limit
has its origin just above the lateral epicondyle on the humerus the number of injections to 3 or 4, mostly because of the
and the intermuscular septum. The ECRB originates from the secondary effects of the steroids on the overlying soft tis-
lateral epicondyle (common extensor origin) and the lateral sue. The steroid injections can result in significant atrophy
ligament of the elbow. of the fat and overlying skin and may also result in hypo-
The natural history of lateral epicondylitis is variable. pigmentation of the area.
Many authors believe that over time (1 to 2 years), the condi- Some authors have tried platelet-rich plasma or even the
tion burns itself out and therefore no specific treatment may patient’s own blood injected into the lateral epicondyle. Gossen
be warranted. The level of discomfort, however, dictates the et al. compared corticosteroid with platelet-rich plasma injec-
treatment. If the condition is mild, and the patient can tol- tions in patients with refractory lateral epicondylitis for at
erate benign neglect, improvement with anti-inflammatory least 6 months.7 The long-term outcomes were similar in both
medication is probable. In general, patients are offered physi- groups following the injections but it was generally felt that
cal therapy, splinting, and oral anti-inflammatory medication. the corticosteroid injection was more effective in reducing
The physical therapy regimen includes stretching the exten- the pain in the short term. Autologous blood injections were
sor muscle origin and gradual loading. Counterforce braces thought to initiate an inflammatory response at the lateral epi-
or forearm support bands are common splints utilized for condyle with subsequent fibrosis that improved the condition
lateral epicondylitis (Figure 79.2). The counterforce brace by decreasing strain at the origin. Edwards and Calandruccio
essentially changes the origin of the muscles to a more distal injected autologous blood in 28 patients and demonstrated
site. The brace acts to decrease the force of muscle contraction an 80% reduction in pain over 9 months.7 Missra and Delco
by inhibiting muscle expansion, thereby reducing tension at injected buffered platelet-rich plasma into patients with lateral
the origin of the muscle. This essentially off-loads the mus- epicondylitis with similar findings comparing corticosteroid
cle origin, prevents repetitive trauma at this site, and allows and the platelet-rich plasma.7
healing. Most therapists will have patients wear the counter- Botulinum toxin A has been injected into extensor muscles
force brace throughout the day, particularly when perform- to induce paralysis as a means of off-loading the muscle’s ori-
ing activities utilizing the extensor muscles. The brace can be gin.8 Other topical agents have been used for lateral epicondy-
removed during periods of inactivity and when they are sleep- litis, including topical nitrates, steroid creams, and salicylate
ing. The brace is typically applied approximately 2 cm distal creams; however, no randomized controlled studies have been
to the lateral epicondyle and should fit with a comfortable performed with these agents.17
Surgery For Lateral Epicondylitis

The surgical treatment for lateral epicondylitis is restricted
to those patients who have failed conservative measures and
have been treated for 6 months to a year or are significantly
disabled as a result of the discomfort.
A 2 to 3 cm incision is made over the lateral epicondyle
and the extensor fascia is incised. Any degenerative muscle or
granulation tissue is debrided. The prominent lateral epicon-
dyle is shaved with an osteotome. Care is taken not to disrupt
the collateral ligament of the elbow. Hemostasis is secured
and the fascia is repaired. The wounds are typically closed
with a resorbable sutures and a bulky dressing is applied.
Variations to the procedure include resecting the sensory
nerves to the lateral epicondyle, transposing the anconeus
muscle over the shaved epicondyle. To denervate the lateral
epicondyle, the incision is usually extended proximally to
Figure 79.2. Nonsurgical treatment for lateral epicondylitis. identify the arcade of nerves that innervate the lateral epi-
A static band at the origin of the ECRB off-loads the epicondyle. condyle in the elbow. The nerves are resected and allowed to
retract proximally or are buried in the brachialis muscle.8

Chapter 79: Tenosynovitis Disorders of the Upper Extremity 801
or the patients’ symptoms may not resolve subsequent to the
De Quervain’S Tenosynovitis surgery. The release of the first dorsal wrist compartment is
The anatomy of the first dorsal compartment is variable. There extended to the basilar joint and then proximally into the
may be multiple slips of the abductor pollicis longus (APL) forearm. This procedure can be performed under local anes-
tendon which may insert in a variety of locations around the thetic, regional anesthesia and is often considered an office
basilar joint, including the thumb metacarpal, the trapezium, procedure. Following closure of the wound, a gentle wrap is
the volar carpal ligament, the opponens pollicis, and abduc- applied to the wrist and the patient is encouraged to start gen-
tor pollicis brevis (APB) (Figure 79.3). The extensor pollicis tle active and passive ROM the following day. Postoperative
brevis (EPB) tendon is also housed within the first dorsal com- physical therapy is usually not required but may have a role if
partment. The EPB tendon, however, may travel in its own hypersensitivity or if limited motion is noted.
separate compartment within the first dorsal compartment
along with the APL tendon. This septation of the EPB tendon Intersection Syndrome
seems to increase the probability of acquiring de Quervain’s
tenosynovitis, and it may also increase the probability that Intersection syndrome is a rare tendonitis syndrome observed
conservative measures will not be successful and that surgical at the junction of the outcropping muscles and the tendons
decompression is warranted. The treatment of de Quervain’s of the second dorsal compartment. The outcropping muscles
tenosynovitis is usually conservative at the first presentation. include the APL and the EPB as well as the extensor pollicis
Nonsteroidal anti-inflammatories, corticosteroid injections, longus muscles. The second dorsal compartment is comprised
and off-loading of the APL and EPB tendon are the mainstay of the ECRL and ECRB tendons. The area of intersection
of treatment in de Quervain’s tenosynovitis. Failing all nonste- between these two compartments is approximately 4 cm prox-
roidal anti-inflammatories, most patients should receive a trial imal to the radial carpal joint (Figure 79.5). Patients present
of corticosteroid injections into and around the first dorsal with pain and swelling in this area. The most likely etiology
compartment. This steroid is injected around the radial sty- is that of repetitive trauma, such as using a hammer or any
loid, which is the site of greatest constriction. Most studies repetitive radial and ulnar deviation of the wrist as well as
quote steroid injections’ success rates of 50% to 80%.9,10 abduction and extension of the thumb. The tenderness and
Repeat injections may be required if the symptoms fail to swelling at the site of intersection occurs as the APL and APB
resolve. Most surgeons will offer second or third injections at tendons glide over the ECRL and ECRB tendons. The friction
3- to 4-month intervals. Corticosteriod injections, however, that arises from this intersection results in acute inflammation
may result in atrophy of the overlying soft tissue or hypo- and, in severe cases, may even have an audible crepitus on
pigmentation of the skin and may not be suitable for those with flexion and ulnar deviation of the wrist. There is some contro-
dark pigmentation. The surgical treatment for de Quervain’s versy about the true pathology that causes the pain. Crunburg
tenosynovitis requires an incision over the first dorsal com- and Regan felt that friction was not the etiology of the inter-
partment and its retinaculum to provide frictionless glide of section syndrome but rather a tenosynovitis of the second dor-
the APL and the EPB tendons. A longitudinal or transverse sal compartment alone.24,25
incision is made at the level of the radial styloid over the first Examination of a patient with intersection syndrome
dorsal compartment (Figure 79.4). The subcutaneous tissue reveals tenderness and swelling 4 to 6 cm proximal to Lister
is dissected with blunt dissection to avoid injury to the super- tubercle. Palpable or audible crepitus may be observed but sig-
ficial radial nerve which must be retracted to appropriately nificant pain is predictable on flexion and ulnar deviation of
visualize the thickened retinaculum over the first dorsal com- the wrist.
partment. The incision in the retinaculum is made on the dor-
sal aspect of the first dorsal compartment so that the released Treatment
APL tendon does not subluxate forwardly upon abduction
Intersection syndrome is usually self-limited. Off-loading the
of the thumb or flexion of the wrist (Figure 79.4B). The EPB
second dorsal compartment and the first dorsal compartment
must be identified and the potential separate secondary tunnel
is often sufficient to resolve the symptoms. Static wrist splint-
within the first dorsal compartment visualized and released
ing with the wrist in a neutral position is commonly preferred
by many therapists, although slight extension and abduction
of the thumb may also help off-load the offending tendons
(Figure 79.6). Nonsteroidal anti-inflammatories and occasion-
ally steroid injections have been employed. Surgical release of
intersection syndrome is rarely needed. If conservative modali-
ties fail to resolve the tenosynovitis, surgical decompression of
the second dorsal compartment and the outcropping muscles
is warranted. The procedure involves a longitudinal incision
6 cm proximal to the Lister tubercle on the extensor surface
Hand
of the forearm. The subcutaneous tissue is deepened with

blunt dissection to preserve the superficial sensory nerves and
veins. The second dorsal compartment is released freeing up
the ECRL and ECRB tendons. The fascia of the first dorsal
compartment is also released. Occasionally, the EPL fascia is
released as well. A distinct bursa over the muscle bellies or
tendons is usually not identified. After closure of the wound,
the wrist is wrapped in a soft dressing, which can be removed
in 48 hours and the patient can start active and passive ROM.
Prolonged splinting is not necessary.
Figure 79.3. Anatomy of de Quervain’s tendonitis. The first dor-

sal compartment houses the abductor pollicis longus and the extensor Trigger Finger
pollicis brevis. There may be multiple slips of the abductor pollicis
longus. The extensor pollicis brevis may also be compartmentalized in Trigger finger is also known as stenosing tenosynovitis and
a separate sheath within the first dorsal compartment. is one of the more common disorders of the hand. Stenosing
tenosynovitis of the thumb was first described in 1850 by

802 Part VIII: Hand
A B
Figure 79.4. Surgical release of the first dorsal compartment. A. A longitudinal incision (2.5 cm) is made along the first dorsal compartment to
expose the abductor pollicis longus and extensor pollicis brevis. B. The retinaculum of the first dorsal compartment is released on its dorsal side
to prevent tendon subluxation.
Notta and documented as a size discrepancy between the flex- Patients can present with variable stages of trigger fin-
ortendon and retinacular sheath, resulting in tendon entrap- ger. Table 79.4 describes Green’s classification of trigger
ment (Figure 79.7). The exact etiology of the trigger finger is finger. Tenderness over the A1 pulley is a common find-
unknown but it is commonly believed that thickening around ing often associated with an inability to grasp objects.
the A1 pulley, a nodule formation within the flexor tendon, Occasionally, there is swelling around the volar aspect of
or a combination of both results in active triggering of the the metacarpal head. The term triggering refers to a click-
finger as the fullness of the tendon catches on the thickened ing sensation the patient has as a result of the size discrep-
A1 pulley. As a result of the repetitive motion friction between ancy of the flexor tendon and the overlying retinaculum
the A1 pulley and the flexor tendons, the pulley may become sheath of the A1 pulley. Many patients believe that their
significantly thickened and undergo cicatricial fibrocartilagi- clicking is at the proximal interphalangeal (IP) joint, but
nous metaplasia. There is an upregulation of collagen type 3 in reality the pathology is at the A1 pulley site. As the con-
relative to the normal type 1 collagen found in the A1 pul- dition progresses, there is an active locking of the finger
leys. Other histologic changes at the A1 tendon sheath include as the flexor tendon is unable to glide back underneath
fibrous tissue without leukocyte infiltration, extracellular the A1 pulley to allow for extension of the finger. Further
mucoid collections, fraying, degeneration, cyst formation, and progression of the disorder results in the inability of the
lymphatic or plasma cell infiltration.11,12,13 The true underly- patient to even passively correct the locking of the finger
ing etiology of primary trigger finger is unknown. There are a in the flexed position. For unknown reasons, the ring fin-
number of associated conditions listed in Table 79.3 that may ger is the most commonly affected followed by the long
result in triggering. finger and the thumb. Approximately 20% of nondiabetic
Triggering is not always associated with a thickening of the patients have multiple digit involvement and women are
A1 pulley. The proximal aponeurotic pulley system may also be more commonly affected than men. A statistically signifi-
thick and result in triggering. The pain and discomfort is usually cant relationship between occupation and development of
associated with a more proximal site than the A1 pulley. idiopathic trigger finger has not been found.
Figure 79.5. Intersection syndrome. Inflammation in intersection Figure 79.6. Conservative treatment for intersection syndrome.
syndrome causes pain and tenderness approximately 4 to 10 cm prox- Anti-inflammatory agents and a splint that off-loads the first and
imal to the radial carpal joint. second dorsal compartments are employed.

