Grabb and Smith’s Plastic Surgery [8th Edition] 9781496388261

Table of contents :
Title page......Page 2
Table of Contents......Page 14
Copyright......Page 3
Dedication......Page 4
Foreword......Page 5
Preface......Page 6
Contributors......Page 7
Part IPrinciples, Techniques, and Basic Science......Page 20
1. Fundamental Principles of Plastic 
Surgery......Page 22
2. Basic Science of Wound Healing and 
Management of Chronic Wounds......Page 39
3. Management of Scars......Page 77
4. Principles of Flap Design and 
Application......Page 108
5. Principles of Microsurgery......Page 142
6. Concepts of Skin Grafts and Skin 
Substitutes......Page 182
7. Principles of Flap Reconstruction: Muscle Flaps, Myocutaneous Flaps, and Fasciocutaneous 
Flaps......Page 207
8. Transplantation Biology and Applications to Plastic Surgery......Page 240
9. Principles of Prosthetics in Plastic 
Surgery......Page 285
10. Principles of Nerve Repair and Reconstruction and Neuroma Management......Page 335
11. Principles of Tissue Expansion......Page 363
12. Principles of Procedural Sedation and Local and Regional Anesthesia......Page 384
13. Concepts of Tissue Engineering......Page 415
14. Standardization of Photography and Videography in Plastic Surgery......Page 442
15. Principles of Psychology for Aesthetic and Reconstructive Surgery......Page 467
16. Patient Safety in Plastic Surgery......Page 497
17. Ethics in Plastic Surgery......Page 528
18. Principles of Research Designs and Outcomes Research......Page 543
19. Basic Statistics for the Practicing 
Physician......Page 585
Part IISkin and Soft Tissue......Page 638
20. Skin Care and Benign and Malignant Dermatologic Conditions......Page 640
21. Thermal, Chemical, and Electrical 
Injuries......Page 681
22. Principles of Burn Reconstruction......Page 728
23. Radiation and Radiation Injury......Page 760
24. Lasers in Plastic Surgery......Page 785
Part IIICongenital Anomalies and Pediatric Plastic Surgery......Page 829
25. Cleft Lip and Palate: Embryology, Principles, and Treatment......Page 831
26. Congenital Melanocytic Nevi and Other Common Skin Lesions......Page 866
27. Vascular Anomalies......Page 895
28. Nonsyndromic Craniosynostosis and Deformational Plagiocephaly......Page 919
29. Syndromic Craniosynostosis......Page 952
30. Craniofacial Microsomia and Principles of Craniofacial Distraction......Page 982
31. Orthognathic Surgery......Page 1020
32. Craniofacial Clefts and Orbital 
Hypertelorism......Page 1058
33. Ear Reconstruction......Page 1123
34. Management of Velopharyngeal 
Dysfunction......Page 1159
35. Craniofacial Tumors and Conditions......Page 1198
Part IVHead and Neck......Page 1235
36. Facial Fractures and Soft Tissue Injuries......Page 1237
37. Head and Neck Cancer and Salivary Gland Tumors......Page 1286
38. Reconstruction of the Scalp, Forehead, Calvarium, Skull Base, and Midface......Page 1328
39. Reconstruction of the Eyelids, Correction of Ptosis, and Canthoplasty......Page 1369
40. Nasal Reconstruction......Page 1416
41. Reconstruction of Acquired Lip and Cheek Deformities......Page 1446
42. Facial Paralysis......Page 1478
43. Mandible Reconstruction......Page 1521
44. Reconstruction of the Oral Cavity, Pharynx, and Esophagus......Page 1550
Part VAesthetic Surgery......Page 1597
45. Nonsurgical Facial Rejuvenation and Skin Resurfacing......Page 1599
46. Dermal and Soft-Tissue Fillers: Principles, Materials, and Techniques......Page 1642
47. Botulinum Toxin......Page 1676
48. Fat Grafting in Plastic Surgery......Page 1702
49. Forehead and Brow Rejuvenation......Page 1715
50. Blepharoplasty......Page 1734
51. Facelift and Necklift......Page 1786
52. Rhinoplasty......Page 1822
53. Otoplasty......Page 1893
54. Facial Skeletal Augmentation With Implants and Osseous Genioplasty......Page 1920
Part VIBreast......Page 1950
55. Augmentation Mammoplasty, Mastopexy, and Mastopexy-Augmentation......Page 1952
56. Breast Reduction......Page 1982
57. Gynecomastia......Page 2034
58. Breast Cancer: Current Trends in Screening, Patient Evaluation, and Treatment......Page 2053
59. Breast Reconstruction: Prosthetic 
Techniques......Page 2076
60. Breast Reconstruction: Autologous Flap Techniques......Page 2111
61. Reconstruction of the Nipple-Areolar 
Complex......Page 2146
62. Congenital Anomalies of the Breast: 
Tuberous Breasts, Poland Syndrome, 
and Asymmetry......Page 2161
Part VIIBody Contouring......Page 2201
63. Principles of Plastic Surgery After Massive Weight Loss......Page 2203
64. Liposuction, Abdominoplasty, and Belt Lipectomy......Page 2226
65. Lower Body Lift and Thighplasty......Page 2276
66. Brachioplasty and Upper Trunk 
Contouring......Page 2298
Part VIIIHand......Page 2328
67. Functional Anatomy and Principles of Upper Extremity Surgery......Page 2330
68. Hand Infections......Page 2367
69. Soft Tissue Reconstruction of the Upper Extremity and Management of Fingertip and Nail Bed Injuries......Page 2393
70. Management of Compression Neuropathies of the Upper Extremity......Page 2423
71. Principles and Applications of Nerve Transfers......Page 2458
72. Management of Brachial Plexus Injuries......Page 2492
73. Tetraplegia......Page 2520
74. Management of Hand Fractures......Page 2547
75. Management of Wrist Fractures......Page 2583
76. Flexor Tendon Repair and 
Reconstruction......Page 2642
77. Extensor Tendon Repair and 
Reconstruction......Page 2666
78. Tenosynovitis Disorders of the Upper 
Extremity......Page 2712
79. Principles and Applications of Tendon 
Transfers......Page 2730
80. Ligament Injuries of the Hand......Page 2771
81. Ligament Injuries of the Wrist......Page 2814
82. Management of Mutilating Upper Extremity Injuries......Page 2854
83. Replantation Strategies of the Hand and Upper Extremity......Page 2884
84. Thumb Reconstruction......Page 2935
85. Dupuytren Disease......Page 2978
86. Hand Tumors......Page 3005
87. Treatment of Vascular Disorders of the 
Hand......Page 3024
88. Comprehensive Management of the Burned Hand......Page 3057
89. Compartment Syndrome of the Upper 
Extremity......Page 3077
90. Common Congenital Hand Anomalies......Page 3105
91. Upper Limb Amputations and 
Prosthetics......Page 3134
92. Rheumatoid Arthritis and Inflammatory Arthropathies......Page 3165
93. Osteoarthritis......Page 3199
Part IXTrunk and Lower Extremity......Page 3226
94. Reconstruction of the Chest, Sternum, and Posterior Trunk......Page 3228
95. Abdominal Wall Reconstruction......Page 3266
96. Lower Extremity, Foot, and Ankle 
Reconstruction......Page 3306
97. Perineal Reconstruction......Page 3369
98. Diagnosis and Treatment of 
Lymphedema......Page 3397
99. Pressure Injuries......Page 3426
100. Gender-Affirming Surgery......Page 3464
Index......Page 3514

Citation preview

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Grabb and Smith’s Plastic Surgery Eighth Edition

EDITOR-IN-CHIEF

Kevin C. Chung, MD, MS Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Charles B.G. de Nancrede Professor of Surgery Professor of Plastic Surgery and Orthopaedic Surgery Assistant Dean for Faculty Affairs Associate Director of Global REACH University of Michigan Medical School Ann Arbor, Michigan

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Copyright Acquisitions Editor: Brian Brown Product Development Editor: Ashley Fischer/ Grace Caputo Editorial Assistant: Jeremiah Kiely Marketing Manager: Julie Sikora Production Project Manager: Barton Dudlick/ Linda Van Pelt Design Coordinator: Stephen Druding Artist/Illustrator: Jen Clements Manufacturing Coordinator: Beth Welsh Prepress Vendor: TNQ Technologies Copyright © 2020 Wolters Kluwer. Copyright © 2014 Wolters Kluwer Health / Lippincott Williams & Wilkins. Copyright © 2007 Wolters Kluwer Health / Lippincott Williams & Wilkins. A Wolters Kluwer business. Copyright © 1997 by Lippincott-Raven Publishers. All rights reserved. This book is protected by copyright. No part of this book may be reproduced or transmitted in any form or by any means, including as photocopies or scanned-in or other electronic copies, or utilized by any information storage and retrieval system without written permission from the copyright owner, except for brief quotations embodied in critical articles and reviews. Materials appearing in this book prepared by individuals as part of their official duties as U.S. government employees are not covered by the above-mentioned copyright. To request permission, please contact Wolters Kluwer at Two Commerce Square, 2001 Market Street, Philadelphia, PA 19103, via email at [email protected], or via our website at shop.lww.com (products and services). 9 8 7 6 5 4 3 2 1 Printed in China Library of Congress Cataloging-in-Publication Data Names: Chung, Kevin C., editor. Title: Grabb and Smith’s plastic surgery / editor-in-chief, Kevin C. Chung. Other titles: Plastic surgery Description: Eighth edition. | Philadelphia : Wolters Kluwer, [2020] | Includes bibliographical 
 references and index. Identifiers: LCCN 2019015649 | ISBN 9781496388247 Subjects: | MESH: Reconstructive Surgical Procedures | Cosmetic Techniques | Surgery, Plastic Classification: LCC RD118 | NLM WO 600 | DDC 617.9/5–dc23 LC record available at https://lccn.loc.gov/2019015649 This work is provided “as is,” and the publisher disclaims any and all warranties, express or implied, including any warranties as to accuracy, comprehensiveness, or currency of the content of this work. This work is no substitute for individual patient assessment based upon healthcare professionals’ examination of each patient and consideration of, among other things, age, weight, gender, current or prior medical conditions, medication history, laboratory data and other factors unique to the patient. The publisher does not provide medical advice or guidance and this work is merely a reference tool. Healthcare professionals, and not the publisher, are solely responsible for the use of this work including all medical judgments and for any resulting diagnosis and treatments. Given continuous, rapid advances in medical science and health information, independent professional verification of medical diagnoses, indications, appropriate pharmaceutical selections and dosages, and treatment options should be made and healthcare professionals should consult a variety of sources. When prescribing medication, healthcare professionals are advised to consult the product information sheet (the manufacturer’s package insert) accompanying each drug to verify, among other things, conditions of use, warnings and side effects and identify any changes in dosage schedule or contraindications, particularly if the medication to be administered is new, infrequently used or has a narrow therapeutic range. To the maximum extent permitted under applicable law, no responsibility is assumed by the publisher for any injury and/or damage to persons or property, as a matter of products liability, negligence law or otherwise, or from any reference to or use by any person of this work. shop.lww.com

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Dedication To the memory of Dr. William C. Grabb To the Faculty, Residents, and Fellows at the University of Michigan To Chin-Yin and William

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Foreword It is a distinct privilege for me as the Chief of Plastic Surgery at the University of Michigan to write the Foreword for the 8th Edition of Grabb and Smith’s Plastic Surgery, edited by Kevin C. Chung, MD, MS. What an honor for Dr. Chung to be able to edit this landmark textbook which has its roots at the University of Michigan where William C. Grabb, MD, served as Professor and Chief of the Section of Plastic Surgery. Dr. Grabb was a consummate clinician, surgeon, educator, and innovator whose legacy has lived on through this book. Dr. Grabb, along with his Co-Editor Dr. Smith, has educated a generation of plastic surgeons, helping to prepare plastic surgery residents for the in-service examination, helping to prepare recent graduates for their written examination, and most importantly, helping plastic surgeons care for patients operatively and nonoperatively. Grabb and Smith has always been a great source of information for plastic surgeons during training and many years thereafter. The 8th Edition of Grabb and Smith has been designed by 
 Dr. Chung to build on this important legacy of education. Reviewing the Table of Contents will quickly demonstrate to you that the list of authors reads like a “Who’s Who in Plastic Surgery.” At the same time, the best and brightest young minds in plastic surgery have also contributed to the book. It is this mix of authors that provides a healthy diversity of opinion, viewpoint, and presentation style, which will undoubtedly enhance the value of the material to all readers. The topics may be similar to prior editions of Grabb and Smith, but the chapters have all been completely rewritten. In fact, some of the authors who have contributed chapters to Grabb and Smith in the past have been asked to write new chapters, on different topics, to keep the material fresh, interesting, contemporary, and educational. Additionally, there are many new authors who have not previously contributed to this book, ensuring that the content is current, presented in a way that is relevant to the modern day learner, and yet still maintains the high quality of information necessary to be valuable to all plastic surgeons. The world around us is changing and the only thing that is constant is change. If we are not adapting to this changing world, we will be falling behind. As a result, the 8th Edition has been completely redesigned to optimize its value and to ensure that all of the critical elements of our rapidly changing specialty are captured. The chapters are written in a consistent style to provide the basic knowledge, fundamental principles, and crucial information needed to become a plastic surgeon and to assist those pursuing lifelong learning. The book is formatted in such a way that the information can be gathered quickly through clear and concise writing, visually pleasing full color figures, photographs, expertly crafted decision algorithms, tables, and flowcharts. The days of reading long chapters have gone. The information is provided in a style well suited for in-service examination or written board exam prepara_indentedtion. More importantly, the information is provided in a style that is well suited for plastic surgeons as they provide high-quality, thoughtful, and compassionate care for their patients. The pedagogy of the book has been specifically designed by 
 Dr. Chung with the needs and interests of the plastic surgery resident, young practicing plastic surgeon, or the plastic surgeon who needs rapid access to information “at point of care” with a patient. Each chapter begins with 5 to 7 key points, which have been carefully selected by the authors to be the most critical elements of the chapter. An in-depth discussion of each of these bullet points is performed in the body of the chapter where the learner can find as much depth and breadth of information as they desire. At the conclusion of each chapter, there are 5 to 10 multiple-choice questions, which have been designed to reinforce the learning that has occurred throughout the chapter. This chapter construction follows a very traditional and highly successful model of learning: (1) Tell them what you are going to teach them; (2) Teach them; (3) Tell them what you taught them; and (4) Test them on their new knowledge. This approach has worked for decades in the classroom and works very nicely here as well. Additionally, each question includes a detailed description of why the correct answer is correct and even more importantly, why the incorrect answer is incorrect. Lastly, for those who wish to collect the classic articles in plastic surgery, each chapter includes 5 to 10 classic articles, which have been appropriately cited, highlighted, and briefly annotated for historical perspective. It is such a pleasure to have the 8th Edition of Grabb and Smith’s Plastic Surgery return home to the University of Michigan with 
 Kevin C. Chung, MD, MS, as the Editor, and so many of our faculty as contributing authors. The book has been expertly designed, beautifully executed, and will be an outstanding addition to any library. It is written in a clear and concise way with easy access to all information. At the same time, the book is sufficiently comprehensive to provide lifelong learning from the very infancy of someone’s plastic surgery career to their mature practice. Most of all, this book will help to make us all better physicians and surgeons. I credit the 1st Edition of Grabb and Smith’s Plastic Surgery for teaching me what I needed to know to be a good plastic and reconstructive surgeon. I am sure many will be able to say the same thing about the 8th Edition of this landmark book. Paul S. Cederna, MD Chief, Section of Plastic Surgery Robert Oneal Professor of Plastic Surgery Professor, Department of Biomedical Engineering University of Michigan

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Preface I am honored and most excited to present to you the 8th edition of this classic textbook in plastic surgery. With any historic textbook, at a certain time the content needs complete rejuvenation. In celebration of this 8th edition, I took the liberty of inviting new authors to rewrite every chapter to reflect the innovative spirit of plastic surgery. The authors are some of the best in our specialty, who impart knowledge in a clear and succinct style that is the hallmark of this book. I have also included additional content by presenting annotated classic articles so that the reader can refer to these foundation papers to gain even more insight. Furthermore, the authors have shared select questions and discussed the answer choices in an interactive format. This edition is illustrated richly with artistic drawings to highlight the anatomy and surgical approaches. This para_indentedbook is not meant to be an encyclopedic para_indentedbook, but serves as an essential reference by striving to “get to the facts” in this era of rapid dissemination of information. As I traveled in the United States and around the world, I am struck by how much this para_indentedbook is revered by trainees and senior surgeons during their formative years of becoming a plastic surgeon. The Grabb and Smith para_indentedbook strives to bind the plastic surgery family all over the world, even in remote regions where plastic surgery is not yet recognized as a specialty. I want to acknowledge all of the authors who understood the gravity and honor of contributing to this classic para_indentedbook. They have done a magnificent job in distilling the essence of plastic surgery, for which I am grateful. I want to recognize Brian Brown, the publisher of Grabb and Smith, for his confidence in me after serving as a section editor for many years. I appreciate my team at the University of Michigan, Jennifer Sterbenz and You Jeong Kim, who toiled intensely to help me and our authors ensure timely delivery of the chapters and a quality product. Finally, I would like to thank Grace Caputo, who was relentless in her attention to detail, and her dedication to deliver this para_indentedbook one year early. I welcome Grabb and Smith back to the University of Michigan, for Dr. Grabb was the second chairman of plastic surgery at our historic program. Through the legacy of Dr. Grabb and his trainees, they laid the foundation for our current success. Lastly, I should thank all of the readers of this para_indentedbook. Just because one has purchased previous editions does not mean that this edition is no longer worthwhile. This invigorated 8th edition will certainly set the standard in the publishing world for its educational excellence in synthesizing the encyclopedic plastic surgery specialty into a single para_indentedbook. I am grateful and proud to present to you the 8th Edition of Grabb and Smith’s Plastic Surgery. Kevin C. Chung, MD, MS Chief of Hand Surgery, Michigan Medicine Director, University of Michigan Comprehensive Hand Center Charles B.G. de Nancrede Professor of Surgery Professor of Plastic Surgery and Orthopaedic Surgery Assistant Dean for Faculty Affairs Associate Director of Global REACH University of Michigan Medical School Ann Arbor, Michigan

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Contributors Joshua M. Adkinson MD Assistant Professor of Surgery, Chief of Hand Surgery, Division of Plastic Surgery, Department of Surgery, Indiana University School of Medicine, Indianapolis, Indiana Jayant P. Agarwal MD Chief, Division of Plastic Surgery, Associate Professor of Surgery, University of Utah School of Medicine, Salt Lake City, Utah Shailesh Agarwal MD Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Rachel E. Aliotta MD Department of Plastic and Reconstructive Surgery, Cleveland Clinic, Cleveland, Ohio Oluseyi Aliu MD, MS Assistant Professor, Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, Maryland Ashley N. Amalfi MD Assistant Professor of Surgery, Division of Plastic Surgery, University of Rochester School of Medicine and Dentistry, Rochester, New York R. Rox Anderson MD Professor of Dermatology, Harvard Medical School, Director, Wellman Center of Photomedicine, Department of Dermatology, Massachusetts General Hospital, Boston, Massachusetts Anne Argenta MD Assistant Professor , Medical College of Wisconsin, Milwaukee, Wisconsin Mohammed Asif MD Clinical Instructor , Department of Plastic Surgery, Johns Hopkins Burn Center, Johns Hopkins School of Medicine, Baltimore, Maryland William G. Austen, JR MD, FACS Division Chief, Plastic and Reconstructive Surgery, Burn Surgery, Massachusetts General Hospital, Boston, Massachusetts Deniz Basci MD Aesthetic Fellow, Department of Plastic Surgery, University of Texas Southwestern Medical Center , Dallas, Texas John H. Bast MD Clinical Assistant Professor of Surgery, Penn Medicine Lancaster General Hospital, Lancaster, Pennsylvania Omar E. Beidas MD Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Nicholas L. Berlin MD, MPH Resident, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Jessica I. Billig MD Resident, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Gregory H. Borschel MD, FAAP, FACS Associate Professor, Institute of Biomaterials and Biomedical Engineering, Associate Scientist, SickKids Research Institute Program in Neuroscience and Mental Health, Sickkids Hand, Nerve and Microsurgery, Nerve Regeneration Laboratory, The Hospital for Sick Children, Division of Plastic and Reconstructive Surgery, Toronto, Ontario, Canada James P. Bradley MD Professor, Vice Chairman, Department of Surgery, Zucker School of Medicine at Hofstra/Northwell, New York, New York Gerald Brandacher MD Associate Professor of Surgery, Scientific Director, Reconstructive Transplantation Program, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland David A. Brown Assistant Professor, Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina David L. Brown MD Professor of Surgery, Section of Plastic Surgery, University of Michigan Medical School , Ann Arbor, Michigan Steven R. Buchman MD, FACS M. Haskell Newman Professor of Plastic Surgery, Professor of Neurosurgery, Professor of Surgery, Program Director, Craniofacial Surgery Fellowship, University of Michigan Medical School, Chief, Pediatric Plastic Surgery, CS Mott Children’s Hospital, Director, Craniofacial Anomalies Program, University of Michigan Medical Center, Ann Arbor, Michigan Grant W. Carlson MD Chief, Division of Plastic Surgery, Emory University School of Medicine, Emory Aesthetic Center, Atlanta, Georgia Christi M. Cavaliere MD, MS Medical Director of Wound Care, Staff Plastic Surgeon, Cleveland Clinic, Cleveland, Ohio

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Rodney Chan MD, FACS, FRCSC Chief, Plastic and Reconstructive Surgery, Clinical Division and Burn Center, U.S. Army Institute of Surgical Research, San Antonio Military Medical Center, Associate Professor, Department of Surgery, Uniform Services University of the Health Sciences, San Antonio, Texas James Chang MD Chief, Division of Plastic and Reconstructive Surgery, Johnson & Johnson Distinguished Professor of Surgery (Plastic Surgery) and Orthopaedic Surgery, Stanford University Medical Center, Palo Alto, California Edward I. Chang MD, FACS Associate Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas Ming-Huei Cheng MD, MBA, FACS Professor, Division of Plastic Reconstructive Microsurgery, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kweishan, Taiwan Ernest S. Chiu MD Director and Associate Professor of Plastic Surgery, Institute of Reconstructive Plastic Surgery, Helen L. & Martin S. Kimmel, Hyperbaric and Advanced Wound Healing Center, New York University Langone Medical Center, New York, New York Carrie K. Chu MD Assistant Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center , Houston, Texas Kevin C. Chung MD, MS Chief of Hand Surgery, Michigan Medicine, Director, University of Michigan Comprehensive Hand Center, Charles B.G. de Nancrede Professor of Surgery, Professor of Plastic Surgery and Orthopaedic Surgery, Assistant Dean for Faculty Affairs, Associate Director of Global REACH, University of Michigan Medical School, Ann Arbor, Michigan Mark W. Clemens II MD, FACS Associate Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas Amy S. Colwell MD Associate Professor, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts Carisa M. Cooney MPH Assistant Professor, Director of Education Innovation, Clinical Research Manager, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland Damon S. Cooney MD, PhD Assistant Professor, Associate Program Director, Johns Hopkins/University of Maryland, Plastic Surgery Residency Training Program, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland Wendy L. Czerwinski MD, PhD Associate Professor, Division of Plastic Surgery, Department of Surgery, Baylor Scott & White Medical Center, Texas A&M University College of Medicine, Dallas, Texas Leahthan F. Domeshek MD Fellow, Division of Plastic and Reconstructive Surgery, The Hospital for Sick Children, Toronto, Ontario, Canada Matthias B. Donelan MD Chief of Staff, Shriners Hospital for Children, Visiting Surgeon, Massachusetts General Hospital, Associate Professor of Surgery, Harvard Medical School, Boston, Massachusetts A. Samandar Dowlatshahi MD Instructor, Harvard Medical School, Division of Hand Surgery, Department of Orthopaedics, Division of Plastic Surgery, Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts Katherine E. Duncan MD Ophthalmologist/Oculoplastic Surgeon, Greater Baltimore Medical Center, Baltimore, Maryland Paul D. Durand MD Chief Resident, Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio William W. Dzwierzynski MD Professor and Program Director, Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin Kyle R. Eberlin MD Assistant Professor of Surgery, Division of Plastic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts Kate E. Elzinga MD, FRCSC Section of Plastic Surgery, University of Calgary, Calgary, Alberta, Canada Benjamin P. Erickson MD Assistant Professor, Department of Ophthalmology, Stanford University School of Medicine, Palo Alto, California William B. Ericson, Jr. MD, FACS, FAAOS Orthopaedic Hand Surgeon, Ericson Hand and Nerve Center, Seattle, Washington Russell E. Ettinger MD Chief Resident, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Kenneth L. Fan MD Department of Plastic and Reconstructive Surgery, MedStar Georgetown University Hospital, Washington, DC Frank Fang MD Assistant Professor, Division of Plastic Surgery, Department of Surgery, Icahn School of Medicine at Mount Sinai, Attending Physician, Division of Plastic Surgery, Department of Surgery, The Mount Sinai Hospital, New York, New York Jeffrey B. Friedrich MD, FACS Professor of Surgery and Orthopaedics, Division of Plastic Surgery, University of Washington, Seattle,

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Washington Natalia Fullerton MD Plastic and Reconstructive Surgery, New York-Presbyterian Hospital of Columbia and Weille Cornell Medicine, New York, New York Warren L. Garner MD, FACS Professor of Plastic Surgery, University of Southern California, Los Angeles, California Michael S. Gart MD Fellow, Hand and Upper Extremity Surgery, OrthoCarolina Hand Center, Charlotte, North Carolina Katherine M. Gast MD, MS Assistant Professor, Division of Plastic Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin Aviram M. Giladi MD, MS Hand Surgery and Plastic Surgery, Research Director, The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltmiore, Maryland Justin Gillenwater MD, MS Assistant Professor, Plastic and Reconstructive Surgery, Burn and Critical Care, University of Southern California, LAC+USC Burn Center, Los Angeles, California Robert H. Gilman MD, DMD Clinical Assistant Professor, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan Jesse A. Goldstein MD Associate Professor, Department of Plastic Surgery, Children’s Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Arun K. Gosain MD Professor and Chief, Division of Pediatric Plastic Surgery, Lurie Children’s Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois Amanda A. Gosman MD Professor and Interim Chief of Plastic Surgery, Residency Program Director, Craniofacial Fellowship Director, Director of Craniofacial and Pediatric Plastic Surgery, Division of Plastic Surgery, University of California San Diego , Chief of Plastic Surgery, Rady Children’s Hospital San Diego, San Diego, California Arin K. Greene MD. MMSc Department of Plastic and Oral Surgery, Boston Children’s Hospital, Associate Professor of Surgery, Harvard Medical School, Boston, Massachusetts Buket Gundogan BSc (Hons), MBBS East and North Hertfordshire NHS Trust, Hertfordshire, United Kingdom Jeffrey A. Gusenoff MD Associate Professor of Plastic Surgery, Clinical and Translational Science, Co-Director, Life After Weight Loss Program, Department of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Steven C. Haase MD Associate Professor, Section of Plastic Surgery , Department of Surgery, Department of Orthopaedic Surgery, University of Michigan Medical School, Ann Arbor, Michigan Warren C. Hammert MD Professor of Orthopaedic Surgery and Plastic Surgery, Chief, Division of Hand Surgery, Department of Orthopaedics and Rehabilitation, University of Rochester Medical Center, Rochester, New York Matthew M. Hanasono MD Professor , Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas Chelsea A. Harris MD Research Fellow, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Asra Hashmi MD Craniofacial Surgery Fellow, Division of Plastic Surgery, University of San Diego, San Diego, CA Lydia A. Helliwell MD Division of Plastic Surgery, Instructor of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts Gwendolyn Hoben MD, PhD Hand Surgery Fellow, Department of Plastic Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin Scott T. Hollenbeck MD, FACS Associate Professor, Plastic and Reconstructive Surgery, Duke University Medical Center, Durham, North Carolina Ian C. Hoppe MD Craniofacial Surgery Fellow, Division of Plastic Surgery, Children’s Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania Henry C. Hsia MD, FACS Associate Professor of Surgery, Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, Director, Yale Regenerative Wound Healing Program, Yale New Haven Hospital, New Haven, Connecticut Katherine M. Huber MD Chief Resident, Division of Plastic Surgery, Department of Surgery, University of South Florida Morsani College of Medicine, Tampa, Florida C. Scott Hultman MD, MBA, FACS Professor and Vice Chair, Department of Plastic and Reconstructive Surgery, Johns Hopkins University, Director, Johns Hopkins Bayview Medical Center Burn Center, Department of Plastic and Reconstructive Surgery, Johns Hopkins Hospitals,

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Baltimore, Maryland Paul F. Hwang MD Chief of Breast Reconstruction, Assistant Professor of Surgery, Department of Surgery, Division of Plastic and Reconstructive Surgery, Walter Reed National Military Medical Center, Bethesda, Maryland Paul H. Izenberg MD Clinical Instructor, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Medical Director Outpatient Surgical Center, Department of Surgery, St. Joseph Mercy Hospital, Ann Arbor, Michigan Oksana A. Jackson MD Associate Professor of Surgery, Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Surgical Associate, Division of Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Jeffrey E. Janis MD, FACS Professor of Plastic Surgery, Neurosurgery, Neurology, and Surgery, Executive Vice Chairman, Department of Plastic Surgery, Chief of Plastic Surgery, University Hospitals, Ohio State University Wexner Medical Center, Columbus, Ohio Reza Jarrahy MD, FACS, FAAP Associate Clinical Professor of Surgery, Neurosurgery, and Pediatrics, Division of Plastic and Reconstructive Surgery, David Geffen School of Medicine at UCLA, Los Angeles, California Christine M. Jones MD Assistant Professor, Division of Plastic Surgery, Temple University Hospital, Lewis Katz School of Medicine, Philadelphia, Pennsylvania Neil F. Jones MD, FRCS, FACS Chief of Hand Surgery, Professor of Orthopaedic Surgery, Professor of Plastic and Reconstructive Surgery, University of California Irvine, Irvine, California Loree K. Kalliainen MD, MA Associate Professor, Division of Plastic Surgery, University of North Carolina, Chapel Hill, North Carolina Sirichai Kamnerdnakta MD, FRCST Associate Professor, Division of Plastic Surgery, Department of Surgery, Faculty of Medicine, Siriraj Hospital, Bangkok, Thailand Steven J. Kasten MD Section of Plastic and Reconstructive Surgery, University of Michigan Medical School, Ann Arbor, Michigan Brian P. Kelley MD Surgeon, Institute of Reconstructive Plastic Surgery of Central Texas, Dell Seton Medical Center of the University of Texas, Austin, Texas Jeffrey Kenkel MD Professor and Chair , Department of Plastic Surgery, UT Southwestern Medical Center, Dallas, Texas Jason H. Ko MD Associate Professor, Division of Plastic and Reconstructive Surgery, Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois Stephen J. Kovach MD Associate Professor of Surgery, Divisions of Plastic Surgery and Orthopaedic Surgery, University of Pennsylvania, Perelman Center for Advanced Medicine, Philadelphia, Pennsylvania Carrie A. Kubiak MD House Officer, Department of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan Medical School, Ann Arbor, Michigan Theodore A. Kung MD Assistant Professor of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan Medical School, Ann Arbor, Michigan William M. Kuzon, Jr. MD Reed O. Dingman Collegiate Professor of Surgery, Section of Plastic and Reconstructive Surgery, University of Michigan Medical School, Chief of Surgery, VA Ann Arbor Healthcare, Ann Arbor, Michigan Alvin C. Kwok MD, MPH Division of Plastic and Reconstructive Surgery, University of Utah, Salt Lake City, Utah W. P. Andrew Lee MD The Milton T. Edgerton, MD, Professor and Chairman, Department of Plastic and Reconstructive Surgery, Johns Hopkins University School of Medicine, Baltimore, Maryland Justine C. Lee MD, PhD Associate Professor , Bernard G. Sarnat Endowed Chair, Department of Plastic and Reconstructive Surgery, University of California Los Angeles, Los Angeles, California Benjamin Levi MD Director, Burn/Wound and Regenerative Medicine Laboratory, Director, Burn/Scar Rehabilitation Program, Associate Burn Director, Assistant Professor in Surgery, University of Michigan Medical School, Ann Arbor, Michigan L. Scott Levin MD, FACS Paul B. Magnuson Professor of Bone and Joint Surgery, Chairman, Department of Orthopaedic Surgery, Professor of Surgery (Plastic Surgery), University of Pennsylvania, Philadelphia, Pennsylvania Howard Levinson MD, FACS Director of Plastic Surgery Research, Associate Professor of Plastic and Reconstructive Surgery, Division of Surgical Sciences, Associate Professor of Pathology and Dermatology, Departments of Surgery, Pathology, and Dermatology, Duke University Medical Center, Durham, North Carolina Samuel J. Lin MD, MBA Program Director, Aesthetic Plastic Surgery Fellowship, Associate Professor of Surgery, Division of Plastic and Reconstructive Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts

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Joseph E. Losee MD Ross H. Musgrave Endowed Chair in Pediatric Plastic Surgery, Associate Dean for Faculty Affairs, University of Pittsburgh School of Medicine, Professor and Executive Vice Chair, Department of Plastic Surgery, UPMC, Division Chief, Pediatric Plastic Surgery, UPMC Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania David W. Low MD Professor of Surgery, Division of Plastic Surgery, Perelman School of Medicine at the University of Pennsylvania, Surgical Associate, Division of Plastic Surgery, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania Michele Ann Manahan MD Associate Professor, Department of Plastic and Reconstructive Surgery, Johns Hopkins Medical Institution, Johns Hopkins Hospital, Baltimore, Maryland Ernest K. Manders MD Professor of Plastic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania Malcolm W. Marks MD Wake Forest University Baptist Medical Center, Department of Plastic and Reconstructive Surgery, Medical Center Boulevard, Winston Salem, North Carolina Alan Matarasso MD, FACS, PC Clinical Professor of Plastic Surgery, Zucker School of Medicine at Hofstra/Northwell, President, Executive Committee and Board of Directors, American Society of Plastic Surgeons, Past President, Board of Trustees, Chairman, 2016-2017 Traveling Professor, The Rhinoplasty Society, Past President, Board of Trustees, Chairman, New York Regional Society of Plastic Surgeons, New York, New York Evan Matros MD, MPH Associate Attending, Memorial Sloan Kettering Cancer Center, Weill Cornell Medical College, New York, New York Alexander F. Mericli MD Assistant Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas Brett F. Michelotti MD Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery , University of Wisconsin – School of Medicine and Public Health, Madison, Wisconsin Nathanial R. Miletta MD, FAAD Board-Certified Dermatologist and Fellowship-Trained Dermatologic Surgeon, Chief, Laser Surgery and Scar Center, San Antonio Military Medical Center, Assistant Professor, Uniformed Services University of the Health Sciences, San Antonio, Texas Erin A. Miller MD Department of Plastic and Reconstructive Surgery, University of Washington, Seattle, Washington Gabriele C. Miotto MD, MEd Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery, Emory University School of Medicine, Atlanta, Georgia Adeyiza O. Momoh MD Associate Professor of Surgery, Program Director, Integrated Plastic Surgery Residency, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Brian A. Moore MD, FACS Chair, Otorhinolaryngology and Communication Sciences, Director, Ochsner Cancer Institute, Ochsner Health System, New Orleans, Louisiana Neal Moores MD Division of Plastic Surgery, University of Utah School of Medicine, Salt Lake City, Utah Terence M. Myckatyn MD, FACS, FRCSC Professor, Plastic and Reconstructive Surgery, West County Plastic Surgeons, Washington University School of Medicine, Saint Louis, Missouri Maurice Y. Nahabedian MD Professor and Section Chief, Department of Plastic Surgery, MedStar Washington Hospital Center, Georgetown University, Washington, DC Foad Nahai MD Marice J. Jurkiewicz Chair in Plastic Surgery, Professor of Surgery, Emory University School of Medicine, Atlanta, Georgia Anne C. O’Neill MBBCh, MMedSci, FRCS(Plast), MSc, PhD Assistant Professor, Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada Dennis P. Orgill MD, PhD Medical Director, The Wound Care Center, Brigham and Women’s Hospital, Professor of Surgery, Harvard Medical School, Boston, Massachusetts Wayne Ozaki MD, DDS Clinical Professor, Director of Craniofacial Surgery, Chief of Pediatric Plastic Surgery, Division of Plastic and Reconstructive Surgery, UCLA David Geffen School of Medicine, Los Angeles, California, Chief of Plastic Surgery, Olive View-UCLA Medical Center, Sylmar, California Christopher J. Pannucci MD, MS Division of Plastic and Reconstructive Surgery, University of Utah, Salt Lake City, Utah Julie E. Park MD, FACS Stephan R. Lewis Professor of Surgery, Division of Plastic Surgery, University of Texas Medical Branch, Galveston, Texas Sabrina N. Pavri MD, MBA Chief Resident, Section of Plastic Surgery, Department of Surgery, Yale University School of Medicine, Yale New Haven Hospital, New Haven, Connecticut

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Wyatt G. Payne MD Professor of Surgery, Division of Plastic Surgery, University of South Florida, Tampa, Florida, Chief, Plastic Surgery, Bay Pines VA Healthcare System, Bay Pines, Florida Chad A. Perlyn MD, PhD Chief, Division of Plastic Surgery, Florida International University College of Medicine, Attending Surgeon, Nicklaus Children’s Hospital, Miami, Florida Ivo A. Pestana MD Wake Forest University Baptist Medical Center, Department of Plastic and Reconstructive Surgery, Medical Center Boulevard, Winston-Salem, North Carolina Mitchell A. Pet MD Fellow, Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, Maryland Nicole A. Phillips MD Senior Resident, Division of Plastic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts Brett T. Phillips MD, MBA Division of Plastic, Maxillofacial, and Oral Surgery, Department of Surgery, Duke University Medical Center, Durham, North Carolina Julian J. Pribaz MD Professor of Surgery, Morsani College of Medicine, University of South Florida, Tampa, Florida Brian C. Pridgen MD Division of Plastic and Reconstructive Surgery, Stanford University Medical Center, Stanford, California Mark E. Puhaindran MBBS, MRCS, MMed Senior Consultant, Department of Hand and Reconstructive Microsurgery, National University Hospital, Singapore Xuan Qiu MD, PhD Hand Surgery Fellow , Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Ali A. Qureshi MD Washington University in St Louis, Barnes-Jewish Hospital, St Louis, Missouri Paymon Rahgozar MD Hand Surgery Fellow, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan Kavitha Ranganathan MD Resident, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Patrick L. Reavey MD, MS Assistant Professor , Department of Surgery, Section of Plastic and Reconstructive Surgery, Department of Orthaepedic Surgery and Rehabilitation Medicine, University of Chicago Medicine, Chicago, Illinois Christine Hsu Rohde MD, MPH Associate Professor of Surgery, Vice Chair of Faculty Development and Diversity, Department of Surgery, Columbia University Medical Center, New York-Presbyterian Hospital, New York, New York Jessica F. Rose MD Microsurgery Fellow, Division of Plastic Surgery, University of Pennsylvania, Philadelphia, Pennsylvania J. Peter Rubin MD, FACS UPMC Endowed Professor and Chair, Director, Life After Weight Loss Surgical Body Contouring Program, Department of Plastic Surgery, University of Pittsburgh, Pittsburgh, Pennsylvania Ara A. Salibian MD Resident Physician, Hansjörg Wyss Department of Plastic Surgery, New York University Langone Health, New York, New York Ian C. Sando MD Plastic and Reconstructive Surgeon, Ascension St. Vincent, Indianapolis, Indiana Sarah E. Sasor MD Hand Surgery Fellow, Section of Plastic Surgery, University of Michigan Medical School, Ann Arbor, Michigan Jesse C. Selber MD, MPH Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center, Houston, Texas Akhil K. Seth MD Division of Plastic and Reconstructive Surgery, NorthShore University HealthSystem, Clinical Assistant Professor of Surgery, University of Chicago Pritzer School of Medicine, Evanston, Illinois Sammy Sinno MD Private Practice, Chicago, Illinois Sheri Slezak MD Professor, Division of Plastic Surgery, University of Maryland School of Medicine, Baltimore, Maryland David J. Smith MD Professor of Surgery, Chief, Division of Plastic Surgery, University of South Florida Monsani School of Medicine, Tampa, Florida Darren M. Smith MD Voluntary Faculty, Department of Plastic Surgery, Manhattan Eye, Ear, and Throat Hospital, Lenox Hill Hospital, New York, New York Alison K. Snyder-Warwick MD Assistant Professor of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri Nicole Z. Sommer MD Associate Professor of Surgery, Director of SIU Cosmetic Clinic, Institute for Plastic Surgery , Southern Illinois

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University School of Medicine, Springfield, Illinois Mark W. Stalder MD Assistant Professor of Plastic and Reconstructive Surgery , Department of Surgery, Louisiana State University Health Sciences Center School of Medicine, New Orleans, Louisiana Jill P. Stone MD Microvascular Reconstructive Surgery Fellow, Department of Plastic Surgery, Johns Hopkins Hospital, Baltimore, Maryland Christopher C. Surek DO Aesthetic Surgery Fellow, Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio Amir H. Taghinia MD, MPH, MBA Staff Surgeon, Boston Children’s Hospital, Assistant Professor of Surgery, Harvard Medical School, Boston, Massachusetts Jesse A. Taylor MD Mary Downs Endowed Chair of Craniofacial Surgery, Division of Plastic Surgery, Children’s Hospital of Philadelphia, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania Peter W. Thompson MD Assistant Professor of Plastic Surgery, Emory University Hospital, Atlanta, Georgia Matthew D. Treiser MD, PhD Assistant Professor, Department of Surgery, Albert Eistein College of Medicine, Faculty, Department of Surgery, Division of Plastic and Reconstructive Surgery, Montefiore Medical Center, Bronx, New York Sergey Y. Turin MD Resident Physician, Division of Pediatric Plastic Surgery, Lurie Children’s Hospital of Chicago, Northwestern Feinberg School of Medicine, Chicago, Illinois John A. van Aalst MD Chief, Division of Plastic Surgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio Christian J. Vercler MD, MA Associate Professor, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Jennifer F. Waljee MD, MPH, MS Associate Professor, Section of Plastic Surgery, Department of Surgery, University of Michigan Medical School, Ann Arbor, Michigan Derrick C. Wan MD Associate Professor, Department of Surgery, Director of Maxillofacial Surgery, Lucile Packard Children’s Hospital, Endowed Faculty Scholar, Child Health Research Institute at Stanford University, Hagey Family Faculty Scholar in Stem Cell Research and Regenerative Medicine, Stanford University Medical Center, Stanford, California Jeremy Warner MD, FACS Associate Professor, Section of Plastic and Reconstructive Surgery, University of Chicago, Chicago, Illinois Robert A. Weber MD Professor and Vice Chair of Surgery, Chief, Section of Hand Surgery, Baylor Scott & White Medical Center, Texas A&M University College of Medicine, Temple, Texas Thomas D. Willson MD Assistant Professor of Surgery, Larner College of Medicine at the University of Vermont, Director of the Cleft/Craniofacial Program, Vermont Children’s Hospital, Burlington, Vermont Alex K. Wong MD, FACS Associate Professor of Surgery, Director, Basic, Translational, and Clinical Medicine, Director, Microsurgery Fellowship and Medical Student Education, Division of Plastic and Reconstructive Surgery, Keck School of Medicine of University of Southern California, Los Angeles, California Sang Hyun Woo MD, PhD President, W Institute for Hand and Reconstructive Microsurgery, W Hospital, Daegu, Korea Akira Yamada MD, PhD Professor of Surgery , Northwestern University Feinberg School of Medicine, Department of Plastic Surgery, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, Illinois Guang Yang MD Associate Professor, Department of Hand Surgery, China-Japan Union Hospital of Jilin University, Changchun, People’s Republic of China Peirong Yu MD Professor, Department of Plastic Surgery, University of Texas MD Anderson Cancer Center , Houston, Texas Frank Yuan MD General Surgery Resident, Department of Surgery, University of Massachusetts Medical School, Worcester, Massachusetts Toni Zhong MD, MHS, FRCS Associate Professor, Departments of Surgery and Surgical Oncology, University of Toronto, Clinical and Scientific Director, UHN Breast Reconstruction Program, Fellowship Director, Division of Plastic and Reconstructive Surgery , University of Toronto, Toronto, Ontario, Canada James E. Zins MD Chairman, Department of Plastic Surgery, Cleveland Clinic, Cleveland, Ohio Terri A. Zomerlei MD Resident, Department of Plastic Surgery, Ohio State University Wexner Medical Center, Columbus, Ohio

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Contents Part IPrinciples, Techniques, and Basic Science 1. Fundamental Principles of Plastic 
 Surgery Theodore A. Kung and Kevin C. Chung

2. Basic Science of Wound Healing and 
 Management of Chronic Wounds Buket Gundogan and Dennis P. Orgill

3. Management of Scars Wyatt G. Payne and David J. Smith

4. Principles of Flap Design and 
 Application Julian J. Pribaz and Katherine M. Huber

5. Principles of Microsurgery Sarah E. Sasor and Kevin C. Chung

6. Concepts of Skin Grafts and Skin 
 Substitutes Sabrina N. Pavri and Henry C. Hsia

7. Principles of Flap Reconstruction: Muscle Flaps, Myocutaneous Flaps, and Fasciocutaneous 
 Flaps Michele Ann Manahan

8. Transplantation Biology and Applications to Plastic Surgery Gerald Brandacher and W. P. Andrew Lee

9. Principles of Prosthetics in Plastic 
 Surgery Ara A. Salibian and Ernest S. Chiu

10. Principles of Nerve Repair and Reconstruction and Neuroma Management Carrie A. Kubiak, David L. Brown, and Theodore A. Kung

11. Principles of Tissue Expansion Paul F. Hwang and Samuel J. Lin

12. Principles of Procedural Sedation and Local and Regional Anesthesia Neal Moores and Jayant P. Agarwal

13. Concepts of Tissue Engineering Matthew D. Treiser and William G. Austen

14. Standardization of Photography and Videography in Plastic Surgery Frank Yuan and Kevin C. Chung

15. Principles of Psychology for Aesthetic and Reconstructive Surgery Sergey Y. Turin and Sammy Sinno

16. Patient Safety in Plastic Surgery Omar E. Beidas and Jeffrey A. Gusenoff

17. Ethics in Plastic Surgery Christian J. Vercler

18. Principles of Research Designs and Outcomes Research

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Chelsea A. Harris and Kevin C. Chung

19. Basic Statistics for the Practicing 
 Physician Damon S. Cooney and Carisa M. Cooney

Part IISkin and Soft Tissue 20. Skin Care and Benign and Malignant Dermatologic Conditions John H. Bast and Alex K. Wong

21. Thermal, Chemical, and Electrical 
 Injuries Justin Gillenwater and Warren L. Garner

22. Principles of Burn Reconstruction Benjamin Levi and Rodney Chan

23. Radiation and Radiation Injury Natalia Fullerton and Christine Hsu Rohde

24. Lasers in Plastic Surgery Nathanial R. Miletta, R. Rox Anderson, and Matthias B. Donelan

Part IIICongenital Anomalies and Pediatric Plastic Surgery 25. Cleft Lip and Palate: Embryology, Principles, and Treatment Russell E. Ettinger and Steven R. Buchman

26. Congenital Melanocytic Nevi and Other Common Skin Lesions David W. Low and Oksana A. Jackson

27. Vascular Anomalies Kavitha Ranganathan and Steven J. Kasten

28. Nonsyndromic Craniosynostosis and Deformational Plagiocephaly Jesse A. Taylor and Ian C. Hoppe

29. Syndromic Craniosynostosis Wayne Ozaki and Thomas D. Willson

30. Craniofacial Microsomia and Principles of Craniofacial Distraction Sergey Y. Turin and Arun K. Gosain

31. Orthognathic Surgery Reza Jarrahy and Thomas D. Willson

32. Craniofacial Clefts and Orbital 
 Hypertelorism Jesse A. Goldstein and Joseph E. Losee

33. Ear Reconstruction Akira Yamada and Arun K. Gosain

34. Management of Velopharyngeal 
 Dysfunction Asra Hashmi and Amanda A. Gosman

35. Craniofacial Tumors and Conditions James P. Bradley and Justine C. Lee

Part IVHead and Neck 36. Facial Fractures and Soft Tissue Injuries Christine M. Jones and John A. van Aalst

37. Head and Neck Cancer and Salivary Gland Tumors Matthew M. Hanasono and Brian A. Moore

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38. Reconstruction of the Scalp, Forehead, Calvarium, Skull Base, and Midface Alexander F. Mericli, Jesse C. Selber, and Matthew M. Hanasono

39. Reconstruction of the Eyelids, Correction of Ptosis, and Canthoplasty Benjamin P. Erickson and Derrick C. Wan

40. Nasal Reconstruction Akhil K. Seth and Evan Matros

41. Reconstruction of Acquired Lip and Cheek Deformities Ian C. Sando and David L. Brown

42. Facial Paralysis Leahthan F. Domeshek and Gregory H. Borschel

43. Mandible Reconstruction Mark W. Stalder and Chad A. Perlyn

44. Reconstruction of the Oral Cavity, Pharynx, and Esophagus Carrie K. Chu and Peirong Yu

Part VAesthetic Surgery 45. Nonsurgical Facial Rejuvenation and Skin Resurfacing Deniz Basci and Jeffrey Kenkel

46. Dermal and Soft-Tissue Fillers: Principles, Materials, and Techniques Ivo A. Pestana and Malcolm W. Marks

47. Botulinum Toxin Scott T. Hollenbeck and David A. Brown

48. Fat Grafting in Plastic Surgery Edward I. Chang

49. Forehead and Brow Rejuvenation Alan Matarasso and Darren M. Smith

50. Blepharoplasty Sheri Slezak and Katherine E. Duncan

51. Facelift and Necklift Gabriele C. Miotto and Foad Nahai

52. Rhinoplasty Robert H. Gilman and Jeremy Warner

53. Otoplasty Arin K. Greene

54. Facial Skeletal Augmentation With Implants and Osseous Genioplasty Paul D. Durand, Christopher C. Surek, and James E. Zins

Part VIBreast 55. Augmentation Mammoplasty, Mastopexy, and Mastopexy-Augmentation Ali A. Qureshi and Terence M. Myckatyn

56. Breast Reduction Paul H. Izenberg and Nicholas L. Berlin

57. Gynecomastia Ashley N. Amalfi and Nicole Z. Sommer

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58. Breast Cancer: Current Trends in Screening, Patient Evaluation, and Treatment Alvin C. Kwok and Christopher J. Pannucci

59. Breast Reconstruction: Prosthetic 
 Techniques Peter W. Thompson and Grant W. Carlson

60. Breast Reconstruction: Autologous Flap Techniques Shailesh Agarwal and Adeyiza O. Momoh

61. Reconstruction of the Nipple-Areolar 
 Complex Anne C. O’Neill and Toni Zhong

62. Congenital Anomalies of the Breast: 
 Tuberous Breasts, Poland Syndrome, 
 and Asymmetry Kenneth L. Fan and Maurice Y. Nahabedian

Part VIIBody Contouring 63. Principles of Plastic Surgery After Massive Weight Loss Omar E. Beidas, Jeffrey A. Gusenoff, and Ernest K. Manders

64. Liposuction, Abdominoplasty, and Belt Lipectomy Terri A. Zomerlei and Jeffrey E. Janis

65. Lower Body Lift and Thighplasty Omar E. Beidas and J. Peter Rubin

66. Brachioplasty and Upper Trunk 
 Contouring Amy S. Colwell and Nicole A. Phillips

Part VIIIHand 67. Functional Anatomy and Principles of Upper Extremity Surgery Robert A. Weber and Wendy L. Czerwinski

68. Hand Infections Anne Argenta and William W. Dzwierzynski

69. Soft Tissue Reconstruction of the Upper Extremity and Management of Fingertip and Nail Bed Injuries Sirichai Kamnerdnakta and Kevin C. Chung

70. Management of Compression Neuropathies of the Upper Extremity Loree K. Kalliainen and William B. Ericson, Jr

71. Principles and Applications of Nerve Transfers Gwendolyn Hoben and Alison K. Snyder-Warwick

72. Management of Brachial Plexus Injuries Frank Fang and Kevin C. Chung

73. Tetraplegia Jennifer F. Waljee and Kevin C. Chung

74. Management of Hand Fractures Joshua M. Adkinson and Kevin C. Chung

75. Management of Wrist Fractures Mitchell A. Pet and Warren C. Hammert

76. Flexor Tendon Repair and 
 Reconstruction Xuan Qiu and Kevin C. Chung

77. Extensor Tendon Repair and 
 Reconstruction

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Amir H. Taghinia and A. Samandar Dowlatshahi

78. Tenosynovitis Disorders of the Upper 
 Extremity Lydia A. Helliwell and Kyle R. Eberlin

79. Principles and Applications of Tendon 
 Transfers Michael S. Gart and Jason H. Ko

80. Ligament Injuries of the Hand Aviram M. Giladi and Kevin C. Chung

81. Ligament Injuries of the Wrist Brett F. Michelotti

82. Management of Mutilating Upper Extremity Injuries Jessica I. Billig and Kevin C. Chung

83. Replantation Strategies of the Hand and Upper Extremity Sang Hyun Woo

84. Thumb Reconstruction Patrick L. Reavey and Neil F. Jones

85. Dupuytren Disease Steven C. Haase

86. Hand Tumors Mark E. Puhaindran

87. Treatment of Vascular Disorders of the 
 Hand Brian C. Pridgen and James Chang

88. Comprehensive Management of the Burned Hand C. Scott Hultman and Mohammed Asif

89. Compartment Syndrome of the Upper 
 Extremity Guang Yang and Kevin C. Chung

90. Common Congenital Hand Anomalies Paymon Rahgozar and Kevin C. Chung

91. Upper Limb Amputations and 
 Prosthetics Kate E. Elzinga and Kevin C. Chung

92. Rheumatoid Arthritis and Inflammatory Arthropathies Brian P. Kelley and Kevin C. Chung

93. Osteoarthritis Erin A. Miller and Jeffrey B. Friedrich

Part IXTrunk and Lower Extremity 94. Reconstruction of the Chest, Sternum, and Posterior Trunk Alexander F. Mericli and Mark W. Clemens II

95. Abdominal Wall Reconstruction Brett T. Phillips and Howard Levinson

96. Lower Extremity, Foot, and Ankle 
 Reconstruction Jessica F. Rose, Stephen J. Kovach, and L. Scott Levin

97. Perineal Reconstruction Julie E. Park

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98. Diagnosis and Treatment of 
 Lymphedema Oluseyi Aliu, Jill P. Stone, and Ming-Huei Cheng

99. Pressure Injuries Christi M. Cavaliere and Rachel E. Aliotta

100. Gender-Affirming Surgery William M. Kuzon, Jr. and Katherine M. Gast

Index

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PA R T I

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Principles, Techniques, and Basic Science 1. Fundamental Principles of Plastic Surgery 2. Basic Science of Wound Healing and Management of Chronic Wounds 3. Management of Scars 4. Principles of Flap Design and Application 5. Principles of Microsurgery 6. Concepts of Skin Grafts and Skin Substitutes 7. Principles of Flap Reconstruction: Muscle Flaps, Myocutaneous Flaps, and Fasciocutaneous Flaps 8. Transplantation Biology and Applications to Plastic Surgery 9. Principles of Prosthetics in Plastic Surgery 10. Principles of Nerve Repair and Reconstruction and Neuroma Management 11. Principles of Tissue Expansion 12. Principles of Procedural Sedation and Local and Regional Anesthesia 13. Concepts of Tissue Engineering 14. Standardization of Photography and Videography in Plastic Surgery 15. Principles of Psychology for Aesthetic and Reconstructive Surgery 16. Patient Safety in Plastic Surgery 17. Ethics in Plastic Surgery 18. Principles of Research Designs and Outcomes Research 19. Basic Statistics for the Practicing Physician

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CHAPTER 1

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Fundamental Principles of Plastic Surgery Theodore A. Kung and Kevin C. Chung

Key Points Plastic surgery is a diverse surgical specialty and its practice is guided by a set of fundamental principles. There is an inexorable connection between cosmetic surgery and reconstruction surgery because every plastic surgery operation aims to restore both form and function. Elective surgeries should be pursued only after considering whether the benefits of surgery will outweigh the risks. Outcomes in plastic surgery can be enhanced by addressing modifiable patient factors, adequately preparing wounds prior to reconstruction, replacing lost structures with tissues of similar quality, ensuring optimal vascularity, minimizing donor site morbidity, and deliberately protecting the surgical site. A plastic surgeon is always prepared to confront complications with a series of surgical backup plans. Plastic surgeons must continually innovate new solutions to clinical problems and will remain at the vanguard of surgical innovation. Plastic surgery is an incredibly diverse specialty that is challenging to define because its scope cannot simply be characterized by patient age, gender, organ system, or pathology. The purview of plastic surgery extends from neonatal to end-of-life care and is inclusive of a myriad of conditions that affect every single area of the human body. Plastic surgeons possess unique and versatile skills for reconstructing defects relating to cancer extirpation, cosmetically enhancing normal anatomy, salvaging limbs after trauma, rehabilitating burn patients, ameliorating childhood deformities, and performing autotransplantation as well as allotransplantation. This expertise is also critical in devising creative solutions to a variety of problems faced by other physicians, and for this reason, plastic surgeons are frequently consulted by their colleagues in other specialties. How is it possible for one surgical specialty to encompass this enormous breadth and depth of practice? The unifying trait of all plastic surgeons is a comprehensive understanding of a set of important fundamental principles. Every plastic surgeon abides by these principles to successfully execute the many complex assessments, judgment calls, and technical decisions in the daily practice of plastic surgery. Therefore, the specialty of plastic surgery is exceptional because it is distinguished not by its association to a particular patient population or anatomic region, but by a dedication to imperative principles that enable plastic surgeons to provide effective and individualized care. These principles were conceptualized through centuries of plastic surgery evolution and formalized in recent history by Gillies and Millard, who outlined a collection of philosophical yet practical principles in their text The Principles and Art of Plastic Surgery. 1 Years later, Millard published an expanded set of tenets in Principalization of Plastic Surgery. 2 This chapter modernizes and expounds on 10 of the most essential fundamental principles of plastic surgery and provides relevant examples of how plastic surgeons utilize these principles in a wide range of clinical scenarios.

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Principle I: Make an Informed Decision to Operate or Not Operate Some types of plastic surgery are mandatory. A wound resulting from resection of a sarcoma with exposed bone requires a reconstructive operation that provides soft tissue coverage over the defect durable enough to withstand the infliction of adjuvant radiation therapy. However, in many situations, the plastic surgeon must make an informed decision whether to perform an operation or not based on a thorough evaluation of the potential benefits against the potential risks. Although this is conspicuously germane to cosmetic surgery, the same thought process is necessary for reconstructive surgery. For example, a large but clean traumatic wound on a patient’s thigh could be treated reasonably with one of several options, from nonsurgical strategies such as dressing changes to surgical intervention such as local tissue rearrangement. A multitude of factors must be carefully pondered to select the most appropriate treatment. If dressing changes are used, the wound may be healed eventually but at what burden to the patient? Does the patient have the patience or ability to perform satisfactory dressing changes? Would a definitive surgery result in a healed wound more efficiently? How feasible is the surgery, and what is the likelihood of specific complications? Ultimately, the surgeon must decide if the benefits of surgery will outweigh the risks and predict that the expected outcomes of surgery will enhance the patient’s overall health status. This determination is made more difficult because of the inherently subjective nature of plastic surgery outcomes. Success in plastic surgery is not measured solely on binary scales, such as patency versus occlusion or union versus nonunion. Instead, success is also subjectively gauged by patient satisfaction and is influenced by patient expectations. 3 Consider a consultation between a plastic surgeon and a woman interested in postmastectomy breast reconstruction, an elective operation with substantial psychosocial advantages. In a relatively short amount of time, the plastic surgeon needs to educate the patient regarding the available surgical choices for breast reconstruction and provide an individualized assessment of her candidacy for each option. To guide the patient to the most suitable decision for her, the surgeon must shrewdly evaluate the patient’s expectations and her level of understanding of the desired reconstructive surgery. Are her expectations consistent with what is possible from a technical standpoint? Does the patient seem ready to make this decision amidst the other stresses associated with a breast cancer diagnosis? Does the patient understand the possible setbacks that may occur with the surgery? The answers to these types of questions will greatly affect the patient’s perception of the success of reconstruction and her reported satisfaction with both the surgery and the plastic surgeon.

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Principle II: Optimize Modifiable Patient Factors Deliberate identification and management of patient risk factors will decrease the chances of complications and increase the likelihood of successful surgical outcomes. For example, smoking is a commonly encountered modifiable risk factor. Nearly 20% of Americans are smokers and cigarette smoking remains the leading cause of preventable disease and death in the United States. 4,5 The noxious components of cigarette smoke are known to cause vasoconstriction, induce endothelial injury, cause thrombogenesis, diminish oxygen transport, and hinder cellular repair mechanisms. 6 Together, these detrimental processes work synergistically to impair wound healing and will directly confer additional risk to plastic surgery patients. Other modifiable medical risk factors that also exacerbate poor wound healing include uncontrolled diabetes, obesity, infection, steroid use, certain homeopathic medications, and malnutrition. 7 These treatable comorbidities should be recognized during preoperative screening and sufficiently addressed prior to any operation. Social risk factors should also be carefully considered during the preoperative evaluation. After surgery, patients will frequently need assistance with their activities of daily living and comply with strict restrictions. The plastic surgeon should inquire about the social support available to the patient and ensure that the patient’s postoperative safety is entrusted to either family members or a rehabilitation center. The importance of risk factor optimization is demonstrated in the care of body contouring patients. During the preoperative consultation, a thorough history is taken to solicit all modifiable risk factors that would impair the patient’s ability to heal long incisions and wide dissection planes. 8 For a majority of plastic surgeons, smoking is an absolute contraindication to any body contouring operation. Cessation of smoking for at least 4 weeks and confirmation with a urine cotinine test is a common requirement before surgery is scheduled. Frequently, collaboration with the patient’s primary care physician is critical in correcting hyperglycemia, anemia, or vitamin deficiencies. Patients who would benefit from additional weight loss may be referred to a nutritionist or a bariatric surgeon. After the operation, the patient will have considerable activity restrictions and will need to care for the wounds; therefore, a detailed preoperative discussion with the patient about postoperative care and limitations will serve to set expectations and to establish a social support system for the patient.

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Principle III: Perform Adequate Debridement Prior to Reconstruction Debridement is performed to physically remove any barriers to tissue growth, such as infection, biofilm, and senescent cells. 9 The plastic surgeon may choose one of many forms of debridement, from dressing changes to operative excision of the wound, but the critical concept is that the debridement must be adequate to remove all elements hindering wound healing. In many instances, this objective is accomplished only after the wound is debrided serially in the operating room. Chronic wounds are often associated with some degree of necrotic tissue that must be sharply and completely debrided away before definitive reconstruction can be performed. Failure of reconstruction is often attributed to inadequate debridement of the wound. Although adequate debridement is usually a term associated with the management of chronic wounds, this essential principle also applies to acute wounds. Acute traumatic wounds, such as open fractures of the lower extremity or lacerations from bite injury, are notoriously contaminated, and adequate debridement in this setting is also critical to the success of reconstruction. In fact, this principle of adequate debridement is so relevant to all forms of plastic surgery that it may even be applied to clean surgical wounds. For example, during reduction mammoplasty, there is often a widespread accumulation of devitalized globules of fat and clots scattered throughout the surgical field. Prior to closure, meticulous removal of this biologic debris facilitates wound healing by decreasing the risks of fat necrosis and infection. Certain situations will complicate the plastic surgeon’s ability to perform adequate debridement. For example, in some traumatic wounds, exposed orthopedic hardware cannot be removed because doing so would result in unacceptable fracture instability. 10 In these challenging cases, debridement serves to decrease the microbial burden of the wound, and deep tissue cultures are taken to help guide antimicrobial therapy. However, the persistent presence of contaminated material will be a major risk factor for infection, and therefore the patient may need suppressive antibiotic therapy until the hardware can be removed. This necessary adaptation of the principle of adequate debridement is also exemplified in the treatment of pressure ulcers with underlying osteomyelitis. These chronic wounds exhibit many deleterious factors that impede wound healing. 11 The first step in surgical treatment is completely excising the soft tissue bursa surrounding the wound. If the osteomyelitis is limited to a small focus of bone at the base of the pressure ulcer, it is possible to remove the area of bone infection entirely during debridement. However, if the osteomyelitis is extensive, complete resection of this bone is not feasible, and the patient will often need suppressive antibiotic therapy guided by intraoperative bone cultures. In this situation, aggressive excision of the bursa is still beneficial because this promotes healing of the soft tissues after surgery and results in a smaller, cleaner, and more manageable chronic wound.

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Principle IV: If Possible, Replace Like With Like; If Not Possible, Create It One of the most famous plastic surgery principles is that lost tissues should be replaced in kind. The plastic surgeon examines the defect carefully and determines the best donor tissues necessary to optimally achieve both a durable reconstruction and an optimal aesthetic outcome. For instance, when primary skin closure is not possible after excision of a cutaneous tumor from an upper eyelid, a frequently chosen donor site is full-thickness skin from the opposite upper eyelid. 12 This option is elegant because it replaces the missing tissue with tissue of the same thickness, color match, pliability, and elasticity. In addition, donor site morbidity is acceptably low when relatively excess skin from one eyelid is used to reconstruct the other eyelid. When such an ideal donor site is unavailable, the next most similar tissue substitute is selected; in this example, skin for eyelid reconstruction can be harvested from postauricular skin or supraclavicular skin. This principle can also be applied to substantially more challenging wounds. An extensive mandibular tumor may necessitate the removal of bone, muscle, mucosa, and skin, and successful reconstruction is predicated on the replacement of these tissues with appropriately similar donor tissues. In these complex cases, reconstruction often requires the use of free flaps that are transferred to the defect, such as a fibula bone flap with associated skin based on the peroneal vascular system. 13 In some cases, no suitable donor sites exist, and innovative strategies must be employed to create sufficient replacement tissues of similar quality. One example of this is the use of tissue expanders to induce growth of tissues through cellular proliferation. 14 Tissue expansion has revolutionized the treatment of various conditions and given plastic surgeons another tool to better replace like with like in clinical scenarios that were previously impossible because of the severity of tissue deficiency. Tissue expanders now serve a critical role in the replacement of hair-bearing skin for large scalp defects, the creation of additional abdominal wall tissue for the closure of large hernias, the expansion of mastectomy skin for breast reconstruction, and the resurfacing of skin affected by giant congenital nevi. This concept of cellular response to force is also the mechanism behind distraction osteogenesis in craniofacial surgery. 15 This technique leverages the natural processes of fracture healing to yield outcomes superior to those achievable through other means such as nonvascularized bone grafting or free tissue transfer. For example, distraction osteogenesis is an excellent strategy for treating micrognathia in children with Pierre Robin sequence. 16 Internal or external distractors are placed surgically around the site of mandibular osteotomies, and a tensile force is slowly delivered to gradually elongate the intervening callus. One major advantage of distraction osteogenesis is that during the process of new bone formation, the overlying soft tissue envelope is also expanded incrementally. This reduces the constrictive effects of the soft tissue on the growing bone and consequently results in a stable reconstruction that is less prone to relapse. These powerful techniques to grow living structures outside of the laboratory setting have completely transformed the plastic surgeon’s ability to replace missing tissues and are often principal options for many complex clinical problems.

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Principle V: Optimize Vascularity at Every Opportunity Plastic surgeons are obsessed with blood supply. Vascularity is paramount to tissue viability and therefore to the success of healing. The plastic surgeon must possess an unparalleled comprehension of the blood supply to various types of tissues and methods to preserve this blood supply during surgery. For example, knowledge of the vastness of the subdermal plexus allows a plastic surgeon to reliably raise thin flaps of skin during a facelift operation. In reconstructive surgery, donor tissues must remain wellvascularized to transfer from one location to another. A detailed understanding of the vascular anatomy of these flaps permits their use for definitive closure of any wound. When vascularity to a surgical site is insufficient, the plastic surgeon must strive to improve it. For instance, surgery may be postponed to await smoking cessation or time may be given for other specialists to help optimize blood flow. An illustration of the latter is when a patient with arterial insufficiency and a chronic lower extremity wound is referred to a vascular surgeon for revascularization prior to surgical treatment of the wound. Vascularity of a particular flap may also be enhanced by performing a delay procedure, which is a staged operation whereby the plastic surgeon partially raises the flap and then waits 1 to 2 weeks before fully elevating the flap for reconstruction. A delay period allows choke vessels to physiologically dilate within the flap and results in greater flap reliability. 17 This respect for blood supply is also evident in many intraoperative decisions that are made by plastic surgeons. Judicious placement of incisions, especially in the context of unfavorable previous incisions, requires a careful consideration of blood supply. Additionally, at many points during an operation, the plastic surgeon will tailor numerous surgical techniques to maximize vascularity. For example, when a local flap such as a V-Y flap or a rotational flap is used for closure of a wound, minimal undermining is performed during flap elevation to reduce disruption of the flap’s underlying blood supply. Any sizable perforating vessels that are encountered during dissection of these local flaps are deliberately preserved if possible. During flap inset, pickups and retractors are handled thoughtfully to prevent iatrogenic tissue injury, and undue tension of the closure is avoided to minimize tissue ischemia. Even the selection of sutures and suturing technique is weighed against the effects on vascularity. For instance, placement of too many deep dermal sutures may cause relative ischemia of the edge of a cutaneous flap, and the choice of horizontal mattress suturing may lead to more ischemia compared with vertical mattress suturing. Each of these intraoperative decisions may influence the quality of the blood supply to the closure and may make a meaningful difference in the functional or cosmetic outcome of the surgery.

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Principle VI: Preserve Form and Function Every plastic surgery operation seeks to restore and preserve form and function. In many instances, the goals of surgery are both cosmetic and reconstructive. Patients with excess upper eyelid skin, for example, may describe dissatisfaction with their appearance as well as visual field deficits. During the preoperative consultation, the plastic surgeon must establish that the objectives of upper lid blepharoplasty are to both rejuvenate the upper eyelids and expand the visual field. A more challenging consideration of form and function occurs in children presenting with congenital facial nerve paralysis. In these patients, abnormalities of the facial nerve result in severe facial asymmetry that leads to devastating psychological consequences such as social isolation and difficulties with eating, speech articulation, emotional expression, and control of saliva. Frequently, the optimal solution for these cases is facial reanimation using a microsurgical transfer of an innervated muscle. 18 This reconstruction elevates the corner of the mouth and nasal ala on the paralyzed side to enhance resting facial symmetry and improve the dynamics of mastication, speech, and oral competence. Furthermore, because the muscle is innervated by a functional donor nerve at the recipient site, this operation can achieve animation of the paralyzed face, and in many instances, continued rehabilitation will result in spontaneous smiling. 19 In some situations, restoration of form and function is accomplished through a surgical solution that replaces multiple tissue deficiencies. An illustrative example of this is reconstruction after pelvic exenteration for advanced colorectal cancer. 20 Removal of organs such as the bladder and rectum will result in a void in the pelvis, and occasionally, the extent of tumor invasion mandates resection of other structures such as the vagina and perianal skin. The goals of reconstruction in these cases are to recreate normal anatomy, obliterate dead spaces within the pelvis, and supply additional vascularity to a surgical site that often is subject to neoadjuvant radiation. One exceptionally suitable choice that fulfills many of these reconstructive needs is the oblique rectus abdominis myocutaneous (ORAM) flap. 21 The ORAM flap has long reach for a pedicled flap, comprises a large amount of soft tissue bulk, and possesses a highly reliable blood supply. Furthermore, the flap is capable of supporting a large skin paddle that can be used for resurfacing vaginal defects as well as perianal skin deficits. With proper surgical planning, the ORAM flap can achieve excellent form and function by filling the pelvic dead space with vascularized tissue after tumor resection, providing sufficient lining for vaginal reconstruction, and decreasing the tension of closure in the perineum to optimize wound healing.

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Principle VII: Minimize Donor Site Morbidity When donor tissues are required, the plastic surgeon must focus on minimizing the functional and cosmetic sacrifices to the patient. Each operation already possesses inherent risks relating to the surgical site, such as hematoma, infection, or abnormal scarring. The donor site adds an additional anatomic area where complications may arise, and the plastic surgeon must weigh the possibility of donor site morbidity against the benefits of the use of that tissue for reconstruction. Often, several suitable donor sites exist, and a surgeon’s ultimate decision will be based upon careful consideration of the potential complications with each site. For example, during a rhinoplasty operation, structural support can be augmented by performing autologous cartilage grafting to the nasal framework. 22 Cartilage grafts can be harvested from the nasal septum, from the conchal bowl of the ear, or from the cartilaginous portion of a rib. The nasal septum would be an ideal donor site if septoplasty is also being performed, but use of this cartilage may cause further destabilization of the nasal framework and has a small risk of septal perforation. Harvest of conchal cartilage can provide adequate grafting material but may be complicated by hematoma, keloid formation, or ear asymmetry. The rib donor site offers an abundance of high-quality cartilage, but its indications must warrant the additional scar and added potential for pneumothorax. Ultimately, the plastic surgeon must choose the most appropriate donor site for reconstruction and justify the unique risks associated with that donor site. To reduce donor site morbidity, plastic surgeons avoid unnecessary sacrifice of important adjacent anatomic structures. This focus on preservation of function during the harvest of donor tissues contributed to the advent of perforator flaps. For example, breast reconstruction using transverse rectus abdominis myocutaneous flaps commonly results in considerable abdominal wall morbidity, including bulges, hernias, and the need for mesh placement. 23 This morbidity is directly related to the removal of one or both rectus abdominis muscles from their native position, which weakens core strength and the integrity of the anterior abdominal wall. In contrast, the use of deep inferior epigastric perforator flaps for breast reconstruction is associated with lower morbidity to the abdominal donor site. During harvest of a deep inferior epigastric perforator flap, the perforating vessels supplying the skin and fat overlying the abdominal wall are meticulously dissected out of the rectus abdominis muscle, and every effort is made to maintain the continuity of the muscle. Segmental nerves are identified and protected whenever possible to preserve innervation to the rectus abdominis muscle, and a minimal amount of fascia is taken to reduce the tension of fascial closure. A continued ambition to limit donor site morbidity and extensive recent experience with perforator flap techniques have now led to the widespread use of many other workhorse perforator flaps for reconstruction, such as the anterolateral thigh (ALT) flap, the superior gluteal artery perforator flap, the thoracodorsal artery perforator flap, and the internal mammary artery perforator flap. 24

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Principle VIII: Protect the Surgical Site Postoperatively In plastic surgery, an operation cannot be deemed fully successful at the time of its completion; instead, this evaluation can only be made several weeks to months after the operation. This interval allows for preliminary healing to occur, subsidence of postsurgical swelling, initiation of rehabilitation therapy, and management of any complications. During this critical time, the surgical site must be protected diligently to facilitate recovery and to prevent injury to the healing tissues. The plastic surgeon must actively counsel patients to follow strict activity restrictions and help patients understand the rationale behind the necessary postoperative protocols. Strenuous activity, for example, may increase the likelihood of bleeding, seroma, or wound dehiscence and should be avoided for a period of time that commensurates with the magnitude of the operation and its associated risks. Clear postoperative instructions are provided to patients and may include customized information on various relevant issues such as wound care, splinting, compression garments, weight-bearing status, or limb elevation. Regular follow-up visits are also necessary to ensure that wounds are healing appropriately and to recognize the development of any complications. All of these efforts are directed at protecting the surgical site. Failure to do so may jeopardize the final outcome. Complex lower extremity reconstruction exemplifies the importance of this principle. 25 An open tibial fracture with a large soft-tissue defect can be reconstructed with a free muscle flap and skin grafting to provide durable coverage of the underlying bone and orthopedic hardware. However, postoperative protection of the surgical site is as influential to successful salvage of the limb as the reconstructive surgery itself. 26 After surgery, the free flap is safeguarded from compression, especially when the muscle extends posteriorly where it would be crushed by the weight of the limb without proper elevation. This can be done using pillows, blankets, or foam; alternatively, if the patient has an external fixator in place, attachments can be added to prop up the leg much like the kickstand of a bicycle. Limb elevation also opposes venous congestion and facilitates the resolution of postsurgical edema. Immobilization is also a critical component of the postoperative protocol because it safeguards the reconstruction from any shearing forces that might disrupt either the muscle or the skin graft. Plaster or plastic splints are useful adjuncts to aid in immobilization of joints after surgery. Although each clinical scenario is unique, soft tissues generally require several weeks of protected healing time before being able to sustain any significant challenges. Therefore, once this initial healing period has occurred, a gradual and supervised release of these restrictions is commenced until complete return to normal activities is possible.

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Principle IX: Have a Backup Plan (and a Backup Plan for THAT Backup Plan) Complications will always arise, and the prepared plastic surgeon will be ready with multiple contingency plans. Most commonly, complications such as wound infection, marginal flap necrosis, or dehiscence can be successfully managed with straightforward and standardized treatment protocols. However, occasionally, the first operative plan fails to adequately address the goals of surgery, and a new plan is necessary. In reconstructive surgery, an old paradigm known as the reconstructive ladder advocates for a linear, stepwise approach to surgical problems whereby less-complicated surgical techniques are initially attempted, and progression up the ladder to more complex strategies is pursued only when needed. More recently, significant advancements in the field of plastic surgery have led to a shift away from this paradigm in favor of a treatment algorithm that encourages selection of the most definitive method for reconstruction even if it means picking a more complex one first. 27 If a backup plan is necessary, the plastic surgeon may either choose an alternative surgical plan from another rung of the reconstructive ladder or decide to try the previous plan again. Despite the antiquated adage in plastic surgery that instructs: “Make sure that plan B is not the same as plan A,” the same approach may in fact be attempted if careful consideration is given to the reasons why the prior surgery resulted in a failed reconstruction. If these factors can be readily identified and appropriately corrected, the same operative strategy may be performed another time and a successful outcome can be expected. Reconstruction of upper extremity defects frequently exemplifies this fundamental principle. For example, a dorsal hand wound from a full-thickness burn injury with several exposed extensor tendons and metacarpal bones can be reconstructed by numerous techniques. 28 Although less-sophisticated approaches such as dermal substitutes and skin grafting may ultimately result in a closed wound, these options would not provide sufficiently durable soft tissue coverage over gliding tendons and therefore would result in unacceptable hand stiffness. A superior first choice for reconstruction might be a reverse radial forearm flap from the ipsilateral extremity or another regional flap. Should the plastic surgeon encounter insurmountable complications with the reverse radial forearm flap, a reasonable backup plan might entail the use of a free gracilis muscle flap. If the free flap reconstruction fails, the next backup option might be another free tissue transfer as long as the problems that led to loss of the previous flap are elucidated and the surgeon is confident that these issues can be sufficiently overcome prior to performing another free flap. Alternatively, the plastic surgeon might choose to reconstruct the dorsal hand wound with a pedicled groin flap. This fundamental principle of having a series of sensible backup plans guides the plastic surgeon to prepare for any number of potential setbacks during the reconstructive process and serves to optimize the chances of successful surgical outcomes.

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Principle X: Innovate New Solutions to Old Problems Innovation drives the practice and progress of plastic surgery. Plastic surgeons possess an inherent ambition to improve surgical approaches to existing clinical problems. For this reason, rarely is the exact same operation ever performed twice. Each surgery is individualized according to the clinical situation and specific patient needs. Thus, the plastic surgeon must strive to tailor every operation and often makes numerous adjustments to the accepted standard techniques. For example, a cleft lip repair for one child is never precisely the same as that for another child. 29 Although the basic tenets are constant, such as restoring continuity of the orbicularis oris and re-establishing labial subunits, the surgeon must remain flexible during the operation and modify the repair technique to account for the unique abnormalities present in each patient. This spirit of adaptation and creative problem-solving is a large part of what distinguishes plastic surgery from other surgical disciplines and contributes to the constant evolution of the specialty. Over the course of the last century, plastic surgery has undergone enormous cycles of change that has resulted in significant paradigm shifts in patient care. One of the most profound examples is the advent of microsurgery. Previously, wounds resulting from tumor extirpation, infection, or trauma were reconstructed with either devascularized grafts that were often too thin to provide reliable soft tissue coverage or pedicle flaps that were frequently limited in reach or size. With the development of the operating microscope in the 1960s and a concomitant surge in our understanding of the vascular anatomy of muscle and myocutaneous flaps, 30-33 plastic surgery experienced an explosion of innovation and growth. The ability to raise and transfer a variety of tissue types as free flaps opened an entire realm of reconstructive solutions for problems that were once deemed impossible. For instance, distal third injuries of the lower extremity that commonly resulted in amputation could now be reconstructed with a free flap. Free tissue transfer quickly became the primary reconstructive choice after head and neck cancer resection. Hand surgery was completely revolutionized by the ability to replant amputated parts and reconstruct challenging defects of the upper extremity through the use of free flaps consisting of a variety of tissues including skin, muscle, fascia, and bone. More recently, microsurgical techniques have made vascularized composite allotransplantation a reality, and replacement of an entire complex anatomic structure such as a face, hand, or abdominal wall is now being performed at multiple centers around the world. 34-36 Plastic surgery will no doubt continue to be at the vanguard of innovating solutions to surgical problems. Plastic surgeons are spearheading ongoing research and development in a variety of emerging fields that are gaining increasing momentum, including tissue engineering, 37 transplant immunosuppression, 38 supermicrosurgery, 39 prosthetic interfaces, 40 perforator flap surgery, 41 and robotic surgery. 42 The ensuing chapters of this textbook will illustrate the persistent evolution of plastic surgery and demonstrate how numerous critical innovations in the field have completely transformed the care of our patients. Additionally, while each chapter will focus on a different aspect of plastic surgery, the reader will appreciate frequent allusions to the themes presented in this introduction and understand that plastic surgery is truly a specialty characterized by a devotion to a set of fundamental principles that guides its practice.

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Acknowledgment This work was supported by the American Association of Plastic Surgeons Academic Scholar Program to Theodore A. Kung and a Midcareer Investigator Award in Patient-Oriented Research (2 K24-AR05312006) to Kevin C. Chung. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Association of Plastic Surgeons or the National Institutes of Health.