TABLE 79.4
Classification Of Trigger Finger
Grade 1: Pretriggering associated with pain, history of

catching but not demonstrable on physician
exam; tenderness over the A1 pulley
Grade 2: At the demonstrable catching but the patient
(Active) can actively extend the digit
Grade 3: The demonstrable catching requiring passive
(Passive) extension (Grade 3) or inability to actively flex
(Grade 3b)
Grade 4: The demonstrable catching with a fixed flex-
(Contracture) ion contracture at the proximal interphalangeal
joint
Data from DP Green. Green’s Operative Hand Surgery. Vol. 2. 4th ed.
Philadelphia, PA: Churchill Livingstone; 1998:2029.
with an aberrant nodule within the flexor tendon which is

unable to pass underneath the A1 and oblique pulleys of
the thumb. Carpal tunnel and trigger finger are common
comorbid conditions.12 Diabetes is also associated with an
increased incidence of both conditions. Repetitive trauma
in overuse can result in inflammation around the A1 pul-
ley with significant swelling and constriction of the tendon
sheath. Free glide of the tendons is inhibited, friction is
increased, and greater inflammatory process ensues result-
ing in the thickening of the pulley. The hypovascular area
between the A1 and A2 pulleys compounds poor blood flow
and attrition to the tendons that may result in nodule for-
mation distal to the A1 pulley. Nodular fullness of the ten-
Figure 79.7. Trigger fingers. The A1 pulley of each digit is the site don forcibly rubs against the proximal distal edges of the A1
of pathology in trigger fingers.
pulley causing further inflammation, and pain is produced
by clicking or popping of the finger.12
Treatment
Reverse triggering is a condition why the finger has an Conservative measures in treating trigger finger include immo-
inability to flex because of the size discrepancy of the flexor bilizing the tendon, nonsteroidal anti-inflammatories, and ste-
tendon and the A1 pulley. In essence, the digit is locked in roid injection. In some cases, nonsteroidal anti-inflammatories
the extended position rather than the flexed position. Partial may relieve the symptoms and no further treatment is required.
tendon injury is the most common cause of reverse trigger- As the condition progresses, the tenderness and the triggering
ing. Congenital triggering of the thumb has been associated of the finger often respond to a single steroid injection. The
effectiveness of a single steroid injection ranges from 50% to
90%. Commonly used steroids include betamethasone, dexa-
methasone, methylprednisolone, and triamcinolone; however,
TABLE 79.3
little data support one corticosteroid over another. Ray et al.
Causes Of Trigger Finger compared dexamethasone with triamcinolone in a prospec-
tive randomized study and concluded that triamcinolone has
Idiopathic a faster onset but a shorter duration of action. The corticoste-
Rheumatoid arthritis roid is injected in and around the A1 pulley, with care taken
not to enter the flexor tendon. As the needle is introduced into
Hand
Gout the flexor tendon, resistance is felt within the syringe. The
Diabetes needle is drawn back until no resistance is noted and the ste-
roid is injected to bathe the A1 pulley. The duration of action
Partial flexor tendon lacerations of the corticosteroid is variable, ranging from weeks to years.
Mucopolysaccharide storage diseases Complications of corticosteroid injections include tenderness,
joint stiffness, bruising, fat atrophy, infection, pulley rupture,
Phalangeal exostosis and tendon rupture.
Anomalous lumbrical insertions Splinting for trigger finger is uncommon but may be
designed to restrict tendon glide through the A1 pulley until
Calcified tenosynovitis
the inflammatory process resolves. Atell et al. reported 77%
Giant cell tumors success rate with splinting in patients who presented with trig-
gering for 6 months or less.
Trauma
Hand-based splints that immobilize the metacarpo-
Acromegaly phalangeal joints in extension leaving the IP joints free
Synovial tumors are the most commonly used orthosis for trigger finger
(Figure 79.8).

804 Part VIII: Hand
in its entirety and the release may even include the leading
edge of the A2 pulley. Appropriate glide of the tendon should
be confirmed prior to closure of the wound. Appropriate skin
closure and soft dressing is applied, and immediate ROM is
initiated. The percutaneous release of the A1 pulley utilizes an
18G to 19G needle that is inserted over the A1 pulley while
the patient maintains the hand with the metacarpophalangeal
joint extended. The needle is inserted under local anesthetic
down to the A1 pulley which is then scored back and forth
with the double end of the needle to completely release the
pulley. Again, the patient should demonstrate no further
triggering following the procedure. The digital nerves of the
thumb and index finger may come to lie very close to the
entrance site of the needle; therefore, care must be taken not
to injury these nerves. Bain et al. reported superficial scoring
of the flexor digitorum superficialis tendon in 75 of 83 cadav-
Figure 79.8. Nonsurgical treatment of trigger finger. To off-load eric digits using percutaneous methods.16 Bain et al. as well as
the friction between the flexor tendon and the A1 pulley, a hand- Pope and Wolfe found incomplete releases in their cadaveric
based splint is designed to immobilize the metacarpophalangeal joints. studies and felt the technique should be used cautiously for the
thumb because of the proximity of the digital nerves.16,17
Complications have also been noted for the open surgical
technique for trigger release. Complications include stiffness,
tenderness, wound infection, incomplete release, bowstring-
Surgical Treatment ing, reflex sympathetic dystrophy, and digital nerve laceration.
Refractory triggering requires surgical release of the A1 pul-
ley. The two main types of release of the A1 pulley include
open incision and percutaneous release.11-15 The open tech-
Other Tendonopathies
nique utilizes a longitudinal or oblique 1.5-cm incision Other uncommon tendonopathies of the upper extremity
over the A1 pulley at the affected digit (Figures 79.9A–C). include flexor carpi radialis (FCR) tendonitis, flexor carpi
Subcutaneous tissue is deepened with blunt dissection down ulnaris tendonitis, extensor pollicis longus stenosing tendo-
to the flexor sheath. The A1 pulley is identified and transected vaginitis, and EDC tendonitis. The FCR has a rather thin
A B
Figure 79.9. Surgical release of trigger thumb. A. An oblique inci-

sion is made over the A1 pulley. B. The A1 pulley is exposed. C.
A longitudinal excision through the A1 pulley is made to fully release
the tendon.
C

synovial sheath in the forearm. As the FCR tendon dives dor- Following suture removal, scar massage and desensitiza-
sally under the trapezium, the fibrous canal thickens and may tion exercises may be initiated. Progressive strengthening may
result in stenotic tenosynovitis. The condition may be exac- be introduced at 3 to 4 weeks after surgery. In general, recov-
erbated by basilar joint osteoarthritis, scaphoid fractures, de ery after trigger finger release will only be 3 to 4 weeks; how-
Quervain’s tenosynovitis, and volar ganglion. Conservative ever, it is important to inform the patient that it may take up
treatment is commonly employed successfully. Wrist splinting to 6 months for all of the swelling, stiffness, and tenderness in
in a neutral position, nonsteroidal anti-inflammatory medica- the palm at the incision site to completely go away.
tion, and occasional steroid injections are common treatment
options for FCR tendonitis, which usually presents with ten-
derness directly over the distal aspect of the FCR tendon. De Quervain’S Release
Occasionally, patients also have tenderness on flexion of the Edema control and active and passive ROM exercises are
wrist or on forced extension of the wrist. Failing conservative occasionally required after de Quervain’s release. Exercises
measures, surgical release involves dividing the sheath through should include wrist flexion and extension as well as wrist
a longitudinal incision over the FCR. radial and ulnar deviation. The ultimate goal of ROM exer-
The treatment option for tenosynovitis of the third, fourth, cises will be to gradually achieve a pain-free Finkelstein’s posi-
fifth, or sixth dorsal compartments is similar to that of the tion of thumb flexion with wrist ulnar deviation. Initially, a
first dorsal compartment. thumb spica splint may be fit for up to 2 weeks after surgery
to prevent subluxation of the APB and EPB in the first dorsal
Postoperative Care compartment after release.
One significant postoperative complication that may occur
Rehabilitation goals following postoperative treatment of
following de Quervain’s release is irritation/injury to the dorsal
tendonopathies include monitoring wound status, decreasing
sensory branch of the radial nerve (DSBRN). Hypersensitivity
edema and inflammation, desensitization exercises to decrease
of this nerve can be quite painful for the patient and can
hypersensitivity, increasing ROM, facilitating tendon glide,
ultimately affect functional use of the hand. Instruction in
scar remodeling, and returning the patient to pain-free func-
proper desensitization exercises will be crucial in an attempt
tional use, including work and sporting activities.
to decrease hypersensitivity of the DSBRN. Other pain control
Typically, the immobilization period following surgery
or desensitization techniques such as TENS and fluidotherapy
should be minimal. Formal therapy is usually not required
may also be beneficial. Adherent painful scar at the incision
postoperatively; however, consideration should be given to
site may be another postoperative complication that will affect
a referral for a one-time therapy visit to provide edema con-
rehabilitation. Several scar management techniques such as
trol as well as for instruction in the proper exercise tech-
scar compression, scar mobilization, silicone gel sheeting, and
niques and precautions. In some cases, if the pain level is
Kinesio tape may be utilized for this condition.
significant or if there is significant limitation in the ROM,
a referral for more formal therapy may be warranted. A
therapist knowledgeable in these conditions and surgical Intersection Syndrome
techniques will be able to assist the patient in regaining full
ROM and in decreasing pain levels. Formal therapy can Edema control and active and passive exercises may be initi-
offer pain control techniques that may include the use of ated within 24 hours of a release of intersection syndrome.
thermal agents such as heat and ice. Ultrasound or trans- Typically, immobilization is not required; however, if the
cutaneous electrical stimulation (TENS) may also prove to patient is experiencing significant pain, a thumb spica splint
be beneficial for patients with a significant amount of pain. with the IP free can be fitted to wear between exercise sessions
An upper extremity therapist can provide scar remodeling and at night.
techniques as well as assist with progressive strengthening
while respecting the patient’s pain level. Therapy can also
assist with patient education on how to modify provocative
Lateral Or Medial
activities as well as to teach proper ergonomic measures for Epicondylectomy
returning to work or sporting activities. In addition, there Although the vast majority of epicondylitis patients respond
may be options for a therapist to recommend soft supports to conservative measures, a small percentage of patients will
to help transition a patient through the early postoperative continue to have debilitating pain after 6 to 12 months. These
pain and into the strengthening phase that may in turn mini- patients may require surgical intervention. Postoperative
mize the chance of recurrence. immobilization may be warranted to off-load the extensor
origin and reduce pain for the first 3 to 10 days. The immo-
bilization may be in the form of continuing the surgical bulky
Trigger Finger Release dressing or having the patient fit with a custom-made ortho-
Trigger finger release typically does not require immobiliza- sis to immobilize the elbow, forearm, and wrist. Splinting is
Hand
tion. Active ROM is initiated immediately after surgery and not commonly required but occasionally pain relief is maxi-
generally the patient will achieve full ROM within 3 to 5 days mized with the elbow positioned in 90° flexion and the wrist
following surgery. As stated previously, a one-time referral to in neutral. Active and passive ROM exercises may be initi-
a hand therapist will be beneficial for wound management, ated at 7 to 10 days after surgery beginning with isolated joint
edema control, and proper instruction in ROM, including motions and gradually increasing stress to EDC and radial
differential tendon glide and intrinsic stretches. A common wrist extensors. Full composite motion should be achieved by
postoperative complication following trigger finger release is 4 weeks after surgery. Thermal agents, ultrasound, or TENS
a loss of composite extension, which can ultimately lead to may be utilized for pain management as needed. The patient is
contracture if not treated early. This is common in patients instructed in scar massage, scar mobilization, and desensitiza-
who present with a preoperative contracture or in the digit tion exercises. At 6 to 8 weeks, progressive strengthening and
that was locked in flexion. In cases where full extension is resistive exercises may be introduced. Gradual progression to
not present, extension splinting may be necessary. A custom normal use, including ergonomic modifications for work and
fit extension splint can be fabricated to wear at night and as sports will occur between 8 and 12 weeks. It will be impor-
needed during the day. If there is significant loss of passive tant to progress slowly and work within a pain-free range to
extension, a dynamic splint such as an LMB spring extension ultimately achieve full normal pain-free use of the affected
splint can be used. extremity.

806 Part VIII: Hand
References 9. Harvey FJ, Harvey PM, Horsley MW. de Quervain’s disease: surgical or
nonsurgical treatment. J Hand Surg (Am). 1990;15:83-87.
1. Fantone J, Ward P. Inflammation in Pathology. 3rd ed. Philadelphia, Pa 10. Weiss APC, Akelman E, Tabatabai M. Treatment of de Quervain’s disease.
Lippincott – Ravin; 1999. J Hand Surg (Am). 1994;19:595-598.
2. Boyd HD, McLeod AC Jr. Tennis elbow. J Bone Joint Surg Am. 11. Sato ES, Gomes Dos Santos JB, Belloti JC, Albertoni WM, Faloppa F.
1973;55:1183-1187. Treatment of trigger finger: randomized clinical trial comparing the meth-
3. Gellman H. Tennis elbow (lateral, epicondylitis). Orthop Clin North Am. ods of corticosteroid injection, percutaneous release and open surgery.
1992;23:75-82. Rheumatology (Oxford). January 2012;51(1):93-99.
4. Verhaar J, Walenkamp G, Kester A, et al. Lateral extensor release from 12. Lundin AC, Eliasson P, Aspenberg P. Trigger finger and tendinosis. J Hand
tennis elbow. J Bone Joint Surg Am. 1993;75:1034-1043. Surg (Eur). 2012;37:233–236.
5. Nirschl RP, Pettrone FA. Tennis elbow: the surgical treatment of lateral 13. Miyamoto H, Miura T, Isayama H, Masuzaki R, Koike K, Ohe T. Stiffness
epicondylitis. J Bone Joint Surg Am. 1979;61:832-839. of the first annular pulley in normal and trigger fingers. J Hand Surg (Am).
6. Regan W, Wold LE, Coonrad R, et al. Microscopic histopathology of September 2011; 36(9):1486-1491.
chronic refractory lateral epicondylitis. Am J Sports Med. 1992;20:746-752. 14. Lyu SR. Close division of the flexor tendon sheath for trigger fingers. J Bone
7. Price R, Sinclair H, Heinrich I, Gibson T. Local injection treatment of Joint Surg. 1992;74:418-420.
tennis elbow: hydrocortisone, triamcinolone, and lignocaine compared. 15. Eastwood DM, Gupta MB, Johnson DP. Percutaneous release of the trigger
Br J Rheumatol. 1991;30:39-44. fingers: an office procedure. J Hand Surg (Am). 1992;17:114-117.
8. Lin YC, Tu YK, Chen SS, Lin IL, Chen SC, Guo HR. Comparison between 16. Bain GI, Turnbull J, Charles MN, Roth JH, Richards RS. Percutaneous
botulinum toxin and corticosteroid injection in the treatment of acute A1 pulley release: a cadaveric study. J Hand Surg (Am). September
and subacute tennis elbow: a prospective, randomized, double blinded, 1995;20(5):781-784.
active drug-controlled pilot study. Am J Phys Med Rehabil. August 17. Pope DF, Wolfe SW. Safety and efficacy of percutaneous trigger finger
2010;89(8):653-659. release. J Hand Surg (Am). March 1995;20(2):280-283.

CHAPTER 80 n Principles of tendon transfers
Douglas M. Sammer
In other words, the excursion of the donor MTU should be

Introduction equal to or greater than that of the MTU it is replacing. A
A tendon transfer is the re-routing of a functioning muscle– good rule of thumb is that the extrinsic finger flexors have
tendon unit (MTU) (Table 80.1) to a new insertion, in order approximately 70 mm of excursion, the extrinsic finger exten-
to restore a function that has been lost. Tendon transfers sors have approximately 50 mm of excursion, and the extrin-
were first developed in the 19th century to restore ambula- sic wrist motors have approximately 30 mm of excursion.5
tion in patients with poliomyelitis. During the subsequent Unfortunately, it is not always possible to match donor and
World Wars, thousands of soldiers returned home with upper recipient excursion. In some cases, the tenodesis effect can be
extremity nerve injuries.1 This influx of patients with upper employed by the patient to augment the effective excursion of
extremity nerve palsies coincided with the development of the donor MTU. For example, the flexor carpi radialis (FCR) is
hand surgery as a surgical specialty. Over the ensuing decades, often transferred to the extensor digitorum communis (EDC)
tendon transfer techniques were adapted and refined for use to restore finger metacarpophalangeal (MCP) extension.
in the upper extremity by pioneers Bunnell, Boyes, Brand, However, the FCR only has 30 mm of excursion, whereas the
Burkhalter, Riordan, Zancolli, and others. EDC normally has 50 mm of excursion. The excursion of the
Today, the most common indication for a tendon transfer in FCR is therefore inadequate to fully extend the MCP joints.
the upper extremity is a nerve injury that has no potential for The patient can overcome this lack of excursion via the teno-
recovery.2 This includes irreparable injuries like nerve root avul- desis effect, by simultaneously flexing the wrist and extending
sions, failed nerve repairs or reconstructions, or nerve injuries the fingers. Wrist flexion increases the distance between the
that present too late for recovery due to motor end-plate fibro- origin and insertion of the tendon transfer, resulting in greater
sis. Other common indications include loss of tendon or muscle effective excursion and full MCP extension.
substance from trauma, tendon rupture (such as in rheumatoid
arthritis), and central neurologic deficits (e.g., spinal cord inju- Appropriate Strength of Donor
ries, stroke, and cerebral palsy).3 Although historically important,
leprosy, a mycobacterial granulomatous disease that affects the The strength of the donor MTU should be matched to that of
peripheral nerves, is a rare indication for tendon transfer today.4 the MTU whose function is being restored. This means that
the donor MTU must be strong enough to achieve the desired
movement. A weak donor MTU will not be able to move the
Principles of Tendon Transfer target joint through a functional range of motion, particularly if
Over the last century, a number of principles have been estab- there is any stiffness, or if there is a strong antagonist. The pal-
lished to guide the performance of tendon transfers. Although maris longus (PL), for example, does not have adequate strength
adhering to these guidelines does not guarantee success, to to power wrist extension. On the other hand, an excessively
ignore them inevitably results in failure. strong donor MTU results in muscle imbalance and abnormal
posture. A transfer of the brachioradialis (BR) to the extensor
pollicis longus (EPL), for example, would result in an extension
Supple Joints contracture or an abnormal position of the thumb at rest.
Often, patients with upper extremity nerve palsies will pres- When considering potential donor MTUs for transfer, it
ent with stiff joints. Performing a tendon transfer in this set- is more practical to compare relative muscle strength than it
ting will not improve function. Joints must be supple prior is to compare absolute muscle strength.2 The strongest donor
to tendon transfer. Hand therapy or surgical release may be MTUs are the BR and the flexor carpi ulnaris (FCU), which
required to maximize passive motion in preparation for a ten- each have a relative strength of 2 units. The FCR, the wrist
don transfer. It should be noted that a joint or contracture extensors, the finger flexors, and the pronator teres (PT) each
release should never be performed at the same time as the ten- have a relative strength of 1 unit. The finger extensors are
don transfer. The postoperative management of a joint release weaker, with a relative strength of 0.5 units each. The weak-
includes immediate mobilization and prolonged rehabilitation est donor MTUs are the polmaris longus (PL) and the thumb
in order to restore passive motion, whereas a tendon transfer extensors and abductors, each of which has a relative strength
must be immobilized for 3 to 4 weeks to allow tendon healing. of 0.1 units. Ideally, the relative strength of the donor MTU
should match that of the recipient MTU.
Soft Tissue Equilibrium It is also important to choose a donor MTU that has not
Hand
The soft tissue bed through which a tendon transfer will be routed been weakened by injury or denervation. In general, a donor
should reach “equilibrium” prior to performing the transfer.4 MTU will lose up to one grade of motor strength simply by
This means that it should be free of edema, inflammation, or being transferred.6 In some situations, such as brachial plexus
scar, so that the tendon transfer can glide freely. A tendon trans- palsy, the availability of donor MTUs may be severely lim-
fer that passes through an inflamed or scarred bed will develop ited. Although it can be tempting to use a donor MTU that
adhesions, reducing the effectiveness of the transfer. At times, it has recovered function after initial denervation or injury, this
is necessary to route the transfer along a non-standard path in should be avoided if at all possible.
order to avoid an area of scar. If the area of scar is extensive and
cannot be avoided, it may be necessary to resurface this area with Expendable Donor
a fasciocutaneous flap prior to performing the tendon transfer. It is essential to consider the potential functional deficit that
will be created by a tendon transfer. It is of little use to restore
Adequate Excursion one function but lose another equally important function.
The donor MTU should have enough excursion, or linear Fortunately, there is ample redundancy built into the hand and
movement, to achieve the desired motion at the target joint. forearm. For example, there are two wrist flexors and three
807
808 Part VIII: Hand
Table 80.1 pull that produces thumb opposition. In some cases, this line
of pull cannot be achieved without routing the tendon transfer
Abbreviations Used around a pulley. Although this direction change weakens the
transfer, it is necessary to achieve opposition.
ADM Abductor digiti minimi
APB Abductor pollicis brevis Synergy
APL Abductor pollicis longus The original function of the donor MTU should be synergistic
with the function that is being restored.8 A tendon transfer
BR Brachioradialis that is synergistic, as opposed to antagonistic, is easier for
DIP Distal interphalangeal the patient to learn to use. Synergy refers to certain move-
ments that are typically combined during routine hand use.
ECRB Extensor carpi radialis brevis For example, wrist extension and finger flexion are synergistic
ECRL Extensor carpi radialis longus for grasping, whereas wrist flexion and finger extension are
synergistic. When a wrist flexor is transferred to restore finger
ECU Extensor carpi ulnaris extension (FCR to EDC transfer), the patient can learn to use
EDC Extensor digitorum communis the transfer without much difficulty. On the other hand, if
a wrist extensor were to be transferred to the finger exten-
EDM Extensor digiti minimi
sors, the patient may have difficulty learning to use the tendon
EIP Extensor indicis proprius transfer in a natural manner. Although a synergistic transfer
EPB Extensor pollicis brevis is ideal, it is not always possible. Furthermore, it should be
noted that certain donor MTUs, such as the FDS, are able to
EPL Extensor pollicis longus adapt to a new function readily, whether that function is syn-
FCR Flexor carpi radialis ergistic or not.
FCU Flexor carpi ulnaris Single Transfer, Single Function
FDI First dorsal interosseous Finally, a single tendon transfer should only perform a single
FDP Flexor digitorum profundus function. Attempting to restore multiple functions with a sin-
gle donor MTU will result in loss of strength and motion. The
FDS Flexor digitorum superficialis exception to this rule is that a single donor MTU may be used
FPL Flexor pollicis longus to restore the same movement in multiple digits. For example,
it is acceptable to use the FDS or FCR to restore MCP exten-
PL Palmaris longus
sion for all four fingers. However, the FDS or FCR would be
IP Interphalangeal inadequate to restore both wrist and finger extensions.
MCP Metacarpophalangeal
MTU Muscle–tendon unit
Biomechanical Considerations
PIP Proximal interphalangeal The moment arm of a tendon transfer affects how much rota-
tion will occur at the joint, and will affect the torque gener-
PT Pronator teres ated. The moment arm is determined by the distance between
the joint axis of rotation and the tendon that crosses the
joint. A tendon that passes far from the joint axis of rota-
tion or inserts far from the joint will have a large moment
wrist extensors. The FCR or the FCU can be transferred with-
arm, whereas a tendon that lies close to the joint axis of rota-
out losing wrist flexion, and two of the three wrist extensors
tion and inserts close to the joint will have a small moment
can be transferred without compromising wrist extension. The
arm. A tendon transfer with a large moment arm will generate
PL is completely redundant, and the extensor indicis proprius
greater torque, but at the expense of the arc of motion (greater
(EIP) and extensor digiti minimi (EDM) are excellent donors
muscle excursion will be required for a given degree of rota-
whose harvest results in minimal donor deficit. In addition,
tion). A tendon transfer with a smaller moment arm will have
each finger has two flexors, the flexor digitorum profundus
an increased arc of motion (less muscle excursion is required
(FDP) and flexor digitorum superficialis (FDS). The FDS is
for a given degree of rotation), but the transfer will not gener-
often used as a donor MTU, and the finger retains flexion via
ate as much torque. In many cases, the insertion point of a
the intact FDP.
tendon transfer is determined by the normal insertion of the
recipient tendon. However, there are instances in which the
Straight Line of Pull surgeon can choose the insertion point of the tendon transfer.
A tendon transfer that has a direct path to its insertion is Understanding the concept of the moment arm will help the
most effective. Any direction change or pulley decreases the surgeon determine the optimal insertion point, balancing the
force of the transfer. However, there are instances in which a needs for joint rotation and generation of torque.
direct line of pull is not ideal. For example, a PT to extensor Setting the tension of the tendon transfer is the most critical
carpi radialis brevis (ECRB) transfer is commonly performed and difficult part of the operation. Ideally, a tendon transfer
to restore wrist extension in patients with radial nerve palsy. should be tensioned in such a way as to maximize actin–
The transfer is typically performed in an end-to-end fashion, myosin overlap. Unfortunately, it is impossible to determine
which creates a straight line of pull. However, if there is a pos- this intraoperatively, although research is being conducted into
sibility of ECRB recovery in the future, the PT is transferred using laser diffraction intraoperatively to determine the opti-
in an end-to-side fashion into the ECRB tendon. Although mum tension for a tendon transfer.9,10 The pragmatic solution
this results in an indirect line of pull, the end-to-side insertion is that the tendon transfer should be set at a tension as close
allows the ECRB to participate in wrist extension if it recovers as possible to the donor MTUs preoperative resting tension.
function in the future.7 In other situations, the required line of The donor muscle belly is marked at regular intervals before
pull cannot be achieved without a direction change. For exam- dividing its insertion, and the tendon transfer is tensioned in
ple, opponensplasties are routed from the level of the pisiform such a way as to restore the distance between the intervals. On
toward the abductor pollicis brevis (APB) insertion, a line of the other hand, many authors recommend tensioning a tendon