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Questions 1. A 55-year-old woman with long-standing bilateral symptomatic macromastia presents to the office to discuss breast reduction surgery. Her medical history is significant for hypertension and obesity with a body mass index of 39. During the consultation, the plastic surgeon notices a faint smell of cigarette smoke in the room. The patient states she quit smoking 6 months ago but her husband still smokes in the house. What course of action will result in the most favorable patient outcomes? a. Perform the surgery after thoroughly discussing the risks of the operation. b. Refer the patient to another plastic surgeon. c. Defer the operation until modifiable risk factors are addressed. d. Refuse to perform the operation because it will not benefit the patient. e. Perform the surgery but remove as little breast tissue as possible. 2. A 45-year-old man with vascular disease presents with a nonhealing wound on the medial ankle. Workup is negative for underlying infection, and a reverse sural artery flap is planned for reconstruction to provide durable soft tissue coverage over the wound. The plastic surgeon is concerned about the blood supply to this flap. What can be done to optimize vascularity? a. Keep the foot in a dependent position after reconstruction. b. Perform a delay operation first and then the definitive operation 2 weeks later. c. Apply nitroglycerin ointment to the proximal lower extremity to dilate the vasculature. d. Apply compression wraps to the lower extremity after the flap is inset. e. Place the patient on a high-protein diet to improve preoperative nutrition. 3. A 65-year-old woman undergoes abdominoperineal resection followed by reconstruction using a pedicled ORAM flap. On postoperative day 1, the plastic surgeon examines the skin paddle of the ORAM flap within the perineum and notes that the flap is mottled with several areas of blistering. It is noted that the patient has been in an upright sitting position since she arrived to the floor after her operation. Which fundamental plastic surgery principle was most likely not heeded? a. Make an informed decision to operate or not operate. b. Perform adequate debridement prior to reconstruction. c. If possible, replace like with like. d. Protect the surgical site postoperatively. e. Have a backup plan. 4. An 8-year-old boy presents with a 5 cm × 4 cm full-thickness burn of the plantar foot. After adequate debridement and dressing changes, the wound is now ready for reconstruction. There is healthy granulation tissue throughout, and there are no exposed critical structures such as bone or tendon. Which of the following reconstructive options is the best choice for this patient? a. Letting the wound heal secondarily with dressing changes b. Free ALT flap c. Applying a negative pressure device to expedite secondary healing d. Split-thickness skin from the thigh e. Full-thickness skin from the lower abdomen 5. A 50-year-old woman undergoes excision of a large squamous cell carcinoma from the scalp. The resultant defect is approximately 40% of the total area of the hair-bearing scalp. A temporary dressing is placed on the wound until final negative margins are confirmed by pathology. The open wound is now ready for reconstruction. There is no exposed calvarium, and the wound consists of healthy granulation tissue and galea aponeurotica. The patient desires a reconstruction that will optimize the appearance of the scalp. Which of the following reconstructive options is the best choice

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for this patient? a. Elevate multiple rotation-advancement flaps from the remaining scalp to close the wound with one operation. b. Apply a negative pressure device now and then perform split-thickness skin grafting in a separate operation. c. Perform a free latissimus dorsi muscle flap with split-thickness skin grafting. d. Close the wound with a split-thickness skin graft now and then place tissue expanders in a separate operation to expand the remaining hair-bearing scalp. e. Apply a dermal substitute now, and then perform full-thickness skin grafting in a separate operation. 1. Answer: c. The plastic surgeon should make an informed decision to defer the operation until a later date. This patient has several modifiable risk factors that significantly increase the likelihood of postoperative complications. Patients who are obese have a higher risk of wound healing complications after breast reduction surgery. In addition, she is living with an active smoker, and therefore the second-hand smoke will further contribute to wound healing difficulties. Preoperative interventions such as weight loss, smoking cessation, and control of hypertension will reduce her risks of experiencing complications. 2. Answer: b. During a delay operation, the plastic surgeon partially raises a flap and then waits 1 to 2 weeks before fully elevating the flap. This results in opening of choke vessels within the tissues and enhances the vascularity of the flap. The other answers do not directly improve the inherent vascularity of a flap. 3. Answer: d. Postoperative protection of the surgical site can be as important as the reconstruction itself. The patient has been sitting immediately after perineal reconstruction, and this is causing vascular compromise of the ORAM flap. Once this problem is identified, safeguards must be in place to offload the flap to avoid further tissue injury or else the entire reconstruction may be jeopardized. The other fundamental principles that are listed may very well have been followed during the patient’s perineal reconstruction. 4. Answer: e. When selecting a donor site to close a wound, the plastic surgeon must choose the most reliable tissue for reconstruction while minimizing donor site morbidity. Plantar wounds that demonstrate healthy granulation tissue without exposure of critical structures can be resurfaced with a skin graft. In this location, a full-thickness skin graft is preferable to a split-thickness skin graft because it results in a more durable reconstruction on the weight-bearing surface of the foot. Letting the wound heal secondarily (choices a and c) would result in more scarring and possibly contractures of the toes. A free ALT flap may be considered for more complex wounds with exposed critical structures. 5. Answer: d. The primary goals in this case are to close the wound and to optimize the appearance of the scalp. The best tissue to replace lost hair-bearing scalp is the patient’s own hair-bearing scalp, but in this case the size of the wound precludes the success of local flap options (choice a). Because the base of the wound consists of healthy granulation tissue and galea aponeurotica, a split-thickness skin graft is an appropriate choice to close the wound. Subsequently, after the skin graft is well healed, tissue expanders are placed to slowly grow the hair-bearing scalp. When sufficient growth has been achieved, an operation is performed to remove the implants and excise the split-thickness skin graft, and then the expanded hair-bearing scalp is used to resurface the wound. Scalp defects up to approximately 50% of the hair-bearing scalp can be reconstructed in this manner. A free flap operation (choice c) is not indicated in this scenario because there are no exposed critical structures and because it does not provide hair-bearing tissue. Choices b and e are incorrect because there is no need to delay skin grafting because the wound already consists of healthy vascularized tissue.

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References 1. Gillies, HD, Millard, DR. The Principles and Art of Plastic Surgery. Boston: Little, Brown & Co; 1957.Ambroise Pare is often credited as the first to publish a set of five plastic surgery principles in 1564. However, this classic text by Gilles and Millard modernized the idea that the practice of plastic surgery is guided by fundamental principles. The principles compiled in this book reflect Gilles’ distinguished career, including his experience treating countless wounded patients during World War I. 2. Millard, DR. Principalization of Plastic Surgery. Boston, MA: Little Brown & Co; 1986.Three decades after the publication of The Principles and Art of Plastic Surgery, Millard published this second text, elaborating on 33 principles of plastic surgery. This collection of principles was organized in various categories and included innovational principles as well as inspirational principles. 3. Waljee, J, McGlinn, EP, Sears, ED, Chung, KC. Patient expectations and patient-reported outcomes in surgery: a systematic review. Surgery. 2014;155(5):799-808. 4. The Health Consequences of Smoking – 50 Years of Progress: A Report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2014. https://www.cdc.gov/tobacco/data_statistics/sgr/50th-anniversary/index.htm. Accessed February 22, 2018. 5. Centers for Disease Control and Prevention. Current cigarette smoking among adults—United States, 2016. MMWR. 2018;67(2):53-59. 6. Rinker, B. The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Ann Plast Surg. 2013;70(5):599-605.This is an excellent review of the detrimental effects of nicotine on wound healing and summarizes the known effects of smoking on plastic surgery patients. The article also discusses smoking cessation methods and emphasizes the importance of quitting at least 4 weeks prior to a planned operation. 7. Harrison, B, Khansa, I, Janis, JE. Evidence-based strategies to reduce postoperative complications in plastic surgery. Plast Reconstr Surg. 2016;137(1):351-360. 8. Rubin, JP, Nguyen, V, Schwentker, A. Perioperative management of the post-gastric-bypass patient presenting for body contour surgery. Clin Plast Surg. 2004;31(4):601-610, vi. 9. Anghel, EL, DeFazio, MV, Barker, JC, et al. Current concepts in debridement: science and strategies. Plast Reconstr Surg. 2016;138(3 Suppl):82S-93S. 10. Leland, HA, Rounds, AD, Burtt, KE, et al. Soft tissue reconstruction and salvage of infected fixation hardware in lower extremity trauma. Microsurgery. 2018;38(3):259-263. 11. Kwok, AC, Simpson, AM, Willcockson, J, et al. Complications and their associations following the surgical repair of pressure ulcers. Am J Surg. 2018;216(6):1177-1181. 12. Patel, SY, Itani, K. Review of eyelid reconstruction techniques after Mohs surgery. Semin Plast Surg. 2018;32(2):95-102. 13. Largo, RD, Garvey, PB. Updates in head and neck reconstruction. Plast Reconstr Surg. 2018;141(2):271e-285e. 14. Razzak, MA, Hossain, MS, Radzi, ZB, et al. Cellular and molecular responses to mechanical expansion of tissue. Front Physiol. 2016;7:540. 15. Buchman, SR, Muraszko, K. Frontoorbital reconstruction. Atlas Oral Maxillofac Surg Clin North Am. 2002;10(1):43-56. 16. Lee, JC, Bradley, JP. Surgical considerations in Pierre Robin sequence. Clin Plast Surg. 2014;41(2):211-217. 17. Lucas, JB. The physiology and biomechanics of skin flaps. Facial Plast Surg Clin North Am. 2017;25(3):303-311. 18. Kim, J. Neural reanimation advances and new technologies. Facial Plast Surg Clin North Am. 2016;24(1):71-84. 19. Dong, A, Zuo, KJ, Papadopoulos-Nydam, G, et al. Functional outcomes assessment following free muscle transfer for dynamic reconstruction of facial paralysis: a literature review. J Craniomaxillofac Surg. 2018;46(5):875-882. 20. Nelson, RA, Butler, CE. Surgical outcomes of VRAM versus thigh flaps for immediate reconstruction of pelvic and perineal cancer resection defects. Plast Reconstr Surg. 2009;123(1):175-183. 21. Lee, MJ, Dumanian, GA. The oblique rectus abdominis musculocutaneous flap: revisited clinical applications. Plast Reconstr Surg. 2004;114(2):367-373. 22. Sajjadian, A, Rubinstein, R, Naghshineh, N. Current status of grafts and implants in rhinoplasty: part I. Autologous grafts. Plast Reconstr Surg. 2010;125(2):40e-49e. 23. Shubinets, V, Fox, JP, Sarik, JR, et al. Surgically treated hernia following abdominally based autologous breast reconstruction: prevalence, outcomes, and expenditures. Plast Reconstr Surg. 2016;137(3):749-757. 24. Geddes, CR, Morris, SF, Neligan, PC. Perforator flaps: evolution, classification, and applications. Ann Plast Surg. 2003;50(1):90-99.This comprehensive review describes the advent, advantages, and disadvantages of perforator flaps. In addition, it provides a discussion of the most commonly used perforator flaps in reconstructive surgery. 25. Soltanian, H, Garcia, RM, Hollenbeck, ST. Current concepts in lower extremity reconstruction. Plast Reconstr Surg. 2015;136(6):815e-829e. 26. Rohde, C, Howell, BW, Buncke, GM, et al. A recommended protocol for the immediate postoperative care of lower extremity free-flap reconstructions. J Reconstr Microsurg. 2009;25(1):15-19. 27. Gottlieb, LJ, Krieger, LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93(7):1503-1504. 28. Bashir, MM, Sohail, M, Shami, HB. Traumatic wounds of the upper extremity: coverage strategies. Hand Clin. 2018;34(1):61-74. 29. Greives, MR, Camison, L, Losee, JE. Evidence-based medicine: unilateral cleft lip and nose repair. Plast Reconstr Surg. 2014;134(6):13721380. 30. Jacobson, JH, Suarez, EL. Microvascular surgery. Dis Chest. 1962;41:220-224.

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31. Buncke, HJ, Schulz, WP. Experimental digital amputation and replantation. Plast Reconstr Surg. 1965;36:62-70. 32. Buncke, HJ, Schulz, WP. Total ear reimplantation in the rabbit utilising microminiature vascular anastomoses. Br J Plast Surg. 1966;19(1):15-22.The pioneering work of Buncke, among others, provided the essential foundation that led to an incredible transformation in the field of microsurgery. This study presents the use of specially designed microsurgical instruments to anastomose vessels less than 1 mm in diameter in a rabbit ear model. 33. Mathes, SJ, Nahai, F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-187.This landmark publication by Mathes and Nahai classifies muscle flaps into five distinct categories based on patterns of vascular anatomy. An increased comprehension of the blood supply of muscle flaps expanded the reconstructive utility of these flaps in various clinical scenarios and contributed to the subsequent development of perforator flaps. 34. Siemionow, M. The decade of face transplant outcomes. J Mater Sci Mater Med. 2017;28(5):64. 35. Shores, JT, Malek, V, Lee, WPA, Brandacher, G. Outcomes after hand and upper extremity transplantation. J Mater Sci Mater Med. 2017;28(5):72. 36. Patel, NG, Ratanshi, I, Buchel, EW. The best of abdominal wall reconstruction. Plast Reconstr Surg. 2018;141(1):113e-136e. 37. Levi, B, Longaker, MT. Concise review: adipose-derived stromal cells for skeletal regenerative medicine. Stem Cells. 2011;29(4):576-582. 38. Chang, J, Graves, SS, Butts-Miwongtum, T, et al. Long-term tolerance toward haploidentical vascularized composite allograft transplantation in a canine model using bone marrow or mobilized stem cells. Transplantation. 2016;100(12):e120-e127. 39. Badash, I, Gould, DJ, Patel, KM. Supermicrosurgery: history, applications, training and the future. Front Surg. 2018;5:23 40. Kung, TA, Bueno, RA, Alkhalefah, GK, et al. Innovations in prosthetic interfaces for the upper extremity. Plast Reconstr Surg. 2013;132(6):1515-1523. 41. Koh, K, Goh, TLH, Song, CT, et al. Free versus pedicled perforator flaps for lower extremity reconstruction: a multicenter comparison of institutional practices and outcomes. J Reconstr Microsurg. April. 34(8):572-580. doi:10.1055/s-0038-1639576. 42. Selber, JC. Robotic surgery. J Reconstr Microsurg. 2012;28(7):433-434.

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CHAPTER 2

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Basic Science of Wound Healing and Management of Chronic Wounds Buket Gundogan and Dennis P. Orgill

Key Points Wounds present with a discontinuity of tissue and rely on complex processes for healing to occur. Most wound healing research focuses on molecular and cellular pathways, but we now appreciate the importance of the extracellular matrix (ECM) and mechanical forces. Classically, wound healing has been summarized into four phases: (1) hemostasis, (2) inflammation, (3), proliferation, and (4) remodeling. Aberrant wound healing occurs when normal pathways are disrupted, most commonly in the inflammatory or proliferative phases leading to chronic wounds. The most common chronic wounds are arterial ulcers, pressure injuries, venous stasis ulceration, and diabetic foot ulcers. Other factors that adversely affect wound healing include radiation therapy, nutrition, and microorganisms. Healing strategies involve keeping the wound moist, platelet-derived wound healing techniques, biological skin equivalents, topical growth factors, stem cells, scaffolds, and the application of biophysical forces.

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Basic Science of Wound Healing Wound healing is a complex and highly coordinated biological process. A sound understanding of the traditional stages of wound repair underpins many aspects of wound healing research. The four phases of wound healing—hemostasis, inflammation, proliferation, and remodeling—do not follow a simple and linear chronological order but overlap in time and are densely interconnected. Importantly, increasing research has demonstrated the importance of mechanical forces and the extracellular matrix (ECM) in wound healing biology (Figure 2.1).

FIGURE 2.1 Factors involved in wound healing. Wound healing strategies involve the use of biologics (in particular cells and signal transduction pathways influenced by growth factors), matrix (intrinsic extracellular matrix proteins and extrinsic mechanical forces), and biophysical forces (electric fields and mechanotransduction). These domains have considerable overlap.

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Classic Stages of Wound Healing Hemostasis Tissue injury and the consequent damage to capillary blood vessels initiates the coagulation cascade through the activation of fibrinogen. This activation results in the formation of platelet aggregation and fibrin scaffold that stems blood loss and allows for the migration of cells. Platelets play a critical role in the stages of wound healing and in particular are the chief effector cells during hemostasis. In addition to contributing to the hemostatic plug, their cytoplasm contains α-granules that release several growth factors and cytokines, such as platelet-derived growth factor (PDGF) and transforming growth factor-β (TGF-β), which facilitate wound healing by attracting neutrophils, macrophages, and fibroblasts. 1,2 Platelets are also responsible for releasing several proangiogenic and antiangiogenic growth factors that are critical for revascularization of wounds, such as vascular endothelial growth factor (VEGF) and platelet-derived stromal cell–derived factor 1 (SDF-1).

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Inflammation The coagulation cascade, the activation of complement, and bacterial degradation facilitate and trigger the inflammatory phase, which typically lasts 48 hours. 3 These pathways produce various chemotactic factors (such as TGF-β) and complement components (such as C3a and C5a) to attract inflammatory cells to the scaffold. Neutrophils invade the wound and phagocytose foreign debris, followed by monocytes that eventually differentiate into macrophages and further consume debris in their paths. 2 Macrophages are responsible for releasing a whole host of mediators primarily through binding to integrin receptors on the ECM, such as tumor necrosis factor α and interleukin-1 (IL-1) 4 (Figure 2.2). These proinflammatory cytokines stimulate fibroblast infiltration from the surrounding healthy ECM. It is important to note that macrophage invasion is critical to the inflammatory phase because macrophage-defective or macrophagedepleted animals undergo abnormal wound healing. 5

FIGURE 2.2 Inflammatory phase of wound healing. The inflammatory phase typically lasts 48 hours. Neutrophils invade the wound and phagocytose foreign debris, followed by monocytes that eventually differentiate into macrophages, which further consume debris in their paths.

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Proliferation From approximately 48 hours to 10 days after tissue injury, healing enters the proliferation phase (Figure 2.3). Keratinocytes migrate to eventually proliferating enough to create an epithelial layer that covers the wound. This is directly stimulated by epidermal growth factors, heparin-binding epidermal growth factor (HB-EGF), and transforming growth factor-alpha (TGF-α), which are the main members of the epidermal growth factor family involved in wound healing. 6 Fibroblasts are also critical to this stage of wound healing, as they produce collagen that acts as a scaffold for a vascular network. The hypoxic environment increases expression of hypoxia-inducible factor 1 (HIF-1α) protein to serve as the primary stimulus of angiogenesis. 7 HIF-1α activates several target genes such as VEGF and SDF-1 to induce neovascularization. 7 Fibroblasts and macrophages replace the fibrin mesh to form granulation tissue. Granulation tissue, also known as new stroma, consists of new connective tissue (specifically hyaluronic acid, procollagen, elastin, and proteoglycan) and blood vessels. It owes its granular appearance to the new capillary network. 1 The formation of blood vessel networks increases oxygen supply to the wound surface. Finally, fibroblasts that have differentiated into myofibroblasts have contractile ability to assist in bringing the wound edges together in a process known as wound contraction. 8

FIGURE 2.3 Proliferative phase of wound healing. During the proliferative phase, the hypoxic environment increases expression of hypoxia-inducible factor 1 (HIF-1α) protein, which is the primary stimulus of angiogenesis. Further downstream growth factors influencing the vascular network include vascular endothelial growth factor (VEGF) and platelet-derived stromal cell–derived factor 1 (SDF-1). Keratinocytes also migrate eventually proliferating enough to create an epithelial layer that covers the wound. This is directly stimulated by epidermal growth factors (EGFs), heparin-binding epidermal growth factor (HB-EGF), and transforming growth factor-alpha (TGF-α), which are the main members of the EGF family involved in wound healing. Factors such as transforming growth factor-β (TGF-β) facilitate wound healing by attracting neutrophils, macrophages, and fibroblasts.

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Remodeling The fourth and final stage of wound healing is the remodeling phase, which starts at approximately 2 weeks and can last for years. Throughout this stage, many of the cells contained in the wound undergo apoptosis or exit the wound, to eventually leave collagen and ECM proteins. This entire matrix is remodeled and strengthened from type III collagen into mainly type I collagen by matrix metalloproteinases (MMPs). MMPs are produced by fibroblasts as well as other cell types. The wound eventually forms scar tissue and never fully regains complete strength comparable to undamaged skin, at approximately 80% normal strength. 9 The ECM is also implicated in the formation of scarring. Cutaneous scar tissue is composed of the same ECM macromolecules as normal tissue but contains different ratios of these macromolecules and typically an absence of hair follicles or fat. 10 Increased levels of TGF-β1 have been implicated in hypertrophic adult scars. 11

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Mechanical Forces in Wound Healing Human cells and tissues are subjected to many biophysical forces such as electrical, magnetic, and mechanical forces. These forces have various biological effects, and here we specifically discuss mechanical forces. Mechanical forces on cells include but are not limited to tension, shear force, gravity, and osmosis. 12 It is now clear that all phases of wound healing are affected by mechanical forces. In a process known as mechanotransduction, cells have the ability to detect mechanical stimuli in its microenvironment and respond by activating specific cellular pathways. These pathways can modulate cell functions such as proliferation, migration, and differentiation. Focal adhesion (FA) complexes that are transmembrane proteins to anchor the cell cytoskeleton to other cells or the ECM are key to understanding mechanotransduction. FA complexes contain integrins, which act as primary receptors for the ECM. 13 This process of anchorage generates intracellular mechanical tension and serves not only to sense the wound microenvironment but also to modify its behavior and the surrounding ECM. Cell migration is of critical importance in wound healing and mechanical forces are key to this. Tension generated by the cytoskeleton-integrin connections pulls the cell cytoplasm of the leading edge forward in a process known as protrusion. At the same time protein complexes of the trailing edge must disconnect from the ECM, resulting in the entire cell body moving forward and the cell producing traction forces. 13 Fibroblasts are thought to generate cell traction forces that are much greater than needed for cell migration, and this excess force deforms the ECM contributing to collagen reorganization in wound healing. 14 Similarly, mechanical forces involved in cellular migration also occur during epithelial repair and restoration. It is also known that cell proliferation is influenced by mechanical stress, which can be defined as the force per unit area. Keratinocytes respond to mechanical stress by changing morphology, such as stretching, and these mechanotransduction pathways regulate cell proliferation. For example, cells without mechanical stress or stimuli adopt a spherical shape and enter cell-cycle arrest and apoptosis. 15 Electric fields also play an important role in wound healing. Transepithelial electric potentials are created by the movement of ions across pumps in the epithelium, termed the skin battery. Damage to the continuous epithelium generates a current of injury whereby electric potential is directed toward the wound to signal cell migration, termed electrotaxis. 16 Studies have demonstrated that influencing such electric fields can alter wound healing in vivo. 16 The effect of mechanical stimuli on the wound microenvironment is utilized by treatments, such as negative-pressure wound therapy (NPWT) and extracorporeal shock wave therapy (ESWT), which are explained in later sections.

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Extracellular Matrix in Wound Healing The ECM is a meshlike dynamic structure composed of different macromolecules and proteolytic enzymes. These macromolecules include collagen, elastin, glycosaminoglycans, glycoproteins, and proteoglycans. The ECM plays an important role in wound healing. Its function includes providing organization for cells as a physical scaffold, storage for growth factors, controlling cell shape, cell metabolism, and influences many cell behaviors such as migration, proliferation, and differentiation (Figure 2.4).

FIGURE 2.4 Biophysical forces in wound healing. Several biophysical forces influence wound healing. In a process known as mechanotransduction, cells have the ability to detect mechanical stimuli in its microenvironment and respond by activating specific cellular pathways. For example, cells without mechanical stress or stimuli adopt a spherical shape and enter cell-cycle arrest and apoptosis. Myofibroblasts also contract and exert tension on the extracellular matrix. Damage to the continuous epithelium generates a current of injury whereby electric potential is directed toward the wound, which has been shown to signal cell migration, termed electrotaxis.

The composition, density, and stiffness of the ECM influence the wound microenvironment. In newly injured tissue, ECM is soft and fibrin-rich and this change initiates a repair process of fibroblast differentiation into myofibroblasts that contract and exert tension on the surrounding ECM. After cutaneous tissue injury, mechanical forces activate the focal adhesion kinase pathway. This pathway is known to be the main regulator of FAs. The focal adhesion kinase pathway has been shown to potentiate the secretion collagen, as well as monocyte chemoattractant protein-1, which has been linked to human fibrosis. 17,18 The most prominent glycosaminoglycan, hyaluronic acid (hyaluronan) is known to interact with cell surface receptors, mainly CD-44 and RHAMM (receptor for hyaluronan-mediated mobility) to trigger a cascade of processes involved in wound healing, such as modulation of inflammation, chemotaxis, cell

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migration, collagen secretion, and angiogenesis. 19

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Aberrant Wound Healing Chronic Wounds Chronic wounds can be defined as a loss of continuity of the skin secondary to injury that persist for longer than 6 weeks. Chronic wounds are classified into vascular ulcers (arterial and venous), diabetic ulcers, and pressure ulcers. Despite each type of wound having different underlying pathologies, they all share common features such as an excessive and persistent inflammatory phase, impaired cell proliferation, abnormal cell migration, microbial colonization, the presence of biofilms, and ultimately an inability to complete all four phases of wound healing within the normal timeframe. However, they each have distinct pathophysiologies, which are further discussed in this section.

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Vascular Ulcers Vascular ulcers include venous, arterial, or mixed etiology. It has been reported that ulcers related to venous insufficiency constitute 70%, arterial disease 10%, and ulcers of mixed etiology 15% of leg ulcer presentations. The remaining 5% of leg ulcers result from less common pathophysiological causes.

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Venous Ulcers Chronic venous leg ulceration is common and is thought to occur in up to 5% of the population older than 65 years. 20 Venous ulcers are classically distributed in the gaiter area on the medial aspect between the knee and ankle. They occur secondary to venous insufficiency where there is valvular incompetence in veins, and the resulting backflow of blood results in increased venous pressure. This leads to capillary leakage of plasma constituents into the surrounding perivascular area, such as fibrin, which is known to decrease collagen production. 21 The primary pathological events leading to venous disease and therefore venous ulceration are changes in the vein wall and vein valve environment. Elevated venous pressures change shear stress and mechanical forces, which are then detected by endothelial cell intercellular adhesion molecule-1 (ICAM-1, CD54) and the mechanosensitive transient receptor potential vanilloid channels. The endothelial cells respond by secreting vasoactive molecules to begin an inflammatory cascade, ultimately leading to the progression of venous disease. 22

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Arterial Ulcers Arterial ulcers occur because of arterial insufficiency where there is narrowing of the arterial lumen most commonly secondary to atherosclerosis. They are classically located over bony prominences including the toes, heels, and ankles. Apart from atherosclerosis, other conditions that cause arterial obstruction include embolism, diabetes mellitus, vasculitis, pyoderma gangrenosum, and hematological disorders of sickle cell disease and thalassemia.

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Diabetic Foot Ulcers The prevalence of diabetic foot ulcers in individuals with diabetes mellitus is common and occurs in approximately 15% of patients over their lifetime. 23 There are several pathophysiological factors that contribute to aberrant healing in diabetic individuals. These include abnormal and chronic inflammatory response, hyperglycemia, microvascular abnormalities, hypoxia, and changes of the ECM scaffold. Peripheral neuropathy, peripheral arterial disease, and trauma also contribute to diabetic ulceration. Chronic inflammation and an impaired inflammatory response is also the hallmark of diabetic wounds. Studies have demonstrated persistent and raised levels of proinflammatory cytokines, such as IL-1, IL-6, and tumor necrosis factor α. 24 Wounds also typically have imbalances in protease production and their inhibitors, which stop normal matrix synthesis and remodeling. 25 Hyperglycemia leads to nonenzymatic binding of sugar residues to proteins through free amino acid groups, and further alterations lead to advanced glycation end-products. Advanced glycation endproducts are known to decrease the solubility of the ECM and exacerbate the inflammatory changes. 26 Glycation of the ECM is linked to cell apoptosis and disruption of normal wound healing processes such as angiogenesis, cell migration, and proliferation. 27 High levels of glucose induce expression of MMP by fibroblasts, endothelial cells, and macrophages to break down the matrix. Oxygen supply to a wound is also essential for healing, and hypoxic environments adversely affect wound healing. Chronic hyperglycemia prolongs inflammation and delays wound healing by increasing the levels of free radicals. 26

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Pressure Injuries The pathophysiology underlying pressure injury is a combination of pressure, friction, shearing forces between tissue planes, and moisture. Pressure exceeding arteriolar pressure results in tissue hypoxia, the creation of free radicals, an ischemic reperfusion injury, and consequent tissue necrosis. 28 Factors contributing to the development of pressure ulcers include prolonged immobility, patient position, neuropathy, and existing arterial or venous insufficiency. 28 The National Pressure Ulcer Advisory Panel (NPUAP) staging system defines four stages of severity to pressure injuries: stage 1 pressure injury is nonblanchable erythema of intact skin (Figure 2.5A), stage 2 pressure injury is a partial-thickness skin loss with exposed dermis (Figure 2.5B), stage 3 pressure injury involves full-thickness skin loss (Figure 2.5C), and stage 4 pressure injury involves full-thickness skin and tissue loss (Figure 2.5D). 29

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FIGURE 2.5 Pressure injury staging. A. Stage 1 is the least severe according to NPUAP staging system. It is defined as nonblanchable erythema of intact skin. B. Stage 2 is defined as a partial-thickness skin loss with exposed dermis. C. Stage 3 involves full-thickness skin loss. D. Stage 4 is the most severe stage of pressure injury. It involves full-thickness skin and tissue loss. Reproduced with permission from National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel, Pan Pacific Pressure Injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. In: Haesler, E, ed. Cambridge Media: Osborne Park, Western Australia; 2014.

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Factors That Adversely Affect Wound Healing Radiation Therapy Radiation therapy such as those used as part of oncologic therapies disrupts the complex pathways of wound healing. Ionizing radiation produces both acute and late effects on tissues. Acutely, basement membrane is damaged, and increased vascular permeability introduces edema to reduce neovascularization of wounds. 30 During the inflammatory phase, there is excess expression of several growth factors, leading to tissue fibrosis. Fibroblasts are also injured and contribute to the late effects of radiation injury such as fibrosis and contraction. 30

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Nutrition Nutrition has long been known to affect wound healing and chronic wounds. This includes a general malnutrition state, inadequate caloric intake, and deficiencies in vitamins, micronutrients, and macronutrients. Malnutrition is known to prolong the inflammatory phase of wound healing through reducing the proliferation of fibroblasts and the formation of collagen. 31 It can also increase the risk of infection of wounds by altering the function of immune cells, such as reducing phagocytosis and decreasing complement levels. 31 Micronutrients such as copper, zinc, and magnesium are elements and minerals that are essential to bodily chemical processes and, in particular, in wound healing. Deficiencies in these micronutrients can adversely affect wound healing, for example, in copper deficiency. Macronutrients include protein, amino acids, carbohydrates, fiber, water, and fats. These are required at sufficient levels to promote optimal wound healing. Significantly reduced protein intake is associated with increased rates of wound infection and wound strength. 31 Similarly, lipid deficiencies are associated with altered wound healing. 31

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Microorganisms Microorganisms have long been known to influence the healing of chronic wounds, and all open wounds contain microbes. Bacteria predominantly exist in biofilms in clinical and natural settings, as opposed to planktonic states (single organisms/free-floating). Biofilms describe adherent populations of microbes that form three-dimensional populations and are organized on extracellular polymers. Over time, chronic wounds are known to develop biofilms, as complex interactions between the host wound microenvironment and heterogeneous bacterial populations mean they are able to proliferate unchecked. Biofilm bacterial populations delay and inhibit wound healing by not only producing toxins and damaging enzymes, but also promoting the complex chronic inflammatory pathways. 32 Proteases released from bacteria impede growth factors and wound healing proteins. Large levels of microbial exudate have also been shown to affect cell proliferation and wound healing. 32 Biofilm-infected chronic wounds are clinically challenging to manage and are resistant to elimination by antimicrobials and by the immune system. The current mainstay management of dealing with microorganism-related complications in chronic wounds includes pressure off-loading, appropriate dressings, systemic antibiotics, tissue debridement, and the instillation of NPWTs such as vacuumassisted closure devices. Similarly, antiseptic dressings such as those containing chlorhexidine, silver, or iodine and topical antimicrobials (e.g., fusidic acid creams) have been developed over the years to a limited degree of success. Topical antimicrobials have promoted bacterial resistance, and several studies concluded that antiseptic dressings are not significantly better than saline gauze alone. 33 However, there are special situations when topical antimicrobials are proven beneficial. They are particularly useful in burn injuries (especially second-degree burn injuries) to treat infection and therefore prevent sepsis. 34 Systemic antibiotics are beneficial in infected chronic wounds but are not indicated for most chronic wounds that are merely colonized with bacteria. Antibiotics should have high tissue bioavailability and should be targeted to the specific organisms from deep wound cultures. Studies demonstrate that superficial cultures do not represent the diverse populations of bacteria of the biofilm. 33 Debridement involves the removal of necrotic tissue and debris at the wound edges and is often surgical, although other mechanical modes and enzymatic and autolytic methods are also utilized. The current theory is that debridement reduces biofilm. It is thought to promote wound healing and decrease the biofilm load. Recolonization of the wound after debridement is common, and often sequential debridements are required for successful healing. NPWTs, such as vacuum-assisted closure devices, are known to aid wound healing. Several studies have investigated their effect on the microorganisms within chronic wounds, and observational data of NPWT with adjunctive topical dressings have demonstrated decreased biofilm load. 33 A recent small randomized trial (n = 20) of NPWT with instillation and adjunctive sodium hypochlorite solution was effective at reducing both planktonic and nonplanktonic (biofilm) microorganisms. 35

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Obesity and Metabolic Syndromes Obesity is correlated with increased rates of wound complications such as wound infection, impaired wound healing, pressure injuries, venous ulcers, hematoma, and seroma formation. Hypovascularity, difficulty in repositioning, and friction between skin-to-skin contact points in skin folds are all known to contribute to the formation of pressure injuries in obese individuals. On a molecular level, obesity is related to lower levels of lymphocyte proliferate, altered cytokine levels and peripheral immune function which improves upon weight loss. 23

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Advanced Wound Healing Strategies Nonsurgical, advanced would healing strategies can briefly be categorized into those that employ biological therapeutics, use or enhance the matrix, and exploit biophysical forces (see Figure 2.1). Although these modalities are important, basic and simple strategies still form the foundation of wound care. These measures are manifold and include optimizing the management of primary pathological conditions that lead to wound formation, such as optimal lifestyle measures (e.g., nutrition), medication, and patient education. Other measures include debridement of necrotic tissue, local ulcer care, mechanical off-loading, mechanical compression (for venous ulcers), and infection control.

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Biological Therapies Biological therapies have been of great interest in wound healing therapies, and we specifically discuss the use of cadaveric skin and xenografts, placental constructs, growth factors, hyperbaric oxygen therapy (HBOT), biological skin equivalents, and stem cells (see Figure 2.1).

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Growth Factors Growth factor–related wound repair has been of immense interest in wound healing science. Commercially marketed growth factors currently available include recombinant human fibroblast growth factor, recombinant human platelet-derived growth factor, and recombinant human epidermal growth factor. Several other growth factors are also being developed. Recombinant human epidermal growth factor is a well-known growth factor that can be applied topically or injected and has been shown to improve wound healing in small clinical trials worldwide. 36 Fibroblast growth factor has also shown promising results, in particular an isoform known as recombinant human keratinocyte growth factor-2 to be applied as a topical spray. The trial showed significantly increased wound healing compared with placebo. 37

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Platelet-Derived Growth Factors and Platelet-Rich Plasma Several studies shown the efficacy of platelet-rich plasma (PRP) and PDGFs obtained from centrifugation of blood. 38 PDGF has been demonstrated to be effective when compared with placebo, with 7 studies totaling 685 patients that showed a statistically significant percentage of ulcers healed compared with sham therapy. 39 The first commercially available topical PDGF in the United States is becaplermin gel (Regranex®), which was studied in chronic diabetic foot ulcers. It is important to note that becaplermin gel contains the US Food and Drug Administration (FDA) black box warning, whereby consumers are cautioned to the increased risk of rate of mortality secondary to malignancy if several tubes are used. 40 Conversely, the evidence for PRP has been scant, with randomized controlled trial (RCT) data showing no significant difference in the percentage of ulcers healed when compared with placebo or platelet-poor plasma therapy. 39

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Stem Cells There has been significant interest in the use of stem cells to address the defective pathways in aberrant wound healing. Stem cells are undifferentiated cells that possess the ability to mature into differentiated cells of either one embryonic germ layer (multipotent) or all three embryonic germ layers (pluripotent). 41 Perhaps one of the most widely studied multipotent adult stem cells in wound healing research has been mesenchymal stem cells (MSCs). In several animal-based studies, MSCs have demonstrated the ability to migrate to areas of cutaneous injury, secrete angiogenic and immune-mediating factors, and differentiate into skin cells. 41 There are now several ongoing and published clinical trials using MSCs in wound healing as well as a few commercial products. 41 Multiple clinical trials have shown promising outcomes with regard to wound closure rates; however, they have been limited by small sample sizes and lack of controls. 41 At the time of writing, several clinical trials in the United States are recruiting patients to study the use of MSCs in healing cutaneous wounds. 41 However, challenges remain with stem cell technologies. Firstly, there are numerous ethical concerns surrounding its use, in particular, pluripotent stem cells; hence, much of the research has focused on multipotent stem cells. 41 Secondly, there are still many questions that need to be answered in the field. Two important questions posited by Sorice et al are which population of stem cells are the most effective in healing wounds and what is the best method to deliver stem cells into a wound? 41 These are important considerations if stem cells are to move into clinical translation.

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Hyperbaric Oxygen Therapy HBOT utilizes compression chambers to deliver high levels of oxygen concentration at raised atmospheric pressures. HBOT aims to promote oxygen-dependent wound healing pathways and has particularly been a treatment strategy when revascularization in vascular insufficiency has been unsuccessful. 42 Systematic review evidence of four long-term studies totaling 233 patients concluded that there was a significant difference in percentage of healed ulcers compared with sham therapy when HBOT was used adjunctively, with one short-term study finding no significant difference. However, strength of evidence was deemed low for all studies. One study of poor quality found HBOT less effective compared with ESWT (n = 84). 39

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Cell Cultured Products Cell cultured products, also known as tissue-engineered constructs, include Apligraf, Epicel, and Dermagraft. Apligraf (Organogenesis, Canton, MA) utilizes a bovine collagen matrix incorporated with human neonatal fibroblasts and neonatal keratinocytes to act as a scaffold as well as providing cells that produce growth factors and ECM components. Similarly, Dermagraft (Organogenesis, Canton, MA) comprises a polyglactin scaffold with dermal neonatal fibroblasts. A large Apligraf RCT (n = 309) found a significant increase in the number of healed ulcers and a reduced length of time to complete healing compared with standard therapy with compression. 39 Furthermore, cultured epithelial autografts using patients’ own keratinocytes, such as Epicel, have been utilized to treat large burns and take 2 to 3 weeks in culture to grow. 43 Genetic manipulation of keratinocytes has recently been reported to regenerate an entire fully functional epidermal layer in junctional epidermolysis bullosa. 44

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Scaffolds Scaffolds act as a platform for cell migration and angiogenesis and are a key therapeutic modality. Scaffolds can be of human origin (donated tissue or cadaveric) and nonhuman origin (porcine or synthesized through extraction and cross-linking). Several such scaffolds are commercially available. Integra™ (Integra LifeSciences) is a bilayer matrix of bovine collagen and glycosaminoglycan derived from shark skin that is lyophilized to form a highly porous scaffold. Integra™ has been used with considerable success in burns, and clinical trial data have attested its use in the healing of chronic wounds, specifically decreasing time to wound closure in diabetic foot ulcers. 45 Allopatch®, which is a decellularized scaffold derived from human cadaveric tissue, has demonstrated efficacy in closure of nonhealing diabetic foot ulcers. 46 Placental constructs, such as Grafix, which is a cryopreserved placental membrane, have shown to significantly improve diabetic foot ulcer healing and reduce related complications. 47

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Biophysical Forces Negative-Pressure Wound Therapy NPWT effectively ensures wound drainage, aids granulation tissue development, and expedites wound contraction. 48 RCT data have shown improved healing of ulcers as well as reduced second amputations. 39

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Extracorporeal Shock Wave Therapy ESWT delivers high-energy acoustic pulses to tissues and is the standard of care in treating nephrolithiasis and various musculoskeletal conditions. It has been reported to improve cutaneous wound healing through increasing cell proliferation and stimulating angiogenesis. 49

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Electromagnetic Therapies Electromagnetic therapies, such as pulsed electromagnetic field therapy, have effectively been used in orthopedic practice, and numerous in vitro and animal studies have demonstrated improved cutaneous wound healing. These therapies are thought to interact with endogenous electric fields in the skin to increase expression of growth factors and nitric oxide and also promote angiogenesis 50 (see Figure 2.4). However, RCT data showed mixed results, with one showing no difference between placebo and electromagnetic therapy and another reporting a significant increase in the percentage of healed ulcers between the two groups. 39

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Knowledge Gaps There has been an explosion in therapeutic options for wound healing in the last 30 years, as the number of wounds has increased because of our aging population, increases in the incidence of type 2 diabetes, and increases in obesity. Currently, there is a lack of clinical data in well-controlled prospective studies to document the clinical efficacy of several of the modalities now used clinically including HBOT, PRP, antimicrobial dressings, topical oxygen therapy, and pulsed electromagnetic stimulation. There is also almost a complete lack of comparative studies on advanced wound healing modalities. Prospective RCTs are challenging in wound healing because of the difficulty in binding both the patient and practitioner as well as the desire by both to achieve a healed wound. Registry studies may provide a powerful method to look at comparative advanced healing modalities and also allow us to better assess the cost-effectiveness of these therapies.

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Acknowledgment We would kindly like to acknowledge Mr. Ilya Shiltsin for the artwork in this chapter.

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Questions 1. A 65-year-old woman with diabetes mellitus presents with a heel ulceration not involving the calcaneus. She has palpable pulses. Which therapy has the best published efficacy for healing? a. HBOT b. Silver alginate dressings c. NPWT d. Pulsed electromagnetic therapy 2. A 25-year-old man with paraplegia presents with a large ulcer over his right ischium that probes to bone. What stage of pressure injury would this be considered? a. Stage 1 b. Stage 2 c. Stage 3 d. Stage 4 e. Unstageable 3. A patient presents with a heavy scar 3 weeks following a stab wound to the back. What phase of wound healing would this be considered? a. Hemostasis b. Inflammatory c. Proliferation d. Remodeling 4. Which of the following wound care modalities would mechanical forces be considered a major factor in the mechanism of action? a. Platelet-derived growth factor b. Placental-derived constructs c. Negative-pressure wound therapy d. Saline wash 5. Which of the following would be considered a chronic wound? a. A 67-year-old man with a 2-cm heel ulceration for 1 month who just completed external iliac angioplasty b. A 75-year-old woman with a prosthetic heart valve on Coumadin who presents with severe bruising of her anterior tibial area 3 weeks after injury c. A 30-year-old man with Crohn disease on steroids presents with a dehisced laparotomy wound 1 month following surgery d. A 45-year-old woman with breast cancer who has severe desquamation of her skin at the end of her radiation therapy e. A 24-year-old man paraplegic with an ischial stage 4 pressure injury for 3 months 1. Answer: c. Although all of these modalities have been proposed for use in this patient population, NPWT has the most published high-level studies in wounds. 2. Answer: d. Pressure injuries that go to bone are considered stage 4. 3. Answer: d. Although there are components of inflammation and proliferation that are still occurring, 3 weeks after an injury, the wound is being actively remodeled and would generally be considered to be in the remodeling phase. 4. Answer: c. Negative-pressure wound therapy. This therapy is commonly used by placing an openpore polyurethane sponge directly over the wound and connecting this to suction. This induces deformations to the wound surface and draws the wound together.

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5. Answer: e. Wounds should be present for 6 weeks to be considered chronic. Although the severe bruising and the radiation injury cases could turn into chronic wounds, at this point these patients do not have an actual wound.

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References Diegelmann, RF, Evans, MC. Wound healing: an overview of acute, fibrotic and delayed healing. Front Biosci. 2004;9:283-289. Velnar, T, Bailey, T, Smrkolj, V. The wound healing process: an overview of the cellular and molecular mechanisms. J Int Med Res. 2009;37(5):1528-1542. Gurtner, GC, Werner, S, Barrandon, Y, Longaker, MT. Wound repair and regeneration. Nature. 2008;453(7193):314-321.Review article highlighting the basics of wound repair and wound regeneration biology. Singer, AJ, Clark, RA. Cutaneous wound healing. N Engl J Med. 1999;341(10):738-746.Similar key review paper highlighting the stages of wound healing, reviewing pathways in abnormal wound healing and a review of skin substitutes. Enoch, S, Leaper, DJ. Basic science of wound healing. Surgery (Oxford). 2005;23(2):37-42. Oda, K, Matsuoka, Y, Funahashi, A, Kitano, H. A comprehensive pathway map of epidermal growth factor receptor signaling. Mol Syst Biol. 2005;1:2005.0010. Ahluwalia, A, Tarnawski, AS. Critical role of hypoxia sensor: HIF-1alpha in VEGF gene activation. Implications for angiogenesis and tissue injury healing. Curr Med Chem. 2012;19(1):90-97. Olsen, L, Sherratt, JA, Maini, PK. A mechanochemical model for adult dermal wound contraction and the permanence of the contracted tissue displacement profile. J Theor Biol. 1995;177(2):113-128. Levenson, SM, Geever, EF, Crowley, LV, et al. The healing of rat skin wounds. Ann Surg. 1965;161:293-308. Profyris, C, Tziotzios, C, Do Vale, I. Cutaneous scarring: pathophysiology, molecular mechanisms, and scar reduction therapeutics Part I. The molecular basis of scar formation. J Am Acad Dermatol. 2012;66(1):1-10. O’Kane, S, Ferguson, MW. Transforming growth factor beta and wound healing. Int J Biochem Cell Biol. 1997;29(1):63-78. Ingber, DE. Tensegrity, II. How structural networks influence cellular information processing networks. J Cell Sci. 2003;116(Pt 8):1397-1408. Bokel, C, Brown, NH. Integrins in development: moving on, responding to, and sticking to the extracellular matrix. Dev Cell. 2002;3(3):311321. Ehrlich, HP, Rajaratnam, JB. Cell locomotion forces versus cell contraction forces for collagen lattice contraction: an in vitro model of wound contraction. Tissue Cell. 1990;22(4):407-417. Huang, S, Ingber, DE. The structural and mechanical complexity of cell-growth control. Nat Cell Biol. 1999;1(5):E131-E138.Article outlining the importance of extracellular matrix and cytoskeletal tension in cell signalling and cell growth. Hunckler, J, de Mel, A. A current affair: electrotherapy in wound healing. J Multidiscip Healthc. 2017;10:179-194. Wong, VW, Rustad, KC, Akaishi, S, et al. Focal adhesion kinase links mechanical force to skin fibrosis via inflammatory signaling. Nat Med. 2012;18(1):148-152.Key research paper that concluded the importance of mechnical forces in inflammatory pathways, particularly through focal adhesion kinase signalling. Wynn, TA. Common and unique mechanisms regulate fibrosis in various fibroproliferative diseases. J Clin Invest. 2007;117(3):524-529. Prosdocimi, M, Bevilacqua, C. Exogenous hyaluronic acid and wound healing: an updated vision. Panminerva Med. 2012;54(2):129-135. Lautenschlager, S, Eichmann, A. Differential diagnosis of leg ulcers. Curr Probl Dermatol. 1999;27:259-270. Pardes, JB, Takagi, H, Martin, TA, et al. Decreased levels of alpha 1(I) procollagen mRNA in dermal fibroblasts grown on fibrin gels and in response to fibrinopeptide B. J Cell Physiol. 1995;162(1):9-14. Schmid-Schonbein, GW, Takase, S, Bergan, JJ. New advances in the understanding of the pathophysiology of chronic venous insufficiency. Angiology. 2001;52(suppl 1):S27-S34. Guo, S, DiPietro, L. Factors affecting wound healing. J Dent Res. 2010;89(3):219-229. Ochoa, O, Torres, FM, Shireman, PK. Chemokines and diabetic wound healing. Vascular. 2007;15(6):350-355. Pierce, GF. Inflammation in nonhealing diabetic wounds: the space-time continuum does matter. Am J Pathol. 2001;159(2):399-403. Blakytny, R, Jude, E. The molecular biology of chronic wounds and delayed healing in diabetes. Diabet Med. 2006;23(6):594-608. Kuo, PC, Kao, CH, Chen, JK. Glycated type 1 collagen induces endothelial dysfunction in culture. In Vitro Cell Dev Biol Anim. 2007;43(10):338343. Thomas, DR. Does pressure cause pressure ulcers? An inquiry into the etiology of pressure ulcers. J Am Med Dir Assoc. 2010;11(6):397-405. National Pressure Ulcer Advisory Panel, European Pressure Ulcer Advisory Panel and Pan Pacific pressure injury Alliance. Prevention and treatment of pressure ulcers: quick reference guide. In: Haesler E, ed. Osborne Park, Western Australia: Cambridge Media; 2014. Tibbs, MK. Wound healing following radiation therapy: a review. Radiother Oncol. 1997;42(2):99-106. Stechmiller, JK. Understanding the role of nutrition and wound healing. Nutr Clin Pract. 2010;25(1):61-68. Percival, SL, McCarty, SM, Lipsky, B. Biofilms and wounds: an overview of the evidence. Adv Wound Care (New Rochelle). 2015;4(7):373-381. Gompelman, M, van Asten, SA, Peters, EJ. Update on the role of infection and biofilms in wound healing: pathophysiology and treatment. Plast Reconstr Surg. 2016;138(3 suppl):61s-70s. Neely, AN, Gardner, J, Durkee, P, et al. Are topical antimicrobials effective against bacteria that are highly resistant to systemic antibiotics? J Burn Care Res. 2009;30(1):19-29. Yang, C, Goss, SG, Alcantara, S, et al. Effect of negative pressure wound therapy with instillation on bioburden in chronically infected wounds. Wounds. 2017;9(8):240-246.

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Fernandez-Montequin, JI, Valenzuela-Silva, CM, Diaz, OG, et al. Intra-lesional injections of recombinant human epidermal growth factor promote granulation and healing in advanced diabetic foot ulcers: multicenter, randomised, placebo-controlled, double-blind study. Int Wound J. 2009;6(6):432-443. Robson, MC, Phillips, TJ, Falanga, V, et al. Randomized trial of topically applied repifermin (recombinant human keratinocyte growth factor2) to accelerate wound healing in venous ulcers. Wound Repair Regen. 2001;9(5):347-352. Driver, VR, Hanft, J, Fylling, CP, Beriou, JM. A prospective, randomized, controlled trial of autologous platelet-rich plasma gel for the treatment of diabetic foot ulcers. Ostomy Wound Manage. 2006;52(6):68-70. Greer, N, Foman, N, Dorrian, J, et al. Advanced wound care therapies for non-healing diabetic, venous, and arterial ulcers: a systematic review. VA-ESP Project #09-009. Ann Intern Med. 2013;159(8):532-542. Regranex Gel post Market Drug Safety Information; 2008. https://www.fda.gov/downloads/drugs/drugsafety/postmarketdrugsafetyinformationforpatientsandproviders/ucm142821.pdf. Sorice, S, Rustad, KC, Li, AY, Gurtner, GC. The role of stem cell therapeutics in wound healing: current understanding and future directions. Plast Reconstr Surg. 2016;138(3 suppl):31s-41s. Kranke, P, Bennett, M, Roeckl-Wiedmann, I, Debus, S. Hyperbaric oxygen therapy for chronic wounds. Cochrane Database Syst Rev. 2004(2):Cd004123. Carsin, H, Ainaud, P, Le Bever, H, et al. Cultured epithelial autografts in extensive burn coverage of severely traumatized patients: a five year single-center experience with 30 patients. Burns. 2000;26(4):379-387. Hirsch, T, Rothoeft, T, Teig, N, et al. Regeneration of the entire human epidermis using transgenic stem cells. Nature. 2017;551(7680):327332.Recent seminal research paper demonstrating that genetic manipulation of keratinocytes can regenerate an entire fully functional epidermal layer in junctional epidermolysis bullosa. Driver, VR, Lavery, LA, Reyzelman, AM, et al. A clinical trial of Integra Template for diabetic foot ulcer treatment. Wound Repair Regen. 2015;23(6):891-900. Zelen, CM, Orgill, DP, Serena, T, et al. A prospective, randomised, controlled, multicentre clinical trial examining healing rates, safety and cost to closure of an acellular reticular allogenic human dermis versus standard of care in the treatment of chronic diabetic foot ulcers. Int Wound J. 2017;14(2):307-315. Lavery, LA, Fulmer, J, Shebetka, KA, et al. The efficacy and safety of Grafix((R)) for the treatment of chronic diabetic foot ulcers: results of a multi-centre, controlled, randomised, blinded, clinical trial. Int Wound J. 2014;11(5):554-560. Saxena, V, Hwang, CW, Huang, S, et al. Vacuum-assisted closure: microdeformations of wounds and cell proliferation. Plast Reconstr Surg. 2004;114(5):1086-1096. Contaldo, C, Hogger, DC, Khorrami Borozadi, M, et al. Radial pressure waves mediate apoptosis and functional angiogenesis during wound repair in ApoE deficient mice. Microvasc Res. 2012;84(1):24-33. Callaghan, MJ, Chang, EI, Seiser, N, et al. Pulsed electromagnetic fields accelerate normal and diabetic wound healing by increasing endogenous FGF-2 release. Plast Reconstr Surg. 2008;121(1):130-141.

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CHAPTER 3

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Management of Scars Wyatt G. Payne and David J. Smith

Key Points Keloids: Heaped scars that extend beyond the margins of the original wound; rarely spontaneously regress; frequently result from minor trauma; familial predisposition common. Hypertrophic scar: Raised; erythematous; pruritic; remains confined to the limits of the original wound. Fibroproliferative scars/healing describe a state of excessive healing with collagen formation imbalance. TGF-beta excess contributes to fibroproliferative scar formation (keloids and hypertrophic scar). A combination of treatment modalities may be required for scar improvement management. With the exception of fetal healing, 1,2 the end result of wound healing is a scar. In terms of evolution, this process developed as a necessity to traumatic injury and as a response to the alternative—failure to survive. Scars can pose numerous problems and complications: seizures (brain scar), intestinal obstruction (bowel scar), loss of range of motion (soft tissue, skin, muscle, joint scar), etc. Although normal scarring is beneficial, as it achieves a healed wound, the site and extent of scar, as related to plastic surgery, may pose both aesthetic and/or functional problems. Normal wound healing is a complex series of dynamic interactive processes that begin at the moment of wounding and involves soluble mediators, many cell types, and extracellular matrices. The process follows a specific time sequence and includes coagulation, inflammation, deposition and differentiation of extracellular matrix, fibroplasia, epithelialization, contraction, and remodeling with the end result— formation of a healed wound, by scar. 3,4 The end result of normal scar is an equilibrium between collagen synthesis/deposition and collagen lysis/degradation; the mature scar, which has approximately 80% of the tensile strength of normal unwounded skin, occurs between 6 and 18 months after wounding. 5 Proliferative healing has been described by Dvorak as a spectrum with normal healing on one end and tumor cell proliferation at the other. 6 Proliferative scar formation describes a series of events resulting in overhealing as if an equilibrium point between collagen deposition and collagen lysis has never been reached. 3,7 Types of proliferative scar formation include the following: Keloids 3,5,8 (Figure 3.1) Familial predisposition Enlarged heaped-up scar that extends beyond the margins of the original wound Rarely regress Frequently result from relatively minor injury or insult Elevated TGF-beta Hypertrophic scars 3,5,8-10 (Figure 3.2) Raised Erythematous Pruritic Remain at the site or confines of the original wound

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Partial or total resolution or regression can spontaneously occur Result from trauma, incision, burns Result from prolonged wound healing Increased epidermal/dermal thickness Lack of epithelial ridges Random orientation of collagen fibrils Decreased collagen content Elevated TGF-beta Increased number of mast cells Decreased collagen production

FIGURE 3.1 A. Keloid scarring of the ear after ear piercing. B. Massive keloid scarring of the ear. C. Extreme keloid formation on the back and neck. (Photos courtesy of Matthew Hiro, MD.)

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FIGURE 3.2 A,B. Hypertrophic burn scar of the hand with thumb web space contracture. C to E. Hypertrophic burn scar of the axilla with axillary contracture. (Photos courtesy of Matthew Hiro, MD.)

Related fibroproliferative disorders, all of which demonstrate similarities to proliferative scar 3,11-13 : Periprosthetic capsules—capsular contracture Dupuytren contracture—palmar fascia contractures Rhinophyma—tissue fibrosis

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The Problem Aesthetic Problems Scarring may create a variably noticeable abnormality because of the direction, quality, position, size, or orientation of the scar. Beauty is in the eye of the beholder. Assessing scars can be problematic, and subjective measures sometimes determine the aesthetic problem for the patient, significant others, professionals, or casual observers. Validated scar measures are described and used; however, what one may declare acceptable, another may deem unsightly and unacceptable. 14-20 The displeasing scar is no less problematic for some patients as functionally impairing scars.

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Functional Problems Scarring can limit functional capability, and the mere presence of scar can be symptomatic, in and of itself. Pain and pruritus are common symptomatic complaints. Scar contractures leading to diminished range of motion at joints, or other structures dependent upon mobility for their function, can cause variable disability. Scar bulk can also lead to pain, decreased function, and aesthetic concerns (as with keloids).

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Prevention As with most problems, an ounce of prevention is worth a pound of cure. The use of sound, meticulous surgical wound closure technique to optimize operative incisional and traumatic wound closures to minimize tension, adequately debride nonviable tissue, remove foreign bodies, approximate layers, fill dead space, prevent hematoma and seroma, and prevent infection, and removing sutures at appropriate time intervals, can contribute to minimizing scarring. 21-23 Adequate undermining with deep dermal suturing creating wound edge eversion can aid to reduce wound tension and diminish/minimize scar width. 21,24-26 Reducing chronic inflammation by alleviating foreign bodies, infection, and/or prolonged time to healing can improve eventual wound/scar outcomes. 27 Adequate debridement, minimization of foreign materials (including sutures), and wound closure timing (especially as with burn wound grafting) are all advantageous to improve scarring outcomes. 28 Incision placement and orientation are of prime concern to eventual scar formation/noticeability and also to relieve incisional tension. The noticeable scar is a function of light reflection that catches attention. Placing scars in natural creases, in junctions between contours, and at the edges of hair-bearing skin can camouflage to produce more inconspicuous scar lines. Working within the relaxed skin tension lines, as described by Borges, Kraissl, and Langer, allows scars to lie in planes and directions of less obvious orientation, and reduces the tension on incisions to produce less widened scars. 29-31

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Scar Management Medical Management Massage Frequently advised for postoperative scarring, this noninvasive, inexpensive method of scar manipulation/reduction does have evidence of effectiveness. 27,28 Although its usefulness is generally limited, massage can aid in the flattening and softening of scars and limiting some scar contractures (e.g., after lower eyelid procedures). Reported to be of benefit in the scenario of burn scarring, improvements in scar appearance, pruritic pain, and psychologic effects have been shown. 32 Professional massage therapists appear to be of benefit in scarring related to burn. 32

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Silicone Gel Application of silicone gel has been shown to benefit the appearance of hypertrophic scar, keloids, and surgical incisions. 33-38 The mechanism of action appears to be the occlusive nature of silicone dressing and epithelial hydration, not that of temperature increase, nor by any chemical effects of absorbed silicone. 36,39,40 Likely the effect is an influence in the collagen remodeling phase of wound healing. There is differing evidence as to the efficacy of silicone gel as a preventative treatment measure as compared with good evidence to indicate effective management after scarring. 21,23,33,41 Recommendation for treatment is to wear the silicone gel dressing for 12 to 24 hours per day for 2 to 3 months at the onset of visible scar abnormality.

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Compression, Pressure, and Mechanomodulation Pressure garments are commonly utilized after burn injury/treatment to aid in hypertrophic scar control. 28,42 Compression garments are recommended prophylactically in burn injury after extensive skin grafting and/or if spontaneous wound healing requires longer than 10 to 14 days. 27,28,43 The exact mechanism that pressure garments influence hypertrophic scarring is not completely understood; however, influence on collagen synthesis and remodeling is a likely effect. 43 Pressure requirements for effectiveness have not been established, although 15 to 25 mm Hg is the target pressure reported by many authors. 9,43,44 The appearance, discomfort, texture, and heat reflection/generation (especially in warm climates) of pressure garments limit patient compliance and therefore their effectiveness. Pressure therapy is also effective for keloid treatment/therapy, generally as a postoperative adjunctive measure. 9,45 Compression earrings (for ear lobe keloids) are commercially available for postoperative application but require patient compliance. Effectiveness may be up to 80% following complete surgical excision. 9,21,22,45,46 Significant wound tension leads to widened scarring. 24-26,45 Mechanomodulation to relieve scar tension at the time of incision closure can positively affect incisional scar formation and improve scar appearance. 23,25,26 Available as a commercial device and placed to redistribute and relieve tension across an incision line, the device is well tolerated by patients, is effective, and has a minimal complication rate. 23,25 This device is recommended for truncal incisions such as abdominoplasty.

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Corticosteroids Injection of steroids (triamcinolone) is widely used as an initial treatment for keloids and hypertrophic scars and is commonly applied in conjunction with other modalities including surgical excision to decrease scar recurrence rates. 5,9,21,23,33,45 Dosage may range from 2.5 to 40 mg either as primary solo treatment or prior to surgical excision and can be injected with a mixture of xylocaine + epinephrine to diminish local pain and to decrease steroid dispersion, to maximize its effect. 22,46 Solo steroid therapy for hypertrophic scars can be repeated at 4-week to 6-week intervals until the desired effect is observed, side effects are observed, or if surgical excision is expected. Steroid pretreatment for keloids followed by surgical excision and follow-up postoperative injections produce reported cure rates of up to 80%. 45,47-51 Complications and side effects arising from the use of injectable corticosteroids include skin atrophy, hypopigmentation, and pain with injection. 45,47

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Radiation Therapy Radiation therapy can be utilized as an adjunct therapeutic with surgical excision in the treatment of keloids. Keloid excision followed by radiation therapy within 24 to 48 hours either as a single dose or as multiple doses can reduce recurrence and lead to cure rates between 67% and 98%, depending on the anatomic area. Although there is no overwhelming prospective evidence to indicate definitive effectiveness of radiation therapy after surgical excision in keloid treatment, retrospective data from relatively large clinical patient series indicate it as a worthwhile treatment. 52-55 Radiation damages keloid fibroblasts, affecting collagen production and structure. 45,53,56 Radiation monotherapy is not effective. Concern for generation of malignancy due to radiation therapy is advisable, especially in the pediatric age patient or in areas prone to radiation-induced carcinomas, such as thyroid and breast. 57 The reported rates for carcinogenesis are low, with few cases associating radiation therapy for treatment of keloids with malignant tumor generation. Recommendations are for adequate shielding of vulnerable areas from radiation and careful patient selection. 58 Radiation therapy for refractory/intractable hypertrophic scarring has been reported as effective; however, there are few data to support its use. 53 Side effects of hyperpigmentation, hypopigmentation, and transient erythema have been reported. Few wound healing problems have been attributed to the low-dose radiation, and soft tissue fibrosis as encountered with higher doses of radiation therapy is not likely. 53

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Cryotherapy Topical cryotherapy may achieve initial positive results in hypertrophic scars and keloid treatment; subsequent recurrence rates are high, making this therapy less than optimal, unless repetitive treatments/sessions are utilized. 58 Intralesional cryotherapy requiring a specialized cryoprobe does show effectiveness, but this method is not widely used. 58

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Molecular Therapies There is experimental (and some clinical) evidence to indicate that treatment of hypertrophic scar and/or keloids with agents such as 5-fluorouracil, bleomycin, mitomycin C, tamoxifen, paclitaxel, methotrexate, TGF-beta 3, and interferon may be of benefit. Likely the mechanisms of antiscarring action are due to their interaction with TGF-beta receptors and downregulation of fibroblast function. 59-63 The current utility of these agents is limited because of a lack of adequate clinical evidence.

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Botulinum Toxin Botulinum toxin has recently been reported to improve surgical incisional scars. 64 Although only reported as a small case series, final scar outcome improved with intraoperative injection of botulinum toxin type A, 10 U/cm in a split-scar randomized trial. The presumed mechanism of action of botulinum toxin is inhibition of TGF-beta 1 and cell cycle interaction, diminishing fibroblast cell functions/regulation. 64

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Other Modalities Vitamin E and onion extract have little clinical evidence to recommend their use for treatment. 21,65 Reviews of over-the-counter products with claims to scar treatment and scar improvement provide little evidence for these products’ effectiveness beyond the earlier discussions. 66,67

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Surgical Management Scar revision surgery can vary from excision(re-excision) and closure to more complex modalities and combinations of modalities. The type of scar, extent of scarring, size, orientation, location, etiology, symptomatology, and patient preferences are all factors to consider when planning surgical scar treatments. Surgical adjuvants (corticosteroid injection, laser therapy, radiation therapy) deserve consideration in planning scar treatment/management for their possible benefits (versus risks and side effects).

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Excision and Direct Closure Considered in instances where local tissue conditions warrant, minimal/no tension and optimal orientation would be prime considerations. The etiology of unsatisfactory scar in this instance should be considered so that results similar to the initial scarring problem are not repeated.

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Excision and Z-Plasty or W-Plasty Closure Redirecting the orientation and tension of the scar to a more favorable or more optimal direction can produce less tension, more proper alignment, and improved appearance. Borges 29,30 described extensively the relaxed skin tension lines and the utilization of Z-plasty and W-plasty for the revision of scars to improve their appearance as well as to describe the placement of incisions in orientations for improved primary outcomes. Z-plasty can be considered to realign tissue in instances of scar creating functional deficits such as joint contracture. Functional reorientation and scar lengthening may improve limitation of motion and decrease scar tension. A standard Z-plasty with equivalent length sides and an angle of 60 degrees provides lengthening along the central limb of approximately 75% of its original length. A longer central limb provides (theoretical) linear increase, as does increasing the Z-plasty angle. 29 Multiple in-series Zplasties can be used for longitudinal gain and reorientation. Adequate skin laxity lateral to the original scar is necessary for adequate Z-plasty flap closure. W-plasty serves to break up the scar outline and camouflage the appearance, producing less light reflection and less noticeability.

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Excision and Skin Grafting This is helpful in instances of hypertrophic/widened scars with poor appearance and/or scars causing functional limitations, such as with cicatricial ectropion of the eyelid or minor axillary contracture with minimal linear banding. Attention to recreating the original tissue deficiency with adequate scar release to the point of allowing full range of motion and overgrafting the original area of scarring can help to minimize tension on the newly created site. Once skin grafting is complete, compression garments, range of motion therapy, and scar massage may contribute to eventual improved outcomes.

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Excision, Dermal Replacement, and Grafting Recent reports of improved scar revision outcomes have described the use of dermal replacement after scar excision as a basis for secondary skin grafting as an adjuvant to scar and keloid surgical revisions. 6872 Acellular dermal matrix products allow for vascular ingrowth from contact of matrix edges with normal tissue. These matrices are used over nonvascularized and minimally vascularized structures such as exposed bones and tendons. As opposed to the time-limited nature of skin autografts, which require relatively immediate revascularization for survival, dermal matrices time line of wound bed preparation are longer but provide immediate wound coverage until second-stage grafting can be successfully accomplished.

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Excision/Flap Closure Flap closure after scar excision is worthy of consideration. Flaps including cutaneous, myocutaneous, and fasciocutaneous, whether local, random, pedicled, perforator, or a free tissue transfer, can serve to relieve tension in the area of original scar, fill dead space, and improve aesthetics and/or function. The more severe the scar contracture, especially across major joints such as the knee, elbow, and axilla, the more likely flap closure is indicated and beneficial. Maximal scar release, dead space filling, and tension-free closure are required for adequate results.

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Combination Surgical Revision With Adjuvants Excision with radiation therapy, excision with corticosteroids, and excision with pressure garments have been discussed earlier.

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Laser Treatment Laser has been successfully utilized and shown to improve scar appearance, although further investigations are warranted. 72-75 Much of the positive supporting data are reported for hypertrophic burn scarring utilizing pulsed dye 585/595-nm wavelength as treatment for pruritus and erythema. 72,76,77 Treatments for scar prevention as well as established hypertrophic scar therapy indicated response rates in the range of 70%. 72,74 Other hypertrophic scarring etiologies such as median sternotomy and inframammary scars have been reported to respond to, with good results. 78,79 Results concerning the timing of pulsed dye laser treatments on hypertrophic burn scars appear to indicate that earlier treatment with pulsed dye laser may lead to improved outcomes. 75,80 Hypertrophic scars, treated when early, less than 1-year while still erythematous, responded better than those of more mature age. Pulsed dye laser therapy works by destruction of scar microvasculature via photothermolysis, and possibly collagen modulation by reducing TGF-beta expression. 75,76 CO2 laser is ablative, causing tissue vaporization due to selective absorption by water in the tissues. 76

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Fat Grafting Recent enthusiasm for fat grafting as scar treatment appears to have merit and effectiveness. Effects of fat grafting include filling and elevating of depressed scars, improvement in the quality and pliability of scar, and improvement and pliability in radiated soft tissue. 81-86 The exact effects and mechanism of action on scars and scarring are unknown. There appears to be more effects than simple volumetric filling, and a tissue regenerative effect may occur. 82-86 Adipose-derived stem cells may stimulate local cytokine growth factors leading to increased vascularization, collagen remodeling, and inflammatory response modulation. 82,83 Positive results in studies using fat grafting in the treatment of scar and fibrosing entities are found, although there are few controlled trial and quantitative data. There is growing subjective evidence to suggest that fat grafting may become a mainstay for scar treatment.

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Conclusion Scar tissue is the end result of the normal healing process. Abnormal scarring is enhanced healing or overhealing, usually with resulting aesthetic unacceptability and/or functional impairment. Exact mechanisms of unfavorable scarring are not well elucidated, although excess TGF-beta receptor activity appears to have a major molecular influence. Many treatment options are available either surgically or in combination; however, problematic recurrence remains high. There is no single good therapeutic option in all situations, and individual treatment is advised based on the clinical scenario, available modalities, and patient preference.

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Questions 1. Radiation therapy is useful for treatment of keloids: a. Preoperatively b. Infrequently c. As a sole modality d. At high doses e. In the immediate postoperative period 2. Common complications from corticosteroid injection for scar treatment include: a. Skin atrophy b. Cushing disease c. Hypopigmentation d. a, b, and c e. a and c 3. Definitive scar improvement has been demonstrated with randomized controlled trials for which of the following modalities? a. Mechanomodulation b. Laser therapy c. Fat grafting d. Pressure therapy e. Excision and XRT 4. A 60-degree angle Z-plasty theoretically lengthens the central limb of the method by: a. 50% b. 60% c. 75% d. 100% 5. Concerning laser therapy for hypertrophic burn scars: a. Pulsed dye laser is indicated for scar erythema. b. CO2 laser is indicated for scar erythema. c. CO2 laser is indicated for scar texture treatment. d. Pulsed dye laser is indicated for scar texture treatment. e. a and c f. b and d 1. Answer: e. Radiation therapy is an effective, frequently used treatment as an adjunct to surgical excision in a relatively low dose, usually in divided multiple sessions, immediately postoperatively. Radiation therapy is not effective preoperatively, or as a solitary treatment, as recurrence rates of keloids are high. 2. Answer: e. Corticosteroid injection for scar management is an effective management, usually requiring multiple interval injections. Pain, skin atrophy, and hypopigmentation are common side effects encountered. Cushing disease as a result of local corticosteroid injection would be very unusual, because of the relative low doses and minimal systemic absorption of the drug. 3. Answer: a. Although evidence exists to consider laser therapy, fat grafting, pressure therapy, and excision plus radiation therapy, the majority of reports utilizing these modalities are case series, retrospective studies, and comparative studies. Only mechanomodulation with a device to alleviate tension at the time of surgical incision has shown improvement in randomized controlled trials. 4. Answer: c. Theoretical geometric lengthening of the central limb of a Z-plasty with flaps incised at

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60 degrees is 75%. 5. Answer: e. Pulsed dye laser at 585/595-nm wavelength is used to treat scar erythema. CO2 laser works by tissue ablation and water vapor absorption and is indicated for scar texture treatment.

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References Walmsley, GG, Maan, ZN, Wong, VW, et al. Scarless wound healing: chasing the holy grail. Plast Reconstr Surg. 2015;135:907-917. Ferguson, MWJ, O’Kane, S. Scar-free healing: from embryonic mechanisms to adult therapeutic intervention. Pil Trans R Soc Lond. 2004;359:839-850. Robson, MC, Steed, DL, Franz, MG. Wound healing: features and approaches to maximize healing trajectories. Curr Prob Surg. 2001;38(2):61140.A comprehensive monograph on wound healing including abnormal wound healing and fibroproliferative/scarring entities. Discussion on the molecular biology of scarring. Robson, MC, Stenberg, BD, Heggers, JP. Wound healing alterations caused by infection. Clin Plast Surg. 1990;17(3):485-492. Tredget, EE, Nedelec, B, Scott, PG, Ghahary, A. Hypertrophic scars, keloids and contractures. Surg Clin North Amer. 1977;77(3):701-730. Dvorak, HF. Tumors that do not heal-similarities between tumor stroma generation and wound healing. N Engl J Med. 1986;315(26):16501659. Como, CB. Scars and keloids. In: Jurkiewicz, MJ , Krizek, TJ , Mathes, SJ , Ariyan, S , eds. Plastic Surgery: Principals and Practice. St Louis, MO: CV Mosby; 1990:1411-1428. Kisher, CW, Bunce, H, Shetlar, MR. Mast cell analysis in hyphic scars, hypertrophic scars treated with pressure, and mature scars. J Invest Dermatol. 1978;70(6):355-357. Ogawa, R. The most current algorithms for the treatment and prevention of hypertrophic scars and keloids. Plast Reconstr Surg. 2010;125:557568.Recent review of hypertrophic scar and keloid treatment by a long-time scar researcher. Polo, M, Ko, F, Busillo, F, Cruse, CW, Krizek, TJ, Robson, MC. The 1997 Moyer Award. Cytokine production in patients with hypertrophic burn scars. J Burn Care Rehibil. 1997;18:477-482. Kuhn, A, Singh, S, Smith, PD, et al. Periprosthetic breast capsules contain the fibrogenic cytokines TGF-beta 1 and TGF-beta 2, suggesting possible new treatment approaches. Ann Plast Surg. 2000;44:387-391. Kuhn, MA, Payne, WG, Kierney, PC, et al. Cytokine manipulation of explanted Dupuytren’s affected human palmar fascia. J Surg Invest. 2001;2(6):443-456. Pu, LL, Smith, PD, Payne, WG, et al. Overexpression of transforming growth factor beta-2 and its receptor in rhinophyma: an alternative mechanism of pathobiology. Ann Plast Surg. 2000;45:515-519. Brown, BC, McKenna, SP, Solomon, M, et al. The patient-reported impact of scars measure: development and validation. Plast Reconstr Surg. 2010;125:1439-1449. Trong, PT, Lee, JC, Soer, B, et al. Reliability and validity testing of the patient and observer scar assessment scale in evaluating linear scars after breast cancer surgery. Plast Reconstr Surg. 2007;119(2):487-494. Kerrigan, CL, Homa, K. Visual assessment of linear scars: a new tool. Plast Reconstr Surg. 2009;124(5):1513-1519. Thompson, CM, Sood, RF, Honari, S, Carrougher, GJ, Gibran, NS. What score on the Vancouver scar scale constitutes a hypertrophic scar? Results from a survey of North American burn-care providers. Burns. 2015;41(7):1442-1448. Bae, SH, Bae, YC. Analysis of frequency of use of different scar assessment scales based on the scar condition and treatment method. Arch Plast Surg. 2014;41:111-115. Fearmonti, R, Bond, J, Erdmann, D, Levinson, H. A review of scar scales and scar measuring devices. EPlasty. 2010;10:354-363. Draaijers, LJ, Tempelman, FRH, Botman, YAM, et al. The patient and observer scar assessment scale: a reliable and feasible tool for scar evaluation. Plast Reconstr Surg. 2004;113:1960-1965. Khansa, I, Harrison, B, Janis, JE. Evidence-based scar management: how to improve results with technique and technology. Plast Reconstr Surg. 2016;138;165S-178S. Recent comprehensive review of clinical scar therapies. Wolfram, D, Tzankov, A, Pulzl, P, Piza-Katzer, H. Hypertrophic scars and keloids: a review of their pathophysiology, risk factors, and therapeutic management. Dermatol Surg. 2009;35:171-181. Perez, JL, Rohrich, RJ. Optimizing postsurgical scars: a systemic review on best practices in preventive scar management. Plast Reconstr Surg. 2017;140:782e-793e. Recent comprehensive, evidenced-based treatment review of scar prevention. Useful algorithms for treatment. Wray, RC. Force required for wound closure and scar appearance. Plast Reconstr Surg. 1983;72(3):380-382. Longacre, MT, Rohrich, RJ, Greenberg, L, et al. A randomized controlled rial of the embrace advanced scar therapy device to reduce incisional scar formation. Plast Reconstr Surg. 2014;134(3):536-546.Excellent study design and execution showing benefits of tension reduction to reduce scarring in high-tension abdominoplasty incisions. Lim, AF, Weintraub, J, Kaplan, EN, et al. The embrace device significantly decreases scarring following scar revision surgery in a randomized controlled trial. Plast Reconstr Surg. 2014;133(2):398-405. Atiyeh, BS. Nonsurgical management of hypertrophic scars: evidence-based therapies, standard practices, and emerging methods. Aesth Plast Surg. 2007;31:468-492. Bloemen, MCT, van der Veer, WM, Ulrich, MMW, van Zuijlen, PPM, Niessen, FB, Middelkoop, E. Prevention and curative management of hypertrophic scar formation. Burns. 2009;35:463-475. Borges, AF. Elective Incisions and Scar Revision. Boston, MA: Little, Brown & Co; 1973.Classic textbook with definitive explanations of relaxed skin tension lines, Z-plasty, and incision placement to reduce or minimize scarring. Borges, AF. Relaxed skin tension lines (RTSL) versus other skin lines. Plast Reconstr Surg. 1984;73(1):144-150.

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Wilhelmi, BJ, Blackwell, SJ, Phillips, LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999;104:208-214. Ault, P, Plaza, A, Paratz, J. Scar massage for hypertrophic burn scarring: a systematic review. Burns. 2018;44:24-38. Mustoe, TA, Cooter, RD, Gold, MH, et al. International clinical recommendations on scar management. Plast Reconstr Surg. 2002;110(2):560571. Mustoe, TA. Evolution of silicone therapy and mechanism of action in scar management. Aesth Plast Surg. 2008;32:82-92.A comprehensive review of silicone and its benefits and mechanism of action on scars. Li-Tsang, CWP, Zheng, PY, Lau, JCM. A randomized clinical trial to study the effects of silicone gel dressing and pressure therapy on posttraumatic hypertrophic scars. J Burn Care Res. 2010;31(3):448-457. Tandara, AA, Mustoe, TA. The role of the epidermis in the control of scarring: evidence for the mechanism of action for silicone gel. J Plast Reconstr Aesth Surg. 2008;61:1219-1225. Ahn, ST, Monafo, WW, Mustoe, TA. Topical silicone gel for the prevention and treatment of hypertrophic scar. Arch Surg. 1991;126:499-504. Gold, MH, Foster, TD, Adair, MA, et al. Prevention of hypertrophic scars and keloids by the prophylactic use of topical silicone gel sheets following a surgical procedure in an office setting. Dermatol Surg. 2001;27:641-644. Quinn, KJ, Evans, JH, Courtney, JM, Gaylor, JD, Reid, WH. Non-pressure treatment of hypertrophic scars. Burns Incl Therm Inj. 1985;12(2):102-108. Mustoe, TA, Gurjala, A. The role of the epidermis and the mechanism of action of occlusive dressings in scarring. Wound Rep Reg. 2011;19:S16-S21. O’Brien, L, Pandit, A. Silicon gel sheeting for preventing and treating hypertrophic and keloid scars. Cochrane Database Syst Rev. 2006;9:1-77. Kisher, CW, Shetlar, MR, Shetlar, C. Alteration of hypertrophic scars induced by mechanical pressures. Arch Dermatol. 1975;111:60-64. Macintyre, L, Baird, M. Pressure garments for use in the treatment of hypertrophic scars: a review of the problems associated with their use. Burns. 2006;32:10-15. Van den Kerckhove, E, Stappaerts, K, Fieuws, S, et al. The assessment of erythema and thickness on burn related scars during pressure garment therapy as a preventive measure for hypertrophic scarring. Burns. 2005;31:696-702. Al-Attar, A, Mess, S, Thomassen, JM, Kauffman, CL, Davison, SP. Keloid pathogenesis and treatment. Plast Reconstr Surg. 2006;117:286-300. Agrawal, K, Panda, N, Arumugam, A. An inexpensive self-fabricated pressure clip for the ear lobe. Br J Plast Surg. 1998;51:122-123. Brissett, AE, Sherris, DA. Scar contractures, hypertrophic scars, and keloids. Facial Plast Surg. 2001;17(4):263-271. Roques, C, Teot, L. The use of corticosteroids to treat keloids: a review. Int J Lower Ext Wounds. 2008;7(3):137-145. Ketchum, LD, Robinson, DW, Masters, FW. Follow-up on treatment of hypertrophic scars and keloids with triamcinolone. Plast Reconstr Surg. 1971;48(3):256-259. Ketchum, LD, Smith, J, Robinson, DW, Masters, FW. The treatment of hypertrophic scar, keloid and scar contracture by triamcinolone acetonide. Plast Reconstr Surg. 1966;38(3):209-218. Griffith, BH, Monroe, CW, McKinney, P. A follow-up study on the treatment of keloids with triamcinolone acetonide. Plast Reconstr Surg. 1970;46(2):145-150. Ogawa, R, Mitsuhashi, K, Hyakusoku, H, Miyashita, T. Postoperative electron-beam irradiation therapy for keloids and hypertrophic scars: retrospective study of 147 cases followed for more than 18 months. Plast Reconstr Surg. 2003;111:547-553.Extensive retrospective look at a large series of patients treated by scar excision with postoperative radiation therapy, indicating benefit of the combined therapy. Ogawa, R, Miyashita, T, Hyakusoku, H, et al. Postoperative radiation protocol for keloids and hypertrophic scars – statistical analysis of 370 sites followed for over 18 months. Ann Plast Surg. 2007;59(6):688-691. Norris, JEC. Superficial x-ray therapy in keloid management: a retrospective study of 24 cases and literature review. Plast Reconstr Surg. 1995;95(6):1051-1055. Kim, K, Son, D, Kim, J. Radiation therapy following total keloidectomy: a retrospective study over 11 years. Arch Plast Surg. 2015;42:588-595. Sclafani, AP, Gordon, L, Chadha, M, Romo, T. Prevention of earlobe keloid recurrence with postoperative corticosteroid injections versus radiation therapy. Dermatol Surg. 1996;22:569-574. Ogawa, R, Yoshitatsu, S, Yoshida, K, Miyashita, T. Is radiation therapy for keloids acceptable? The risk of radiation-induced carcinogenesis. Plast Reconstr Surg. 2009;124(4):1196-1201. Har-Shai, Y, Amar, M, Sabo, E. Intralesional cryotherapy for enhancing the involution of hypertrophic scars and keloids. Plast Reconstr Surg. 2003;111(6):1841-1852. Uberti, MG, Pierpont, YN, Bhalla, R, et al. Down regulation of scar fibroblasts by antineoplastic drugs: a potential treatment for fibroproliferative disorders. Surg Sci. 2016;7:258-271. Shridharani, SM, Magarakis, M, Manson, PN, et al. The emerging role of antineoplastic agents in the treatment of keloids and hypertrophic scars. Ann Plast Surg. 2010;64(3):355-361. Gragnani, A, Warde, M, Furtado, F, Ferreira, LM. Topical tamoxifen therapy in hypertrophic scars or keloids in burns. Arch Dermatol Res. 2010;302:1-4. Uppal, RS, Khan, U, Kakar, S, et al. The effects of a single dose of 5-flurouracil on keloid scars: a clinical trial of timed wound irrigation after extralesional excision. Plast Reconstr Surg. 2001;108(5):1218-1224. Haurani, M, Foreman, K, Yang, JJ, Siddiqui, A. 5-Flurouracil treatment of problematic scars. Plast Reconstr Surg. 2009;123(1):139-148. Hu, L, Zou, Y, Chang, S, et al. Effects of botulinum toxin on improving facial surgical scars: a prospective, split-scar double-blind, randomized controlled trial. Plast Reconstr Surg. 2018;141(3):646-650.Recent study describing improvement of scars treated intraoperatively with

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botulinum toxin. A split-scar study demonstrating efficacy. Curran, JN, Crealey, M, Sadadcharam, G, et al. Vitamin E: patterns of understanding, use, and prescription by health professionals and students at a university teaching hospital. Plast Reconstr Surg. 2006;118(1):248-252. Shih, R, Walzman, J, Evans, GRD. Review of over-the-counter topical scar treatment products. Plast Reconstr Surg. 2007;119(3):1091-1095. Morganroth, P, Wilmot, AC, Miller, C. Over-the-counter scar products for postsurgical patients: disparities between online advertised benefits and evidence regarding efficacy. J Am Acad Dermatol. 2009;61:e31-47. Moiemen, NS, Staiano, JJ, Ojeh, NO, et al. Reconstructive surgery with a dermal regeneration template: clinical and histologic study. Plast Reconstr Surg. 2001;108(1):93-103. Frame, JD, Still, J, Lakhel-LeCoadou, A, et al. Use of dermal regeneration template in contracture release procedures: a multicenter evaluation. Plast Reconstr Surg. 2004;113(5):1330-1338. Bloemen, MCT, van Leeuwen, MCE, van Vucht, NE, et al. Dermal substitution in acute burns and reconstructive surgery: a 12-year follow up. Plast Reconstr Surg. 2010;125(5):1450-1459. Clayman, MA, Clayman, SM, Mozingo, DW. The use of collagen-glycosaminoglycan copolymer (Integra) for the repair of hypertrophic scars and keloids. J Burn Care Res. 2006;27:404-409.Comprehensive review describing current evidence for the use of laser therapy for hypertrophic burn scars. Hultman, CS, Fredstat, JS, Edkins, RE, et al. Laser resurfacing and remodeling of hypertrophic burn scars. Ann Plast Surg. 2014;260(3):519532. Friedstat, JS, Hultman, CS. Hypertrophic burn scar management: what does the evidence show? A systematic review of randomized controlled trials. Ann Plast Surg. 2014;72:S198-S201. Jin, R, Huang, X, Li, H, et al. Laser therapy for prevention and treatment of pathologic excessive scars. Plast Reconstr Surg. 2013;132(6):17471758. Brewin, MP, Lister, TS. Prevention or treatment of hypertrophic burn scarring: a review of when and how to treat with the pulsed dye laser. Burns. 2014;40:797-804. Al Harithy, R, Pon, K. Scar treatment with lasers: a review and update. Curr Derm Rep. 2012;1:69-75. Kim, DH, Ryu, HJ, Choi, JE, et al. A comparison of the scar prevention effect between carbon dioxide fractional laser and pulsed dye laser in surgical scars. Dermatol Surg. 2014;40:973-978. Alster, TS, Williams, CM. Treatment of keloid sternotomy scars with 585-nm flashlamp-pumped pulsed dye laser. Lancet. 1995;345:1198-1200. Alster, T. Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids. Dermatol Surg. 2003;29(1):25-29 Goldman, MP, Fitzpatrick, RE. Laser treatment of scars. Dermatol Surg. 1995;21:685-687. Negenborn, VL, Groen, J, Smit, JM, et al. The use of autologous fat grafting for treatment of scar tissue and scar-related conditions: a systematic review. Plast Reconstr Surg. 2016;137(1):31e-43e. Conde-Green, A, Marano, AA, Lee, ES, et al. Fat grafting and adipose-derived regenerative cells in burn and wound healing and scarring: a systematic review of the literature. Plast Reconstr Surg. 2016;137(1):302-312. Klinger, M, Caviggioli, F, Klinger, FM, et al. Autologous fat in scar treatment. J Craniofac Surg. 2013;24:1610-1615. Coleman, SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 suppl):108S-120S. Kan, HJ, Selles, RW, van Nieuwenhoven, CA, et al. Percutaneous aponeurotomy and lipofilling (PALF) versus limited fasciectomy in patients with primary Dupuytren’s contracture: a prospective, randomized, controlled trial. Plast Reconstr Surg. 2016;137(6):1800-1812. Khouri, RK, Khouri, RK. Current clinical applications of fat grafting. Plast Reconstr Surg. 2017;140(3):466e-486e.Review of a broad spectrum of fat-grafting indications including the utility in scar and fibroproliferative disease treatment.

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CHAPTER 4

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Principles of Flap Design and Application Julian J. Pribaz and Katherine M. Huber

Key Points A flap is a body of tissue with its own inherent blood supply that can be elevated and moved to reconstruct defects. Thorough knowledge of blood supply to tissue is critical for safe and reliable flap elevation and transfer. Use of two- and three-dimensional templates will assist with proper flap design. Attempt to minimize residual donor site deformity. Consider the consequences of scar contracture, contour deformity, and functional loss. For a complex defect, consider staged reconstruction with methodical planning of each stage. Always have a backup plan. The primary goal of flap reconstruction is to maintain adequate flap vascularity. Plan for secondary revisions to improve contour and appearance. The word principle stems from the Latin princeps meaning a beginning. Tenets of practice should begin with the principles, yet these should be subject to change as knowledge of the subject increases. 1 There has been significant evolution of our knowledge of flaps in recent years, primarily due to improvements in the understanding of vascular anatomy. This has led to noteworthy advances in the reconstructive options available. The simplest definition of a flap is a body of tissue with its own original inherent blood supply that can be elevated and moved to repair and reconstruct defects. In this way, a flap differs from a graft, which does not carry its own blood supply. Flaps, in one form or another, serve as the basis of reconstructive surgery.

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Flap Blood Supply and Physiology A thorough knowledge of blood supply to the skin and accompanying tissue is critical in safe and reliable flap elevation and transfer of flaps. The skin, because of its role in thermoregulation to maintain homeostasis and its immunological function, has a rich blood supply, far greater than what is needed for its own inherent metabolic demand. This is an important fact in facilitating skin flap survival. The blood reaches the skin from deeper named vessels, via multiple perforating arteries and their accompanying veins that course through overlying muscles, septa, and fascia to supply the more superficial vascular plexuses, creating a continuous three-dimensional (3D) network of vessels supplying all layers of tissues. For the skin, the blood supply is concentrated at the suprafascial and subdermal levels, from which smaller vessels branch to supply the intervening tissues 2 (Figure 4.1).

FIGURE 4.1 Vascular plexuses of the skin and subcutaneous tissue.

In 1987, Taylor and Palmer rediscovered and further elaborated on the work of Manchot and Salmon on the blood supply of the skin and underlying tissue, and proposed the concept of the angiosome, which they defined as a 3D body of tissue supplied by a source (segmental or distributing) artery and its accompanying vein(s) that span between the skin and bone. 3 Each angiosome could be subdivided into a matching arteriosome (arterial territory) and venosome (venous territory). Angiosomes can vary in size and interdigitate with adjoining angiosomes via true small anastomotic bidirectional arterioles and venules by reduced-caliber choke (retiform) anastomotic vessels. 4 More recent work by Saint-Cyr et al. 5 advanced the angiosome concept to provide additional and more practical insight into vascular territory and flow characteristics that are important in flap design. They studied both 3D (static) and 4D (dynamic) blood flow through multiple single perforators and mapped out the territory supplied, calling this a perforasome (Figure 4.2). They found greater complexity and

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variability than was initially anticipated, and they confirmed that each perforasome is connected to an adjacent perforasome by both direct (fascial) and indirect (subdermal) linking vessels (Figure 4.3).

FIGURE 4.2 Perforators have a distinct arterial and venous vascular territory. This image depicts the vascular arterial anatomy of a perforasome. Note the dense vascular network centered around the perforator that decreases progressively toward the periphery. Large linking vessels branch peripherally in multiple directions away from the perforator origin. From Saint-Cyr, M, Wong, C, Schaverien, M, Mojallal, A, Rohrich, RJ. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124(5):1529-1544; with permission.

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FIGURE 4.3 Interperforator flow occurs by means of direct and indirect linking vessels. Direct linking vessels communicate directly with an adjacent perforator to maintain perfusion, and travel within the suprafascial and adipose tissue layers. Indirect linking vessels communicate with adjacent perforators by means of recurrent flow through the subdermal plexus. Communicating branches between direct and indirect linking vessels are also seen and help maintain vascular perfusion in case of injury. From Sur, YJ, Morsy, M, Michel Saint-Cyr, M. The pedicled perforator (propeller) flap in lower extremity defects. In: Strauch, B , Vasconez, LO , Herman, CK , Lee, BT , eds. Grabb’s Encyclopedia of Flaps: Upper Extremities, Torso, Pelvis, and Lower Extremities. 4th ed, vol. 2. Philadelphia, PA: Wolters Kluwer; 2016:1420-1425.

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Nomenclature and Classification The nomenclature of flap classification is somewhat imperfect and fluid. As Converse stated, “There is no simple and all-encompassing system which is suitable for classifying skin flaps.” 6 This is true for skin flaps as well as flaps of other tissue types. Although the nomenclature is imperfect and overlapping, it is important to develop a vocabulary of terms to describe flaps for improved understanding and communication with other medical professionals. Flaps can be classified in multiple ways. Classification occurs according to flap content and tissue type, mechanics of movement or transfer, blood supply, and manipulation prior to harvest.

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Flap Content Flap classification begins with the content of the planned flap. The simplest flap contains skin and subcutaneous tissue. These are referred to as cutaneous flaps. Cutaneous flaps can be harvested relatively thinly to fit a similar defect. Generally, the blood supply in a cutaneous flap is random in nature and located within the subdermal plexus. As defects become more complex, so can the harvested flap. Flaps containing skin, subcutaneous tissue, and fascia are referred to as fasciocutaneous flaps. 7 Fascial flaps devoid of the overlying skin can also be harvested if a very thin flap that is easily contoured is desired. These are known as fascial and adipofascial flaps and are usually accompanied by an overlying skin graft to maintain a thin contour. Fasciocutaneous flaps were described and further classified by their pattern of blood supply by Cormack and Lamberty in 1984 8 (Table 4.1). The temporoparietal and anterolateral thigh fasciocutaneous flaps are excellent examples. TABLE 4.1 Cormack and Lamberty Classification of Fasciocutaneous Flaps Type A B C D

Description A pedicled fasciocutaneous flap dependent on multiple fasciocutaneous perforators at the base and orientated with the long axis of the flap A pedicled or a free flap depending on a single sizeable and consistent fasciocutaneous perforator feeding a plexus at the level of the deep fascia The blood supply of the skin is dependent upon the fascial plexus that is supplied by multiple small perforators along its length, which reach it from a deep artery by passing along the fascial septum between muscles. The fascial septum is taken in continuity with adjacent muscle and bone which derive their blood supply from the same artery

Example Lateral arm flap Parascapular fap Radial forearm flap Free fibula flap

Muscle flaps are a staple of reconstructive surgery. They may be used in stand-alone fashion, or with an overlying skin graft. These flaps can be harvested with overlying skin and soft tissue for added bulk and are called myocutaneous flaps. Muscle and myocutaneous flaps were classified by Mathes and Nahai in 1981 based on their inherent blood supply 9 (Figure 4.4). Often in cases of lower extremity trauma with exposed bone or hardware, well-vascularized muscle tissue is desired for coverage and has the advantage of conforming to an irregular wound bed to minimize dead space. However, recent literature shows that muscle and fasciocutaneous flaps achieve comparable rates of limb salvage and functional recovery. 10

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FIGURE 4.4 Mathes and Nahai classification. Patterns of vascular anatomy: type I, one vascular pedicle; type II, dominant pedicle(s) and minor pedicles; type III, two dominant pedicles; type IV, segmental vascular pedicles; type V, one dominant pedicle and a secondary segmental pedicle. Reproduced with permission from Mathes, SJ, Nahai, F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-187.

When structural support at the defect is required, flaps containing bone can be used. Vascularized bone flaps, or osseous flaps, can be harvested free from surrounding tissue. For example, a bone-only free fibula can be harvested on the peroneal artery and is a workhorse of head and neck bony reconstruction. Conversely, overlying soft tissue and skin can be included. In this case, the flap is categorized as osteomyocutaneous and osteocutaneous. In a separate category are omental and intestinal flaps. The omental flap can be raised on the gastroepiploic vessels and utilized in pedicled fashion to fill sternal or other chest wall defects. The omentum has angiogenic and immunogenic properties that make it ideal for reconstruction of sternal wound infections. As a free flap, it is extremely useful as thin vascularized tissue that can be covered with skin grafts for defects in the head and neck or lower extremity. 11 Various intestinal flaps can be harvested to reconstruct laryngopharyngeal and esophageal defects. 12 Composites of any of the above categories are used frequently and can include other local tissue such as cartilage, tendon, or mucosa.

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Movement and Proximity to Defect The type of movement or transfer required to inset a flap provides an additional system of classification. Based on proximity to the defect to be reconstructed, flaps are described as local, regional, or distant. Local flaps are moved into an adjacent defect by a process of advancement, transposition, rotation, and interpolation, or combinations of these basic movements (Table 4.2). TABLE 4.2 Classification of Flaps by Movement Type Flap Movement Rotation

Advancement

Subtypes

Illustration

Rotation

V-Y Bipedicled Keystone

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Transposition

Z-plasty Rhomboid Bilobed

Islandization

Propeller Pedicled

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Regional flaps such as pedicled muscle flaps require larger movements than those seen in local flaps. These often still include rotations (Figure 4.5), advancements (Figure 4.6), and transpositions (Figure 4.7). Distant flaps include tubed flaps and free flaps. Tubed flaps are the oldest known type of flaps, first described in the literature in 1917 by Filatov. 13,14 These involve harvest of a pedicled flap followed by a series of transpositions known as walking. After inset of each transposition, the flap obtains new blood supply from the surrounding tissue by neovascularization and vessel ingrowth. At the subsequent stage, the opposite end is transposed, allowing for movement of the flap and maintenance of blood supply. In this way, the flap is walked or waltzed to its final destination for inset, often necessitating several stages. The advent of free tissue transfer has reduced the use of tubed flaps; however, a distant tubed flap may still play a role in patients who are poor candidates for free tissue transfer.

FIGURE 4.5 Rotation flap. A. Cheek defect after excision of a basal cell cancer with plans for a cheek rotation flap and excision of dog-ear. B. Scars are placed along natural crease lines to maximize cosmesis.

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FIGURE 4.6 V-Y advancement flap. A. Left temple basal cell carcinoma showing planned excision and design of V-Y flap. This type of advancement flap causes minimal distortion to surrounding tissues and replaces like with like. B. Final result includes a well-vascularized flap without alteration of brow position.

FIGURE 4.7 Transposition flap. A. Ulcerated lesion with planed excision and rhomboid flap. B. Transposed flap closes defect while distributing tension along the planes of the donor site.

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Blood Supply A flap can be further classified by the orientation of its blood supply. The pattern of blood supply to cutaneous flaps is generally described as either axial or random. An axial pattern flap has a known or named artery coursing along its longitudinal axis. A random-pattern flap is designed without a known vessel at its core and relies on the random subdermal plexus for perfusion. 15 Random-pattern flaps must generally be limited to a 3:1 length to width ratio to remain viable at the tip. 16,17 Axial pattern flaps can be designed with a longer length to width ratio and may carry a random extension with the same limitations described earlier. Flaps containing muscle or fascia can also be classified further by the type of blood flow that supplies them. The Mathes and Nahai classification of muscle flaps and the Cormack and Lamberty classification of fascial flaps are mentioned above (see Figure 4.4 and Table 4.1). The blood supply of a flap can additionally be classified as either pedicled or free. Pedicled flaps remain attached to a known native vascular pedicle and are limited to the arc of rotation or advancement that these vessels afford. The pedicle can be dissected free from surrounding tissues and the flap islandized for maximizing transfer distance. Conversely, a free flap is one that is raised on a known vascular pedicle that is transected and anastomosed to a new blood supply at the recipient site, largely requiring microsurgical techniques. 18 Free flaps allow for true freedom of tissue transfer. A flap harvested in one location can reconstruct a defect that is distant from it, assuming adequate blood flow exists at the recipient site. Perforator flaps are those based on a perforating artery from a named vessel and include the surrounding 3D area of tissue perfused by that perforator, also known as the perforasome 5,19 (see earlier). Perforating vessels can be thought to travel in a plane perpendicular to that of the skin surface and the axial vessels beneath. Perforators are frequently identified by use of a handheld Doppler on the skin, and one or more perforators can be included in any given flap. Blood flow then arborizes and fills vessels linking one perforasome to the next (see Figure 4.2). Flaps designed around a perforator often also include proximal dissection of the named vessel from which the blood flow originates, and this allows for longer pedicle length or larger caliber of vessels for free tissue transfer. Perforator flaps have become increasingly popular as local flaps for reconstructing both difficult small and larger defects that previously had required a free tissue transfer. The keystone perforator island flap was described by Behan and has been used throughout the body as an island flap designed adjacent to a defect, and typically based on one or more smaller perforators. The flap has the shape of a keystone-like arch that is designed parallel to the defect and is at least as wide as the defect. It extends beyond each end of the defect, completing the archlike design (Figure 4.8). The dissection extends through the skin, subcutaneous tissue, and fascia, thus mobilizing the flap to advance into the defect. The closure borrows tissue from all directions, as each end is repaired as a V-Y advancement. 20

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FIGURE 4.8 Keystone flap. A. Lower extremity lesion with planned excision and keystone flap design. B. Resulting flap redistributes tension as each end is closed in V-Y fashion.

Another local use of a perforator flap is as a propeller flap. This was first described by Hyakusoku et al. in 1991 21 and is based on a single large perforating vascular pedicle close to the defect that is rotated up to 180°. The main perforator is identified with a handheld Doppler and will be the pivot point for flap rotation. Careful measurement and precise flap design to reach the distal end of the defect is mandatory. The perforator can be visualized early in the dissection and the flap design confirmed prior to circumscribing the island flap. It is important to dissect the perforator through the fascia and free up the adventitia so that there is no venous kinking 21,22 (Figure 4.9).

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FIGURE 4.9 Propeller flap. A. Unstable scar in patient undergoing total knee replacement. Perforator marked with red dot is used as center of rotation. B. Flap elevation includes dissection of perforator. C. Rotation and final inset offers excellent coverage of hardware and primary closure of donor site.

Modifications to flap blood flow have resulted in added classifications such as the reverse-flow flap, the venous flap, and the supercharged flap. A reverse-flow flap is one in which the native direction of flow through the main pedicle is reversed at inset. An example is the reverse radial forearm flap, in which the radial artery is transected proximally, and the flap must rely on reverse blood flow in the radial artery across the palmar arch 23 (Figure 4.10). A venous flow-through flap is composed of skin, subcutaneous tissue, and a plexus of veins. It is devoid of arterial tissue within the flap. A linear vein is anastomosed to an artery proximally and a vein distally, allowing for both inflow and outflow. These are generally small flaps and can be prone to congestion and partial necrosis. 24 A supercharged flap is one in which the arterial inflow or venous outflow is augmented by using microsurgical techniques to perform a second anastomosis, bringing in an additional inflow or outflow capabilities. 25

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FIGURE 4.10 Reverse radial forearm flap. A. 70-year-old woman with a left dorsal hand wound after intravenous extravasation injury. B. Reverse radial forearm flap is designed based on retrograde flow across the palmar arch. Note the inclusion of palmaris longus tendon for extensor tendon reconstruction. C. An added layer of antebrachial fascia is utilized to wrap the tendon reconstruction for improved glide. D. Routine inset and healing with primary closure of the donor site.

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Manipulation A discussion of classification of flaps would be incomplete without mention of the different types of flap manipulation that can occur prior to harvest. First, tissue that is desired for a planned flap can undergo tissue expansion. An expanded flap allows for greater reach and coverage and can minimize the donor site defect. 26 Furthermore, the mechanical force of stretching tissues has also been shown to enhance tissue neovascularity, 27 and the accompanying thinning of the flap can be an additional bonus in reconstruction. In situations where there is concern for the ultimate perfusion of the flap, flap delay can be employed. A delayed flap is one in which a preliminary surgical stage is planned to partially raise the flap and divide a portion of the blood supply, delivering a sublethal ischemic insult that stimulates vessel dilation, ischemic preconditioning, and neovascularization. This allows for axialization of blood flow and conditioning of the flap tissues to lower oxygen levels in anticipation of flap transfer at a second stage 28 (Figure 4.11).

FIGURE 4.11 Diagrammatic representation of the same flap raised with and without a surgical delay to illustrate the necrosis line and the changes in the choke vessels between a and b. In B, vessel a has been delayed by a previous operation before raising the flap. Note the dilation of choke vessels and the more distal site of the necrosis line.

The techniques of flap prefabrication and prelamination are other more recent additions to our armamentarium and can greatly expand the functional capacity of the flap. These will be discussed in more detail later in this chapter.

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Flap Design and Application The reconstructive surgeon must be familiar with the full spectrum of reconstructive options and select the flap or method of repair that will give the best outcome. The optimal reconstructive strategy may involve multiple modalities of treatment and/or multiple staged procedures. One must take care not to burn bridges and compromise the final result. The flap options available have increased greatly in recent years, and the focus has shifted from ensuring flap survival to limiting the number of flaps required to close a defect and ultimately to enhanced flap selection and refinements. Refinements are achieved by careful preoperative and intraoperative assessment of the defect, determining the reconstructive requirements, and then selecting the donor tissue that gives the best functional and aesthetic result.

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Assessing the Defect For successful flap reconstruction, an accurate diagnosis of the defect, its underlying causes, and reconstructive requirements is needed. The surgeon should consider what tissues are missing (e.g., skin, functional muscle, bone). Precise measurements of shape and size should be taken, including consideration of the 3D depth of the defect for appropriate contour restoration. Photos, templates, and 3D moulages are of great assistance in defect assessment and should be used liberally 29 (Figure 4.12). Modern image-guided planning, especially in planning bony flaps, is also advantageous and can reduce operative time. 30

FIGURE 4.12 A. A 67-year-old woman had a complex defect of the left orbit with palatal and nasal defect after cancer resection. B. Three-dimensional alginate moulage is used for on-table flap planning. C. Moulage is wrapped with a template to represent flap folding. D. Template is used to create flap outline overlying the deep inferior epigastric vessels on the abdomen. E. Flap elevation including a portion of rectus abdominis for filling of dead space. F. Final inset with complete reconstruction of internal lining and excellent external contour.

One of the most important steps in reconstruction is satisfactory preparation of the defect. The wound bed should be debrided of necrotic material, granulation tissue, and attenuated or scarred tissue. In some cases, quantitative cultures are beneficial to verify the wound is free from infection and bacterial balance has been achieved. 31 In oncologic defects, pathology should ensure clear margins prior to reconstruction. Despite excellent flap selection and harvest technique, inadequate preparation of the wound can lead to flap compromise and reconstructive failure. Patient selection is also a consideration when planning reconstruction. Inherent patient factors such as diabetes, clotting disorders, and poor compliance can hamper flap success. Modifiable factors such as smoking and patient weight should also be contemplated. If risk factors for flap failure are high, a simple

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method of wound closure may be better than complex multistage reconstruction. In free tissue transfer, the presence of recipient vessels must be evaluated. Ideal recipient vessels are in close proximity (either deep or adjacent) to the wound to be reconstructed. The quality of these vessels should be assessed. If the planned recipient vessels appear injured either on preoperative angiogram or during direct inspection intraoperatively, consider use of different vessels. Use of vessels outside the zone of injury during free flap reconstruction leads to increased rates of lower extremity limb salvage. 32 Additionally, recipient vessels should be of adequate caliber to anastomose easily to the flap vessels and provide adequate perfusion. If there are no adequate recipient vessels near the defect, consideration can be given to vein grafts or creation of an AV loop from a regional blood supply source. 33 In the extremities, flow-through flaps should be considered if perfusion of the hand or foot would otherwise be compromised by anastomosis of a flap.

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Selection and Management of the Donor Site The full extent of the reconstructive ladder is contemplated for each wound, preferably from simplest to most complex. Local tissue will often provide better color match and appearance but may be limited depending on the location of the wound. Many local, regional, and distant donor sites are available. Consider the suitability of each donor site to fulfill the goals of reconstruction and the logistics and positioning on the operating table, avoiding positional changes if possible. Attempt to minimize residual donor site deformity.

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Site and Content Selection In selecting the appropriate donor site, first consider the skin surrounding the defect. Color match, texture, thickness, and special characteristics such as hair growth should be taken into account. Design the flap to be slightly larger than the defect for adequate skin coverage. This will help account for the thickness of the flap, avoid tight closure over the vascular pedicle, and facilitate donor site closure. Often significant edema of the flap occurs during the procedure that will make closure tight if some excess tissue is not included in flap design. After assessment of skin requirements, flap thickness and content can be selected. Can adequate thickness be reconstructed with skin and subcutaneous fat? Is muscle bulk needed to fill the defect, or is a functional muscle needed to restore movement? Is bone or cartilage support of the soft tissues necessary? For complex reconstructions of the head and neck, lining may be required in addition to external skin coverage. Mucosal lining can be fashioned from skin, skin graft, mucosa, or raw muscle surface, which will mucosalize with time.

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Pedicle Considerations Once content requirements of the flap have been determined, decisions can be made concerning the pedicle. The surgeon should consider both caliber and length required, especially in the case of free tissue transfer. The caliber should approximate that of the recipient vessels; however, if significant size mismatch exists, end-to-side anastomosis is an option. 34 Concerning pedicle length, the surgeon should consider the ergonomic constraints of microsurgical vessel anastomosis. Free tissue transfer can be made significantly easier with slight slack in the pedicle for creation of a tension-free anastomosis that occurs in an orientation that is comfortable for the operating surgeon’s hands. Appropriate length can be obtained either by initial selection or by dissection proximally on the flap pedicle to its origin.

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Manipulation of Donor Site Tissue Manipulation of donor site tissue at the time of flap transfer is utilized for complex reconstruction to provide a better-tailored flap and minimize donor defects. For a complex wound, two (or more) flaps can be carried on one pedicle. These flaps are known as compound or chimeric flaps. 35 An example is the latissimus dorsi, parascapular, scapular bone, serratus anterior flap, which can be one complex compound flap based on the subscapular vascular system (Figure 4.13).

FIGURE 4.13 Compound chimeric flap to heel defect. A. A young man with a medial foot wound with exposed calcaneus after osteomyelitis. B. Compound flap design using the teres major muscle and fasciocutaneous parascapular flap harvested on the subscapular vascular system. Note the intraoperative use of templates for better planning reconstruction of this threedimensional defect. C. The harvested flap. D. After inset and healing.

Conversely, a very large flap may benefit from a double pedicle. A simple example of this is the bipedicled advancement flap. However, in more complex cases, very large flaps, such as double pedicle TRAM (transverse rectus abdominis myocutaneous) flaps, may be raised and left pedicled, or transferred as a double pedicle free flap if the volume of tissue required exceeds the amount that can be transferred on a single pedicle. 36,37 Flaps can be designed to be folded on themselves to create added bulk or can be employed in reconstruction of a lamellar surface such as the lower lip. In this case, a donor site with a thin subcutaneous layer should be selected. 38 Complex central facial defects often require reconstruction of the multiple external and internal epithelial surfaces. As mentioned earlier, the use of a 3D intraoperative alginate moulage to facilitate flap planning and folding to accurately repair the multiple epithelial defects has been found to be very useful (see Figure 4.12).

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Management of the Donor Site Inherent in flap design is management of residual donor site defects. Commonly the donor site of a flap is repaired primarily, or in cases of undue tension, skin grafted. Attempts should be made to minimize donor site deformity as much as possible. Consider the consequences of scar contracture such as decreased range of motion and pain. When possible, orient incisions within resting skin tension lines. Contour deformity may be considered cosmetic; however, functional issues with hygiene may occur in severe cases. Functional loss from muscle or nerve transfer must be contemplated preoperatively and discussed with the patient. Choose muscle flaps that have redundant function when possible. Revision of donor site deformities should be offered when a functional problem exists and a solution is apparent.

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Staging Reconstruction in Complex Defects Staged reconstructions are often required for complex defects. In such cases, it is important to plan ahead and perform the best possible surgery at each stage, keeping in mind the opportunity cost of additional procedures and time for maturation at each stage. Avoid burning bridges and consider adjunct techniques, including delay, expansion, prelamination, and prefabrication. Delay of a flap involves a preliminary surgical stage to partially raise the flap and divide a portion of the blood supply. This allows for axialization of blood flow and conditioning of the flap tissues to low oxygen levels in anticipation of flap transfer at a second stage. Delay can increase survival of a larger surface area on a given pedicle. 28 As discussed previously, tissue expansion of the donor flap provides more tissue and a thinner flap and alleviates tension at the donor site, resulting in easier closure and improved scarring. Prefabrication of a flap involves transferring a vascular pedicle into a desired block of tissue, then waiting 8 weeks for spontaneous neovascularization, thus creating a new vascular territory not previously found in nature. 39 After maturation, the neovascularized tissue is transferred based on the implanted pedicle. This technique has been used to provide thin axial flaps and to transfer tissue with enhanced color and texture match (Figure 4.14).

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FIGURE 4.14 Flap prefabrication. A. A 40-year-old man with hypertrophic burn scar contracture of the anterior neck. B. To avoid areas of scarring on the thigh, a prefabricated flap is designed on the anteriomedial thigh using the descending branch of the lateral femoral circumflex vessels. C. Vessels are transposed to the desired area; a tissue expander is also placed to expand the new flap. D. After expansion and neovascularization of the tissue around the new pedicle. E. Flap inset. F. After flap debulking the patient is left with a thin, pliable flap, excellent color match, functional improvement, and minimal scarring.

The technique of prelamination involves implantation of tissue (usually bone or cartilage) or an alloplastic device into a vascular territory prior to transfer. It has been used mainly for reconstruction of complex defects in the central third of the face. 40

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Options in Case of Flap Compromise Despite the surgeon’s best efforts, some flaps will inevitably experience decreased arterial perfusion or venous congestion after elevation and inset. In pedicled or free flaps, inadequate arterial flow is usually recognized early and may be the result of poor flap design or pedicle kinking. In a free flap, the arterial insufficiency represents thrombosis of the new anastomosis until proven otherwise. These cases require revision on the table or urgent return to the operating room to revise the anastomosis. Venous insufficiency of a flap is more common and the onset more insidious than that of arterial insufficiency. This phenomenon is multifactorial. In elevating a flap, longitudinal venous channels in the flap are disconnected. Additionally, the low pressure in the venous system is more vulnerable to extrinsic pressure because of compression from inset and flap edema. Numerous methods have been described to improve flap survival in the case of venous congestion. First, the surgeon should attempt to release insetting sutures causing tension or kinking. The flap may be pricked with a needle serially to reduce the venous burden. Deepithelialization of a portion of the flap, or removal of the nail plate in the case of a digit, with periodic application of heparin solution may increase venous outflow. Use of Hirudo medicinalis or medicinal leeches can ensure ongoing flap outflow until venous microanastomoses form. Finally, augmenting outflow by cannulation of a vein with an angiocatheter and periodically draining the flap may be useful. 41

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Conclusion Flaps are the mainstay of reconstructive surgery. In the words of Gillies, always consider “blood supply before beauty.” 1 Remember to maintain adequate flap vascularity and plan for secondary revision to improve contour and appearance. When performing staged reconstructions for complex defects, plan ahead and do not burn bridges.

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Questions 1. A 62-year-old man with squamous cell cancer of the ear is treated with total auriculectomy including burring of the mastoid bone. Flap reconstruction to close the wound is planned with a pedicled supraclavicular flap. The blood supply to the supraclavicular flap is considered which of the following? a. Random b. Free c. Reverse flow d. Axial e. Perforator 2. A 45-year-old woman with recurrent breast cancer undergoes mastectomy and free deep inferior epigastric artery perforator flap. Routine anastomoses of one artery and one vein are completed, and the flap is inset. On the table, the flap appears congested. Insetting sutures are released with no improvement. The arterial and venous anastomoses are visualized and noted to be patent. What is the next best step to resolve the congestion? a. Anastomose the superficial inferior epigastric vein (SIEV). b. Revise the venous anastomosis. c. Start leech therapy. d. Administer systemic TPA. e. Revise the arterial anastomosis. 3. A 70-year-old man is involved in a motor vehicle collision. A large portion of his scalp was avulsed and could not be salvaged. After multiple debridements, the resultant defect comprises 70% of the scalp with exposed calvarium at the base. Reconstruction is best achieved with which of the following? a. Split-thickness skin graft b. Free omental flap with split-thickness skin graft c. Wet-to-dry dressing changes with healing by secondary intention d. Tissue expansion with staged advancement of flaps e. Scalp flap with skin graft to the donor defect 4. A 13-year-old girl is diagnosed with rhabdomyosarcoma of the left orbit and face. Orbital exenteration and radical en bloc resection including bone is planned followed by chemotherapy and radiation. Which of the following best reconstructs the resulting 3D defect? a. Dermal substitute b. Skin graft c. Local advancement flap including skin and subcutaneous fat d. Free anterolateral thigh (ALT) flap including skin, subcutaneous fat, and fascia e. Free ALT flap including skin, subcutaneous fat, fascia, and vastus lateralis muscle 5. A 65-year-old man is evaluated for reconstruction of a chronic wound to the lateral malleolus. Because of medical comorbidities, he is a poor candidate for free tissue transfer. Reverse sural flap is planned. On the evening of postoperative day zero, the patient has mild hypotension, and the flap is noted to be dark and congested distal to a line of tension created by insetting sutures. What is the next best step? a. Apply moisturizer cream to the affected area. b. Release insetting sutures at area of maximum tension. c. Administer a fluid bolus.

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d. Elevate extremity. e. Observe and reassure that this will likely improve with time. 6. An otherwise fit 30-year-old man, following a compound fracture of the distal third of the tibia, previously treated by the orthopedist with open reduction and internal fixation, presents with a small open wound breakdown (4 × 3 cm) with exposed hardware. He has good pulses. After further debridement and removal of hardware and application of an external fixator, the soft tissue defect is repaired with a local propeller perforator flap, based on a posterior tibial artery perforator. During flap dissection and inset, the flap becomes progressively more congested along its entire length. Which of the following is the most appropriate next step in management? a. Observation b. Application of nitropaste c. Postoperative leech therapy d. Proximal perforator dissection to source vessel e. Free flap salvage 1. Answer: d. The supraclavicular flap is an axial flap based on axial blood flow through the supraclavicular artery. 42 It is not considered a random flap, although random-pattern extensions can be added to the distal aspect. 43 Blood flow in the supraclavicular artery is antegrade and not considered a reverse-flow flap. As the flap is based on a named axial vessel, it is not a perforator flap. A supraclavicular flap is typically left pedicled and rotated to fill defects of the head and neck. It is particularly useful in patients who are not good candidates for free flaps. In this question, a pedicled flap is desired and therefore the tissue is not harvested as a free flap. 2. Answer: a. In this case, the best course of action is to locate the SIEV at the edge of the flap and create a second venous anastomosis, thereby supercharging venous outflow. 44,45 Some surgeons routinely preserve the SIEV during dissection in case of need for added venous drainage. Revision of the existing venous and arterial anastomoses would likely provide no benefit if each is already a visibly patent anastomosis, as mentioned in the question stem. Leech therapy is useful in smaller, thin flaps; however, in this bulky high-flow flap, the small amount of venous outflow leech therapy provides would be negligible. Systemic use of tissue plasminogen activator would not improve venous outflow and could increase the risk of hemorrhagic complications. 3. Answer: b. The omental free flap is an excellent option in large defects of the calvarium and can be easily skin grafted for ultimate coverage. A skin graft alone would be inadequate coverage for exposed bone as graft take would be limited because of a poorly vascularized wound bed. Wet-to-dry dressing changes may be considered as a temporizing measure to help debride devitalized tissue and prepare the wound for coverage; secondary intention healing would progress very slowly and leave the patient at risk for infection and desiccation of bone. Tissue expansion is an appropriate option for defects comprising up to 50% of the hair-bearing scalp, but would be insufficient for a 70% defect. A scalp flap with skin grafting of the donor defect is also not appropriate for near total scalp loss. 46 4. Answer: e. Three-dimensional contour deformities are best reconstructed using a flap that contains muscle, which can conform to the defect and fill dead space. The same flap without muscle would not be the best option. 47 A skin graft would likely not vascularize over exposed bone. Dermal substitutes would likewise be unsatisfactory coverage in this complex defect. Local flaps may play a role in coverage of a large wound; however, insufficient local tissue exists to fill a defect this large and would likely lead to unsightly scarring and additional deformity. 5. Answer: b. The flap described is likely suffering from impaired venous outflow distal to the area of tension. Release of insetting sutures in this area will likely improve outflow at this site. 41 Moisturizing cream is unlikely to improve venous outflow. Mild hypotension postoperatively is not ideal for flap survival and would be more likely to impair arterial inflow. Augmentation of blood

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pressure with a fluid bolus would not reliably improve venous outflow. Elevation of the extremity may decrease flap edema and offer some mild improvement in venous outflow but would not solve the issue of a specific line of tension across the flap. Observation is incorrect, as the congestion will likely progress if left unrevised. 6. Answer: d. Propeller flaps, which are single perforator flaps, are being used more commonly in reconstruction of small defects that had previously been treated with free flaps. However, proper dissection of the pedicle is mandatory in this type of flap which usually has to rotate 180°. The most common complication associated with propeller flap dissection is venous congestion. This is usually due to impaired venous outflow through the very thin and fragile comitant veins running with the perforating artery. This is more likely to happen if there is a bulky pedicle due to additional soft tissue and fascia, which makes kinking of these small veins more likely when the flap and pedicle is twisted 180°. The best way to minimize this is to fully dissect the pedicle and free it from surrounding soft tissue and fascia. 48,49 If venous congestion persists, this suggests injury to the draining veins; the flap can be returned to its initial position, and venous leeching from a distended vein within the flap may be used to salvage the flap. This is much more effective than topical leech therapy. Nitropaste therapy is not effective with venous congestion. Traditionally, free flap salvage was the preferred choice of treatment for distal third leg defects and may be required should the perforator flap fail, but one should try to salvage the problem at hand before proceeding to another method of repair.

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References Gillies, H, Millard, D. The Principles and Art of Plastic Surgery. Boston: Little and Brown; 1957. Daniel, RK, Kerrigan, CL. Skin flaps: an anatomical and hemodynamic approach. Clin Plast Surg. 1979;6(2):181-200. Taylor, GI, Palmer, JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40(2):113-141. Taylor, GI, Corlett, RJ, Ashton, MW. The functional angiosome: clinical implications of the anatomical concept. Plast Reconstr Surg. 2017;140(4):721-733.The authors review data from experimental work of other researchers on vascular imaging of skin flaps in various animal models. The study then used a rabbit model to focus on the role of anastomotic vessels between angiosome territories in tissue perfusion. Using fluorescein infusion, rabbit perforator flaps showed conversion of choke vessels to true anastomoses by 7 days, allowing distal territory survival in 95% of flaps. This highlights the dynamic, functional nature of anastomotic vessels as they can control flow between territories. The functional angiosome is thereby defined as the volume of tissue that clinically can be isolated on a source vessel. The area extends beyond its anatomical territory to capture an adjacent territory if connections are by choke anastomoses, or more if they are by true anastomoses. Saint-Cyr, M, Wong, C, Schaverien, M, et al. The perforasome theory: vascular anatomy and clinical implications. Plast Reconstr Surg. 2009;124(5):1529-1544. Converse, JM. Introduction to Plastic Surgery. Reconstructive Plastic Surgery. 2nd ed, vol. 1. Philadelphia, PA: WB Saunders; 1977:3-68. Cormack, GC, Lamberty, BG. Fasciocutaneous vessels. Their distribution on the trunk and limbs, and their clinical application in tissue transfer. Anat Clin. 1984;6(2):121-131. Cormack, GC, Lamberty, BG. A classification of fascio-cutaneous flaps according to their patterns of vascularisation. Br J Plast Surg. 1984;37(1):80-87. Mathes, SJ, Nahai, F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-187.The authors summarize data from previous studies involving vascular injections of latex solutions into muscle of cadavers. They determine the pattern of blood supply to each muscle establishes the extent of safe transposition and usefulness in reconstruction. A classification system is suggested based on the blood supply of each muscle. This classification of vascular anatomy is shown clinically to predict arcs of rotation and ultimate muscle flap survival after elevation. Cho, EH, Shammas, RL, Carney, MJ, et al. Muscle versus fasciocutaneous free flaps in lower extremity traumatic reconstruction: a multicenter outcomes analysis. Plast Reconstr Surg. 2018;141(1):191-199. McLean, DH, Buncke, HJ. Autotransplant of omentum to a large scalp defect, with microsurgical revascularization. Plast Reconstr Surg. 1972;49(3):268-274. Moradi, P, Glass, GE, Atherton, DD, et al. Reconstruction of pharyngolaryngectomy defects using the jejunal free flap: a 10-year experience from a single reconstructive center. Plast Reconstr Surg. 2010;126(6):1960-1966. Filatov, V. Plastic procedure using a round pedicle. McDowell F, trans. Vestnik Oftalmol. 1917;34:149-158. Gillies, H. The tubed pedicle in plastic surgery. N Y Med J. 1920;111:1. Stell, PM. The viability of skin flaps. Ann R Coll Surg Engl. 1977;59(3):236-241. Milton, SH. Pedicled skin-flaps: the fallacy of the length : width ratio. Br J Surg. 1969;56(5):381. McGregor, IA, Morgan, G. Axial and random pattern flaps. Br J Plast Surg. 1973;26(3):202-213. Taylor, GI, Daniel, RK. The free flap: composite tissue transfer by vascular anastomosis. Aust N Z J Surg. 1973;43(1):1-3. Morris, SF, Tang, M, Almutari, K, Geddes, C, Yang, D. The anatomic basis of perforator flaps. Clin Plast Surg. 2010;37(4):553-570, xi. Behan, FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73(3):112-120. Hyakusoku, H, Yamamoto, T, Fumiiri, M. The propeller flap method. Br J Plast Surg. 1991;44(1):53-54. Teo, TC. The propeller flap concept. Clin Plast Surg. 2010;37(4):615-626, vi. Timmons, MJ. The vascular basis of the radial forearm flap. Plast Reconstr Surg. 1986;77(1):80-92. Fukui, A, Inada, Y, Maeda, M, et al. Venous flap: its classification and clinical applications. Microsurgery. 1994;15(8):571-578. Tan, O, Atik, B, Bekerecioglu, M. Supercharged reverse-flow sural flap: a new modification increasing the reliability of the flap. Microsurgery. 2005;25(1):36-43. Zhou, XT. Effects of tissue expansion on the ratio of length to width of random-pattern skin flaps. Zhonghua Wai Ke Za Zhi. 1989;27(7):417418, 445. Leighton, WD, Russell, RC, Feller, AM, et al. Experimental pretransfer expansion of free-flap donor sites: II. Physiology, histology, and clinical correlation. Plast Reconstr Surg. 1988;82(1):76-87.The authors endeavor to evaluate the changes in blood flow and tissue histology that occur with tissue expansion. Using pig models, flaps are designed, expanded, and elevated. Blood flow and angiography were recorded and tissue samples were examined and compared with a nonexpanded control site. The authors found the vascular trees within flaps enlarge following expansion, and pronounced neovascularization is seen in the papillary dermis and capsular layers. There is thinning of all the tissue layers except for the epidermis. Successful clinical application of these principles in humans is depicted. Taylor, GI, Corlett, RJ, Caddy, CM, Zelt, RG. An anatomic review of the delay phenomenon: II. Clinical applications. Plast Reconstr Surg. 1992;89(3):408-416. Kane, WJ, Olsen, KD. Enhanced bone graft contouring for mandibular reconstruction using intraoperatively fashioned templates. Ann Plast Surg. 1996;37(1):30-33.

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Toto, JM, Chang, EI, Agag, R, et al. Improved operative efficiency of free fibula flap mandible reconstruction with patient-specific, computerguided preoperative planning. Head Neck. 2015;37(11):1660-1664. Breidenbach, WC, Trager, S. Quantitative culture technique and infection in complex wounds of the extremities closed with free flaps. Plast Reconstr Surg. 1995;95(5):860-865. Stranix, JT, Lee, ZH, Jacoby, A, et al. Not all Gustilo type IIIB fractures are created equal: arterial injury impacts limb salvage outcomes. Plast Reconstr Surg. 2017;140(5):1033-1041. Atiyeh, BS, Sfeir, RE, Hussein, MM, Husami, T. Preliminary arteriovenous fistula for free-flap reconstruction in the diabetic foot. Plast Reconstr Surg. 1995;95(6):1062-1069. Ikuta, Y, Watari, S, Kawamura, K, et al. Free flap transfers by end-to-side arterial anastomosis. Br J Plast Surg. 1975;28(1):1-7. Hallock, GG. Simultaneous transposition of anterior thigh muscle and fascia flaps: an introduction to the chimera flap principle. Ann Plast Surg. 1991;27(2):126-131.The authors endeavor to differentiate a chimeric flap from the previously described compound or composite flaps. A chimeric flap is defined as a flap in which more than one tissue type is linked together, but tissue components may be independently maneuvered while remaining attached by a common regional source vessel. They describe specific surgical dissection technique of the ALT and rectus femoris muscle chimeric flap and offer a case report of a patient treated with this method. Wagner, DS, Michelow, BJ, Hartrampf, CR Jr. Double-pedicle TRAM flap for unilateral breast reconstruction. Plast Reconstr Surg. 1991;88(6):987-997. Agarwal, JP, Gottlieb, LJ. Double pedicle deep inferior epigastric perforator/muscle-sparing TRAM flaps for unilateral breast reconstruction. Ann Plast Surg. 2007;58(4):359-363. Jeng, SF, Kuo, YR, Wei, FC, et al. Total lower lip reconstruction with a composite radial forearm-palmaris longus tendon flap: a clinical series. Plast Reconstr Surg. 2004;113(1):19-23. Khouri, RK, Upton, J, Shaw, WW. Prefabrication of composite free flaps through staged microvascular transfer: an experimental and clinical study. Plast Reconstr Surg. 1991;87(1):108-115. Pribaz, JJ, Fine, NA. Prelamination: defining the prefabricated flap : a case report and review. Microsurgery. 1994;15(9):618-623. Talbot, SG, Pribaz, JJ. First aid for failing flaps. J Reconstr Microsurg. 2010;26(8):513-515.The authors present a descriptive article on the possible etiologies of arterial and venous insufficiency in flaps. Based on their experience and expertise, they highlight surgical techniques that can prevent blood flow compromise before it occurs. Citing other studies, they propose an algorithm for assessing and treating a flap that is experiencing venous insufficiency or congestion. Pallua, N, Machens, HG, Rennekampff, O, et al The fasciocutaneous supraclavicular artery island flap for releasing postburn mentosternal contractures. Plast Reconstr Surg. 1997;99(7):1878-1884; discussion 1885-1876. Ross, RJ, Baillieu, CE, Shayan, R, Leung, M, Ashton, MW. The anatomical basis for improving the reliability of the supraclavicular flap. J Plast Reconstr Aesthet Surg. 2014;67(2):198-204. Vijayasekaran, A, Mohan, AT, Zhu, L, et al. Anastomosis of the superficial inferior epigastric vein to the internal mammary vein to augment deep inferior artery perforator flaps. Clin Plast Surg. 2017;44(2):361-369. Lee, KT, Mun, GH. Benefits of superdrainage using SIEV in DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery. 2017;37(1):75-83. Leedy, JE, Janis, JE, Rohrich, RJ. Reconstruction of acquired scalp defects: an algorithmic approach. Plast Reconstr Surg. 2005;116(4):54e-72e. Simsek, T, Engin, MS, Yildirim, K, et al. Reconstruction of extensive orbital exenteration defects using an anterolateral thigh/vastus lateralis chimeric flap. J Craniofac Surg. 2017;28(3):638-642. D’Arpa, S, Cordova, A, Pignatti, M, Moschella, F. Freestyle pedicled perforator flaps: safety, prevention of complications, and management based on 85 consecutive cases. Plast Reconstr Surg. 2011;128(4):892-906. Maciel-Miranda, A, Morris, SF, Hallock, GG. Local flaps, including pedicled perforator flaps: anatomy, technique, and applications. Plast Reconstr Surg. 2013;131(6):896e-911e.

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CHAPTER 5

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Principles of Microsurgery Sarah E. Sasor and Kevin C. Chung

Key Points Microsurgical techniques are used to repair blood vessels, nerves, and lymphatics; applications include free tissue transfer, nerve repair, replantation, and transplantation. Surgical precision is the key factor in anastomotic patency. There is no difference in patency rate based on suture technique (simple interrupted versus continuous) or anastomotic technique (end-to-end versus end-to-side). Routine use of antithrombotic agents in the postoperative period is optional. Thrombosis is most common within 24 hours of surgery. Early failure is often related to anastomotic imperfections or pedicle positioning. If a problem is detected early, the flap can be salvaged by exploration and revision of the anastomosis. Microsurgery is a discipline that requires magnification, precision instruments, and specialized surgical techniques. Magnification, using surgical loupes or an operating microscope, makes it possible to repair tiny, delicate structures that exceed the limits of normal human eyesight. Microsurgical techniques are used to repair blood vessels, nerves, and lymphatics; transplant tissue from one area of the body to another; and reattach amputated parts.

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History The origin of microsurgery can be traced back to the late 1890s when surgeons began repairing blood vessels both in laboratory animals and humans without the use of magnification. The first successful endto-end anastomosis was performed on the carotid artery of a sheep in 1889 by Jassinowski. 1 In 1902, Carrel described the triangulation method of anastomosis that is still routinely used today. 2 The following year, Höpfner performed the first experimental extremity replantation on a canine hind limb. 3 The introduction of the operating microscope in Sweden by Nylen 4 and Holmgren 5 in the early 1920s revolutionized the field of microsurgery; it was used successfully in ear and eye procedures in centers throughout Europe. Fine surgical instruments specifically designed for use under magnification were adapted from those used by watchmakers and jewelers. The development of fine sutures swaged on suitably fine needles followed thereafter. Jacobson and Suarez are credited with the first successful microsurgical anastomosis using an operating microscope on a canine carotid artery in 1960. 6 They encountered significant difficulty while attempting the procedure with the unaided eye, and after trying multiple forms of magnification, were successful with a microscope previously used in otology. Throughout the 1960s, Buncke experimented with replantation and transplantation in laboratory animals. In 1966, he performed rabbit ear replantation with the anastomosis of vessels approximately 1 mm in diameter. Buncke developed many important principles and techniques and is often called the founding father of microsurgery. 7 Technological improvements such as coaxial illumination, motorized and optical zoom, binocular viewing, and independent focus controls made small anastomoses more reliable. With flap failure rates less than 2%, 8 microsurgical techniques are now used with confidence.

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Basic Science Concepts in Microsurgery To optimize outcomes, microsurgeons must understand the basic mechanisms of vessel injury and regeneration, the clotting mechanism, and how tissues respond to ischemia and reperfusion.

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Vessel Injury and Regeneration Microvascular anastomoses disrupt all three layers of a vessel wall. Exposure of subendothelial collagen to the bloodstream results in platelet aggregation and the formation of thrombotic plugs. Full-thickness sutures provide intimal continuity at the anastomosis site and result in the highest rates of patency. 9 Soon after anastomosis, a layer of platelets adhere to the denuded endothelium at the suture line— provided there is no exposed media or extensive vessel damage, fibrin deposition and thrombosis will not occur. Platelets gradually dissipate over the next 24 to 72 hours. As the vessel wall heals, a pseudointima forms. Dissipation of platelets in the vessel lumen and formation of the pseudointima correlates clinically with the critical period of thrombus formation within the first 3 to 5 days. 10

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Clotting Mechanism Platelet adherence and aggregation is the first step in thrombus formation. Platelets do not adhere to undamaged endothelium; however, collagen within the subendothelium is highly thrombogenic. If the intima is damaged, exposed collagen within the media triggers platelet adhesion to the vessel wall. Platelets contain alpha and dense granules that secrete von Willebrand factor, fibrinogen, ADP (adenosine diphosphate), calcium, and serotonin. Together, these factors promote the recruitment and adherence of additional platelets through the formation of proteinaceous bridges. Activated platelets stimulate the conversion of fibrinogen to fibrin to strengthen the growing clot. Eventually, a critical mass is reached, resulting in thrombus formation by either occlusion of the vessel lumen or activation of the extrinsic pathway of coagulation. 11 Antithrombotic drugs intervene at various steps in the clotting cascade with the aim to reduce platelet aggregation and clot formation. Heparin increases antithrombin-3 activity, which inactivates thrombin. Aspirin causes irreversible inactivation of cyclooxygenase (COX) and, subsequently, blocks the formation of thromboxane A2. Dextran decreases red blood cell aggregation through both antiplatelet and antifibrin effects; its exact mechanism of action is unknown. Despite widespread use, evidence on the benefit of antithrombotics in microsurgery is equivocal. 12 Dextran has been shown to have no effect on flap survival but a 3.9- to 7.2-fold increase in systemic complications including renal failure, pulmonary edema, and congestive heart failure. 13 Heparin and aspirin continue to be commonly used.

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Tissue Response to Ischemia and Hypoxia Free tissue transfer requires a period of flap ischemia while the vascular anastomosis is performed. The main mechanism of ischemic injury is hypoxia, which leads to anaerobic glycolysis. Cellular acidosis is particularly severe because the absence of blood flow results in the accumulation of local metabolic byproducts (lactic acid). Coagulative necrosis will ensue if ischemia is not promptly reversed. Tissues have varying levels of tolerance to ischemia based on their composition and metabolic requirements. Skin and subcutaneous tissue remain viable for approximately 24 hours. 14 Muscle is less tolerant; irreversible damage to the microcirculation occurs at approximately 6 hours without blood flow. 15 Connective tissue has very low metabolic requirements and can withstand prolonged periods of hypoxia. 16 Cooling prolongs tolerance to ischemia for all types of tissues. 17 Restoration of blood flow to ischemic tissues may cause additional damage owing to the production of free radicals and reactive oxygen species. The localized inflammatory response leads to leakage of intravascular fluid into the interstitial space and cellular swelling. Despite excellent anastomotic technique, it may be difficult or impossible to restore flow in flaps subjected to prolonged ischemia. Brisk inflow immediately after the anastomosis is followed by a sharp decline in flow rate shortly thereafter. The low flow state triggers intravascular thrombosis and flap ischemia. The process is termed the noreflow phenomenon. 18

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Technical Factors Many variables contribute to the success of a microvascular anastomosis: patient selection, operative planning, and technical setup, including magnification, instrumentation, and exposure. Meticulous technique and surgeon experience play the greatest role in success.

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Equipment Instrumentation Basic microsurgical instruments include jeweler’s forceps, smooth-tipped dilating forceps, micro needle drivers, straight and curved microscissors, and single and double microvascular clamps. Instruments should be of the highest quality—glare-free, nonmagnetic, and ergonomic. Heparinized saline irrigation should be available in a 3 mL syringe with a 26-gauge angiocatheter tip. A microsurgical background of contrasting color (yellow, blue, or green) provides improved visualization. Additional necessary instruments include bipolar electrocautery, micro clips and appliers, suction, and a sterile Doppler ultrasound (Figure 5.1).

FIGURE 5.1 Microinstrumentation.

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Magnification Magnification in the form of surgical loupes or an operating microscope is required for microsurgical anastomoses; the choice depends on the clinical scenario, availability of equipment, and individual surgeon preference. The operating microscope provides wide-field, adjustable magnification with excellent depth perception. A halogen or xenon light source projects bright, even light throughout the field, and cool fiber optic systems prevent tissue desiccation. Beam-splitting devices and multiple eyepieces allow surgeons to operate together with the same, full stereoscopic view. Video capability enables the operative field to be displayed on a large monitor, which is helpful for the scrub team. Magnification ranges from 6× to 40×. Low magnification (6–12×) may be used for vessel preparation and suture tying; medium magnification (10–15×) is used for suture placement; and high magnification (>15×) is helpful in performing smallcaliber anastomosis and for careful inspection at the completion of the procedure. Surgical loupes range from 2 to 8× magnification and are available in expanded viewing field options. Generally, 3.5× or higher magnification is recommended for microsurgery. Loupes offer an ergonomic advantage when the anastomosis is performed in a deep cavity or at an odd angle. Loupes-only microsurgery reduces operative time (microscope setup is eliminated), 19 provides an opportunity to perform microsurgery when a scope is not available, and results in equally high patency rates in vessels over 1 mm diameter. 20,21

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Suture Nonabsorbable, monofilament suture (prolene or nylon) is used to perform anastomoses. Suture size depends on vessel caliber and typically ranges from 8-0 to 11-0. Microneedles are 50 to 130 µm in diameter with a sharp, tapered tip to pierce the tissue and a flat body to improve stability when held in the needle driver.

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Automatic Suturing Devices Anastomotic couplers are commonly used to simplify and expedite end-to-end venous anastomoses. Patency rates are equivalent to hand-sewn anastomoses. 22 After matching the bushel size to the vessel diameter, vessel ends are passed through a polyethylene ring, everted, and evenly secured on pins. Once both donor and recipient vessels are prepared, the coupling device is used to approximate the vessel ends and the rings are held together by interdigitating pins. The result is an automated anastomosis that is stented open by a soft, plastic ring (Figure 5.2). This technique provides flexibility in tailoring the anastomosis when vessel size mismatch is present by differential placement of the everted vessel wall on the pins. Coupling devices may also be used on soft-walled arteries over 1 mm in diameter 23 but should not be used on irradiated vessels.

FIGURE 5.2 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. Copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center.

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Preoperative Planning A multitude of flap options are available to the skilled microsurgeon. Donor site choice is dependent on the size, location, and type of defect; the availability of recipient vessels; and functional needs of the patient. Donor site morbidity should be considered and minimized. Preoperative angiography (traditional or image-based) is sometimes required at the defect or donor site; it is particularly helpful when physical examination findings are abnormal or if diseased or injured vessels are suspected. When microsurgical reconstruction is needed for traumatic or infected wounds, adequate debridement of the recipient site is required. Ideally, patients should be medically and nutritionally optimized prior to free tissue transfer.

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Patient Considerations It is essential to consider the patient’s general state of health and mindset when considering microsurgical options. Patients must be fit enough to tolerate prolonged general anesthetic and willing to participate in the lengthy recovery process. Active comorbidities, such as diabetes mellitus (DM), obesity, and nicotine use, should be documented and optimized. Age alone is not a contraindication for microsurgical reconstruction. Studies show that microsurgery can be safely performed in children 24 and elderly patients 25 without an increase in flap failure or surgical complications. Macrovascular and microvascular diseases are known sequelae of diabetes; however, it is controversial as to whether DM affects free flap outcomes. Animal models show poor intimal healing at the anastomotic site and reduced venous patency, 26–28 but clinical studies show no difference in the rate of flap failure. 29 Strict perioperative glycemic control reduces overall surgical complications in diabetic patients. Obesity is a known risk factor for flap and donor site complications. Free flaps in obese patients are twice as likely to fail 30 ; however, the overall rate of flap failure is still very low, 31 especially when compared with nonmicrosurgical alternatives (i.e., implant-based breast reconstruction). 32 The risks of seroma, delayed wound healing, and mastectomy flap necrosis increase in obese patients. 30,33 Patients should be advised to quit smoking at least 4 weeks before surgery to reduce perioperative complications. 34 Smoking impairs oxygenation, causes vasoconstriction, and introduces free radicals. 35,36 Studies indicate that smoking does not reduce anastomotic patency but does affect wound healing, skin graft take over flaps, infection risk, flap necrosis, hernia formation, and length of hospital stay. 33,36,37

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Microsurgical Techniques Surgical precision is the key factor in anastomotic patency. Ergonomic setup is the first step to success. The surgeon should be seated or standing in a comfortable position with the shoulders and neck relaxed and the forearms and wrists adequately supported. Ideally, the surgeon should position his or her body parallel to the long axis of the vessel to allow for ergonomic intubation of the vessel lumen and forehand suture placement. Wide surgical exposure is important; it may be necessary to extend the incision, further mobilize recipient vessels, or reposition retractors to avoid operating in a hole. Recipient vessels are prepared prior to division of the flap pedicle to minimize ischemia time. Adventitia and periadventitial tissue is sharply excised to prevent it from becoming interposed between the donor and recipient vessels, which is highly thrombogenic (Figure 5.3). Side branches are sealed with bipolar electrocautery or micro clips. The vessels are then clamped, divided, and irrigated with heparinized saline to remove intraluminal clot.

FIGURE 5.3 Donor and recipient vessel preparation. The excess adventitial tissue near the cut edge of the vessel is removed with dissecting scissors to prevent intrusion into the lumen during the anastomosis. Care is taken to avoid excessive thinning, which can result in vessel tears during the placement of sutures. Copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center.

The flap pedicle is likewise prepared and divided. Immediately after division, the flap is flushed through with heparinized saline and transferred to the recipient site. It is positioned and secured in close

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proximity to the defect, paying careful attention to the pedicle to ensure that it is not twisted, kinked, compressed, or under tension. Both donor and recipient arteries are dilated by inserting smooth-tipped forceps into the lumen. Repeated dilation is avoided, as it weakens the vessel wall and causes vasospasm. A forward-flow test is performed by releasing the clamp on the recipient artery to check inflow. This is often done in replantation when vasospasm in injured vessels leads to the loss of the spurt sign in which the blood flows intensely from the cut end of the vessel. The clamp is then replaced and the vessel end is irrigated with heparinized saline. A double-opposing clamp is applied to approximate the donor and recipient vessels. Vessels should be positioned for tension-free, intima-to-intima apposition (Figure 5.4). Vascular grafts may be necessary if a tension-free anastomosis cannot be achieved.

FIGURE 5.4 Use of double-approximating microvascular clamps. The donor and recipient vessels are placed within the clamps, and the vessel ends are approximated along the direction of the arrows. This technique maintains the correct orientation of the vessels and facilitates suture placement. After the anterior suture line is complete, the clamps are turned over to allow access to the posterior suture line. Copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center.

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Never start the anastomosis until you are satisfied with the setup.

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Anastomotic Technique Variations on technique exist. Recent literature suggests no difference in patency rate based on suture technique (simple interrupted versus continuous) 38 or anastomotic technique (end-to-end versus end-toside). 39 Surgeon preference and clinical scenario prevail. Interrupted sutures are preferred when there is significant vessel size discrepancy. Continuous sutures require less knot tying and are more time efficient. Continuous sutures have the added advantage of equally distributing tension along the suture line, providing less opportunity for leakage. In practice, interrupted sutures are commonly used for arterial anastomoses and continuous sutures for venous anastomoses. End-to-end anastomosis is appropriate for most arterial and venous anastomoses. End-to-side anastomosis may be necessary in limb reconstruction to maintain distal perfusion, or when significant size mismatch exists (Figure 5.5). End-to-side anastomoses are technically more difficult, evidenced by longer mean ischemia times. 40

FIGURE 5.5 End-to-side anastomosis using continuous (running) sutures. An elliptical opening is created on the recipient vessel wall, and the end of the donor vessel is anastomosed to this opening. The end-to-side technique maintains distal flow in the recipient vessel and is frequently performed when there is a donor and recipient vessel diameter mismatch. Copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center.

Regardless of the anastomotic technique used, the following technical principles are critical:

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The needle should be held halfway along its length. The most difficult sutures should be placed first. Suture must enter the vessel perpendicular to the vessel wall and include all three layers of the wall (Figure 5.6). The distance from the cut end of the vessel to the needle entry point should be slightly greater than the thickness of the vessel wall. The tip of the needle should be visualized at all times within the vessel lumen. Bisecting or trisecting sutures should be used for orientation (Figure 5.7). Sutures should be placed equidistant from each other. Between sutures, the needle should be placed within the visual field of the microscope to facilitate retrieval for the next stitch. The suture should not be tied if there is any concern that it has caught the back wall.

FIGURE 5.6 Forceps countertraction 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 countertraction 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 countertraction on the adventitial surface of the vessel to facilitate needle penetration. Copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center.

FIGURE 5.7 Orientation sutures. A. Bisecting interrupted sutures are placed 180° apart, dividing the vessel circumference into

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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. Copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center.

Throughout the procedure and prior to placement of the last suture, the vessel lumen is irrigated with heparinized saline. After completion of the both arterial and venous anastomoses, clamps are removed. Venous clamps are removed first to restore outflow. The distal arterial clamp is then removed, backflow is checked, and leaks are repaired. The proximal arterial clamp is removed last. At this point, vessel handling should be limited. Topical lidocaine or papaverine and warm saline are applied to reduce spasm. If bleeding occurs near the anastomotic site, the vessels are inspected for unligated side branches, a second outflow vein from the flap, and leakage from the anastomosis itself. After 3 to 5 minutes, the anastomoses are examined for patency. The artery should be pulsatile distal to the anastomosis. Patent veins appear full and maroon in color. The flap is inspected for return of color and bleeding from the edges. If doubt exists, a patency test (Figure 5.8) is performed as follows: 1. 2. 3. 4.

Jeweler’s forceps are used to gently occlude the vessel distal to the anastomosis. A second pair of jeweler’s forceps is used to empty blood for several millimeters downstream. The proximal forceps is then released while maintaining distal compression. If patent, the empty segment fills with blood.

FIGURE 5.8 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. Copyright held by, and used with permission of, The University of Texas M.D. Anderson Cancer Center.

This test is traumatic and should be performed only when necessary. For nonflowing anastomoses, the artery and vein are inspected for twists, kinks, and points of compression. The vessels are left alone for an additional 15 minutes. If the anastomosis is still not patent or has thrombosed, the suture line is excised and the anastomosis redone. Excessive manipulation of thrombosed vessels is avoided to prevent showering clot downstream. In the case of repeated thrombosis despite a technically sound anastomosis, thrombolytic agents may be administered within the flap.

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Secondary Microsurgical Techniques When it is not possible to perform tension-free, primary anastomosis of the donor and recipient vessels, interposition grafts are used; this is often the case in replantation and extremity trauma when recipient vessels must be outside the zone of injury. Autogenous vein grafts are readily available and are the most common conduit used. They should be placed directionally for spanning vein gaps and reversed for arterial gaps. The diameter of the graft should approximate that of the donor and recipient vessels—small grafts are harvested from the volar wrist or forearm, and medium grafts from the dorsal foot. The saphenous veins are often used when large-diameter vessels are required. Grafts should be harvested at least 35% longer than the measured gap to accommodate for contraction; redundancy disappears with time. 41 Long-term patency rates for vein grafts approach 100%, regardless of the length of the graft required. 41 When used to bridge arterial gaps, histologic changes occur in vein grafts over time. A neointima is formed by the ingrowth of smooth muscle cells from the recipient vessel, and the wall thickens. 42 Arterial grafts are similarly reliable but less frequently used. Use of the radial, thoracodorsal, and branches of the lateral femoral circumflex arteries has been described. Synthetic grafts are not common in microsurgery. Animal models using fibrous polyurethane (PU) and microporous polytetrafluoroethylene (PTFE) grafts show adequate early patency in high-flow, 43 short segment conduits, but long-term anastomotic narrowing due to neointimal hyperplasia. 44 Significant thrombosis and occlusion occur early in low-flow flaps. 45

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Microsurgery on Irradiated Vessels Extreme care must be taken if the recipient vessels have been previously irradiated. Radiated vessels are fragile, atherosclerotic, and fibrotic. It is difficult to recognize the junction between adventitia and media. When the media is damaged during dissection, the vessel wall is weakened and at higher risk for leakage and thrombosis. The intima is also more likely to be disrupted during vessel preparation, and sections may lift away from the underlying media, which is highly thrombogenic. If any layer of the vessel wall is injured, the vessel should be trimmed back proximal to the site of injury. Evidence on the patency of microvascular anastomoses in irradiated tissue beds is conflicting; some studies show higher rates of free flap failure, 46 whereas others show no effect on flap-related complications. 47–49

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Anesthetic Considerations Anesthesia is important in maximizing success in microsurgery. Basic intraoperative goals include supporting circulatory volume, avoiding peripheral vasoconstriction, and maintaining normal body temperature. Adequate mean arterial pressure and cardiac output is required for flap perfusion. A combination of crystalloid and colloid is appropriate for volume replacement with the goal of maintaining urine output at 0.5 mL/kg/h. Adequate blood pressure promotes flap perfusion by increasing regional blood flow, enhancing microvascular patency, and maintaining the fluidity of the blood in the microcirculation. Anecdotally, vasopressors are avoided in microsurgery; however, multiple studies show no increase in flap loss with intraoperative use of vasoactive medications. 50,51 Some studies even suggest that pressors may be beneficial in microsurgery by increasing blood flow to skin flaps. 52 It is thought that the rise in blood pressure overcomes any vasospastic effect of the medication. Adventitial stripping leads to denervation of the donor and recipient vessels during dissection, further supporting this theory. Temperature control during and after microsurgery is critical. Hypothermia causes vasoconstriction and increases hematocrit and plasma viscosity because of erythrocyte and platelet clumping. Large body surface areas may be exposed in microsurgical cases, making maintenance of temperature difficult. Patients can be warmed by forced-air blankets, warmed IV fluids, humidified and warmed anesthetic gases, and increased ambient room temperature.

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Postoperative Management Postoperatively, efforts are made to offload pressure from flap and prevent vasospasm. Dressings are minimized so that the whole flap is easily evaluated. Circumferential dressings and ties are avoided. Patients are positioned to prevent direct pressure on the flap; this may include application of an external fixator for extremity reconstruction. The room is warmed. Fluids are managed to maintain adequate urine output and systolic blood pressure and keep hematocrit at 25% to 35%. Pain control is optimized. Caffeine and nicotine are prohibited.

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Antithrombotics The routine use of antithrombotic agents in the postoperative period remains controversial. Multiple studies show that postoperative antithrombotic use of any type offers no protection from microvascular thrombosis and increases complication rates. 12,13 However, in a recent survey, 84% of surgeons who routinely perform lower extremity reconstruction reported using at least one form of antithrombotic before, during, or after surgery. 53 The most common antithrombotic agents used in routine postoperative care are aspirin and heparin. Further investigation is required.

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Postoperative Monitoring Thrombosis is most common within 24 hours of surgery. Early failure is often related to anastomotic imperfections or pedicle positioning. If a problem is detected early, the flap can be salvaged by exploration and revision of the anastomosis. The success rate of flap salvage is inversely related to the time interval from the onset of ischemia to restoration of blood flow. Prompt recognition and timely intervention is required. Overall, approximately 50% of ailing free flaps can be salvaged. 8 Clinical evaluation is standard for flap monitoring. Color, capillary refill, turgor, and temperature are evaluated. A flap without inflow will be cool, be pale, and lack capillary refill. Rapid capillary refill, swelling, or purple discoloration may indicate venous thrombosis. Many adjuncts to clinical evaluation exist. Hand-held Doppler ultrasound is commonly used to monitor both arterial and venous waveforms. Perforators to the skin are identified intraoperatively, and their location is marked with a fine suture on the skin surface for future localization. Implantable, ultrasonic Doppler probes can be used for flaps without a skin paddle or completely buried flaps. Surface temperature measurements and pulsoximetry are helpful in digital replantation. Other monitoring systems include transcutaneous oxygen tension, near-infrared spectroscopy, intravenous fluorescein angiography, pH measurement, interstitial fluid pressure, and reflection plethysmography. There is no consensus on which method is most effective. Regardless of the monitoring technique, flap checks should be performed by an experienced observer at least once every hour for the first 48 hours following surgery. After 48 hours, flap monitoring is spaced out to every 2 hours until postoperative day 5 and then decreased to every 4 hours until discharge. The rate of successful flap salvage is highest in the early postoperative course. 8

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Management of the Ailing Free Flap At the first sign of a problem, the flap and patient are inspected to detect any easily correctable issues— patient positioning, flap dependency, constrictive dressings, etc. Flap inset sutures are released if external pedicle compression is suspected. The threshold to return to the operative room is low. Exploration should proceed immediately if there is any clinical suspicion for thrombosis. Doppler signals may persist for several hours despite venous thrombosis. During a take-back procedure, the flap is elevated and the anastomosis inspected. Intravenous heparin (5000 units) is administered and the anastomosis is taken down. If clot is present, mechanical thrombectomy is performed with a Fogarty catheter. The goal is to remove the thrombus in its entirety— residual clot may be a nidus for additional thrombus or the source of microemboli. Both the donor and recipient vessels are trimmed back to pristine intima. Vein grafts may be required if primary anastomosis cannot be performed without tension. A thrombolytic agent (streptokinase, urokinase, or tissue plasminogen activator) is infused while the flap is occluded from systemic circulation. If there is no longer inflow from the recipient vessels, a different recipient site is chosen. There is no indication for routine anticoagulation when conditions are optimal; however, in the case of postoperative thrombosis, intraoperative, local fibrinolytic therapy and postoperative anticoagulation may be indicated in situations where mechanical and vascular factors are unfavorable.

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Leeches Leeches are a useful adjunct for flaps with signs of venous congestion despite a patent venous anastomosis. They are only indicated when a flap has good inflow but limited drainage, and should not replace reexploration of the venous anastomosis if patency is in question. Leeches are applied directly to the flap. They consume several milliliters of blood at each meal and fall off at satiety. Prophylaxis against Aeromonas hydrophila is necessary because this organism routinely inhabits the digestive tract of leeches.

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Flap Failure Salvage attempts are abandoned when there is no return of perfusion after reexploration. Tissue type and warm ischemia time are also considered. Obviously necrotic flaps should be debrided promptly to reduce inflammation. After removal of a failed free flap, dressings or skin grafts can be used to temporize a wound. Local or regional flap options or a second free flap may be considered.

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Applications of Microsurgery Free Tissue Transfer Free flaps are used to close wounds and restore form and function in patients with traumatic, oncologic, or congenital defects. Multiple types of flaps exist and selection is based on the type of defect and the goals of reconstruction. Muscle flaps are useful when bulk is required or a dead space exists. A skin paddle may be included depending on the contour requirements of the defect, or a skin graft may be placed over the bare muscle. Functional free muscle transfer is also possible; it involves transfer of a muscle with microvascular anastomosis and microsurgical reinnervation at the recipient site. Skin and fascia flaps can be derived from any perforating blood vessel using the angiosome concept. These flaps provide versatile, thin, well-vascularized soft tissue coverage. If desired, bulk may be provided by including subcutaneous tissue. Donor site morbidity is minimal because muscle is spared. Fascia-only flaps have the added advantage of providing a gliding surface for tendon reconstruction. Osseous flaps are used less frequently than soft tissue flaps but are helpful to reconstruct bony defects of the mandible, midface, and extremities. Vascularized bone autografts are superior to nonvascularized bone graft in defects over 5 centimeters in regard to early incorporation, bone hypertrophy, mechanical strength, and osseous mass retention. 54 Microvascular transfer of bowel segments (proximal jejunum or colon) is used to reconstruct the oral cavity, pharynx, and esophagus. The greater omentum is an excellent source of well-vascularized tissue. It is commonly used for sternal and scalp reconstruction. Laparoscopic harvest is possible.

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Nerve Repair Peripheral nerves have some capacity to regenerate after injury; however, poor functional results are common. Microsurgical techniques are required to optimize outcomes. Microdissection, identification and resection of injured nerve segments, fascicular matching, and tension-free epineurial or grouped fascicular repair are prudent. Recent advances in nerve surgery include end-to-side repairs and nerve transfers. In an end-to-side repair, the distal end of an injured nerve is coapted to the side of an uninjured donor nerve. Nerve transfers use redundant or unimportant fascicles from a donor nerve to innervate critical motor or sensory branches close to their target end organ. Techniques such as these improve functional results and reduce morbidity after peripheral nerve injury.

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Lymphatic Surgery Refinements in magnification, equipment, and technique have revolutionized the treatment of lymphedema. Lymphatic surgery is an exciting application of supermicrosurgery, defined as the anastomosis of structures less than 0.5 mm in diameter. Vascularized lymph node transfer and lymphaticovenous bypass offer physiologic solutions for restoration of lymphatic flow. Vascularized lymph node transfer involves transplanting functioning lymph nodes to an area affected by lymphedema. Donor sites include supraclavicular, submental, groin, or gastroepiploic nodes. The exact mechanism of action in vascularized lymph node transfer is unknown; however, two theories exist: (1) transplanted lymph nodes provide growth factors that induce lymphangiogenesis in the affected limb; and (2) transplanted lymph nodes act as a lymphatic pump, driven by high-pressure arterial inflow and low-pressure venous outflow. In lymphaticovenous bypass, obstructed lymphatic channels are identified and their flow is redirected into a nearby low-pressure venule. Restoration of unimpeded flow reduces lymphedema severity, particularly in patients with early-stage upper extremity disease.

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Replantation Microsurgical techniques are used to primarily repair amputations of extremities, genitalia, and facial structures. Replantation is most successful in patients who sustain sharp injuries and seek medical attention immediately. Crush or avulsion-type mechanisms cause a significant zone of injury and replantation is less likely to succeed. Patients with segmental or multilevel injuries are also poor replant candidates. When successful, replantation can help patients avoid disabling or disfiguring defects and complex, multistage reconstructive procedures.

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Conclusion Microsurgical techniques have forever changed the face of plastic surgery. Modern microsurgery has progressed far beyond the simple tenet of keeping a vessel patent. Refined techniques focus on maximizing function, restoring near-normal form, and minimizing donor site morbidity.

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Acknowledgment The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Questions 1. Which of the following conditions is a risk factor for free flap failure? a. Age less than 18 years b. Age greater than 65 years c. Active nicotine use d. Obesity e. DM 2. Which of the following is a proven benefit of using a coupler device? a. Decreased anastomosis time b. Improved anastomotic patency c. Increased intima-to-intima apposition d. Reduced cost e. Decreased vessel kinking 3. A 23-year-old man with a traumatic wound involving the distal third of the leg is scheduled to undergo soft-tissue reconstruction with an anterolateral thigh free flap. Which of the following is most likely to have the greatest effect on anastomotic patency? a. Anastomotic technique b. Magnification type c. Surgical precision d. Antithrombotic use e. Suture technique 4. A 62-year-old woman with invasive ductal carcinoma undergoes mastectomy and reconstruction with a deep inferior epigastric artery free flap. Intraoperatively, the patient experiences hypotension and norepinephrine is administered. Which of the following is the most likely effect of this treatment on the outcome of the flap? a. Microvascular thrombosis b. Partial flap loss c. Delayed wound healing d. Fat necrosis e. No effect 5. Systemic dextran administration is associated with which of the following effects? a. Improved anastomotic patency b. Protection from ischemia reperfusion injury c. Neutropenia d. Hypokalemia e. Increased systemic complications 6. A 73-year-old man undergoes resection of an 8 × 10 cm invasive squamous cell carcinoma of the scalp and immediate reconstruction with a radial forearm free flap. Flap monitoring is planned. Vascular compromise is most likely to occur during which of the following postoperative time periods? a. 0 to 1 days b. 2 to 3 days c. 4 to 5 days d. 6 to 7 days e. 8 to 9 days

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7. A 43-year-old woman is evaluated 6 hours after undergoing delayed breast reconstruction with profunda artery perforator flaps. Arterial signals are present bilaterally on Doppler examination. Capillary refill time is 3 seconds on the right and 1 second on the left. The left flap appears mottled and darker in color compared with the right side. Which of the following is the most appropriate management of the left breast? a. Observation b. Administration of systemic heparin c. Application of nitroglycerin paste d. Application of leeches e. Return to the operating room 8. A 46-year-old women undergoes bilateral breast reconstruction using deep inferior epigastric artery free flaps. On evaluation of the flaps 6 hours later, the right breast appears mottled and engorged. Administration of which of the following is contraindicated in this patient? a. Thrombolytics to the flap vessels b. Systemic thrombolytics c. Heparinized saline irrigation to the flap vessels d. Systemic heparin e. Papaverine to the flap vessels 9. A 17-year-old girl is evaluated 18 hours after undergoing soft-tissue coverage of Gustilo Grade III distal tibia fracture with a latissimus dorsi free flap. The flap appears dark and swollen and Doppler signals are absent. On reexploration in the operating room, thrombus is noted within the artery and vein. Which of the following is the most appropriate treatment to salvage this flap? a. Aspirin b. Heparinized saline to flap vessels c. Systemic dextran d. Systemic thrombolytic e. Mechanical thrombectomy 1. Answer: d. Age is not a contraindication for microsurgical reconstruction. Microsurgery can be safely performed in children and elderly patients without an increase in flap failure. Patients should be advised to quit smoking at least 4 weeks before surgery to reduce perioperative complications. Smoking does not reduce anastomotic patency but does affect wound healing, skin graft take over flaps, infection risk, flap necrosis, hernia formation, and length of hospital stay. Vascular disease is a known sequela of diabetes; however, studies show no difference in the rate of flap failure in diabetic patients. Obesity is a known risk factor for flap and donor site complications. Free flaps in obese patients are twice as likely to fail. 2. Answer: a. Anastomotic couplers expedite end-to-end venous anastomoses. Patency rates are equivalent to hand-sewn anastomoses. The other options have not been proven as benefits of a coupler device over other techniques. 3. Answer: c. Surgical precision is the key factor in anastomotic patency. Magnification in the form of surgical loupes or an operating microscope is acceptable. Studies show equal patency rates in vessels over 1 mm in diameter. Postoperative antithrombotic use offers no protection from microvascular thrombosis and increases complication rates. There is no difference in patency rate based on suture technique (simple interrupted versus continuous) or anastomotic technique (end-to-end versus endto-side). 4. Answer: e. Vasopressors are typically avoided in microsurgery because of the concern that vasospasm of the anastomosis will result in thrombosis. Volume resuscitation is the first-line treatment for hypotension, when possible. Despite this, multiple studies show that intraoperative use

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of vasoactive agents has no effect on postoperative flap outcomes. 5. Answer: e. Dextran is an antithrombotic agent sometimes used in microsurgical procedures. It decreases red blood cell aggregation through both antiplatelet and antifibrin effects. Dextran has no effect on flap survival but a 3.9- to 7.2-fold increase in systemic complications including renal failure, pulmonary edema, and congestive heart failure. Protection from ischemia reperfusion injury, neutropenia, and hypokalemia are not associated with dextran. 6. Answer: a. Thrombosis is most common within 24 hours of surgery. Early failure is often related to anastomotic imperfections or pedicle positioning. If a problem is detected early, the flap can be salvaged by exploration and revision of the anastomosis. Vascular thrombosis can occur at later times, but such events are generally infrequent. 7. Answer: e. The left flap shows signs of venous insufficiency—brisk capillary refill, mottled and dark appearance. Doppler signals may persist for several hours despite venous thrombosis. The most appropriate management is emergent reexploration. If a problem is detected early, the flap can be salvaged by revision of the anastomosis. The success rate of flap salvage is inversely related to the time interval from the onset of ischemia to restoration of blood flow. Observation is unacceptable. Systemic heparin may prevent further clot formation but will not dissolve acute clot or resolve pedicle kinking. Nitroglycerin paste can improve venous congestion in pedicled flaps but does not obviate the need for reexploration in a microsurgical flap. Application of leeches will drain excess blood from the flap but will not address the underlying problem. 8. Answer: b. Heparin may be used locally or systemically during flap salvage to irrigate existing thrombus and discourage clot propagation. Topical papaverine is routinely applied to flap vessels to reduce spasm. Thrombolytic agents, such as tissue plasminogen activator (tPA) or streptokinase, may be used within the flap but should not be administered systemically. 9. Answer: e. The most important treatment in this patient is mechanical thrombectomy of the flap artery and vein, which reduces clot burden and may restore flow. Intraflap tPA is also commonly used during flap salvage to dissolve microthrombi. Systemic thrombolytic administration carries a high risk of distant complications and is unlikely to dissolve clot within the flap. Administration of intraflap heparin will prevent further clot formation but will not dissolve the clot in the flap pedicle. Dextran has mild thrombolytic properties but it is not as effective as tPA in lysing clot within the flap and carries a high risk of systemic complications. Aspirin has no thrombolytic properties and has a slow onset of action.