Chapter 80: Principles of Tendon Transfers 809
transfer substantially tighter than the donor MTUs resting
tension. This is because a tendon transfer tends to loosen or
stretch out during rehabilitation. However, a tendon transfer
that is set too loosely will not tighten postoperatively.
Radial Nerve Palsy

Radial nerve palsy results in loss of wrist extension, finger
MCP extension, thumb abduction, thumb extension, and
thumb retropulsion. In addition, patients notice a substantial
decrease in grip strength due to the inability to stabilize the
wrist during grip. Loss of supinator function is compensated
by the biceps brachii and by shoulder rotation. From a sensory
standpoint, the loss of sensibility is not critical. Furthermore,
there is some overlap with the lateral antebrachial cutane-
ous nerve. Radial nerve palsy can be categorized as high or
low. High radial nerve palsy is a nerve injury proximal to the
elbow, in which all of the above functions are lost. Low radial
nerve palsy, on the other hand, occurs with an injury distal
to the elbow, in which only the posterior interosseous nerve
(PIN) is injured. The BR remains intact, and wrist extension ECRB &
is preserved because the branch to the extensor carpi radia- ECRL
lis longus (ECRL) arises proximal to the take-off of the PIN
(innervation to the ECRB is variable). The goals of tendon ECRB &
transfer are restoration of finger MCP extension, thumb ECRL
extension and radial abduction, and wrist extension in cases BR
of high radial nerve palsy.
All of the median and ulnar nerve innervated MTUs may
be considered potential donors for tendon transfer in patients BR
PT
with radial nerve palsy. Although many different sets of ten-
don transfers have been described for radial nerve palsy, the
PT
PT to ECRB transfer for restoration of wrist extension is
nearly universal (Figure 80.1). This transfer results in mini-
mal, if any, donor deficit, because the transferred PT contin-
ues to act as a forearm pronator after transfer. Insertion on
the ECRB as opposed to the ECRL is preferred, in order to
minimize radial deviation of the wrist. This transfer is typi-
cally performed in an end-to-end fashion. However, if there
is potential for recovery of radial nerve function, the transfer
is performed in an end-to-side fashion, allowing the ECRB to
contribute to wrist extension should it become reinnervated
(Figure 80.1). In fact, the end-to-side PT to ECRB transfer can
be used as an “internal splint” to restore wrist extension while
the radial nerve is recovering.7,11,12
Finger MCP extension is restored by transfer of the FCR, FIGURE 80.1. PT to ECRB transfer, end-to-side, for restoration of
FCU, or FDS to the EDC. Although the FCU transfer was one wrist extension.
of the first described and is still used today (Figure 80.2), the
FCR and FDS transfers are preferred over the FCU by many
surgeons. This is because transfer of the FCU results in loss of
the functionally critical “dart-throwing motion.” In addition, radial and volar position. This results in restoration of radial
in the wrist without a functioning ECU, transfer of the FCU abduction as well as extension, at the expense of retropulsion.
removes the only remaining ulnar-sided wrist motor, leading Alternatively, the FDS can be transferred to both the EPL and
to wrist imbalance and radial deviation. The FCR is a good the EIP in order to restore simultaneous thumb and index fin-
donor for restoration of finger MCP extension. It is expend- ger extension, a functionally useful combination of movements.
able (wrist flexion is maintained by the FCU), and its use does Over the years, three “standard” sets of tendon transfers
Hand
not result in loss of the dart-throwing motion or in radial devi- have been established for reconstruction of radial nerve palsy:
ation. The primary limitation of the FCR is that its excursion the FCR transfer,12–14 the FCU transfer,15,16 and the superfi-
(approximately 33 mm) is inadequate to provide full MCP cialis transfer.17,18 All three sets of transfers employ the PT to
extension. However, the tenodesis effect (wrist flexion with ECRB transfer for restoration of wrist extension. The FCR
concomitant MCP extension) can be used to bring the MCP transfer involves FCR to EDC transfer for MCP extension,
joints into full extension after an FCR to EDC transfer and is and PL to re-routed EPL transfer for thumb extension. The
easily learned by the patient. The FDS is also a good donor for FCU transfer is the same, except the FCU is used in place of
restoration of finger MCP extension. It has excellent excur- the FCR to restore MCP extension. Finally, in the superficialis
sion (approximately 70 mm), and flexion of the donor finger transfer, the ring FDS is transferred to the EPL and EIP for
is preserved by the remaining intact FDP. The primary disad- simultaneous thumb and index extension, and the long FDS
vantage of the FDS to EDC transfer is that some grip strength is transferred to the remaining digital extensors. The FCR is
is lost. In the patient with a fused wrist who cannot employ transferred to the abductor pollicis longus and EPB to restore
the tenodesis effect, the FDS is the preferred donor MTU. thumb MCP extension and radial abduction. The author’s
For restoration of thumb extension and radial abduction, preference is to use the FCR transfer in patients with intact
the PL or an FDS can be transferred to the EPL (Figure 80.3). wrist flexion and the superficialis transfer in patients who
The EPL is usually re-routed and allowed to lie in a more have undergone a wrist arthrodesis.

810 Part VIII: Hand
Extensor
pollicis
longus
Palmaris
longus
Extensor
pollicis
longus
Palmaris
EDC longus
Extensor
pollicis
longus
FCU FIGURE 80.3. PL to re-routed EPL transfer, for restoration of thumb
extension and radial abduction.
tendons. Next, a more proximal subcutaneous tunnel is

made along the radial border of the forearm, and the FCR
is passed to the dorsal incision. The FCR to EDC weave is
performed proximal to the extensor retinaculum in an end-
to-side fashion (Figure 80.4C). Tension is set with the wrist
in neutral and the MCP joints in full extension. The proximal
half of the extensor retinaculum can be divided if it inhibits
FIGURE 80.2. FCU to EDC transfer, end-to-side, for restoration of full excursion of the Pulvertaft weave. Alternatively, the EDC
finger MCP extension. tendons can be divided proximally, released from the exten-
sor retinaculum and weaved end-to-end to the FCR in order
to create a straighter line of pull. Although a straight line of
pull is advantageous, it can result in undesired radial devia-
For the FCR set of transfers, a curvilinear longitudinal inci- tion. Finally, the PT is passed through a subcutaneous tunnel,
sion is made along the course of the FCR in the distal two superficial to the BR and ECRL, and weaved into the ECRB
thirds of the forearm. Skin flaps are elevated, protecting the just distal to its musculotendinous junction. If the periosteal
palmar cutaneous branch of the median nerve. The fascia extension is thin and the Pulvertaft weave is of questionable
is incised and the PL and FCR are identified and mobilized strength, it can be reinforced with a strip of ECRL (preferred)
along their tendinous portion. Proximal retraction is applied or BR tendon. The PT to ECRB transfer is tensioned with
to the PL and FCR tendons with the wrist in flexion, and they the wrist in full extension. The PT to ECRB transfer should
are divided at the distal wrist flexion crease (Figure 80.4A). be tensioned last, so that the surgeon can passively flex and
Dissection continues proximally, mobilizing the distal half of extend the wrist, using the tenodesis effect to evaluate the
the muscle bellies while preserving their innervation and blood tension of the FCR to EDC transfer. With the wrist in flex-
supply. In the proximal aspect of the incision, the PT inser- ion, the MCP joints should move into full extension or slight
tion on the radius is identified. The PT tendon, which is short, hyperextension. With the wrist in extension, the surgeon
is harvested in continuity with a 4 cm cuff of periosteum in should be able to passively flex the MCP and interphalangeal
order to have sufficient length for the Pulvertaft weave. (IP) joints without difficulty, touching the fingertips to the
A dorsal midline longitudinal incision is made over the palm. If the MCP joints do not move into full extension with
distal half of the forearm. Skin flaps are elevated exposing wrist flexion, the finger extensions are too loose. If the fin-
the extensor retinaculum and the musculotendinous junc- gers cannot be passively flexed into the palm with the wrist
tions of the extrinsic extensors, while protecting the super- extended, the transfer is too tight. A sugar-tong splint with
ficial sensory branch of the radial nerve. The EPL and the a thumb spica extension is placed in the operating room.
EDC tendons are identified. The EPL is divided proximal to The wrist should be extended, the MCPs slightly flexed (15°,
the extensor retinaculum and is mobilized in a proximal to without placing tension on the transfer), and the IPs left free.
distal direction, releasing it from the third extensor compart- The thumb spica extension should maintain the thumb in
ment. A subcutaneous tunnel is created around the radial extension and radial abduction.
border of the wrist, deep to the subcutaneous adipose tissue,
and directly on the antebrachial fascia. The EPL is passed
through this tunnel to the volar incision in preparation for
Median Nerve Palsy
Pulvertaft weave to the PL (Figure 80.4B). The tension on Median nerve injuries are categorized as high or low, depend-
the PL to EPL transfer is set with the wrist in neutral posi- ing on whether the injury is proximal or distal to the innerva-
tion and with maximum tension on both the PL and EPL tion of the forearm muscles. Low median nerve palsy usually

Proximal
FCR
EPL
PL
A PL
Distal B
Proximal Distal
EDC
tendons
FIGURE 80.4. A. The FCR and PL have been released distally and
FCR mobilized proximally in the forearm in preparation for FCR to EDC
and PL to EPL transfers. B. On the volar aspect of the forearm, the
first pass of the Pulvertaft weave is made for the PL to EPL transfer.
C. The FCR is passed through all four EDC tendons to create an end-
to-side transfer.
C
results in a loss of thenar function and opposition. However, In the superficialis opponensplasty, the ring FDS is trans-
even when the median nerve has been completely transected, it ferred to the APB insertion (Figure 80.5). A zigzag incision is
is not uncommon to see preserved thenar function via a Riche- made in the distal palm proximal to the ring finger. The A1
Cannieu connection.19,20 High median nerve palsy results not pulley is divided, and the FDS is exposed, retracted proxi-
only in lost thenar function but also in loss of the FDS to all mally, and then divided. The FDS is then retrieved proximal
four fingers, and loss of flexor pollicis longus (FPL) and index to the carpal tunnel through a distal volar forearm incision.
FDP function. This causes severe impairment of fine motor
control and prehension, loss of oppositional and appositional
pinch, and diminished grip strength. Although forearm pro-
nation is lost, the patient compensates with shoulder rota-
tion. FCR function is also lost, but wrist flexion is maintained
via the ulnar nerve innervated FCU. Median nerve palsy is a
devastating motor injury and is compounded by the loss of
critical median nerve distribution sensibility. Even if motor
recovery is not possible and tendon transfers are required, the
median nerve should be repaired or reconstructed, or sensory
transfers in the hand considered to restore this critical area
of sensibility.21,22 The goal of tendon transfer in low median
nerve palsy is simply to restore thumb opposition. In high
median nerve palsy, the goals also include restoration of FPL
Hand
and index FDP function.

Thumb opposition is a complex movement, which includes
components of palmar abduction, pronation, and flexion. The
ideal line of pull and insertion point for opponensplasties are Pisiform
disputed. However, most opponensplasties are routed from the Flexor carpi
level of the pisiform and inserted on the APB tendon, which ulnaris pulley
essentially serves to abduct the thumb, rather than oppose.23–26
A line of pull that originates proximal and radial to the pisi-
form results in increased palmar abduction, whereas a line of Ring finger flexor
pull that originates distal to the pisiform results in increased digitorum superficialis
flexion across the palm. A tendon transfer that approaches the
thumb from the level of the pisiform results in a good com-
bination of both movements. The four most common oppo-
nensplasties are the superficialis opponensplasty (FDS),27 the FIGURE 80.5. FDS opponensplasty, with pulley at level of pisiform,
Huber opponensplasty (ADM),28 the Camitz opponensplasty and insertion on APB tendon.
(PL),29,30 and the EIP opponensplasty.31

812 Part VIII: Hand
It is then routed around a pulley that is created at the level of a tunnel is created across the palm in the subcutaneous plane.
the pisiform.32 Multiple pulleys have been described, including The tendon is passed to the thumb MCP joint and weaved
a distally based strip of FCU that is sutured to itself to form a into the APB insertion (Figure 80.7B). The transfer is tensioned
loop at the level of the pisiform,32 the FCU tendon itself,33,34 the with the thumb in maximum palmar abduction and mild flexion.
flexor retinaculum,35,36 and Guyon’s canal.37 The tendon is then The Camitz transfer (originally described by Bunnell) uti-
routed through a subcutaneous tunnel across the palm toward lizes the PL for restoration of opposition. The primary indica-
the thumb MCP joint and inserted on the APB tendon. The tion for a Camitz transfer is thenar atrophy and loss of palmar
superficialis opponensplasty works well and is a reliable trans- abduction in patients with severe long-standing carpal tunnel
fer. However, it cannot be used in cases of high median nerve syndrome.38 During carpal tunnel release, the PL is mobilized,
palsy, because FDS function is lost. It should also be noted that along with a strip of superficial palmar fascia extending into
the most common cause of low median nerve palsy is a lacera- the distal palm. The extended PL is then routed subcutane-
tion at the wrist. In this situation, the FDS tendons are often ously to the APB insertion. Because no pulley is created, the
injured along with the median nerve. For these reasons, the line of pull originates from a position that is proximal and
superficialis opponensplasty is often not a viable option. radial to the pisiform. This results in palmar abduction, but
The EIP opponensplasty is almost always an option in little flexion across the palm.
cases of isolated median nerve palsy and has the advantages The Huber transfer utilizes the abductor digiti minimus
that no pulley is required, and the donor deficit is minimal (ADM), one of the hypothenar muscles, to restore opposition
(Figure 80.6). A dorsal longitudinal incision is made over the (Figure 80.8). In this transfer the ADM is divided at its inser-
proximal phalanx and MCP joint of the index finger. The sag- tion, mobilized proximally, and turned over like the page of
ittal band is carefully elevated off of the EIP for later repair. a book to insert on the APB tendon. This transfer is typically
The EIP is divided distal to the MCP joint and retrieved to a reserved for patients with congenital hypoplasia of the thumb,
dorsal forearm incision proximal to the extensor retinaculum because it recreates some of the bulk of the thenar eminence.
(Figure 80.7A). It is passed subcutaneously to a third inci- In addition, it can be used in patients in whom the FDS or EIP
sion on the ulnar border of the wrist. Finally, a fourth incision is not available for transfer (such as combined high median
is made over the radial border of the thumb MCP joint, and and radial nerve palsy).
Extensor indicis
proprius
Extensor digitorum
communis
Extensor
indicis
proprius
Extensor indicis proprius
Abductor pollicis brevis
FIGURE 80.6. EIP opponensplasty. Note that no pulley is required.

EIP
EDC-index
Figure 80.7. A. The EIP is identified at the index MCP joint, and at
the wrist in preparation for EIP opponensplasty. B. The EIP is sutured
to the APB tendon with a single suture, to check the tension of the
transfer prior to performing the Pulvertaft weave.
A
In high median nerve palsy, thumb IP flexion is typically transfers. The wrist is flexed to 20°, and the thumb is posi-
restored with a BR to FPL transfer. Index (and sometimes tioned in palmar abduction and flexion. If a tendon transfer
long finger) flexion is restored with a side-to-side suture of for independent index FDP flexion has been performed, the
the index (and sometimes long finger) FDP tendon to the index finger should be placed in the intrinsic plus position. If
adjacent FDP tendons at the level of the distal forearm. a side-to-side FDP suture was performed, all four fingers are
When independent index FDP function is required, an ECRL immobilized in the intrinsic plus position.
to index FDP transfer can be performed. All of these trans-
fers are performed through a volar incision in the distal
half of the forearm. The tenodesis effect is used to evalu- Ulnar Nerve Palsy
ate the tension of the transfers. With the wrist flexed, the In low ulnar nerve palsy, the ulnar nerve is injured distal
surgeon should be able to passively extend the index finger to the innervation of the forearm muscles. Adductor pollicis
and radially abduct and extend the thumb. This ensures that and first dorsal interosseous (FDI) function are lost. This is
the transfers are not too tight, reducing the incidence of manifested by weak key pinch and a Froment sign, in which
flexion contracture. With the wrist passively extended, the the thumb IP joint flexes during attempted key pinch as the
index finger should flex into the palm, and the thumb should FPL compensates for the loss of adductor pollicis function.
pinch firmly against the index finger. A sugar-tong splint The patient also develops clawing (MCP hyperextension and
with thumb spica extension is applied, taking tension off the IP flexion), particularly in the ring and small fingers. Clawing
is the result of unopposed pull by the extrinsic flexors and
extensors due to loss of intrinsic muscle function. The lum-
bricals and interossei, which normally provide flexion force
at the MCP joints and extension force at the IP joints, no
longer oppose the pull of the EDC at the MCP joints, or
the pull of the FDP and FDS at the IP joints, and clawing
occurs. Bouvier test for clawing involves passively correct-
ing MCP hyperextension and checking for extension at the
IP joints. If the IP joints can extend, Bouvier test is posi-
tive, and the clawing is defined as simple. A procedure that
passively maintains MCP flexion can be performed. These
static procedures to keep the MCP joints flexed are volar
plate advancement, MCP joint fusion or even FDS tenode-
sis using half of the slip of the FDS. If the IP joints remain
Hand
flexed, Bouvier test is negative, and the clawing is complex.39

Abductor In this case, dynamic transfer is necessary by using the FDS
digiti minimi to restore the intrinsic tendon function.
In addition to loss of key pinch and the development of
clawing, ulnar nerve palsy causes loss of integration of finger
flexion. Finger flexion normally begins at the MCP joints ini-
Abductor tiated by the intrinsic muscles, followed by flexion at the IP
pollicis brevis joints initiated by the FDP and FDS tendons. This creates a cup-
ping motion as the fingers are folded into the palm. Without
Transferred abductor intrinsic function, flexion begins at the IP joints, and the fin-
digiti minimi gers roll into the palm pushing objects away during attempted
grasp. Finally, finger abduction and adduction are lost, and the
patient loses the ability to spread or cross the fingers.
FIGURE 80.8. Huber opponensplasty, with the ADM turned over In high ulnar nerve palsy, in addition to the above findings,
and inserted on the APB tendon. the FCU and the FDP to the ring and small fingers are lost,
further weakening grip strength. More importantly, absence

814 Part VIII: Hand
of FCU function results in loss of the critical “dart-throwing

motion.” It should be noted that clawing is less pronounced
in high than in low ulnar nerve palsy. Because clawing is
the result of unopposed extrinsic function, the loss of small
and ring finger FDP function makes clawing less severe. This
has two clinical implications. A patient with a recovering
high ulnar nerve injury will experience worsening of claw-
ing as the small and ring finger FDP muscles become rein-
nervated. Therefore, worsening of clawing after a high ulnar
nerve repair should be considered a positive finding indicat-
ing nerve regeneration. A second consideration is that tendon Free palmaris
transfers designed to restore FDP function will result in more longus tendon
pronounced clawing unless an anti-clawing procedure is per- graft
formed. The goals of tendon transfer in ulnar nerve palsy are
restoration of key pinch, correction of clawing, integration of
finger flexion, and restoration of small and ring finger distal
interphalangeal flexion in cases of high ulnar nerve palsy.
In high ulnar nerve palsy, restoration of small and ring fin-
ger FDP function is fairly straightforward and is achieved by
side-to-side suturing of the FDP tendons of the ring and small
Extensor carpi
finger to the adjacent functioning long finger FDP tendon at radialis brevis
the level of the distal forearm (Figure 80.9). The index FDP
should not be included in the transfer, in order to maintain FIGURE 80.10. Transfer of elongated ECRB to adductor pollicis
independent index FDP function. It should be remembered, insertion for restoration of key pinch.
however, that clawing will worsen after this transfer is per-
formed, and the benefits of this transfer should be weighed
against the increase in clawing that will occur. After tendon
transfer, the fingers are immobilized in the intrinsic plus posi- across the palm, deep to the flexor tendons, digital nerves, and
tion, with the wrist flexed to take tension off the transfer. digital arteries, and toward the adductor pollicis insertion. The
Restoration of key pinch may or may not be required. border of the second or third metacarpal acts as a pulley to
Many patients are able to function well because of compensa- achieve the correct line of pull for key pinch. If an FDS transfer
tion by the FPL, or because the adductor pollicis receives aber- is performed, the long FDS is divided in the finger proximal
rant innervation from the median nerve. No tendon transfer is to the PIP joint and retrieved into the palm. It is then passed
necessary unless the patient notices a significant loss of pinch radially across the palm deep to the flexor tendons and neu-
function. In addition, when key pinch is required, it is usually rovascular bundles and inserted on the adductor pollicis inser-
only necessary to restore adductor pollicis function. Although tion. The advantage of this transfer is that a tendon graft is
transfers have been described to restore FDI function, the func- not required. However, harvest of the FDS can further weaken
tion of the FDI is compensated by stabilization of the index grip strength. In addition, care must be taken in choosing
finger against the long finger. Multiple transfers have been which FDS to use. In high ulnar nerve palsy, the ring and small
described for the restoration of key pinch, including the use of finger FDPs have lost innervation, and those fingers rely on the
the ECRB, the BR, the EIP, and the FDS.40–42 When the ECRB median nerve innervated FDS for flexion. Therefore, in high
or BR is used to restore key pinch, it must be elongated with ulnar nerve palsy the long finger FDS should be used instead
a tendon graft (Figure 80.10). The tendon graft is then routed of the ring FDS. In all cases, the surgeon should confirm nor-
through the second or third intermetacarpal spaces from dor- mal FDP function prior to using the FDS in a tendon transfer.
sal to volar, and into the palm. The graft is then routed radially A final option for restoring key pinch is the EIP transfer. In
this transfer, the EIP is divided distal to the MCP joint of the
index finger, as for EIP opponensplasty. It is mobilized up to
the extensor retinaculum, and then directed through the sec-
ond or third intermetacarpal space and across the deep palm
to the adductor pollicis insertion. This tendon is available for
transfer in high and low ulnar nerve palsy, its harvest does not
weaken grip strength, and it does not usually require elonga-
tion with a tendon graft. After a transfer to restore key pinch,
the thumb is immobilized in a position of pinch. Wrist posi-
tion depends upon whether the FDS or another donor MTU
was used. If the FDS was used, tension is taken off the transfer
by immobilizing the wrist in flexion. If another donor MTU
was used and passed through the intermetacarpal space, the
wrist is immobilized in extension.
Correction of clawing is the other major goal in ulnar
nerve palsy and relies on correcting MCP hyperextension.
This can be achieved with many different operations, which
can be divided into static and dynamic procedures. If Bouvier
test is positive, and the IP joints can extend with the MCPs
Flexor digitorum passively flexed, then a simple block to MCP hyperextension
profundus is considered. Creation of a bony block on the dorsal aspect
of the metacarpal head has been described, but is of primar-
ily historical interest.43 A volar plate capsulodesis is another
FIGURE 80.9. Side-to-side suture of small and ring FDP to the static option, in which a distally based flap of the volar plate
long FDP. is advanced proximally, tightening the volar aspect of the joint
and effectively preventing MCP hyperextension.44 Tenodesis

with a tendon graft that limits MCP hyperextension can be Wrist level motors such as the BR, the FCR, the ECRL, and
performed as well.45 All of these static procedures tend to the ECRB can be used to correct clawing, but all require elon-
weaken over time, however, and are best employed in patients gation with a tendon graft. (It should be noted that the FCR
with mild, simple clawing. should only be used in cases of low ulnar nerve palsy, in which
Many dynamic tendon transfers to correct clawing have the FCU is intact.) The elongated tendon is routed to the dor-
been described. These include the use of the FDS, the BR, sal wrist, and the graft is split into the appropriate number of
the FCR, the ECRL, and the ECRB.46–52 Because all of these slips. The slips are then routed through the intermetacarpal
transfers restore active MCP flexion, they integrate finger flex- spaces of the corresponding fingers and then passed along the
ion in addition to correcting clawing. These transfers differ course of the lumbrical, volar to the deep intermetacarpal liga-
in whether tendon grafts are required, whether grip strength ment, and out to the finger (Figure 80.12). Again, the insertion
is augmented or weakened, and whether active IP extension is can be on the lateral band or into the bone of the proximal
provided. In the FDS transfer, the ring or long finger FDS is phalanx, depending on whether active IP extension is required.
divided proximal to the PIP joint and retrieved into the palm. If insertion on the pulley system is preferred, the tendon graft
There, it is split into two slips, one for the ring finger and one is not passed through the lumbrical canal, but rather inserted
for the small finger. If clawing is present in all four fingers, it on the flexor tendon sheath in a “lasso” fashion. In addition
is possible to divide the FDS into four slips. Alternatively, the to requiring tendon grafts for elongation, another drawback
long FDS can be used to correct clawing in the index and long to these transfers is the possibility of adhesions within the
fingers, and the ring FDS can be used to correct clawing in the intermetacarpal space. The primary advantage of using a wrist
ring and small fingers. Various insertions have been described level motor instead of the FDS is that these transfers augment
(Figure 80.11). The FDS slips can be inserted on the flexor rather than diminish grip strength.
tendon sheath in a “lasso” fashion as described by Zancolli, For active transfers to correct clawing, whether the FDS
providing active MCP flexion.50 Alternatively, they can be or a wrist level motor is used, the tendon transfer is tensioned
passed volar to the deep transverse metacarpal ligament along with the wrist in neutral, the MCPs maximally flexed, and the
the path of the lumbrical and inserted on the radial lateral IPs extended. The hand is immobilized with the MCPs flexed
band or into the bone of the proximal phalanx. Insertion on and the IPs extended, in order to take tension off the transfer.
the lateral band provides both MCP flexion and IP extension. The position of wrist immobilization depends upon whether
However, because the FDS normally restrains PIP hyperexten- the FDS or wrist level motor was used.
sion, transfer of the FDS to the lateral band can lead to PIP
hyperextension.49 The main drawback of the FDS transfer is
that it results in further weakening of grip strength. As noted
above, it is important to ensure that the FDP of a given finger
functions normally prior to using the FDS for tendon transfer.
Lateral band
Intermetacarpal
ligament
Flexor digitorum Tendon transfer

sutured into lateral Split free
superficialis tendon graft
band
Intermetacarpal ligament
Extensor carpi
radialis brevis
Tendon transfer sutured to bone

with anchor, or inserted into bone tunnel
Hand
Lateral band
A1 pulley
Flexor digitorum Tendon transfer

superficialis sutured Tendon graft sutured into lateral
back to itself band
Intermetacarpal ligament
FIGURE 80.11. Three classic insertions for transfers to correct
clawing: lateral band, bone of proximal phalanx, and the flexor FIGURE 80.12. Transfer of elongated ECRL to the radial lateral
tendon sheath. bands of the ring and small fingers, for dynamic correction of clawing.