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References Jassinowski, A. Die Artiennhat: eine experimentelle Studie. Inaug Diss Dorpat. 1889. Carrel, A. La technique operatoire des anastomoses vasculaires et la transplantation des visceres. Lyon Med. 1902;98:859-863. Hopfner, E. Uber Gefassnhaht, Gefasstransplantationen und Replantation von amputierten Extremitaten. Arch Klin Chir. 1903;70:417-471. Nylen, CO. The microscope in aural surgery: its first use and later development. Acta Otolaryngol Suppl. 1954;116:226-240. Holmgren, G. Some experiences in surgery of otosclerosis. Acta Otolaryngol. 1923;5:460-466. Jacobson, JH, Suarez, EL. Microsurgery in the anastomosis of small vessels. Surg Forum. 1960;11:243-245. Tamai, S. History of microsurgery. Plast Reconstr Surg. 2009;124(suppl 6):e282-e294. Mirzabeigi, MN, Wang, T, Kovach, SJ, et al. Free flap take-back following postoperative microvascular compromise: predicting salvage versus failure. Plast Reconstr Surg. 2012;130(3):579-589.This article provides recent data on microsurgical success rates from a high-volume center. Harashina, T, Fujino, T, Watanabe, S. The intimal healing of microvascular anastomoses. Plast Reconstr Surg. 1976;58(5):608-613. Hayhurst, JW, O’Brien, BM. An experimental study of microvascular technique, patency rates and related factors. Br J Plast Surg. 1975;28(2):128-132. Chang, WH, Petry, JJ. Platelets, prostaglandins, and patency in microvascular surgery. J Microsurg. 1980;2(1):27-35. Lighthall, JG, Cain, R, Ghanem, TA, Wax, MK. Effect of postoperative aspirin on outcomes in microvascular free tissue transfer surgery. Otolaryngol Head Neck Surg. 2013;148(1):40-46.This article reviews a large case series of patients treated with various combinations of antithrombotic agents and concludes that postoperative thromboprophylaxis with aspirin does not increase the odds of flap survival and may be associated with a higher complication rate. Disa, JJ, Polvora, VP, Pusic, AL, et al. Dextran-related complications in head and neck microsurgery: do the benefits outweigh the risks? A prospective randomized analysis. Plast Reconstr Surg. 2003;112(6):1534-1539.This study evaluates morbidity associated with dextran administration in head and neck microsurgery patients and concludes that there is no effect on overall flap survival and a significantly increased risk of systemic complications. Serafin, D, Lesesne, CB, Mullen, RY, Georgiade, NG. Transcutaneous PO2 monitoring for assessing viability and predicting survival of skin flaps: experimental and clinical correlations. J Microsurg. 1981;2(3):165-178. Eriksson, E, Anderson, WA, Replogle, RL. Effects of prolonged ischemia on muscle microcirculation in the cat. Surg Forum. 1974;25(0):254255. Berggren, A, Weiland, AJ, Dorfman, H. The effect of prolonged ischemia time on osteocyte and osteoblast survival in composite bone grafts revascularized by microvascular anastomoses. Plast Reconstr Surg. 1982;69(2):290-298. Cooley, BC, Hansen, FC, Dellon, AL. The effect of temperature on tolerance to ischemia in experimental free flaps. J Microsurg. 1981;3(1):1114. May, JW, Chait, LA, O’Brien, BM, Hurley, JV. The no-reflow phenomenon in experimental free flaps. Plast Reconstr Surg. 1978;61(2):256-267. Ross, DA, Ariyan, S, Restifo, R, Sasaki, CT. Use of the operating microscope and loupes for head and neck free microvascular tissue transfer: a retrospective comparison. Arch Otolaryngol Head Neck Surg. 2003;129(2):189-193. Pannucci, CJ, Kovach, SJ, Cuker, A. Microsurgery and the hypercoagulable state: a hematologist’s perspective. Plast Reconstr Surg. 2015;136(4):545e-552e. Shenaq, SM, Klebuc, MJ, Vargo, D. Free-tissue transfer with the aid of loupe magnification: experience with 251 procedures. Plast Reconstr Surg. 1995;95(2):261-269. Cope, C, Lee, K, Stern, H, Pennington, D. Use of the vascular closure staple clip applier for microvascular anastomosis in free-flap surgery. Plast Reconstr Surg. 2000;106(1):107-110. Spector, JA, Draper, LB, Levine, JP, Ahn, CY. A technique for atraumatic microvascular arterial coupling. Plast Reconstr Surg. 2007;119(6):1968-1969. Momeni, A, Lanni, M, Levin, LS, Kovach, SJ. Microsurgical reconstruction of traumatic lower extremity defects in the pediatric population. Plast Reconstr Surg. 2017;139(4):998-1004. Serletti, JM, Higgins, JP, Moran, S, Orlando, GS. Factors affecting outcome in free-tissue transfer in the elderly. Plast Reconstr Surg. 2000;106(1):66-70. Barr, LC, Joyce, AD. Microvascular anastomoses in diabetes: an experimental study. Br J Plast Surg. 1989;42(1):50-53. Cooley, BC, Hanel, DP, Anderson, RB, et al. The influence of diabetes on free flap transfer: I. Flap survival and microvascular healing. Ann Plast Surg. 1992;29(1):58-64. Colen, LB, Stevenson, A, Sidorov, V, et al. Microvascular anastomotic thrombosis in experimental diabetes mellitus. Plast Reconstr Surg. 1997;99(1):156-162. Miller, RB, Reece, G, Kroll, SS, et al. Microvascular breast reconstruction in the diabetic patient. Plast Reconstr Surg. 2007;119(1):38-45. Kroll, SS. Necrosis of abdominoplasty and other secondary flaps after TRAM flap breast reconstruction. Plast Reconstr Surg. 1994;94(5):637643. Seidenstuecker, K, Munder, B, Mahajan, AL, et al. Morbidity of microsurgical breast reconstruction in patients with comorbid conditions. Plast Reconstr Surg. 2011;127(3):1086-1092. Garvey, PB, Villa, MT, Rozanski, AT, et al. The advantages of free abdominal-based flaps over implants for breast reconstruction in obese

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patients. Plast Reconstr Surg. 2012;130(5):991-1000. Selber, JC, Kurichi, JE, Vega, SJ, et al. Risk factors and complications in free TRAM flap breast reconstruction. Ann Plast Surg. 2006;56(5):492497. Rohrich, RJ. Cosmetic surgery and patients who smoke: should we operate? Plast Reconstr Surg. 2000;106(1):137-138. Kaufman, T, Eichenlaub, EH, Levin, M, et al. Tobacco smoking: impairment of experimental flap survival. Ann Plast Surg. 1984;13(6):468-472. Chang, LD, Buncke, G, Slezak, S, Buncke, HJ. Cigarette smoking, plastic surgery, and microsurgery. J Reconstr Microsurg. 1996;12(7):467-474. Spear, SL, Ducic, I, Cuoco, F, Hannan, C. The effect of smoking on flap and donor-site complications in pedicled TRAM breast reconstruction. Plast Reconstr Surg. 2005;116(7):1873-1880. Alghoul, MS, Gordon, CR, Yetman, R, et al. From simple interrupted to complex spiral: a systematic review of various suture techniques for microvascular anastomoses. Microsurgery. 2011;31(1):72-80. Tsai, YT, Lin, TS. The suitability of end-to-side microvascular anastomosis in free flap transfer for limb reconstruction. Ann Plast Surg. 2012;68(2):171-174. Apostolides, JG, Magarakis, M, Rosson, GD. Preserving the internal mammary artery: end-to-side microvascular arterial anastomosis for DIEP and SIEA flap breast reconstruction. Plast Reconstr Surg. 2011;128(4):225e-232e. Mitchell, GM, Zeeman, BJ, Rogers, IW, et al. The long-term fate of microvenous autografts. Plast Reconstr Surg. 1988;82(3):473-479. Biemer, E, Holzmann, T, Wriedt-Lubbe, I, et al. Autologous vein grafts as artery replacement in microsurgery. An experimental study of micro- and macromorphologic changes 3 weeks to 12 months postoperatively. Handchirurgie. 1981;13(1-2):108-113. van der Lei, B, Wildevuur, CR. Microvascular polytetrafluoroethylene prostheses: the cellular events of healing and prostacyclin production. Plast Reconstr Surg. 1988;81(5):735-741. Hess, F, Jerusalem, C, Braun, B, Grande, P. Evaluation of the patency rate of fibrous microvascular polyurethane prostheses after implantation in the rat aorta. Microsurgery. 1983;4(3):178-181. Shen, TY, Mitchell, GM, Morrison, WA, O’Brien, BM. The use of long synthetic microvascular grafts to vascularise free flaps in rabbits. Br J Plast Surg. 1988;41(3):305-312. Khouri, RK, Cooley, BC, Kunselman, AR, et al. A prospective study of microvascular free-flap surgery and outcome. Plast Reconstr Surg. 1998;102(3):711-721.This study reviews outcomes from a large group of microsurgeons and concludes that reconstruction of an irradiated recipient site and the use of a skin-grafted muscle flap were the only statistically significant predictors of flap failure. Flap recipient site, indication for surgery, patient factors, anastomosis technique, and thromboprophylaxis did not have a significant effect on flap outcome. Kroll, SS, Schusterman, MA, Reece, GP, et al. Choice of flap and incidence of free flap success. Plast Reconstr Surg. 1996;98(3):459-463. Shaari, CM, Buchbinder, D, Costantino, PD, et al. Complications of microvascular head and neck surgery in the elderly. Arch Otolaryngol Head Neck Surg. 1998;124(4):407-411. Chow, WB, Rosenthal, RA, Merkow, RP, et al. Optimal preoperative assessment of the geriatric surgical patient: a best practices guideline from the American College of Surgeons National Surgical Quality Improvement Program and the American Geriatrics Society. J Am Coll Surg. 2012;215(4):453-466. Chen, C, Nguyen, MD, Bar-Meir, E, et al. Effects of vasopressor administration on the outcomes of microsurgical breast reconstruction. Ann Plast Surg. 2010;65(1):28-31. Harris, L, Goldstein, D, Hofer, S, Gilbert, R. Impact of vasopressors on outcomes in head and neck free tissue transfer. Microsurgery. 2012;32(1):15-19.This study reviews intraoperative vasopressor administration during microsurgical cases and concludes that they are frequently used and do not adversely affect flap outcomes. Cordeiro, PG, Santamaria, E, Hu, QY, Heerdt, P. Effects of vasoactive medications on the blood flow of island musculocutaneous flaps in swine. Ann Plast Surg. 1997;39(5):524-531. Xipoleas, G, Levine, E, Silver, L, et al. A survey of microvascular protocols for lower-extremity free tissue transfer I: perioperative anticoagulation. Ann Plast Surg. 2007;59(3):311-315. Weiland, AJ, Phillips, TW, Randolph, MA. Bone grafts: a radiologic, histologic, and biomechanical model comparing autografts, allografts, and free vascularized bone grafts. Plast Reconstr Surg. 1984;74(3):368-379.

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CHAPTER 6

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Concepts of Skin Grafts and Skin Substitutes Sabrina N. Pavri and Henry C. Hsia

Key Points Split-thickness skin grafts contain epidermis and a portion of underlying dermis, whereas fullthickness skin grafts contain epidermis and the entire dermis. Split-thickness skin grafts, when compared with full-thickness skin grafts, experience less primary contracture, more secondary contracture, may experience more pigment changes, be more susceptible to trauma, and have a lower metabolic demand of the recipient site wound bed. Skin grafts heal by a process of imbibition and revascularization through angiogenesis. Graft healing is associated with swelling of the graft, increased mitotic activity leading to desquamation, and eventual reepithelialization over a span of about 4 weeks. Common causes of graft failure include hematoma, infection, seroma, shear forces, and a poorly vascularized wound bed. Skin substitutes come in a variety of forms and can be considered as biologic dressings that provide clinicians more options in complex wound management, either as an alternative to traditional dressings or as a bridge to more definitive treatment such as surgical closure. Providing wound coverage for a patient through the application and grafting of skin harvested from a distinct or separate region located elsewhere on that patient’s body is a key foundational technique in the armamentarium of the plastic surgeon. Skin grafting originated in India approximately 3000 years ago, where full-thickness grafts comprising the entire dermis and epidermis layers of the skin harvested from the gluteal region were used by the Koomes tilemaker caste for nasal reconstruction after amputation, a common punishment for criminals. 1 The knowledge of this surgical technique did not make its way into Western medicine until the early 19th century. In 1817, Sir Astley Cooper used a full-thickness skin graft from a man’s amputated thumb to provide coverage for the remaining stump. This was followed by a successful nasal reconstruction using a skin graft, performed by Buenger in 1823. However, because of the difficulties his European contemporaries encountered while attempting to replicate his technique, skin grafting did not become widely popular until 1869, when Reverdin published his landmark paper reporting successful pinch grafts. Thin split-thickness grafts were popularized in the late 19th century by Ollier (1871) and Thiersch (1874), as a method to cover defects with a large surface area, becoming known as Ollier-Thiersch grafts. However, the drawbacks of these grafts quickly became evident, with several reports in the 1890s detailing the subsequent wound contractures and graft susceptibility to trauma. During the same period, surgeons and ophthalmologists were using full-thickness skin grafts to correct cases of ectropion. The technique of full-thickness skin grafting was published by Wolfe in 1874 and popularized by Krause, with full-thickness skin grafts becoming known as Wolfe-Krause grafts. 2,3 Despite the development of more advanced surgical techniques, autologous skin grafting remains a mainstay of wound coverage reconstruction, especially for burn trauma. However, the relative lack of donor site availability in patients with extensive burns and the suboptimal aesthetic and functional outcomes commonly associated with autologous skin grafts drive a search for alternatives and led to the development of skin substitutes in recent decades. Although initially intended for primary coverage, skin substitutes have been found to have a salutary impact on wounds even when they fail as permanent wound coverage options. In contemporary applications, skin substitutes have been used more commonly

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as biologic dressings and bridging therapies to eventual definitive closure via autologous skin grafts or other conventional plastic surgical techniques. Nonetheless, much ongoing work continues in efforts to develop an alternative to autologous skin grafts that would promote regenerative healing of wounds in a definitive fashion.

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Anatomy of Skin Grafts The skin is the largest organ in the body, accounting for 15% of total adult body weight, with a layered structure (Figure 6.1) that assists in its functions of protection, sensation, thermoregulation, control of evaporation, and absorption. 4 The epidermis, or the outermost layer of the skin, is of ectodermal origin; and its cells undergo continuous differentiation, migration, and eventual shedding. 90% to 95% of epidermal cells are keratinocytes, with the remainder including Langerhans cells, melanocytes, and Merkel cells. The epidermis is substratified into five layers (from superficial to deep)—stratum corneum, stratum lucidum, stratum granulosum, stratum spinosum, and stratum basale. The epidermis has an average thickness of 100 µm, but this can range widely, from 50 µm on the eyelids to 1 mm on the glabrous skin of the hands and feet.

FIGURE 6.1 The anatomy of autologous skin grafts. Human skin is a layered structure comprised of several elements. Splitthickness skin grafts include the epidermis and the superficial portion of the dermis, whereas full-thickness skin grafts include the epidermis and the entire dermis layers.

The dermis is a structure of mesodermal origin comprised of collagen and elastin fibers, ground substance, and the deeper portions of the epithelial appendages (eccrine and apocrine sweat glands, and pilosebaceous follicles). Although fibroblasts are the dominant cell type in the dermis, it also contains mesenchymal dermal dendrocytes and mast cells. The papillary dermis is the thin uppermost layer of the dermis composed of loosely arranged collagen fibers, which contains a capillary network that provides nutrients to the epidermis and acts as a mechanism of heat exchange and regulation. The reticular dermis

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lies below the papillary dermis and is composed of dense irregular collagen fibers. It also contains most of the dermal elastin, as well as the pilosebaceous units and sweat glands. Within the dermis layer, there exist two horizontal plexuses of vessels connected by bridging vessels that traverse the dermis vertically. The superficial plexus lies at the interface of the papillary and reticular dermis, whereas the deep plexus lies adjacent to the deep border of the dermis. These plexuses are closely associated with nerve bundles and structures that help mediate sensations such as pain, temperature, itch, touch, and pressure. Below the dermis lies the hypodermis or subcutis, which is composed of adipocytes separated by fibrous septa containing fibroblasts, dendrocytes, and mast cells, and into which extend the deepest parts of the epithelial appendages, as well as vessels and nerves that contribute to the overlying dermal plexuses. In structural continuity with the underlying subcutaneous fat, this layer provides thermoregulation, insulation, energy, and mechanical protection for the skin. Split-thickness skin grafts are defined as grafts involving the epidermis and any part of the dermis, and range in thickness from approximately 0.005 to 0.030 inches. They are classified as thin (0.005–0.012 inches), medium (0.012–0.018 inches), or thick 
 (0.018–0.030 inches) grafts, depending on the amount of dermis included. 1 Full-thickness skin grafts are defined as grafts composed of the epidermis and the entire dermis. Many factors play into the choice between a split- and full-
 thickness skin graft for wound coverage. Primary contraction of a skin graft is due to elastin fibers within the dermis and occurs immediately after harvest. The amount of primary contraction that a graft experiences is proportional to the amount of dermis in the graft; therefore full-thickness grafts exhibit more primary contraction than split-thickness grafts harvested from the same site. 5 By comparison, secondary contraction is a myofibroblast-mediated process that occurs during graft healing and is more likely to occur in grafts with a thinner dermal component. Secondary contraction can cause significant limitations in the stretch and mobility of the healed graft, and therefore, full-thickness grafts are favored in areas such as wounds over joint surfaces where mobility affects function. Although both split-thickness and full-thickness grafts are vulnerable to shear forces during the healing process, once healed, grafts with a larger dermal element are less fragile to subsequent trauma. One must also take into account the size of the graft needed, as the harvest of a split-thickness graft heals the donor site by secondary intention with minimal morbidity, whereas the donor site for a full-thickness graft usually necessitates primary closure for optimal mitigation of donor site morbidity (thereby limiting the size and potential donor sites for a full-thickness skin graft). Split-thickness grafts are also more amenable to size expansion via meshing techniques, making them more suitable for large wounds. Thicker skin grafts place greater metabolic demands on the wound bed during healing because of the larger tissue component needing nutrients and eventual revascularization, with full-thickness grafts having a slightly lower chance of complete survival and healing than split-thickness grafts on an equivalent wound bed. Because they include only the most superficial portions of the dermis, splitthickness skin grafts also generally do not contain intact accessory skin structures such as hair follicles and sweat glands.

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Mechanisms of Skin Graft Healing A healthy ungrafted wound bed will typically undergo healing by secondary intention—granulation, contraction, and reepithelialization. Placing a skin graft on a wound bed fundamentally alters these processes. Skin grafts become incorporated into the wound bed by a process known as graft take, a loosely defined term generally accepted to imply graft healing and survival. This process is largely dependent on the reestablishment of vascular perfusion to the graft within a critical time frame. Skin graft take has historically been broken down into three classic phases of engraftment—imbibition (0– 48 hours), inosculation (48–72 hours), and revascularization (>96 hours). Much of our knowledge in this area relies on decades-old research based largely on in vitro models and histologic analysis, and there remain several competing theories of the exact mechanisms of graft revascularization. However, the recent development of in vivo models has proven enlightening in repetitive intravital microscopic analyses of the microcirculation and revascularization of a skin graft within the wound beds of live organisms. 6 With all other factors being equal, graft survival has been shown to be dependent on the vascularity of the donor site (with grafts harvested from a highly vascular area healing better than a graft from a poorly perfused area), as well as the metabolic activity of the graft at the time of placement. Freshly harvested grafts have also been shown to attract blood vessel ingrowth more rapidly than grafts that have been frozen and subsequently thawed, but they are also less tolerant of the ischemic period because of increased metabolic activity. 7

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Imbibition The first stage of skin graft healing is an ischemic phase known as plasmatic or serum imbibition, a concept first developed by Huebscher in 1888, 8 who theorized that grafts were initially nourished by fluid from the wound bed prior to restoration of perfusion. The exact duration of this phase is variable and depends on the characteristics of the wound bed. It lasts approximately 24 hours in a proliferative wound and 48 hours in a fresh wound and can last up to several days in a poorly perfused wound bed. Although it is widely accepted that imbibition allows the graft to survive the initial ischemic period until perfusion is restored, the exact effects on the skin graft of this stage are unclear. Some believe that the graft is nourished by the serum absorbed from the wound bed, 9,10 whereas others believe that the serum has no metabolic function and only serves to keep the graft moist and its vessels patent in the initial period following grafting. 8,11,12 During imbibition, plasma leaks from recipient capillaries into the wound bed-graft interface, and fibrinogen in the plasma is converted into fibrin, which serves to adhere the graft to the wound bed. As the grafts absorb serum, they become edematous and gain as much as 40% of their initial weight in the first 24 hours, starting to decrease in weight after 96 hours, as lymphatic and venous return develop. 8 During imbibition, metabolism within the graft becomes anaerobic and the pH level falls, reaching a pH of 6.8 as determined by Rous. 13 The metabolic demands of the graft also fall, with ATP levels falling 70% and glucose levels falling 80%. Historically, the second stage of skin graft healing was thought to be a process called inosculation, by which blood vessels from the underlying wound bed connect with existing vessels in the skin graft at the graft interface. This mechanism in its traditional definition is no longer considered truly valid, as it would require close approximation of the cut ends of the wound bed and graft vessels. While connections between the wound bed vessels and graft vasculature do occur, they are through the process of angiogenesis and new vessel ingrowth in a unidirectional fashion from the wound bed into the graft. Additionally, these new vascular connections do not necessarily occur at the wound interface with the graft, as inosculation would infer. Recent animal studies have shown that after 48 to 72 hours, microvascular growth of capillary-sized vessels (averaging 10–11 µm in diameter) from the wound bed into the graft has been established in the fibrin interface of the wound. A peak in vessel density is seen at postgraft day 7, with the vascular density at the interface increasing 2.5-fold between postgraft days 3 and 7 before returning to levels near those of postgraft day 3 by day 10. 14

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Revascularization Historically, there have been three theories laid out to explain graft revascularization. The first proposes that anastomoses are formed between the capillaries of the wound bed and the native vessels in the skin graft, and that circulation is restored in the original skin graft vessels. 12,15–17 The second theory involves new vessels originating from the wound bed growing into the skin graft and establishing a new circulation after the initial reperfusion, implying angiogenesis and vasculogenesis, with the native graft vessels eventually degenerating. 18–20 The third theory also suggests reperfusion by angiogenesis from the wound bed but hypothesizes that recipient-derived endothelial cells migrating into the graft use the skin graft’s intrinsic preexisting vascular network as a conduit for ingrowth, with eventual replacement of the graft’s endothelial structure. 21 Recent development of in vivo animal models supports the third theory of skin graft healing. In 2010, an in vivo mouse model was developed by Lindenblatt et al. to model skin graft revascularization, allowing for analysis of the microcirculation of the graft and wound bed using fluorescein and intravital fluorescence microscopy during healing. 6 Microcirculatory analysis included the determination of vessel diameter, red blood cell velocity, and functional capillary density defined as length of perfused capillaries per area of observation. During the first 72 hours after grafting, there were a progressive widening of the wound bed capillaries (from 10.6 ± 0.1 µm to 15.9 ± 0.2 µm) and the development of small capillary protrusions representing early bud formation and angiogenesis, although the skin graft still lacked reperfusion of the dermal plexus. At 72 hours, a sluggish blood flow within the graft appeared in a pattern comparable to the original skin microcirculation at the donor site prior to graft harvest, likely representing reperfusion of preexisting graft capillaries. After 96 hours, both the wound bed and the skin graft demonstrated increased capillary diameter and functional capillary density, indicating continued angiogenesis in the wound bed, and ingrowth of newly formed vessels into the graft tissue. At 120 hours, capillary diameter and functional capillary density within the wound bed began to decrease, while still increasing within the graft. By 10 days after grafting (240 hours), the skin graft was fully revascularized, with the wound bed vessels still showing a slightly increased diameter (but without signs of ongoing angiogenesis), and the capillary diameter and functional capillary density of the graft at baseline. This model supports the theory that angiogenesis is the primary factor in skin graft revascularization, beginning as early as 24 hours after grafting, leading to vessel growth through the fibrin wound bed-graft interface, eventually leading to reperfusion of the graft’s native microcirculation within 48 to 72 hours, predominantly within the center of the skin graft. These findings are supported by previously demonstrated dermal graft vessel growth of 5 µm/h, which would mean that a skin graft 200 to 300 µm in thickness would be fully traversed by new microvessels within 48 to 72 hours. 21 Additional research by Lindenblatt et al. has demonstrated that the graft vessels demonstrate an angiogenic response to reperfusion between 3 and 8 days post grafting, suggesting that they are more than simply mechanical conduits. Buds visualized within the grafts at capillary junctions contained endothelial cells and pericytes on histology, indicating a temporary angiogenic response within the skin graft. 22 Matrix metalloproteinases MT1-MMP and MMP-2 are associated with the initiation of angiogenesis, by promoting the degradation of the endothelium and interstitial matrix. MT1-MMP enables endothelial cells to form invading tubular structures and to lyse the existing capillaries, as these invading structures connect the graft and wound bed vasculature. The temporary angiogenic buds of the graft showed increased expression of MT1-MMP on their surface and served in vivo as docking points for ingrowing capillaries. MMP-2 expression was concentrated around the vessel sprouts of ingrowing vessels as they advanced toward the deep dermal layer of the skin graft. 23 Using a crossover wild-type/green fluorescent protein (WT/GFP) skin transplantation mouse model

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(where WT skin was grafted onto GFP mice), GFP-positive structures appeared within the graft vessels starting 48 to 72 hours after transplantation. Preexisting vascular channels in the periphery of the skin graft were 100% replaced by vessel ingrowth from the wound bed by day 10, whereas those in the center of the graft were replaced to a much lesser extent (50%–60%). 24 This may be because the hypoxic stimulus for angiogenesis is no longer present after subsequent revascularization and nutrient supply in the center of the graft where the revascularization process started. 25 In conclusion, skin graft healing is a process of imbibition and revascularization, which represents a combination of angiogenic vessel outgrowth originating in the wound bed, reperfusion of the preexisting graft vasculature, and partial replacement of the existing graft vessels.

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Histology of the Healing Skin Graft During the first 4 days after grafting, the epidermis of the graft doubles in thickness. This has been hypothesized to be due to multiple processes, including swelling of the nuclei and cytoplasm of epidermal cells, epidermal cell migration to the surface of the graft, and accelerated mitosis of follicular and glandular cells. 26 Between the fourth and eighth days after grafting, the epithelium continues to proliferate and starts to desquamate. This increased cellular turnover does not return to baseline until 4 weeks after grafting. 27,28 The dermis of a healing skin graft also demonstrates considerable turnover of its cellular and noncellular structures. It is generally accepted that fibroblasts within the dermis of a healing skin graft are not native graft fibroblasts. In a rat model, Converse and Ballantyne noted decreased fibrocyte populations in the first 3 days after grafting, with the appearance of new fibroblast-like cells after day 3, which would also coincide with graft reperfusion. 18 Collagen turnover in the dermis parallels that of the epidermal hyperplasia, peaking at 2 to 3 weeks after grafting at three to four times faster than the collagen turnover rate for normal skin. Approximately, 85% of the original collagen in a skin graft is replaced within 5 months of grafting, although split-thickness grafts replace only half as much of their original collagen compared with full-thickness grafts of the same size. 29,30 Elastin within the graft is also replaced, with degeneration from postgraft day 3, and regeneration starting 4 to 6 weeks after grafting.

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Graft Contraction Graft contraction occurs in both split-thickness and full-thickness grafts. Primary contraction occurs immediately after graft harvest and is a result of the recoil of elastin fibers in the dermis. A full-thickness graft loses approximately 40% of its surface area after harvest because of primary contraction, whereas a split-thickness graft loses 10% to 20% of its area. Secondary contraction occurs during the healing of a skin graft and is a myofibroblast-mediated process that is inversely proportional to the amount of dermis in the graft. 31 The mechanism behind the inhibition of wound contraction by the presence of dermal elements in the graft is unclear, although multiple hypotheses have been proposed. Rudolph had suggested that increased dermis causes more rapid turnover and elimination of the myofibroblasts that mediate wound contraction. 32 However, further studies by Oliver et al. demonstrated that grafts without dermal cells and other noncollagenous dermal proteins, but possessing a collagen matrix, in fact behave much like fullthickness skin grafts in terms of inhibiting wound contraction. 33 Once wound contraction is complete, full-thickness grafts are able to grow with the surrounding tissue, whereas split-thickness grafts remain fixed. 5

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Skin Grafting Techniques Choosing a Donor Site A skin graft donor site is selected based on several factors. Split-thickness grafts are commonly taken from the lateral thigh to minimize difficulties during harvest and dressing changes, although patients may prefer donor sites with less visible scarring such as the buttocks. Split-thickness grafts taken from the scalp are also successful with minimal donor morbidity and no visible scarring once hair has regrown, but are less commonly used because of the need to shave the donor area prior to taking the graft. Common full-thickness graft donor sites include the inguinal creases, the postauricular region, and the supraclavicular area. Consideration must also be taken to obtain an appropriate color match, especially with head and neck skin graft reconstruction, with grafts optimally taken from donor sites above the clavicles.

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Graft Fixation Adherence of the skin graft to the wound bed during the revascularization process is critical for graft survival. During imbibition, the graft adheres to the wound bed by a thin fibrin layer. Once revascularization begins, vascular ingrowth from the wound bed into the graft reinforces this bond. Shear forces, fluid collections (hematoma/seroma), and infection all decrease the chances of graft adherence and take. For these reasons, optimal graft fixation methods minimize movement, and gently compress the graft to reinforce hemostasis and minimize the chance of fluid collections. Tie-over bolsters using a xeroform sheet filled with mineral oil–soaked cotton balls are common, especially for the fixation of smaller grafts. For larger skin grafts, grafts in mobile areas, or grafts in areas that are difficult to bolster (e.g., the hand and axilla), negative-pressure dressing techniques such as vacuum-assisted closure therapy (KCI, San Antonio, TX) have become increasingly popular as an alternative bolster dressing for meshed skin grafts. Negative-pressure therapy allows the patient to maintain mobility; however, it does require the patient to carry and recharge the negative-pressure device unit, and the attachment of the dressing to the unit may prove to be cumbersome, especially in patients at increased risks for falls. Spray fibrin sealants such as Evicel (Ethicon, Somerville, NJ) and Artiss (Baxter Healthcare, Deerfield, IL) are also gaining popularity for both securing the edges of the graft (instead of sutures or staples) and increasing adherence of the graft surface. They offer the benefit of immediate mobility, minimal dressings, and ease of application. However, these products may be cost prohibitive in certain settings and also work optimally on thin splitthickness grafts without much primary contraction. The initial dressing over a skin graft is usually removed approximately 1 week following grafting, once adherence of the graft to the wound bed is more secure and the revascularization process has begun. However, adherence does not imply full graft survival and healing, and local wound care (typically with xeroform and gauze to keep the wound moist and minimize shear forces) is necessary in the postacute phase following the removal of the initial dressing until the skin graft has had the opportunity to mature and become more durable, usually by 3 to 4 weeks following grafting.

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Causes of Graft Failure In addition to mechanical factors in the fibrin interface between the wound bed and graft that interfere with revascularization (such as hematoma, seroma, or shear forces), other causes of graft failure include infection, medical comorbidities of the patient (such as diabetes mellitus, peripheral arterial disease, or a history of radiation), and inherent properties of both the wound bed and the graft. Meshing (performed using a hand-driven roller instrument that creates uniform slits throughout the graft) and pie-crusting (using a scalpel to create multiple small fenestrations in the graft) are common techniques intended to avoid fluid buildup under the skin graft. Skin grafts in diabetic patients with associated comorbidities often demonstrate delayed healing, with one study showing skin grafts take approximately 2 weeks longer to heal in diabetic patients than in nondiabetic patients. 34 Diabetic patients are also at increased risk for wound dehiscence, infection, and the need for revision surgery. Lower extremity peripheral vascular disease (PVD) also plays an important role in the ability of the wound bed to support a healing graft needing revascularization. In patients whose clinical pictures suggest PVD, a low threshold should be maintained for obtaining noninvasive vascular studies and arteriography. These patients may be candidates for surgical bypass or endovascular angioplasty techniques to optimize blood flow to the wound bed. A wound bed with necrotic tissue that is poorly perfused, is grossly infected, or has chronically exposed bone or tendon (without periosteum or paratenon) is not appropriate for a graft and will need to be optimized prior to graft placement to maximize the chance of graft survival. Robson and Krizek found that skin grafts are likely to fail if bacterial loads on quantitative culture are greater than 105 organisms per gram of tissue. 35 Additionally, inherent properties of the graft may also play a role in graft failure. A thin split-thickness graft will have a greater chance of engraftment than a full-thickness graft taken from the same area, because the metabolic demands of the graft are less and a thinner graft requires a shorter distance of new vessel ingrowth for full revascularization.

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Management of the Skin Graft Donor Site The optimal dressing for the split-thickness skin graft donor site continues to be a matter for debate, as multiple options exist and there are no comprehensive studies comparing all materials in a standardized manner. Generally speaking, the ideal donor site dressing encourages rapid reepithelialization, minimizes pain, decreases the risk of infection, and curtails scarring. In general, dressings that promote a moist wound environment until reepithelialization occurs (at least 7 days) have been shown to improve rates of healing and pain control. A 2013 multicenter randomized clinical trial compared six common donor site dressings and assessed both primary outcomes (time to reepithelialization and pain scores) and secondary outcomes (itching, scarring, and adverse events such as infection, allergic reaction, and hypergranulation). 36 Patients were randomly allocated to an alginate (Kaltostat; ConvaTec, Skillman, NJ; Algisite; Smith & Nephew, London, UK; or Melgisorb; Mölnlycke Health Care, Gothenburg, Sweden); a semipermeable film (Tegaderm; 3M, St Paul, Minnesota; or Opsite; Smith and Nephew); a gauze dressing (Adaptic; Acelity, San Antonio, TX; or Jelonet; Smith & Nephew); a hydrocolloid (DuoDERM; ConvaTec); a hydrofibre (Aquacel; ConvaTec), or a silicone dressing (Mepitel; Mölnlycke Health Care). Time to complete reepithelialization was 7 days (30%) shorter when hydrocolloid dressings were used (median 16 days) than with any other dressing (median 23 days). Pain scores were lowest in the semipermeable film group, but the difference did not reach statistical significance. Gauze dressings had the highest infection rates. This trial’s protocol prescribed the uniform use of gauze-based secondary dressings; therefore, the effects of other secondary dressings (such as semipermeable film) used in clinical practice could not be studied. Additionally, in clinical practice, other factors such as cost, patient compliance with wound care, and availability must be considered. Skin graft donor site dressings continue to be a matter of surgeon preference with no strong evidence directed to any one option. However, it is generally accepted that the dressing should maintain a moist wound environment for at least 1 week.

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Emerging Alternatives to Conventional Skin Grafts Cultured epidermal grafts have been used clinically since the 1980s, when burn patients were successfully grafted with cultured allografts, 37 and Phillips et al. treated refractory chronic lower extremity wounds with both cultured autografts and cultured allografts. 8 Although it seems intuitive that cultured epithelial autografts would heal on a wound, the successful engraftment of cultured epithelial allografts in the setting of complete lack of immunosuppression needed further explanation. In the 1990s, several studies demonstrated that all donor cells in the graft were replaced by recipient keratinocytes by as early as 1 week following grafting, 38–40 leading to the subsequent conclusion that cultured epidermal allografts provide growth factors that lead to rapid wound healing despite the technical failure when the graft fails to survive. This concept of an epithelial graft as a pharmacologic agent to aid wound healing rather than a technical replacement of the epithelium was an important development in understanding how skin substitutes and similar products may be used to promote wound closure. The clinical applications of cultured epidermal autografts (Epicel; Genzyme, Cambridge, MA) have been limited because of variable graft take rate, limited mechanical resistance, hyperkeratosis, scar contracture, ulceration, and blister formation because of reactions to foreign fibroblasts in feeder media, as well as the lengthy culture time (3–4 weeks) required and the high cost. Recently, there has been development of several modifications of skin grafting technique to address the drawbacks of traditional skin grafting, including dermal-epidermal grafts, fractional skin harvesting, and epidermal grafts. 41,42 In epidermal grafting, harvesting systems provide continuous negative pressure to separate the epidermis from the dermis at the dermal-epidermal junction while preserving the histological architecture of the epidermis. Although it has been used to treat vitiligo for decades, it has only recently been evaluated as a possible treatment for wound healing. Healing of epidermal grafts is associated with keratinocyte activation, growth factor secretion, and reepithelialization from the wound edge, more akin to cultured keratinocytes than full- or split-thickness grafts. 42 Dermal-epidermal grafting creates micrografts of approximately 0.8 mm × 0.8 mm in size from a splitthickness skin graft using the Xpansion Micrografting system (ACell, Colombia, MD). This increases the border area and regenerative capacity of the grafts, and allows expansion by a factor of 1:100 (instead of the typical 1:5 expansion of a full-thickness skin graft and 1:9 expansion of a meshed split-thickness skin graft). Micrografts also do not need to retain their dermal orientation, thereby decreasing the procedural complexity. This minimizes the size of the skin graft required and resultant donor site morbidity, allowing the procedure to take place under local anesthetic in an outpatient setting. 41 Fractional skin harvesting requires harvesting a large number of full-thickness microscopic skin tissue columns measuring approximately 700 µm in diameter using customized hypodermic needles. The extracted skin columns are placed randomly in the wound without maintaining the dermal orientation. Advantages of this technique include minimal morbidity, faster healing of the donor site without scarring, and lack of the expanded mesh graft pattern of the healed graft. Although this is still a new technique currently only being used in experimental animal models, it shows promise for future commercial development. 41 Autologous noncultured cell therapy such as ReCell (Avita Medical, Royston, UK) isolates cells from the dermal-epidermal junction of a thin split-thickness skin graft using trypsin incubation, followed by mechanical agitation to separate the cells, and immediate suspension in a lactate solution, which then undergoes spray application on the wound. Benefits of this system include quick application and a large expansion ratio (1:80). Drawbacks include poor attachment and loss of cells secondary to mechanical pressure while spraying, as well as high cost. One promising application of this technique is potential one-stage creation of an epidermal layer when used concurrently with dermal matrices. In a pilot study, 43 ReCell was combined with the dermal substitute Integra (Integra LifeSciences Corp., Plainsboro, NJ) to

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treat full-thickness wounds in a porcine model. Cells isolated with the ReCell system were sprayed on the underside of the dermal matrix prior to application. The study indicated that cells stay viable, migrate through the dermal substitute, and self-organize into a differentiated epidermis.

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Skin Substitutes The scarcity of donor site availability in patients with extensive burns and the suboptimal aesthetic and functional outcomes commonly associated with autologous skin grafts have prompted the search for viable substitutes for skin grafts. The earliest skin substitutes were allografts of cadaveric human skin used to treat patients with extensive burns and limited donor sites for autograft harvest. The high antigenicity of skin allografts, in particular the epidermal layer, with subsequent graft sloughing and rejection led to the combination of cultured epidermal autografts over dermal allografts in the 1980s. 44 Observation that the formation of a neodermis comprised of healthy connective tissue is stimulated in the wound bed even though the allograft does not successfully survive, as well as concerns about disease transmission from donors and persistent scarring and contractures, has spurred continued efforts to develop bioengineered skin substitutes. 45 In 1984, Pruitt and Levine 46 detailed the attributes of an ideal skin substitute: Little or no antigenicity Tissue compatibility Lack of toxicity, either local or systemic Permeability to water vapor just like normal skin Impenetrability to microorganisms Rapid and persistent adherence to a wound surface Porosity for ingrowth of fibrovascular tissue from the wound bed Malleability to conform to an irregular wound surface Elasticity for motion of underlying tissues Structural stability to resist linear and shear stresses A smooth surface to discourage bacterial proliferation Sufficient tensile strength to resist fragmentation Biodegradability Low cost Ease of storage Indefinite shelf life Although the intervening decades have seen the development of a broad range of products that attempt to embody many of these attributes, the term skin substitute belies how these products are currently used in complex wound management. Furthermore, inconsistency in terminology and how these products are applied can make consistent classification challenging, but skin substitutes and related products may be categorized in several ways: composition of source material (e.g., synthetic versus biologic; human versus animal), intended duration (permanent versus temporary), intended tissue to be replaced (epidermal versus dermal), and number of layers (single versus bilaminate). Many products do not neatly fit into these categories, however. For example, Biobrane (Smith & Nephew) is a biosynthetic composite containing both synthetic elements comprised of silicone and a nylon mesh along with a biologic element derived from porcine collagen. Another composite product, Dermagraft (Organogenesis, Canton, MA) is created by seeding neonatal foreskin fibroblasts onto a biodegradable polyglycolic acid mesh. The fibroblasts are cryopreserved at −80°C and regain their viability once the product is applied on the wound, which must be done within 30 minutes after thawing. 45 Marketed under a variety of terms including artificial skin equivalent, dermal regeneration template, wound matrix, biologic dressing, tissue scaffold, or some other permutation of these words, these bioengineered products share the similar purpose of promoting wound closure, and contrasts are only

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found on whether the emphasis of a product is placed on acting as an in situ replacement of skin tissue that is eventually incorporated into the recipient wound bed, or on promoting endogenous tissue repair processes within the wound bed to achieve a more optimal healing outcome. In fact, rather than evaluating these products as true substitutes for native skin and treating them as equivalent to autologous skin grafts, it is more useful when deciding whether to use them for clinical purposes to regard the role of these bioengineered skin products as constructs that may deliver growth factors and extracellular matrix components, or attract cells to the wound bed, that can stimulate endogenous healing processes to help promote wound closure and assist in preparing the wound bed for definitive surgical treatment, especially for patients with wounds such as diabetic foot ulcers that can be extremely challenging to treat. 45 One product mentioned more frequently on plastic surgery examinations is Integra, a bilaminar membrane system consisting of a porous coprecipitate of bovine tendon type I collagen and shark glycosaminoglycan (chondroitin-6-sulfate), covered by a temporary silicone epidermal substitute. The silicone layer prevents excessive moisture loss and formation of granulation tissue on the matrix surface. Chondroitin-6-sulfate provides elasticity to the matrix, controls the biodegradation rate, and maintains an open pore structure that allows cell migration into the matrix. 49 Integra heals in phases similar to skin graft healing, progressing through (1) imbibition, (2) fibroblast migration, (3) neovascularization, and (4) remodeling and maturation. During imbibition, the interstices of the matrix fill with wound fluid containing red blood cells, and the fibrin in the wound exudate fosters adherence of the matrix to the wound bed. By day 7, myofibroblasts start migrating into the matrix and start producing collagen by the beginning of week 3. The silicone epidermal layer has usually sloughed or been removed by this point in time. New blood vessels can be seen in the deep portion of the matrix by 
 day 12 and reach the superficial surface by day 28, at which point a thin split-thickness skin graft may be applied. Recent data showed clinical effectiveness using Integra to help achieve eventual wound closure with successful skin grafting performed as early as 1 week after Integra application in combination with negative-pressure therapy. 50 However, neovascularization of the matrix at that early time point has yet to be demonstrated at the histological level. Integra can also be used without the silicone layer as a filler for contour deformities, although this does require a lengthier period of neovascularization for vessel ingrowth through a thicker matrix. Though not uniform, empiric observations that use of this product, especially in combination with other modalities such as negative-pressure wound therapy, can often generate granulation tissue even over challenging surfaces, such as bone, tendon, and hardware, have led to its off-label application for clinical situations where other methods of reconstruction are not feasible as illustrated in the accompanying case (Figure 6.2).

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FIGURE 6.2 Using skin substitutes as a bridging therapy. A. This patient sustained an open fracture to his left lateral ankle after a motor vehicle collision. B. After open reduction and internal fixation by the orthopedic surgeon, the patient underwent debridement and was left with a significant soft tissue deficit with exposed bone and hardware (visible near posteroinferior wound border). Lengthy surgical intervention with conventional flap reconstruction techniques was deemed inadvisable because of cardiac issues. C. To provide temporary coverage, Integra was applied over the wound. D. Negative-pressure wound therapy was initiated over the Integra and continued for 8 weeks, at which point viable revascularized neodermis had fully filled the 2-cm deep cavity, provided coverage of the bone and hardware, and was flush with the surrounding skin. E. This allowed placement of a split-thickness skin graft. F. The skin graft demonstrated good take, with near-complete reepithelialization 3 weeks after application.

Each year sees the introduction of new or modified products intended as advanced wound therapy. However, high-level clinical evidence, rigorous cost-benefit analyses, and other research supporting their routine use remain incomplete, with many of the products not uniformly available because of lack of regulatory approval or restrictive reimbursement and formulary policies. Nonetheless, the use of skin substitutes and related products has entered the mainstream of contemporary clinical practice. Recent reviews summarizing these products with extensive lists and tables can be found in the existing medical and scientific literature, 47,48 and therefore will not be duplicated here, given the constant flux and changes in available products and evidence. Although the full potential of skin substitutes remains yet to be achieved, with their ability to promote wound closure and act as important temporizing bridges to definitive treatment, skin substitutes and their related brethren products have become an important adjunct in complex wound management for the plastic surgeon.

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Conclusion Autologous skin grafts are a key foundational technique of plastic surgeons and remain a mainstay of reconstructive surgery for wounds despite the development of more advanced surgical techniques. Surgeons may choose between split-thickness and full-thickness skin grafts depending on various factors including graft characteristics (color match, size, amount of primary and secondary contraction), donor site availability and morbidity, and recipient site requirements. Once applied to a wound bed, skin grafts heal by a process of imbibition and revascularization, which is a combination of angiogenic vessel outgrowth originating in the wound bed, reperfusion of the preexisting graft vasculature, and partial replacement of the existing graft vessels. To minimize shear forces and fluid collecting at the interface, both of which can lead to graft loss, skin grafts are typically immobilized during the postoperative period with bolster dressings, which in recent years are more frequently comprised of negative-pressure wound dressings. Limitations of conventional skin grafts spur the development of biologic and synthetic skin substitutes. Although the goal of using skin substitutes for definitive wound coverage remains elusive, skin substitutes and similar products have established a role in providing temporary wound coverage and assisting in the healing and preparation of wound beds until definitive coverage can be obtained.

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Questions 1. Which option correctly describes the properties of split-thickness skin grafts compared with fullthickness skin grafts? a. More primary contracture, less secondary contracture, more metabolic demand from the graft bed b. Less primary contracture, more secondary contracture, more metabolic demand from the graft bed c. More primary contracture, less secondary contracture, less metabolic demand from the graft bed d. Less primary contracture, more secondary contracture, less metabolic demand from the graft bed 2. Which combination of biologic events characterizes the stage of plasma imbibition of skin graft healing? a. Aerobic metabolism of graft cells, increased metabolic demand of the graft, plasma leak into the wound bed, and increased graft weight secondary to edema b. Plasma leak into the wound bed, increased metabolic demand of the graft, microvascular ingrowth into the graft, and increased graft weight secondary to edema c. Anaerobic metabolism of graft cells, decreased metabolic demand of the graft, plasma leak into the wound bed, and acidic pH d. Anaerobic metabolism of graft cells, acidic pH, decreased weight of the graft secondary to evaporative losses, and fibrinogen conversion to fibrin at the graft interface 3. What is the primary mechanism by which blood flow is reestablished in a skin graft? a. Reperfusion of existing graft vasculature by inosculation, a process by which blood vessels from the underlying wound bed connect end-to-end with existing vessels in the skin graft at the graft interface b. Microvascular ingrowth from the wound bed, with a temporary angiogenic response from the preexisting graft vasculature, which also acts as a conduit for capillary ingrowth c. Revascularization from the wound bed, with formation of entirely new vascular channels via angiogenesis within the graft and obliteration of preexisting vessels d. Temporary angiogenic response within the graft, leading to capillary budding within the graft, increased expression of matrix metalloproteinases MT1-MMP and MMP-2, and microvascular growth from the graft to the wound bed 4. A 23-year-old man presents to the emergency department after sustaining full-thickness burns to the volar fingers of his dominant hand. After debridement, the tendons are exposed, with viable paratenon. The patient wants to minimize his number of surgeries and time out of work. What is the best option for resurfacing? a. Split-thickness skin graft from the anterolateral thigh b. Application of Integra, with staged application of a split-thickness skin graft from the buttock c. Application of Alloderm d. Full-thickness skin graft from the inguinal crease e. Split-thickness skin graft from the scalp 5. A 65-year-old man with PVD, congestive heart failure, and well-controlled type 2 diabetes is evaluated for a chronic lower extremity wound. The wound appears to have a well-granulating bed, and it is not debrided before a split-thickness skin graft from the anterior thigh is applied. What is the factor most likely to lead to graft failure in this patient?

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a. Peripheral edema secondary to congestive heart failure b. PVD c. Type 2 diabetes d. Quantitative wound bacterial count greater than 105 organisms per gram of tissue 1. Answer: d. Split-thickness skin grafts (containing epidermis and a portion of dermis) experience less primary contracture, experience more secondary contracture, may experience more pigment changes, are more susceptible to trauma, and have a lower metabolic demand of the recipient site wound bed, when compared with full-thickness skin grafts (which contain epidermis and the full dermis). 2. Answer: c. The first stage of graft healing, the stage of plasma imbibition, is characterized by fibrinogen conversion to fibrin at the graft interface to facilitate adherence, plasma leak from wound bed capillaries, increased weight of the graft secondary to edema, anaerobic metabolism and decreased metabolic demands of graft cells, and an acidic pH of approximately 6.8. Microvascular ingrowth does not occur until the stage of revascularization. 3. Answer: b. After the stage of plasma imbibition, blood flow to the healing graft is established by revascularization. Angiogenesis begins within the wound bed, with capillary budding and the ingrowth of newly formed vessels into the graft tissue. A temporary angiogenic response within the graft also occurs, with increased expression of matrix metalloproteinases MT1-MMP and MMP-2 allowing lysis of the existing capillaries to connect the graft and wound bed vasculature, leading to reperfusion of parts of the existing graft vasculature. Preexisting graft vasculature acts as a conduit for capillary ingrowth and is replaced either partially or fully by host endothelial cells by 10 days after grafting. 4. Answer: d. To receive a skin graft, a wound bed must have healthy vascularized tissue at its base. A skin graft is less likely to heal over exposed tendon or bone without paratenon or periosteum. The increased secondary contraction of split-thickness skin grafts mean that they are not ideal for resurfacing the flexor surfaces of joint, as they can cause joint contracture and limited range of motion. This patient wants to minimize his number of surgeries and time out of work; therefore a staged reconstruction with Integra and a split-thickness skin graft would be more time-consuming than a one-stage procedure. Alloderm can be used as temporary wound coverage but is only a dermal skin substitute and the wound would likely still need to be definitively covered with an autologous skin graft at a later time point. 5. Answer: d. Skin grafts are likely to fail if bacterial loads on the quantitative culture are greater than 105 organisms per gram of tissue. Although peripheral edema, PVD, and type 2 diabetes are all factors than can contribute to delayed skin graft healing, adequate debridement of the wound leading to decreased bacterial counts is necessary for successful graft healing.

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References Ratner, D. Skin grafting: from here to there. Dermatol Clin. 1998;16(1):75-90. Hauben, DJ, Baruchin, A, Mahler, A. On the history of the free skin graft. Ann Plast Surg. 1982;9(3):242-245. Chick, LR. Brief history and biology of skin grafting. Ann Plast Surg. 1988;21(4):358-365. Kanitakis, J. Anatomy, histology and immunohistochemistry of normal human skin. Eur J Dermatol. 2002;12(4):390-399; quiz 400-391. Corps, BV. The effect of graft thickness, donor site and graft bed on graft shrinkage in the hooded rat. Br J Plast Surg. 1969;22(2):125-133. Lindenblatt, N, Calcagni, M, Contaldo, C, et al. A new model for studying the revascularization of skin grafts in vivo: the role of angiogenesis. Plast Reconstr Surg. 2008;122(6):1669-1680.This 2008 study detailed the development of a mouse model that allowed repeated intravital microscopy to assess the microcirculation during skin graft healing. They determined that capillary widening in the wound bed appeared at day 1 after grafting and increased until day 4, while capillary buds and sprouts first appeared at day 2. Blood filling of autochthonous graft capillaries occurred at day 3, resulting in almost complete restoration of the original skin microcirculation on day 5 through interconnections between the microvasculature of the wound bed and the skin graft through a temporary angiogenic response. O’Donoghue, MN, Zarem, HA. Stimulation of neovascularization: comparative efficacy of fresh and preserved skin grafts. Plast Reconstr Surg. 1971;48(5):474-478. Converse, JM, Uhlschmid, GK, Ballantyne, DL. “Plasmatic circulation” in skin grafts. The phase of serum imbibition. Plast Reconstr Surg. 1969;43(5):495-499.This classic 1969 paper by Converse et al. defined the phase of serum imbibition, referring to the absorption of serum from the wound bed after grafting, which replaced the previously accepted plasmatic circulation. Full-thickness skin grafts were excised in rats, weighed prior to grafting, and re-weighed 1 to 11 postoperative days after grafting. The grafts had a characteristic increase in weight in the first 48 to 72 hours, followed by a steady decrease, which they hypothesized was due to serum absorption from the wound bed, which was followed by the resolution of the edema once the graft microcirculation was reestablished. Pepper, FJ. Studies on the viability of mammalian skin autografts after storage at different temperatures. Br J Plast Surg. 1954;6(4):250-256. Hinshaw , Miller, ER. Histology of healing split-thickness, full-thickness autogenous skin grafts and donor sites. Arch Surg. 1965;91(4):658670. Clemmesen, T. The early circulation in split skin grafts. Acta Chir Scand. 1962;124:11-18. Peer, LA, Walker, JC. The behavior of autogenous human tissue grafts: a comparative study. 1. Plast Reconstr Surg (1946). 1951;7(1):6-23. Rous, P. The relative reaction within living mammalian tissues. VI. Factors determining the reaction of skin grafts; a study by the indicator method of conditions within an ischemic tissue. J Exp Med. 1926;44(6):815-834. Wu, X, Kathuria, N, Patrick, CW, Reece, GP. Quantitative analysis of the microvasculature growing in the fibrin interface between a skin graft and the recipient site. Microvasc Res. 2008;75(1):119-129. Clemmesen, T. Experimental studies on the healing of free skin autografts. Dan Med Bull. 1967;14(suppl 2):1-73. Haller, JA, Billingham, RE. Studies of the origin of the vasculature in free skin grafts. Ann Surg. 1967;166(6):896-901. Birch, J, Branemark, PI. The vascularization of a free full thickness skin graft. I. A vital microscopic study. Scand J Plast Reconstr Surg. 1969;3(1):1-10. Converse, JM, Ballantyne, DL. Distribution of diphosphopyridine nucleotide diaphorase in rat skin autografts and homografts. Plast Reconstr Surg Transpl Bull. 1962;30:415-425. Converse, JM, Rapaport, FT. The vascularization of skin autografts and homografts: an experimental study in man. Ann Surg. 1956;143(3):306-315. Wolff, K, Schellander, FG. Enzyme-histochemical studies on the healing-process of split skin grafts. I. Aminopeptidase, diphosphopyridinenucleotide-diaphorase and succinic dehydrogenase in autografts. J Invest Dermatol. 1965;45:38-45. Zarem, HA, Zweifach, BW, McGehee, JM. Development of microcirculation in full thickness autogenous skin grafts in mice. Am J Physiol. 1967;212(5):1081-1085. Lindenblatt, N, Platz, U, Althaus, M, et al. Temporary angiogenic transformation of the skin graft vasculature after reperfusion. Plast Reconstr Surg. 2010;126(1):61-70. Knapik, A, Hegland, N, Calcagni, M, et al. Metalloproteinases facilitate connection of wound bed vessels to pre-existing skin graft vasculature. Microvasc Res. 2012;84(1):16-23.Skin graft vasculature in this mouse model demonstrated a temporary angiogenic response to reperfusion, which was pruned after several days and exhibited a different morphology than regular sprouting angiogenesis present within the wound bed. Matrix metalloproteinases were found to be involved in capillary ingrowth and regression, with MT1-MMP expressed predominantly on sprout tips imparting vessel-to-vessel connections, and MMP-2 around vessel sprouts during sprouting angiogenesis facilitating the degradation of the extracellular matrix. Calcagni, M, Althaus, MK, Knapik, AD, et al. In vivo visualization of the origination of skin graft vasculature in a wild-type/GFP crossover model. Microvasc Res. 2011;82(3):237-245.To determine the origin of skin graft vasculature once healed, a crossover wild-type/GFP skin transplantation model was created, in which each animal carried the graft from the other strain. This demonstrated a replacement of existing graft capillaries with vessels from the wound bed in 68% of the vessels overall, with vessel replacement in almost 100% of graft vessels at the periphery of the graft. These data indicate an early ingrowth of angiogenic bed vessels into the existing vascular channels of the graft and subsequent partial to full centripetal replacement. Cassavaugh, J, Lounsbury, KM. Hypoxia-mediated biological control. J Cell Biochem. 2011;112(3):735-744. Smahel, J. The healing of skin grafts. Clin Plast Surg. 1977;4(3):409-424.

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Medawar, PB. The behaviour and fate of skin autografts and skin homografts in rabbits: a report to the War Wounds Committee of the Medical Research Council. J Anat. 1944;78(Pt 5):176-199. Medawar, PB. A second study of the behaviour and fate of skin homografts in rabbits: a report to the War Wounds Committee of the Medical Research Council. J Anat. 1945;79(Pt 4):157-176 154. Rudolph, R, Klein, L. Isotopic measurement of collagen turnover in skin grafts. Surg Forum. 1971;22:489-491. Ohuchi, K, Tsurufuji, S. Degradation and turnover of collagen in the mouse skin and the effect of whole body x-irradiation. Biochim Biophys Acta. 1970;208(3):475-481. Brown, D, Garner, W, Young, VL. Skin grafting: dermal components in inhibition of wound contraction. South Med J. 1990;83(7):789-795. Rudolph, R. Inhibition of myofibroblasts by skin grafts. Plast Reconstr Surg. 1979;63(4):473-480. Oliver, RF, Grant, RA, Kent, CM. The fate of cutaneously and subcutaneously implanted trypsin purified dermal collagen in the pig. Br J Exp Pathol. 1972;53(5):540-549. Ramanujam, CL, Han, D, Fowler, S, et al. Impact of diabetes and comorbidities on split-thickness skin grafts for foot wounds. J Am Podiatr Med Assoc. 2013;103(3):223-232. Robson, MC, Krizek, TJ. Predicting skin graft survival. J Trauma. 1973;13(3):213-217. Brolmann, FE, Eskes, AM, Goslings, JC, et al. Randomized clinical trial of donor-site wound dressings after split-skin grafting. Br J Surg. 2013;100(5):619-627. Kirsner, RS, Falanga, V, Eaglstein, WH. The biology of skin grafts: skin grafts as pharmacologic agents. Arch Dermatol. 1993;129(4):481-483. Gielen, V, Faure, M, Mauduit, G, Thivolet, J. Progressive replacement of human cultured epithelial allografts by recipient cells as evidenced by HLA class I antigens expression. Dermatologica. 1987;175(4):166-170. Burt, AM, Pallett, CD, Sloane, JP, et al. Survival of cultured allografts in patients with burns assessed with probe specific for Y chromosome. BMJ. 1989;298(6678):915-917. Phillips, TJ, Bhawan, J, Leigh, IM, et al. Cultured epidermal autografts and allografts: a study of differentiation and allograft survival. J Am Acad Dermatol. 1990;23(2 Pt 1):189-198. Singh, M, Nuutila, K, Kruse, C, et al. Challenging the conventional therapy: emerging skin graft techniques for wound healing. Plast Reconstr Surg. 2015;136(4):524e-530e. Kanapathy, M, Hachach-Haram, N, Bystrzonowski, N, et al. Epidermal grafting for wound healing: a review on the harvesting systems, the ultrastructure of the graft and the mechanism of wound healing. Int Wound J. 2017;14(1):16-23. Hammer, D, Rendon, JL, Sabino, J, et al. Restoring full-thickness defects with spray skin in conjunction with dermal regenerate template and split-thickness skin grafting: a pilot study. J Tissue Eng Regen Med. 2017;11(12):3523-3529. Cuono, C, Langdon, R, McGuire, J. Use of cultured epidermal autografts and dermal allografts as skin replacement after burn injury. Lancet. 1986;1:1123-1124. Lazic, T, Falanga, V. Bioengineered skin constructs and their use in wound healing. Plast Reconstr Surg. 2011;127(suppl 1):75S-90S. Pruitt, BA, Levine, NS. Characteristics and uses of biologic dressings and skin substitutes. Arch Surg. 1984;119(3):312-322. Nyame, TT, Chiang, HA, Leavitt, T, et al. Tissue-engineered skin substitutes. Plast Reconstr Surg. 2015;136(6):1379-1388. Vig, K, Chaudhari, A, Tripathi, S, et al. Advances in skin regeneration using tissue engineering. Int J Mol Sci. 2017;18(4). Moiemen, NS, Vlachou, E, Staiano, JJ, et al. Reconstructive surgery with Integra dermal regeneration template: histologic study, clinical evaluation, and current practice. Plast Reconstr Surg. 2006;117(suppl 7):S160-S174.The healing of the Integra dermal regeneration template was assessed in 20 human patients using weekly punch biopsies. Four stages of dermal regeneration could be demonstrated histologically: imbibition, fibroblast migration, neovascularization, and remodeling, and maturation. Full vascularization of the neodermis occurred at 4 weeks. Molnar, JA, DeFranzo, AJ, Hadaegh, A, et al. Acceleration of Integra incorporation in complex tissue defects with subatmospheric pressure. Plast Reconstr Surg. 2004;113(5):1339-1346.

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CHAPTER 7

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Principles of Flap Reconstruction: Muscle Flaps, Myocutaneous Flaps, and Fasciocutaneous Flaps Michele Ann Manahan

Key Points Understand the definition of the term flap. Understand classifications of types of flaps. Become familiar with elements of essential clinical decision-making with regard to flaps as treatment options. Understand basic procedural elements associated with common flaps. Increase awareness of and vigilance for pitfalls of flap use. An understanding of surgical manipulation of vascularized tissue or flaps, and the ability to employ this, could be considered the defining core competency of plastic surgery. A chapter dedicated to flaps can only ever be a starting point from which to build a lifetime of learning. This chapter could never be considered completely comprehensive, because an understanding of flaps requires a thorough knowledge of basic principles as well as a working knowledge of current popular and successful surgical techniques, balanced with awareness of more historical flap designs that may still be called into use in salvage situations. This chapter will begin with a review of high points in the historical chronology of surgical transfer of vascularized tissue, or flaps. Principles will then be explained as they relate to the broad categories of flaps. Pertinent clinical examples will be reviewed in these areas as well.

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Patient and Technique Selection Although the remainder of the chapter will serve to highlight the vast number of flap choices available for reconstruction, several unifying tenets regarding patient and technique selection remain important. One must always consider patient factors such as comorbidities, nicotine dependence, and local tissue history (e.g., radiation, trauma, previous surgery) in preoperative planning because these may all affect intraoperative and postoperative outcomes. 1 Optimize nutrition when possible. Consideration of the reconstructive ladder is also essential. The great variety of flap techniques, and modern facility with these, makes flap use appealing. One should remember, however, that healing by secondary intention, primary closure, skin grafting, and other techniques continue to have valid places in modern reconstruction. Flap selection should also be considered in terms of the size of the flap, recipient site needs, location of donor site, and potential associated morbidities. Muscle flaps are generally believed to fill dead space effectively, potentially owing to bulk, blood supply, and stickiness of tissue, although many authors believe that fasciocutaneous flaps are fully capable of these tasks. A healthy flap does not obviate the need for appropriate surgical timing, in terms of both overall patient condition and local wound readiness. Proper debridement and control of infection must be balanced with the need for coverage of critical structures when considering flap coverage timing. One must also remember to consider temporizing measures for wound control in situations when preparation of the donor site is necessary. For example, prefabrication of flaps with pretransfer tissue expansion can increase the surface area of the transferred tissue, decrease donor site closure difficulty, and thin flaps for better fit into recipient areas. 1 Understanding of the flap itself is insufficient for adequate use of flaps as surgical treatments. One must also understand the recipient site needs and interactions between flaps and recipient sites. For example, recipient site vessel size, orientation, and flow must be considered prior to free tissue transfer. Techniques including end-to-end anastomoses, end-to-side anastomoses, surgical delays (selective ligation of some vascularity to augment remaining vascularity), vein grafting and/or loops, retrograde vessel properties, supercharging, and many others can salvage a suboptimal situation. Alternative techniques need to be considered preoperatively should an intraoperative failure of the planned flap occur. Patients should be counseled about the potential use of alternative treatments before they become necessary.

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Historical Classifications The key defining feature of transfer of a vascularized segment of soft tissue, the most basic definition of a flap, is maintenance of blood supply. There are many types of vascularity. 2 Esser characterized the necessity of vascular inflow as well as outflow. 3 McGregor and Morgan defined random versus axial patterns of blood supply. They described random pattern flaps as without bias in vascular pattern compared with axial pattern flaps with an arteriovenous system oriented along the long axis. 4 Taylor and Palmer defined angiosomes, or segments of skin reliably supplied by single source vessels. They further described that these vessels can approach the skin directly or indirectly through fascial septae (septocutaneous perforators), perforating through muscle (musculocutaneous perforators), and via choke vessels between cutaneous and fascial networks. 5 Free tissue transfer with microvascular anastomosis was described as a separate method of moving tissue by pedicled transfer in the early 1970s. 6,7 Separation of the target tissue from bulky underlying soft tissue serving as a conduit for the source vessel was first described as perforator surgery in 1989. 8 Increasing variety of designs based not only on known, named vessels but also on a free style fashion by deriving vessels from and to nearly any part of the body. 2 We will now review some of the more widely accepted flap classifications pertinent to current practice.

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Contemporary Classification Systems Muscle Flap Classification Mathes and Nahai created the most widely used classification for muscle flaps based on pedicle type. Their classification is reproduced in Table 7.1. These anatomical variations affect arc of rotation, skin island design, survival of more distal portions of the muscle flap, microvascular utility, and need for consideration of surgical delay techniques (partial harvest separated by a period of weeks from completion of harvest of tissue). 9 TABLE 7.1 Mathes and Nahai Classification of Muscle Flaps Type I II

III IV V

9

Vascular Pedicle One dominant One dominant, minor supplemental Two dominant Multiple segmental

Examples Gastrocnemius, rectus femoris, tensor fascia lata Biceps femoris, gracilis, platysma, peroneus longus/brevis, soleus, temporalis, trapezius, vastus lateralis

Considerations One main blood supply for flap One main blood supply for flap

Semimembranosus, rectus abdominis, gluteus maximus Tibialis anterior, sartorius

One dominant, multiple segmental

Pectoralis major, latissimus dorsi

Two, often equivalent, blood supplies for flap One main blood supply, necessary to maintain pedicle for each transferred segment May be based on dominant or multiple segmental sources

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Myocutaneous Flap Classification Myocutaneous flaps are most easily considered in a similar fashion to the underlying muscle that serves as the bridge of vascularity to the overlying skin and subcutaneous tissue. For myocutaneous flaps, the reliability of the main pedicle is quite important as is the likelihood of musculocutaneous perforators arising from this pedicle. As Mathes and Nahai also describe in their landmark paper, skin islands most distal from the vascular source are least likely to be reliable, and certain patterns (types II and IV, particularly) are known to have the least reliable skin paddles, most particularly distally. 9

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Fasciocutaneous Flap and Perforator Flap Classifications Thorough understanding of muscle flaps and their vascular anatomy stands as an essential base for understanding fasciocutaneous flaps. Over time, the evolution of perforator flaps from basic fasciocutaneous flaps has decreased sacrifice of muscle. The ability to transfer substantial pieces of skin and subcutaneous tissue on single submillimeter diameter vessels perforating into flap substances from underlying source vessels has allowed a nearly uncategorizable plethora of flaps to become useful and popular in modern reconstruction. Perforator flaps provide greater variety and reliability of skin paddle design because individual perforators are now routinely able to be identified and dissected as they enter fasciocutaneous islands. This versatile flap uses tissue from adjacent areas for good color and structural match to the recipient site. These techniques have made classifications of fasciocutaneous flaps less essential and prone to overgeneralization, but an understanding of the core anatomical variations as initially described can be helpful in designing modern flaps. Historically, Cormack and Lamberty described four categories, as shown in Table 7.2. 10 TABLE 7.2 Cormack and Lamberty Historical Fasciocutaneous Flap Classification 10 Type A B C D

Vascular Anatomy Multiple, codominant fasciocutaneous perforators Single, dominant fasciocutaneous perforator Single or multiple septocutaneous perforators Inclusion of other structures like bone and muscle along the source vessel

Examples Sartorius, upper arm Supraclavicular Radial forearm flap Radial forearm with radius

As discussed in this section, the concept of fasciocutaneous flaps has progressed well beyond this more basic classification schema. Much debate has occurred in the effort to better classify modern flap usages. 11-15 Building upon the perforator concept, chimeric flaps can be designed to incorporate various flaps and flap substances (bone, muscle, fascia, skin/subcutaneous fat) based on different perforators coalescing to a single source vessel.

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Local Tissue Rearrangement Understanding of perforator flap anatomy expands the standard random pattern local tissue rearrangement techniques (e.g., bilobed flaps, rhomboids) for wound closure. More recently defined propeller flaps and keystone flaps utilize perforator anatomy for local tissue rearrangement. Greater flexibility of flap design allows for accommodation of local tissue laxity and availability. Insider tip: Design the skin paddle over perforator hot spots to incorporate dominant or multiple perforators. 1

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Propeller Flap Described by Hyakusoku et al. in 1991, the propeller flap is an island flap that reaches the recipient site through an axial rotation. 1,16,17 The propeller flap technique creates a wide exploratory incision near expected perforator vessel sites, followed by selection of the dominant perforator (supra- or subfascially) at the optimal pivot point. Perforator location closest to the defect is preferred for wider angle of rotation to minimize tension on the pedicle. Dissection toward and along the source vessel is performed until adequate length is obtained for a lazy S-turn without kinking. The flap perfusion should be confirmed prior to inset with handheld Doppler evaluation. The remainder of the flap skin island can be incised after perforator dissection to optimize flap rotation. 1,18 Insider tips: Skeletonizing the pedicle toward the flap can increase pedicle length. 1 Design the skin paddle larger than the defect for tension-free closure, even with postoperative edema. 1

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Keystone Flap The keystone flap, described in 2003 by Behan, 19 is designed as two opposing V-Y flaps oriented parallel to the longitudinal axis of the defect, elevated as a single multiperforator fasciocutaneous advancement flap. Several variations have been described. Centering the flap over the perforators expands the undermining, and circumferential incision of the deep fascia at the flap margin can increase mobility. Larger flaps may increase donor site morbidity but may be necessary to accommodate difficult local tissue environments (e.g., inflammation, previous irradiation/undermining). 1

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Free-Style Flaps and Supermicrosurgery By applying basic perforator flap techniques, transfer of fasciocutaneous, fascia only, or cutaneous only components may be accomplished in nearly any part of the body. Technical mastery of the following critical steps will open the entire anatomy to consideration for tissue transfer as a flap with over 350 known potential perforators for use. 1,11 The technique begins with prediction of existence of perforating blood vessels into the superficial soft tissue of choice. Certain locations have fairly predictable perforating blood supply (e.g., periumbilical perforators from the deep inferior epigastric vessel, through the rectus abdominis muscle, and into a vertical or transversely designed lower abdominal skin island). In these areas, and in areas with less interpatient reliability of the presence of these perforators, imaging techniques can optimize preoperative predictability of skin island design. These include handheld Doppler, color duplex scanning, magnetic resonance angiography, multidetector-row helical computed tomography, and laser angiography. 2 Dissection through the soft tissue of the flap is usually followed by elevation of the underlying soft tissue known to contain the source vessel. After identification of the perforator or perforators, selective inclusion of one or several is decided, and these are followed proximally to larger and larger caliber vessels, considered the source. Depending on the unique characteristics of the recipient site needs, the proximal dissection can proceed until sufficient pedicle length and size for anastomosis is obtained. 2 Supermicrosurgery is becoming more popular as the aforementioned techniques are considered for shorter pedicles and smaller-diameter anastomoses with increased magnification and refinement of microsurgical instruments and skills. Anastomoses of vessels well under 1 mm in diameter permit preservation of deep fascia and minimize risk to underlying soft tissues such as muscles that require dissections through their substance to trace to the larger source vessel. 2,20 Donor site size, texture, color, thickness, and pliability can all be optimized with freedom to design flaps over virtually any part of the body. It is expected that in the future, these techniques may be considered routine; however, it is still worth noting that at this point, these are considered technically demanding and best attempted after mastery of more basic perforator flap techniques. 2 Insider tips: Assessment of perforator adequacy can be determined by preoperative imaging, intraoperative imaging and Doppler assessment, visual inspection for size and pulsation, and differential temporary vessel clamping with assessment of end-organ (flap) viability. Incorporating potential lifeboats such as possible backup perforating vessels, backup skin paddle designs, and backup flaps and burning bridges to these options as late as possible in the dissection may allow salvage in the event of an unforeseen and undesirable intraoperative circumstance. 2

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Clinical Examples Lateral Arm Flap This flap is most commonly used when thin, pliable tissue is needed and may be harvested as a chimeric flap with bone. Most of the time, primary closure of the donor site is possible (particularly with skin paddles less than 5-7 cm in width). Some surgeons consider it a workhorse, whereas others express concerns about inconsistent perforator anatomy, short pedicle length, small vessel caliber, and challenging dissection. 21

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Surgical Technique With the arm across the torso, the deltoid insertion and lateral epicondyle may be palpated and connected by a line along which septal perforators from the radial collateral artery between the biceps brachii and triceps can be found with handheld Doppler probe. After marking a skin paddle centered over these, the posterior incision is usually made first, followed by subfascial dissection and identification of the perforators that may then be followed proximally. The skin island dissection can then be completed. 21 Insider tips: Identify and protect the radial nerve during dissection. 21 The deltoid insertion may also be divided to increase pedicle length as the radial collateral artery courses toward the brachial artery. 21 The posterior antebrachial cutaneous nerve must be divided but can be used to create a sensate flap. 21

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Radial Forearm Flap This fasciocutaneous flap provides thin, pliable tissue in most types of bodies. It has been used for many reconstructive needs (e.g., intraoral, penile/urethral, extremity). Its popularity arises from the ease of dissection; robust, reliable vascularity; malleability; and ability to support associated tissues such as bone, tendon, and nerve. 22 The donor site is difficult to hide and may be associated with stigma in certain populations as it often needs a skin graft (meshed or sheet, with or without dermal support) for closure. This flap can be used as a sensate flap, in a reversed fashion, as a flow-through flap, as an adipofascial flap, or with a short segment of partial thickness radius. When harvested with the palmaris longus tendon, the flap can also be used for functional purposes. Some of the versatility arises from the multiple venous drainage options, including the superficial system based on the larger cephalic vein and/or the deep system based on the paired venae comitantes of the radial artery, which are considered to more reliably drain the radial forearm tissue. 22-24

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Surgical Technique The skin paddle is outlined on the volar, distal, radial forearm. Incision through the skin, adipose tissue, and fascia may be performed, elevating these toward the radial artery that runs between the brachioradialis and flexor carpi radialis in the distal forearm, sending multiple septocutaneous perforators to the overlying soft tissue. 25 Lateral antebrachial cutaneous nerve, palmaris longus tendon, and superficial veins may be incorporated in the harvest and followed along their courses prior to transection. The radial nerve should be protected as should the vascularity of the tendon sheaths so that a skin graft may be applied. 25 Insider tips: Check the Allen test prior to flap harvest to confirm a complete arch communication between the ulnar and radial artery to protect distal perfusion. A tourniquet is useful, but keep in mind tourniquet times. Nearby upper extremity flaps to know: Medial arm (introduced by Tagliacozzi in the 1600s), 26 ulnar artery (less hairy, better postoperative donor site appearance than radial), digital flaps

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Rectus Abdominis, Deep Inferior Epigastric, and Superficial Inferior Epigastric Flaps The abdomen, specifically the rectus abdominis muscle and the skin supplied by its musculocutaneous perforators, is a common donor site. Because of its type II, dual blood supply, a superiorly based rectus flap can be pedicled for upper trunk reconstruction. The more reliable blood supply is the deep inferior epigastric system entering the inferior aspect of the muscle. This reliably supplies perforators, most commonly to the periumbilical area, which can be pedicled or free transfer of muscle, muscle and skin island, or skin and subcutaneous tissue alone. The skin is usually oriented either vertically as a VRAM (vertical rectus abdominis myocutaneous) flap or transversely as a TRAM (transverse rectus abdominis myocutaneous) flap. These orientations are also appropriate when used as a perforator flap without muscle or fascial sacrifice. 27 Sensation can be restored with harvest of branches of thoracolumbar spinal nerves. 28 Skin and adipose tissue of a large surface area can also be based on the superficial inferior epigastric system, although reliability of adequate blood vessels in this area is less assured. Flaps are usually harvested as a unilateral single unit based on blood supply from one rectus muscle or as two flaps, each based on its ipsilateral blood supply. These flaps are popular for breast and perineal reconstruction, among other uses. 27

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Surgical Technique Incision of one side of the planned flap is usually accomplished through the subcutaneous fat, and the tissue is elevated superficial to the anterior rectus fascia (if starting in midline) or fascia of the external oblique (if starting laterally). Perforators are identified and followed through the fascia and rectus muscle toward the inferior epigastric vessels’ origins in the groin. When a muscle flap is used, the borders of the rectus muscle are identified rather than perforators, and the anterior fascia is resected with the muscle. Care should be given to identification and ligation of the opposite epigastric system (superior epigastric if deep inferior epigastric vessels are harvested as the pedicle). 27 With perforator flaps, the anterior rectus fascia can often be closed primarily. Some authors choose to reinforce this with prosthetic mesh or biologic matrix. Harvest of a portion of the rectus fascia and/or muscle may require more formal abdominal wall reconstruction using the many available techniques discussed elsewhere in this text. These are important considerations, as abdominal weakness, bulge, and hernia are the most specific complications associated with this flap. 28 Insider tips: Islandization of the umbilical stalk provides a more aesthetic donor site, but patients should understand that harvest of a vertical unilateral skin island may distort the midline. Preservation of portions of the multiple superficial and deep blood supplies to this tissue (e.g., contralateral deep system, ipsi or contralateral superficial system) can salvage clinically marginal tissue noted during flap harvest through additional venous drainage or supercharging. Nearby trunk flaps to know: Superficial circumflex iliac artery , groin, Rubens flaps (deep circumflex iliac artery flaps) 29

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Latissimus Dorsi and Thoracodorsal Artery Perforator Flaps The latissimus muscle flap may be harvested based on multiple medial posterior thoracic intercostal or lumbar perforators or on the laterally based thoracodorsal pedicle. This arises as a terminal branch of the subscapular artery off the axillary artery (or occasionally directly from the axillary artery). 30 The latissimus is a broad, fan-shaped muscle (originating from the posterior iliac crest and lower six vertebrae and inserting into the humerus to form the posterior axillary fold) 30 that can be useful for many defects extending as a pedicled flap to the head and neck and anterior trunk and as free tissue transfer anywhere on the body. 31,32 Its versatility arises from the ease of harvest, large surface area, and long vascular pedicle. 30 Skin islands may be designed in multiple orientations to address reconstructive needs or to minimize donor site morbidity. Using perforator techniques similar to that described earlier for deep inferior epigastric artery perforator flaps, a thoracodorsal artery perforator flap (TDAP) may be harvested with dissection from the desired skin island, along the preferred perforator and more proximally along the thoracodorsal source vessel. 30 The TDAP can still provide a long vascular pedicle and large surface area but decreases potential morbidity and unnecessary bulk. 33 Additionally, the muscle or perforator flap can be harvested with more than one soft tissue island, splitting the tissue based on the transverse and vertical branches of the thoracodorsal, or including bone based on the angular branch to the tip of the scapula.

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Surgical Technique Positioning is often via lateral decubitus for unilateral harvest and prone for bilateral harvest, but some authors advocate supine harvest for a TDAP. 30 Technique depends on skin island design and perforatoror muscle-harvesting technique. Key points include identification of the vascular pedicle when using the muscle and dissection of this as proximal as possible for greater pedicle length, useful either for pedicled or free indications. Closure of the donor site with careful use of percutaneous drains, quilting sutures, or other techniques to minimize seroma is necessary as this donor site has risk for seroma formation. Shoulder function may be impaired, but many authors support preservation of ability to engage in activities of daily living. 30 Insider tips: Consider previous treatment that might interrupt the thoracodorsal pedicle such as axillary dissection. In this situation, this flap can still be used by relying on blood flow through the serratus branch. When used in breast reconstruction, it often requires volume supplementation with an implant. Consider denervating the muscle flap by transecting the thoracodorsal nerve. Nearby posterior trunk flaps to know: Paraspinous muscle, trapezius, scapular/parascapular flaps

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Gluteal and Superior Gluteal Artery Perforator Flaps Early descriptions of the gluteal myocutaneous flap occurred in the 1970s, and the perforator flap based on the superior gluteal artery became widely recognized two decades later. 34,35 The superior gluteal artery perforator flap harvest is considered technically difficult by many. Lateral decubitus or supine positioning is recommended. The buttock tissue yields firmer, more septated, and less malleable flaps than most other areas. Donor scars can be positioned horizontally or obliquely with a lateral translocation in some patients who demonstrate appropriate perforator anatomy for a better lift of the inferior buttock and hip. 36 Concern exists regarding donor site scarring, contour, and possible impact on ambulation, but those who perform many of these flaps report high success. 36-39

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Surgical Technique Markings and skin island design may be approached variably. One method uses Doppler identification of perforators one-third to two-thirds of the distance between the posterior superior iliac spine and greater trochanter with skin island design centered on a line from coccyx to anterior superior iliac spine (ASIS). Dissection can be beveled away from the flap, particularly deep to superficial fascia to capture more tissue. The gluteus maximus fascia is incised and either the muscle flap is harvested or the fascia is elevated off the gluteal muscle (with cautery action parallel to direction of muscle fascicles) to identify the perforator. Deep to the gluteal muscle, a venous plexus requires exacting dissection. 36 Insider tips: Careful hemostasis is required deep to the gluteal muscle within the vascular plexus to avoid damage to surrounding structures or pedicle. Be prepared for a shorter pedicle or smaller vessel size than with some other flaps. Nearby gluteal flaps to know: Inferior gluteal artery perforator, lumbar artery perforator flap

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Upper Thigh Flaps: Gracilis, Transverse/Diagonal Upper Gracilis, Profunda Artery Perforator The gracilis is a versatile muscle that can be used alone (e.g., to fill perineal defects), with branch of obturator nerve (e.g., facial reanimation), or with overlying skin (e.g., breast reconstruction). Soft tissue can be limited, and the flaps necessitate careful management near the femoral triangle to avoid donor site morbidity, damage to nearby structures, or lymphatic disruption. 27 One must consider potentially poor donor site scar appearance/position and sensory disturbance, 40 which may be mitigated with careful technique.