816 Part VIII: Hand
18. Boyes J. Tendon transfers for radial palsy. Bull Hosp Joint Dis. 1960;21:
Rehabilitation 97-105.
19. Riche P. Le nerf cubital et les muscles de l’eminence thenar. Bull Mem Anat
The therapist should be involved in the care of the patient well Paris. 1897:251-252.
in advance of a planned tendon transfer. The therapist will 20. Cannieu A. Note sur une anastomose entre le branche profunde de cubi-
focus on maximizing passive joint motion and on strength- tal et le median. Bull Soc Anat Physiol Horm Path Bordeaux. 1897;17:
339-342.
ening the planned donor MTUs. During this time period the 21. Ozkan T, Ozer K, Gulgonen A. Restoration of sensibility in irreparable
therapist and the patient get to know each other. This allows ulnar and median nerve lesions with use of sensory nerve transfer: long-term
the therapist to gauge the patient’s motivation and compli- follow-up of 20 cases. J Hand Surg Am. January 2001;26(1):44-51.
ance and to communicate with the patient about the postop- 22. Brand PW. Clinical Mechanics of the Hand. St. Louis, MO: Mosby; 1985.
23. Cooney WP, Linscheid RL, An KN. Opposition of the thumb: an anatomic
erative rehabilitation protocol. In general, tendon transfers and biomechanical study of tendon transfers. J Hand Surg Am. November
are immobilized for 4 weeks postoperatively prior to initiat- 1984;9(6):777-786.
ing therapy. During these 4 weeks, it is crucial to maintain 24. Curtis RM. Opposition of the thumb. Orthop Clin North Am. April
motion in the uninvolved joints in order to prevent stiffness. 1974;5(2):305-321.
25. Lee DH, Oakes JE, Ferlic RJ. Tendon transfers for thumb opposition:
The splint applied in the operating room should be removed a biomechanical study of pulley location and two insertion sites. J Hand
at 2 weeks and changed to a cast which is worn for 2 more Surg Am. November 2003;28(6):1002-1008.
weeks. Sutures are removed at the 2-week visit. At 4 weeks 26. Roach SS, Short WH, Werner FW, Fortino MD. Biomechanical evalua-
rehabilitation is initiated. A thermoplast splint is made and is tion of thumb opposition transfer insertion sites. J Hand Surg Am. March
2001;26(2):354-361.
worn when the patient is not performing prescribed exercises. 27. Royle ND. An operation for paralysis of the intrinsic muscles of the thumb.
Gentle active and assisted active range of motion is initiated. JAMA. 1938;111:612-613.
Synergistic movements are taught. Electrical stimulation and 28. Huber E. Hilfsoperation bei median Uhlahmung. Dtsch Arch Klin Med.
biofeedback can be useful in teaching the patient to activate 1921;136:271.
29. Bunnell S. Reconstructive surgery of the hand. Surg Gynecol Obstet.
the transfer. Passive stretching of the transfer is gradually 1924;34:259-274.
introduced, usually at 6 weeks. At 8 weeks postoperatively, 30. Camitz H. Uber die behandlung der oppositionslahmung. Acta Orthop
strengthening is begun, and the splint is gradually weaned Scand. 1929;65:77-81.
off for light hand use. Full unrestricted activity is allowed at 31. Aguirre SC, Caplan S. Sobre secuelas de lesion alta e irreparable de nervios
mediano y cubital, y su tratamiento. Prensa Med Arg. 1956;43:2341-2346.
3 months postoperatively. 32. Bunnell S. Opposition of the thumb. J Bone Joint Surg Am. 1938;20:
269-284.
References 33. Boswick JA Jr, Stromberg WB Jr. Isolated injury to the median nerve
above the elbow. A review of thirteen cases. J Bone Joint Surg Am. June
1. Green DP. Radial nerve palsy. In: Green DP, Hotchkiss RN, Pederson WC, 1967;49(4):653-658.
eds. Green’s Operative Hand Surgery. Vol 2. 4th ed. New York: Churchill 34. Mangus DJ. Flexor pollicis longus tendon transfer for restoration of opposi-
Livingstone; 1999:1481-1496. tion of the thumb. Plast Reconstr Surg. August 1973;52(2):155-159.
2. Richards RR. Tendon transfers for failed nerve reconstruction. Clin Plast 35. Michelinakis E, Vourexakis H. Tendon transfer for intrinsic-muscle paraly-
Surg. April 2003;30(2):223-245, vi. sis of the thumb in Charcot-Marie Tooth neuropathy. Hand. October
3. Van Heest AE, House JH, Cariello C. Upper extremity surgical treatment of 1981;13(3):276-278.
cerebral palsy. J Hand Surg Am. March 1999;24(2):323-330. 36. Bohr HH. Tendon transposition in paralysis of the opposition of the thumb.
4. Boyes JH. Tendon transfers in the hand. Proceedings of the 15th General Acta Chir Scand. 1953;105(1-4):45-54.
Assembly of the Japan Medical Congress. Medicine in Japan in 1959. 37. Brand PW. Tendon transfers for median and ulnar nerve paralysis. Orthop
1959;5:958. Clin North Am. November 1970;1(2):447-454.
5. Boyes JH. Selection of a donor muscle for tendon transfer. Bull Hosp Joint 38. Littler JW, Li CS. Primary restoration of thumb opposition with median
Dis. April 1962;23:1-4. nerve decompression. Plast Reconstr Surg. January 1967;39(1):74-75.
6. Omer GE Jr. Reconstructive procedures for extremities with peripheral 39. Bouvier. Note sur une paralysie partielle des muscles de la main. Bull Acad
nerve defects. Clin Orthop Relat Res. March 1982(163):80-91. Nat Med Paris. 1851;18:125.
7. Burkhalter WE. Early tendon transfer in upper extremity peripheral nerve 40. Smith RJ. Extensor carpi radialis brevis tendon transfer for thumb adduction—
injury. Clin Orthop Relat Res. October 1974(104):68-79. a study of power pinch. J Hand Surg Am. January 1983;8(1):4-15.
8. Littler J. Restoration of power and stability in the partially paralyzed hand. 41. Boyes JH. Bunnell’s Surgery of the Hand. 5th ed. Philadelphia, PA: J.B.
In: Converse J, ed. Reconstructive Plastic Surgery. Philadelphia, PA: WB Lippincott Company; 1970.
Saunders; 1977:3266-3280. 42. Hamlin C, Littler JW. Restoration of power pinch. J Hand Surg Am. July
9. Lieber RL, Jacobson MD, Fazeli BM, Abrams RA, Botte MJ. Architecture 1980;5(4):396-401.
of selected muscles of the arm and forearm: anatomy and implications for 43. Mikhail IK. Bone block operation for clawhand. Surg Gynecol Obstet. May
tendon transfer. J Hand Surg Am. September 1992;17(5):787-798. 1964;118:1077-1079.
10. Lieber RL, Ponten E, Burkholder TJ, Friden J. Sarcomere length changes 44. Zancolli EA. Claw-hand caused by paralysis of the intrinsic muscles: a sim-
after flexor carpi ulnaris to extensor digitorum communis tendon transfer. ple surgical procedure for its correction. J Bone Joint Surg Am. October
J Hand Surg Am. July 1996;21(4):612-618. 1957;39-A(5):1076-1080.
11. Omer GJ. Tendon transfers for reconstruction of the forearm and hand fol- 45. Parkes A. Paralytic claw fingers—a graft tenodesis operation. Hand.
lowing peripheral nerve injuries. In: Omer GJ, Spinner M, eds. Management October 1973;5(3):192-199.
of Peripheral Nerve Problems. Philadelphia, PA: WB Saunders; 1980: 46. Bunnell S. Surgery of the intrinsic muscles of the hand other than those
817-846. producing opposition of the thumb. J Bone Joint Surg Am. 1942;24:1-3.
12. Brand P. Tendon transfers in the forearm. In: Flynn JE, ed. Hand Surgery. 47. Riordan DC. Tendon transplantations in median-nerve and ulnar-nerve
Baltimore, MD: Williams & Wilkins; 1975:189-200. paralysis. J Bone Joint Surg Am. April 1953;35-A(2):312-320; passim.
13. Starr C. Army experiences with tendon transference. J Bone Joint Surg Am. 48. Stiles HJ. Treatment of Injuries of Peripheral Spinal Nerves. London:
1922;4:3-21. Frowde H, Hodder and Stoughton; M F Forrester-Brown.
14. Tsuge K, Adachi N. Tendon transfer for extensor palsy of forearm. 49. Burkhalter WE. Restoration of power grip in ulnar nerve paralysis. Orthop
Hiroshima J Med Sci. December 1969;18(4):219-232. Clin North Am. April 1974;5(2):289-303.
15. Jones R. II. On suture of nerves, and alternative methods of treatment by 50. Hastings H 2nd, McCollam SM. Flexor digitorum superficialis lasso tendon
transplantation of tendon. Br Med J. May 13 1916;1(2889):679-682. transfer in isolated ulnar nerve palsy: a functional evaluation. J Hand Surg
16. Jones R. Tendon transplantation in cases of musculospiral injuries not ame- Am. March 1994;19(2):275-280.
nable to suture. Am J Surg. 1921;35:333-335. 51. Brand PW. Tendon grafting illustrated by a new operation for intrinsic
17. Chuinard RG, Boyes JH, Stark HH, Ashworth CR. Tendon transfers for paralysis of the fingers. J Bone Joint Surg Br. 1961;43B:444-453.
radial nerve palsy: use of superficialis tendons for digital extension. J Hand 52. Enna CD, Riordan DC. The Fowler procedure for correction of the para-
Surg Am. November 1978;3(6):560-570. lytic claw hand. Plast Reconstr Surg. October 1973;52(4):352-360.

Chapter 81 n Ligament Injuries of the Hand
and Wrist
Karim Bakri, Brian T. Carlsen, and Steven L. Moran
a portable fluoro-scanner. Multiple attempts at closed joint