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Surgical Technique Frog leg positioning is usually adequate. The gracilis is expected to run 2 to 3 cm posterior to the palpable adductor longus in this position. If required, the cutaneous island is designed transversely from adductor tendon posteriorly to the buttock crease with the superior incision in the groin/buttock crease (transverse upper gracilis flap). This can also be designed diagonally (diagonal upper gracilis flap). Slight posterior translocation and use of a perforating branch of the profunda femoris vessels (usually through adductor magnus) without use of the gracilis can also be performed (PAP). Width is determined by pinch test. The skin island may be elevated traveling posteriorly in the subfascial plane to identify the intermuscular septum between adductor longus and gracilis and its perforators. These vessels may be followed from the gracilis (usually entering 10 cm distal to the ischium) toward the source medial femoral circumflex vessels off the profunda femoris vessels, sacrificing the branches to the other thigh musculature. The gracilis muscle can be isolated, its distal, minor pedicle divided, and the flap harvested. If muscle only is used, a vertical incision may be used to identify the muscle posterior to the adductor tendon. The scar can be short, with harvest performed through a tunnel with a counterincision near the tendon at the knee. 40 Insider tips: Avoid damaging the greater saphenous vein. 27 Resuspend fascia to avoid labial distortion. 27 If performing a PAP flap, superficial dissection posteriorly may help decrease damage to the posterior femoral cutaneous nerve to the thigh.

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Anterolateral Thigh Perforator Flap The thigh is a versatile donor site for many types of reconstruction. Muscle, myocutaneous, adipofascial, fascial, and fasciocutaneous flaps can all be harvested. Functional limitations can be concerning if they occur, as lower extremity function is important. Techniques should be considered to minimize this. A common flap with many indications and usually minimal impact on donor site function is the anterolateral thigh (ALT) flap.

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Surgical Technique With the patient supine, a line can be drawn from the ASIS to the superolateral border of the patella (overlying the septum between vastus lateralis and rectus femoris). Another line from the midpoint of this line to the midpoint of the distance from ASIS to pubic symphysis will approximate the source vessels’ course (descending branch of lateral circumflex femoral). The perforators are expected at the midpoint of the vertical line (or between 1/3 and 2/3 of the distance along the line), usually within a 3-cm radius, and spaced superiorly and inferiorly apart by about 5 cm. 41 The skin island can be designed twothirds posterior to the vertical line. Dissection from the anterior flap margin can proceed, initially supraor subfascially and then subfascially as the junction between the muscles is approached. The septum can be divided distally and the muscles retracted away from each other. The descending branch and perforators are identified; perforators are selected and dissected through the vastus lateralis and followed proximally. The remainder of the skin island can then be harvested. 41 Skin pinch can be used to determine skin island, but often recipient needs exceed this, necessitating skin graft donor site closure. Insider tips: In the absence of perforators, the same initial incision can become the posterior border of a newly designed skin island based on perforators through rectus femoris. 41 Preserve motor branches of the femoral nerve, but the posterior femoral cutaneous nerve of the thigh can be harvested to provide a sensate flap. 41 A proximal perforator is usually larger, adequate in length, and less intramuscular. 41 Nearby lower extremity flaps to know: Sartorius, rectus femoris, vastus lateralis, tensor fascia lata, anteromedial thigh, posterior thigh, gastrocnemius, soleus, fibula flaps

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Pectoralis Flap The pectoralis muscle and/or myocutaneous flap was first described in 1968 by Hueston and McConchie for sternal reconstruction. 42 Ariyan described its uses in head and neck reconstruction in 1979. 43 Although it has remained as the top choice for anterior sternal reconstruction since its description (sternal wound dehiscence following cardiac surgery), it experienced increased popularity prior to the advent of routine microvascular head and neck reconstruction; however, its values remain in head and neck indications as a fast, versatile, and reliable salvage option. 16 The pectoralis muscle is divided into a clavicular portion (originating from clavicle, inserting into humerus) and the sternocostal portion (originating from sternum and costal cartilages 1-6, inserting into external oblique aponeurosis). Its blood supply is a Mathes and Nahai type V through the thoracoacromial artery and perforators of the internal thoracic, intercostal, and lateral thoracic arteries. 9,44

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Surgical Technique Sternal defects can be covered with unilateral or bilateral advancement based on the thoracoacromial vessel with routine dissection of the superior, medial, inferior, and lateral borders. This is often necessary when the intercostal vessels have been used for cardiac bypass grafts or through extensive sternal debridement. Additional medial translocation can be accomplished through disinsertion from the humerus, which can usually be accomplished from the midline sternal wound but may require a counterincision over the humeral head. Often the reconstruction will be performed with dissection of the muscle from the anterior skin and subcutaneous fat and closure of the muscle flap layer within the midline bony defect and disparate closure of the skin and subcutaneous fat. However, this anterior dissection can be spared, allowing for advancement of the muscle, subcutaneous fat, and skin as a single unit toward midline. Alternatively, a turnover flap based on multiple medial intercostal perforators may be used to introduce bulky muscle into the anterior sternal wounds. This requires anterior and posterior undermining, as well as superior, inferior, and complete lateral release of the muscle borders. 16 Insider tip: Position the arms by the side to facilitate muscle advancement. For head and neck reconstruction the muscle is usually rotated based on the thoracoacromial pedicle (should be visualized and protected on the superior/posterior surface of the muscle) and may include a skin paddle of a variety (over 10 different described approaches) of different designs based medially or inferiorly, particularly along the inframammary fold. 16 The flap is inset most often using a subcutaneous tunnel. Special manipulations can be accommodated. These include double skin paddles, extension based on inclusion of the rectus fascia and overlying skin, fascial release, clavicular manipulation, or division of the sternal portion of the flap. This can also be harvested in concert with a deltopectoral flap. 16 Insider tips: Include a portion of the fifth rib or avascular bone graft for mandibular reconstruction. Denervation of the muscle can decrease bulk over time. 16 Prepare for distortion of the breast and difficulty with hair growth if used for esophageal or pharyngeal reconstruction. 16 Nearby flaps to know: Serratus, deltopectoral flaps

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Conclusion Flaps are essential reconstructive modalities frequently used by plastic surgeons. As techniques evolve, infinite varieties of tissue transfer emerge. Thorough understanding of basic principles, ability to apply these in unique situations, and careful assessments of all aspects of patients and their reconstructive needs are necessary for successful use of this tool.

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Questions 1. The vascular surgery team requests an inpatient consult on a debilitated 74-year-old woman with a recent history of uncontrolled diabetes who was incidentally noted to have a cold foot upon admission for mental status changes associated with diabetic ketoacidosis. Past medical history includes hypertension, hypercholesterolemia, and myocardial infarction treated with three stents 9 months ago. The vascular surgery team completed an urgent femoral popliteal bypass graft with PTFE graft 9 days ago, but the patient’s wound has separated and dressing changes are currently being performed with exposed vessels and PTFE with minimal redundancy of soft tissue at the margins. What is the optimal next step in management? a. Continue dressing changes, optimize nutrition and glucose control, and allow wound to heal secondarily. b. Perform operative debridement and place split thickness skin graft to wound base. c. Perform operative debridement and perform primary closure with extensive undermining to decrease tension. d. Perform operative debridement and perform gracilis muscle rotational flap with split thickness skin graft. e. Perform operative debridement and perform latissimus dorsi myocutaneous free tissue transfer. 2. The orthopedic surgery team requests an inpatient consult for a 24-year-old otherwise healthy man, 6 days after Gustilo IIIB distal third of the tibia and fibula fractures treated with hardware at the fracture site. He returned to the operating room for a second look washout procedure 3 days after injury, and the wound was found to be stable and clean. Free tissue transfer is deemed necessary, but the patient is extremely concerned about visible scars outside of the ankle from flap reconstruction when he is at the pool. Which of the following flaps represents the best option in this circumstance? a. ALT free flap b. Latissimus dorsi free flap c. Vertical rectus abdominis myocutaneous free flap d. Radial forearm free flap e. Lateral arm free flap 3. A 50-year-old woman is undergoing autologous tissue breast reconstruction at the time of bilateral skin-sparing mastectomy for breast cancer. As abdominal skin and subcutaneous flaps are being raised in the abdomen in preparation for a deep inferior epigastric perforator flap, the internal mammary vein is noted to be extremely small on the left despite proximal dissection. Which of the following is least likely to allow salvage of abdominal-based reconstruction? a. Use of thoracodorsal vessels as recipients rather than the internal mammary vessels b. Use of a rotational transverse rectus abdominis myocutaneous flap based on the superior epigastric vessels c. Use of the right distal internal mammary vein in a retrograde fashion as a recipient vein d. End-to-side anastomosis of the flap vein end into the internal mammary vein e. Surgical delay of the internal mammary vessels 4. A 65-year-old man with an anterior chest wall defect due to liposarcoma resection undergoes latissimus dorsi rotational flap reconstruction. Postoperatively, he reports unsightly and uncomfortable motion of his flap when moving the ipsilateral arm. This result is most likely due to which of the following? a. Absence of postoperative complete shoulder immobilization

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b. Failure to divide the thoracodorsal nerve during flap dissection c. Inadequate security of inset into recipient site d. Maintenance of insertion into the humerus e. Fracture of underlying ribs during sarcoma resection 5. A trainee is working on preoperative planning and is marking landmarks and planned incisions for a gracilis muscle flap harvest for use in facial reanimation. The patient is placed in a frog leg position and the most prominent longitudinal medial thigh structure palpable through the skin is which of the following? a. Gracilis muscle b. Rectus femoris muscle c. Adductor longus muscle d. Sartorius muscle e. Tensor fascia lata muscle 1. Answer: d. The clinical scenario represents a common situation in which suboptimal patient factors (i.e., increased age, uncontrolled diabetes, cardiac disease) exist in the setting of exposure of critical structures (in this case, prosthetic material and large vessels). Careful consideration of all aspects and weighing of the risks and benefits improves treatment planning for each unique situation. A gracilis muscle flap would provide bulk to fill dead space, cushioning against external trauma, and increased quantity of healthy tissue to combat bacterial contamination or infection in the groin. Risk of prosthetic infection, anastomotic failure, and difficult-to-control, potentially lifethreatening bleeding from femoral vessels would argue against ongoing dressing changes or skin grafting directly over exposed structures although optimization of patient factors is always ideal. Although some patients with risk factors for wound healing complications have redundancy for primary closure, this patient’s minimal redundancy makes this choice less favorable. A debilitated patient with active, significant medical comorbidities would not be as good a candidate for a free tissue transfer procedure with likely increased operative length and complexity when a less complex, good option exists. 2. Answer: a. Any flap donor site will result in a scar. Some donor sites are able to be closed primarily and are likely less visible than those that require, for example, skin grafting. In this male patient concerned about pool activities, the ALT donor site can be closed primarily if the size of the skin island is not large and is most likely to be covered by clothes compared to the other options, i.e., latissimus dorsi, VRAM, radial forearm, and lateral arm flaps. 3. Answer: e. Understanding of flap harvest is insufficient for successful use of flaps in surgical treatment of patients. One must also understand recipient site dynamics and the interactions between the flap and the recipient site. A surgical delay is not likely a useful technique for internal mammary vein size augmentation as there is not an alternate blood flow to ligate for increased flow through the internal mammary vessels. Internal mammary vessels as well as thoracodorsal vessels are recipient vessels of appropriate reliability and proximity for anastomosis to the usually long deep inferior epigastric vessel pedicle. Vein grafting could also be used if length is insufficient. The nature of the blood supply to the rectus muscle uses the superior blood supply in a rotational fashion for breast reconstruction. Use of retrograde flow in vessels is an established and often successful technique of flap manipulation. End-to-side anastomoses manage size mismatch between donor and recipient vessels. 4. Answer: b. The thoracodorsal nerve supplies motor innervation to the latissimus dorsi muscle and may be divided during pedicle dissection to decrease muscle activity. Complete shoulder immobilization is not a standard practice after latissimus dorsi flap use. Inadequate inset may move the flap out of the ideal position in the recipient site over time but is less likely to impact muscle

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activity itself. Division of the muscle tendon to the humerus may be performed, but this is also less likely to affect motor activity of the muscle itself. Soft tissue tumor resection is not likely to cause unrecognized fracture of underlying osseous structures. 5. Answer: c. It is important to understand the relationship of the gracilis muscle and adductor longus muscle as the more prominent structure is the adductor longus; however, the gracilis is more commonly used for reconstruction as its function is less essential to the lower extremity. The sartorius, while existing in the medial thigh for a portion of its course, does not run longitudinally through the thigh’s length and is not a contributor to the main palpable structure. The rectus femoris and tensor fascia lata muscles do not travel longitudinally along the medial thigh.

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References Mohan, AT, Sur, YJ, Zhu, L, et al. The concepts of propeller, perforator, keystone, and other local flaps and their role in the evolution of reconstruction. Plast Reconstr Surg. 2016;138(4):710e-729e.Classic article describing this area. Wallace, CG, Kao, HK, Jeng, SF, Wei, FC. Free-style flaps: a further step forward for perforator flap surgery. Plast Reconstr Surg. 2009;124(6):e419-426.Classic article describing this area. Esser, J. General rules used in simple plastic work on Austrian war-wounded soldiers. Surg Gynecol Obstet. 1917;34:737. McGregor, IA, Morgan, G. Axial and random pattern flaps. Br J Plast Surg. 1973;26:202-213. Taylor, GI, Palmer, JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg. 1987;40:113-141. Taylor, GI, Daniel, RK. The free flap: composite tissue transfer by vascular anastomosis. Aust N Z J Surg. 1973;43:1-3. Daniel, RK, Taylor, GI. Distant transfer of an island flap by microvascular anastomoses: a clinical technique. Plast Reconstr Surg. 1973;52:111117. Koshima, I, Soeda, S. Inferior epigastric artery skin flaps without rectus abdominis muscle. Br J Plast Surg. 1989;42:645-648. Mathes, SJ, Nahai, F. Classification of the vascular anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg. 1981;67(2):177-187.Classic article describing this area. Cormack, GC, Lamberty, BG. A classification of fascio-cutaneous flaps according to their patterns of vascularization. Br J Plast Surg. 1984;37(1):80-87. Wei, FC, Mardini, S. Free-style free flaps. Plast Reconstr Surg. 2004;114:910-916. Hallock, GG. Direct and indirect perforator flaps: the history and the controversy. Plast Reconstr Surg. 2003;111:855-865. Kim, JT. New nomenclature concept of perforator flap. Br J Plast Surg. 2005;58:431-440. Blondeel, PN, Van Landuyt, KH, Monstrey, SJ, et al. The “Gent” consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg. 2003;112:1378-1383. Wei, FC, Jain, V, Suominen, S, Chen, HC. Confusion among perforator flaps: what is a true perforator flap? Plast Reconstr Surg. 2001;107:874876. Teo, KG, Rozen, WM, Acosta, R. The pectoralis major myocutaneous flap. J Reconstr Microsurg. 2013;29(7):449-456. Hyakusoku, H, Yamamoto, T, Fumiiri, M. The propeller flap method. Br J Plast Surg. 1991;44:53-54. Pignatti, M, Ogawa, R, Hallock, GG, et al. The “Tokyo” consensus on propeller flaps. Plast Reconstr Surg. 2011;127:716-722. Behan, FC. The keystone design perforator island flap in reconstructive surgery. ANZ J Surg. 2003;73:112-120. Koshima, I, Inagawa, K, Urushibara, K, Moriguchi, T. Paraumbilical perforator flap without deep inferior epigastric vessels. Plast Reconstr Surg. 1998;102:1052-1057. Chang, EI, Ibrahim, A, Papazian, N, et al. Perforator mapping and optimizing design of the lateral arm flap: anatomy revisited and clinical experience. Plast Reconstr Surg. 2016;138(2):300e-306e.Classic article to describe this area. Patel, SA, Pang, JH, Natoli, N, et al. Reliability of venous couplers of microanastamosis of the venae comitantes in free radial forearm flaps for head and neck reconstruction. J Reconstr Microsurg. 2013;29(7):433-435. Futran, ND, Stack, BC. Single versus dual venous drainage of the radial forearm free flap. Am J Otolaryngol. 1996;17(2):112-117. Cha, YH, Nam, W, Cha, IH, Kim, HJ. Revisiting radial forearm free flap for successful venous drainage. Maxillofac Plast Reconstr Surg. 2017;39(1):14. Ho, AM, Chang, J. Radial artery perforator flap. J Hand Surg. 2010;35:308-311. Xue, B, Liu, Y, Zhu, S, et al. Total cheek reconstruction using the pre-expanded medial arm flap with functional and aesthetic donor site closure. J Craniofac Surg. 2018;29(3):640-644. Patel, NG, Ramakrishnan, V. Microsurgical tissue transfer in breast reconstruction. Clin Plast Surg. 2017;44:345-359.Classic article describing this area. Rozen, WM, Ashton, MW, Kiil, BJ, et al Avoiding denervation of rectus abdominis in DIEP flap harvest II: an intraoperative assessment of the nerves to rectus. Plast Reconstr Surg. 2008;122(5):1321-1325. Elliott, LF, Hartrampf, CR. The Rubens flap: the deep circumflex iliac artery flap. Clin Plast Surg. 1998;25(2):283-291. O’Connell, JE, Bajwaa, MS, Schachea, AG, Shaw, RJ. Head and neck reconstruction with free flaps based on the thoracodorsal system. Oral Oncol. 2017;75:46-53. Quillen, CG, Shearin, JC, Georgiade, NG. Use of the latissimus dorsi myocutaneous island flap for reconstruction in the head and neck area. Plast Reconstr Surg. 1978;62:113-117. Maxwell, GP, Stueber, K, Hoopes, JE. A free latissimus dorsi myocutaneous flap. Plast Reconstr Surg. 1978;62:462-466. Yang, LC, Wang, XC, Bentz, ML, et al. Clinical application of the thoracodorsal artery perforator flaps. J Plast Reconstr Aesthet Surg. 2013;66(2):193-200.Classic article describing this area. Fujino, T, Harasina, T, Aoyagi, F. Reconstruction for aplasia of the breast and pectoral region by microvascular transfer of a free flap from the buttock. Plast Reconstr Surg. 1975;56:178-181. Allen, RJ, Tucker, C. Superior gluteal artery perforator free flap for breast reconstruction. Plast Reconstr Surg. 1995;95:1207-1212.Classic article describing this area.

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Hunter, C, Moody, L, Luan, A, et al. Superior gluteal artery perforator flap: the beauty of the buttock. Ann Plast Surg. 2016;76(3):S191S195.Classic article describing this area. Yaghoubian, A, Boyd, JB. The SGAP flap in breast reconstruction: backup or first choice? Plast Reconstr Surg. 2011;128:29e-31e. DellaCroce, FJ, Sullivan, SK. Application and refinement of the superior gluteal artery perforator free flap for bilateral simultaneous breast reconstruction. Plast Reconstr Surg. 2005;116:97-103. Hur, K, Ohkuma, R, Bellamy, JL, et al. Patient-reported assessment of functional gait outcomes following superior gluteal artery perforator reconstruction. Plast Reconstr Surg Glob Open. 2013:1(5):1-6. Locke, MB, Zhonga, T, Mureauc, MAM, Hofer, SOP. Tug ‘O’ war: challenges of transverse upper gracilis (TUG) myocutaneous free flap breast reconstruction. J Plast Reconstr Aesth Surg. 2012;65:1041e-1050e.Classic article describing this area. Saint-Cyr, M, Oni, G, Lee, M, et al. Simple approach to harvest of the anterolateral thigh flap. Plast Reconstr Surg. 2012;129(1):207-211.Classic article describing this area. Hueston, JT, McConchie, IH. A compound pectoral flap. Aust NZ J Surg. 1968;38(1):61-63. Ariyan, S. The pectoralis major myocutaneous flap: a versatile flap for reconstruction in the head and neck. Plast Reconstr Surg. 1979;63(1):7381. Wei, WI, Lam, KH, Wong, J. The true pectoralis major mycocutaneous island flap: an anatomical study. Br J Plast Surg. 1984;37(4):568-573.

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CHAPTER 8

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Transplantation Biology and Applications to Plastic Surgery Gerald Brandacher and W. P. Andrew Lee

Key Points Advances in transplant immunology and microsurgical techniques enabled reconstructive transplantation to evolve from an experimental idea to a clinical reality over the past 2 decades For select patients, transplantation of vascularized composite allografts (VCA) provides a means to replace like with like tissue and thus represents the best restorative modality currently available Both functional and immunological outcomes after upper extremity and face transplantation have exceeded initial expectations Minimization of immunosuppression (single drug) and use of alternative regimens have been successfully realized in favoring the risk-benefit equation Innovative immunomodulatory and cell-based tolerance protocols have been proven feasible in translational large animal VCA models and are about to enter the clinical arena Indications for reconstructive transplantation are rapidly expanding including pediatric patients, transplantation of functional subunits, and urogenital reconstructive transplants The idea of transplanting tissues, organs, or even whole-body parts seems to have always been a dream and one of the wild fantasies of mankind that eventually has developed into one of the greatest success stories in Medicine of the last century. In particular, in the field of plastic and reconstructive surgery, transplantation of tissue from one location of the body to another to restore tissue defects is a fundamental concept. Thus, it is not surprising that the first successful application of this technique to transplant tissue from one person to another in the form of allogeneic kidney transplant was first performed by a plastic surgeon. Dr. Joseph E. Murray on December 23, 1954, at the Brigham and Women’s Hospital in Boston helped usher in the dawn of a new field of organ transplantation. 1 The constant and new developments in surgical techniques and more potent, sophisticated types of immunosuppressive agents have enabled us to perform more and more complex types of transplants over the past 60 years. As a consequence, transplantation has become the treatment of choice for endstage organ failure of the liver, heart, lung, pancreas, and kidney, thus allowing longer and better lives for thousands of patients. These advances also enabled us to continuously improve graft survival rates to highly acceptable levels across the board for all types of transplants. According to a recent report by Rana et al. more than 2 million years of lives could be saved in just 25 years of organ transplantation in the United States alone. 2 It is fitting that these techniques have now more than half a century later returned to the field of plastic surgery with the development of reconstructive transplantation as the next chapter and a new era in transplant medicine. However, it is only within the last 2 decades that transplantation of VCAs such as hand/upper extremity, face, abdominal wall, as well as urogenital organs including penis and uterus transplants have become a clinical reality and viable treatment option. These modalities represent the transplantation of composite structures of the human form for reconstructive surgery to fulfill the prime mandate of Plastic and Reconstructive Surgery to replace and restore devastating tissue defects using like with like tissue. 3–5 The ability to transfer VCAs through microvascular surgical techniques, restoring form and function for complex cutaneous and musculoskeletal defects, is revolutionizing the field of

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reconstructive surgery to add another rung to the reconstructive ladder. However, despite all those advancements, long-term allograft survival in reconstructive transplantation can only be achieved, as for any other type of solid organ transplant, through the use of systemic immunosuppression with its associated sequela of organ toxicity, opportunistic infections, and potential for malignant transformation. Current research on immunomodulation and tolerance induction holds great promise to reduce the need for long-term high-dose immunosuppression. 6,7 Although reconstructive allotransplantation in humans is a relatively new area with small numbers of patients, there are reasons to think that new innovations in immunomodulation and tolerance may come from the field of VCAs. For example, reconstructive transplant patients are usually not suffering from life-threatening illness or comorbidities, and therefore the ethical impetus to minimize side effects from immunosuppressive medications is stronger. Also, the ability to directly and continuously observe a graft that includes a skin component allows for the use of novel experimental protocols, as rejection will be seen earlier and potentially could be reversed by topical agents. Finally, the presence of a vascularized bone marrow niche in many VCAs raises the possibility of unique immunomodulatory strategies, as will be discussed.

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Historical Perspective Transplantation of allogeneic tissues has captivated human imagination since antiquity and began as the medicine of mythology with a timeline that spans three millennia. Indeed, Greek mythology and religious texts are rich with examples of xeno- and allotransplantation. Of note, the concept of transplantation transcended temporospatial boundaries and has been reported in Egyptian, Chinese, Indian, and early Christian mythology as early as 2000 bc. 8 Probably the most famous legend highlighting transplantation is the miracle of the black leg in the third century AD by the two Saints Cosmas and Damian —twin brothers who replaced the gangrenous leg of a parishioner with the leg of a deceased Ethiopian Moor. This legend, in particular, describes for the first time a new concept: cadaveric transplantation— where the body of the dead can help the living. Experimentation with various types of transplants continued in the following centuries. Although proper surgical techniques were not available to facilitate successful performance of solid organ transplantation in those days, the procedure of skin grafting had already been performed for many centuries. In the second century BC, the Indian surgeon Sushruta pioneered skin grafting and rotational pedicle flaps for nasal reconstruction and described over a dozen ways to reconstruct ears and lips. His forward-thinking concepts were compiled in the Sushruta Samhita, which served as the primary treatise on plastic and reconstructive surgery for centuries. 9 In the 16th century, Gaspare Tagliacozzi emerged as a popular figure in transplantation, and he, like Sushruta, was a specialist in rhinoplasty. Tagliacozzi successfully performed nasal reconstruction on a patient who had lost his nose using a flap from the patient’s upper arm, which represents one of the earliest records of a human autograft. In 1804, the Milanese surgeon Giuseppe Baronio claimed to perform successful autogenous and xenogeneic skin transplants as well as free tendon allografts in sheep. Baronio’s contributions are considered fundamental to the field of plastic surgery and laid the groundwork for research in the fields of both skin grafting and transplant immunology. Reports of successful allografts began to circulate around the turn of the 19th century, when the Scottish surgeon, John Hunter, successfully transplanted the testes of a chicken into a hen without altering the disposition of the hen. 10 These experiments led Hunter to conclude that transplantation is founded on a disposition in all living substances to unite when brought into contact with each other, one of the earliest revelations regarding chimerism and allograft acceptance. At this point organ transplantation was still not technically feasible owing to limitations in suturing techniques for vascular anastomosis. This obstacle was overcome in 1902 when Alexis Carrel introduced his vascular anastomosis technique, which unlocked a continuum of research in experimental organ transplantation. Within the same year, Austrian surgeon Emerich Ullmann performed the first experimental kidney transplantation in animals in Vienna, which was followed a few years later by reports of unsuccessful attempts in humans by Mathieu Jaboulay. 8,11 The earliest reliable, documented outcomes of allogeneic and xenogeneic skin grafts in human recipients were published by Schone in 1912 and Lexer in 1914. Schone and Lexer demonstrated that these grafts did not survive more than 3 weeks after transplantation. Padgett provided further evidence in 1932, when he reported rejection of all skin allografts within 35 days in 40 patients. However, Padgett also demonstrated that skin grafts exchanged between identical twins survived indefinitely. World War II accelerated progress in allotransplantation. Gibson, a plastic surgeon at the Glasgow Royal Infirmary, described the accelerated rejection of allogeneic tissue due to the presence of humoral antibodies from prior exposure to the same allogeneic source, also known as second set rejection, of skin allografts when treating pilots with burn injuries. Medawar joined Gibson to investigate this phenomenon and, in combination with Billingham and Brent, laid the foundation of modern immunology. Medawar concluded that the rejection of human skin allografts is a result of actively acquired immune reactions— work that was later summarized by Billingham, Brent, and Medawar in their manuscript Actively

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Acquired Tolerance, which became the preeminent treatise on modulating the immune system for transplantation. 12 In this manuscript, the authors discuss the importance of chimerism for tolerance induction, noting the development of donor-specific tolerance by injection of donor cells into neonatal animals. This knowledge of immunology ultimately facilitated the advent of successful solid organ transplantation. Prior to the 1950s, outcomes after organ transplantation were poor. However, the incorporation of Medawar’s findings led 
 Dr. Joseph Murray to perform the first successful living-related kidney transplantation between identical twins in 1954. 1 Shortly thereafter, a rapid development of new chemical immunosuppressive agents occurred. The use of drugs such as azathioprine (AZT), 6mercaptopurine, and steroids in the 1960s allowed for the success of cadaveric renal transplants in 1962 and paved the way for a new era in solid organ transplantation. 13 Thereafter, many organs were successfully transplanted for the first time. In 1963, Dr. James Hardy transplanted the first lung at the University of Mississippi; 1966, the first successful pancreas transplant was performed at the University of Minnesota; Dr. Thomas E. Starzl performed the first liver transplant in the following year on a 3-year old child; the first successful heart transplant was carried out by Christian Barnard in 1967, followed by the first successful bone marrow transplant by E. Donnall Thomas in 1968. 14 A 4-month-old boy who had Wiskott-Aldrich syndrome received a bone marrow transplant from his sibling that effectively restored his immune system duplicating Medawar’s animal findings that had previously resulted in immune tolerance in chimeric mice. In 1972, Jean-François Borel discovered cyclosporine, which further improved survival outcomes after transplantation enabling the first successful small bowel transplant in 1988 by Goulet et al. Since then, many potent and more selective immunosuppressive agents have been developed that controlled acute rejection and prolonged the survival of transplanted organs, which enabled transplantation to become the standard of care for patients with end-stage organ disease. Out of these immunologic and surgical innovations, the idea of reconstructive transplantation was being formulated and as a result human hand transplantation was first attempted in Ecuador in 1964. 8,15 Although the procedure was a surgical technical success, the available immunosuppressive agents at the time were insufficient to prevent rejection, and the graft was eventually lost. This failure underscored the previously described immunological challenges of skin transplants between genetically disparate individuals. As a result, it was felt that the transplantation of any skin-
 bearing allograft would be an insurmountable hurdle and another attempt was not carried out for over 3 decades. During this hiatus, accumulating evidence suggested that the skin of a VCA behaved differently than an isolated skin graft and, therefore, would not be rejected as vigorously. In addition, animal models of VCAs designed to investigate newer generations of immunosuppressive agents such as calcineurin inhibitors (CNIs) (e.g., tacrolimus) and antiproliferative agents (e.g., mycophenolate mofetil [MMF]) indicated that the loss of VCAs could now be prevented. 16 These findings paved the way to preforming the first successful unilateral hand transplantation in September 1998 by a French team led by Prof. Jean Michel Dubernard. 17 This was followed shortly thereafter by the first US hand transplant in January 1999 and many more around the world since then. 3,5 In the past decade, over 140 hand and upper extremity transplants have been performed with encouraging functional and immunologic outcomes that have exceeded all initial expectations. 18 The success of clinical hand transplantation heralded other new eras for reconstructive transplantation. In November 2005, Dubernard and Devauchelle performed the first successful face transplant in Amiens, France. 19 Since then almost 40 face transplants have been performed at multiple centers around the world. 20,21 In addition, many other types of VCAs have successfully been carried out with highly encouraging outcomes including the transplantation of larynx, trachea, vascularized knee, femur, abdominal wall, tongue, penis, uterus, as well as individual tissue components such as peripheral nerve, flexor tendon, and skin. 8,22–25 Although the surgical techniques to perform these complex procedures have been optimized, broad application of this reconstructive modality is still hampered by the risks of life-long, high-dose, multidrug, immunosuppression needed to prevent

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rejection. 7 Thus, continued progress in the field of transplant immunology is critical to the continued success of reconstructive transplantation, as minimization or elimination of immunosuppressive agents is a key goal in bringing this life-changing procedure to routine clinical applicability. 6 The field of reconstructive transplantation will become ubiquitous once transplant tolerance can be reliably achieved. Currently great strides are being made in experimental large animal studies and first clinical trials, moving ever closer to elucidating the immunological processes that will help overcome these barriers.

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Nomenclature and Definitions A brief note on nomenclature will help clarify further discussions of transplantation techniques outlined in this chapter. Certain terms such as transplant, flap, and graft are often loosely used to refer to a VCA. However, these terms should be used carefully with knowledge of their specific meaning to ensure clear communication. Transplantation can be defined as the transfer of tissue or solid organs to another person or to a different anatomical location in the same person. According to this definition much of what reconstructive surgeons do can be classified as a type of transplant. However, in its usual medical usage the term transplantation is used to describe an allotransplant or tissue transferred from a living or deceased human donor to another genetically not identically human patient. Within this chapter, our discussion of transplantation will be focused mostly on the topic of allotransplantation, as the transfer of autologous tissue locally or distantly is covered elsewhere in the text. A graft is tissue completely separated from its donor bed and moved to a separate recipient bed, with its survival relying on ingrowth of new vessels from the surrounding recipient tissue. A vascularized graft or flap either remains attached to its native blood supply or becomes revascularized via microvascular anastomoses to recipient vessels (aka, free flap). An autograft refers to tissue transplanted from one anatomical location to another within the same individual. An isograft is tissue transplanted between genetically identical individuals, such as transplants between syngeneic animals or human monozygotic twins. An allograft or homograft is tissue transplanted between unrelated individuals of the same species. A xenograft or heterograft is tissue transplanted between different species. Transplantation can also be described according to the anatomical site into which the tissue is transferred. An orthotopic transplant is transferred into an anatomically similar site, whereas a heterotopic transplant is transferred into a different site from its donor origin. The term reconstructive transplantation is used to differentiate the transfer of composite tissues such as the hand or face from more traditional solid organ transplants. However, the issuance of a Final Rule in July 2013 by the United States Secretary of Health has redefined VCAs as organs rather than tissues and thereby acknowledged the importance of reconstructive transplantation as a vital treatment option as well as opened up the potential to formalize policies and procedures, under the auspices of the Organ Procurement and Transplantation Network, that can improve VCA donation and procurement practices, develop allocation algorithms, and provide transparent oversight equal to solid organ transplantation. 26

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Transplant Immunology Three-Signal Model of Alloimmunity Transplantation of organs or tissues between genetically disparate individuals of the same species leads to recognition and rejection of the allogeneic tissue by the recipient’s immune system. This alloimmune response that discriminates between self- and nonself tissues remains the main barrier to successful transplantation. The key initiators of an alloimmune response are genetically encoded polymorphic proteins that constitute graft antigens referred to as major histocompatibility complex (MHC) or in humans are known as human leukocyte antigens (HLA). The MHC complex is a cell surface molecule (glycoprotein) that is common to a polymorphic multigene cluster located on chromosome 6 in humans. There are two classes of MHC molecules, class I and II, that differ in their structure, function, and tissue distribution. MHC class I antigens consist of two polypeptide chains, an α-chain with a transmembranous domain and the β2-microglobulin chain that is expressed on all nucleated cells. MHC class II antigens consist also of two polypeptide chains an α- and a β-chain; however, their expression is restricted to antigen-presenting cells (APCs) such as dendritic cells (DCs), monocytes, macrophages, some endothelial cells, thymic epithelial cells, and B lymphocytes. 27 Each MHC has an inherited group of HLA genes or haplotypes: HLA class I genes known as HLA-A, -B, and -C and HLA class II genes known as HLA-DR, -DP, and -DQ. The HLA determines the compatibility of all organ and tissue transplants. The primary function of MHC molecules is to bind short peptides that are derived from proteins processed by the cell. Such non–self-protein-MHC complexes coordinate the interaction of lymphocytes during the acute and chronic alloimmune response. There are two main pathways by which host T cells recognize donor alloantigens (Figure 8.1). Following transplantation, donor APCs migrate toward host lymphoid tissues and can directly activate naïve recipient T cells. Once T cells are activated, they become effector T cells and migrate to the graft and mediate rejection. This is aptly named the direct pathway of allorecognition. In contrast to the direct pathway, recipient APCs play a significant role in the indirect pathway of allorecognition where they take up, process, and present donor antigens to host T cells. Both pathways of allorecognition are important in mediating graft rejection; however, the direct pathway is considered to be the main initiator of acute rejection, whereas the indirect pathway is thought to be of greater significance in the physiology of chronic graft rejection in the long term. 28

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FIGURE 8.1 T cell recognition of alloantigens. A. Direct pathway, recipient T cells interact with intact allogeneic major or minor histocompatibility peptide complexes presented by donor APCs. B. Indirect pathway, recipient T cells interact with processed allogeneic major or minor histocompatibility peptide complexes presented by recipient APCs. APC, antigen-presenting cell; MHC, major histocompatibility complex.

The initiation of an alloimmune response is a well-orchestrated and choreographed interplay of various different players of the immune system including DCs, naïve and memory T cells, and B cells. DCs are key players in the initiation of an alloimmune response post transplant, as they express high levels of MHC class II and costimulatory molecules essential for T cell activation. 29 Upon activation, DCs of both donor and recipient origin migrate to the T cell areas of secondary lymphoid organs of the host where they encounter naive CD4+ T cells and central memory T cells, which recirculate within the lymphoid tissues. Within the secondary lymph nodes, T cells encounter the MHC alloantigen that is expressed on the surface of the DCs with their specific T cell receptors (TCRs) combined with the CD3 complex that facilitates signal transduction. This interaction of MHC, TCR, and CD3 complex is referred to as signal 1 (Figure 8.2). Typically, MHC class I molecules present antigen peptides derived from intracellular sources to CD8+ T cells, whereas MHC class II molecules present antigen derived from endolysosomal compartments to CD4+ T cells.

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FIGURE 8.2 Costimulatory blockade. A. Antigen-specific T cell activation depends on T cell receptor-ligand interaction (signal 1) and costimulatory signals (signal 2) for full activation and proliferation. B. Blocking of T cell costimulatory pathways (signal 2) results in T cell anergy and thus prevents allograft rejection, promotes long-term graft survival, and induces tolerance in various rodent and nonhuman primate transplant models. APC, antigen-presenting cells; MHC, major histocompatibility complex; TCR, T cell receptor.

In addition to signal 1, APCs provide so called costimulatory signals to fully activate T cells. These costimulatory signals are also referred to as signal 2 during T cell activation. Two of the best-characterized costimulatory signals/pathways in transplantation are the B7/CD28 and the CD40/CD154 pathways. In addition, there are a multitude of other second signals including 4-1BB (CD137) and 4-1BBL, inducible costimulator and ligand of inducible costimulator, OX40/OX40L, LFA1/ICAM-1, or PD-1/PDL-1/2 29,30 (see Figure 8.2). Once a naïve T cell receives both signal 1 and signal 2 through a single specific APC, three intracellular

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signal transduction pathways are activated including the calcium-calcineurin pathway, RAS-mitogenactivated protein kinase pathway, and the NF-κB pathway. Through those pathways, several transcription factors such as NFAT, AP-1, and NF-κB are activated, which subsequently leads to the expression of cytokine-encoded genes for IL-2, CD154, and CD25. These cytokines, in particular IL-2 and IL-15, then act via autocrine mechanisms to initiate T cell proliferation and expansion. This final step is also referred to as signal 3.

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Types of Rejection Based on the timing of allograft, transplant rejection has been divided into three major categories: hyperacute, acute, and chronic. 31

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Hyperacute Rejection This type of rejection is a peracute form with a very rapid onset that occurs within minutes to hours after transplantation and can destroy the allograft in an equally short period of time. It is mediated through preexisting antibodies against HLA or ABO antigens which have been acquired as a result of pretransplant blood transfusions, pregnancies, or previous transplants. These antibodies bind to their corresponding antigen expressed on endothelial cells of the transplant and subsequently can activate the coagulation and complement cascade. This leads to the formation of microthrombi, vascular occlusion, and ultimately necrosis of the allograft. However, blood type matching, HLA typing of donor and recipient, and pretransplant routine clinical cross-matching, whereby preformed anti-HLA antibodies are screened for have virtually eliminated hyperactive rejection episodes in both solid organ as well as reconstructive transplantation.

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Acute Rejection Acute rejection episodes typically manifest within a period of days or weeks after transplant but can occur also at much later time points (months or years) if the immune system is awakened either by infection or by a significant reduction in immunosuppression. The primary mediator of acute rejection episodes are effector T cells that infiltrate the graft and lead to inflammatory damage and parenchymal necrosis. About 30% of all cases of acute rejection, however, are mediated by antibodies (donor-specific IgG antibodies) and are referred to as humoral or vascular rejection episodes. These antibodies bind to endothelial cells and activate the complement cascade which in turn leads to deposition of complement factors C3d and C4d that trigger endothelial inflammation and cellular infiltration resulting in vascular damage and occlusion. Given the advances in modern immunosuppression, acute rejection episodes for most type of organ transplants are ranging between 3% and 10% and can usually be successfully reversed with either steroid bolus therapy, antibody treatment (thymoglobulin or alemtuzumab), or with plasmapheresis and high-dose IVIG.

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Chronic Rejection Chronic rejection is the leading cause affecting long-term outcomes after transplantation. This type of rejection is a slow form of rejection that primarily targets the graft vasculature (concentric vascular stenosis also referred to as graft vasculopathy) and causes graft fibroses. The onset of chronic rejection is usually beyond 1 year post transplant and most often progresses gradually over several years, eventually leading to a gradual decline in organ function and ultimately graft loss. Mechanistically both humoral as well as cellular responses, including DTH reactions and proinflammatory cytokines (IFN-g, fibroblast growth factor, or TGF-b), are involved in the onset and progression of chronic rejection. In addition, residual scarring from episodes of acute rejection contributes to chronic graft failure. Alloreactive T cells are infiltrating the transplant and release cytokines and chemokines such as CCL5 which in turn recruit monocytes that differentiate into macrophages. The second phase of this chronic inflammatory process is dominated by macrophages which release IL-1, TNF-a, and MCP-1 and thereby perpetuate the chronic inflammatory state, ultimately leading to graft fibrosis and sclerosis and loss of function. In addition to these antigen-specific mechanisms, antigen-independent factors such as ischemia-reperfusion injury, chronic toxicity of maintenance immunosuppression, and infectious complications such CMV can contribute to the development of chronic rejection and graft vasculopathy.

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Immunosuppression In addition to advances in surgical techniques, the development of potent and targeted immunosuppressive agents has probably contributed the most to the success story of organ transplantation. 29,32,33 Today, there is a whole armamentarium of pharmacological agents available that can be used to prevent and control allograft rejection 32 (Figure 8.3; Table 8.1). Based on their mode of action, there are six major categories of immunosuppressive drugs: induction agents (e.g., mono- and polyclonal antibodies), antiproliferative agents, CNIs, mTOR inhibitors, corticosteroids, and biologic agents.

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FIGURE 8.3 Targets of immunosuppressants during T cell activation. Immunosuppressive medications interrupt T cell activation at various pathways. CsA and tacrolimus interrupt the TCR signaling cascade by blocking calcineurin activation, the latter by interaction with FK-binding proteins. RAPA blocks mTOR signaling from both IL-2 receptor activation and from TCR coreceptors interrupting the second signal pathway. Steroids alter gene transcription by modulating the effects of transcription factors including several necessary for T cell activation. AZT and MMF inhibit the production of nucleotides in lymphocytes blocking the cell cycle and proliferation. APC, antigen-presenting cells; AZT, azathioprine; MMF, mycophenolate mofetil; TCR, T

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cell receptor.

TABLE 8.1 Immunosuppressive Agents in Current Use Class of Drug Induction agents

Agents Antithymocyte globulin (ATG), alemtuzumab Azathioprine Mycophenolate mofetil (MMF) Cyclosporine A (CsA) Tacrolimus Rapamycin Everolimus

Mode of Action Antibody-dependent cellmediated cytotoxicity Blockade of DNA synthesis and replication Inhibition of IL-2 gene transcription Inhibits signal transduction

Steroids

Methylprednisolone Prednisolone

Biologics

Cytotoxic T-lymphocyte–associated antigen-4 immunoglobulin (CTLA4Ig) (Belatacept) Basiliximab Rituximab Infliximab

Inhibition of multiple transcription factors antiinflammatory Blocks costimulatory pathway B7-CD28

Antiproliferative agents Calcineurin inhibitors mTOR inhibitors

IL-2 receptor antagonism CD20 binding on B cells TNF-a inhibition

Main Adverse Effects Cytokine release syndrome, leukopenia, anemia, bleeding, hypertension Gastrointestinal (GI) complaints, diarrhea, viral reactivation, myelosuppression/leukopenia Nephrotoxicity, hypertension, hyperglycemia, tremor, hirsutism, gingival hyperplasia, acne Hyperlipidemia, wound-healing problems, thrombocytopenia, anemia, peripheral edema, ulceration of oral mucosa Diabetes, fluid retention, weight gain, dyslipidemia, hip necrosis, acne, glaucoma Cytokine release syndrome, fever, leukopenia, anemia Tremor, bleeding, fever, chills Infusion reaction, cytokine release syndrome Infection, tuberculosis reactivation, drug-induced lupus

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Induction Agents Polyclonal antithymocyte globulin or antilymphocyte globulin reagents can be distinguished from each other by the cells used for the immunization and the animal species from which they are produced. The mechanism by which antithymocyte globulins achieve their immunosuppressive action is by peripheral blood lymphocyte depletion through antibody-dependent cell-mediated cytotoxicity or Fas-dependent apoptosis. Alemtuzumab (Campath-1H) is an anti-CD52 monoclonal antibody that similarly depletes T cells, B cells, and NK cells by antibody-dependent cellular-mediated lysis. Basiliximab is a recombinant monoclonal antibody that binds to and blocks the IL-2 receptor on the surface of T cells. Induction therapy with lymphodepleting agents has allowed for a significant reduction in the incidence of acute allograft rejection and to a diminution of maintenance immunosuppression to promote CNI reduction and steroid avoidance or withdrawal.

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Antiproliferative Agents Cytotoxic/antiproliferative drugs include cyclophosphamide, methotrexate, AZT, and MMF. These agents interfere with DNA replication and arrest proliferating alloreactive lymphocytes. Earlier nonspecific antiproliferative agents such as AZT had many side effects and unwanted toxicities. MMF has replaced these agents in many protocols due to its ability to selectively block purine synthesis in T and B cells, which dramatically improves the side effect profile.

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Calcineurin Inhibitors Cyclosporine A (CsA) and tacrolimus both inhibit the signaling pathways of T cell activation by interfering with calcineurin activation and IL-2 gene transcription. CsA is a metabolic extract from the fungus Tolypocladium inflatum Gams first described in 1976. Its discovery revolutionized the field of solid organ transplantation by significantly increasing survival of kidney, heart, and liver allografts. CsA has been shown to prolong limb allograft survival in various experimental animal models and thereby significantly encouraged to pursue clinical VCA in the 80s and 90s. Tacrolimus is a macrolide lactone antibiotic isolated from soil fungus and also inhibits the calcineurin/IL-2 pathway of T cell activation, although at a different point in the pathway from cyclosporine. It has a favorable side effect profile as compared with CsA and less transplant-associated malignancy potential, although it has significant nephrotoxicity when used for long periods of time. Tacrolimus has replaced cyclosporine in many protocols in solid organ and has been the backbone of all the clinical reconstructive transplantation treatment regimens. A beneficial side effect of immunosuppression with tacrolimus in the setting of VCA is its dose-dependent acceleration of axonal regeneration, which promotes functional recovery after reconstructive transplantation.

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mTOR Inhibitors The unfavorable toxicity profile of CNIs, in particular its considerably high nephrotoxicity, has led some centers to switch to the mTOR inhibitor rapamycin (sirolimus, everolimus). Rapamycin and other mTOR inhibitors act downstream of signal 3, inhibiting the response to IL-2 (as well as IL-4, IL-7, IL-12, and IL15), thereby effectively inhibiting T cell proliferation. Rapamycin is a very attractive alternative to CNIs, as it has a significantly different side effect profile in particular with regard to its nephrotoxicity and having antiproliferative and antineoplastic properties. It does, however, suffer the drawback of having profound negative effects on wound healing that may preclude its use in the early postoperative period.

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Corticosteroids One of the first available immunosuppressants for transplantation was steroids with broad antiinflammatory actions (i.e., prednisone, prednisolone). These medications inhibit activation of several transcription factors, thus modifying gene expression, inhibiting cellular activation, and cytokine production. Prednisolone was one of the first pharmacological agents used in allogeneic organ transplantation. Despite the well-known side effects of long-term use, steroids are still widely utilized today in combination with other immunosuppressive agents in most solid organ and VCA protocols. However, steroid avoidance, minimization, and withdrawal had been common practice even from the beginning of transplantation. Short courses of high-dose bolused steroids continue to be the frontline treatment for acute rejection episodes in all types of transplantation.

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Biologic Agents Biologic agents such as cytotoxic T-lymphocyte–associated antigen-4 immunoglobulin (CTLA4-Ig) (e.g., abatacept, belatacept), which block T cell costimulation, were developed to overcome the limitations of conventional immunosuppressants and represent a new paradigm in immunosuppression—biological therapy for maintenance immunosuppression devoid of the toxicities associated with CNIs. CTLA4-Ig is an engineered fusion protein comprised of the extracellular human domain of CTLA4 and the hinge CH2 and CH3 domains of a human or mouse IgG1 that binds to B7 molecules with high affinity thus preventing CD28-B7 engagement and leading to partial T cell activation and T cell anergy. Multiple groups have demonstrated potent immunosuppressive properties of CTLA4-Ig in vivo using rodent models of transplantation and autoimmunity. Recently a novel mutant of CTLA4-Ig (LEA29Y, belatacept) with increased binding affinity to B7 has been generated and successfully introduced into human trials with favorable results. These phase II and III studies in renal transplantation demonstrated that belatacept-based immunosuppression is an effective alternative to CNIs. 34 Other biologic agents used for immunosuppression in transplantation include rituximab, a chimeric murine/human monoclonal antibody that reacts with the CD20 antigen on B cells, infliximab a highmolecular-weight (149 kDa) chimeric monoclonal antibody against TNF-a, CFZ533 a new, fully human, Fc-silenced, nondepleting, IgG1 mAb preventing CD40 pathway signaling and activation of CD40 + cell types, and the IL-2 receptor antagonists also referred to as anti-CD25 monoclonal antibodies, basiliximab and daclizumab. 32 Despite this plethora of immunosuppressive agents, there is currently no standard immunosuppressive protocol established for either solid organ or reconstructive transplantation. The current immunosuppressive protocols applied to hand, upper extremity, and face transplantation are extrapolated from various different regimens and protocols used in solid organ transplantation. The overall amount of immunosuppression required to ensure graft survival is comparable or even slightly higher than it is for kidney transplantation.

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Transplantation Tolerance Sir Peter Medawar’s seminal experiments with skin transplantation laid the foundation for Transplant Immunology; subsequent experimentation by his group in animal models led to the first documentation of acquired immune tolerance. This phenomenon was defined as a state of donor-specific hyporesponsiveness, in the absence of immunosuppression, while maintaining adequate immune responses to third party antigens. 12 This definition is still valid today and implies that a state of tolerance must coexist with general immune competence, including normal immune responses to pathogens and cancer risks no different than the general population. During development, one of the critical functions of the immune system is to prevent responses directed toward self-antigens and thereby preventing autoimmune disease. This vital ability of the immune system to distinguish between self- and foreign antigens is controlled by two main mechanisms referred to as central and peripheral tolerance. Central tolerance is facilitated in the thymus whereas peripheral tolerance is induced in extrathymic secondary lymphoid tissues. The mechanism of T cell tolerance in the thymus is based on the deletion of self or alloreactive T cells upon interaction with bone marrow–derived APCs. In general, during T cell development, the majority of T cells found in the thymus have undesirable reactivities and are therefore deleted via negative selection. T cells that recognize foreign antigen in the context of self-MHC are positively selected and allowed to circulate in the peripheral blood. Another widely researched approach for the induction of tolerance is the use of hematopoietic stem cell transplantations to induce mixed chimerism. 35 Mixed chimerism refers to a state in which donor and recipient cells coexist within the recipient. This state can be established in clinical practice via donor hematopoietic stem cells, which are mobilized from the donor bone marrow, collected from peripheral blood, and then administered to the recipient. Donor HSCs engraft into the recipient’s bone marrow and, in conjunction with recipient HSCs, ensure the constant production of myeloid and lymphoid cell lineages: the recipient’s immune system is now composed by cells both of donor and of recipient origin. Immune tolerance was achieved via mixed chimerism in a variety of animal models; clonal deletion was demonstrated as one of the primary mechanism in this process. In humans, mixed chimerism was achieved, in the vast majority of cases, only as a transient state; however, in certain patients, immune tolerance persists long after the loss of mixed chimerism: this indicates that mechanisms other than clonal deletion might be at play. A remaining major challenge to achieving tolerance routinely through the induction of mixed chimerism is the need for intense preconditioning regimens with considerable toxicities. 35,36 Peripheral tolerance in contrast is maintained by a number of mechanisms, including clonal deletion, anergy (e.g., nonresponsiveness), and suppression/regulation. The induction of T cell anergy has been demonstrated by blockade of costimulatory signals (signal 2) using monoclonal antibodies during T cell activation (see Figure 8.2). Anergic T cells are incapable of producing IL-2 and are unresponsive to repeat antigen stimulation unless exogenous IL-2 is added. The induction of T regulatory/suppressor cells is another mechanism to induce T cell tolerance specific to donor antigens. T regulatory cells (CD4+CD25+Foxp3+ T regs) play a key role in the maintenance of tolerance to both self- and foreign antigens. 37 Furthermore, studies in recent years have demonstrated the potential role for particular subtypes of DCs such as plasmacytoid to promote and maintain peripheral tolerance to transplantation antigens. Another mechanism leading to peripheral tolerance is clonal exhaustion and deletion, which is due to chronic or overwhelming antigen 
 exposure/stimulation under suboptimal conditions.

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Transplantation Applications in Plastic Surgery Skin Skin allografts are the most commonly performed human allotransplant and were the basis of the first transplantation research. Pioneering experiments by Giuseppe Baronio, as outlined above, on auto- and allografts in sheep laid the groundwork for research in the fields of both skin grafting and transplant immunology. 8 The most frequent clinical use for skin allografts is in the treatment of extensive burns. The ability to place temporary skin grafts without jeopardizing limited autogenous donor sites in these patients has resulted in dramatic improvements in survival of high total body surface area burn wounds. In some patients who are immunosuppressed either through medications or through severe illness, skin allografts have been shown to be tolerated with continued immunosuppression. Anecdotal reports of patients who have undergone slow withdrawal of immunosuppression have not required regrafting either through permanent tolerance of the graft or more likely through slow substitution of the allograft with recipient cells. 38 Future research developments that enable prolonged graft survival in the absence of immunosuppression would precipitate a significant paradigm shift in the treatment of severe wounds and burns.

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Skin Xenograft Porcine xenograft has been used as a temporary dressing for large burns. It is applied with a technique similar to that used for human allograft, with seeding of autologous grafts beneath it. The application of xenogeneic dermis has also been found valuable in preparing a wound for subsequent grafting by stimulation of granulation tissue formation. Xenogeneic tissue has limited uses in skin grafting at present, and its cellular components are susceptible to hyperacute rejection typical of all xenograft materials.

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Bone Allograft Reconstruction of large bony defects in the axial and peripheral skeleton with nonvascularized allogeneic bone has been widely practiced. Well-organized tissue banks and improved methods of bone sterilization and preservation have made this possible. Very few of the donor cells, if any, in the nonvascularized bone allograft survive. These donor cells express antigens similar to other allogeneic tissues and are susceptible to rejection. The remaining bone acts as a scaffold for ingrowth of recipient mesenchymal stem cells (osteocyte precursors), which repopulates the donor by creeping substitution. Although technically an allogeneic tissue transplant, these grafts are essentially totally replaced by recipient cells once the healing process is complete and no immunosuppression is given. Owing to slow union, long-term fixation is required of bone allograft, which is prone to stress fracture and loosening of fixation hardware. In studies of retrieved human allografts, however, union was seen at the graft-host interface. Vascularized bone allograft on the other hand contains living donor cells and is susceptible to immunologic rejection. The humoral and cellular response generated to transplanted bone was found to be similar in intensity and timing as that generated by other vascularized allogeneic limb tissues such as the skin and muscle. Although individual bone cells express antigens, the predominant antigenic stimulus in a bone allograft is thought to be derived from the marrow. Removal of bone marrow by irradiation or replacement with recipient marrow has been shown experimentally to prolong allograft survival. Like any other allogeneic tissue, this rejection process can be ameliorated with immunosuppression, and long-term survival of orthotopic vascularized skeletal allograft has been achieved in animal models. However, the adverse effects of prolonged immunosuppression required for survival of a vascularized bone allograft preclude its clinical application currently as an autologous sources of vascularized bone. Non-vascularized allografts are usually sufficient to reconstruct most simple bone defects.

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Cartilage Allograft Cartilage is composed of chondrocytes within lacunae dispersed throughout a water-laden matrix. The matrix is composed predominantly of proteoglycans and type II collagen. Water is important as cartilage has no intrinsic blood supply and relies on diffusion of nutrients and oxygen through this matrix. The combination of water and proteoglycans imparts the characteristic of viscoelasticity depending on the relative concentrations of both elements. The variable water content in the matrix causes a balanced tension within it and helps maintain its three-dimensional shape. The viscoelastic property of the matrix confers memory such that cartilage returns to its original shape after deformation. Surgical manipulation or scoring disrupts this equilibrium. In contrast to osteocytes, chondrocytes have little reparative ability and heal by forming fibrous scar tissue. There are histologically three types of cartilage: hyaline, elastic, and fibrocartilage. Chondrocytes express HLA antigens on their surface and are thus immunogenic in isolation. Cartilage, however, is immunologically privileged owing to the shielding of chondrocytes by its matrix, which is only weakly antigenic. Surgical scoring or dicing of cartilage allograft with resultant exposure of allogeneic cells has been shown to hasten cartilage resorption. Cartilage allografts have been used successfully for similar applications as autologous cartilage. Allogeneic cartilage can be either preserved or fresh. Preserved cartilage has the advantage of a more abundant supply and decreased risk of infection in comparison to fresh cartilage. Although immunologically privileged, cartilage allografts are still susceptible to loss of volume through resorption. Whether this is due to immunologic rejection or lack of viable cells following preservation is a matter for debate.

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Cartilage Xenograft Some authors have advocated the use of bovine-derived cartilage xenografts. However, both chondrocytes and matrix are subject to xenogeneic mechanisms of rejection with a generally poorer outcome in comparison to autologous or allogeneic cartilage grafts. Attempts to modify these xenogeneic responses by altering the graft’s immunologic stereotactic structure have been reported as being beneficial.

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Nerve Allograft The best clinical outcome following nerve transection is achieved with primary repair. More extensive injuries or a delay in repair may result in a nerve gap following debridement of damaged nerves, and a nerve graft may be necessary to achieve neurorrhaphy without tension. The nerve graft undergoes the same degenerative process as in the distal nerve after division. The myelin sheath remains with Schwann cells that act as a biological conduit for the regenerating axons. Vascularized nerve grafts are theoretically advantageous particularly in scarred beds. Other conduits used as nerve grafts have included autologous vein, silicone tubes seeded with Schwann cells, and freeze-fractured autologous muscle. Autologous nerve grafts with acceptable donor site morbidity are limited, and extensive nerve reconstruction may require other sources such as nerve allografts. Immunological rejection of nerve allograft can be ameliorated experimentally with immunosuppressive drugs, and axons were found to traverse the allogeneic nerve graft in rodents. A similar result has also been demonstrated in primates. Immunosuppression was necessary during axonal regeneration but could be terminated afterward in some studies with satisfactory nerve functions. In the only clinical experience, Mackinnon reported return of motor and sensory functions in the upper or lower limbs of six out of seven patients following nerve allograft reconstruction. 39

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Reconstructive Transplantation Reconstructive transplantation or, as it is also referred to, vascularized composite allotransplantation (VCA) has become a valid therapeutic and restorative option for patients with severe tissue defects not amendable to conventional reconstruction. 3–5,20,21 Significant advances in both basic science and translational research related to transplant immunology paired with the development of more potent and targeted immunosuppressive agents over the past 2 decades as well as highly encouraging functional and immunological clinical outcomes have led VCA to transition from an experimental and sometimes controversial procedure to an accepted and rapidly expanding field with great promise.

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Upper Extremity Transplantation It has been well documented that reconstructive transplants can be maintained on conventional triple drug immunosuppression at levels similar to that used in solid organ transplantation. 40,41 Patients after upper extremity transplantation have functional motor and sensory recovery similar to that seen with replantation. Since the beginning of the modern era of hand transplantation in 1998, there have been over 140 hand and upper extremity transplants performed worldwide in centers across the United States, Europe, and Asia. In general, and as reported in the International Registry on Hand and Composite Tissue Transplantation, results have been highly satisfactory with very few grafts lost, on average good hand function, and relatively few major side effects and complications. 3,5,18 Immunosuppressive side effects included predominately opportunistic infection (i.e., CMV), metabolic complications such as diabetes and hypertension, nephrotoxicity (requiring renal transplantation in some cases), avascular necrosis of the hip, and the occurrence of posttransplant malignancy such as PTLD. Although the risk/benefit equation of placing a patient on long-term immunosuppressive medications for a nonlifesaving type of transplant must always be considered, advances such as minimization protocols using donor bone marrow infusion and monotherapy maintenance have been successfully developed in large animal models and are currently being studied in humans. 6,7,42–44 Such innovative alternative protocols are anticipated to favorably alter this balance in the future. Thus, the consensus among many patients is that VCA delivers considerable improvements in function, independence, and quality of life. Such functional gains allow these patients to perform a variety of daily activities such as eating, writing, driving, grasping, shaving, while, in some cases, dramatically improving their social life and enabling them to return to work full time (Figure 8.4). As a consequence, upper extremity transplantation is increasingly being seen as another alternative in the reconstructive armamentarium used to treat patients with upper extremity amputations. Hand and upper extremity transplantation has demonstrated the ability to restore the structure and function of the hand in a way not possible with any other reconstructive technique by truly replacing like with like (Figure 8.5). Hence, it appears that reconstructive transplantation will continue to play an increasing role in the treatment of patients with upper limb amputations. However, balancing the risk/benefit ratio in particular the risks of and toxicities of systemic immunosuppression against all the improving in function, patient autonomy, and quality of life will remain the prime task of this field for the foreseeable future.

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FIGURE 8.4 Functional outcome after bilateral upper extremity transplantation. Demonstration of excellent functional outcome in a patient more than 8 years after bilateral upper extremity transplantation (left side at wrist level and right side above elbow at mid humerus level).

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FIGURE 8.5 Upper extremity 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.

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Face Transplantation No other area of reconstructive transplantation captures the imagination of patients, clinicians, and the public like face transplantation. Especially because human beings’ perception of self is intimately tied to one’s facial appearance. In addition, the face provides information not only about self-identity, but also age, gender, and ethnicity of an individual and thus affects social interactions, integration, and perception of body image. For patients with severe and devastating injuries to the craniofacial skeleton and soft tissues of the face, there is currently no other acceptable, effective restorative option using standard reconstructive techniques. For these patients, transplantation of allogeneic cadaveric facial structures has shown to be the only viable option of regaining normal facial appearance and being able to reintegrate into society in a meaningful way. Since the first partial face transplantation has been carried out in 2005 by Drs. Dubernard and Devauchelle in France, a total of 40 cases of craniofacial transplantation have been performed worldwide and thereby shown technical feasibility and promising immunological, functional, psychological, and aesthetic results. 20,21,45 Transplanted grafts have consisted of just soft tissue (the nose and lips) up to and including all facial soft tissue and portions of facial bones and the tongue (entire face, maxilla, anterior portion of the mandible, and tongue). Indications for these procedures have included ballistic trauma sustained by military personnel and civilians, animal bites, tumor resection, neurofibromatosis, and burns. All of the facial allografts have included either portions of the orbicularis oris or oculi; loss of the sphincter function of the mimetic muscles of the face is generally considered to be one of the indications for facial transplantation. In general, patients have been maintained on immunosuppression similar to that used for upper extremity or solid organ transplantation with all patients receiving induction therapy followed by triple drug immunosuppression. Tacrolimus has been the cornerstone of nearly the majority of immunosuppression protocols used in face transplantation with target trough levels of 10 to 15 ng/mL for the first 6 months with most patients subsequently lowering to a maintenance level of 8 to 10 ng/mL. Corticosteroids have been safely tapered after a few months, with complete withdrawal possible within a year in some cases, depending on the immunosuppression regimen. Overall, immunological and functional patient outcomes have been highly satisfactory. All patients receiving facial transplantation have dramatically improved their aesthetic appearance allowing them to be reintegrated into society and have a normal and productive social life. However, functional outcomes are difficult to quantify uniformly owing to the complexity of facial functions and the wide range of extend of injures across face transplantation recipients. All patients for whom outcomes have been reported in the literature have developed nearly normal sensory function with return of two-point discrimination and temperature differentiation between 3 and 8 months after transplantation. Motor recovery has been slightly slower but all patients have recovered some degree of motor function allowing for oral competence, the ability to breathe, eat, taste, smell, and speak, and for facial expression. Typical motor recovery is detectable as early as 6 to 8 months post transplant with maximum recovery around 18 months after transplant. Unfortunately, there have now been first cases of chronic rejection reported for face transplantation which resulted in subsequent graft loss, including the very first French patient. In addition, as of the time of this writing and to the best of the author’s knowledge, there have been five mortalities associated with facial transplantation. Two perioperative deaths occurred when combined VCA face + upper extremity was attempted. One case of mortal tumor recurrence in an HIV + recipient, one case of de novo posttransplant lung cancer, and one case due to noncompliance, resulting in an 86% patient survival rate after face transplantation. Other known risks include the development of systemic infections, metabolic complications, or the chance to develop cancer due to long-term immunosuppression. 20,21 Although technically highly demanding and the potential for serious and eventually life-threatening complications, facial transplantation has the unique potential to restore patients to normalcy and save them from social

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death. There is a clear indication that for carefully selected patients, facial transplantation offers a procedure that, although not lifesaving, is potentially life restoring.

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Other Areas and Latest Developments in Reconstructive Transplantation Developments in reconstructive transplantation have clearly been led by upper extremity and facial transplantation. However, there have been smaller series of patients treated with transplantation of several other composite structures including vascularized knee joints, lower extremities, trachea, larynx, abdominal wall, and reproductive organs. With the exception of vascularized knee joints (which have failed in five of the six patients attempted owing to chronic vascular complications), reconstruction with these varied types of transplants has met with some qualified success. Although these less common types of transplants continue to be highly experimental, they demonstrate the possibilities that reconstructive transplantation offers. Traditional plastic surgery techniques are unable to restore complex tissues and anatomical structures with the fidelity equal to that of reconstructive transplantation as evidenced by recipients’ functional and aesthetic outcomes.

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Uterus Transplantation Given the highly encouraging outcomes seen in upper extremity and face transplantation, indications for VCA to reconstruct other devastating tissue defects or organ losses are rapidly expanding. One such example is uterus transplantation, which has now emerged as the first therapy for women with absolute uterine factor infertility, who have traditionally been regarded as unconditionally infertile. Two isolated cases of uterine transplantation were reported in 2000 and 2011 by teams in Saudi Arabia and in Turkey. Although both surgeries were initially successful, the first patient lost the graft at 3 months due to uterine artery thrombosis and the second patient suffered two early miscarriages after embryo transfer. In 2014, a team in Sweden reported the first birth of a child to a uterine transplant recipient, who had undergone single embryo transfer 1 year after transplantation. 46 Several more successful live births have been reported since then from the nine women who have entered this initial Swedish trial. The field of uterus transplantation is expanding at a staggering pace, with active centers being established all around the world. At least 10 new clinical trials have just started or are in the process to start as of 2018. Of note, uterine transplantation represents the first ephemeral type of transplantation. 47 As hysterectomy can be performed after successful pregnancy, concerns about long-term side effects from immunosuppression would not apply. Although uterus transplantation has been shown to be a highly effective and successful treatment for absolute uterine factor infertility, it also raises a series of ethical questions. For instance, Huet et al. reviewed potential candidates for transplantation: some presented with complete androgen insensitivity syndrome. 48 These patients are phenotypically and psychosocially female but genetically male; the question that has been posed was should they be considered eligible? This question can further be extended to transgender individuals and will require further sensitive discussion.

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Penile Transplantation Penile transplantation is another emerging option for patients with severe genital defects not amenable to traditional reconstructive techniques. 49 Patients with penile defects frequently suffer from debilitating physical and psychosocial impairments, including inability to have sexual intercourse or urinate while standing, feelings of emasculation, disruption of interpersonal relationships, and profound loss of quality of life. Although traditional phalloplastic reconstruction can produce satisfactory outcomes in many cases, it is limited by a high rate of complications involving prosthesis extrusion and urinary strictures and fistulae. Furthermore, there is a growing cohort of patients with traumatic penile loss and concomitant extremity injuries who are not candidates for autogenous reconstruction because they lack adequate donor sites. For patients who have either failed autogenous reconstruction or are not appropriate candidates, penile allotransplantation may offer a viable alternative. The first penile transplant was performed in 2006 by a team in Guangzhou, China: a patient who sustained traumatic amputation received a transplant from a deceased donor. The surgery involved microsurgical anastomoses of the urethra, deep and superficial dorsal veins, dorsal arteries, and dorsal nerves, as well as of the corpus spongiosum and corpora cavernosa. Despite encouraging early results, the graft was explanted 2 weeks later at the recipient’s request because of severe psychological problem of the patient and his wife. The second and third cases were performed in 2014 and 2016 in South Africa and in the United States, respectively. The South African patient was a 21-year-old man who suffered partial loss of his penis as a complication of ritual circumcision. 50 The Boston patient was a 64-year-old man who, 4 years earlier, underwent penectomy to treat penile squamous cell carcinoma. 51 In March 2018, a team at Johns Hopkins University performed the world’s first entire penis and scrotum transplantation in a wounded warrior who had sustained a devastating injury several years earlier from an improvised explosive device while serving in Afghanistan. These three successful transplants provide proof of principle that penile transplantation is technically feasible with encouraging functional outcomes (urination, erogenous sensation, and erectile function) and thus constitutes a promising option for repair of extensive urogenital tissue loss. Given that penile transplantation is still in its infancy, implementing a successful penile transplantation program will require development of de novo protocols that take into account a number of important immunological, diagnostic, logistical, procedural, and ethical considerations. To maximize the utility and viability of penile transplantation as a reconstructive option, careful attention must be given to these important aspects pertaining to penile transplantation.

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Novel Technologies and Future Outlook Novel technologies such as tissue engineering and regenerative medicine will play a significant role in the future development of reconstructive transplantation. Regenerated nerves, vessels, bone, etc., will further expand indications to full arm and lower extremity and to eventually perform transplants in a more rapid, safer, and successful fashion. Along those lines, three-dimensional bioprinting could help to further optimize outcomes by enhancing the graft or advancing rehabilitation strategies and approaches currently in use for upper extremity transplantation. Ultimately, bioengineering technologies, which are currently developed in advanced prosthetic programs, could further help to improve outcomes and efforts and even augment or enhance function after VCA in the future. As clinical experience with these techniques is accumulated and immunosuppressive and immunomodulatory protocols are optimized, the risk-benefit ratio of reconstructive transplantation will continue to shift in favor of these procedures, making these techniques an increasingly available and important part of plastic surgeons’ reconstructive options for treating these crippling defects.

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Questions 1. Which of the following immunosuppressive agents belongs to the class of CNIs? a. Rapamycin b. Belatacept c. Tacrolimus d. Thymoglobulin 2. The initiation of an alloimmune response is a well-orchestrated and choreographed interplay of various different players of the immune system. Alloreactive T cells require three distinct signals for full activation. What constitutes signal 2? a. The NF-κB pathway b. Costimulatory pathways (B7-CD28, CD40-CD154) c. The interaction of MHC and TCR d. None of the above 3. What cell type is predominantly driving an acute alloimmune response? a. B cells b. Macrophages c. T regulatory cells d. CD4+ and CD8+ T cells e. DCs 4. Most upper extremity and face transplant patients experience episodes of acute rejection during the first year post transplant. In which tissue component of the graft does acute rejection predominately manifest in VCA? a. Muscle b. Vasculature c. Bone d. Skin e. Nerves 5. Technical limitations with regard to the feasibility of performing vascular anastomosis have hampered the development of organ transplantation for centuries. This obstacle was finally overcome when which surgeon introduced his vascular anastomosis technique? a. Joseph E. Murray b. Alexis Carrel c. Giuseppe Baronio d. Gaspare Tagliacozzi e. Thomas E. Starzl 1. Answer: c. Tacrolimus and CsA are CNIs and are the most widely used maintenance immunosuppressive agents for both solid organ and reconstructive transplantation. Both agents inhibit the calcineurin/IL-2 pathway of T cell activation and due to their potent immunosuppressive activity have revolutionized the field of solid organ transplantation by significantly increasing survival of kidney, heart, and liver allografts in the 80s and 90s. Belatacept is a biologic agent (monoclonal antibody CTLA-Ig) and inhibits the costimulatory signal B7-CD28. Rapamycin is an mTOR inhibitor and acts downstream of signal 3 inhibiting the response to IL-2. Thymoglobulin is a polyclonal antithymocyte antibody primarily used as induction agent to deplete peripheral blood lymphocytes through antibody-dependent cell-mediated cytotoxicity. 2. Answer: b. In addition to signal 1, APCs provide so called costimulatory signals to fully active T

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cells. These costimulatory signals are also referred to as signal 2 during T cell activation. Two of the best-characterized costimulatory signals/pathways in transplantation are the B7/CD28 and the CD40/CD154 pathways. The NF-κB pathway is activated as part of the intracellular signal transduction cascade referred to as signal 3 during T cell activation. Within the secondary lymph nodes, T cells encounter the MHC alloantigen that is expressed on the surface of the DCs with their specific TTCRs combined with the CD3 complex that facilitates signal transduction. This interaction of MHC, TCR, and CD3 complex is referred to as signal 1. 3. Answer: d. The primary mediators of acute rejection episodes are CD4+ and CD8+ T cells that upon activation infiltrate the graft and lead to inflammatory damage and parenchymal tissue necrosis. B cells are involved in the production of donor-specific antibodies and late antibodymediated rejection. These antibodies bind to endothelial cells and activate the complement cascade, which in turn leads to deposition of complement factors C3d and C4d that trigger endothelial inflammation and cellular infiltration resulting in vascular damage and occlusion. T regulatory cells (CD4+CD25+Foxp3+ T regs) play a key role in the maintenance of peripheral tolerance to both selfand foreign antigens. DCs are key players in the initiation of an alloimmune response and serve as APCs to T cells but do not have effector function. Macrophages contribute to both the innate and acquired arms of the alloimmune response and play pluripotent roles during allograft rejection. They can induce allograft injury but, conversely, can also promote tissue repair in ischemia-reperfusion injury and acute rejection. 4. Answer: d. Acute rejection remains a considerable challenge in reconstructive transplantation. Notably, 85% of all hand, upper extremity, and face allograft recipients have experienced at least one episode of acute rejection within the first year after transplant, and as much as 56% experienced multiple episodes. The skin is the most antigenic component of a vascularized composite allograft and thus represents the primary manifestation of acute rejection. The high antigenicity of the skin can in part be related to the high proportion of potent APCs (Langerhans cells) and keratinocytes which express MHC I constitutively and MHC II, ICAM-I, and proinflammatory cytokines upon stimulation. Skin rejection usually manifests clinically with maculopapular skin lesions restricted to small areas or spread over the whole allograft, varying in color and location and presenting with or without edema. While skin rejection is most frequently observed after human hand and face allotransplantation, an immune response toward tissues other than the skin such as muscle, nerves, and bone has been documented, however, to a much lesser extend and usually only during very advanced stages of untreated rejection. More recent findings, furthermore, indicate that also the vasculature of the graft may be affected and proliferation of the myointima can occur as a sign of chronic rejection. 5. Answer: b. The obstacle of vascular anastomosis was overcome in 1902 when Alexis Carrel introduced his vascular anastomosis technique, which unlocked a continuum of research in experimental organ transplantation. Within the same year, Austrian surgeon Emerich Ullmann performed the first experimental kidney transplantation in animals in Vienna. Dr. Joseph E. Murray performed the first successful living-related kidney transplantation between identical twins in 1954 and was awarded the Nobel Prize for this pioneering effort in 1990. Giuseppe Baronio’s (1758–1814) contributions are considered fundamental to the field of plastic surgery, and he laid the groundwork for research in the fields of both skin grafting and transplant immunology. Gaspare Tagliacozzi was a surgeon in the 16th century who emerged as a popular figure in transplantation and was a specialist in rhinoplasty. Thomas E. Starzl performed the first human liver transplant in 1967 at the University of Colorado in Denver and has often been referred to as the father of modern transplantation.

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References Guild, WR, Harrison, JH, Merrill, JP, Murray, J. Successful homotransplantation of the kidney in an identical twin. Trans Am Clin Climatol Assoc. 1956;67:167-173. Rana, A, Gruessner, A, Agopian, VG, et al. Survival benefit of solid-organ transplant in the United States. JAMA Surg. 2015;50(3):252-259. Shores, JT, Brandacher, G, Lee, WP. Hand and upper extremity transplantation: an update of outcomes in the worldwide experience. Plast Reconstr Surg. 2015;35(2):351e-360e.This review provides a comprehensive overview of the current status and outcomes after upper extremity transplantation globally. Brandacher, G. Composite tissue transplantation. Methods Mol Biol. 2013;1034:103-115. Petruzzo, P, Lanzetta, M, Dubernard, JM, et al. The International Registry on hand and composite tissue transplantation. Transplantation. 2010;90(12):1590-1594. Fryer, M, Grahammer, J, Khalifian, S, et al. Exploring cell-based tolerance strategies for hand and face transplantation. Expert Rev Clin Immunol. 2015;11(11):1189-1204. Brandacher, G, Lee, WP, Schneeberger, S. Minimizing immunosuppression in hand transplantation. Expert Rev Clin Immunol. 2012;(7):673683. Brandacher, G, Khalifian, S, Lee, WPA. Reconstructive transplantation: from scientific dream to clinical reality. The Science of Reconstructive Transplantation. New York, NY: Humana Press; 2015. Bhishagratna, KL. Sushruta Samhita. Vol 1. 1907. Forgotten Books. Martin, C. John Hunter and tissue transplantation. Surg Gynecol Obstet. 1970;131(2):306. Schultheiss, D, Bloom, DA, Wefer, J, Jonas, U. Tissue engineering from Adam to the zygote: historical reflections. World J Urol. 2000;18(1):8490. Billingham, RE, Brent, L, Medawar, PB. Actively acquired tolerance of foreign cells. Nature. 1953;172(4379):603-606. Merrill, JP, Murray, JE, Takacs, FJ, et al. Successful transplantation of kidney from a human cadaver. JAMA 1963;185:347-353. Starzl, TE. History of clinical transplantation. World J Surg. 2000;24(7):759-782. Gilbert, R. Transplant is successful with a cadaver forearm. Med Trib Med News. 1964;5:20. Jones, JW Jr, Ustuner, ET, Zdichavsky, M, et al. Long-term survival of an extremity composite tissue allograft with FK506-mycophenolate mofetil therapy. Surgery. 1999;126(2):384-388. Dubernard, JM, Owen, E, Herzberg, G, et al. Human hand allograft: report on first 6 months. Lancet. 1999;353:1315-1320. Shores, JT, Malek, V, Lee, WPA, Brandacher, G. Outcomes after hand and upper extremity transplantation. J Mater Sci Mater Med. 2017;(5):72. Devauchelle, B, Badet, L, Lengele, B, et al. First human face allograft: early report. Lancet. 2006;368(9531):203-209. Khalifian, S, Brazio, PS, Mohan, R, et al. Facial transplantation: the first 9 years. Lancet. 2014;384(9960):2153-2163. Tasigiorgos, S, Kollar, B, Krezdorn, N, et al. Face transplantation-current status and future developments. Transpl Int. 2018;(7):677-688.This review provides a comprehensive overview of the current status and outcomes after upper extremity transplantation globally. This review provides an excellent summary of the current status and latest developments of the field of face transplantation. Strome, M, Stein, J, Esclamado, R, et al. Laryngeal transplantation and 40-month follow-up. N Engl J Med. 2001;344:1676-1679. Delaere, P, Vranckx, J, Verleden, G, et al. Tracheal allotransplantation after withdrawal of immunosuppressive therapy. N Engl J Med. 2010;362(2):138-145. Hofmann, GO, Kirschner, MH. Clinical experience in allogeneic vascularized bone and joint allografting. Microsurgery. 2000;20(8):375-383. Levi, DM, Tzakis, AG, Kato, T, et al. Transplantation of the abdominal wall. Lancet. 2003;361(9376):2173-2176. McDiarmid, SV. Donor and procurement related issues in vascularized composite allograft transplantation. Curr Opin Organ Transpl. 2013; (6):665-671. Ali, JM, Bolton, EM, Bradley, JA, Pettigrew, GJ. Allorecognition pathways in transplant rejection and tolerance. Transplantation. 2013;96(8):681-688. DeWolf, S, Sykes, M. Alloimmune T cells in transplantation. J Clin Invest. 2017;127(7):2473-2481. Halloran, PF. Immunosuppressive drugs for kidney transplantation. N Engl J Med. 2004;351(26):2715-2729. Borges, TJ, Murakami, N, Riella, LV. Current status of alloimmunity. Curr Opin Nephrol Hypertens. 2016;(6):556-562. Etra, JW, Raimondi, G, Brandacher, G. Mechanisms of rejection in vascular composite allotransplantation. Curr Opin Organ Transpl. 2018; (1):28-33. Wiseman, AC. Immunosuppressive medications. Clin J Am Soc Nephrol. 2016;11(2):332-343.An excellent overview of immunosuppressive agents in current use in transplantation and their individual mode of action. Agarwal, A, Ally, W, Brayman, K. The future direction and unmet needs of transplant immunosuppression. Expert Rev Clin Pharmacol. 2016; (7):873-876. Schwarz, C, Mahr, B, Muckenhuber, M, Wekerle, T. Belatacept/CTLA4Ig: an update and critical appraisal of preclinical and clinical results. Expert Rev Clin Immunol. 2018;(7):583-592. Zuber, J, Sykes, M. Mechanisms of mixed chimerism-based transplant tolerance. Trends Immunol. 2017;(11):829-843.A comprehensive discussion of the principles and underlying mechanisms of mixed chimerism-based tolerance induction in solid organ transplantation.

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Mahr, B, Granofszky, N, Muckenhuber, M, Wekerle, T. Transplantation tolerance through hematopoietic chimerism: progress and challenges for clinical translation. Front Immunol. 2017;8:1762. Vaikunthanathan, T, Safinia, N, Lombardi, G. Optimizing regulatory T cells for therapeutic application in human organ transplantation. Curr Opin Organ Transpl. 2018;23(5):516-523. doi: 10.1097/MOT.0000000000000561. Wendt, JR, Ulich, TR, Ruzics, EP, Hostetler, JR. Long-term survival of human skin allografts in patients with immunosuppression. Ann Plast Surg. 2004;113(5):411-417. Mackinnon, SE, Doolabh, VB, Novak, CB, Trulock, EP. Clinical outcome following nerve allograft transplantation. Plast Reconstr Surg. 2001;107(6):1419-1429. Howsare, M, Jones, CM, Ramirez, AM. Immunosuppression maintenance in vascularized composite allotransplantation: what is just right? Curr Opin Organ Transpl. 2017;(5):463-469. Schneeberger, S, Khalifian, S, Brandacher, G. Immunosuppression and monitoring of rejection in hand transplantation. Tech Hand Up Extrem Surg. 2013;17(4):208-214. Kueckelhaus, M, Fischer, S, Seyda, M, et al. Vascularized composite allotransplantation: current standards and novel approaches to prevent acute rejection and chronic allograft deterioration. Transpl Int. 2016;(6):655-662. Cetrulo, CL Jr, Drijkoningen, T, Sachs, DH. Tolerance induction via mixed chimerism in vascularized composite allotransplantation: is it time for clinical application? Curr Opin Organ Transplant. 2015;(6):602-607. Vyas, KS, Mohan, AT, Morrison, SD, et al. Cell-based therapies in vascularized composite allotransplantation. J Reconstr Microsurg. 2018;34(8):642-650. doi:10.1055/s-0038-1661336. Giatsidis, G, Sinha, I, Pomahac, B. Reflections on a decade of face transplantation. Ann Surg. 2017;5(4):841-846. Brännström, M, Johannesson, L, Bokström, H, et al. Livebirth after uterus transplantation. Lancet. 2015;385(9968):607-616.Seminal report of the pioneering efforts and the first livebirth after uterus transplantation. Brännström, M. Womb transplants with live births: an update and the future. Expert Opin Biol Ther. 2017;17:1105-1112. Huet, S, Tardieu, A, Filloux, M, et al. Uterus transplantation in France: for which patients? Eur J Obstet Gynecol Reprod Biol. 2016;205:7-10. Tuffaha, SH, Cooney, DS, Sopko, NA, et al. Penile transplantation: an emerging option for genitourinary reconstruction. Transpl Int. 2017; (5):441-450. van der Merwe, A, Graewe, F, Zühlke, A, et al. Penile allotransplantation for penis amputation following ritual circumcision: a case report with 24 months of follow-up. Lancet. 2017;390(10099):1038-1047.Seminal report of the first successful penis allotransplanation. Cetrulo, CL Jr, Li, K, Salinas, HM, et al. Penis transplantation: first US experience. Ann Surg. 2018;7(5):983-988.

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CHAPTER 9

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Principles of Prosthetics in Plastic Surgery Ara A. Salibian and Ernest S. Chiu

Key Points Prosthetics, when used appropriately, can successfully provide a variety of restorative functions including permanent reconstruction of osseous and soft tissue defects, reinforcement of complex wound closures, stabilization of bony discontinuities, optimization of autologous tissue for reconstruction, and augmentation of aesthetic features. The ideal prosthetic should minimize foreign body reactions, incorporate into the surrounding tissues, resist infection, retain its shape, easily be implanted and manipulated, and be permanent. Implantation of prosthetics requires strict sterile technique, minimization of handling by multiple personnel, use of antibiotic solutions, and limitation of contact with skin or other potential sources of infection. Facial prosthetics can provide excellent cosmetic results, alone or in combination with autologous techniques for skeletal augmentation as well as bony and soft tissue reconstruction with the appropriate implant choice, incision design with respect for aesthetic subunits, and proper implant placement in the subperiosteal plane. Success with temporary implants for tissue expansion relies on good soft tissue coverage, appropriate implant shape and position, controlled expansion, patient counseling, and patience. The use of prosthetics for skeletal and soft tissue augmentation requires balancing the requests of the patient with the surgeon’s understanding of what is medically appropriate for each individual patient. The most common complications with prosthetics are infection and extrusion, which can be minimized by adherence to the aforementioned principles but must be addressed promptly if present for eventual reconstructive salvage. A thorough preoperative discussion of the potential risks of prosthetics is crucial, including the need for explantation as well as other rare and serious complications such as implant-associated neoplasm.

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Background Prosthetics are a subset of biomaterials or substances used to support, augment, or replace a particular tissue or group of tissues of function in the body. 1 Prosthetics have a variety of critical functions as an adjunct to or a replacement of autologous methods of reconstruction and augmentation. Lack of availability of adequate autologous material for reconstruction may require the use of synthetic compounds. At other times, an implant can enhance the reconstructive capabilities of autologous tissue, as with mechanical and biologic creep, 2,3 or can support the healing of autologous structures, as with titanium internal fixation of fractures. Implants can also be used in aesthetic surgery to augment the appearance of the facial skeleton, or enhance volume and soft tissue contours throughout the body. The utilization of prosthetic implants requires adherence to basic guidelines, many of which parallel general plastic surgery principles. All implants should be meticulously handled using strict sterile technique and limited contact with personnel, skin and external surfaces. Implantation requires creation of an adequate pocket in the appropriate tissue planes that provides a well-vascularized environment to prevent infection and extrusion and minimize palpability and visibility. Along the same lines, infected, irradiated, and poorly vascularized tissue must be avoided. The ideal prosthetic implant has long been sought after and unfortunately has still not been developed. There is a commonality of important characteristics to minimize complications from prosthetics and maximize their benefits. These central traits were outlined by Cumberland 4 and Scales 5 in the 1950s. They can be summarized as principles pertaining to the utility of an implant such as its ability to be adaptable but still resist mechanical strain as well as requirements for safety and compatibility such as minimizing inflammation and cellular foreign body responses (Table 9.1). Considering these characteristics when determining the need for a prosthetic can help guide the appropriate utilization of implants. TABLE 9.1 Characteristics of Ideal Prosthetic Implants 4,5

Allow for tissue ingrowth Nonallergenic Noncarcinogenic Sterilizable Permanence (when indicated) Minimize foreign body reaction High tolerance for mechanical stress Easily fabricated at low cost Adaptable Easy to manipulate and handle Resistant to infection

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History The search for adequate replacements of damaged or missing bodily structures is not a recent phenomenon. Implantable materials have been traced back to the use of suture over 32,000 years ago and later to the ancient Egyptians. 6 Dental fillings made of beeswax have been found in Neolithic mandibles that are 6500 years old. 7 Trephination defects from Peru dating to 3000 BC have been found to be filled with various materials from gold and silver to shells. 8 Limitations of early prosthetic implantation were several, and included the nature of materials utilized as well as the handling of these items that would inevitably lead to breakdown, infection and failure. The concept of aseptic technique, introduced in the 19th century, 9 was a critical scientific advancement for the successful utilization of implants. The development of radiography in the late 19th century 10 was also a major milestone, as many of the initial modern implants consisted of metal internal fixation hardware for fractures since introduced in 1895. 11 The 20th century marked the transition from the reliance on natural materials for implants to the development of metal alloys, ceramics, and polymers. The infamous accidental discovery of the suitability of a plastic polymer as a prosthetic after the traumatic implantation of the material led Harold Ridley to utilize PMMA for artificial lenses in 1949. 6 Soon thereafter Arthur Voorhees used fabric grafts to develop arterial prostheses, 12 and Cumberland described nylon mesh for ventral hernia. 4 Major strides continued in the mid-20th century as scientists worked to improve the applicability and biocompatibility of implants, an effort that persists today.

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The Foreign Body Response The foreign body reaction is the body’s immunologic response to implantation of a nonhost material. The reaction is mediated by a cascade of molecular factors initiated by platelets, fibrinogen, and complement proteins that results in a chronic inflammatory state with the recruitment of macrophages, the formation of foreign body giant cells, and the persistence of inflammation and eventually fibrosis. 13 The extent of this response is influenced by the nature of the implant. Biocompatibility of an implanted prosthetic characterizes the ability of the device to coexist within the host. This concept has migrated away from describing an inert material in isolation from the body to representing a mutual but favorable interaction between the implant and the host. With regard to implantable devices, biocompatibility can be redefined as the ability of the device to perform its intended function, with the desired degree of incorporation in the host, without eliciting any undesirable local or systemic effects in that host. 1 The long-term implications of the foreign body response can be practically divided into two end points: fibrous encapsulation versus tissue incorporation. Fibrous encapsulation of an implant results in a dense scar plate around the foreign, whereas tissue incorporation results in more random extracellular matrix deposition, cellular infiltration, and neovascularization. 14 The characteristics of a particular implant, such as pore size, can significantly impact which pathway predominates. 15 Macroporous mesh will allow tissue to cross pores and promote mesh incorporation whereas microporous mesh prevents cell migration and results in mesh encapsulation.

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Implant Materials Different prosthetic materials have different reconstructive implications with regard to physical properties, interaction with the surrounding tissues, management of complications, and long-term retention. Although many different implant materials have been used historically, this review will summarize only the most commonly used synthetic materials (Table 9.2). TABLE 9.2 Common Prosthetic Implant Materials Metals Stainless steel Titanium Gold Platinum Ceramics Hydroxyapatite Tricalcium phosphate Calcium phosphate cement Polymers Polyester Polyethylene PMMA Polypropylene Expanded polytetrafluoroethylene Polyurethane urea Silicone Biodegradable polymers

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Metals Initial metal implants, typically for fracture fixation, suffered from corrosion. 11 It was not until the refinement of different combination of metals, or alloys that promoted the more widespread applicability of metal implants. Key characteristics of biocompatible metal implants include nontoxicity, resistance to corrosion, ability to osseointegrate (when needed), appropriate mechanical properties and high wear resistance, or resistance to loss of surface material secondary to mechanical forces. 16

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Stainless Steel Stainless steel refers to a number of iron-based alloys that usually contain a high percentage of chromium and varying amounts of nickel. Stainless steel has a high tensile strength and elastic modulus as well as low cost and was one of the earlier alloys to be utilized for medical implants. Stainless steel, however, is limited by its poor resistance to fatigue as well as corrosion, which has resulted in premature failure of these implants. Stainless steel also has poor wear resistance that results in debris that can induce inflammation and allergic reactions. In addition, leaching of nickel and chromium from the alloy has been shown to be toxic. These characteristics limit the utility of this alloy in long-term applications. Currently, stainless steel is most often used for temporary implants such as surgical wires and arch bars for maxillomandibular fixation.

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Titanium Titanium is utilized as a pure low-density chemical element or a stronger but less malleable alloy usually combined with aluminum and vanadium. This alloy was developed more recently and has replaced many of its prior counterparts such as stainless steel and vitallium. The most important properties of titanium include its low density, high strength-to-density ratio, inert character, and high resistance to corrosion secondary to formation of a protective stable oxide layer. 17 It is therefore considered to be the most biocompatible of metals, which has led to its widespread use in implantable medical devices. Titanium also has a lower modulus of elasticity than stainless steel and cobalt-chromium alloys. 16 This modulus more closely matches that of bone and therefore decreases stress shielding, allowing for more loading of bone. Titanium integrates with bone without formation of an intervening fibrous capsule, which allows it to be used for osseointegrated implants. Furthermore, titanium is nonferromagnetic and therefore does not preclude patients from undergoing magnetic resonance imaging. In the realm of plastic surgery, titanium is primarily utilized for osteosynthesis plates and screws (Figure 9.1), maxillofacial implants, and cranioplasty.

FIGURE 9.1 Titanium mandible plate and mini-plate with screws to provide rigid fixation of a comminuted parasymphyseal fracture. Also pictured are stainless steel arch bars and wire for placement in temporary maxillomandibular fixation.

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Gold Gold has been used for medicinal purpose since ancient civilization. It is a useful metal implant owing to its resistance to corrosion and nontoxic and highly inert character. Pure gold does not react with any known substances in the body. Although gold is very malleable, it lacks strength, limiting its applications. The most common use of gold implants is for upper eyelid weight in the treatment of lagophthalmos secondary to facial nerve palsy. These implants typically are purer 24-carat gold alloys to maximize nonreactivity and biocompatibility.

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Platinum Platinum is a dense and malleable chemical element. Plastic Surgery applications are primarily for eyelid weights for treatment of paralytic lagophthalmos. The higher density of platinum than gold allows for the use of smaller, lower profile implants. The high malleability of platinum is also beneficial when molding of an implant is needed. Platinum is also used in the cross-linking of medical-grade silicone or poly(dimethylsiloxane) (PDMS) in silicone breast implants.

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Calcium Ceramics Ceramics are inorganic compounds with a spectrum of crystalline structures. The most commonly used ceramic implants in plastic surgery are calcium phosphate–based ceramics typically utilized as alloplastic bone substitutes. These materials are typically porous, allowing for tissue ingrowth and osteoconductive. A critical limitation of the widespread application of calcium phosphates is their mechanical properties. These cements have low impact resistance and low tensile strength and are brittle, limiting their use in any load-bearing areas. They are therefore typically used for reconstruction, and less so, augmentation of the craniofacial skeleton. The most common ceramics are hydroxyapatite, Ca10(PO4)6(OH)2; tricalcium phosphate, Ca3(PO4)2; and derivatives of calcium phosphate cement pastes.

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Hydroxyapatite Hydroxyapatite is formed from naturally occurring calcium carbonate coral and has organized porous channels. It is available in particulate and block forms that can be carved to fit a cranioplasty defect, as well as bone cement pastes that set isothermally and have decreased radiologic scatter. These cement pastes (Mimix [Walter Lorenz Surgical, Inc., Jacksonville, FL]; BoneSource [Stryker Leibinger, Portage, MI]) have been widely use in craniofacial reconstruction, usually for cranioplasty 18,19 but also for interpositional bone grafts in orthognathic surgery. Hydroxyapatite is osteoconductive, but as a microporous cement, direct bony and vascular ingrowth is limited, and bony replacement tends to occur by resorption and turnover of hydroxyapatite to bone at the periphery of the implant.

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Tricalcium Phosphate Tricalcium phosphate is a synthetic, porous ceramic that, like hydroxyapatite, provides a scaffold for tissue ingrowth. It has more random pore structure and is more quickly resorbed and replaced by bone than hydroxyapatite. It is also available both in block and particulate form.

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Carbonated Calcium Phosphate Cement Carbonated calcium phosphate pastes have also been developed from calcium phosphate and calcium carbonate. Dahllite, a carbonated apatite (Norian Cranial Repair System, Synthes, Paoli, PA), has higher tensile and compressive strength and a composition that closely resembles bone. 20 This carbonated apatite cement has been shown to have a greater resistance to fracture when compared with hydroxyapatite cement products. 21 The solubility of dahllite at a lower pH has been suggested to increase resorption and replacement by natural bone.

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Polymers Polymers are a broad category of synthetic and naturally occurring macromolecules that are composed of repeating subunits. Unlike metals and ceramics, they have widespread indications in both hard and soft tissue reconstruction and augmentation. There are a wide variety of different polymers used as prosthetic implants; the most common synthetic materials are covered here.

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Polyester Polyesters are polymers containing an esther group and usually refer to the compound polyethylene terephthalate. This material is a high-molecular-weight polymer that is primarily used as knitted mesh such as Mersilene mesh (Ethicon, Inc., Somerville, NJ) for hernia repair. Mersilene is a nonabsorbable mesh with high tensile strength that allows for tissue ingrowth and has also been used for chin and nasal augmentation. Certain polyesters such as poly-4-hydroxybutyrate are bioderived, in that they are produced by microorganisms and have been used in biodegradable mesh products such as Phasix (Bard Davol, Warwick, RI). 22

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Polyethylene Polyethylene is the most commonly produced plastic. There are multiple different types of this polymer differentiated primarily by their density and branching. The molecular weight of polyethylene influences its mechanical properties, which can range from 40,000 daltons (low density) resulting in a ductile material used for bags, to ultrahigh-molecular-weight polyethylene (2–6 million daltons) used for orthopedic hip implants. Importantly, the material is inert and has low tissue reactivity and long-term structural stability when used as implants. Polyethylene implants are typically used for facial reconstruction and augmentation. These are usually high-density porous implants (e.g., Medpor, Stryker, Kalamazoo, MI), which permit vascularization as well as soft tissue and bony ingrowth with pore sizes ranging from 100 to 250 µm in diameter. 23 This porosity results in incorporation of the implant and prevention of migration, though simultaneously makes incorporated implants difficult to remove. High-density porous polyethylene implants are utilized in cranioplasty, ear reconstruction, and orbital implants as well as reconstruction and augmentation of the mandible, malar eminence, nose, and frontal bone among others areas. 24 Complications with these implants include infection, exposure, extrusion, and visibility, which are highly reliant on the vascularity of the surrounding tissues and the placement technique. 25

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PMMA PMMA is a nondegradable acrylic resin formed by mixing liquid methyl methacrylate monomer with the accelerator, PMMA powder. The resulting strong but light high-molecular-weight polymer is chemically inert, rigid, nonconductive, and easily handled. The material is not porous, and therefore does not allow of tissue ingrowth and osteoconduction when utilized on its own. PMMA is most commonly used for cranioplasty owing to its rigidity and lack of significant movement or mechanical stress in this region. 26 This material can be molded in situ or can be preformed as a custom implant. PMMA is also used for stabilization of chest wall. It can be added to or sandwiched between mesh reinforcement for some tissue incorporation and durability. A significant exothermic reaction occurs during curing of PMMA that can reach temperatures of 40 to 56°C. Active cooling of the surrounding tissues with saline is therefore required to prevent thermal tissue necrosis. Furthermore, curing in vivo can results in a small amount of shrinkage that must be accounted for and can also release the unbound monomer systemically, which is toxic.

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Polypropylene Polypropylene is similar to the chemical structure of polyethylene but with the inclusion of a methyl group. Polypropylene is most widely used as a high-tensile, nonabsorbable suture and mesh. Polypropylene mesh is typically used for bridging repair of fascial defects or reinforcements of hernia repairs as well as chest wall reconstruction. These meshes are macroporous and therefore allow for tissue ingrowth, but also can have an increased risk of adhesions if placed intraperitoneally.

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Expanded Polytetrafluoroethylene Expanded polytetrafluoroethylene (ePTFE) or Gore-Tex (W.L. Gore, Flagstaff, AZ) is created by expanding a linear polymer of fluorine and carbon molecules to create a microporous structure. ePTFE is a modification of PTFE that is a more lightweight and pliable material with good biocompatibility, a high strength-to-weight ratio, and a similarly low coefficient of friction. Owing to its microporous structure, the material has significantly less tissue ingrowth compared with macroporous mesh and a higher propensity for encapsulation. 14 ePTFE products have a variety of applications in plastic surgery. Woven microporous meshes are used in abdominal and chest wall reconstruction. Solid blocks can be carved and adapted for volume restoration in facial reconstruction and augmentation such as with malar, chin, and nasal implants.

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Polyurethane Urea Polyurethane urea is a multiblock copolymer with good mechanical properties and biocompatibility. These polymers have been modified to form slow-degrading, filament-based meshes that serve as scaffolds for tissue ingrowth. The Artelon CMC Spacer (Artimplant, Vastra Frolunda, Sweden) is a fabric of the polymer designed for interposition between the metacarpal and trapezium for treatment of basal joint arthritis by stabilizing the carpometacarpal joint by augmentation of the capsule and joint resurfacing. 27

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Silicone Medical-grade silicone is formed from PDMS, a polymer of organosilicone. Silicone is biologically inert, does not dissolve in the environment found within the body, and is nontoxic. The mechanical properties of silicone, most practically its viscosity, are altered by changing the length of the polymer and its molecular weight. Cross-linking of PDMS chains has also become a clinically useful chemical alteration that creates a firmer gel used for form-stable, highly cohesive implants. Silicone is a widely used material across multiple different specialties in medicine and is used as components of thousands of medical products. Short polymer chains of PDMS result in a low-viscosity liquid form of silicone. Liquid silicone has been used extensively as a soft tissue filler but causes several adverse effects including ulceration, cellulitis, abscesses, foreign body migration, and granulomas. 28 Liquid silicone injections are not Food and Drug Administration approved and must be avoided. The polymerization of Dimethyl sulfoxide into longer chains is used to form silicone gels for implants. Silicone has had a tumultuous past in the field of Plastic Surgery owing to the temporary restriction on silicone gel implants by the Food and Drug Administration over concerns on toxicity and association with connective tissue disease in 1992. Since then, however, studies have demonstrated the safety of silicone breast implants with regard to a lack of toxicity and association with connective tissue disease 29 with a cessation of the ban in 2006. Silicone implants are now utilized for a wide spectrum of indications in Plastic Surgery including breast reconstruction, breast augmentation, facial reconstruction and augmentation, ear reconstruction, gluteal augmentation, and joint and flexor tendon reconstruction. Because silicone implants are not porous, they become encapsulated with scar tissue. This foreign body reaction can have significant consequences for the long-term implications of silicone implants as fibrosis, and encapsulation can result in contracture of surrounding tissues, aesthetic distortion, and pain.

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Biodegradable Polymers Biodegradable polymers are designed to break down into natural byproducts such as water and carbon dioxide. The most common biodegradable polymers include poly (lactic acid), poly (glycolic acid) (PGA), and poly (lactic-co-glycolic acid), which are degraded into lactic or glycolic acid. Formulations of these materials and their combinations, such as Vicryl mesh (Polyglactin 910; Ethicon, Inc., Somerville, NJ) are used for support in abdominal and chest wall reconstruction as well as breast reconstruction. Biodegradable plates and screws consist of similar polymers and are useful in craniofacial surgery and fracture fixation in pediatric patients in whom bone growth limits the use of permanent devices. 30 Other devices such as biodegradable suture anchors (e.g., Endotine, Coapt Systems, Inc., Palo Alto, CA) consist of a mix of poly (lactic acid) and PGA.

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Indications by Body Region Prosthetic implants have a wide range of indications for both reconstructive and aesthetic purposes. The following sections summarize the most common uses of prosthetic implants in plastic surgery by body region and indication (Table 9.3). TABLE 9.3 Common Prosthetic Implant Indications and Materials in Plastic Surgery Facial Reconstruction Skeletal reconstruction (titanium, porous polyethylene, ePTFE, silicone) Osteosynthesis hardware (titanium, biodegradable polymers) Arch bars (stainless steel) Ear reconstruction (polyethylene, silicone) Eyelid weights (gold, platinum) Facial Augmentation Solid implants (porous polyethylene, ePTFE, silicone) Mesh (polyester) Anchoring devices (titanium, biodegradable polymers) Calvarial Reconstruction Osteosynthesis hardware (titanium, biodegradable polymers) Cranioplasty (titanium, calcium phosphate ceramics, PMMA, polyethylene) Breast Reconstruction and Augmentation Breast implants (silicone) Tissue expanders (silicone) Support scaffolds (titanium, biodegradable polymers) Chest Wall Reconstruction Mesh (polypropylene, ePTFE, polyglycolic acid, biodegradable polymers) Rigid reconstruction (PMMA) Abdominal wall reconstruction Mesh (polyester, polypropylene, ePTFE, biodegradable polymers) Lower Extremity Gluteal implants (silicone) Hand Osteosynthesis hardware (titanium, stainless steel) Joint replacement (polyurethane urea, silicone, pyrolytic carbon, polyethylene) Tendon reconstruction (polyester/silicone) Skin Tissue expanders (silicone) ePTFE, expanded polytetrafluoroethylene.

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Facial Reconstruction Bony Skeleton Osteosynthesis of the facial skeleton is usually performed with different titanium hardware consisting of load-bearing and load-sharing plates, secured with screws to provide rigid or semirigid fixation. In the setting of pediatric reconstruction, hardware composed of biodegradable polymers may be chosen for facial growth without having to remove hardware. Temporary implants in the form of internal and external titanium distraction devices are also commonly used in craniofacial surgery for manipulation of the skeleton after osteotomies. Implants to restore the devoid facial skeleton are commonly used in orbital blowout fractures to reconstruct the orbital floor. These implants usually consist of titanium, porous polyethylene, or a combination of both and can be custom fabricated to the individual defect. A variety of other implants, typically porous polyethylene, can also be used to restore bony contours in the face such as the mandible, malar eminence, and zygoma. 24 These implants are placed in the subperiosteal plane to prevent disruption of the overlying structures, visualize skeletal contours, maximize soft tissue coverage, and ensure a well-vascularized environment.

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Ear Reconstruction of the cartilaginous framework of the ear is most commonly required for defects and malformations secondary to anotia, microtia, and trauma such as burns. Cited benefits of alloplastic reconstruction include limitless material, age independence, decreased patient discomfort, and improved ear definition. 31 Moldable implants usually consist of porous polyethylene, which have been revolutionized by the utilization of a temporoparietal fascial flap to provide well-vascularized coverage of the implant and minimize complications of infection and extrusion.

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Eyelid Eyelid weights are commonly used for treatment of paralytic lagophthalmos secondary to facial nerve palsy. Original implants were stainless steel, 32 which were later replaced with gold 33 and platinum. The implant is typically placed in a pocket deep to the orbicularis oculi and can be secured to the tarsal plate, without disrupting the insertion of the levator apparatus. Complications include implant migration, extrusion, skin ulceration, capsule formation, implant visibility, over/undercorrection, and infection. Platinum has been suggested to be superior, as its higher density allows for a smaller, thinner profile implant, with potentially lower rates of extrusion. 34

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Facial Augmentation Aesthetic augmentation of the facial skeleton is typically performed with alloplastic prosthetic implants. Similar to reconstruction, implants are fixated to the underlying bone in the subperiosteal plane to minimize injury to nerves and directly visualize bony contours. The most common implants are porous polyethylene, ePTFE, and silicone; the last does not allow for tissue ingrowth and heals with fibrous encapsulation. Common areas of augmentation include the malar eminence, infraorbital rim, and paranasal regions in the midface, as well as almost all anatomic areas of the mandible including the mentum, body, angle, and ramus. 35

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Calvarial Reconstruction Calvarial reconstruction often utilizes titanium plates and screws for osteosynthesis of traumatic fractures or for fixation of osteotomy sites. Osteosynthesis of the skull in pediatric patients may utilize biodegradable hardware to allow for skull growth. Temporary stainless steel hardware has also been utilized in infants such as the use of stainless steel springs to promote outward expansion of the skull in sagittal craniosynostosis. 36 Prosthetic implants have proven to be valuable in large calvarial defects given the lack of adequate autologous replacements. Alloplastic cranioplasty materials most commonly are calcium phosphate ceramics including hydroxyapatite and derivatives of calcium phosphate cement pastes. Use in large quantities in areas with potential bacterial contamination has been associated with an increased risk of complications. 37 Customizable cranial implants with both PMMA and polyethylene, as well as titanium implants, have also been described for adult cranioplasty with low major complication rates (Figure 9.2). 38 Preoperative radiation has been shown to be the strongest independent predictor of postoperative complications. 39

FIGURE 9.2 Cranioplasty with custom prefabricated 3D-printed implant made of titanium mesh and calcium phosphate tiles designed with virtual surgical planning (OssDsign AB, Uppsala, Sweden) and secured with titanium mini-plates.

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Breast Implants First generation Cronin-Gerow implants from 1963 had a teardrop-shaped silicone rubber shell filled with silicone gel and a posterior Dacron patch for fixation. Subsequent generations of implants have progressively improved to provide more natural results while minimizing complications such as silicone leakage, capsular contracture, palpability, and visibility. Modern day implants consist of an elastic silicone shell and highly cohesive silicone gel filling or a hard outer shell filled with saline (Figure 9.3).

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FIGURE 9.3 Tabbed tissue expander (A; Mentor, Irvine, CA) being filled with saline (B) during first stage of two-stage breast reconstruction.

Silicone implants are approved for breast augmentation in patients age 22 years or older or for breast

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reconstruction in women of any age. Complications of silicone breast implants include capsular contracture, infection, extrusion, rippling, double-bubble deformity, and rupture. 29 Implants with textured surfaces have lower rates of capsular contracture; however, only when placed in the subglandular and not submuscular plane. 40 Fifth generation cohesive gel implants have increased crosslinking allowing for the production of anatomic implants that retain their shape. These highly cohesive implants tend to have lower rates of contracture and rippling but higher rates of malposition and seromas.

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Capsular Contracture As silicone breast implants are not porous, the foreign body reaction to these implants is one of fibrous encapsulation. Capsular contracture is an exaggeration of this response with the immune system playing a central role believed to be triggered by multiple factors including subclinical infection and biofilm. This response can have significant clinical implications with severe cases resulting in aesthetic deformities and pain secondary to contracture, which requires total capsulectomy and implant exchange. Several risk factors have been identified including smooth implants, periareolar incisions, subglandular placement, and postoperative hematoma, among others. 41

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Breast Implant–Associated Anaplastic Large Cell Lymphoma Breast implant–associated anaplastic large cell lymphoma (BIA-ALCL) is a rare T cell lymphoma associated with primarily textured breast implants. 42 Patients most commonly present with a delayedonset seroma (>1 year) and less commonly a capsular mass. Any suspicious cases require aspiration of periprosthetic fluid and/or biopsy of masses sent for cytology, histology, flow cytometry, and CD30+ immunohistochemistry. Most localized cases have a good prognosis with complete capsulectomy and implant removal. Successful management of this disease is highly reliant on identification, treatment, and proper reporting by plastic surgeons.

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Support: Polypropylene and Vicryl Mesh Various synthetic materials have also been described to provide implant support in dual-plane reconstruction. These include polypropylene-based (TiLoop Bra [pfm medical, Köln, Germany]) and biodegradable polymer–based (Polyglactin 910 [Ethicon, Inc., Somerville, NJ]) products as cheaper alternatives to biologic materials such as acellular dermal matrix. Superiority in outcomes between biologic and synthetic products has yet to be determined in large, prospective studies.

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Chest Wall Prosthetic implants can be useful tools in reconstruction of chest wall owing to the strength, rigidity, and adaptability of certain materials to the three-dimensional contours of the thoracic cage. Proposed criteria for the need for skeletal reconstruction of the chest wall include the absence of four or more ribs or a defect greater than 5 cm in size owing to the potential for developing a flail chest. 43 Several types of implantable materials have been utilized in chest wall reconstruction. Polypropylene meshes such as Marlex (CR Bard, Murray Hill, NJ) and Prolene (Ethicon Inc., Somerville, NJ) are commonly used for tissue ingrowth whereas ePTFE (Gore-Tex, Gore, Flagstaff, AZ) can be used to provide a watertight closure. 44 Multiple other polymers such as PGA and poly (lactic acid) serve the same purpose. PMMA can be used to create a rigid, moldable reconstruction and can be sandwiched between layers of macroporous mesh for tissue incorporation.

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Abdominal Wall Mesh plays a critical role in abdominal wall reconstruction by providing support for primary repair of the musculofascial wall or serving as a bridging material. Reinforcement of primary midline repairs with mesh has been shown to significantly decrease the rate of recurrence in ventral hernia repair in a multicenter, randomized controlled trial. 45 Synthetic mesh materials can be divide into three categories: (1) macroporous mesh (e.g., polypropylene; Figure 9.4), which allows for tissue ingrowth but also has a high risk for adhesions of placed intraperitoneally; (2) microporous mesh (e.g., ePTFE), which does not have tissue-growth and heals with a capsule; and (3) composite mesh that contains an additional coating such as cellulose or collagen to decrease adhesions when placed intraperitoneally. Recently developed biosynthetic meshes are made of fully absorbable synthetic polymers (Bio-A [Gore], Phasix [Bard/Davol], TIGR [Novus Scientific]) and are aimed at providing better support of the abdominal wall than biologic matrices while still undergoing tissue ingrowth and resorption.

FIGURE 9.4 Abdominal reconstruction with synthetic macroporous polypropylene mesh (©Ethicon, Inc. Reproduced with permission).

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Lower Extremity and Gluteal Region Augmentation Silicone implants have been utilized for augmentation of different lower extremity structures. Gluteal augmentation with silicone implants is the most well-studied region. A variety of different placement techniques exist, usually differing in plane of placement with the most common approaches being intramuscular or subfascial implant placement. 46

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Hand Osteosynthesis A variety of different titanium plates and screws are available for rigid fixation of phalangeal, metacarpal, and carpal fractures. Stainless steel Kirschner wires are also frequently used in hand surgery for percutaneous pin fixation of bone fragments.

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Joint Replacement Sequelae of rheumatoid arthritis, osteoarthritis, trauma, and even infection may necessitate the replacement of joints in the hand. Arthroplasty is most often performed in the basal joint (osteoarthritis) and the metacarpophalangeal and interphalangeal joints (rheumatoid arthritis). Traditional alloplastic arthroplasty has utilized silicone joint replacement, though complications include synovitis, displacement, and giant cell reactions. Polyurethane urea joint replacements (Artelon CMC Spacer; Artimplant, Vastra Frolunda, Sweden) have also been introduced; however, evidence is still lacking on the superiority of outcomes among different materials. Other implant materials include pyrolytic carbons and polyethylene-based products.

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Tendon Reconstruction Two-stage tendon reconstruction involves the placement of temporary tendon implants. The use of a prosthetic implant overcomes the problem of a scarred tendon bed through the foreign body response to the implant that results in a well-organized pseudosheath, allowing for tendon graft gliding. These implants consist of variations silicone rods with different cores, such as polyester. Permanent tendon implants have also been described but are limited owing to unreliable fixation to the bone distally and native tendon proximally.

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Skin (Tissue Expanders) Tissue expanders are used frequently throughout the body owing to the benefits of mechanical and physiologic creep in providing adequate skin for closure of a defect. Two-stage breast reconstruction utilizes tissue expanders that consist of an outer silicone shell and internal port to allow the breast pocket to reach the appropriate size for implant placement without placing excess stress on the breast skin envelope. Other common locations for tissue expansion are the scalp, forehead, neck, and back. Tissue expansion is particularly useful in infants with lesions that have a high size-to-body surface area ratio such as congenital nevi and vascular malformations. The success of tissue expansion relies on a thorough knowledge of appropriate incision for insertion, 47 planes of implant placement, use of correct expanders, appropriate expansion timing, design of expanded skin flaps, and management of complications. Tissue expansion often initially causes skin erythema and mottling without fever or signs of infection in which expansion should be continued. On the other hand, pain and erythema may suggest the need for fluid removal whereas fever, purulence, and signs of infection require expander removal.

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Future Directions There is still a significant need to continue to improve the characteristics of implantable prosthetics. Although creating an autologous equivalent is the standard, today’s products are still by no means the ideal implant first outlined in the 1950s. Recent research advances in prosthetics aim at creating new materials while utilizing well-known products for different indications. As technology moves forward, research must be focused on further understanding the interaction between the implant and the host at the macroscopic and molecular level to continue to work toward optimizing the biocompatibility of implants.

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Questions 1. A 13-month-old child with a giant congenital nevus of the flank undergoes uncomplicated placement of a 10 × 15 cm subcutaneous rectangular tissue expander in preparation for subsequent reconstruction with adjacent tissue. After initiation of expansion in the following weeks, the parents of the child are worried that the skin over the expander looks red. Upon examination, there is slight erythema of the skin overlying the expander without warmth or surrounding skin changes and with no palpable fluid collections. The child is afebrile and well appearing and does not appear to be in pain. The next appropriate step in management of this patient involves a. Starting intravenous antibiotics b. Removing the tissue expander c. Continuing with expansion d. Starting oral antibiotics e. Aspirating fluid from the tissue expander to send for culture 2. A 24-year-old patient presents with dissatisfaction of his facial appearance. Examination reveals a retruded chin, and alloplastic chin augmentation is planned. Compared with porous polyethylene implants for facial augmentation, silicone implants have a. Lower infection rate b. Decreased concern for migration c. Better contour to the facial skeleton d. Easier removal e. Increased visibility 3. A 23-year-old woman presents for consultation regarding breast augmentation. The patient has small, symmetric breasts, without breast ptosis. She desires to be at least two bra sizes larger. Breast augmentation with form-stable anatomic implants is planned with placement in the subglandular plane. Which of the following answer choices best describes the advantages of using textured, anatomic implants compared with smooth, round implants in this patient? a. Decreased risk of malrotation b. Decreased risk of postoperative capsular contracture c. Superior cosmetic result d. Decreased risk of seroma e. e. Increased risk of rippling 4. A 56-year-old man undergoes resection of a large left anterior chest wall sarcoma, and you are consulted intraoperatively for reconstruction. The resection includes the full-thickness chest wall with five ribs and the left half of the sternum. Intraoperative defect size is 10 × 20 cm. He has not received any other neoadjuvant treatments. Which of the following is the best choice for reconstruction? a. PMMA sandwiched in polypropylene mesh and left latissimus dorsi flap b. PMMA sandwiched in polypropylene mesh and left vertical rectus abdominis myocutaneous (VRAM) flap c. Polypropylene mesh and left latissimus dorsi flap d. Polypropylene mesh and left VRAM flap e. Acellular dermal matrix and left latissimus dorsi flap 5. A 60-year-old woman with a history of right breast cancer and bilateral mastectomy and implantbased reconstruction 6 years ago presents to your office complaining of right breast discomfort. The patient initially had a two-staged reconstruction with placement of highly cohesive textured

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implants. She denies any changes in size of her breasts, skin changes, fever, or recent trauma to her breasts. On examination, she has no significant abnormalities. A magnetic resonance image is obtained, which reveals a moderately sized right periprosthetic fluid collection. Which of the following is the most appropriate next step in management? a. Fine-needle aspiration of the collection to send for culture b. Fine-needle aspiration of the collection to send for CD30+ immunohistochemistry c. Explantation of bilateral breast implants and total capsulectomy d. Admission to the hospital and intravenous antibiotics e. Observation 1. Answer: c. Skin undergoing tissue expansion can often become slightly hyperemic upon initial expansion. Although skin erythema should always raise suspicion for infection with an underlying foreign body, the absence of other signs of infection in this case including surrounding cellulitis, pain, warmth, or fever makes infection unlikely. If the erythema persists or is worsening, further workup for an infection is warranted. However, mild skin changes are expected, and expansion should proceed normally in the absence of other symptoms. Starting antibiotics would be the correct choice if an early infection was suspected. Although the traditional dogma for any tissue expander infection entails explantation, more recent studies have shown that mild cellulitis without exposure can be salvaged with oral antibiotic regimens. 1 In these cases, aspiration of fluid for culture can also help guide antibiotic therapy. Severe infection, impending implant exposure or extrusion, requires explantation of the expander, washout of the pocket, antibiotic therapy, and delayed reimplantation after the infection has cleared. 2. Answer: d. Polyethylene and silicone implants are commonly used in facial augmentation. Both implants are usually placed subperiosteally to maximize soft tissue coverage, minimize damage to overlying neurovascular structures, and directly visualize bony contours. Both implants are contoured to the facial skeleton and have different profiles that can be selected and adjusted as needed. Porous polyethylene allows for tissue ingrowth and therefore is theoretically better vascularized and has less of a risk of migration than silicone implants if not secured to bone. Because silicone implants are not porous, they do not allow for tissue ingrowth and therefore are easier to remove. 3. Answer: b. Fifth generation breast implants have increased cross-linking that results in a highly cohesive implant that maintains this shape. Textured implants have been shown to have decreased rates of capsular contracture than smooth implants; however, only when placed in the subglandular plane. This difference is not significant in implants placed in the submuscular plane. Textured anatomic implants have not been demonstrated to have superior cosmetic outcome. In fact, evaluation by both plastic surgeons and nonmedical professional has not been able to identify anatomic versus round patients in photographs of patients with breast augmentation. Anatomic implants have a higher rate of malposition than round implants owing to their asymmetric shape, which is visible with rotation. Highly cohesive fifth generation implants have also been shown to have higher rates of seroma and decreased rates of rippling. 4. Answer: a. The patient has undergone a large chest wall resection that involves five ribs and a portion of the sternum. He has a composite defect that includes the skin, soft tissue, and bone. Patients who undergo resection of four or more ribs or have a bony defect greater than 5 cm are at a higher likelihood of developing flail chest. Therefore, mesh and dermal allograft alone will not provide adequate rigidity in this patient. PMMA is frequently used in chest wall reconstruction as a polymer that can be molded but cures into a rigid structure. In certain cases, rigidity of the chest wall secondary to fibrosis after radiation therapy may preclude the need for rigid chest wall reconstruction, as flail chest is less prevalent in this cohort. However, this is not the situation in this

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patient who has not previously received radiation. As the patient had resection of the sternum as well as ribs on either side, there is likely compromise of the internal mammary vessels, which would prevent the use of a flap based on the superior epigastric vessels. Therefore, the best answer choice provides a rigid reconstruction with PMMA sandwiched in macroporous mesh to allow for some tissue ingrowth as well as durable soft tissue coverage with a latissimus dorsi myocutaneous flap. 5. Answer: b. More than 500 worldwide cases of BIA-ALCL have been reported. This rare T cell lymphoma is primarily associated with textured implants and usually presents with a delayed-onset seroma and less commonly a capsular mass. Patients who present with a seroma greater than 1 year postoperatively should raise suspicion for BIA-ALCL. Appropriate steps in diagnosis include sending periprosthetic fluid for CD30+ immunohistochemistry. Additional diagnostic tests from fluid aspirate include cytology, flow cytometry, and histology. If a mass is present, it should also be biopsied and sent for pathology. Observation is not correct, as the presentation of seroma greater than 1 year postoperatively in a patient with textured implants is highly suggestive of BIA-ALCL. Although explantation of implants and total capsulectomy is the treatment for BIA-ALCL localized to the implant pocket, this would be premature without a diagnosis of BIA-ALCL. This patient does not report any symptoms concerning for infection and the examination is otherwise benign. An indolent infection is possible but unlikely this later postoperatively.

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References Williams, DF. On the nature of biomaterials. Biomaterials. 2009;30:5897-5909. De Filippo, RE, Atala, A. Stretch and growth: the molecular and physiologic influences of tissue expansion. Plast Reconstr Surg. 2002;109:24502462. Cherry, GW, Austad, E, Pasyk, K, et al. Increased survival and vascularity of random-pattern skin flaps elevated in controlled, expanded skin. Plast Reconstr Surg. 1983;72:680-687. 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. Scales, JT. Tissue reactions to synthetic materials. Proc R Soc Med. 1953;46:647-652. Ratner, BD, Bryant, SJ. Biomaterials: where we have been and where we are going. Annu Rev Biomed Eng. 2004;6:41-75. Bernardini, F, Tuniz, C, Coppa, A, et al. Beeswax as dental filling on a neolithic human tooth. PLoS One. 2012;7:e44904. Verano, JW, Andrushko, VA. Cranioplasty in ancient Peru: a critical review of the evidence, and a unique case from the Cuzco area. Int J Osteoarchaeol. 2010;20:269-279. Miller, JT, Rahimi, SY, Lee, M. History of infection control and its contributions to the development and success of brain tumor operations. Neurosurg Focus. 2005;18:e4. Scatliff, JH, Morris, PJ. From Roentgen to magnetic resonance imaging: the history of medical imaging. N C Med J. 2014;75:111-113. Lane, WA. Some remarks on the treatment of fractures. Br Med J. 1895;1:861-863. Voorhees, AB. The development of arterial prostheses. A personal view. Arch Surg. 1985;120:289-295. Major, MR, Wong, VW, Nelson, ER, et al. The foreign body response: at the interface of surgery and bioengineering. Plast Reconstr Surg. 2015;135:1489-1498.A review of the mechanisms behind the foreign body response to implants and the current strategies to manipulate these pathways. Bellon, JM, Bujan, J, Contreras, L, Hernando, A. Integration of biomaterials implanted into abdominal wall: process of scar formation and macrophage response. Biomaterials. 1995;16:381-387. Jordan, SW, Fligor, JE, Janes, LE, Dumanian, GA. Implant porosity and the foreign body response. Plast Reconstr Surg. 2018;141:103e-112e. Chen, Q, Thouas, GA. Metallic implant biomaterials. Mater Sci Eng R. 2015;87:1-57. Healy, KE, Ducheyne, P. A physical model for the titanium-tissue interface. ASAIO Trans 1991;37:M150-M151. David, L, Argenta, L, Fisher, D. Hydroxyapatite cement in pediatric craniofacial reconstruction. J Craniofac Surg. 2005;16:129-133. Burstein, FD, Williams, JK, Hudgins, R, et al. Hydroxyapatite cement in craniofacial reconstruction: experience in 150 patients. Plast Reconstr Surg. 2006;118:484-489. Constantz, BR, Ison, IC, Fulmer, MT, et al. Skeletal repair by in situ formation of the mineral phase of bone. Science. 1995;267:1796-1799. Miller, L, Guerra, AB, Bidros, RS, et al. A comparison of resistance to fracture among four commercially available forms of hydroxyapatite cement. Ann Plast Surg. 2005;55:87-92. Deeken, CR, Matthews, BD. Characterization of the mechanical strength, resorption properties, and histologic characteristics of a fully absorbable material (poly-4-hydroxybutyrate-phasix mesh) in a porcine model of hernia repair. ISRN Surg. 2013;2013:238067. Spector, M, Flemming, WR, Sauer, BW. Early tissue infiltrate in porous polyethylene implants into bone: a scanning electron microscope study. J Biomed Mater Res 1975;9:537-542. Yaremchuk, MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg. 2003;111:1818-1827. Rubin, JP, Yaremchuk, MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg. 1997;100:1336-1353. Zanotti, B, Zingaretti, N, Verlicchi, A, et al. Cranioplasty: review of materials. J Craniofac Surg. 2016;27:2061-2072. Nilsson, A, Wiig, M, Alnehill, H, et al. The Artelon CMC spacer compared with tendon interposition arthroplasty. Acta Orthop. 2010;81:237244. Singh, M, Solomon, IH, Calderwood, MS, Talbot, SG. Silicone-induced granuloma after buttock augmentation. Plast Reconstr Surg Glob Open. 2016;4:e624. Spear, SL, Murphy, DK, Allergan Silicone Breast Implant USCCSG. Natrelle round silicone breast implants: core study results at 10 years. Plast Reconstr Surg. 2014;133:1354-1361.Ten-year results of Allergan core study on silicone implants used in breast reconstruction and breast augmentation. The study provides important data on rates of common complications after these procedures such as infection, malposition, capsular contracture and need for implant removal/replacement. Eppley, BL, Morales, L, Wood, R, et al. Resorbable PLLA-PGA plate and screw fixation in pediatric craniofacial surgery: clinical experience in 1883 patients. Plast Reconstr Surg. 2004;114:850-856; discussion 857. Reinisch, J, Tahiri, Y. Polyethylene ear reconstruction: a state-of-the-art surgical journey. Plast Reconstr Surg. 2018;141:461-470.Detailed summary of the author’s evolution of technique for polyethylene ear reconstruction from experience with over 1500 patients. Sheehan, JE. Progress in correction of facial palsy with tantalum wire and mesh. Surgery. 1950;27:122-125. Illig, KM. A new method of lagophthalmos surgery. Klin Monbl Augenheilkd Augenarztl Fortbild. 1958;132:410-411. Silver, AL, Lindsay, RW, Cheney, ML, Hadlock, TA. Thin-profile platinum eyelid weighting: a superior option in the paralyzed eye. Plast Reconstr Surg. 2009;123:1697-1703. Yaremchuk, MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Reconstr Surg. 2003;112:1422-1432.

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van Veelen, MC, Kamst, N, Touw, C, et al. Minimally invasive, spring-assisted correction of sagittal suture synostosis: technique, outcome, and complications in 83 cases. Plast Reconstr Surg. 2018;141:423-433. Gilardino, MS, Cabiling, DS, Bartlett, SP. Long-term follow-up experience with carbonated calcium phosphate cement (Norian) for cranioplasty in children and adults. Plast Reconstr Surg. 2009;123:983-994. Wolff, A, Santiago, GF, Belzberg, M, et al. Adult cranioplasty reconstruction with customized cranial implants: preferred technique, timing, and biomaterials. J Craniofac Surg. 2018;29(4):887-894. Reddy, S, Khalifian, S, Flores, JM, et al. Clinical outcomes in cranioplasty: risk factors and choice of reconstructive material. Plast Reconstr Surg. 2014;133:864-873. Liu, X, Zhou, L, Pan, F, et al. Comparison of the postoperative incidence rate of capsular contracture among different breast implants: a cumulative meta-analysis. PLoS One. 2015;10:e0116071. Calobrace, MB, Stevens, WG, Capizzi, PJ, et al. Risk factor analysis for capsular contracture: a 10-year Sientra study using round, smooth, and textured implants for breast augmentation. Plast Reconstr Surg. 2018;141:20S-28S. Clemens, MW, Brody, GS, Mahabir, RC, Miranda, RN. How to diagnose and treat breast implant-associated anaplastic large cell lymphoma. Plast Reconstr Surg. 2018;141:586e-599e.CME article summarizing diagnostic criteria for BIA-LCL, appropriate workup for suspected cases of BIAALCL, and proper treatment and reporting of documented cases. McCormack, PM. Use of prosthetic materials in chest-wall reconstruction: assets and liabilities. Surg Clin North Am 1989;69:965-976. Arnold, PG, Pairolero, PC. Chest-wall reconstruction: an account of 500 consecutive patients. Plast Reconstr Surg. 1996;98:804-810.A large case consecutive case series of chest wall reconstruction using both autologous and alloplastic materials. The study outlines basic principles of chest wall reconstruction and highlights reconstructive options. Luijendijk, RW, Hop, WC, van den Tol, MP, et al. A comparison of suture repair with mesh repair for incisional hernia. N Engl J Med. 2000;343:392-398.A multicenter randomized controlled trial of mesh reinforcement versus primary repair only of primary and first recurrent ventral hernias less than 6 cm in length or width. Mesh reinforcement of repairs was found to have a 75% lower recurrence rate irrespective of hernia size. Mofid, MM, Gonzalez, R, de la Pena, JA, et al. Buttock augmentation with silicone implants: a multicenter survey review of 2226 patients. Plast Reconstr Surg. 2013;131:897-901. Zide, BM, Karp, NS. Maximizing gain from rectangular tissue expanders. Plast Reconstr Surg. 1992;90:500-504.

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CHAPTER 10

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Principles of Nerve Repair and Reconstruction and Neuroma Management Carrie A. Kubiak and David L. Brown and Theodore A. Kung

Key Points Appropriate management of nerve injuries is dictated by correct identification of the degree of nerve injury and the time since injury. Acute nerve transection injuries are best treated with primary, tensionless repair. Restoring appropriate alignment of corresponding fascicles in the proximal and distal nerve segments is important for optimizing outcomes in primary neurorrhaphy. In crush or avulsion nerve lesions where the zone of nerve injury is unclear, the viability of injured nerve should be allowed to demarcate before definitive reconstruction is attempted. Electrodiagnostic studies (EMG/NCV) can be used to help diagnose nerve injuries as well as track nerve regeneration. Autologous nerve grafts are the most reliable method to reconstruct segmental nerve gaps. Nerve transfers should be considered in proximal injuries and when there is concern that degradation of neuromuscular junctions will occur prior to reinnervation. Peripheral nerve injuries result in a myriad of symptoms, ranging from minor sensory disturbances to devastating loss of function. Debilitating chronic pain can be difficult to manage even with surgical intervention. The mechanism, level, and severity of the trauma directly contribute to the expected morbidity, prognosis, and recommended treatment following peripheral nerve injury. Recent advances in microsurgical techniques, graft materials, and nerve transfer strategies have greatly improved our ability to address peripheral nerve injuries, but reliable restoration of sensation and motor function can still be difficult to achieve. Outcomes following nerve repair or reconstruction can be optimized by ensuring a timely diagnosis and treatment, performing meticulous alignment of nerve ends during surgery, and following appropriate rehabilitation protocols. This chapter discusses the pathophysiology of nerve injury and summarizes the various operative strategies that are employed after trauma to peripheral nerves.

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Peripheral Nerve Anatomy Peripheral nerves consist of three main cell types. Neurons facilitate the transfer of information to and from the central nervous system, conveying both afferent sensory stimuli as well as efferent motor signals. Axons are extensions from the neuron cell bodies that reside in the spinal cord and spinal ganglia. Axons are either myelinated or unmyelinated and are grouped together spatially in bundles known as fascicles. Anterograde and retrograde axonal transport transfers structural proteins, as well as communicate between the cell body and the target end organ through cycling of neurotransmitters. 1 Supportive glial and stromal cells play an important role in the support and function of peripheral nerves. Schwann cells are the principal glial cells of the peripheral nervous system and produce the myelin sheath to myelinated axons. Myelin acts as an insulating coating to axons, efficiently augmenting the propagation of action potentials and increasing the conduction velocity in a process known as saltatory conduction. Stromal cells form the connective tissue scaffold around neurons and glial cells. 2 The endoneurium is the innermost layer of loose connective tissue that surrounds individual axons and their supporting Schwann cells to provide nourishment through microvessels. The perineurium serves to bundle axons together to form fascicles and is a major contributor to peripheral nerve tensile strength. A fascicular group consists of two or more fascicles surrounded by perineurium. The internal epineurium is the connective tissue that envelops individual fascicles and group fascicles. The epineurium is the outermost layer and is the tissue that defines an anatomically distinct peripheral nerve. Finally, the mesoneurium is a thin layer of loose areolar tissue that connects the peripheral nerve to surrounding structures and permits smooth gliding during bodily movements (Figure 10.1).

FIGURE 10.1 The normal peripheral nerve consists of myelinated and unmyelinated axons organized into bundles of fascicles. Peripheral neural tissue is supported by three major connective tissue sheaths: the endoneurium, perineurium, and epineurium.

Peripheral nerves are supplied by a series of segmental nutrient arteries that feed into a network of blood vessels within the nerve. The vasa nervorum vessels run superficially and longitudinally along the

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epineurium. These vessels send branches to intraneural vessels located within the interfascicular perineurium and in turn join a multitude of capillaries that extend into the endoneurium. This extensive communication maximizes the blood supply within the nerve and permits mobilization of a segment of a nerve for a length up to 45 times its diameter. 3

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Physiology of Peripheral Nerve Injury Loss of axonal continuity leads to an irreversible cascade of cellular and inflammatory events known as Wallerian degeneration. 4 This process begins within 24 to 48 hours of injury and involves complete axonal degeneration distal to the site of injury. Additionally, axonal degeneration occurs for a short distance proximally. An influx of calcium and sodium ions triggers the sequence of axonolysis. Disruption of both anterograde and retrograde transport systems leads to a buildup of proteins and subsequent swelling of the nerve on both sides of the injury. 5 Schwann cells transform into a more dedifferentiated and reactive phenotype 6 and begin to break down their own myelin, phagocytose debris, and recruit macrophages to the site of injury. 7 These macrophages in turn promote a positive feedback loop that further stimulates Schwann cell proliferation through the release of growth factors. 8 Wallerian degeneration proceeds until empty endoneurial tubes remain, devoid of axonal or myelin material. In the proximal nerve segment, Wallerian degeneration halts at the closest intact node of Ranvier, which also serves as the site of subsequent axonal growth. 9 To begin regeneration, dedifferentiated Schwann cells proliferate along the residual endoneurial tubes and create columns known as Bands of Büngner. These longitudinally aligned Schwann cells provide a supportive microenvironment and serve to guide regenerating axons to their appropriate distal target organs. 10 For this reason, superior clinical outcomes are observed when endoneurial tube remains intact. 11 Schwann cells further support regenerating axons via release of cytokines and neurotrophic factors that stimulate axonal growth. 12 Axonal regeneration is mediated by a host of neurotrophic factors that are released from local tissue including sensory and motor targets. 13 A divided neuron may form up to 50 to 100 axonal sprouts in an effort to reinnervate its target tissue. Each regenerating axon forms a growth cone consisting of multiple filopodia that guide outgrowth during regeneration. Proteases are also released from the growth cone to aid in the removal of any physical barriers hindering its path. Clinically, the site of axonal regeneration can be localized by tapping along the course of the peripheral nerve. A positive Tinel sign occurs when an electric shock or pins and needles sensation is produced. Elongation proceeds until the axons reach intact endoneurial tubes within the distal nerve segment that serve to guide growth towards the end organ. When functional connections are not made in a timely fashion, axons can degenerate in a process known as pruning. Axons that continue to grow aimlessly will form a disorganized and painful mass known as a neuroma. 14 Studies have shown that more severe nerve injuries lead to greater scarring and disordered axonal regeneration. 15 Axonal regeneration occurs at a rate of approximately 1 to 3 mm per day or just slightly more than an inch per month. 16 Therefore, when the location of nerve injury is known, one can predict the amount of time regenerating axons will take to reach their end organ. In distal peripheral nerve transections, regenerating axons will need to grow a relatively short distance. However, with more proximal peripheral nerve injuries, the time for regenerating axons to reach their targets can be estimated at many months to several years, resulting in Schwann cells losing their ability to facilitate nerve regeneration and distal endoneurial sheaths collapsing. 17 This precludes successful reinnervation even with the most optimal surgical techniques. For this reason, the level of peripheral nerve injury is critically relevant to the expected functional outcome. Muscle fibers will undergo irreversible loss of neuromuscular junctions and progressive fibrosis if not reinnervated with 1 to 2 years. In contrast, sensory end organs do not undergo such degeneration and can be reinnervated many years later with satisfactory results.

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Classification of Nerve Injury In 1943, Seddon described three degrees of peripheral nerve injury: neuropraxia, axonotmesis, and neurotmesis. 18 Sunderland later expanded this classification to five degrees based on histologic and structural changes seen within the nerve after injury 19 (Table 10.1, Figure 10.2). TABLE 10.1 Classification of Peripheral Nerve Injuries is Based on the Level of Anatomic Disruption Seddon Classification

Sunderland Classification

Nerve Anatomy b Myelin Axon Endoneurium

Perineurium

Epineurium

Recovery

Surgery

Full spontaneous recovery within days to months Full spontaneous recovery; regenerates at a rate of 1–3 mm per day Partial spontaneous recovery; regenerates at a rate of 1–3 mm per day No spontaneous recovery; regenerates at a rate of 1–3 mm per day after appropriate surgical intervention No spontaneous recovery; regenerates at a rate of 1–3 mm per day after appropriate surgical intervention Recovery depends on combination of degrees of nerve injury

None

a

Neurapraxia

First degree

−

+

+

+

+

Axonotmesis

Second degree

−

−

+

+

+

Third degree

−

−

−

+

+

Fourth degree

−

−

−

−

+

Fifth degree

−

−

−

−

−

Sixth degree

−

+/−

+/−

+/−

+/−

Neurotmesis

a

Degree of nerve injury determines likelihood of spontaneous recovery and/or need for surgical intervention.

b

+ Indicates structure is intact; − indicates structure is injured.

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None

None

Nerve repair, graft, or transfer Nerve repair, graft, or transfer Variable

FIGURE 10.2 Classification of nerve injuries. A. Uninjured nerve consists of myelinated axons surrounded by endoneurium. B. In first-degree injury, axons are demyelinated but intact. C. In second-degree injury, axons are injured and undergo degeneration. D. A third-degree injury includes damage to axons, myelin, and endoneurium. E. A fourth-degree is a complete scar block that prevents regeneration. F. A fifth-degree injury is a division of the nerve. G. A sixth-degree injury is a combination

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of any of the five levels of injury within the same nerve.

Neuropraxia is equivalent to Sunderland first-degree nerve injury. In this condition, the axons within the nerve remain intact, but a temporary, localized conduction block results from segmental demyelination. Acutely, neuropraxia can ensue after stretching injuries or blunt force trauma, whereas chronic etiologies of neuropraxia include longstanding compression neuropathies at locations where peripheral nerves pass through tight anatomic spaces (e.g., carpal tunnel syndrome). Axonal integrity is preserved, neurons maintain their connections to end organs, and Wallerian degeneration with subsequent axonal regeneration is not required for restoration of function. Electrodiagnostic studies (EDS) will show normal electromyographic (EMG) findings with decreased nerve conduction velocities and increased latencies. Recovery time is dependent on remyelination of the axons by Schwann cells and requires approximately 6 to 8 weeks. In axonotmesis, there is focal demyelination as well as axonal injury with Wallerian degeneration. Axonotmesis is a component of Sunderland second-, third-, and fourth-degree injuries and is usually caused by severe traction or crush injuries. Second-degree injury is characterized by the disruption of the continuity of axons but with preservation of intact endoneurial tubes. Regenerating axons are guided by their original endoneurial tubes that lead them directly to their target tissues, and therefore full functional recovery can be expected. Third-degree injury involves damage to the axon, myelin sheath, and endoneurium. The perineurium is intact, and the fascicular structure remains patent. Because the endoneurial sheaths are violated, scarring may serve as a physical barrier to regenerating axons. Functional recovery is variable and often incomplete. In fourth-degree injury, there is injury to the myelin, axon, endoneurium, and perineurium, and only the epineurium remains intact. Common causes of fourth-degree nerve injury include traction and iatrogenic nerve injection. Spontaneous recovery does not occur due to interposed fibrosis, and surgical intervention is required. Sunderland fifth-degree injury is equivalent to Seddon neurotmesis. This type of injury is the complete transection of axons and all connective tissue layers, commonly due to a sharp laceration. Surgical intervention is required, and functional outcomes are more unpredictable. Although the Sunderland classification is a useful paradigm for organizing peripheral nerve injuries into differing severities, it does have limited clinical utility. For instance, there is no diagnostic test to distinguish between second-, third-, and fourth-degree injuries, as these can only be diagnosed histologically. 20 Therefore, Mackinnon and Dellon introduced a sixth-degree category, which represents a mixed injury pattern. 21 Sixth-degree injury represents a combination of any of the previous five levels of injury within the same nerve. Sixth-degree injury results in variable recovery that is dependent on an accurate diagnosis and timely intervention.

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Diagnosis A critical factor in the management of peripheral nerve injuries is the timeliness of both diagnosis and surgical treatment. Therefore, a thorough clinical assessment and history is performed to establish the location, nature, and severity of the injury. This includes testing motor, sensory, and pain fibers of the suspected injured nerves. When possible, muscles innervated by the nerve should be evaluated individually. The extent of motor nerve injury is determined by assessment of muscle strength, range of motion, and atrophy. Sensory impairments can be identified by decreased sensation, hypersensitivity, or allodynia in the distribution of the nerve territory. In the classic ten test, patients rank the magnitude of sensation in the affected region compared with that in the contralateral region using a scale from 0 to 10. Quantitative sensory testing can also be performed as a means to detect the perception threshold for mechanical stimuli in patients with injured peripheral nerves. 22 This approach utilizes the pressurespecified sensory device 22 to objectively quantify sensory innervation by measuring pressure thresholds for perception of static and moving one- and two-point discrimination of the skin in the distribution of the injured nerve. Vibration instruments and Semmes-Weinstein monofilaments are also used to evaluate the sensory innervation and are most useful in evaluating chronic compressive neuropathies. The exact site of nerve injury can be identified by clinical examination or through the use of electrodiagnostic or imaging studies. The progress of axonal regeneration can be localized by tapping along the course of the peripheral nerve. This finding is known as a positive Tinel sign and is experienced as an electric shock or pins and needles sensation. Over the course of several weeks, distal migration of a Tinel sign demonstrates ongoing regeneration and suggests that functional improvements may be expected as long as the distance from the site of nerve injury to the target end organs is not exceedingly long. Nerve block may also play an important role in establishing a diagnosis and discerning the location of injury. Blocks are performed by injecting local anesthetic to anesthetize specific peripheral nerves to identify the source of pain or allodynia. Symptomatic improvement after injection helps to isolate the affected nerve, but the test is fairly nonspecific. 23

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Electrodiagnostics The term electrodiagnostic studies (EDS) encompasses both nerve conduction studies (NCS) and EMG. These tests are often performed together and provide useful information about the location of nerve injury as well as severity and prognosis. NCS are used to assess both motor and sensory function by measuring the conduction velocity of action potentials traveling through a nerve. To measure conduction velocity in motor axons, a transcutaneous electrical stimulus is given and subsequently compound muscle action potentials (CMAPs) from the corresponding distal muscle are recorded. For sensory axons, recording skin electrodes are placed within the cutaneous territory of a sensory nerve to record the transmission of the stimulus. Slower conduction velocities or increased latencies indicate the presence of demyelination and reflect at least a first-degree Sunderland nerve injury. The position of the distal recording electrodes can be repositioned at various places over the length of the peripheral nerve to localize the conduction block. Amplitude of the recorded CMAPs provides an estimate of the number of intact motor axons activating muscle fibers. Small or absent CMAP amplitudes indicate that some degree of axon loss has occurred. The amplitude of the recorded compound sensory nerve action potential similarly provides a reflection of the number of intact sensory axons. The addition of needle EMG studies provides further insight regarding the condition of peripheral nerves. In this test, a needle is inserted into a target muscle to measure muscle activity at rest and during voluntary contraction. 24 Fibrillations and positive sharp waves (PSWs) on needle EMG indicate axonal loss and therefore at least second-degree Sunderland injury, but these findings may not be apparent for several weeks depending on how proximal the lesion is. 25 PSWs can be observed as early as 3 weeks after nerve injury, whereas fibrillations are typically observed around 6 weeks after nerve injury. The presence of fibrillations and PSWs on EMG are significant to the prognosis because they reveal that the distal motor plates in the target muscle fibers are still available for reinnervation. The size, shape, and recruitment pattern of motor unit potentials (MUPs) on needle EMG is helpful in determining the duration of nerve injury and the expected potential for functional recovery. Immediately after denervation, the number of motor units is reduced to a level that is commensurate with injury severity. The reappearance of MUPs on EMG about 12 weeks after injury reflects the collateral sprouting of adjacent, uninjured nerve fibers and thus represents second- and third-degree Sunderland nerve injuries. These findings can become evident before any clinical signs of recovery are apparent. Owing to the extensive nature of intraneural damage and scarring seen in fourth- or fifth-degree Sunderland injuries, MUPs are not typically seen on EMG because all of the axons have lost continuity with their target muscle fibers. Electrodiagnostic studies may be obtained immediately after significant trauma to help determine the presence and degree of nerve injury (Table 10.2). However, these studies are unable to distinguish between severe axonotmetic and neurotmetic injuries in the acute setting. Total division of a peripheral nerve may be better diagnosed with imaging studies such as ultrasound or magnetic resonance imaging. NCS and EMG do play an important role in the timing of surgical intervention. For example, after a suspected injury to a peripheral nerve, the presence of at least some motor units under voluntary control shows that the lesion is incomplete, which implies a more favorable prognosis. On the contrary, the lack of any signs of recovery on NCS or EMG after 3 to 6 months is usually an indication for surgical exploration. Even when functional recovery is identified, these electrodiagnostic tests can also be performed serially over time to help follow the progress of axonal regeneration and end organ reinnervation. TABLE 10.2 Electrodiagnostic Findings by Degree of Peripheral Nerve Injury

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Sunderland Classification of Nerve Injury First degree Second degree Third degree Fourth degree Fifth degree Sixth degree c

Acute Nerve Injury Fibrillations/PSWs MUPs No Normal Yes b Present: secondary to collateral sprouting Yes b Present: secondary to collateral sprouting Yes b No Yes b No Yes b Variable

Chronic Nerve Injury Fibrillations/PSWs MUPs No a Normal No a Present: secondary to axonal regeneration No a Present: secondary to axonal regeneration No a No No a No No a Variable

a

Fibrillations and PSWs disappear after a period of chronic denervation.

b

Fibrillations and positive sharp waves (PSWs) are not identifiable until 3 to 6 weeks after nerve injury.

c

Electrodiagnostic findings vary depending on the mixed severity and location of damage in sixth degree nerve injuries.

PSWs, positive sharp waves; MUPs, motor unit potentials.

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Management of Acute Nerve Injuries The management of acute traumatic peripheral nerve injuries is largely dependent of the severity of injury, the mechanism of trauma, and the distance from the injury to the target end organs. Intact but contused nerves can often be expected to recover. Continued observation with close follow-up may be appropriate before surgical intervention is warranted. However, with a more severe injury, prompt surgical exploration and nerve repair may be the more suitable course of action. In acute closed injuries, such as from blunt force trauma and blast mechanisms, peripheral nerves usually suffer a contusion but remain structurally intact. Frequently, these are first-, second-, and third-degree Sunderland injuries that are treated expectantly with sufficient time before surgery is considered. For several weeks following the injury, patients should be seen frequently and serial examinations are performed to look for any signs of recovery, such as a progressing Tinel sign and electrodiagnostic evidence of recovery. These clinical findings help distinguish axonotmetic lesions that may recover spontaneously from neurotmetic lesions that require surgical intervention. If there is confirmation of return of function clinically or electrophysiologically, the patient should continue to be followed expectantly, as recovery is still possible. If there is no return of function or if functional improvement plateaus, nerve exploration may be considered. During this observation period, if none of these signs are noted, it is more likely the patient sustained a higher grade injury (e.g., at least third degree) such that axons either cannot find their way into distal endoneural tubes or their passage is blocked by intervening scar tissue. Nerve exploration should be pursued and definitive surgical management will be dictated by intraoperative findings. For example, neurolysis is indicated to excise pathologic scarring around and within the substance of the peripheral nerve whereas a neuroma-in-continuity that is discovered is often excised and reconstructed. In contaminated wounds with acute crush or avulsion nerve injuries, the type and zone of injury can be difficult to determine. In these scenarios, it is better to first debride any devitalized tissue and tack the two nerve ends to a surrounding structure to prevent retraction. The wound and injured nerve are then allowed to heal for at least 3 weeks for demarcation of the zone of injury. At the time of reexploration, the extent of nerve injury will be more evident. The neuroma located at the proximal nerve segment must be excised in bread-loaf fashion until a healthy fascicular pattern is seen. A similar technique is used for the distal nerve segment, although there will be no neuroma present in this location. The resultant defect will require either direct nerve repair or nerve reconstruction using a graft (Figure 10.3).

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FIGURE 10.3 Management of severe crush or avulsion injuries. A. When the zone of nerve injury is unclear, the nerve should be allowed to demarcate for at least 3 weeks before definitive debridement of devitalized tissue is performed. B. Neuroma and scar must then be excised in bread-loaf fashion until a healthy fascicular pattern is seen in both proximal and distal nerve stumps. C. Only upon sufficient debridement should the nerve defect be repaired or reconstructed.

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Primary Repair Acute, clean peripheral nerve lacerations are best repaired immediately. If the wound bed is well vascularized and end-to-end approximation is possible, tension-free primary repair should be performed within the first 2 to 3 days following injury. Transposition or mobilization of the nerve may be required to minimize tension and facilitate repair. Excessive tension at the suture line results in compromise of endoneurial blood supply, causing necrosis, fibrosis, and scar blockage of nerve regeneration. 3 This diminishes the potential for successful functional recovery. Restoring appropriate alignment of corresponding fascicles in the proximal and distal segment is similarly important for optimizing regenerative outcomes in primary neurorrhaphy. Epineurial vascular landmarks are useful to ensure optimal alignment of fascicles. If performed within 72 hours after injury, direct stimulation of distal motor fascicles can further aid in mapping fascicular arrangements in the distal nerve stump. 26 After this amount of time, the distal nerve segment is depleted of neurotransmitters, and direct stimulation will not reliably result in muscle contractions. Intraoperative histologic staining of proximal and distal nerve ends has been described as a means to align motor and sensory fascicles, although this process can take up to an hour in even experienced hands. 27 Direct epineurial nerve coaptation with microsutures remains the standard surgical treatment for peripheral nerve lacerations that can be repaired without undue tension. Microsutures (9-0 or 10-0) are loosely placed through the external epineurium such that nerve ends and fascicular groups are kissing and not bulging to the sides. Should bulging occur, trimming of the fascicles with microscissors will facilitate end-to-end approximation within the endoneurial sheath (Figure 10.4). The fewest number of epineurial sutures should be used for the repair to decrease iatrogenic harm to the nerve. In contrast, in a fascicular repair technique, intraneural dissection is performed at the edges of the cut nerve and then individual fascicles are realigned with microsutures. Adjunctive epineurial sutures may be placed or may be omitted. However, the advantages that might be 
 gained from direct alignment of individual fascicle segments may be offset by the higher chances of axonal injury during the procedure and increased foreign body reaction caused by the greater suture material burden within the nerve. A more conservative method of controlling the alignment of fascicles is known as group fascicular repair, whereby identifiable groups of fascicles are aligned before a standard epineural repair is performed. Although this modification is conceptually logical, clinical studies have not shown a clear superiority of one technique over another. 28

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FIGURE 10.4 Primary 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. B. Well-performed nerve repairs will result in good alignment of fascicles without the need for fascicular sutures.

An alternative repair technique utilizes tissue adhesives such as fibrin glue or poly(ethylene glycol) hydrogel to supplement or replace epineurial sutures. Advantages of using adhesives for nerve repair include its ease of use, reduced operative times, less tissue trauma, and less intraneural scarring compared with using microsutures. 29 However, concerns remain about the lack of adequate tensile strength after the application of these strategies alone. 30 Although animal studies have reported superiority or at least equivalency to suture repair, 31 there are limited clinical data to support a complete shift away from traditional microsurgical repair of nerve transection injuries.

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Autografts When tensionless primary repair is not possible, an autologous nerve graft is preferred for nerve gap reconstruction. A nonvascularized graft can be harvested from an expendable sensory nerve and is interposed in the segmental nerve defect. The harvested nerve graft undergoes Wallerian degeneration but maintains the supportive scaffold (i.e., endoneurium, perineurium, and epineurium) with Schwann cell basal laminae, neurotrophic factors, and adhesion molecules to support regenerating axons. Axonal regeneration through the nerve graft proceeds in a manner identical to that following primary neurorrhaphy. Utilization of a nerve autograft requires the sacrifice of a healthy, functioning nerve (usually sensory) for reconstruction of a more important injured nerve (often motor). Autogenous nerve grafts can be harvested from several sites, the most common being the sural nerve, medial antebrachial cutaneous (MABC) nerve, and lateral antebrachial cutaneous (LABC) nerve. A sural nerve graft offers 30 to 40 cm of graft length from each leg, whereas the medial antebrachial cutaneous nerve provides up to 20 cm of length and the LABC up to 8 cm. These nerves are selected as donors because the sensory deficit is either negligible owing to sensory innervation overlap or is considered acceptable compared to the potential gain in motor function by using that nerve. The distal stump of the donor nerve can be sewn end-to-side to an adjacent normal nerve to restore improved sensation to the donor dermatome. Expendable motor nerves that can be harvested for autogenous grafting have a much more limited availability owing to increased donor site morbidity. Harvest of motor nerves grafts are thus reserved for instances where no sensory donors are available and nerve transfers would not provide a better option. A nerve innervating a free muscle transfer can be considered as a possible graft (e.g., thoracodorsal nerve to the latissimus dorsi muscle). Autografts should be approximately 10% to 20% longer than the segmental defect in anticipation of fibrosis-related graft shortening to ensure a tension-free repair. The autograft should be placed in reversed orientation at the repair site to prevent loss of regenerating axons down side branches. If the nerve graft diameter matches that of the segmental defect, the autograft can be simply interposed between the two cut ends. Reconstruction of large diameter nerves often requires cable grafts. By aligning multiple smaller caliber grafts (i.e., cable grafts) in parallel between corresponding fascicular groups, the entire diameter of the large caliber nerve can be reconstructed. Autografts are associated with a number of disadvantages including a separate donor site for the nerve graft harvest, the potential for neuroma formation at the donor site, and occasionally insufficient donor nerve availability. Still, nerve autografts are considered the standard for reconstruction of any segmental nerve defect.

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Allografts When there is a paucity of autologous nerve donor tissue available, human cadaveric allografts can be utilized in nerve reconstruction. Clinical implementation of allograft nerve reconstruction is hampered by the substantial immunogenic response elicited from resident Schwann cells present in the allograft. 24 Recipients of cadaveric allografts must therefore be immunosuppressed (e.g., with tacrolimus) for up to 2 years until the donor nerve graft has been repopulated with host Schwann cells. 32 Allografts can be decellularized to avoid the need for immunosuppression. A chemical detergent process with enzyme degradation and irradiation removes all cellular and immunogenic material from the graft, including residual nerve material and donor Schwann cells. This technique preserves the natural extracellular matrix and physical architecture (e.g., endoneurial tubes, basal lamina) that facilitate axonal regeneration but eliminates the need for immunosuppression. 33 The decellularized allograft can then serve as a scaffold to be repopulated by host axons and Schwann cells over time. These conduits confer the beneficial characteristics inherent to autograft nerve tissue while avoiding donor site morbidity, having unlimited off-the-shelf availability, and being associated with decreased surgical time. However, there remain significant costs with their use. 34

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Nerve Conduits A prodigious amount of research has focused on the development of synthetic nerve guidance conduits designed to facilitate axonal regeneration across segmental nerve gaps. An ideal nerve conduit needs to be widely available, have low antigenicity, and be biocompatible. Currently commercially available conduits are constructed from biocompatible materials such as collagen, polyglycolic acid (PGA), polyDL-lactide-co-caprolactone, polyvinyl alcohol, and N-fibroin (silk protein). 35 These materials have varying degrees of permeability for diffusion of supportive nutrients while providing adequate structural scaffolding for regenerating axons. The absorbable nature of these conduits limits the associated foreign body reaction that can result in scar tissue encapsulation and subsequent inhibition of axonal growth. 36 The newest tissue-engineered conduits incorporate structural elements for delivery of molecular- or cellular-based therapies to optimize regeneration potential. 37 Stem cells and Schwann cells seeded into nerve conduits have demonstrated significantly better functional outcomes compared with empty conduits. 38 Controlled release of regenerative neurotrophic factors (e.g., nerve growth factor [NGF], brain-derived neurotrophic factor [BDNF], neurotrophin-3 [NT3], neurotrophin-4-5 [NT4-5] others) from conduits has also been shown to be beneficial for axonal growth. 39 There is mounting evidence to support synthetic nerve conduit reconstruction of short defects in sensory nerves. Specifically, these constructs have been shown to support successful nerve regeneration across small diameter nerves with gaps up to 3 cm or with large diameter nerves with gaps less than 0.5 cm. In fact, all alternatives to autologous nerve grafts, including decellularized allografts and tissue-engineered conduits, demonstrate similar efficacy in reconstruction of sensory nerve defects of less than 3 cm. However, for motor defects or nerve defects that span more than 3 cm, autologous nerve grafting is still considered the standard of care.

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Nerve Transfers In proximal nerve defects, functional outcomes following nerve repair or reconstruction at the site of injury are poor due to the extended length of time and distance until regenerating axons can be expected to reach their distal targets. The effect of prolonged denervation results in target muscle fibrosis with loss of motor end plates 40 and senescence of Schwann cells that normally provide trophic support to regenerating axons. In these cases, nerve transfers can provide regenerating axons from a donor nerve to the distal aspect of the injured nerve by considerably shorten the time until reinnervation of important muscles and to preserve function. 41 When done properly, donor site morbidity is minimal and the procedure can produce predictably good outcomes. 42,43 Nerve transfers are traditionally reserved for restoration of muscle function, but the technique has also been used in the reconstruction of critical sensory nerves. The most common applications of motor nerve transfers include the restoration of elbow flexion, shoulder abduction, ulnar-innervated intrinsic hand function, forearm pronation, and radial nerve function. 44 For example, the thoracodorsal nerve transferred to the musculocutaneous nerve can restore elbow flexion after brachial plexus injury. This nerve transfer purposefully sacrifices the motor function to the latissimus dorsi muscle, for which action can be compensated by other shoulder muscles, to power the more critical contraction of the biceps brachii, brachialis, and coracobrachialis muscles. The choice of optimal donor nerve for motor transfer is based on factors such as the quantity of motor axons, proximity to the target muscle, and synergy of muscle function. 44 Motor fascicles that can be readily separated from a mixed nerve (e.g., the flexor carpi ulnaris fascicle of the ulnar nerve) can also serve as ideal donor nerves. 44 Sensory nerve transfers are more frequently performed at the level of the distal forearm or palm to restore critical digit sensation, such as the contact surfaces of the thumb and index finger. For sensory transfers, suitable donor nerves should innervate noncritical sensory distribution, contain a large number of purely sensory axons, and be located close in proximity to the target sensory end organs. If possible, the distal end of a transferred sensory nerve can be coapted end-to-side to an adjacent sensory nerve for some recovery of sensation in the donor territory. When an end-to-end repair is planned, the donor nerve is ideally transected as distally as possible and the recipient nerve is transected as proximally as possible to optimize a tension-free coaptation.

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Recovery Functional outcomes following nerve repair and reconstruction depend on the degree of nerve injury, level of injury, and time since injury, as well as number of patient and surgical factors. In 1990, Sunderland summarized 40 years of clinical experience highlighting the principles of peripheral nerve repair and expected outcomes 16 : early repairs are better than late; nerve coaptation is better than interposing nerve grafts; and sharp transection injuries have better outcomes than crush or avulsion injuries. Younger patients also have better prognosis and distal nerve repairs do better than proximal repairs. Furthermore, pure sensory or pure motor nerve repairs do better than mixed nerve repairs. 16 After surgical intervention, functional recovery is monitored with serial physical examinations and electrodiagnostic studies. The most widely used grading system for nerve recovery is the Medical Research Council Grading System for Nerve Recovery. This system is grades sensory recovery from S0 to S5 and motor recovery from M0 to M5 based on physical examination findings. 24 The greater the numerical grade, the greater the functional recovery.

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Neuromas Any peripheral nerve injury involving transection of axons is at risk for neuroma formation. 45 Neuromas result from failure of the regenerative growth cone to reach peripheral targets. Sprouting axons that are unable to reach the distal endoneurial tube will continue to elongate at the site of injury, forming a mass of disorganized fibroneural tissue containing axons, connective tissue, and scar. 45 Neuromas can form at the site of axonal disruption along the course of a peripheral nerve (i.e., neuroma-in-continuity) or at the end of a transected peripheral nerve (i.e., terminal bulb or end neuromas). Neuromas signify the presence of unsuccessful reinnervation and can often be associated with disabling neuropathic pain. Efforts to prevent neuroma formation should be considered during management of any nerve injury. Even small sensory nerves can produce debilitating neuroma pain after transection. Therefore, when these minor nerves are identified during surgery, formal repair is recommended to prevent aberrant axonal sprouting and subsequent neuroma formation. When a painful neuroma does develop, a course of desensitization therapy is warranted as first-line treatment. When the pain is refractory to conservative measures or if functional recovery is poor, surgical intervention is indicated. Surgery may entail neurolysis or neuroma resection and interposition nerve graft reconstruction. 46 If the nerve is expendable (e.g., a noncritical sensory nerve), neurectomy may be considered. Numerous methods have been explored to prevent neuroma formation, yet there remains no standard for treatment or prevention. Several surgical approaches utilizing epineurial closure, nerve transposition with muscle implantation, and neurorrhaphy techniques have all been employed with inconsistent results. 47 Traditional neuroma prevention methods are all aimed at minimizing or masking aberrant nerve regeneration. However, these methods do not seek to prevent neuroma formation but instead place the anticipated recurrent neuroma in a less symptomatic location. Newer strategies for neuroma management provide functional connections for regenerating axons and consequently prevent neuroma formation. Both targeted muscle reinnervation 48 and regenerative peripheral nerve interface 49 techniques provide distal physiologic targets (i.e., denervated muscle fibers) for regenerating axons for new neuromuscular junctions. The number of axons from a regenerating nerve without a functional connection is greatly reduced, and this results in significantly lower chances of neuroma formation.