Introduction reduction should be avoided due to potential damage to the
Ligament injuries to the hand and wrist are common. In joint cartilage. In cases of irreducible dislocations, soft tis-
many cases, these injuries occur in the absence of concomitant sue interposition is usually preventing reduction and an open
fractures or gross radiographic abnormalities and therefore reduction in the operating room is indicated.
diagnosis is delayed. In addition to performing a history and If the joint is amenable to closed reduction, the finger
physical examination, the plastic surgeon must have sufficient can then be assessed for tendon function and joint stability.
knowledge of joint anatomy and pathology to expediently Stability of the joint can be assessed passively by 1) laterally
make the correct diagnosis. In this chapter, the spectrum of stressing the joint, 2) applying translational stress in a volar–
major ligamentous injuries to the hand and wrist are reviewed dorsal direction, and 3) with active motion. Signs of sublux-
with attention to pertinent anatomy, pathology, and treat- ation or joint surface incongruity while the patient actively
ment options. moves can be assessed in a fluoro-scanner. Joints that are sta-
ble throughout the full range of active motion are splinted or
buddy taped for comfort for a few days, but can and should
Proximal Interphalangeal be mobilized early to prevent stiffness. Recurrent subluxation
Joint or dislocation with active motion necessitates splinting the
joint in a position of stability to allow for ligament healing
Ligament injuries around the proximal interphalangeal (PIP) prior to mobilization.
joint are common. Immobility and improper splinting of the
PIP joint can lead to permanent stiffness and contracture
in as early as 2 weeks. It is imperative that these injuries be
Dorsal PIP Joint Dislocations
diagnosed and treated early. The most common injury pat- Dorsal dislocation or subluxation of the base of the middle
terns include ligament avulsions, dislocations, and fracture phalanx is the most common PIP joint injury. The injury
dislocations. occurs as a result of hyperextension of the joint with axial
The PIP joint is a bicondylar hinge joint with 110° arc of loading. Dorsal PIP dislocations are classified into three types
motion in a single plane and has been called the functional (Figure 81.2).1,2
locus of the hand because it produces 85% of intrinsic digi- Type 1(Hyperextension) injuries represent a hyperexten-
tal flexion and contributes 20% to the overall arc of finger sion injury with an associated avulsion of the volar plate from
motion. PIP joint stability is due to congruity of the articular the proximal phalanx. Although the degree of hyperextension
surfaces and ligamentous anatomy including the proper and may be dramatic, the articular surface of the middle phalanx
accessory collateral ligaments laterally and volar plate pal- remains in contact with the dorsal third of the proximal pha-
marly (Figure 81.1). lanx’s articular surface (Figure 81.2A).
PIP dislocations occur in four major patterns: 1) dorsal Type 2 (Dorsal dislocation) injuries produce a complete
dislocations, 2) fracture dislocations, 3) volar dislocations, longitudinal splitting of the collateral and accessory collateral
and 4) lateral subluxation or dislocations. The extensor ligaments and result in dorsal dislocation with incongruent
mechanism provides little support for the joint dorsally, joint surfaces and parallel phalanges in a bayonet configura-
and the bulk of dislocations occur dorsally as the middle tion (Figure 81.2B).
phalanx is driven dorsally and proximally. Dislocations Type 3 (Fracture dislocation) injuries result in an impac-
occurring laterally or volarly are less common and require tion fracture at the volar base of the middle phalanx, the frac-
a greater force for dislocation; these dislocation patterns ture fragment remains attached to the volar plate, while the
often require operative intervention for successful manage- middle phalanx displaces dorsally. In acute injuries, defor-
ment. A general treatment algorithm for all forms of PIP mity, swelling, and tenderness are frequently obvious; how-
dislocation is 1) joint reduction, 2) verify the congruency ever, dedicated A-P and true lateral X-rays of the involved
of the joint surfaces throughout a normal arc of motion, finger are essential and allow for the evaluation of subtle frac-
3) assess joint stability after reduction, and 4) institute early tures or avulsed bone fragments. Fracture dislocations may
hand therapy to minimize stiffness. As a general rule, stable either be stable or unstable based on the size and comminu-
Hand
joints, following reduction, are treated nonoperatively, tion of the fracture fragment. Stable fractures usually involve
whereas unstable joints often require operative manage- less than 30% to 40% of the volar articular surface of the
ment to restore joint stability. middle phalanx. In cases of stable fracture dislocations, a
portion of the proper collateral ligament remains attached to
General Evaluation the middle phalanx, providing stability once the fracture is
reduced. Unstable fractures usually involve more than 40%
A history is obtained to determine the mechanism of injury. of volar articular surface of the middle phalanx. In these
Radiographs are obtained to assess concomitant fractures cases, the majority of the proper collateral ligament remains
or evidence of ligament avulsion, which may present radio- with the fracture fragment; thus, the middle phalanx has
graphically as small bone fragments near the site of ligament no remaining ligamentous support. Congruent reduction in
insertion. In partial injuries, with subluxation only, palpation such cases is unlikely and some means of fixation is required
over the volar plate and collateral ligaments can identify areas (Figure 81.2C).3
of injury. Dislocations are reduced with the aid of a digital
block. If joint reduction does not occur easily, then further Treatment. Dorsal dislocations of the PIP joint are usu-
joint reduction maneuvers can be attempted with the aid of ally amenable to closed reduction by axial finger traction
817
818 Part VIII: Hand
Middle phalanx Proximal phalanx A Type I Accessory collateral ligament

Proper collateral ligament
Volar plate
Annular Volar plate B Type II

Iigament Proper Accessory
collateral collateral
ligament ligament
FIGURE 81.1. PIP joint anatomy. The soft tissue constraints include
the proper and accessory collateral ligaments laterally and volar plate
palmarly. The proper collateral ligaments attach to the bone of the
middle phalanx while the accessory collateral ligaments attach to the
volar plate.
under digital block anesthesia. Hyperextension of the PIP

and gentle pressure applied to the dorsal base of the middle
phalanx facilitate reduction. Difficulty reducing a dorsal C Type III
dislocation should always raise the suspicion of soft tissue
interposition between the joint surfaces and may necessitate
open reduction. The volar plate is most commonly inter-
posed, although interposition of the profundus tendon or
a portion of the extensor mechanism is also possible. After
reduction, the joint should be assessed for stability, and
X-rays should be obtained to confirm the reduction and fur-
ther assess for fractures. FIGURE 81.2. (A–C) PIP dislocations are divided into three types as
described by Eaton. In a type I hyperextension injury (A) there is an
injury to the volar plate, in addition to an incomplete tear that occurs
Stable Joints between the proper and accessory collateral ligaments. The joint sur-
The majority of type 1 and type 2 injuries are stable after face remains congruent after the injury. In a type II dorsal dislocation
reduction and are treated nonoperatively with buddy-taping injury (B) there is a complete disruption of the volar plate and a com-
or extension block splinting. Simple hyperextension injuries, plete tear between the accessory and proper collateral ligament. The
which are stable following reduction and without evidence middle phalanx lies on the dorsum of the proximal phalanx in a bayo-
net fashion. In a type III hyperextension injury (C) there is a fracture
of subluxation, can be splinted for comfort for 2 to 3 days
and a dislocation. The volar plate, accessory collateral ligament, and
and then patients may be started on active motion therapy proper collateral ligament are damaged. The volar margin of the mid-
protocols. Stable joints that have sustained more severe inju- dle phalanx fractures at the site of proper collateral ligament inser-
ries (including congruent fracture dislocations that involve tion and remains with the proximal phalanx while the middle phalanx
less than 40% of the articular surface of the middle pha- moves dorsal and proximal. (Redrawn from Eaton RG, Lister JW.
lanx) are placed in an extension block splint with the joint Joint injuries and their sequelae. Clin Plast Surg. 1976;3:85-98.)
in 20° to 30° of flexion, which improves joint stability.2,4
Fluoroscopy is helpful in determining the angle to splint
the joint to assure joint congruity in cases of fracture dis-
locations. The joint is allowed to flex within the splint. The contracture, and patient dissatisfaction. This type of injury
splint is refashioned weekly to allow for gradual extension as is difficult to treat and complications may occur despite an
the soft tissues heal. Alternatives to extension block splint- optimally executed treatment regimen. The goals of treat-
ing include extension block pinning which involves passing ment are to restore congruity at the articular surface and
a K-wire into the head of the proximal phalanx to mechani- allow early active motion of the joint. There are several
cally block PIP extension and prevent dorsal translation of treatment options for unstable fracture dislocations and
the middle phalanx.5 Downsides of extension block pinning these include:
include the possibility of infection and the inability to gradu-
ally increase the amount of extension without removal of 1. Dynamic skeletal traction—Longitudinal digital traction
the pin. For stable dislocations, stiffness and swelling may tightens the soft tissue envelope holding the bone frag-
persist for several months but long-term functional deficits ments reduced (ligamentotaxis), and early range of motion
are uncommon. can be initiated (Figure 81.3A–E).6
2. ORIF—Open reduction internal fixation using a lag screw
can be performed through a volar approach if there is a
Unstable Joints and Fracture Dislocations single large volar fragment.
Intra-articular fractures and fracture dislocations that 3. Trans-articular K-wire fixation—A single K-wire is passed
involve more than 30% to 40% of the articular surface proximally across the fracture site and into the head of the
leave little collateral ligament attached to the middle proximal phalanx with the joint in approximately 20° of
phalanx and are frequently unstable. These joints are flexion. The K-wire is removed after 3 weeks and the fin-
much more prone to developing debilitating stiffness, ger is mobilized,

Chapter 81: Ligament Injuries of the Hand and Wrist 819
4. Extension block splinting—Unstable PIP fracture dislo- 6. Hemihamate osteochondral arthroplasty—For severe
cations tend to become more stable with an increasing comminution of the middle phalanx, reconstruction of
degree of flexion. A dorsal splint can be used to block the volar portion of the middle phalanx is possible with
extension beyond the point of instability but allow for the use of an osteochondral graft from the hamate. This
ongoing active flexion. The splint can be modified weekly procedure can be useful when there is >50% bone loss
to progressively decrease the degree of extension blocking. with instability. The dorsal central ridge of the hamate
Extension blockade in greater than 30° of flexion for more lies between the ring and small finger metacarpals and
than 3 weeks should be avoided, to minimize the risk of correlates nicely to the central ridge at the base of the
long-term PIP flexion contracture.4,7 middle phalanx. The graft is centered on this ridge and
5. Volar plate arthroplasty—When the articular surface of the harvested slightly larger than the measured defect to
middle phalanx is severely comminuted, restoration of sta- allow for final contouring before inset. A volar approach
ble congruent bone surfaces is difficult. Soft-tissue interposi- to the PIP joint is used and the graft is secured with
tion arthroplasty using the volar plate to resurface the base two or three bicortical screws. Early motion is begun at
of the middle phalanx can be used to restore joint function.8 1 week.9
B C
Hand
D E
FIGURE 81.3. Unstable type III dorsal fracture dislocation in a 32-year-old laborer. A. Radiograph of injury. B, C. Following closed reduction
the joint remained unstable; hence, dynamic traction pinning was used to restore articular alignment and allow the patient to begin immediate
motion therapy. D, E. At 6 weeks the pins were removed and at 6 months the patient has regained acceptable motion.

820 Part VIII: Hand
Volar PIP Dislocation Distal Interphalangeal Joint

Volar dislocation of the base of the middle phalanx is a rare The distal interphalangeal (DIP) joint is also a uniaxial hinge
injury and is usually associated with either 1) rupture of joint and has an anatomic ligamentous structure similar to the
the central slip of the extensor tendon with or without an PIP joint; however, additional volar support is provided by
avulsion fracture of the base of the middle phalanx or 2) a the profundus tendon insertion at the base of the distal pha-
torsional force causing rotatory subluxation of the middle lanx. The checkrein ligaments are shorter and more laterally
phalanx volarly. Pure volar dislocations cause injuries to the situated in comparison to the PIP joint which allows the joint
collateral ligaments, volar plate, and extensor mechanism; to passively hyperextend by about 15°. The normal active
however, the joint is easily reducible with longitudinal trac- motion arc is 0° to 60°, and restricted motion or fusion of the
tion and extension of the middle phalanx. Rotatory volar DIP joint is well tolerated. Dislocation of this joint is rare, and
dislocations usually result in disruption of only one of the most cases are associated with concomitant flexor or extensor
collateral ligaments. As the associated side of the base of injury, and these will be discussed in greater detail in the sec-
the middle phalanx subluxes in a volar direction, the cor- tion on extensor and flexor tendon injuries.
responding proximal phalangeal condyle may buttonhole in
the interval between the central slip and the lateral band, Dorsal DIP Dislocation
making reduction challenging. In such a situation, attempt-
ing reduction by longitudinal traction tightens the lateral This is the most common DIP joint injury. Closed dislocations
band further entrapping the condyle. For these disloca- can be reduced by longitudinal traction and splinted for 2 to
tions, reduction should be performed by placing the joint 3 weeks, with protected motion beginning at 1 week. The lack
in full flexion, which relaxes the volarly displaced lateral of soft tissue laxity often results in a dorsal skin laceration and
band, and gentle rotation of the base of the middle phalanx. an open joint, which should be irrigated, closed, and splinted.
Radiographs are obtained to confirm success, and active Rarely, DIP or thumb interphalangeal (IP) dislocations are
extension is tested to assess the central slip stability. Failure irreducible due to interposition of the volar plate, flexor digi-
to achieve full extension requires splinting in extension for torum profundus (FDP) tendon, or even sesamoid bones and
6 weeks; otherwise, the joint can be mobilized after 2 weeks. require open reduction. Hyperextension of the DIP joint can
Inability to achieve closed reduction necessitates open result in fracture of the volar lip of the distal phalanx. Small
e xploration to reduce the entrapped condyle and repair fragments proximal to the FDP insertion are usually inconse-
the extensor mechanism. Small dorsal avulsion fractures quential; fragments involving a large portion of the articular
can be immobilized in extension for 6 weeks. Larger, intra- surface or the FDP insertion require operative fixation.14
articular dorsal fragments that are not comminuted are rare;
however, ORIF should be considered if there is significant Metacarpophalangeal Joint
displacement.10
Ligamentous injuries about the finger metacarpophalangeal
PIP Collateral Ligament Injuries (MP) joints are rare due to the significant amount of soft tis-
sue stabilization around the metacarpal head. The MP joints
Forced lateral deviation of the PIP joint puts significant stress are diarthrodial joints and are stabilized by a volar plate, as
on the associated collateral ligament, which may rupture at well as proper and accessory collateral ligaments. The MP
its proximal attachment causing lateral joint instability. With joint has a complex articular geometry and extrinsic stabiliz-
more severe injury, the volar plate is also avulsed causing dis- ing structures that allow for stability in a multiplanar arc of
ruption of two sides of the ligamentous “box”; the middle motion. The metacarpal head is offset volarly from the shaft,
phalanx dislocates laterally and should be reduced by longi- which causes the collateral ligaments to tighten with increas-
tudinal traction. Joint stability can be assessed by stressing ing flexion. As such, the joint is lax in extension allowing for
the injured collateral ligament following reduction. Isolated abduction and adduction when the hand is open. In flexion,
collateral ligament injuries usually heal after a course of pro- the collateral ligaments are taut and joint stability is gained at
tection and immobilization in extension for 7 to 10 days, fol- the expense of lateral mobility. The volar plate is robust and
lowed by controlled active motion. Buddy taping can be used cartilaginous distally, but thin and membranous proximally
to allow motion while protecting from further lateral stress lacking checkrein ligaments and allowing for some hyperex-
injuries. Operative collateral ligament repair may be appropri- tension. Extrinsic stabilizers include the flexor tendons, the
ate if the joint is irreducible or persistently unstable. In these extensor mechanism, and the sagittal bands.15-17 Dislocations
circumstances, the ligament should be reattached through a of the finger MP joints are usually dorsal or ulnar and occur
midaxial approach using suture anchors.11-13 most commonly in the index and small fingers. Volar disloca-
tions and isolated collateral ligament injuries are rare.18
Outcomes and Complications. Outcomes are predicated
on appropriate reduction and early postoperative therapy.
Type I injuries usually heal with few complications. Complete Dorsal MP Dislocation
dorsal dislocations and fracture dislocations represent com- Dorsal dislocation usually occurs as a result of forced MP
plete disruption of the volar plate and collateral ligaments hyperextension. Patients present with pain, deformity, and,
and are associated with poorer outcomes. Collateral ligament usually, MP joint hyperextension. The diagnosis is confirmed
fibrosis following dislocation is the most common complica- radiographically. When the proximal phalanx is forced into
tion, resulting in late joint stiffness and flexion contracture. hyperextension, the volar plate is torn proximally at its mem-
For such cases, early therapy is the first-line treatment. If ther- branous portion. In a simple dorsal subluxation, there is often
apy fails to improve the stiff joint, consideration can be given a marked hyperextension deformity of the finger; however by
to joint release, which can include total collateral ligament definition, the base of the proximal phalanx remains in con-
excision and volar plate release. tact with the metacarpal head; these injuries may be treated
Other complications can include persistent volar plate lax- with closed reduction. In contrast, a complex dorsal disloca-
ity, which can lead to a hyperextension deformity (swan-neck) tion occurs when the torn volar plate, which remains attached
or early degenerative arthritis. In volar dislocations, extension to the base of the proximal phalanx, becomes interposed in
lag can be troublesome even after repair of the central slip. the joint. The finger assumes a bayonet position lying dorsally
Failure to identify central slip injuries in these patients will on the metacarpal head, and the deformity may be less impres-
lead to chronic joint subluxation or a chronic boutonniere sive in appearance than a simple subluxation. The metacarpal
deformity. head is forced into the palm and “buttonholes” between the