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Conclusion Significant advances in strategies for peripheral nerve repair and reconstruction have improved our ability to optimize functional outcomes after various types of nerve injury. Accurate diagnosis of the level and severity of nerve injury is paramount to the selection of the most appropriate treatment. Whenever possible, direct end-to-end repair of a transected nerve is performed. Nerve autografts remain the standard option for reconstruction of segmental nerve defects. Continuing research will elucidate the roles of allografts and nerve conduits in nerve repair, and further development of techniques to diminish symptomatic neuroma formation will greatly improve functional recovery following peripheral nerve injury.

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ACKNOWLEDGMENT This work was supported by the American Association of Plastic Surgeons Academic Scholar Program to Theodore A. Kung. The content is solely the responsibility of the authors and does not necessarily represent the official views of the American Association of Plastic Surgeons.

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Questions 1. 1. A 23-year-old man is brought to the emergency department 6 hours after sustaining a single gunshot to the right upper arm. Physical examination shows an open wound and a high radial nerve palsy. Which of the following is the most appropriate first step in management of potential nerve injury? a. Immediate surgical exploration and primary nerve repair if the nerve is lacerated b. Immediate surgical exploration and repair with a nerve graft if the nerve is lacerated c. Immediate surgical exploration, resection of devitalized nerve, and suture tagging of the nerve ends for delayed repair d. Observation with EMG 6 months after injury followed by exploration and repair if no return of function 2. A 45-year-old woman is brought to the emergency department after a rollover motor vehicle accident. Physical examination shows significant soft tissue loss and a median nerve injury at the wrist. The patient is taken immediately back to the operating room where a 5 cm segmental nerve gap is observed. Which of the following treatment options is most likely to provide the best longterm functional outcome for this patient? a. PGA conduit b. Acellular allograft reconstruction c. Collagen conduit reconstruction d. Peripheral nerve autograft e. Primary nerve repair 3. A 37-year-old woman presents to clinic with nerve compression of her right ulnar nerve at the elbow. Both NCS and EMG are planned. Which of the following best indicates loss of motor axons? a. Decreased distal motor latency b. Presence of fibrillation potentials c. Absent PSWs d. Increased amplitudes e. Increased conduction velocity 4. A 25-year-old woman presents to clinic 8 months after sustaining a stab wound to her right forearm with complaints of weakness of grip strength in her right hand. Physical examination reveals a Tinel sign present over the ulnar aspect of the mid-volar forearm adjacent to a well-healed laceration. She is taken to the operating room where a neuroma-in-continuity is identified along her right ulnar nerve. The neuroma is resected, and a 3 cm nerve gap remains. Which of the following is the most appropriate next step in management? a. Nerve reconstruction with synthetic nerve conduit b. Mobilize nerve both proximally and distally and perform primary neurorrhaphy c. Nerve reconstruction with LABC nerve graft d. Sural nerve cable grafting e. Perform tendon transfers to assist with grip 5. A 21-year-old man presents to the emergency department after sustaining a deep laceration to his left elbow. Physical examination shows decreased function of the ulnar nerve, and the patient is taken for urgent operative exploration. Following proximal and distal dissection, a 1 cm gap persists between the proximal and distal nerve ends. Which of the following is the most appropriate next step in management? a. Nerve transfer

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b. Primary neurorrhaphy c. PGA nerve conduit d. Nerve transposition e. Sural nerve grafting 6. A 27-year-old man comes to clinic after sustaining a brachial plexus injury in a motorcycle accident. Nerve transfer to the biceps for restoration of elbow flexion is planned. Which of the following fascicles or nerves is the most appropriate donor? a. Distal spinal accessory nerve b. Medial pectoral nerve c. Thoracodorsal nerve d. Palmaris longus fascicle of the median nerve e. Flexor carpi ulnaris fascicle of the ulnar nerve 7. A 7-year-old girl is brought to the emergency department after sustaining an injury to the left upper extremity, 3 cm proximal to the antecubital fossa. Which of the following factors is associated with improved functional outcomes following peripheral nerve repair? a. Proximal nerve injury b. Young patient age c. Increased time between injury and repair d. Tension at nerve repair e. Few suture strands used in nerve repair 1. Answer: c. In general, nerve injuries associated with open wounds should be explored and, if appropriate, repaired early. For example, if the nerve injury resulted from a relatively clean laceration or wound, it should be explored and repaired immediately. However, in the case of crush or significant soft tissue injury, like in the case of a gunshot wound, nerve repair should be delayed until the extent of devitalized tissue can be determined and the soft tissue repair is stable. 2. Answer: d. Peripheral nerve autografts are the most reliable choice for reconstruction of nerve gaps greater than 3 cm. Autograft use is limited by availability and donor site morbidity from additional incisions, loss of sensation, and possible neuroma formation. Nerve conduits, such as PGA conduits, collagen conduits, and acellular allografts are limited in their use in short gaps (10 METs Strenuous sports (i.e., swimming, tennis, football, basketball, skiing) Plastic surgery is generally considered low-risk surgery, having less than 1% risk of major adverse cardiac event. 2 However, long, complex reconstructive procedures may pose additional risk. Patients unable to achieve 4 METs, a measure of functional capacity, have an increased cardiac risk. No preoperative cardiac testing is needed in patients undergoing low-risk surgery or in patients who can perform greater than 4 METs, irrespective of other factors. 1 Similarly, no routine testing is required on a patient who can perform greater than 4 METs, even if undergoing high-risk surgery. Patients with a history of cardiac disease or previous percutaneous cardiac interventions are at an increased risk of cardiac events if medications are managed inappropriately. Discontinuation of dual antiplatelet therapy (DAPT) within weeks after percutaneous cardiac intervention is one of the strongest risk factors for stent thrombosis. One must weigh this risk against the risk of delaying surgery or performing surgery while the patient remains on DAPT. Decisions regarding management are best made with the interventionist who performed the procedure or physician managing the medications. ACC recommendations for patients undergoing elective noncardiac surgery on DAPT are summarized in Table 16.1. If a patient requires an urgent procedure within the minimum duration of DAPT, the ACC recommends continuing DAPT unless the relative risk of bleeding outweighs the benefit of prevention of stent thrombosis. If the risk of bleeding is too high, the patient is to continue aspirin but hold the P2Y12 platelet receptor inhibitor (i.e., clopidogrel [Plavix]) and restart it as soon as possible. For obvious reasons, emergency surgeries will have to proceed on DAPT and therapy-related decisions made postoperatively. Guidelines by the ACC/American Heart Association are routinely updated, 3 and the most recent recommendations are published online (http://www.acc.org/guidelines). TABLE 16.1 Management of Patients With Previous Cardiac Intervention Previous Cardiac Intervention SIHD (Stable Angina or Low-Risk 
 Unstable Angina) Medical therapy*

Minimum Duration of DAPT ACS (NSTE-ACS 
 or STEMI) N/A

1y

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Balloon angioplasty Bare-metal stent Drug-eluting stent Coronary artery bypass graft

2 wk 1 mo 6 mo 1y

1y 1y 1y 1y

*P2Y12 platelet inhibitors include clopidogrel (Plavix), prasugrel (Effient), and ticagrelor (Brilinta). This table summarizes 2016 ACC recommendations regarding the minimum duration of DAPT depending on cardiac intervention and timing of noncardiac surgery. It is advised to communicate the decision to perform surgery and the associated risks with the physician managing the patient’s medications. DAPT, dual antiplatelet therapy; NSTE-ACS, non–ST-elevation acute coronary syndrome; SIHD, stable ischemic heart disease; STEMI, STsegment elevation myocardial infarction.

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Anemia and Blood Disorders Preoperative anemia is associated with increased morbidity and mortality. 4,5 The World Health Organization (WHO) and Centers for Disease Control (CDC) define anemia as 1 mode, you should determine whether your data are truly multimodal or if you have two or more overlapping data sets that can be separated. Median and interquartile range (IQR): The median is the middle value of a data set, or the value at which exactly half of the data values are to the right and the other half are to the left. Median is most informative when it includes the IQR. The IQRs are the median values for the left half of your data range (1%–50%, or the 25th percentile [Q1]) and the right half of your data (51%–100%, or the 75th percentile [Q3]). IQR can be written as the values (Q1:Q3), or as a single number representing the range (Q3 − Q1 = IQR). By definition, the IQR will contain 50% of your data set’s values. The smaller the IQR, the less variability present in the data values. Why does this matter? Importantly, the mean (±SD) may not be meaningful in skewed data sets. One example of this is hospital length-of-stay (LOS). Outliers are common for this variable and can cause the standard deviation to be large, pushing the left side of your LOS SD range into negative days (e.g., LOS = 3 days ± 7 days, range = (−)4 days through (+)10 days), which is nonsensical. In such cases it is better to choose a different measure of your data’s central tendency. Finally, you may characterize your data using more than one of these measures as each provides additional information regarding your data’s distribution.

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One-Tailed versus Two-Tailed Tests When looking for differences in your data, it is important to understand how the value of interest in the experimental group may differ from the value of interest in the control or comparison group. For example, can the experimental group’s value only be greater than the comparison group’s value? Only less? Or is the answer merely anticipated to be different, with the direction of the anticipated difference unknown? Answers to these questions determine whether you should use a one-tailed or two-tailed test. One-tailed test: Used when the value you are testing in the experimental group would only be anticipated to be more or less (change in value is one-directional) than the comparable value in the control group. Generally, your evidence of only needing a one-tailed test should be very strong to choose this test type. 8 Two-tailed test: Used when the value you are testing in the experimental group is anticipated to be different from (change in value may be more or less than) the comparable value in the control group. A common question may be, To what does tail refer in these tests? The tail or tails are the extremes of the data distribution. 8 When picturing the bell-shaped curve, the tails are the small areas to the far left and/or right of your histograms. In a one-tailed test, the area not covered by the certainty of your P-value is all in the one tail of your distribution. In a two-tailed test, the area of uncertainty is evenly divided between both the left and right tails.

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Choosing Statistical Tests Statistics, much like plastic surgery, is as much an art as a science: although there is a formal structure, there is room for interpretation and some creativity. Approaches to the same study can vary between statisticians or with the same statistician asked at different points in time. Keeping this in mind, it is important to make sure your research is reproducible, meaning that all methods including the details of your analysis are meticulously recorded. The statistical tests you choose may depend on your statistical expertise. If you are inexperienced with statistics, it is recommended that you use simple, straightforward, less flexible yet robust analyses. 3 Although such tests may slightly minimize any real effect present in your data, they are more likely to yield meaningful results (avoid false-positive findings). We review some relatively simple statistical tests in the following sections, starting with the relatively simple t-test and progressing through ANOVA and regression analyses.

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t-Test The t-test, also known as student’s t-test, compares the means of two samples to tell you if the means differ, and how much they differ from each other (if difference is significant). There are three primary types of t-tests: Independent t-test: Compares the means of two different (independent) samples (e.g., 6-month postintervention scores in two different treatment groups). Paired t-test: Compares the means of two related (dependent) samples (e.g., repeated measures of a value in the same group, like pre-to-post-intervention). Also called the paired samples t-test, dependent samples t-test, or repeated measures t-test. Note: When using a paired t-test, the repeated measures tested should be from the same source, such as the exact same patients, for both variables. Using data collected from slightly different pre-to-post patient groups is unlikely to represent your sample’s true pre-to-post change. Although it is tempting to include as many patients as possible in these types of analyses, this is a misuse of the paired t-test. If your samples differ slightly, you may be able to use the comparable nonparametric Wilcoxon signed-rank test. 10 One-sample t-test: Compares the mean of a single group against a known or hypothesized mean (which you provide and should justify in your methods). It may also be used to find the statistical difference between the sample mean and the sample midpoint. Also called the single sample t-test. 11

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ANOVA or Analysis of the Variance When determining if differences exist between the means of ≥2 independent groups, ANOVA, or analysis of the variance, can be used. ANOVA expresses this difference through the F statistic, a ratio of the between-groups and within-groups variances. (Interestingly, the ANOVA can be used instead of the independent t-test to compare two independent samples, with the resulting ANOVA F statistic equal to t 2 from the independent t-test.) There are several data requirements you should check in order to use the one-way ANOVA correctly (including confirming that your data are normally distributed). 12 Here we briefly address two: variance and balanced sample size. Variance: The amount of variability or range of values within a group. The within-groups variance and between-groups variance should be approximately equal; otherwise, ANOVA results may not be trustworthy. To analyze data with unequal variances between groups, it is better to use tests that do not assume equal variances among populations, such as the Brown-Forsythe or Welch statistics. 13 Note: The Brown-Forsythe and Welch statistics are not nonparametric correlates to the ANOVA, that is, the Kruskal-Wallis test, used for nonnormal data distributions. Brown-Forsythe or Welch statistics are intended for use in parametric data sets with unequal variances. Balanced sample size: When performing a one-way ANOVA, you should have at least six subjects (and hopefully more) in each group; it is best to have balanced sample sizes in each comparison group, as extremely unbalanced group comparisons increase the possibility of decreasing the validity of the ANOVA’s F statistic. We briefly describe four types of ANOVA tests here: One-way ANOVA: Also called one-factor ANOVA, one-way analysis of variance, or between-subjects ANOVA, the one-way ANOVA will tell you if there is a significant difference between the means of any of the included groups. However, it will not tell you which group(s) is/are significantly different. Additional post hoc testing (after running the ANOVA), such as with Dunnett C or the Tukey test, is needed to determine this. 12,14 Dunnett C test compares each sample mean to a control mean (hence the C) that you provide. If you do not have a control mean for comparison purposes, then the Tukey or another post hoc test can be used. Two-way ANOVA: A two-way ANOVA can be used to efficiently compare the impact ≥2 independent variables may have on one dependent variable. This test provides information about the effect of each independent variable by itself as well as the interaction between the two variables (e.g., effect modification). Note: ANOVA techniques can be extended to three-way, four-way, and beyond, provided your sample size is large enough. Repeated measures ANOVA: The repeated measures ANOVA is used for variables measured more than once for the same subject, like those that change over time. (In this case use of the standard ANOVA is inappropriate because it does not account for the correlation between repeated measures of the same variable.) The repeated measures ANOVA is used frequently in longitudinal studies when subjects are measured repeatedly in regard to some outcome. Multivariate analysis of variance (MANOVA): This test is essentially an ANOVA with several continuous dependent variables. 14 It combines the selected dependent variables into a weighted combination or composite variable to see how the new composite variable differs by groups or levels of the independent variable.

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Regression Analysis Regression analyses allow one variable (a dependent variable) to be predicted or estimated from one or more other variables (independent variables). These mathematical models are one-directional, meaning that the independent variable(s) can be used to predict the dependent (outcome) variables, but not the other way around. Regression analysis is a useful tool in medical research and clinical practice because it helps researchers determine who might be at risk for various illnesses, behaviors, etc., based on different exposures. An example is predicting who may be at risk for postoperative complications based on their preoperative comorbidities. Several pieces of data are derived from regression analyses to describe the predictive relationship between your independent and dependent variables. Three of these are slope, correlation coefficient, and P-value: Slope: Indicates where different patients may be mapped in your predictive model. In univariate regression analyses, the slope indicates how much your dependent variable will change with each unit change in your independent variable. In multiple linear regression analyses, the slope indicates how much your dependent variable will change as a result of the combined influence of all your independent variables. Correlation coefficient (r): Also called r value, or Pearson product-moment correlation coefficient. This indicates the strength of a predictive relationship. Values for r range from (+)1 to (−)1, where (+)1 represents a perfect positive correlation, (−)1 represents a perfect negative correlation, and zero represents a perfect lack of any correlation. Correlation coefficients of ≥(+)0.7 or ≤(−)0.7 may be considered strong. 15 P-value: Determines how likely it is that the correlation between your independent and dependent variables is due to chance. P-values should always accompany the r values. Several types of regression analyses are commonly used in biomedical studies. We briefly describe them here with the goal of illustrating when each can be used. Univariate or simple linear regression: Also called linear regression. Analysis performed using one independent variable to predict the variable of interest (dependent variable). 15,16 In simple linear regression, the outcome (dependent) variable is continuous. 16 These analyses are often performed first to determine which independent variables warrant further investigation using more complex and realistic regression models (e.g., multiple linear regression). Multiple linear regression: Also called multivariable linear regression. Analysis performed using ≥2 independent variables (also called covariables or covariates) to predict the variable of interest (dependent variable). 15 In multiple linear regression, the outcome (dependent) variable is continuous. 16 Multivariate regression: Differs from multiple or multivariable linear regression in that it deals with multiple dependent variables (e.g., repeated measures or clustered data) to predict an outcome. 16 Multiple logistic regression: Useful for identifying potential confounders. This differs from multiple linear regression in that the outcome (dependent) variable of interest is dichotomous. In these models, the independent variables are called covariates and can be categorical, ordinal, or continuous. Despite its implication of a directional influence, regression in of itself does not prove causality. 15 It is important to note that multivariate regression and multivariable regression are not the same. This can be confusing as the two terms are sometimes used interchangeably although they represent two different

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analyses.

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Survival Analysis Understanding how long patients may remain disease-free following treatment or survive given certain predisposing factors, or how long an intervention may be effective, can be very informative for patients and physicians. Survival analysis, or what is now more often referred to as Kaplan-Meier curves, are one way to perform such analyses. Kaplan-Meier curves were developed to help account for incomplete observations and differing survival times. 17,18 This type of analysis is also called time-to-event analysis as successful survival (the event) does not need to be limited to the absence of mortality. Instead, the event of interest can be any of many different outcomes including a complication, the efficacy of an intervention, or resolution of an adverse event, with the analysis observing the time it takes for the variable of interest to develop, occur, or resolve. 17,18 Although there are a few methods to conduct survival analyses, the Kaplan-Meier method is generally preferred. When used, data that should be included are the time-to-event (expressed as the median, not the mean) confidence limits (as a measure of variability) and the number of patients who are included at each point of survival (e.g., censoring versus duration of known survival). It should be noted that the further away in time the results are from the beginning of the study, the greater the censoring (attrition/dropout, death) rate and the more approximate the curve calculation becomes. Finally, when comparing two or more survival curves, a suitable rank test should be used. 17

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Summary of Simple Parametric and Nonparametric Tests There are some straightforward situations in which a nonparametric test can be substituted for a parametric test. These are included in Table 19.1. However, when exploring options for more complex ANOVAs and regression analyses, several additional factors, such as variable type, factor into the type of test that should be used. TABLE 19.1 Parametric and Nonparametric Tests Used for Various Statistical Comparisons 8 Analysis You Want to do Compare means between two independent samples or groups Compare two quantitative measures taken from the same individual Compare means between three or more samples

Compare the distributions of a discontinuous variable in two or more independent samples

Example Group A versus group B Pre-to-postintervention differences Group A versus group B versus group C Is x more likely to occur given y?

Parametric Test Independent t-test (onetailed or two-tailed) Paired t-test

Nonparametric Test Mann-Whitney U test

Analysis of variance (ANOVA), or one-way ANOVA Chi-square test

Kruskal-Wallis test, or oneway ANOVA on ranks

Wilcoxon signed-rank test

Fisher exact test

Now that we have reviewed several commonly performed types of analyses, we will review when you should develop your statistical plan within the context of your protocol or study design.

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Analytic Approaches: A Priori Versus Post Hoc The time at which you design your statistical plan, meaning before conducting the study or after all data are collected, is important in identifying the presence or absence of true effects within your data set. We review best practice guidance for including appropriately performed a priori and post hoc analytical designs to ensure your findings are as trustworthy and meaningful as possible.

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A Priori Analyses Definition Best practices for research recommend designing your data analysis plan beforehand (a priori), or when you plan the project or write up a proposal. This is considered the purest type of analysis and is intended to achieve several goals: Provide evidence regarding whether your hypotheses should be accepted or rejected. Demonstrate the least amount of bias in the results obtained. Prevent inappropriate use of statistics to obtain statistically significant results. Help determine sample size and study power sufficient to detect an effect size, if present. Help inform appropriate budget development based on determination of number of subjects needed.

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Appropriate Use A priori analyses are designed in parallel with protocol development. Details of the analysis should be included in a dedicated section of the protocol document (or grant proposal). The analysis should then be completed according to this description following collection of the necessary data (e.g., interim analysis, final analysis). Being faithful to your statistical approach is vital to minimizing bias and producing reproducible results. One concern when following a strictly outlined data analysis plan for which the results are not statistically significant is that the study was meaningless (or worse: not publishable). However, this is not necessarily the case. If you have carefully designed the study, meaning that it was appropriately powered and you used appropriate statistical tests, your negative results are likely important and should be shared with the field. a Certainly, you should not panic and turn your analysis into a fishing expedition intended to identify statistically significant results. Although this is tempting given the time and costs to conduct research, it is an inappropriate use of statistics, will potentially introduce false data into the literature and clinical practice, and may ultimately hurt patient care. However, in certain circumstances performing exploratory, post hoc analyses on an existing data set can be informative.

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Post Hoc Analyses Definition Post hoc analyses are any statistical analyses not described previously (a priori) in the protocol and performed after data collection has been completed. Generally, these analyses do not address the study’s primary or secondary aims. Instead, they help generate future hypotheses. Importantly, these results do not provide proof regarding these newly generated hypotheses. 21

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Appropriate Use Certain post hoc analyses are an integral part of your a priori analysis plan. Examples include post hoc testing following ANOVA to determine which means differ significantly from each other, or conducting a Bonferroni correction. 22 Although these types of tests technically meet the definition of post hoc analysis, chances are you were able to plan for these prior to study implementation. This section is intended to address unplanned analyses researchers would like to perform based on the collected data after the study has been finished. Researchers can conduct post hoc analyses and include these in publications, provided that this is clearly stated in the study methods, results, and discussion of these results. 1 After completing a study and reviewing your data, additional questions may arise. These may have been anticipated based on the literature and included as exploratory study aims, or they may arise from the data itself. In these situations, it is acceptable to perform exploratory analyses. The objectives of conducting post hoc analyses include the following 21 : Identification of unsuspected findings or associations Development of new hypotheses Informing the design of future prospective studies (e.g., inclusion/exclusion criteria, study design, statistical power) Additionally, retrospective studies, meta-analyses, and secondary analysis of existing data sets are all subject inherently to post hoc analysis. Authors need to acknowledge the limitations of their data sets or source data used (e.g., existing data sets, retrospective studies) and level of evidence of included studies (e.g., meta-analyses), as relevant. This knowledge helps readers determine how much weight to give to such studies. Finally, just as with your a priori analysis, meticulous documentation of your post hoc analysis to demonstrate your process and facilitate reproducibility helps readers determine the relative impact of your study.

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Adjusted Analyses: to Control or Not to Control Despite the best planning, it is not always possible or practical to design a study to minimize your between-groups variation. In these situations, adjusted analyses may be used. Study results may be expressed as unadjusted (aka, crude) or adjusted. Adjusted refers to controlling for potential overestimation of the influence of any single independent variable on your outcome when several variables may be at work. This can also be thought of as controlling for bias. In addition to adjustment, we address a few factors that can influence your findings and make adjustment necessary, such as confounding, effect modification, and interaction.

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Adjustment Adjustment is needed when several independent variables may be influencing your outcome of interest. To perform an adjusted analysis, you first need to know how to choose the independent variables to include. This can be done by (1) reviewing the literature to determine what variables have been identified in other similar studies (the usual suspects) and (2) performing a preliminary unadjusted or univariate analysis to help identify variables that may be affecting the outcome variable. Because unadjusted analyses are prone to alpha (type I) error (overestimating significance), it is normal for certain variables that looked promising after unadjusted analysis (have significant P-values) to become statistically insignificant after an adjusted analysis. Adjusted analyses reduce the combined alpha value to mitigate the chance for alpha error. This provides more realistic estimations of the relationships between variables. One example of such a multiplecomparison correction is the Bonferroni correction. 23 Adjusted analysis can be very helpful when comparing two different groups. Here different means unmatched. The advantages of these analyses are you may use them on groups with nonidentical sample sizes and to account for characteristics you were unable to match based on study design, recruitment, or your source data.

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Overadjustment and Unnecessary Adjustment When faced with many interesting variables, it can be challenging to limit the number to include for an adjusted analysis. However, selecting too many variables by which to adjust your analysis can result in overadjustment and/or unnecessary adjustment. Although they differ slightly and their influence is relative, b both can introduce bias. 24,25 . Overadjustment: Occurs when your controlling variable introduces, rather than eliminates, bias. 25 It can also cause problems by subsetting your groups to such an extent that the results are not meaningful and can put researchers at risk for beta error (false-negative results). 24 Simple first steps to help prevent overadjustment are (1) taking care to select independent variables based on knowledge (e.g., those substantiated by the literature or indicated by your data set via univariate analysis) and (2) having ≥10 subjects for each dependent variable included in a multivariate adjusted analysis. 24 Unnecessary adjustment: Similar to but different from overadjustment. It is unlikely to introduce additional bias (aka, bias-neutral adjustment) but can affect precision, here meaning a clear understanding of the influence of the exposure on the outcome. 24,25 Unnecessary adjustment occurs when the variable used to control an analysis is a variable (1) unrelated to the relationship being investigated, (2) that only causes the exposure, (3) that is created as a result of the exposure but is not involved in the causal (exposure-to-outcome) pathway, or (4) that causes the outcome but is not involved in the causal (exposure-to-outcome) pathway. 24 Importantly, its role is relative, b can be subtle, and may go unnoticed.

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Confounding, Effect Modification, and Interaction Confounding, effect modification, and interaction are three similar yet different events in which two (or more) variables influence the outcome of interest in a way that makes the resulting apparent association inaccurate. Confounding bias: Comes from a variable that influences both the outcome of interest and the independent variable (or exposure) being assessed, but is not involved in the pathway between the two. This confounding factor makes an inaccurate association between the exposure and the outcome. An example is breast cancer treatment assignment and postoperative complications. As patients’ cancer stage increases, they are more likely to receive more aggressive treatment. Such patients would have more complications due to both their more aggressive treatment and their advanced cancer stage, not merely treatment alone. Although not a statistical panacea, adjusted analyses help control for potential confounders. 26 Another way to minimize confounding is by using propensity scores. 26,27 Propensity scores are intended to replace many different pieces of baseline data with one summary score and are calculated using a specific type of logistic regression model. 27 The propensity scores can then be used to help match patients between your groups, or as an independent variable for which you can adjust your analysis. In other words, propensity score analysis attempts to retrospectively recreate randomization. 27 However, these potential solutions only work for known confounders and cannot address unknown confounders. 27 Effect modification: Comes from a variable that influences the outcome but not the exposure and occurs when an exposure has a different effect in different subgroups. This third variable can potentially mask (conceal) or increase (sometimes multiplicatively) the true impact of the exposure on the outcome. In this situation, analysis of pooled data can be misleading. Effect modification can be checked using multivariable analysis or stratification to control for the potential effect modifier. Tools that can be used to measure the impact of effect modification include risk ratio, odds ratio, and risk difference. 28 Interaction: Occurs when two exposures or interventions influence an outcome. 29 Although similar, interaction and effect modification are different; while they often are, the two terms should not be used interchangeably. 29

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Stratification Another method by which you may control your comparative analyses between populations is stratification. It allows you to further subdivide your comparison groups to better match control and treatment groups. 27 Although stratification can work well in large populations with a few variables (and thus, a few strata), it rapidly falls apart when there are many baseline characteristics for which you want to stratify. One way you may address the problem of excessive population subsetting is to stratify by propensity scores. 27

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Presenting Data After you have designed your analysis; selected your tests; completed the study, data collection, and analysis; and assessed your results for bias, you get to the final reward: presenting your hard-earned data for publication. When presenting data, it is helpful to remember a few things: You or your team is the expert on the study you just completed, so be sure to present your audience with a complete picture of the study. Keep in mind the most important or interesting finding(s) and how to present them in the most meaningful way. Use simple language, particularly if you are presenting something complex; your audience will thank you for it. We have included some tips here for how you can present a comprehensive view of your findings in concise and meaningful ways.

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Formatting Findings Statistical results tend to be most meaningful when several measures describing the same finding are presented together. This provides a more comprehensive picture of your sample, its relative heterogeneity or homogeneity, and the potential strength of the effect you found. Some recommended formats for presentation of statistical findings follow: Mean ± SD, n = __ (95% CI:_-_), P-value = __ Median (IQR), (95% CI:_-_), P-value = __ Odds ratio (OR), (95% CI:_-_), P-value = __ Writing your findings in this way or including these data in a well-conceived table can improve your use of journal space and be more effective than wordier verbal descriptions. This efficiency can also enable you to share more information about your findings by freeing up your word count.

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Correlation Versus Causation When discussing findings there is some confusion surrounding the terminology used to indicate relationships between variables. Here we briefly clarify correlation and causation. Correlation (or association): This term indicates that there appears to be a relationship between your exposure (independent variable) and outcome of interest (dependent variable), but that you are unable to determine if one causes the other. Correlation and association are important when conducting studies in which it is not possible to collect every variable that could affect an outcome and to help indicate what variables should be investigated further through more vigorous studies (e.g., controlled clinical trials). Causation: This term indicates that there is a quantifiable relationship between your exposure (independent variable) and outcome of interest (dependent variable), and that you can prove that one is causing the other. Causation is difficult to prove in complex interactions, such as situations in which many different exposures may contribute to an outcome over many years.

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A Word About Data Collection When discussing statistics, it is necessary to touch upon data collection, or considerations regarding your source data set. For one thing, your findings can only ever be as good as the data used to derive them. An example of this is a beautifully designed meta-analysis of level 3 evidence papers; regardless of how perfectly the meta-analysis is performed, the resulting paper’s level of evidence cannot exceed that of its source material (per this example, level 3 evidence). The old term still applies: garbage in, garbage out. Therefore, collecting good data and understanding what your data can or cannot tell you are vital to understanding what you can ask of it.

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Potential Database Tools Research can be more expensive than anticipated, whether conducting a relatively small retrospective review or a phase 3 clinical trial. This causes many people to make use of free (or prepaid) resources for the purposes of storing data. Though understandable, researchers must be aware of the strengths and weaknesses of commonly used tools. We provide a summary of some commonly used electronic data collection tools and their strengths and weaknesses in Table 19.2. This is not intended to be comprehensive; rather, this table touches upon points meant to help researchers in selecting the tool most appropriate for them. TABLE 19.2 Strengths and Weaknesses of Some Common Data Collection Tools Data Collection Tool Excel 30,31

Strengths

Weaknesses

Inexpensive or free, easily accessible, nearly universal across operating systems and versions, can be password-protected.

REDCap 32

Web-based for easy access between team members, has tiered access for users, inexpensive or free, easily updated by study team if changes need to be made to DB design, creates data dictionary for users. Designed for research use. Can be HIPAA-compliant. Included in many MS Office packages, has capacity to hold relatively large amounts of data, creates data dictionary for users. Has tiered access for users, DB can be changed easily by study team if needed, can be made to create data dictionary for users.

Easily corrupted (e.g., missorted), users have to create their own data dictionary. Flat (not relational) database, will need to pay for database design/setup if no team members know how to do this. Designing queries can be taxing, not inherently HIPAA-compliant. Paid licenses are needed for all users. Will need to pay for database design/setup if no team members know how to do this.

Access 33 FileMakerPro

Regardless of the tool used, some forethought and design need to go into creating your data collection tool. Once created, it should be tested. You can do this by entering data using a few sample or test cases. This step can be very helpful in the long-term as it will illustrate any problems that may exist (e.g., missing or redundant data fields, imprecise prompts or descriptors, forms that do not work correctly) and the changes that may be needed. 30 It is much more efficient and cost-effective to recognize and correct any potential problems early than after all your data have been collected. Finally, although it can be challenging to identify funding on the front end of a project, it may be more cost-effective to pay for a database that is unlikely to corrupt data or that can provide structure to enable easy and uniform data entry by individuals of varying medical or research knowledge. Realizing halfway through or at the end of a project that your source data and/or analyses are corrupted or flawed is enough to make anyone give up research.

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Data Collection Like other disciplines, there is a science to data collection to ensure accuracy, completeness, and patient privacy. Good practices for data collection for industry, as published in the Food and Drug Administration’s good laboratory practice, follow the acronym ALCOA to identify elements of data quality. 34 ALCOA stands for: Attributable: Data entries and any changes can be traced back to the person who made the entries or changes. Legible: Data entries and any changes are easily read, even after being corrected. This pertains to hard copies (paper) and electronic records (entry history). Contemporaneous: That data collection and entry occurs as close in time as possible to the observation. Original: The first and therefore generally considered to be the most accurate and reliable recording of data. Accurate: The recorded data correctly reflect the observation. Following these principles puts you on the right track for high-quality data collection that you can trust months or years later.

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Preexisting Data Sets There can be great value in secondary analysis of preexisting data sets. Some examples are: Access to sample sizes to which you might not otherwise have access Leverages preexisting resources making research more affordable May consist of data from more than one institution, state, or country Larger sample size may make study population more comparable to general population However, researchers must be aware of the potential drawbacks of preexisting data sets. Some examples are: Potential for missing data Data collected may change from year to year, making multiyear comparisons challenging or infeasible May require significant data preparation and cleaning prior to analysis May not include variables most informative for testing your hypothesis When using a preexisting data set, you must familiarize yourself with the data, how it was collected, and obtain and review the user’s guide or primary protocol documenting how the data were collected. Taking these steps will educate you as to what questions you can ask appropriately of the data set. Design of an appropriate research question, thoughtful design of a post hoc analysis plan, and transparency in stating how the study was conducted are important parts of reporting findings for studies conducted using these resources.

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Data Preparation Although it is best to proactively prevent data entry errors, some entry errors are inevitable. Data preparation, also called data cleaning, is a crucial and potentially time-consuming part of ensuring your data are as amenable to analysis as possible. Data preparation is when you review and format your data in a spreadsheet to make it compatible with the program the statistician will use. 30,35 This is intended to enable direct importing of the data from a shared spreadsheet into the statistical software program without any unintended changes being performed automatically by the analysis software on your data. It can include many different levels of review, from formatting to editing abnormalities. Importantly, this is not manipulation of your data: corrections may be made, but data values should not be changed. Changes should be tracked such that it is possible to compare the originally exported data set with the cleaned version. 35 Some examples of data cleaning activities: Indicating missing data versus zero values. Blank fields can present problems during analysis. Therefore, missing data may have a specific entry such as a “.” (period) instead of remaining blank. Fields whose values are left unaddressed may be assigned values by the analysis software and are likely to yield inaccurate results. Variable name length. Software programs often have character limits for their field names. This can cause some overly long names to be cut off and potentially unrecognizable. Checking, editing names down, and tracking changes in your data dictionary can prevent this from occurring. Data accuracy. Ensuring that data are correctly and consistently displayed (no typographical errors, use of letters in number fields, revisiting abnormal values to ensure they are real results, etc.). Additional variable categorization. Although data were collected on a precise level, it can be helpful to recategorize certain variables into larger classes prior to analysis (e.g., BMI into BMI classes). Such choices may be made based on the literature. It is important for the study team to complete this work because (1) it can be time-consuming and (2) you are more likely than your statistician to be an expert on your data and how it should be included in analyses. To best streamline the data preparation process, ask your statistician about desired formatting or formatting requirements before preparing and sharing your data.

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Data Dictionaries A data dictionary is a comprehensive document that includes the full and abbreviated names of all of your data fields, the possible answers for coded or categorized data, and indications for which fields are labeled as free-text fields. This document acts as a translation book to ensure you and your statistician are referring to and using the same field(s) when discussing your study and performing analyses. You must be aware when selecting a data management tool which ones will and will not generate a data dictionary. Importantly, if your data management tool does not create a data dictionary, you will need to create one and keep it updated. This can require a considerable amount of effort and should not be underestimated.

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When to Consult a Statistician Many individuals new to research ask when they should consult a statistician. To misquote a phrase, you should consult one early and often. As previously stated, a carefully designed study including an a priori statistical plan is vital to producing meaningful results or convincing a review committee to fund your project. 36

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Finding a Knowledgeable Statistician Though not necessary, it is helpful to work with statisticians who understand your area of study or who can understand it based on similar work in a different field. Familiarity often means that the statistician will be able to apply his or her time more efficiently to your project. If the statistician is unfamiliar with your area of study, be prepared to orient him or her. This will go into how much time you need to spend with the individual during the planning phase. First, there may be several types of statisticians who are available to you: Academics (master’s or PhD level) Students studying statistics (earning their MPH, PhD) Students formally overseen by PhD-level statisticians Private or ad hoc personnel A member of the team who is comfortable with statistics The complexity of your study, importance of results, and availability of funding may dictate the level of statistician you approach. It may also be advisable to obtain references for their work and/or to look up past publications to determine if the statistician’s past experience aligns with your research needs. There are advantages and drawbacks to each of the aforementioned individuals: be aware that going with the inexpensive option may require more oversight and knowledge on your part, whereas going with a highly qualified individual may require significant wait-time prior to gaining assistance and payment for their time.

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Keeping the Statistician On-Board There are several approaches researchers can take to engage a statistician. It is best to ask directly regarding the relative importance of hourly compensation, documentation of utility across an organization, and authorship as any of these may apply.

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Compensation for Time As with all skilled positions, hourly rates for statisticians can vary depending on their level of education and years of experience. If you are looking for a less costly but reasonably reliable option, blended rates may be available for students who are overseen by a PhD-level statistician. It is important to understand how skilled a statistician you need for your project so that your efforts are adequately supported.

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Authorship Depending on whether your statistician is an academician interested in the area of your study, you may be able to offer authorship for their involvement. Certain types of studies rely heavily on the statistician and warrant prominent authorship. Such studies include secondary analyses of preexisting databases (e.g., NSQIP, NIS) or in-depth meta-analyses of multiple studies. In these cases, the statistician’s authorship may need to be as high as co-first authorship. If the statistical consultation is used to confirm your statistical plan, you may only need to include the statistician’s contribution in the acknowledgments section. It is important to fully understand the effort request you are making of the statistician so that you can make an appropriate offer of authorship.

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Documenting Organization Utility or Benefit In certain academic environments, biostatistics core facilities are available. These can be funded in any number of ways (indirect costs, federal grants, etc.) and often include reporting metrics to justify ongoing funding. If this is the case, a certain number of in-kind hours may be available to faculty, students, or staff. (In the case of grant design, these free hours are also intended to assist with budgeting for future use of the statistician’s time when data collection is complete.) In these situations, a combination approach that includes compensation and authorship in published articles may be needed: be sure to ask.

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Statistical Plans: Get Them in Writing Research, and particularly prospective clinic trials in human subjects, can take much longer than anticipated to complete. For example, delays in IRB approvals, start-up, and recruitment; dropout or lostto-follow-up rates; and stringent inclusion/exclusion criteria can all contribute to slower study completion timelines. Given all the other details to which one must pay attention during a research study or clinical trial, it is easy to forget one’s analysis plan. If you have not written out your a priori analysis plan, chances are you will not remember it when you finally have data to analyze. Additionally, you need to have the analysis plan in writing in case the original biostatistician is no longer available to you at the time the study is completed. Because statistics can be somewhat open to interpretation, different statisticians may create different yet valid approaches for analyzing the same set of data. This is fine unless it renders your collected data inappropriate.

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Questions 1. PRS has published a study examining the pre-to-post change in patient satisfaction with breast reconstruction comparing a new implant sling technique (n = 13) with conventional implant placement (n = 28). What is the most appropriate test to use to determine if a statistically significant difference in satisfaction exists between groups? a. Paired t-test b. Independent t-test c. Wilcoxon signed-rank test d. One-way ANOVA 2. Which of the following scenarios would require an increase in the sample size? a. Changing the significance level from 0.05 to 0.01 b. Changing the power of the study from 90% to 80% c. Determining that the difference in the means is less than originally calculated d. Determining that the standard deviation of the means is less than originally calculated 3. A P-value of 0.05 indicates which of the following? a. 5% chance the null hypothesis is correct b. 5% chance the null hypothesis was incorrectly rejected c. 95% chance the null hypothesis was correctly accepted d. 95% chance the null hypothesis is correct 4. A study is performed to determine the outcomes between two different breast reconstruction techniques. One technique is performed by surgeon A at hospital X and the second technique is performed by surgeon B at hospital Y. Surgeon A has significantly better patient satisfaction scores based on a P-value of less than 0.01. Which type of bias is at risk for affecting the data? a. Skewing b. Post hoc analysis c. Confounding bias d. Overadjustment 5. A study team conducts a prospective, randomized, placebo-controlled trial designed to determine the effect of an experimental medication on flap necrosis rates. While completing the analysis of the study aims, the team notices an apparent correlation between participant BMI and postoperative infection rates. After conferring with the protocol principal investigator, the team decides to publish these additional findings in a separate manuscript. Which type of bias is at risk for affecting the data? a. Skewing b. Post hoc analysis c. Stratification d. Overadjustment 1. Answer: c. The sample size is small indicating that a nonparametric analysis should be performed because it cannot be assumed that the data are normally distributed. The pre-to-post change in patient satisfaction indicates that the data are dependent (repeated measurements in the same patients) and should be analyzed as such. 2. Answer: a. When performing a power calculation four pieces of information are needed: the event rate, the smallest clinically important difference, power (to detect the difference), and significance level. Decreasing power (answer b) reduces the sample size needed but increases the chance of beta error. Lowering the significance level (answer a) decreases the likelihood of alpha error and increases the number of subjects needed in the study. This is because you are seeking a greater level of

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confidence with which to correctly reject the null hypothesis (a 99%, or 99 in 100, chance). 3. Answer: b. A P-value is a measurement of the strength of the evidence against a null hypothesis; the smaller the P-value, the stronger the evidence that you should reject the null hypothesis. However, the P-value indicates the percent (%) chance that the null hypothesis would be incorrectly rejected, in this case a 5%, or a 1 in 20, chance. 4. Answer: c. Many different factors may be influencing differences in patient satisfaction between the two groups of patients being compared, including the surgeon’s skill level and interpersonal skills, the breast reconstruction technique employed, the hospital, the clinic and nursing staff, and more. Although this may serve as an initial hypothesis-generating study to help indicate how to better ascertain what precisely is causing these differences, this study alone is not very informative. 5. Answer: b. The analysis exploring a correlation between participant BMI and postoperative infection rates was not a part of the originally approved protocol’s specific aims or a priori statistical plan. By definition, this analysis was done post hoc and is subject to all the shortcomings inherent to post hoc analyses. Although it can be acceptable to publish post hoc findings, the study team needs to clearly state this fact and may not assume that a post hoc finding has proven a true correlation. Instead, post hoc findings can be considered hypothesis-generating and informative to future study designs.

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References Moher, D, Hopewell, S, Schulz, KF, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. Int J Surg. 2012;10(1):28-55.A published statement developed and refined by experts in clinical research to guide investigators toward best practices when designing and conducting clinical trials. This statement is widely endorsed by leading medical journals and international editorial groups. Ioannidis, JPA. The proposal to lower P value thresholds to .005. JAMA. 2018;319(14):1429-1430. Leek, J. On the scalability of statistical procedures: why the p-value bashers just don’t get it. Simply Statistics, A Statistics Blog by Rafa Irizarry, Roger Peng, and Jeff Leek. https://simplystatistics.org/2014/02/14/on-the-scalability-of-statistical-procedures-why-the-p-valuebashers-just-dont-get-it/. Published February 14, 2014. Accessed May 9, 2018. Wasserstein, RL, Lazar, NA. The ASA’s statement on p-values: context, process, and purpose. Am Stat. 2016;70(2):129-133.The American Statistical Association’s statement articulates in nontechnical terms a few select principles that could improve the conduct or interpretation of quantitative science, according to widespread consensus in the statistical community. Kirby, A, Gebski, V, Keech, AC. Determining the sample size in a clinical trial. Med J Aust. 2002;177(5):256-257. Sedgwick, P. What is intention to treat analysis? BMJ. 2013;346:f3662. AButhman. Dealing with non-normal data: strategies and tools. iSixSigma. https://www.isixsigma.com/tools-templates/normality/dealingnon-normal-data-strategies-and-tools/. Accessed May 7, 2018. Greenhalgh, T. How to read a paper. Statistics for the non-statistician. I: different types of data need different statistical tests. BMJ. 1997;315(7104):364-366.The first in a series of articles excerpted from the book, How to Read a Paper: The Basics of Evidence-Based Medicine. This article provides clinicians with a checklist of preliminary questions to help assess the statistical validity of a scientific publication. Mean and Standard Deviation. BMJ. https://www.bmj.com/about-bmj/resources-
 readers/publications/statistics-square-one/2-mean-andstandard-deviation. Statistical Consulting, Kent State University Libraries. SPSS Tutorials: Paired 
 Samples t Test. https://libguides.library.kent.edu/SPSS/PairedSamplestTest. Updated 
 May 24, 2018. Accessed May 25, 2018. Statistical Consulting, Kent State University Libraries. SPSS Tutorials: One Sample t Test. https://libguides.library.kent.edu/SPSS/OneSampletTest. Updated May 25, 2018. Accessed May 25, 2018. Statistical Consulting, Kent State University Libraries. SPSS Tutorials: One-Way ANOVA. https://libguides.library.kent.edu/SPSS/OneWayANOVA. Updated May 25, 2018. Accessed May 25, 2018. Reed, JF III, Stark, DB. Robust alternatives to traditional analysis of variance: Welch W*, James J I*, James J II*,Brown-Forsythe BF*. Comput Methods Progr Biomed. 1988;26(3):233-237. Bird, KD. Simultaneous contrast testing procedures for multivariate experiments. Multivariate Behav Res. 1975;10(3):343. Greenhalgh, T. How to read a paper: statistics for the non-statistician. II : “Significant” relations and their pitfalls. BMJ. 1997;315(7105):422425.The second in a series of articles excerpted from the book, How to Read a Paper: The Basics of Evidence-Based Medicine. This article provides clinicians with a checklist of preliminary questions to help assess the statistical validity of a scientific publication. Hidalgo, B, Goodman, M. Multivariate or multivariable regression? Am J Public Health. 2013;103(1):39-40. Mathew, A1, Pandey, M, Murthy, NS. Survival analysis: caveats and pitfalls. Eur J Surg Oncol. 1999;25(3):321-329. Rich, JT, Neely, JG, Paniello, RC, et al. A practical guide to understanding Kaplan-Meier curves. Otolaryngol Head Neck Surg. 2010;143(3):331336. Duyx, B, Urlings, MJE, Swaen, GMH, et al. Scientific citations favor positive results: a systematic review and meta-analysis. J Clin Epidemiol. 2017;88:92-101. Carroll, HA, Toumpakari, Z, Johnson, L, Betts, JA. The perceived feasibility of methods to reduce publication bias. PLoS One. 2017;12(10):e0186472. Elliott, HL. Post hoc analysis: use and dangers in perspective. J Hypertens Suppl. 1996;14(2):S21-S24. EWWeisstein. “Bonferroni correction.” From MathWorld – A Wolfram Web Resource. http://mathworld.wolfram.com/BonferroniCorrection.html. Guyatt, G, Walter, S, Shannon, H, et al. Basic statistics for clinicians: 4. Correlation and regression. CMAJ. 1995;152(4):497-504. Schisterman, EF, Cole, SR, Platt, RW. Overadjustment bias and unnecessary adjustment in epidemiologic studies. Epidemiology. 2009;20(4):488-495. VanderWeele, TJ. On the relative nature of overadjustment and unnecessary adjustment. Epidemiology. 2009;20(4):496-499. Cook, JA, Ranstam, J. Statistical models and confounding adjustment. Br J Surg. 2017;104(6):786-787. Adamina, M, Guller, U, Weber, WP, Oertli, D. Propensity scores and the surgeon. Br J Surg. 2006; 93: 389-394. VanderWeele, TJ, Robins, JM. Four types of effect modification: a classification based on directed acyclic graphs. Epidemiology. 2007;18(5):561568. VanderWeele, TJ. On the distinction between interaction and effect modification. Epidemiol. 2009;20(6):863-871. Errata in: Epidemiology. 2011;22(5):752, and 2010;21(1):162. Juluru, K, Eng, J. Use of spreadsheets for research data collection and preparation: a primer. Acad Radiol. 2015;22(12):1592-1599. Elliott, AC, Hynan, LS, Reisch, JS, Smith, JP. Preparing data for analysis using Microsoft Excel. J Investig Med. 2006;54(6):334-341.

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Harris, PA, Taylor, R, Thielke, R, et al. Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inform. 2009;42(2):377-381. Schneider, JK, Schneider, JF, Lorenz, RA. Creating user-friendly databases with microsoft access. Nurse Res. 2005;13(1):57-75. TJKuhn. ALCOA: a standard for evidence. GxP zone: good practice for the pharmaceutical industry from the quality assurance perspective. https://tjkuhn.wordpress.com/2008/07/23/alcoa/. Posted July 23, 2008. Accessed June 28, 2018. Van den Broeck, J, Cunningham, SA, et al. Data cleaning: detecting, diagnosing, and editing data abnormalities. PLoS Med. 2005;2(10):e267. De Muth, JE. Preparing for the first meeting with a statistician. Am J Health Syst Pharm. 2008;65(24):2358-2366.

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PA R T I I

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Skin and Soft Tissue 20. Skin Care and Benign and Malignant Dermatologic Conditions 21. Thermal, Chemical, and Electrical Injuries 22. Principles of Burn Reconstruction 23. Radiation and Radiation Injury 24. Lasers in Plastic Surgery

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CHAPTER 20

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Skin Care and Benign and Malignant Dermatologic Conditions John H. Bast and Alex K. Wong

Key Points Understand the role of Fitzpatrick skin types and their role when choosing a chemical peel regimen or laser treatment Understand the spectrum of dermatitis and be able to distinguish eczema from psoriasis Identify risk factors for development of NMSCs Be able to formulate a surgical treatment plan for melanoma The skin serves as an important interface to the external environment as both a physical and an immunologic barrier. Over the course of a lifetime, the skin undergoes characteristic changes as a result of aging and the constant damage and remodeling that takes place. Plastic surgeons will frequently encounter patients with concerns regarding the skin because it is the most visible of all the organs. It also plays an important role in the manifestation of disease processes through dermatologic symptoms. An example of a well-established form of external insult is ultraviolet (UV) radiation. UV radiation has been implicated as a strong risk factor for the development of both nonmelanoma skin cancers (NMSCs) and melanoma skin cancer, but also contributes to other benign skin lesions that develop. Latitude plays an important part in UV radiation exposure with lower latitudes having more direct and greater UV radiation exposure. 1 Although an external stimulus is often required, phenotypes of an individual also play a factor in the development of diseases affecting the skin. Inadequate DNA repair mechanism (xeroderma pigmentosum), those lacking melanin (albinism and lower Fitzpatrick score [I-IV]), and immune deficiency have all been implicated in increased risk for skin cancer. In the United States, a significant portion of health care dollars is spent managing the effects of UV damage to the skin in the form of skin rejuvenation therapies as well as skin cancer treatment. 2 Skin cancer has the highest incidence worldwide of all cancers. 3 There is also significant expenditure in the prevention strategies in the form of sunscreen and other agents for skin resurfacing to reverse the effects of sun damage. This chapter will review the effects of UV damage on the skin as well as go over some benign skin conditions that may present to the clinician for evaluation. It will also cover the most common skin cancers and the treatment strategies around those cancers.

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Skin Anatomy The skin is composed of two distinct layers—the epidermis, which is the most superficial layer, and the dermis, which is the deeper layer. Below this is a layer of subcutaneous fat. Glabrous skin is found on the palm and soles. It is without hair and has much thicker layer than the other skin of the body (Figure 20.1). Hair-bearing skin is found throughout the body.

FIGURE 20.1 Glabrous versus nonglabrous (hair-bearing) skin layers. Reproduced with permission from Bear, MF, Connors, BW, Paradiso, WA. The somatic sensory system. In: Bear, MF, Connors, BW, Paradiso, WA, eds. Neuroscience: Exploring the Brain. 4th ed. Philadelphia, PA: Wolters Kluwer; 2016:415-482. Figure 12-1.

There are four layers of epidermis in the skin, and the glabrous has an additional fifth layer. The epidermis is primarily composed of keratinocytes along with melanocytes, Langerhan cells, and Merkel cells. The dermis is divided into two layers, with the more superficial papillary dermis and the deeper reticular dermis. The dermis holds its integrity through a dense matrix composed of collagen and elastin fibers that give both strength and elasticity. The dermis also houses the other skin appendages such as hair follicles, sebaceous glands, and the apocrine and eccrine sweat glands. With photoprotection, the skin will become thin, dry, smooth, and unblemished with aging. Aging photodamaged skin is characterized by fine and course wrinkles, roughness, laxity, scaling, dryness, telangiectasia, and dyschromia with an increase in the frequency of both benign and malignant lesions. Solar elastosis describes the photodamaged extracellular matrix of the dermis with abnormal elastin and decreased, disorganized collagen fibrils.

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Fitzpatrick Skin Type Fitzpatrick skin type classifies the skin into six phenotypes based on the melanin content of the skin (color), the inherent pigmentation of the skin, and the sensitivity of the skin to sun damage. 4 Lower Fitzpatrick score indicates less melanin in the skin and hence a greater sensitivity to sun damage. This leads to an increased risk for skin cancer in these individuals. The Fitzpatrick classification system has also been applied to other modalities of skin resurfacing such as chemical peels and laser resurfacing as a guide to how the skin will respond and the propensity for pigmentation damage and scarring after resurfacing procedures. 4,5

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Sunscreen There has been a clear and consistent link of sun exposure history (UV) and skin cancer. UV radiation that reaches the earth’s surface is UVA and UVB. 95% is in the form of UVA; however, UVB is the most carcinogenic through direct photochemical damage to cellular DNA and to the DNA repair mechanism of the cell. Primary means of preventing damage from UV include ways that minimize the UV that can penetrate the skin and cause photodamage, especially at a young age. Avoiding UV radiation exposure at peak times (10 am–4 pm) and wearing protective outer clothing are examples of primary prevention. Sunscreens protect the skin either chemically or physically. Chemical sunscreens absorb UV (usually UVB) radiation with the most common sunscreen ingredient being para-aminobenzoic acid (PABA), benzophenones, and cinnamates. Physical sunscreens work by reflecting UV radiation and producing a protective barrier. They are usually opaque and include agents such as zinc oxide and titanium dioxide. Sunscreens that block both UVA and UVB are best; however, the UV protection listed on the sunscreen is for the UVB only, and many do not effectively block the UVB. Appropriate application ensures the protective effect of the sunscreen.

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Retinoids Retinoids (derivative of vitamin A) are well studied for the protective effects in the skin and reversal of photoaging. They work by binding to nuclear receptors and modulating cellular gene expression. Clinically, this leads to epidermal thickening and increased collagen in the dermis because of decreased breakdown and increased collagen synthesis in the dermis. 6 They are available as topical (e.g., tretinoin or Retin-A) and can be used to treat areas of actinic damage. Retinoids are also available systemically (e.g., isotretinoin) and can be used to treat acne and rosacea; however, they are known teratogen and thus must be used under close monitoring in women of childbearing years. Side effects such as pruritus, burning, erythema, and peeling are usually seen with onset of treatment and can lead to noncompliance, especially in patients with a history of sensitive skin. Photosensitivity is another common side effect of topical therapies, and patients are advised to avoid sun exposure when starting therapy.

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Chemical Peels Chemical peel strength is typically classified based on the depth of effect with deeper peels having longer-lasting effects: superficial, medium, or deep. Superficial peels cause exfoliation of the epidermis without deeper penetration. Medium peels affect the epidermis and penetrate into the papillary dermis, and deep peels penetrate into the reticular dermis where they cause realignment of collagen. Peels are used for a wide variety of skin conditions ranging from management of photodamage and melasma to hyperpigmentation, rosacea, and acne. Deeper peels tend to have more profound and longer-lasting effect compared with superficial peels. Common superficial peels include glycolic acid and salicylic acid, whereas TCA (20%–35%) and Jessner’s are considered medium peels. Phenol and TCA (45%–50%) are examples of deep peels. Peels are commonly used in conjunction with other skin resurfacing modalities for improved outcomes. 7

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Laser Resurfacing Laser resurfacing relies on the principles of selective thermal destruction (photothermolysis) to disrupt damaged areas of skin and to induce remodeling. Ablative laser resurfacing causes wounding of the skin to the dermis and then allows wound healing from dermal regenerative cells. Examples include the CO2 laser and erbium:yttrium-aluminum-garnet laser. Fractional lasers create microthermal zones of injury that are spatially confined rather than confluent. This preserves some epidermis and shortens the recovery time and diminishes the side effects. Healing occurs from the surrounding unaffected follicular units. 8

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Evaluation and Management of Common Skin Disorders Skin and Soft-Tissue Infections Bacterial Infections As a barrier to the external environment, the skin is in constant balance with the external bacteria. When this balance is shifted, as in an open wound, bacteria proliferate, which can manifest as cellulitis and/or an abscess. Cellulitis is caused by a break in the skin barrier that allows bacteria access to the deep dermis. It manifests as spreading erythema and warmth. 85% of the time, no bacteria are cultured from cellulitis, and treatment should cover the staph and strep of the skin flora with consideration of methicillin-resistant Staphylococcus aureus (MRSA) in certain at-risk groups. 9 An abscess is a collection of pus in the dermis/subcutaneous space. In the immunocompetent patient, the most common cause of abscess is S. aureus but can be multifloral. In the immunocompromised patient, other more atypical bacteria and fungi need to be considered.

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Bites and Stings Bites and stings from mammals, spiders, reptiles, ticks, and insects are a common source of bacterial infection. By causing a break in the normal protective skin barrier and inoculation of bacteria into the deeper layers, the skin flora invades into the dermis. When treating bites from mammals and reptiles, the oral flora of the animal should be considered for targeting therapy. Tetanus is also a risk, and appropriate treatment is warranted depending on immunization history. Bites can also deliver toxins that can produce both local and systemic effects. The brown recluse spider, for example, causes wide local tissue destruction from the enzyme sphingomyelinase D. 10 Systemic toxicity from envenomation includes neurotoxicity and coagulopathy and can be quickly fatal. Early treatment with respiratory management, treatment of shock, and antivenom administration can be lifesaving.

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Infestations Infestations including pediculosis (from lice [e.g., Pediculus humanus capitis, Pediculus humanus humanus, and Phthirus pubis]), scabies, infection from bedbugs, schistosome cercarial dermatitis, and myiasis are another source of skin lesion/irritation. Lice present with excoriated erythematous papules along with pruritus and regional lymphadenopathy. Permethrin is first-line treatment for the condition. Scabies (Sarcoptes scabiei var homonis) involves female mites living within epidermal burrows that create a hypersensitivity reaction after 3 to 4 weeks (Figure 20.2). Usually the web space, wrists, and/or genitalia are pruritic and erythematous. Topical permethrin 5% is the treatment of choice. Schistosomiasis is manifested by pruritic erythematous plaques after the larvae penetrate the skin. Typically treatment is symptomatic because most are animal schistosomes.

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FIGURE 20.2 Scabies of the axillary fold. (Courtesy of Henry K. Wong, MD, PhD.)

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Cutaneous Viral Infections and Exanthems Viral infections are well studied for the effect they can have on the skin by both direct infection of the skin and mucus membranes and the cutaneous manifestations of a viral illness through exanthemas. Human papillomaviruses (HPVs) are DNA viruses that often induce benign papillomas or warts but have the potential to cause cancerous lesions in the skin. The virus is passed by person-to-person contact or by contact with a contaminated surface. The virus affects basal keratinocytes. Anogenital HPV infections represent the most common sexually transmitted infection in the United States and include high-risk types such as HPV 16 and 18, which have been implicated in cervical and anal cancers. 11 These high-risk strains are the target of prophylactic HPV vaccines and have been shown to protect from the targetspecific HPV types when given prophylactically. 12 Herpes virus represents a large family of DNA viruses that are known to have a clinical history of infection, latency period, and reactivation. Common examples include herpes simplex, which presents with vesicular eruptions usually in the orolabial and genital regions (Figure 20.3), varicella-zoster virus (chicken pox/shingles; Figure 20.4), Epstein-Barr virus (EBV), and cytomegalovirus. Topical and systemic antiviral therapies have been helpful in modifying the disease presentation.

FIGURE 20.3 Herpes simplex virus infection of the gluteal area. (Courtesy of Henry K. Wong, MD, PhD.)

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FIGURE 20.4 Varicella-zoster virus infection of the hip in a dermatomal distribution. (Courtesy of Henry K. Wong, MD, PhD.)

Viruses can also present with clinical manifestations, especially in the juvenile population. Some of these exanthemas (a skin eruption occurring as a sign of a general disease) can be pathognomonic for a virus, whereas others are more generalized. Diagnosis is aided by identification of other symptoms, including low-grade fever, malaise, GI complaints, and rhinorrhea to help suggest it is the manifestation of viral illnesses. Some common examples include hand, foot, and mouth (Coxsackie virus), measles (rubeola), German measles (rubella), Fifth disease (parvovirus B19). Generally, treatment is supportive; however, some of these can pose a significant health risk if left untreated.

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Fungal Infections Fungal skin infections are also common and classified based on depth and extent of involvement. Superficial infections include dermatophytoses and tinea versicolor along with cutaneous candidiasis. Deeper infections include sporotrichosis and result from the organism being deposited in the dermis or subcutaneous tissue. They can have a prolonged course and are often treated with topical agents to avoid the side effects of systemic antifungals. Diagnosis is usually clinical but can be made with scrapings.

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Dermatologic Manifestations of Sexually Transmitted Diseases The most common sexually transmitted diseases (STDs) with skin changes include syphilis, gonorrhea, chancroid, and lymphogranuloma venereum. Syphilis has mucocutaneous manifestations that range from a chancre typically in the genital (sometimes oral) area in the primary stage of the disease to widespread papulosquamous eruptions (Figure 20.5) in the secondary stage and in the last stage may present with granulomatous nodules called gummas. The lesions of the primary and secondary stage are highly contagious, and care must be taken when examining patients suspected of having the disease.

FIGURE 20.5 Syphilis of the palm and ring finger. (Courtesy of Henry K. Wong, MD, PhD.)

Gonorrhea is an STD that can manifest with cutaneous pustules along with arthritis and fever. Disseminated gonococcal infections should be treated with IV ceftriaxone. Chancroids are another STD, causing genital ulcers and inguinal lymphadenopathy. Treatment is with antimicrobials.

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Benign Skin Lesions Contact Dermatitis Contact dermatitis is a common condition that is caused by a delayed hypersensitivity reaction (type IV) within the skin that clinically presents with pruritus and a well-demarcated, erythematous, sometimes vesicular patch (Figure 20.6). It is typically localized to the area of contact by the allergen. Common allergens include poison ivy and nickel. Patch testing remains the standard for identification where allergens are placed on the skin and the patient is monitored for a response to identify causative agents after 48 hours. Treatment starts by avoiding the offending allergen. If there is a reaction, corticosteroids are the treatment of choice and have many formulations that can be administered depending on severity of reaction, with topical being the most common form for milder presentations. 13,14

FIGURE 20.6 Contact dermatitis due to nickel (A) and necklace (B). (Courtesy of Henry K. Wong, MD, PhD.)

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Eczema (Atopic Dermatitis) Eczema (atopic dermatitis) is a benign condition that often develops in infancy and childhood with relapsing curse of pruritus that may become chronic. It may be accompanied by other disorders such as allergic rhinitis, asthma, food allergies, and more rarely eosinophilic esophagitis. There is usually an agespecific distribution pattern affecting extensor surfaces, face, and neck in infants and then flexor surfaces later. Management typically involves patient education, daily use of moisturizers, and use of antiinflammatory medications (topical corticosteroids) during a flare up. Severe disease may require the use of systemic medications. 15

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Nevi (Benign Melanocyte Proliferation) Congenital nevi are present at birth or appear in infancy and are classified based on their size (small, medium, large, and giant). Common acquired melanocytic nevi include: Junctional nevi: where there is proliferation of the melanocytes at the dermal-epidermal junction Intradermal nevi: with the melanocytes being located in the dermis Compound nevi: with both intraepidermal and intradermal complexes of melanocytes Differentiating these from melanoma can be difficult, and often the ABCDE pneumonic—asymmetry, border irregularity, color variation, diameter >6 mm, enlarging or evolving—is used as a guide for when to intervene with biopsy and further workup (Figure 20.7, Table 20.1). 16

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FIGURE 20.7 ABCDE mnemonic as a guide for assessing pigmented lesions. (From www.skincancer.org.)

TABLE 20.1 Indication for Mohs Excision in Primary Lesions

Areas with high rate of treatment failure (periorbital, periauricular, Nose, paranasal) Tumor with poorly delineated clinical borders or arising from scar tissue Tumors with aggressive malignant features SCC: Breslow depth >2 mm, poorly differentiated or undifferentiated, spindle cell, acantholytic, sclerosing, small cell, clear cell, lymphoepithelioma-like, sarcomatoid BCC: Morpheaform (sclerosing), micronodular, basosquamous(metatypical), infiltrating Location in critical structures such as the eyelid or where desirable to preserve as much uninvolved tissue as possible Perineural invasion Dermatofibrosarcoma protuberans Microcystic adnexal carcinoma

Reprinted from Connolly, SM, Baker, DR, Coldiron, BM, et al. AAD/ACMS/ASDSA/ASMS 2012 appropriate use criteria for Mohs micrographic surgery: a report of the American Academy of Dermatology, American College of Mohs Surgery, American Society for Dermatologic Surgery Association, and the American Society for Mohs Surgery. J Am Acad Dermatol. 2012;67(4):531-550. Copyright © 2012 American Academy of Dermatology, Inc. and the American Society for Dermatologic Surgery, Inc. With permission. BCC, basal cell carcinoma; SCC, squamous cell carcinoma.

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Rosacea Rosacea is a common chronic inflammatory facial dermatosis usually affecting lighter-skinned individuals and typically appearing in middle age. Clinically, it has variable presentation from facial flushing and telangiectasias to papules and pustules. There are four subtypes, and treatment includes patient education on skin care and need for maintenance therapy along with the use of topical and oral antibiotics such as doxycycline and topical ivermectin. 17

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Seborrheic Dermatitis Seborrheic dermatitis is characterized by sharply demarcated patches or plaques that can range from pink-yellow to red-brown and may have flaky greasy scales. It typically affects areas high in sebaceous glands including the face, scalp, ears, parasternal region, and sometimes intertriginous areas. It may present in infancy cradle cap where it tends to have a more limited course or in adults typically presents as a chronic relapsing course and often affects the scalp. Treatment in infants is often satisfactory with emollients, with more extensive cases requiring ketoconazole and low-potency steroids to suppress inflammation. In adults, the condition usually responds well to topical azoles (e.g., ketoconazole along with emollients).

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Psoriasis Psoriasis is a common inflammatory disease affecting the skin that causes characteristic silver scaly, erythematous plaques that are often well demarcated (Figure 20.8). It typically affects the scalp, extensor surface of elbow and knees, and intergluteal folds. It can also affect the nails, hands, and trunk. The disease is thought to be caused by T-cells interacting with dendritic cells and other innate cells of immunity. The pathognomonic pathologic finding is accumulation of neutrophils as spongiform pustules in the epidermis. Other associated manifestations include arthritis but also some cardiovascular diseases and depression. Treatment of the condition depends on disease severity with mild forms being treated with topical steroids and other topical agents such as vitamin D analogues. Patients with more advanced disease can be treated with phototherapy and immunomodulators, which have shown to be effective in more severe disease forms. Treatment of the disease should focus on managing acute flares as well as maintenance when not having flares because it is a chronic disease process. 18

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FIGURE 20.8 Psoriasis of the back. (Courtesy of Henry K. Wong, MD, PhD.)

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Urticaria (and Drug Eruptions) Urticaria, commonly referred to as hives, welts, or wheals, is typically a well-circumscribed intensely raised pruritic plaque. It is usually caused by a trigger, such as food, insect bites, or drugs. Urticaria may also present with angioedema, representing deeper swelling in the skin and typically affecting the face and lips, extremities, and genitals. It is mediated by mast cells and basophils releasing mediators that include histamine. A majority of new acute urticaria lesions are self-limiting, but in severe cases, chronic cases, and cases that include angioedema, H1 blockers and glucocorticoids can be considered for treatment. 19

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Acne Acne represents a common dermatologic condition affecting the pilosebaceous units and typically presents in adolescence. Commonly affected areas include the face and upper trunk. Clinical manifestations can vary but are generally broken down into inflammatory (papules, pustules, and nodules) and noninflammatory (open and closed comedones). Clinical presentation varies in severity, and many factors are known to play a role in disease manifestation including genetics, hormones, and environmental factors. Treatments are typically geared toward reducing the predisposing risk factors and include facial cleansers, hormone therapy and vitamin A analogues, and antibiotic therapy (both oral and topical).

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Alopecia and Hair Disorders Alopecia can be the result of hair follicle loss, loss of the hair shaft, or a combination of both. There are three phases of hair growth: anagen, telogen, and catagen. Identifying hair follicles in their phases and any disruption in this cycle can help lead to a diagnosis and treatment. Androgenic alopecia represents one of the most common acquired forms of hair loss and is known to be genetically driven in the presence of androgen. In genetically susceptible hair follicles, there is miniaturization of hairs in a symmetric pattern (on the crown, vertex, or frontal region) in response to normal levels of circulating androgens. Antiandrogen medications have been helpful in treating this condition. Telogen effluvium represents an increase in shedding of otherwise normal telogen hairs in response to a pathologic or physiologic change. This is, for example, seen in the postpartum period, after some medications, and there will be time of shedding usually around 3 months after the event. Alopecia areata is a form of noncicatricial alopecia that is thought to be from hair-specific autoimmune disorder. Clinically, there are often circular patches of hair loss but can involve the entire scalp in some cases. Topical and intralesional steroids are often first-line therapy in smaller areas.

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Nail Disorders The nail serves many purposes including protection of the finger, counterpressure for the pulp, and utility in fine object manipulation and scratching. The nail is composed of the nail bed (germinal and sterile matrices), hyponychium, and the nail plate. The nail matrix produces the nail plate through keratinization and this is occurs continuously. The nail grows approximately 0.1 mm/d. Nail disorders are a wide range of clinical disorders, and presentations vary depending on what part of the nail is affected and how it manifests. Trauma to the underlying matrix can lead to a wide assortment of disorders depending on the severity of damage to the nail bed (e.g., nail ridge, split nail, onycholysis [nonadherence]). Pitting and clubbing represent two aberrant nail presentations that can be indicative of systemic processes. Melanonychia is caused by melanin production of nail matrix melanocytes. It presents as a longitudinal pigmented band starting at the proximal nail fold, and in adults without a history of trauma, the clinician should consider a matrix biopsy to rule out melanoma. Infections are also common and can be acute as in a paronychial infection usually bacterial in origin or chronic with bacterial and often fungal.

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Hyperpigmentation and Hypopigmentation Hypopigmentation is a general term to describe lightening of the skin, which is most often from a decreased melanin content in the skin. It may be localized or diffuse depending on the underlying cause. This decreased melanin production (e.g., albinism) can be from the melanocytes not synthesizing melanin or from destruction of the melanocytes, which may be hereditary or the result of trauma or autoimmune attack (e.g., vitiligo). Inflammation can also cause a state of hypomelanosis that may resolve once the cause of inflammation is treated. Tyrosinase inhibitors and hydroquinone work by preventing tyrosinase, which is essential in melanogenesis, and have been used to prevent hyperpigmentation in patients seeking resurfacing procedures. Hyperpigmentation disorders are usually the result of increase in melanin production but rarely can be from an increase in the melanocyte number. It may be diffuse, circumscribed, linear, or more rarely reticulated. If the hyperpigmentation is acquired, removal of the inciting stimulus may help ameliorate the issue.

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Nonmelanoma Skin Cancers (Keratinocyte Cancers) NMSCs are the most common form of cancer in the United States with the incidence estimated to be 5.5 million in 2012. 3 The most important risk factor for NMSC is the skin phenotype, but it is also influenced by UV radiation exposure. For basal cell carcinoma (BCC), especially, intermittent intense episodes of UV exposure appear to increase the risk, whereas a history of childhood sunburns, especially severe burns, gives an increased risk for actinic keratosis (AK) and squamous cell carcinoma (SCC). Another wellestablished risk factor is immunosuppression. Patients with human immunodeficiency syndrome are known to have a 1.8- and 5.4-fold increase in the risk for developing BCC and SCC, respectively, compared with the general population. 20 Patients on immunosuppressive therapy also exhibit a greater incidence of NMSC development. The standard for diagnosis of NMSC remains a thorough physical examination followed by conventional biopsy with histopathology for definitive diagnosis. Dermoscopy and confocal microscopy, crosspolarized light, and fluorescence photography have all been used as adjunct screening tools to identify atrisk lesions before proceeding with biopsy. In terms of biopsy technique, there are several techniques but no one standard method. Options for biopsy include shave, excisional, incisional, and punch biopsy. All have advantages and disadvantages with the goal of identifying cancerous cells for eventual destruction without significant tissue distortion.

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Basal Cell Carcinoma Basal cell cancer represents the most common form of skin cancer and malignancy in the Caucasian population. They arise from the pluripotent stem cells within the epidermis and hair follicles. BCC is well known to be locally aggressive, and the biggest risk for recurrence is locally rather than with metastasis. Because of its propensity to occur in sun-exposed areas, particularly on the face, head, and neck, they can cause great disfigurement. There is no role for lymph node sampling in BCC because it stays local. Factors in BCC that are known to be prognostic include location with high-risk regions being on the face, forehead, scalp, neck, and pretibial regions, where lesions in these areas that are >10 mm are considered high risk. Other factors that increase the risk for recurrence include poorly defined borders, recurrent cancer, perineural invasion, immunosuppression, and prior XRT at the site. There are 26 listed subtypes of BCC. A general schematic for breakdown include dividing them based on their histopathologic pattern, which is more important than the differentiation. The two subtypes are circumscribed BCC and the diffuse subtypes of BCC. In the circumscribed group, nodular represents the most common form of BCC and accounts for about 50% of all BCC. Its appearance is a pink/red papule that has a pearly appearance. Other examples that would fall in the circumscribed group include adenoid cystic, keratotic, fibroepithelioma of Pinkus. Diffuse basal cell cancers include superficial, micronodular, infiltrating, and morpheaform (sclerosing). Morpheaform is the most aggressive type and typically has the appearance of a firm depressed plaque in a scar. Typically, there is invasion beyond the visible edges of the lesion that will often extend into the deep dermis. Treatment of BCC can be broken down into three categories: surgical, destructive, and medical. Surgical is either primary surgical excision or Mohs surgical excision. Surgical margins in primary excision depend on risk factors including location, tumor size, and histologic subtype. Mohs surgical incision uses saucer-like layers to remove all tumor, creating a map for the surgeon to mark areas of tumor for further excisions. Mohs excision is recommended for most recurrent basal cell and squamous cell cancers (see Table 20.1). Mohs has the advantage of preserving normal tissue, and this technique is used in the face or for other lesions that may be more aggressive. Destructive therapy aims to destroy the tissue and is only indicated for superficial lesions. Techniques include electrodissection, cryotherapy, and radiotherapy. Medical therapy includes 5-FU and imiquimod but is inferior to surgical and destructive techniques.

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Squamous Cell Carcinoma AK represents an intradermal early stage SCC and is most commonly seen in areas of prolonged UV exposure in fair-skinned and elderly patients. It has a rough erythematous papule appearance and is typically located in sun-exposed areas (helices of ear, upper forehead, nasal bridge, bald scalp, etc.). Lesions may be small or very large and broad. They are characterized as precancerous because they have atypical keratinocytes confined to the epidermis. Their risk of transformation to invasive carcinoma is up to 0.06% per year. 21 SCC in situ is commonly referred to as Bowen disease. It typically presents as a scaly elevated plaque often in sun-exposed areas but in younger patients, may be in sun-protected sites. SCC in situ and AK can be difficult to distinguish from psoriasis papules and plaques that may resemble these processes. Keratoacanthomas are considered by many to be a variant of SCC. They typically present as rapidly enlarging papules over a few months that are sharply circumscribed and have a keratotic core. Sometimes, they spontaneously resolve, but this can take months and given similar appearance to SCC most advocate excision. 22 They often present as a solitary lesion but may be in multiple locations as part of a syndrome. Invasive SCC often develops in sun-exposed areas such as the scalp, face, neck, dorsal hands, skin and extensor forearms, with the risk factor being more related to the cumulative effect. It can have a variable presentation with some becoming hyperkeratotic and having crusting, erosions, and ulcerations. The growth history is variable, but signs of paresthesia, anesthesia, and pain are indicative of perineural invasion (at least T3). Diagnosis of SCC is with tissue biopsy and also clinical examination of draining lymph node basins. SCC is staged using the AJCC TNM with recent changes in 2017 to reflect the clinicohistopathologic features that increase the risk for recurrence. Sites where the tumor behaves more aggressively include the ear, lips, and mucosal sites. When evaluating patients, palpation of regional lymph nodes should be performed to assess for the presence of palpable nodes as well as the size. Any palpable nodes should be biopsied with fine needle aspiration. Risk factors that increase risk for metastasis are listed in Table 20.2. TABLE 20.2 High-Risk Features of Squamous Cell Carcinoma Features on History and Physical Borders: poorly defined Diameter: Area L ≥ 20 mm; Area M ≥ 10 mm Recurrent Arising within a scar, prior RT site or other chronic inflammatory process Immunosuppression Features on Pathology Poorly differentiated or undifferentiated, developing within Bowen disease Acantholytic, adenosquamous, desmoplastic, or metaplastic subtypes Tumor thickness: ≥2 mm or Clark IV, V

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Perineural, lymphatic, or vascular involvement

Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Squamous Cell Carcinoma V.2.2018. © 2018 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. The NCCN Guidelines are a work in progress that may be refined as often as new significant data become available.

Treatment of SCC depends on the stage of SCC, with some low-risk cancers being amenable to destructive therapy similar to BCC. Direct surgical excision (primary or with Mohs) can be used for both low- and high-risk lesions.

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Melanoma Melanoma is the most deadly of all the skin cancers and accounts for 75% of all the deaths related to skin cancer whereas only accounting for less than 5% of skin cancer diagnosis. Trends suggest that its incidence continues to rise. Melanocytes that undergo a malignant transformation are most commonly in the skin but may also be present in the eye or mucus membranes. Melanomas arise from the melanocyte that is a dendritic cell located in the basal layer of skin. It is responsible for producing the melanin pigment that gives the skin phenotypes. Melanocyte numbers are equal among all skin colors; however, the production of melanin varies. Melanomas can grow in both a radial and vertical growth pattern. The radial pattern is usually in the epidermis and some melanomas can stay in this radial growth pattern for a long time. In the vertical growth, the growth shifts down into the dermis and indicates a worse prognosis. Melanomas can be broken down into five clinical and histological growth patterns. Superficial spreading is the most common. This can occur anywhere but often occurs in regions of sun exposure. As the name might suggest, it typically has a prolonged radial growth pattern before transforming into a more vertical. Nodular melanoma is the second most common type and has a classic presentation of a singular lesion with a domed-shaped dark appearance that can resemble a blood blister. It tends to develop in a vertical growth pattern more quickly and often occurs on the trunk, and head and neck regions. Because of the growth pattern, it is often more advanced at the time of diagnosis. Lentigo melanoma is a rare form that presents as large tan lesions with convoluted patterns and amelanotic patterns. It has a low malignancy potential and is more common in women, typically on the head, face, and neck. Acral-lentiginous melanoma is the rarest in Caucasians but accounts for greater than 30% of all melanomas that occur in dark-skinned individuals. 16 This often occurs on the palms, on soles of feet (Figure 20.9), and beneath the nail beds. In the subungual presentation, they commonly cause a longitudinal line in the nail plate known as Hutchinson sign. Amelanotic melanomas are responsible for 2% to 8% of invasive cases and characterized by malignant cells that lack pigment, making them clinically difficult to identify and leading to later identification. Desmoplastic melanomas are another rare melanoma form that typically has an aggressive local growth pattern but less propensity to metastasize.

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FIGURE 20.9 A. Melanoma of the heel. B. Result after wide local excision and reconstruction with free radial forearm fasciocutaneous flap.

Diagnosis of a melanoma starts with clinical examination. The ABCDE mnemonic (see Figure 20.7) can be used as a guide for assessing pigmented lesions and can guide a clinician on when to biopsy a lesion. 23 Definitive diagnosis of melanoma is with incisional biopsy. The two classic staging classifications are the Clark and Breslow classifications. The Clark classification is based on the anatomic level of local invasion. Breslow classification is based on vertical depth of the invasion in millimeters. The AJCC is what is used for staging, but part of the staging related to depth is similar to the Breslow classification because it was a better prognosticator of disease severity and risk recurrence. 24 As part of staging workup, it is important that the specimen is viewed with standard stains rather than frozen sectioning to prevent specimen distortion and allow for adequate assessment of Breslow depth, which is calculated using ocular micrometer and is in reference to the greatest depth of invasion of the tumor measured down from the granular layer of the epidermis. This has been shown to be one of the best prognostic values for tumor prognosis as well as lymph node metastasis. 25 Management of the primary tumor is with wide excision of the primary tumor site. Excision should include skin and subcutaneous fat down to but not including the fascia. The National Comprehensive Cancer Network (NCCN) has recommended surgical margins based on Breslow depth, which are listed in Table 20.3. TABLE 20.3 NCCN Guidelines for Tumor Margin Based on Breslow Thickness Tumor Microstage Melanoma in situ (Tis) Thin (T1) Intermediate (T2) Intermediate (T3)

Thickness ≤1.0 mm 1.0–2 mm 2.0–4.0 mm

Margin 0.5 cm 1.0 cm 1.0–2.0 cm 2.0 cm

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Thick (T4)

>4 mm

2.0 cm

Adapted with permission from the NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines®) for Squamous Cell Carcinoma V.2.2018. © 2018 National Comprehensive Cancer Network, Inc. All rights reserved. The NCCN Guidelines® and illustrations herein may not be reproduced in any form for any purpose without the express written permission of NCCN. To view the most recent and complete version of the NCCN Guidelines, go online to NCCN.org. The NCCN Guidelines are a work in progress that may be refined as often as new significant data become available.

In addition to tumor depth, ulceration and mitotic rate also play a role in staging. Mitotic rate has also been identified as an independent predictor of survival and so is also a part of the AJCC staging. 26 The thickness correlates with prognosis with modifications in each T category if there are mitotic figures or ulceration indicating worse prognosis. The sentinel lymph node is the first lymph node in the draining basin from the primary tumor site. Because this node is usually involved, if there is regional nodal metastasis it can be used as a selective sample marker to see if the rest of the nodal basin is affected. Sentinel lymph node sampling is advocated in patients with stage I/II melanoma with tumor thickness 1.0 to 4.0 mm Breslow depth, or those with depth of 0.76 to 1.0 mm with other high-risk factors, including ulceration, lymphovascular invasion, significant vertical growth phase, and increased mitotic rate. Additionally patients with tumor >4.0 mm depth and clinically negative nodes also benefit from SLN biopsy. Complete surgical lymphadenectomy is recommended for any patient with clinically involved nodes diagnosed via examination, FNA, or SLN biopsy. Node status is the most important prognostic factor in staging melanoma. Clinically advanced (stage IV) melanoma carries a poor prognosis, with only 10% to 15% of patients living past 5 years.