Chapter 81: Ligament Injuries of the Hand and Wrist 821
lumbrical radially, and the FDP tendon ulnarly. The flexor injuries.27 The most common ligament injury occurring in the
tendon is pulled dorsally by the intact A1 pulley and the thumb is an acute tear of the MP ulnar collateral ligament
structures form a noose around the narrow metacarpal neck. (UCL), more commonly referred to as a “skier’s thumb.”
Attempts at closed reduction by hyperextension or traction
tighten this noose, preventing relocation of the interposed Thumb MP UCL Injury (Skier’s Thumb)
volar plate and proximal phalanx.19 This mechanism should
Acute tears of the UCL are 10 times more common than RCL
be considered even when attempting reduction of a simple dis-
injuries.28-30 The mechanism of injury is hyperabduction and
location, as digital traction causing excessive MP joint distrac-
forced radial deviation of the proximal phalanx during a fall.
tion can inadvertently draw the torn volar plate dorsally, thus
Patients will present with tenderness, swelling, and potentially
converting a simple dislocation into a complex one requiring
bruising along the ulnar border of the thumb.
operative intervention. Closed reduction of a simple disloca-
There are several important factors to determine when
tion requires the wrist and PIP joints to be in flexion to relax
treating UCL injuries:
the flexor tendons, and pressure is then directed over the base
of the proximal phalanx volarly, sliding it over the metacarpal 1. Is the injury a partial or complete ligamentous tear?
head, keeping the joint surfaces in contact to prevent inadver- 2. Is there a Stener lesion present?
tent volar plate interposition. 3. Is there an associated fracture?
Complex, irreducible dislocations require open reduction. 4. Is the injury acute or chronic?
This can be approached through either a dorsal or volar inci-
Each of these factors will be discussed in greater detail
sion.20 The dorsal approach carries a lower risk of injury to
below.
the neurovascular structures and allows direct visualization of
the entrapped volar plate.21,22 The volar approach gives excel-
lent access to the musculotendinous structures that entrap the Physical Examination
metacarpal head, and reduction can be achieved by incising The treatment of a UCL injury largely depends on whether
the A1 pulley, which allows the flexor tendon to return to its the injury is a partial or complete ligament disruption. Partial
volar location by relaxing the noose around the metacarpal tears (sprains) can be differentiated from complete tears on
neck. In such cases, the neurovascular bundles will be placed physical examination by assessing the degree of angulation on
on stretch and displaced superficially by the metacarpal head; valgus stress testing, comparing this with the “normal” side,
the surgeon must be careful not to injure these structures dur- and evaluating for the presence of a “firm” endpoint. The dif-
ing the skin incision and dissection to expose the joint.23 After ferential attachment of the proper and accessory collateral
reduction of simple or complex dislocations, a dorsal blocking ligaments normally allows the proper collateral ligaments to
splint should be applied to prevent recurrent hyperextension, be taut in flexion and the accessory collateral ligaments to be
and the reduction should be confirmed radiographically. taut in extension.
There is no consensus in the literature on how to clinically
Volar MP Dislocation differentiate between partial and complete tears. However, if
>35° of joint angulation is noted on valgus stress of the flexed
Biomechanical studies in cadavers have shown that forced MP joint, a complete tear of the proper collateral ligament is
hyperflexion of the finger MP joints often results in a trans- likely. In addition, if the degree of angulation with stress of the
verse proximal phalanx fracture rather than a volar MP injured thumb exceeds that of the uninjured thumb by more
dislocation; consequently, volar dislocation of the MP joint than 15°, a complete tear is likely (Figure 81.4). Similarly,
is an infrequent occurrence. Volar dislocations are usually tears of the accessory collateral ligament can be identified
irreducible due to interposition of the dorsal capsule, volar when valgus stress testing of the extended MP joint results
plate, juncturae tendinae, or collateral ligaments within the in more than 35° of radial deviation. Finally, the complete
joint. Closed reduction may be attempted, but open reduction absence of resistance (“firm endpoint”) to lateral stress testing
is usually required to remove the intervening structures prior is also indicative of a complete UCL rupture. Pain and spasm
to reduction.24 of the injured adductor pollicis can confound the examina-
Isolated collateral ligament injuries at the MP joint are tion findings and a local anesthetic wrist block can be used
also rare, but may occur as a result of forced ulnar deviation to obtain a reliable examination. Partial tears are typically
at the MP joint and can be associated with a fracture of the
base of the proximal phalanx. Injuries to the radial collateral
ligament (RCL) of the index finger deserve special surgical
consideration, as the integrity of this ligament is required to
resist lateral deviation during pinch activities. If this injury is
suspected, X-ray of the MP joint (Brewerton view) should be
obtained to rule out avulsion fractures.25 Joint stability may
be assessed by flexing the joint to 60° and placing a radial
and ulnar lateral stress to the joint. Joints that are stable or
Hand
have a firm endpoint on lateral stress testing can be splinted in

30° to 60° of flexion, and the patient may begin early active
motion therapy. Such injuries may be expected to heal with-
out surgical repair. Lack of a firm endpoint on lateral stress
testing indicates a complete tear. Verification of such an injury
can be performed with a magnetic resonance imaging (MRI).
Unstable avulsion injuries are surgically repaired.26
Ligament Injuries of
the Thumb
The thumb is capable of circumduction, opposition, flexion,
extension, abduction, and adduction. The thumb contributes
up to 40% of hand function, but due to its wide arc of motion, FIGURE 81.4. Example of ulnar collateral ligament instability.
the thumb is at risk for hyperabduction and hyperextension

822 Part VIII: Hand
stable and can be treated by immobilizing the MP joint for a [EPB]) to the base of the proximal phalanx, stabilizing the
minimum of 4 weeks in a thumb spica or hand-based splint, MP joint by pulling the phalanx in an ulnar direction.42 Static
leaving the IP joint free.16,31-33 procedures involve using free tendon grafts to reconstruct the
Complete rupture of the UCL should be repaired to pre- proper and accessory collateral ligaments through bone tun-
vent long-term laxity and instability. The ligament usually nels.2,43 Satisfactory results have been reported with secondary
tears at its distal attachment, although proximal and intra- ligament reconstruction; however, at the time of surgery the
substance tears have been reported. The surgical approach is surgeon should still evaluate the mobility of the UCL because
through a lazy-S or chevron incision with the apex located some surgeons have found that even after 2 years from the
at the volar, ulnar aspect of the MP joint. Mid-substance time of injury, the UCL can be dissected from the surround-
tears can be primarily repaired with nonabsorbable suture, ing scar tissue and repaired to

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Grabb and Smith’s

(c) 2015 Wolters Kluwer. All Rights Reserved.

Geoffrey C. Gurtner, md Scott L. Spear, md

(c) 2015 Wolters Kluwer. All Rights Reserved.

© 2014 by Lippincott Williams & Wilkins, a Wolters Kluwer business

Two Commerce Square

Library of Congress Cataloging-in-Publication Data

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(c) 2015 Wolters Kluwer. All Rights Reserved.

David M. Adelman, MD, PhD Scott P. Bartlett, MD

Katerina Anesti, MD, MRCS Bruce S. Bauer, MD

Duc T. Bui, MD Benjamin Chang, MD

(c) 2015 Wolters Kluwer. All Rights Reserved.

Mark W. Clemens, MD Matthias B. Donelan, MD

(c) 2015 Wolters Kluwer. All Rights Reserved.

Chief, Department of Plastic and Reconstructive Surgery Richard A. Hopper, MD, MS

Eric G. Halvorson, MD Erik A. Hoy, MD, MBA

(c) 2015 Wolters Kluwer. All Rights Reserved.

Suhail K. Kanchwala, MD Emil J. Kohan, MD

Michael A.C. Kane, MD John C. Koshy, MD

Armen K. Kasabian, MD Angela Song Landfair, MD

(c) 2015 Wolters Kluwer. All Rights Reserved.

Z. Paul Lorenc, MD Maurice Y. Nahabedian, MD

(c) 2015 Wolters Kluwer. All Rights Reserved.

Kate W. Nellans, MD, MPH Ivona Percec, MD, PhD

Leo R. Otake, MD, PhD Mark E. Puhaindran, MBBS, MRCS

(c) 2015 Wolters Kluwer. All Rights Reserved.

Sandeep Jacob Sebastin, MCh (Plast) Alisa C. Thorne, MD

Kenneth C. Shestak, MD Paul H. Tran, MD

Scott L. Spear, MD Walter P. Unger, MD., FRCP(C), FACP

(c) 2015 Wolters Kluwer. All Rights Reserved.

Allen L. Van Beek, MD Carlos K. Wesley, MD

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Preface xv 18 Lasers In Plastic Surgery . . . . . . . . . . . . . . . . . . . . . 163

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(c) 2015 Wolters Kluwer. All Rights Reserved.

Principles, Techniques, and

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Principles, Techniques, and

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Absorbable or nonabsorbable suture can be used, with the lat-

Half-Buried Horizontal Mattress Suture. Half-buried

Continuous Over-and-Over Suture. Continuous over-

Skin Staples. Skin staples are particularly useful as a time-

Skin Tapes. Skin tapes can effectively approximate the

Wedge Excision. Lesions located at or adjacent to free

(c) 2015 Wolters Kluwer. All Rights Reserved.

Principles, Techniques, and

as for historical purposes. Circular defects can also be closed

Serial Excision. Serial excision is the excision of a lesion

(c) 2015 Wolters Kluwer. All Rights Reserved.

Figure 1.7. Skin graft thickness.

Principles, Techniques, and

(c) 2015 Wolters Kluwer. All Rights Reserved.

Planning the flap in reverse is an important principle. A

Flaps Rotating about a Pivot Point

Figure 1.11. Transposition flap. (A) The secondary defect is often

(c) 2015 Wolters Kluwer. All Rights Reserved.

Principles, Techniques, and

(c) 2015 Wolters Kluwer. All Rights Reserved.

n Angels of z-plasty n theoretical gain

n Name n Abbreviation n Source n Description