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Merkel Cell Carcinoma Merkel cell carcinoma is a rare form of skin cancer typically affecting older (>50) fair-skinned individuals in sun-exposed areas. It usually presents as a solitary erythematous nodular lesion in sun-exposed areas of the head and neck. It commonly spreads to lymph nodes with 25% to 30% of initial presenting patients having positive nodes. It is aggressive like melanoma, and like melanoma staging depends on node involvement with SLN biopsy. Primary surgical excision with wide margins or Mohs is standard treatment. Local recurrence is 40% to 45%. Radiation can be used as adjuvant therapy. 27

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Questions 1. Sentinel lymph node biopsy (SLNB) would have the most benefit in which of the following patients? a. A 50-year-old man with a 4.0 cm diameter BCC with lymphovascular invasion b. A 80-year-old woman with a 1.0 cm diameter melanoma with thickness of 1.0 mm and a palpable 2 cm lymph node in the affected extremity c. A 4-year-old boy with a 10.0 cm diameter congenital melanocytic nevus d. A 67-year-old man with a 0.5 cm diameter melanoma with a thickness of 1.5 mm 2. Choose the most correct statement regarding retinoids. a. Derived from vitamin C, they work by binding to nuclear receptors and modulating gene expression. b. Derived from vitamin A, they work by binding to transmembrane receptors and modulating gene expression. c. Common side effects include of topical retinoids include pruritus, peeling, photosensitivity, and erythema. d. Treatment results in epidermal thinning and decreased collagen in the dermis. 3. Clinically, psoriasis is a characterized by silver scaly, erythematous plaques that are often well demarcated. Histologically, psoriasis is characterized by: a. Vacuolar alteration of basal keratinocytes b. Accumulation of neutrophils as spongiform pustules in the epidermis c. Dermal changes consisting of interstitial mucin deposition and a sparse lymphocytic infiltrate d. Basement membrane degeneration 4. Which Fitzpatrick skin type rarely burns and tans dark easily? a. II b. III c. IV d. V 5. Patients with which systemic disease are known to have a significantly increased risk for developing a primary NMSC compared with the general population? a. Rheumatoid arthritis b. Hyperlipidemia c. EBV infection d. Human immunodeficiency syndrome 1. Answer: d. SLNB is useful in the prognostic evaluation of patients with melanoma who have stage IB/II lesions. It allows these patients with tumor of 1 to 4 mm Breslow depth (0.8–1 mm plus ulceration) to be evaluated for nodal spread without doing a full nodal dissection. Patients with tumors 50 dysplastic moles and a family history of dysplastic nevi. Wallace Clark first described dysplastic nevus syndrome while at Penn, and noted that patients with many dysplastic nevi and two or more first-degree relatives with melanoma have perhaps a lifetime risk of melanoma approaching 100%. Clark is best known for describing the depth of invasion of a melanoma (Clark levels I–V), the deeper the level, the worse the prognosis (Figure 26.7). In most patients, Clark level correlates with the tumor thickness, measured in millimeters (Breslow classification). Tumor thickness, however, is the most important prognostic indicator. A full-thickness biopsy is indicated for any suspicious lesion. Patients with large numbers of dysplastic nevi are best followed with full body photographs to help determine which nevi are truly changing and deserve biopsy.

FIGURE 26.6 A. Dysplastic nevi have irregular fuzzy borders and variegation in pigmentation. A family history of melanoma and many dysplastic nevi warrants close dermatologic surveillance, usually with full body photographs to determine which nevi are changing and require biopsy. B. Dysplastic nevus with severe atypia. In the epidermal component of this dysplastic nevus, there is high cellularity and focal pagetoid growth of nevomelanocytes. (Courtesy of Rosalie Elenitsas, MD.)

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FIGURE 26.7 Malignant melanoma characteristically shows pagetoid growth of melanocytes in the epidermis. This term refers to the proliferation of these atypical melanocytic cells at all layers of the epidermis. Invasive melanoma is demonstrated by the presence of the atypical cells in the dermis (lower right-hand corner of photomicrograph). (Courtesy of Rosalie Elenitsas, MD.)

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Surgical Management of Melanocytic Nevi The malignant potential for most melanocytic nevi is less than 1% over a lifetime; therefore guidelines have been established to alert the patient and the clinician to suspicious nevi warranting biopsy. The ABCDEs of suspicious nevi include asymmetry, irregular border, variegation in color, diameter larger than a pencil eraser (>6 mm, probably the least important feature), and most importantly a changing nevus (evolution). Changing features may also include crusting, bleeding, and itching. A full-thickness biopsy rather than a shave biopsy is indicated to include all skin layers and subcutaneous tissue, and it may include a punch biopsy, an incisional biopsy, or an excisional biopsy. If a melanoma is diagnosed, a wide local excision is indicated down to the muscle fascia, and the thickness and depth of the melanoma, mitosis per square mm, presence of tumor infiltrating lymphocytes, presence or absence of regression, and other features such as tumor ulceration, tumor satellitosis, and neurotropism may dictate the need for sentinel lymph node staging, node dissection, metastatic screening, and periodic follow-up. Small benign nevi can be excised in their entirety during initial biopsy. Large nevi may be managed with serial excision (Figure 26.8), excision and skin grafting, or tissue expansion of adjacent skin for large or giant congenital nevi (Figure 26.9). The role of lasers for congenital nevi has remained controversial over the past three decades. Lasers that target melanin can destroy melanocytes, but one can never guarantee complete removal of the nevus. Therefore, concerns that melanoma transformation may still occur and the lack of pigment may delay the diagnosis of melanoma that discourages most clinicians from offering laser as an option. However, in cosmetically challenging areas such as the eyelid where surgical options for nevi usually result in poor results, laser may provide a reasonable option where the cosmetic benefit outweighs the very small risk of melanoma transformation.

FIGURE 26.8 A. Nevi that are too large to be excised in a single stage and too small to warrant tissue expansion can be approached by serial excision. B. Fortunately, this nevus allowed the surgical scar to be hidden in the nasolabial crease after a

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series of 3 excisions.

FIGURE 26.9 Giant congenital nevi can either be followed conservatively or excised with the help of tissue expansion. Parents should be advised that multiple cycles of expander insertion/removal and skin advancement may be necessary to serially excise these nevi, obligating the patient and family to endure considerable pain and morbidity. A. Expander placed under normal skin below the nevus. B. Same patient 4 years later after serial expansion and nevus excision.

Neurocutaneous melanosis is a rare condition thought to arise from abnormal development of the neuroectoderm that results in melanotic tissue in both the skin and meninges. It can be associated with large (>20 cm) congenital nevi, or with multiple nevi in association with meningeal melanosis or melanoma. A screening MRI can be done at 4 to 6 months, but the prognosis is poor, even in the absence of meningeal melanoma, as patients may exhibit hydrocephalus, seizures, developmental delay, cranial nerve palsies, and a tethered spinal cord.

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Epidermal Nevi Epidermal nevi have no malignant potential, but they may carry significant psychologic burden as they typically become increasingly verrucous and unsightly over time (Figure 26.10). The skin lesions may resemble warts, and in some cases, there are associated ocular, neurologic, skeletal, and endocrine abnormalities. Cataracts, colobomas, seizures, developmental delay, hemiparesis, scoliosis, growth abnormalities of the extremities, and vitamin D–resistant rickets have been described. When these extracutaneous associated findings are present, the term epidermal nevus syndrome may be applied, but fortunately the vast majority of patients have random occurrence of epidermal nevi with no other symptoms.

FIGURE 26.10 An epidermal nevus is benign, but the texture of the skin often becomes increasingly verrucous and unsightly. Removal by shave excision, dermabrasion, and laser vaporization may provide adequate palliation. Full-thickness excision is curative for small or linear lesions at the expense of a permanent surgical scar.

Treatment includes tangential shave excision (scalpel or iris scissors), dermabrasion, CO2 laser vaporization (Figure 26.11), or surgical excision. Partial-thickness removal appears to be more effective if

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it is performed before the nevus becomes verrucous as the cleavage plane between the epidermis and dermis appears to separate more uniformly. However, despite being in an epidermal plane, some degree of nevus recurrence is common, and repeat treatments may be indicated. In cases where the shape of the nevus lends itself to complete full-thickness excision, permanent removal is possible at the expense of a surgical scar.

FIGURE 26.11 Epidermal nevi can be vaporized with a CO2 laser if a large surface area is involved. Laser may be more precise, less bloody, and less likely to catch regional hairs compared with sharp dissection or dermabrasion. It works best if done while the nevus is relatively flat, as the nevus separates at a nice dermal cleavage plane.

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Sebaceous Nevi (Nevus Sebaceous of Jadassohn) Described in 1885 by German dermatologist Josef Jadassohn, these congenital nevi have a fleshy, tan, and cobblestone appearance and are often located on the scalp and face (Figure 26.12). Unlike congenital melanocytic nevi, they have prominent sebaceous glands, and when located on the scalp they are non– hair bearing. During puberty they commonly become oily and crusty, presenting a cosmetic nuisance. More significantly, they have a 10% to 15% risk of basal cell skin cancer in adulthood. For these reasons, the treatment of choice for scalp sebaceous nevi is surgical excision. Evaluation of the surgical margins can be difficult for pathologists, but wide excision is overly aggressive and unnecessary. When these nevi occur on the face, conservative observation, tangential shave excision, and CO2 laser vaporization may be chosen to avoid an obvious surgical scar, as long as parents understand the risk of basal cell skin cancer will not be removed.

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FIGURE 26.12 A sebaceous nevus has a cobblestone texture that worsens during puberty. There is a 10% to 15% risk of basal cell carcinoma in adulthood. Most parents will opt for removal and accept a surgical scar prior to the patient’s teenage years.

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Cysts Epidermal Cysts Epidermal cysts will forever be inaccurately called sebaceous cysts, owing to the assumption that they are filled with sebum because of a blocked pore. In fact, they are actually lined by epidermis and filled with desquamated epidermal cells and fatty acids, which give them a cheesy texture and odor. Complete excision of the capsule with a small amount of adherent overlying skin is necessary to minimize the risk of recurrence. Some surgeons will intentionally evacuate the contents of a large cyst and allow the capsule to contract, resulting in a smaller scar when the residual cyst is excised at a later date. If they become secondarily infected, they become inflamed and painful, and also contain purulent drainage under pressure. In this setting, incision and drainage is usually palliative rather than curative, and patients return after the inflammation subsides for definitive excision. Unruptured and noninflamed cysts usually shell out easily from the surrounding subcutaneous tissue (Figure 26.13), whereas previously inflamed or recurrent cysts often have dense adhesions to the surrounding fat.

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FIGURE 26.13 An epidermal inclusion cyst is adherent to the overlying dermis and can sometimes be confused with a superficial lipoma. Excision of the entire capsule is necessary to minimize the risk of recurrence.

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Pilomatrixomas (Calcifying Epithelioma of Malherbe) French physician Albert Malherbe described a benign tumor of hair cell origin (pilo = hair) that clinically appears similar to an epidermal cyst, but with a rock-hard texture. They are usually adherent to the overlying skin, and sometimes may be mistaken for a vascular malformation as the overlying skin may contain a bluish hue and small telangiectasias, which resolve after excision. The capsule is thin and fragile, and clusters of calcified granules are easily visualized through it. Complete excision with a small amount of adherent overlying skin is curative (Figure 26.14).

FIGURE 26.14 Pilomatrixoma (calcifying epithelioma of Malherbe). Unlike an epidermal cyst, a pilomatrixoma contains hard

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calcified granules. The overlying skin may have telangiectasias or a bluish pigmentation, mimicking a vascular lesion. The pigmentation resolves once the pilomatrixoma is excised.

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Dermoid Cysts Dermoid cysts can occur anywhere along sites of embryologic fusion, but in the head, they can commonly occur in the periorbital, glabellar, and nasal regions as well as the scalp and temporal region. They contain dermis, epidermis, sebaceous glands, and hair and exhibit slow growth. Intracranial extension can occur with midline nasal, glabellar, and temporal dermoids; therefore, dermoids in these locations are best worked up with MRI or CT scans. Collaboration with neurosurgery may be required for complete cyst removal in these cases. Lateral brow dermoids are best approached through lateral supratarsal fold incisions that leave an imperceptible scar rather than through the eyebrow (Figure 26.15). They are commonly adherent to the periosteum and may even cause bony indentations that resolve after cyst removal.

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FIGURE 26.15 A dermoid cyst in the periorbital area is usually adherent to the underlying periosteum. Lateral brow dermoids are best approached through a lateral upper eyelid incision, which leaves an imperceptible scar.

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Acknowledgments The authors are indebted to the contributions of Albert Yan, MD, Professor of Pediatrics and Dermatology, and Rosalie Elenitsas, MD, Herman Beerman Professor of Dermatology, Perelman School of Medicine at the University of Pennsylvania.

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Questions 1. Sebaceous nevi (nevus sebaceous of Jadassohn) may demonstrate all of the following except: a. Lack of hair growth when located on the scalp b. Crusting and oily discharge during puberty c. 10% to 15% risk of basal cell carcinoma in adulthood d. 10% to 15% risk of squamous cell carcinoma in adulthood e. Difficult margins for the pathologist to interpret 2. Appropriate treatment of congenital melanocytic nevi may include all of the following except: a. Photographic documentation and periodic physical examination b. Punch biopsy or incisional biopsy c. Tangential shave biopsy d. Excisional biopsy e. Serial excision 3. The ABCDEs of suspicious nevi include all of the following except: a. Asymmetry b. Border irregular c. Color variegation d. Diameter >1 cm e. Evolution 1. The following lesions are benign without malignant potential except: a. Spitz nevus b. Pilomatrixoma c. Sebaceous nevus d. Nevus of Ota e. Nevus of Ito 5. Which of the following statement is not true? a. Dermoid cysts are present at birth. b. Dermoid cysts can contain hair in addition to dermis, epidermis, and sebaceous glands. c. Intracranial extension can occur with temporal dermoid cysts. d. Intracranial extension does not occur with lateral brow dermoid cysts. e. Dermoid cysts in the periorbital region may be adherent to the periosteum and cause bony indentations. 1. Answer: d. Parents will usually elect surgical excision when sebaceous nevi are located in their child’s scalp because they are typically non–hair bearing and will develop oily crusts because of hormonal stimulation of the sebaceous glands during puberty, and because of the malignant potential (basal cell, not squamous cell carcinoma). Pathologists note that complete excision can be difficult to confirm because the margins can be challenging to interpret since normal skin contains sebaceous glands. 2. Answer: c. Photodocumentation of a congenital nevus allows the clinician to determine whether it is changing, and an evolving nevus warrants a biopsy. This is particularly useful when patients have many dysplastic nevi and excision of all of them is impossible or impractical. Periodic follow-up every 6 to 12 months with good-quality photographs is an appropriate way to monitor patients. A full-thickness biopsy is appropriate because it will allow one to determine tumor thickness and the level of invasion in the event of a melanoma. A shave biopsy can establish the diagnosis of melanoma, but it may make it impossible to ever know the true tumor thickness of a melanoma, and

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therefore removes the most import prognostic indicator (Breslow tumor thickness in millimeters). A punch or incisional biopsy of the thickest part of the nevus should include subcutaneous fat. An excisional biopsy or a serially excised nevus should also include superficial subcutaneous tissue. 3. Answer: d. Nevus size that should raise concern and prompt closer evaluation is >6 mm or about the size of a pencil eraser. Size, however, is probably the least important feature. The most important feature to note by history or repeated examination is changes in the appearance or evolution of the nevus over time. Other concerning symptoms may include crusting, bleeding, and itching. 4. Answer: c. Sebaceous nevi have a 10% to 15% risk of basal cell skin cancer in adulthood. Spitz nevi resemble melanoma histologically; however, their potential for malignant transformation is no greater than other small melanocytic nevi. Pilomatrixomas are benign tumors of hair cell origin that are adherent to the overlying skin and have a rock-hard texture due to the presence of calcified granules. Nevus of Ota is a dermal melanocytic nevus located on the face (V1 and V2 distribution). Nevus of Ito is characterized by dermal melanocytosis and location on the shoulder, upper chest, and back. 5. Answer: d. Dermoid cysts develop during pregnancy and can occur anywhere along sites of embryologic fusion. They contain dermis, epidermis, sebaceous glands, and hair and exhibit slow growth. Intracranial extension can occur with midline nasal, glabellar, and temporal dermoids; therefore, dermoids in these locations are best worked up with MRI or CT scans. Lateral brow dermoids are commonly adherent to the periosteum and may even cause bony indentations that resolve after cyst removal.

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BIBLIOGRAPHY Arad, E, Zuker, RM. The shifting paradigm in the management of giant congenital melanocytic nevi: review and clinical applications. Plast Reconstr Surg. 2014;133(2):367-376.An updated review is presented of controversial topics in the management of congenital melanocytic nevi, and clinical applications are demonstrated through clinical cases. Chung, C, Forte, AJ, Narayan, D, Persing, J. Giant nevi: a review. J Craniofac Surg. 2006;17(6):1210-1215.A comprehensive review article describing the incidence, histology, and management of giant melanocytic nevus. Ferguson, RE Jr, Vasconez, HC. Laser treatment of congenital nevi. J Craniofac Surg. 2005;16(5):908-914.Review of laser terminology is presented along with a review of nevus of Ota, nevus of Ito, and congenital melanocytic nevi. Gosain, AK, Santoro, TD, Larson, DL, Gingrass, RP. Giant congenital nevi: a 20-year experience and an algorithm for their management. Plast Reconstr Surg. 2001;108(3):622-636.A retrospective review of 61 patients with giant congenital nevi is presented including the surgical treatments used. An algorithm for management is presented by the authors based on their experience over time. Schaffer, JV. Update on melanocytic nevi in children. Clin Dermatol. 2015;33(3):368-386.This review article summarizes the natural history and clinical spectrum of nevi in pediatric patients, and provides an update in their dynamic evolution over time, molecular insights into nevogenesis, and phenotypic markers for increased risk of melanoma. Schaffer, JV, Bolognia, JL. The clinical spectrum of pigmented lesions. Clin Plast Surg. 2000:27(3):391-408.Review article presenting the clinical features of a spectrum of pigmented lesions, including congenital, Spitz, and blue nevi, as well as each subtype of cutaneous melanoma.

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CHAPTER 27

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Vascular Anomalies Kavitha Ranganathan and Steven J. Kasten

Key Points Vascular malformations fall into two broad categories: neoplastic and nonneoplastic. Vascular malformations are present at birth and grow concurrently with the patient, whereas hemangiomas present postnatally and commonly involute by adolescence. First-line pharmacologic treatments for hemangiomas include beta blockers, systemic steroids, and intralesional steroids. Vascular malformations are characterized based on whether they are slow or fast flow; lesions with an arterial component are fast flow, whereas all other lesions including venous, capillary, and lymphatic malformations are slow flow. Treatment for malformations is by multiple modalities depending on classification and anatomic location. Sclerotherapy is one potential intervention for venous and lymphatic malformations. Asymptomatic vascular malformations can be observed, but it is important to rule out other comorbid conditions and syndromes first. It is critical to remember that vascular anomalies can present as part of a syndrome; recognizing the associated symptoms and pathology is of utmost importance.

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Historical Perspective In the 1800s, Virchow developed one of the first methods of characterizing vascular anomalies. 1,2 Subsequently, in 1996, the International Society for the Study of Vascular Anomalies (ISSVA) stratified these vascular anomalies into two main types: vascular malformations and vascular tumors. This work was heavily influenced by the work of Mulliken and Glowacki, whose initial research defined these types of lesions according to vessel composition, namely by whether the vessel is a capillary, venous, lymphatic, arterial, or combined malformation. 3 These guidelines were subsequently updated in 2014 and represent the most recent consensus on the definitions and clinical manifestations of vascular malformations and tumors. Accurate diagnosis of vascular anomalies and tumors relies on obtaining a thorough history and physical examination, with timing of onset of the condition being one of the most critical considerations. Imaging is useful when determining the extent of the lesion as well as the amount of flow, particularly for vascular malformations. Slow-flow lesions include capillary, venous, and lymphatic malformations, whereas fastflow lesions include any malformation with an arterial component. Historically, one of the most difficult aspects of caring for patients with such congenital anomalies has been the use of inconsistent terminology. 3 As the treatment and time course are quite different between vascular malformations and tumors, these variations in terminologies have affected progress within the field and have led to inconsistencies in treatment. The goal of the current chapter is to educate the reader on how to properly diagnose and differentiate vascular malformations from vascular tumors including hemangiomas, and manage these lesions based on the initial presentation of the patient as well as over time.

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Vascular Tumors Infantile Hemangiomas Epidemiology and Clinical Course Hemangiomas are the most common tumor of infancy and occur at a rate of 11 in 10 infants. These lesions are not present at birth and are commonly visualized at approximately 2 weeks after birth. These tumors are more common in females (3:1) and Caucasians (1 in 10) with the most common location occurring in the head and neck region. 4,5 Diagnosis is largely clinical, when the diagnosis is in question based on history and physical examination. Hemangiomas are distinguished from vascular malformations by the timing of onset occurring after birth; conversely, vascular malformations are always present at birth. These benign vascular proliferations of endothelial cells go through three main phases during development: proliferation (0 to 12 months), involution (12 months to 10 years), and finally, regression (after 10 years). 4,5 Consideration for early intervention is critical for patients presenting with functional deficits associated with the presence of the anomaly. For example, early surgical or medical resection should be considered among patients presenting with hemangiomas that result in amblyopia, distortion of critical anatomic structures, ulceration and bleeding complications, or airway compromise. As infantile hemangiomas can present as part of a defined syndrome, patients may need to be evaluated for additional anomalies based on their clinical presentation (Table 27.1). Infantile hemangiomas are positive for glucose transporter 1 (GLUT-1) on biopsy of the lesion as well as within the urine. TABLE 27.1 Syndromes/Anomalies Associated With Hemangiomas Syndrome Kasabach-Merritt syndrome PHACES Maffucci syndrome Von Hippel-Lindau disease

Characteristic Features Thrombocytopenia (35 years of age did not show any significant difference in relapse rates for advancements 10 mm. One of the other controversial topics in this discussion is the natural growth of the affected mandible, maxilla, and soft tissues. Although it is clear that the affected tissues do not catch up in growth when compared with the contralateral side, it is less clear whether it is the relative or absolute size discrepancy of the affected side that worsens over time. The mandible that has been distracted or reconstructed with a graft can exhibit growth, albeit at a slower rate than the contralateral side, thus sometimes necessitating a

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revision surgery at maturity if the initial correction was done at a young age. The overall timeline is as follows: Infancy (up to 2 years of age) Correction of macrostomia, clefts, and minor auricular anomalies (pits, accessory appendages) should be performed early on to improve function and make a dramatic improvement in appearance. Distraction of the affected mandible is considered at this early stage for patients with airway compromise. Early childhood (to 6 years of age) Type I: If the deformity is mild, treatment is delayed until skeletal maturity. Type IIa/IIb: If the aesthetic deformity is severe or airway problems exist, which were not addressed in infancy, distraction osteogenesis is considered for type IIa and type IIb mandibles with adequate bone stock. Type III: The ramus, zygomatic arch, and the temporomandibular articulation is reconstructed using costochondral grafts at approximately 4 years of age or older, with secondary distraction if needed to expand the construct once healed. Late childhood/adolescence (6–16 years of age) Orthodontic treatment is applied during this period. If the mandible has already been corrected, orthodontia can help bring the maxilla into occlusion. The goal is to correct the maxilla enough to avoid a Le Fort I osteotomy in the future. Adolescence and later (after age 16) If the mandible has already been operated on: Once the patient is deemed to be at skeletal maturity, the occlusion and results of orthodontic treatment are assessed. There is a high likelihood that secondary surgery will be needed to correct the maxilla, to revise the mandible to account for the unaffected side’s growth, or to perform an asymmetric genioplasty to restore the chin to the midline. If the patient has not yet had mandibular surgery (typically type I mandibles or if the decision was made to delay treatment): The surgical plan must be customized to each patient, but will usually include: Sagittal split osteotomy with or without bone graft to address the mandibular vertical deficiency. Le Fort I osteotomy, often with impaction on the affected side, to level the occlusal plane. Asymmetric osseous genioplasty, to correct the facial asymmetry. Advanced soft-tissue correction can also be undertaken at this time. Severe soft-tissue deficit is best addressed by choosing distraction for the mandible: as the bone is expanded, so is the overlying soft-tissue envelope. For residual defects, an adipofascial free flap or serial fat injection may be used to correct volume deficiency, depending on the defect size. Adipofascial free flaps have been associated with ptosis and less predictable volume over time with patient weight loss or gain. There is currently an increasing trend for serial fat injection to treat facial soft-tissue deficit because this is less likely to undergo ptosis and patients can be regrafted with much less morbidity.

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Craniofacial Distraction The problem of deficient bone stock has long been present in both the pediatric population (e.g., hypoplastic mandible in children with CFM or Pierre Robin sequence) and in adults (e.g., bone loss due to trauma or need of orthognathic surgery with large [>1 cm] advancements). Solutions such as vascularized bone transfer are often impractical and carry a large donor site burden, and an avascular graft carries the risks of infection, nonunion, and resorption. Distraction osteogenesis solves this problem by expanding the existing bone stock along the vector specified by the surgeon, essentially replicating for bone what tissue expansion has done for the skin. Although it was described earlier, Ilizarov is credited with proving the concept and establishing its efficacy in long bones. 34 McCarthy and colleagues later applied these principles to craniofacial scenarios, supporting the clinical efficacy of this technique. 35 The basic principle of distraction osteogenesis consists of an osteotomy across the bone to be distracted and then carefully controlled separation of the two segments at a rate that promotes bony regeneration to close the gap. Although details may differ based on surgeon preference and patient age, the basic timeline is as follows: Osteotomy and hardware placement The bone to be distracted is divided into segments with an osteotomy or corticotomy, creating the distraction zone. The surgeon must ensure that the segments are mobile so that distraction can take place—an incomplete osteotomy/corticotomy will skew the vector of distraction or cause hardware failure. The distractor hardware is placed across the distraction zone aligned with the desired vector of movement to promote new bone deposition. No distraction takes place at this time, and the bony segments remain in opposition. Latency period Approximately 1 week (5–7 days) is allowed for healing and initial callus formation in the distraction zone prior to initiation of distraction. Activation period The distraction hardware is used to separate the bony segments at some predetermined rate (usually 0.5 mm twice per day). Faster rates are commonly seen in infants because of their ability to quickly deposit bone regenerate—the guiding principle here is to set such a rate that separation of the bony segments will not outpace the deposition of new callus, yet will also not be so slow so that ossification leading to bony union causes premature end of distraction. The device is periodically checked for alignment and solid fixation to ensure the desired vector of distraction is maintained. Consolidation period Once the desired amount of travel is achieved, distraction is stopped and the callus formed in the distraction space ossifies. This period is usually 8 weeks in length, after which time the new bony construct should be stable and hardware can be removed. However, in infants, the consolidation period is often shortened to 6 weeks because of rapid bone consolidation. McCarthy and colleagues examined the histology of the bony generate 36 in the distraction zone, with later studies providing further detail (Figure 30.8). 37 The healing response is initiated similar to any other fracture with hematoma formation and inflammatory cell influx during the latency period, producing the initial callus. Infiltration of fibroblast-like cells and neovascularization are noted after beginning of activation. Osteogenesis is noted at 2 weeks after activation is started with osteoid deposition and mineralization, and osteoblasts seen another week later. The basic histologic structure shown in Figure

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30.8 reflects the findings of McCarthy et al., although later studies revealed a more stratified organization to the generate. The key findings agree in that bony trabeculae start forming along the axis of distraction with concomitant neovascularization and then continue this process after distraction is stopped until mature lamellar bone is produced. In an in vitro model, Slack et al. 38 found that skipping the latency period and starting distraction immediately appears to lead to marked delays in cell proliferation, alkaline phosphatase activity, osteogenic gene expression, and higher apoptosis at the osteotomy site; however, the bone volume and quality at the clinical endpoints were unaffected. Of note is that latency periods are often shortened to 1 day or completely eliminated in infants. Future studies are required to further investigate the importance, duration, and age-dependence of the latency period.

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FIGURE 30.8 Diagram of the bony generate in the setting of distraction. 36 Central zone is area of mesenchymal proliferation and collagen deposition. Transition zone has osteoid formation on the scaffold of collagen bundles. Remodeling zone is area of osteoclast activity and new bone remodeling, leading up to mature bone zone.

The cellular-level processes underlying osteogenesis in this scenario are understandably complex, but one of the key factors is TGF-B1 (transforming growth factor B1), which peaks during the activation period, ostensibly inducing deposition of collagen and extracellular matrix necessary for further ossification. 39 TGF-B1 subsequently induced VEGF and FGF, which in turn are key to neovascularization of the bony generate and fibroblast activity necessary for the process. 40 Bone morphogenic protein, insulin-like growth factor, and osteonectin/osteopontin also appear to play key roles. 37

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Hardware A major decision for each distraction case is whether to use internal or external hardware. Applications in the mandible can use either type with no significant difference in efficacy, whereas others, such as posterior vault distraction, appear to be better suited for buried (internal) hardware. In general, the external distractors act similarly to an external fixator with a mechanism for applying a distracting force between two sets of pins. Each center has its own preference for internal versus external hardware for mandibular distraction. There are some data that buried devices lead to higher satisfaction with quality of life and the decision to undergo the procedure in the face of equivalent functional and aesthetic outcomes. 41 However, internal distraction devices have the disadvantage of requiring a second surgical procedure for device removal. This is a significant consideration given that injury to the marginal mandibular nerve with long-term weakness of depressor function of the oral commissure has been reported in 15% of cases following internal mandibular distraction in patients with Pierre Robin sequence. 42 One must consider the increased risk of nerve injury following internal distractor placement, given the need for reentry into the incision for distractor removal when the nerve may be obscured by scar following the initial procedure. In summary, the guiding principle for hardware choice is to ensure that fixation will be secure, and the desired vector of distraction will be maintained, with remaining factors determined by surgeon preference and experience. Table 30.3 shows the general pros and cons of each design. TABLE 30.3 KEY DIFFERENCES BETWEEN INTERNAL AND EXTERNAL DISTRACTION HARDWARE

Profile Incisions Monitoring

Adjustments

Internal Lower profile, only the activator arm needs to be externalized Requires a larger incision for the bulky hardware and wide exposure of the bony for footplate fixation Difficult to assess distraction and hardware position/security because only the activator arm is visible No adjustments can be made once the hardware is in place

External Bulkier profile, multiple pin sites require more hygienic care Smaller stab incisions for pins may reduce external incision burden if other approach (intraoral) can be used to complete osteotomy Position and movement of hardware is easily examined; however, correlation with bone movement is speculative Vector can be manipulated and multivector distraction can be carried out

With the establishment of distraction osteogenesis as a clinically effective and safe technique, its indications have widened. Large early analyses reported pooled complication rates approximating 1 in 3 patients, with markedly lower rates reported by surgeons experienced in the technique. 43 As the specialty’s collective experience has grown, so has the safety profile, as shown below for the specific applications. Figure 30.6 shows the application of internal distraction hardware for mandible distraction. In the same setting of mandibular distraction, it is easy to appreciate the differences when compared with external distraction, as shown in Figure 30.9.

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FIGURE 30.9 Mandible distraction using external hardware. An oblique vector addressing the mandibular body is shown in (A) and a vertical vector addressing a ramus height deficiency is shown in (B).

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Mandibular Distraction The mandible was the first bone where craniofacial distraction was successfully implemented—it is accessible, the progress of distraction is easy to assess, and it addresses a significant clinical need. Mandibular distraction has enabled craniofacial surgeons to address mandibular hypoplasia at a younger age with less morbidity than traditional methods. It has shown to be effective in infants with Pierre Robin sequence, Treacher Collins syndrome, and CFM. Patients with these conditions suffering from airway compromise often find significant improvement after distraction and can be successfully decannulated. One of the key decisions in mandibular distraction is the choice of vector. This hinges on the morphology of the patient’s mandible: adequate bony stock in the body with a deficient or absent ramus dictates a vertical vector (perpendicular to the occlusal plane), whereas the converse (short body but adequate ramus) dictates a horizontal vector. If both the body and ramus are deficient, an oblique vector can be chosen. It is important to account for autorotation when distracting with a vertical or oblique vector, as the extraposterior height will result in anterior movement of the body and increase chin projection. In unilateral cases, there will also be some correction of the chin point deviation. When performing this in infants or children who have not yet reached skeletal maturity, the goal should be to achieve overcorrection as the distracted mandible exhibits slower growth than age-matched controls. 44 One must also determine whether unilateral or bilateral mandibular distraction is indicated based on the relative asymmetry of mandibular position relative to the maxilla.

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Monobloc and Le Fort III Distraction Despite over two decades of experience with monobloc and Le Fort III distraction, 45 in a review of Monobloc and Le Fort III advancement, it appears there are mixed data regarding the complication profiles for distraction versus traditional advancement. Monobloc advancements incurred higher complication rates with distraction, and the opposite was seen in Le Fort III advancements, indicating that further refinement of these techniques is needed. 46 Nevertheless, for younger children in need of significant midface advancement, distraction has been 47 and continues to be the preferred method of midfacial advancement. Both rigid external devices and buried distraction hardware have been successfully used in this setting.

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Cranial Vault Distraction Distraction of the cranial vault, and the posterior vault specifically, is a relatively new application of distraction osteogenesis. The intracranial volume gained by posterior vault distraction is markedly higher when compared with fronto-orbital advancement, 48 and compared with traditional methods of posterior vault cranioplasty, the complication rate appears to be comparable. 49 Notably, great care must be paid to avoid inadvertently injuring the dura with the screws, as the multiple footplates will likely span areas of variable bone thickness (Figure 30.10). Although the argument exists for distraction to obtain the maximal possible gain in intracranial volumes, there are not yet enough data to show clear superiority of distraction to traditional cranioplasty for posterior vault expansion. 33

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FIGURE 30.10 This patient demonstrates the application of posterior cranial vault distraction for correction of brachycephaly because of bilateral coronal synostosis. Note that internal hardware was used, as is the norm for these cases, with three distractors placed to stabilize the distracted segment against rotation. A, B. Pre-operative clinical and radiographic appearance prior to distractor placement. C. Patient appearance at 10 days of distraction at 1 mm per day. D. Radiographic results of distraction after 40 mm of distraction. E. Patient appearance at 6 months follow up after distractor hardware removal.

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Complications of Distraction Osteogenesis The complex nature of the deformity and surgical course is associated with complications at any point. Complications more specific to distraction include hardware problems, soft-tissue ulceration and breakdown, incorrect distraction vectors, and postdistraction sequelae. The practice of distraction osteogenesis is heterogeneous because of the varied indications, patient scenarios, hardware types, and surgeon experience. Accordingly, although there is evidence that surgeon experience is associated with lower complication rates, complication rates vary widely. Infectious complications include infection of the hardware, but the more common finding is localized cellulitis at the pin or activator arm sites, which may be due to poor hygiene. This can often be treated medically and with improved pin site care. With internal hardware, breakage can occur, leading to premature distraction termination or repeat surgery for distractor replacement. With external hardware, distractors can be replaced without requiring repeat surgical procedures. Inappropriate distraction vectors will lead to poor occlusal outcomes and asymmetry. Cranial distraction has its own unique complications with dural injury or CSF leaks. Some of the complications of distractions are less avoidable, such as decreased growth of the distracted bones or loss of dentition at the site of the osteotomy in cases of mandible distraction. These, as well as some mild relapse in the year after distraction is complete, appear to be sequelae of the techniques themselves.

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Questions 1. A new patient shown in the photograph is referred to your clinic by the pediatrician for facial asymmetry. You tentatively diagnose the patient with CFM and assign which of the following grades? a. 1 b. 2a c. 2b d. 3 e. 4 f. None of the above 2. During the initial evaluation of a new patient suspected of having CFM, which of the following testing or imaging modalities are recommended? I. Echocardiogram II. Renal ultrasound III. Cervical spine X-rays IV. Skeletal survey a. I only b. I and II c. I, II, and III d. All four are recommended 3. Which of these answers correctly associates a category of mandible hypoplasia seen in the setting of a patient with CFM, with the correct treatment strategy? a. Type III, treat at 2 years of age with a costochondral graft to definitively reconstruct the TMJ b. Type I, treat at 5 to 7 years of age with unilateral sagittal split osteotomy to improve facial symmetry and contour c. Type IIb, treat at 5 to 7 years of age with distraction osteogenesis to create a pseudo-TMJ d. Type III, treat at 2 to 3 years of age with a costochondral graft to reconstruct TMJ and free softtissue transfer to improve facial contour 4. Which of the following is true regarding distraction osteogenesis? a. Exposure of the bone that is to be distracted is similar for both internal and external hardware placement, despite different external incision patterns. b. A latency period is necessary to prevent overly fast distraction. c. Distraction of a hypoplastic mandibular ramus should not affect chin projection or asymmetry; an asymmetric genioplasty is always necessary to correct these. d. The optimal rate of distraction is 0.25 mm twice per day or slower in adults. e. Distraction osteogenesis has proven efficacy in both long bones of the extremities as well as the flat bones of the skull. 5. Which of the following is true regarding the treatment of CFM? a. Distraction of the hypoplastic mandible in early childhood mandates maxillary surgery at maturity. b. Distraction of the hypoplastic mandible in early childhood resolves any appearance concerns until secondary correction is necessary. c. Correctly executed distraction of the hypoplastic mandible will obviate any need for osseous genioplasty at maturity. d. Aside from difference in size, the anatomy of the hypoplastic mandible in CFM is otherwise

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the same. e. When a costochondral graft is used for ramus reconstruction, a TMJ prosthesis is not necessary to obtain a functional outcome. 1. Answer: f. The morphology and functional status of the TMJ are key to grading and treatment planning in a patient with CFM. Without clear information regarding the status of the TMJ, no definitive grade can be assigned. 2. Answer: c. Cardiac, renal, and cervical spine evaluation is recommended for all CFM patients because of the high prevalence of associated anomalies in these systems. There is no evidence that shows any benefit to evaluating the rest of the skeleton aside from the cervical spine. 3. Answer: c. Although there are multiple points of view regarding the specific timing of surgical intervention for craniofacial macrosomia, certain guidelines are agreed upon. For type III mandibular hypoplasia, treatment should be considered at 4 years of age and they will likely need revision procedures after they reach skeletal maturity. Type I mandible hypoplasia is better addressed with distraction to produce a lower relapse rate and may also require revision in adulthood. Type IIb may be treated with either distraction and creating of a pseudo-TMJ or a costochondral graft to create a neo-TMJ. However, type III hypoplasia is not amenable to treatments solely with distraction and requires bone graft to fabricate an acceptable neomandible and TMJ. Moreover, free soft-tissue transfer for facial contour would likely be more appropriately performed in a delayed fashion, 6 to 8 months after the bony skeleton reconstruction is in place. 4. Answer: e. Internal and external hardware requires the same osteotomy, but internal hardware requires much greater periosteal stripping and bony dissection to gain access for securing the hardware footplates. A latency period is often skipped in very young patients and has been shown to not significantly alter the final bony generate. Distraction of a mandibular ramus will lead to autorotation of the mandible on that side, moving the chin toward the contralateral side and increasing its projection. The most widely used rate of distraction is 0.5 mm twice per day in adults, with higher rates possible in infants. Distraction osteogenesis has been shown to be an effective technique in both the extremities (as originally described by Ilizarov) as well as in the bones of the craniofacial skeleton. 1. Answer: e. Distraction of the hypoplastic mandible in early childhood, coupled with orthodontia, may often obviate the need for maxillary surgery maturity. Hypothetically, this is due to allowing the maxilla to resume its normal downward growth on the affected side once the obstruction presented by the mandible is addressed. Although addressing the mandible in early childhood improved patients’ appearance as they grow, there is no guarantee the correction will be complete. Moreover, other associated anomalies (macrostomia, microtia) may continue to cause psychosocial distress until they are addressed as well. If the size of the affected hemimandible is corrected, the shape will likely still be asymmetric, with some deviation of the chin, and thus an osseous genioplasty is often needed at maturity to obtain the best possible result. The anatomy of the hypoplastic mandible in CFM is different both in terms of altered shape, hypoplasia or lack of condylar or coronoid processes, as well as displacement of the inferior alveolar foramen superiorly and the canal buccally.

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References Grabb, WC. The first and second branchial arch syndrome. Plast Reconstr Surg. 1965;36(5):485. Poswillo, D. The aetiology and pathogenesis of craniofacial deformity. Development. 1988;103(suppl):207. Cohen, MM, Rollnick, BR, Kaye, CI. Oculoauriculovertebral spectrum: an updated critique. Cleft Palate J. 1989;26(4):276. Poswillo, D. The pathogenesis of the first and second branchial arch syndrome. Oral Surg Oral Med Oral Pathol. 1973;35(3):302. Sadler, TW, Rasmussen, SA. Examining the evidence for vascular pathogenesis of selected birth defects. Am J Med Genet A. 2010;152A(10):2426-2436. Johnston, MC, Bronsky, PT. Prenatal craniofacial development: new insights on normal and abnormal mechanisms. Crit Rev Oral Biol Med. 1995;6(4):368-422. Luquetti, DV, Heike, CL, Hing, AV, et al. Microtia: epidemiology and genetics. Am J Med Genet A. 2012;158A(1):124-139. Rollnick, BR, Kaye, CI. Hemifacial microsomia and variants: pedigree data. Am J Med Genet. 1983;15(2):233-253. Heike, C, Luquetti, D, Hing, A. Craniofacial microsomia overview. In: Adam, MP , Ardinger, HH , Pagon, RA , et al, eds. GeneReviews® [Internet]. Seattle, WA: University of Washington. March 19, 2009; Updated October 9, 2014. Kaye, CI, Martin, AO, Rollnick, BR, et al. Oculoauriculovertebral anomaly: segregation analysis. Am J Med Genet. 1992;43(6):913-917. Rollnick, BR, Kaye, CI, Nagatoshi, K, et al. Oculoauriculovertebral dysplasia and variants: phenotypic characteristics of 294 patients. Am J Med Genet. 1987;26(2):361. Converse, JM, Wood-Smith, D, McCarthy, JG, et al. Bilateral facial microsomia. Diagnosis, classification, treatment. Plast Reconstr Surg. 1974;54(4):413. Vento, AR, Labrie, RA, Mulliken, JB. The O.M.E.N.S. classification of hemifacial microsomia. Cleft Palate Craniofac J. 1991;28(1):68. Tuin, AJ, Tahiri, Y, Paine, KM, et al. Clarifying the relationships among the different features of the OMENS+ classification in craniofacial microsomia. Plast Reconstr Surg. 2015;135(1):149e.This article delineated the development and criteria for the most widely used classification system at this time. Caron, CJJM, Pluijmers, BI, Wolvius, EB, et al. Craniofacial and extracraniofacial anomalies in craniofacial microsomia: a multicenter study of 755 patients. J Craniomaxillofac Surg. 2017;45(8):1302. Chen, X, Zin, AM, Lin, L, et al. Three-dimensional analysis of cranial base morphology in patients with hemifacial microsomia. J Craniomaxillofac Surg. 2018;46(2):362. Schaal, SC, Ruff, C, Pluijmers, BI, et al. Characterizing the skull base in craniofacial microsomia using principal component analysis. Int J Oral Maxillofac Surg. 2017;46(12):1656. Renkema, RW, Caron, CJJM, Wolvius, EB, et al. Central nervous system anomalies in craniofacial microsomia: a systematic review. Int J Oral Maxillofac Surg. 2018;47(1):27. Marsh, JL, Baca, D, Vannier, MW. Facial musculoskeletal asymmetry in hemifacial microsomia. Cleft Palate J. 1989;26(4):292. Suzuki, N, Miyazaki, A, Igarashi, T, et al. Relationship between mandibular ramus height and masticatory muscle function in patients with unilateral hemifacial microsomia. Cleft Palate Craniofac J. 2017;54(1):43. Zim, DS, Lee, DJ, Rubinstein, DB, Senders, DC. Prevalence of renal and cervical vertebral anomalies in patients with isolated microtia and/or aural atresia. Cleft Palate Craniofac J. 2017;54(6):664-667. Keogh, IJ, Troulis, MJ, Monroy, AA, et al. Isolated microtia as a marker for unsuspected hemifacial microsomia. Arch Otolaryngol Head Neck Surg. 2007;133(10):997-1001. Rahbar, R, Robson, CD, Mulliken, JB, et al. Craniofacial, temporal bone, and audiologic abnormalities in the spectrum of hemifacial microsomia. Arch Otolaryngol Head Neck Surg. 2001;127(3):265. Horgan, JE, Padwa, BL, Labrie, RA, Mulliken, JB. OMENS-Plus: analysis of craniofacial and extracraniofacial anomalies in hemifacial microsomia. Cleft Palate Craniofac J. 1995;32(5):405.Horgan et al. studied the relationships between varied manifestations of CFM that may be treated by the craniofacial surgeon and the multiple other developmental anomalies that may be found in these patients. Meurman, Y. Congenital microtia and meatal atresia; observations and aspects of treatment. AMA Arch Otolaryngol. 1957;66(4):443-463. Pruzansky, S. Not all dwarfed mandibles are alike. Birth Defects. 1969;4:120. Kaban, LB, Moses, MH, Mulliken, JB. Surgical correction of hemifacial microsomia in the growing child. Plast Reconstr Surg. 1988;82(1):9.Landmark article modifying the original Pruzansky classification to produce what is currently used to stratify hypoplastic mandibles. Birgfeld, CB, Luquetti, DV, Gougoutas, AJ, et al. A phenotypic assessment tool for craniofacial microsomia. Plast Reconstr Surg. 2011;127(1):313. Patel, PK, Novia, MV. The surgical tools: the LeFort I, bilateral sagittal split osteotomy of the mandible, and the osseous genioplasty. Clin Plast Surg. 2007;34(3):447.This excellent publication lays out the fundamentals of the surgical techniques that are the foundation of correcting the findings in CFM. Tiwari, P, Chin, DHL, Cutting, CB, et al. The course of the inferior alveolar nerve in craniofacial microsomia: virtual dissection using threedimensional computed tomography image analysis. Plast Reconstr Surg. 2002;109(5):1513. Luquetti, DV, Brajcich, MR, Stock, NM, et al. Healthcare and psychosocial experiences of individuals with craniofacial microsomia: patient and caregivers perspectives. Int J Pediatr Otorhinolaryngol. 2018;107:164. Dufton, LM, Speltz, ML, Kelly, JP, et al. Psychosocial outcomes in children with hemifacial microsomia. J Pediatr Psychol. 2011;36(7):794.

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Fearon, JA. Discussion: an algorithm for managing syndromic craniosynostosis using posterior vault distraction osteogenesis. Plast Reconstr Surg. 2016;137(5):842e. Ilizarov, GA. The tension-stress effect on the genesis and growth of tissues. Part I. The influence of stability of fixation and soft-tissue preservation. Clin Orthop Relat Res. 1989(238):249. Karp, NS, Thorne, CH, McCarthy, JG, Sissons, HA. Bone lengthening in the craniofacial skeleton. Ann Plast Surg. 1990;24(3):231.This is one of multiple publications from this very productive group describing their development of the tools and techniques of craniofacial distraction. Karp, NS, McCarthy, JG, Schreiber, JS, et al. Membranous bone lengthening: a serial histological study. Ann Plast Surg. 1992;29(1):2. Rachmiel, A, Rozen, N, Peled, M, Lewinson, D. Characterization of midface maxillary membranous bone formation during distraction osteogenesis. Plast Reconstr Surg. 2002;109(5):1611-1620. Slack, GC, Fan, KL, Tabit, C, et al. Necessity of latency period in craniofacial distraction: investigations with in vitro microdistractor and clinical outcomes. J Plast Reconstr Aesthet Surg. 2015;68(9):1206. Mehrara, B, Rowe, N, Steinbrech, D, et al. Rat mandibular distraction osteogenesis: II. Molecular analysis of transforming growth factor beta1 and osteocalcin gene expression. Plast Reconstr Surg. 1999;103(2):536. Davidson, EH, Sultan, SM, Butala, P, et al. Augmenting neovascularization accelerates distraction osteogenesis. Plast Reconstr Surg. 2011;128(2):406. Hindin, DI, Muetterties, CE, Lee, JC, et al. Internal distraction resulted in improved patient-reported outcomes for midface hypoplasia. J Craniofac Surg. 2018;29(1):139. Steinberg, JP, Brady, CM, Waters, BR, et al. Mid-term dental and nerve-related complications of infant distraction for robin sequence. Plast Reconstr Surg. 2016;138(1):82e-90e. Mofid, MM, Manson, PN, Robertson, BC, et al. Craniofacial distraction osteogenesis: a review of 3278 cases. Plast Reconstr Surg. 2001;108(5):1103. Peacock, ZS, Salcines, A, Troulis, MJ, Kaban, LB. Long-term effects of distraction osteogenesis of the mandible. J Oral Maxillofac Surg. 2018;76(7):1512-1523. Polley, JW, Figueroa, AA, Charbel, FT, et al. Monobloc craniomaxillofacial distraction osteogenesis in a newborn with severe craniofacial synostosis: a preliminary report. J Craniofac Surg. 1995;6(5):421.The authors describe their novel application of distraction principles to the complex monobloc advancement scenario and demonstrate the feasibility of the distraction techniques in these settings. Knackstedt, R, Bassiri Gharb, B, Papay, F, Rampazzo, A. Comparison of complication rate between LeFort III and monobloc advancement with or without distraction osteogenesis. J Craniofac Surg. 2018;29(1):144. Fearon, JA. The Le Fort III osteotomy: to distract or not to distract? Plast Reconstr Surg. 2001;107(5):1091. Derderian, CA, Wink, JD, McGrath, JL, et al. Volumetric changes in cranial vault expansion: comparison of fronto-orbital advancement and posterior cranial vault distraction osteogenesis. Plast Reconstr Surg. 2015;135(6):1665.This important study showed that posterior cranial vault distraction resulted 
 in greater intracranial volume gain compared with front-orbital advancement, supporting the growing use of distraction techniques for cranial vault 
 remodeling. Taylor, JA, Derderian, CA, Bartlett, SP, et al. Perioperative morbidity in posterior cranial vault expansion: distraction osteogenesis versus conventional osteotomy. Plast Reconstr Surg. 2012;129(4):674e.

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CHAPTER 31

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Orthognathic Surgery Reza Jarrahy and Thomas D. Willson

Key Points Orthognathic surgery repositions the maxilla, mandible, or both to correct improper occlusal relationships and improve facial aesthetics. Patients with clefts and syndromic dentofacial deformities frequently require orthognathic surgery. Members of the general population without clefts or congenital facial syndromes, however, may also require orthognathic correction. Virtual surgical planning (VSP) has largely supplanted traditional dental impression/cast stone model surgery in developing and executing a treatment plan for orthognathic surgery. Close collaboration between the orthodontist and surgeon remains critical to successful outcomes. Skeletal movements significantly impact the position of overlying soft tissues and the overall appearance of the patient. Movements that expand the face can smooth rhytids and provide support to otherwise ptotic tissues, resulting in a rejuvenated appearance. In contrast, contraction of the facial skeleton may decrease soft tissue support and contribute to undesirable aesthetic results. Following the completion of skeletal movements and rigid fixation of the mobilized jaw segments, the surgeon must meticulously confirm the final occlusion to ensure it specifically corresponds to the preoperative plan. Minor misalignments can usually be corrected with postsurgical orthodontics, but lack of attention to detail can result in persistent malocclusion that may require secondary surgical correction. Orthognathic surgery is a discipline that focuses on surgical manipulation of the maxilla and mandible to optimize the occlusal relationship between the upper and lower jaws. The primary goal of most orthognathic procedures is to restore function. Malocclusion can result in a variety of functional deficits of varying severity. These include the development of dental pathology, temporomandibular joint (TMJ) dysfunction, speech abnormalities, airway obstruction, and problems with deglutition. Surgical restoration of normal maxillomandibular relationships can successfully correct aberrancies in all of these areas. Although the functional impact of jaw surgery is usually the driving force behind orthognathic procedures, we cannot underestimate the profound effect that surgical movements of the jaws have on facial aesthetics. Normal dentofacial skeletal relationships help define human standards of beauty and balance. All surgical planning for orthognathic procedures must therefore consider the aesthetic implications of specific maneuvers. Similarly, the aesthetic changes that are predictably associated with certain techniques must be considered when developing the surgical plan. The most common indication for orthognathic surgery is malocclusion associated with a history of cleft lip and palate. Up to 25% of cleft lip and palate patients will require orthognathic surgery by the time they complete adolescence. Similarly, patients with syndromic craniofacial differences, including the various craniofacial dysostoses, represent another group of patients where the need for orthognathic surgery is predictably higher than that seen in the general population, where the incidence of jaw surgery rests at around 2.5%. Orthognathic surgery is a truly multidisciplinary endeavor. Our best and most stable surgical outcomes are achieved when surgeon and orthodontist work closely with their patients to develop a unique plan that is best suited to each individual.

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Dental Anatomy and Jaw Development A comprehensive review of dental anatomy and physiology is beyond the scope of this chapter, but a working knowledge of dental development is important for all surgeons who engage in orthognathic procedures. Dental development begins in utero. The primary, or deciduous, teeth form during the sixth to eighth weeks of gestation, and permanent teeth begin development around the 20th week. In an individual with no dental anomalies, there are a total of twenty deciduous teeth: two central and two lateral incisors, two canines (or cuspids), and four molars in each of the maxillary and mandibular dental arches. Each quadrant contains one central incisor, one lateral incisor, one cuspid, and two molars. By comparison, an adult with complete dentition has thirty-two teeth. The most mesial (anterior) teeth are the central incisors. These are flanked by the lateral incisors. Distal (posterior) to the lateral incisors are the canine teeth. They have a single cusp and typically contain a single root. Distal to the canine teeth are the two bicuspids, or premolars, each with two cusps and a single root (except the first maxillary premolar, which has two roots). Distal to the premolars are three molars, which have four or five cusps and two or three roots each. Shedding of the deciduous teeth begins at around age six with the appearance of the first mandibular molar. The period when an individual has both deciduous and permanent dentition in place is called the period of mixed dentition. This period usually lasts until age 12 years, at which time the deciduous teeth have all typically been lost. The third molars are the last teeth to erupt, late in the second decade of life. Jaw growth generally proceeds in a cranial to caudal pattern and is mediated by multiple factors, including dental eruption and movement. The maxilla typically reaches its adult size in the mid-teenage years. Growth of the mandible typically continues for several years after the maxillary growth has ceased, as the mandible is usually the last of the bones of the craniofacial skeleton to cease its growth.

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Terminology In the care of patients requiring orthognathic surgery, clear communication between treating specialists, including pediatric and adult dentists, orthodontists, prosthodontists, and orthognathic surgeons, is critical to making an accurate diagnosis and creating an effective treatment plan. Common knowledge of relevant terminology is a requisite to effective communication between treating specialists. Some of the more common terms used to discuss dental and oral anatomy are discussed below. Because the dental arches are U-shaped, terms such as anterior and posterior are not always applicable in describing the position of dental structures, nor to their movements in orthodontic or orthognathic interventions. Instead, the terms mesial, meaning toward the midline sagittal plane along the dental arch, and distal, meaning away from the midline along the dental arch, are used to describe dental positions. Occlusion is most commonly described using a classification proposed by Edward Angle in the late 19th century. The nomenclature is based on the relationship between the mesiobuccal cusp of the maxillary first molar and the buccal groove of the mandibular first molar. In an Angle class I malocclusion, the mesiobuccal cusp of first maxillary molar aligns with the buccal groove of the mandibular first molar. In an Angle class II malocclusion, the mesiobuccal cusp of the maxillary first molar is located mesial to the buccal groove of the mandibular first molar. Patients with class II malocclusion have a retrognathic appearance, where the mandible appears posteriorly positioned relative to the maxilla. By comparison, in an Angle class III malocclusion, the mesiobuccal cusp of the maxillary first molar is located distal to the buccal groove of the mandibular first molar, giving the patient a relatively prognathic appearance. Overbite, in dental terms, refers to the vertical overlap between the maxillary and mandibular incisors. It is usually reported either as a percentage of the tooth covered or in millimeters. By comparison, overjet refers to the space in millimeters between the labial surfaces of the most distal incisor in each arch. A normal overjet is 2 to 4 mm. When the mandibular incisor is more prominent (e.g., in a prognathic patient with Angle class III malocclusion), the overjet is referred to as negative. Retrognathia and prognathia can refer to the position of either jaw, but in common usage, these terms refer to the position of the mandible relative to the maxilla and help describe the appearance of an individual’s facial profile. In retrognathia, the mandible appears to be posterior relative to the maxilla. In the prognathic patient, the mandible appears to be positioned anterior to the maxilla. Note that with either a retrognathic or prognathic appearance, both of the jaws may actually be malpositioned; the anatomically correct position of the maxilla and mandible can be specifically determined by cephalometric analysis.

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Cephalometrics Cephalometry refers to the study and measurement of the bones of the head and the face. In the setting of orthognathic surgery, cephalometry specifically focuses on measuring the spatial relationships of the maxilla and mandible to each other, to the upper face, and to the cranial base. Cephalometric analysis has, and continues to be, foundational in making accurate diagnoses and generating appropriate surgical plans for patients presenting with malocclusion. 1,2 Historically, cephalometric analysis has been performed manually, using overlay acetate tracings of lateral cephalograms upon which markings of skeletal and soft tissue landmarks are placed. Once these landmarks are identified, numerous types of formal analyses can be performed that quantify a myriad of facial planes and angles to determine the contribution of each jaw to the patient’s deformity. The orthodontist and surgeon can move the tracings to position the maxilla, mandible, and genioplasty segment into optimal positions. The sella-nasion-subspinale (SNA) and sella-nasion-supramentale (SNB) angles are the two most critical measurements in determining the relative positions of the maxilla and mandible and their relationships to the cranial base. SNA and SNB angles that are less than normal indicate that the maxilla or mandible, respectively, is positioned more posteriorly than normal relative to the cranial base; angles that are greater than the norm indicate relative anterior positions. The cephalometric measurements and movements are then used to guide model surgery, or manipulation of dental models that are based on impressions taken from the patient’s upper and lower dental arches, as further described below. The model surgery process yields acrylic splints that capture the new spatial relationship between the jaws. These splints are used in the operating room, where the surgeon replicates the same movements made in the dental laboratory to achieve the same occlusion obtained in the model surgery planning process. In recent years, however, this manual process has been supplanted by computer-based software systems that can rapidly and accurately perform an endless number of cephalometric analyses using the same anatomic landmarks (Figure 31.1). Surgeons are increasingly turning to these digital platforms to render accurate diagnoses and plan optimal surgical movements via VSP, which is discussed in greater detail below.

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FIGURE 31.1 Digital cephalometric analysis. Cephalometric landmarks can be labeled on a digital lateral cephalogram. Multiple detailed analyses of the positions of the upper and lower jaws and the teeth can be instantaneously calculated for use in surgical planning.

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Patient Evaluation Cephalometric analysis is critical to making an accurate diagnosis, counseling the patient, and planning for the most appropriate surgical intervention. However, a thorough history and detailed physical examination are prerequisites to successful surgical outcomes.

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History A thorough medical history is important in any surgical patient. General questions should include inquiry into any underlying medical conditions that may have a negative impact upon surgery, such as diabetes, connective tissue disease, or autoimmune problems. Medications including steroids and anticoagulants that may affect wound healing or bleeding and clotting should be noted and managed perioperatively as appropriate. Any history of adverse reaction to anesthesia should be thoroughly investigated, as should any prior or current manifestation of cardiac disease, venous thromboembolic disease, or other disease process that might contribute to the development of potentially life-threatening complications. A specific history related to dental and jaw surgery should also be elicited. Previous surgical interventions, such as mandibular or maxillary distraction, surgically assisted rapid palatal expansion (SARPE), or fracture repair, can significantly impact treatment planning. Patients should be questioned about a history of (TMJ) symptoms such as pain, clicking, popping, and trismus. When jaw asymmetries are noted on physical examination, potential etiologies should be investigated, including syndromic, neoplastic, or traumatic causes of unilateral mandibular hypoplasia or hyperplasia. The surgeon should have an open discussion with the patient regarding his or her expectations for surgical outcomes. Orthognathic surgery is a major undertaking, frequently preceded by months of orthodontic preparation followed by additional postoperative treatment. The surgery itself results in weeks of swelling and can dramatically alter a patient’s appearance. The surgeon should describe the perioperative process in detail, including specific goals of surgery and the potential risks that are inherent to a surgical procedure of such magnitude.

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Physical Examination A general physical examination should be performed on every patient before surgery. Specific evaluation for patients scheduled to undergo orthognathic surgery begins with an objective evaluation of the face, including analysis of the standard horizontal thirds and vertical fifths of the face. This assessment can help identify clinical entities such as vertical maxillary excess (VME) or deficiency or transverse deficiencies because of a narrow or constricted palate. The width of the alar bases should be evaluated, as maxillary advancement may widen the base of the nose, potentially resulting in an unexpected and unappreciated alteration in the nasal appearance if this is not addressed during the surgical procedure. The malar eminence, inferior orbital rim, and pyriform aperture projections are evaluated. Deficiencies in these areas are a relative indication for maxillary advancement. Soft tissue coverage and contours of the midface, lower face, and neck are noted. Mentalis strain and lip incompetence should be noted if present, as these are additional signs of vertical maxillary excess, as is excessive gingival show when smiling (a gummy smile). The dental midlines of the maxilla and mandible should be noted and any deviation from the facial midline documented. Any other asymmetries of the maxilla or mandible, particularly those associated with facial clefting or occlusal cant, should be documented. Oral evaluation should focus on hygiene and periodontal health. Patients must demonstrate good hygiene before and during orthodontic preparation to proceed with surgery. Damaged, loose, or missing teeth should be noted, as should any retained deciduous teeth. If present, the third molars should be extracted several months before surgery to facilitate safe osteotomies at the time of surgery. Evaluation of the patient’s profile should note the projection of the forehead, malar eminences, nose, maxilla, mandible, and chin. An experienced orthognathic surgeon can frequently determine which jaw or jaws are responsible for the patient’s dentofacial deformity on profile view before confirming the diagnosis with cephalometric analysis. Careful evaluation of the nose and its spatial relation to the maxilla is critical, as maxillary movements can potentially change the position of the nose and the nasolabial angle. Similarly, the predicted postoperative position of the chin should factor into the presurgical discussion and guide any discussion of the potential need for genioplasty.

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Common Diagnoses Prognathism Prognathism technically refers to prominence of either jaw but is generally used to indicate prominence of the mandible relative to the maxilla. Mandibular prognathism is most often associated with class III malocclusion. On profile, the patient often demonstrates a strong chin and a long jaw line. Cephalometric analysis will typically reveal posterior positioning of the maxilla relative to the cranial base (small SNA), anterior positioning of the mandible compared with the cranial base (large SNB), or both. Treatments may include maxillary advancement, mandibular setback, or a combination of both procedures (Figure 31.2A–C).

FIGURE 31.2 Relative contributions of maxilla and mandible to retrognathism and prognathism. A–C. Frontal, oblique, and lateral views, respectively, of a patient with mandibular prognathism and a class III malocclusion with decreased sella-nasionsubspinale and increased sella-nasion-supramentale. Both jaws are malpositioned. A maxillary advancement and mandibular setback are both indicated to achieve a normal jaw relationship. D–F. Frontal, oblique, and lateral views, respectively, of a

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patient with mandibular retrognathism and a class II malocclusion with decreased sella-nasion-supramentale. A mandibular advancement is an appropriate correction.

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Retrognathism Retrognathism refers to a relative prominence of the maxilla compared with the mandible. Cephalometry usually shows anterior positioning of the maxilla relative to the cranial base (large SNA), posterior positioning of the mandible relative to the cranial base (small SNB), or a combination of both. Most commonly, the retrognathic patient presents with a class II malocclusion because of a small mandible; in these cases, mandibular advancement is the procedure of choice to correct the condition (Figure 31.2D–F).

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Vertical Maxillary Excess VME is also known as long face syndrome. Patients with VME have facies that appear long with excessive gingival show in repose and with smiling. Mentalis strain and lip incompetence are also frequently seen. Surgical correction involves maxillary impaction with cephalad repositioning of the maxilla to shorten the midface. The mandible rotates counterclockwise in a compensatory movement. Resultant changes in chin position should be noted in the preoperative planning phase to determine whether simultaneous genioplasty is indicated. 3

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Vertical Maxillary Deficiency In vertical maxillary deficiency, the patient’s lower face appears short, with little or no incisor show on repose and minimal show with smiling. Appropriate surgical treatment includes downfracture and caudal repositioning of the maxilla to lengthen the face. 4 Bone grafting to the resultant maxillary gap ensures a stable result. 5 The mandible compensates with a clockwise rotation, and the chin moves inferiorly and posteriorly. Again, preoperative planning should include an assessment of the potential need for genioplasty.

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Maxillary Constriction Maxillary constriction refers to a deficiency in the transverse dimension of the maxilla. It is commonly seen in patients with cleft palate. This results in a posterior crossbite on one or both sides of the maxilla. The condition can be treated, at least in part, with orthodontic palatal expansion. If orthodontic expansion fails, the palate can be transversely expanded surgically.

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Presurgical Planning In addition to taking a history, performing a physical examination, and completing a cephalometric analysis, several additional steps must be taken before performing orthognathic surgery. Initial preparation for surgery is carried out by an orthodontist, including obtaining dental models, radiographic records, and composite facial and occlusal photos. Based on the cephalometric analysis, the planned surgical movements are then executed on traditional models of the teeth or on three-dimensional (3D) digital renderings. Regardless of the technique used, the process yields splints that index the desired final positions of the jaws following the orthognathic correction. These splints are used in the operating room to confirm that the planned movements are precisely replicated in the surgical procedure. Planning should not only focus exclusively on correction of abnormal values identified in the cephalometric analysis but also account for the effect of skeletal movements on the overlying soft tissues to optimize the aesthetic outcomes. 6 Movements that reduce the size of the skeleton, such as maxillary impactions and maxillary or mandibular setbacks, can have aging effects on the face. When the soft tissue envelope covers a relatively contracted skeletal framework, deeper creases, more jowling, and an overall aged appearance may result. By contrast, movements that expand the skeleton tend to flatten creases and provide greater support to the soft tissues, contributing to a more youthful appearance 7 (Figure 31.3).

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FIGURE 31.3 Impact of skeletal movements on soft tissue support and aesthetics. A,B. The impact of a high Le Fort I osteotomy and advancement on soft tissue support and facial aesthetics is demonstrated in this 18-year-old patient who presented with class III malocclusion and prematurely aged appearance characterized by ptotic malar soft tissues, deep nasolabial folds, marionette lines, and upper lip ptosis. C,D. Her malocclusion is corrected with maxillary advancement, which also results in a more youthful appearance with improved malar soft tissue support, softening of the perioral skin creases, and improved upper lip projection.

As noted above, clockwise or counterclockwise autorotation of the mandible secondary to maxillary movements—and the impact of these movements on chin position—must be considered in the presurgical plan to achieve balanced facial aesthetics along with a functional postoperative occlusion.

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Orthodontic Preparation The goal of preoperative orthodontia is to position the teeth, so that at the end of the surgical procedure, the patient is in a class I malocclusion with optimal dental intercuspation. This requires a considerable degree of skill on the part of the orthodontist, but also clear communication between the orthodontist and the surgeon regarding the planned operation. Orthodontic preparation for a single-jaw movement differs from that for two-jaw surgery; the surgical plan should therefore be clear to all caregivers and the patient from the outset. In addition to straightening and appropriately spacing the teeth, the orthodontist is charged with reversing any natural dental compensations that the patient develops in association with his or her malocclusion. This includes correcting the aberrant orientation of any proclined or retroclined teeth that have become malpositioned in the absence of normal anatomic relationships between the upper and lower dental arches.

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Dental Models and Model Surgery As practitioners of orthognathic surgery increasingly adapt VSP to their perioperative practices, a thorough understanding of the fundamentals of traditional model surgery remains requisite to a true appreciation of the intricacies of jaw surgery and how best to implement VSP platforms in its execution. Before surgery, the surgeon or the orthodontist will obtain wax-bite registrations and plaster models of the patient’s presurgical occlusion. These models can be mounted on an articulator, which mimics the relationship of the maxilla to the cranial base and the relationship of the mandible to the maxilla as it hinges on the articulator’s joints. In a planned single-jaw surgery, the jaw that is to be cut and moved during surgery is repositioned on the articulator based on the cephalometric analysis and intended surgical movement. An acrylic splint that captures the new relationship between the maxillary and mandibular models is fabricated and brought to the operating room for use in surgery (Figure 31.4).

FIGURE 31.4 Model surgery. A. An articulator is used to mount maxillary and mandibular dental models in their baseline occlusal relationship (in this case, a class III malocclusion). B. The maxillary model is repositioned to achieve a class I relationship. The red arrow indicates the vector of movement, simulating a Le Fort I osteotomy and advancement. C. An acrylic splint is fabricated to capture this new occlusal relationship and will be used in the operating room. D. These images demonstrate typical steps taken to plan an orthognathic surgery procedure. Preparation begins with cephalometric analysis (i). The arrow indicates the next step in the process: tracings and planned jaw movements (ii). After the jaw movements are planned on paper, they are replicated on the mounted dental models (iii). Model surgery results in splint fabrication to facilitate the actual surgery (iv).

In two-jaw surgery, the model of the jaw that is to receive the first movement is repositioned on the articulator, again according to the cephalometric analysis and surgical plan. This temporary relationship

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between upper and lower jaws is indexed with an intermediate splint that is used to guide the position of the first jaw undergoing osteotomy. Once this splint is fabricated, the second jaw to be moved in surgery is repositioned on the articulator to arrive at the appropriate occlusal relationship. A final splint is then created based on this occlusion and used to guide the upper and lower jaws into their final desired positions in the operating room while rigid fixation is obtained.

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Virtual Surgical Planning Although traditional model surgery has historically allowed surgeons to achieve excellent results, it is a laborious and time-consuming process. By comparison, the combination of high-resolution maxillofacial CT scanning, 3D printing, and sophisticated software platforms now allows surgeons to engage in a more streamlined but equally accurate approach to cephalometric analysis and presurgical planning that obviates many of the manual components described earlier. As a result, VSP protocols are rapidly replacing more traditional approaches to orthognathic surgery. VSP begins with the acquisition of a high-resolution CT scan of the face. These radiographic images are imported into specialized computer-assisted design software, which generates 3D renderings of the craniofacial skeleton. Incorporating digital scans of the patient’s dental models into the renderings can increase the level of detail of the 3D images. The surgeon can perform digital osteotomies on these renderings, and the positions of the jaws can be subsequently altered to achieve a desired occlusion (Figure 31.5). A 3D printer can then fabricate splints that capture the new occlusal relationship for use in the operating room. VSP software can also generate 3D renderings of how the soft tissues of the face may change as the underlying skeletal components are repositioned, although these renderings are digital projections only; they should not be used to guide specific patient expectations.

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FIGURE 31.5 Virtual surgical planning for orthognathic surgery. A. The virtual surgical planning summary for this maxilla-first two-jaw surgery demonstrates the preoperative condition (top), the intermediate position of the jaws (center), and the final occlusion (bottom). In this case, the maxilla was split and expanded transversely to correct a posterior crossbite, impacted to correct for vertical maxillary excess, and advanced. Next a bilateral sagittal split osteotomy was used to rotate the mandible in a counterclockwise direction. A reduction and advancement genioplasty was added to the surgical plan to provide facial balance and optimize aesthetic results. Cephalometric measurements such as sella-nasion-subspinale and sella-nasion-supramentale can easily be incorporated into the planning process (B), as can other data such as facial height measurements before and following planned jaw movements (C).

Although VSP represents a resource that has transformed the process of planning for orthognathic surgery without any compromise of surgical results, users of this technology must be aware that like any computer program, VSP outputs are only as good as their inputs. Computer-assisted design software allows one to make unrestricted movements on a screen, regardless of whether those movements might be stable or desirable in an actual clinical setting. The surgeon must therefore always rely on his or her experience and fundamental cephalometric and surgical principles to determine the optimal technique for each individual patient.

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Surgical Techniques General Principles Orthognathic surgery is a true team sport. Active and effective communication between the surgeon and multiple other specialists is necessary for a successful surgical outcome. Before surgery, the surgeon must confer with the patient’s orthodontist to confirm that the patient has been adequately prepared for surgery. On the day of surgery, the surgeon must confirm with the operating room nursing staff that all necessary equipment is available and in good working order, including powered and manually driven bone-cutting tools, procedure-specific instruments, and rigid fixation hardware. Ongoing communication with the anesthesiologist throughout the surgery is of paramount importance. Elective jaw surgery patients are nasotracheally intubated, preferably with a Ring-Adair-Elwyn (RAE) tube that is secured to prevent unintentional extubation during surgical manipulation of the jaws. Preoperative antibiotics covering oral flora are administered intravenously. Hypotensive anesthesia during osteotomies and maxillary downfracture can help to reduce blood loss.

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Maxillary Osteotomies Le Fort I The Le Fort I osteotomy allows for multivector movement of the maxilla. Anterior-posterior, cranialcaudal, and rotational movements in axial, coronal, and sagittal planes are all possible. This flexibility permits correction of occlusal cants, midline shifts, and overjet. 8 The medial canthi are marked with ink, and the vertical height of the maxilla between the canthi and the maxillary dental arch is measured with a caliper. These measurements are important when correcting occlusal cants or altering the maxillary height (e.g., in cases of maxillary impaction or lengthening). An upper gingivobuccal sulcus incision is made. The anterior wall of the maxilla is dissected in the subperiosteal plane with careful preservation of the infraorbital nerve. Lateral dissection continues around the lateral maxillary walls to the pterygomaxillary buttresses. Subperiosteal dissection of the floor of the nasal cavity is performed through the pyriform aperture. When designing the Le Fort osteotomy, the surgeon must note the vertical height of the dental roots to avoid injury to the teeth. In addition, higher osteotomies that incorporate the upper maxilla and even the caudal portion of the zygoma into the Le Fort segment can be designed when more soft tissue support is indicated. The osteotomies through the medial and lateral buttresses and the anterior maxillary wall are performed with a reciprocating saw or an ultrasonic bone cutter. The nasal septum is released from the vomer with either a double-guarded osteotome or the saw blade. Finally, pterygomaxillary osteotomes are used to create controlled vertical fractures of pterygoid plates and release the Le Fort segment from the skull base. Downfracture can then be performed (Figure 31.6A).

FIGURE 31.6 Maxillary osteotomies. A. In this cadaver, differential Le Fort I osteotomy levels have been performed for demonstration purposes. The high osteotomy on the patient’s right will provide increased soft tissue support in the upper midface if the maxilla is advanced. Regardless of the vertical level, osteotomies are made above the levels of the dental roots to avoid injury to the teeth. The nasal septum and maxillary sinuses are clearly visible following downfracture. B. In maxilla-first two-jaw surgery, a bulky intermediate splint is used to index the temporary relationship between the jaws following the Le Fort I manipulation and before the mandibular movement.

The Le Fort segment is completely mobilized to allow for easy positioning into the splint. Maxillomandibular fixation (MMF) is obtained using wires or elastics (Figure 31.6B). L-shaped plates fixed to the medial and lateral buttresses are used to secure the position of the Le Fort segment. During fixation, the surgeon must ensure that the condyles are properly seated to avoid a postoperative malocclusion. Once rigid fixation is achieved, the splint is removed and the new occlusion is evaluated. If the surgery

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was planned as a maxilla-only procedure and the position of the maxilla is consistent with the presurgical plan, the incision is closed and guiding elastics are placed. The patient is followed closely during the first few weeks after surgery to monitor stability of the maxillary movement. If the surgery was designed as a maxilla-first two-jaw manipulation, MMF is reestablished after the appropriate intermediate position of the maxilla in confirmed and the surgeon proceeds with the mandibular osteotomies.

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Surgically Assisted Rapid Palatal Expansion In adolescence, transverse maxillary deficiency can usually be corrected orthodontically with palatal expansion devices. Once the midline palatine suture fuses, however, surgical assistance may be required to effectively expand the maxilla if correction of posterior crossbite is needed. In these cases, a Le Fort I osteotomy is then performed as described earlier. The maxilla is then bisected between the roots of the central incisors and through the hard palate in the midline. Great care must be taken to preserve the palate mucosa to avoid development of an iatrogenic oronasal fistula. The Le Fort I segment is not rigidly fixed as in a traditional Le Fort I procedure. Following surgery, a palatal expander is placed and activated by the orthodontist to correct the transverse deficiency. This approach offers the best correction of transverse maxillary deficiency with the lowest rate of relapse in skeletally mature patients or in patients for whom traditional expansion techniques fail.

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Mandibular Osteotomies Numerous types of mandibular osteotomies have been described for implementation in orthognathic surgery. The sagittal split osteotomy (SSO) and the vertical ramus osteotomy (VRO) are by far the most commonly used and are discussed in further detail below. These techniques provide great versatility to surgeons and consistent, stable results for patients.

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Sagittal Split Osteotomy SSO is the most common technique used in orthognathic procedures involving the mandible. It is technically straightforward, can be performed intraorally, and allows for advancement, setback, rotation, and closure of anterior open bites. Bony overlap between the proximal and distal segments facilitates stable healing, but the proximity of the inferior alveolar nerve to the osteotomy line contributes to the risk of permanent sensory changes associated with this approach. 9,10 Surgery begins with an incision in the gingivobuccal sulcus at the level of the first molar that is extended along the anterior border of the ascending mandibular ramus. Subperiosteal dissection is used to elevate the soft tissues from the buccal surfaces of the body and ramus, as well as the anterior and lingual surfaces of the ramus. The osteotomy begins on the lingual surface of the ramus, above the occlusal plane, to avoid injury to the inferior alveolar nerve at the level of the lingula. A reciprocating saw or ultrasonic bone cutter is used to cut the medial ramus. The osteotomy continues across the anterior border of the ramus and along the external oblique line of the mandible to the first molar, where a vertical cut is made from the oblique line to the inferior border (Figure 31.7).

FIGURE 31.7 Mandibular osteotomies. A–C. A typical line of corticotomy for the SSO is demonstrated on this skull model from buccal, lingual, and frontal perspectives. D. This intraoperative photo demonstrates the proximity of the mental nerve exiting its foramen in a patient undergoing SSO with mandibular advancement. Rigid fixation is achieved with locking titanium alloy plates and screws.

These bone cuts are corticotomies; once they are made, the sagittal split is completed using osteotomes

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and a mallet. A successful split results in a mandibular segment that contains the buccal plate, ascending ramus, condyle, and coronoid process (the proximal segment) and a distinct segment that contains the tooth-bearing portion of the body and symphysis (the distal segment). Once the proximal and distal segments are mobilized, the mandible is advanced or set back as dictated by the surgical plan and brought into the prefabricated occlusal splint. 11,12 Rigid fixation is achieved with either bicortical positional screws or monocortical plates and screws (Figure 31.7D). Again, during fixation, the surgeon must ensure that the condyles are properly seated in the glenoid fossae. MMF is released, the occlusion is checked, and guiding elastics are placed as indicated. The incisions are closed in the surgeon’s preferred fashion.

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Vertical Ramus Osteotomy In contrast to the SSO, the VRO creates a distal segment that includes the tooth-bearing portion of the mandible, coronoid process, inferior alveolar nerve, and anterior ramus, and a proximal segment that includes the mandibular condyle and the posterior ramus. The procedure can be performed via an external or internal approach, and subperiosteal exposure of the mandible is similar to that of the SSO. The osteotomy is placed 7 to 8 mm in front of the posterior border of the ramus between the sigmoid notch and the inferior border of the mandible. Adequate bone stock must be preserved on the posterior segment to accommodate fixation hardware. The procedure is of limited utility when mandibular advancement is indicated: significant advancement creates a long vertical gap between the two segments, increasing the risk of nonunion and relapse. However, VRO is particularly suited to address horizontal mandibular excess and asymmetries requiring setback. 13 As with the SSO, occlusion is established intraoperatively using a splint and MMF. Once rigid fixation is obtained, the patient is taken out of interdental fixation to confirm the position of the jaws. If all is satisfactory, the incision is closed and guiding elastics are placed.

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Osseous Genioplasty (Horizontal Osteotomy of the Mandible) Genioplasty, or horizontal osteotomy of the mandible, can significantly complement the orthognathic surgery plan and optimize the aesthetic surgical result. Osseous genioplasty is an extremely powerful tool, allowing for advancement, setback, reduction, lengthening, widening, narrowing, and rotation of the chin. 14-16 The procedure is performed via a central gingivobuccal sulcus incision, with subperiosteal dissection to the inferior border of the mandible and lateral dissection to the mental foramina. Surgeons should carefully consider the anatomy of the inferior alveolar nerve, which drops 5 to 6 mm bselow the mental foramen before exiting the bone, when planning their osteotomies (Figure 31.8A). A cuff of mentalis at the incision line and muscle attachments to the caudal symphysis are preserved to allow resuspension of the muscle at the end of the procedure and prevent development of a witch’s chin deformity (Figure 31.8B). Once the genioplasty segment is freed, it is manipulated to correct the identified deformity and rigidly fixed in place with titanium plates and screws. The mentalis muscle is resuspended, and the gingivobuccal sulcus incision is closed with absorbable sutures.

FIGURE 31.8 Osseous genioplasty. A. The anatomy of the mental nerve should be appreciated before performing a genioplasty. Specifically, the surgeon should be aware that the intraosseous excursion of the nerve carries it 5 to 6 mm below the mental foramen before it curves cephalad and exits the bone. B. This cadaver dissection demonstrates exposure of the nerves bilaterally with preservation of caudal central muscle attachments. A reciprocating saw or other bone-cutting instrument can make the osteotomy with preservation of the soft tissue attachments.

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Two-Jaw Surgery Moving the maxilla and the mandible in a single surgery is more involved than simply combining individual Le Fort and SSO techniques. Two-jaw surgery requires precision at every step, from orthodontic preparation to presurgical planning to performing the osteotomies to rigid fixation to the use of postoperative guiding elastics. 17-20 The maxillary and mandibular movements are performed in series. Traditionally, the Le Fort I osteotomy is performed first, followed by the mandibular movement. More recently, mandible-first surgery has been widely adopted with results that are equal to the more time-honored maxilla-first approach. Currently, the choice of technique is often an arbitrary one based on surgeon preference. 21 Regardless of the order of osteotomy, as described earlier, an intermediate splint is generated during the presurgical planning process that indexes the position of the jaws following the first movement. Interdental fixation is obtained and the intermediate splint holds the jaws in the desired position while rigid fixation is achieved. MMF is then released, bone cuts for the second jaw movement are made, and the final splint is used to stabilize the mandible and maxilla in the final desired occlusion while rigid fixation is obtained.

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Perioperative Care and Management of Complications Postoperative management focuses on patient comfort and the prevention of complications. Cold packs or compresses and head elevation can significantly decrease edema. In addition, a short course of oral steroid therapy may help minimize swelling, as well as the risk of postanesthesia nausea and vomiting. Antiemetics are routinely provided to the patient. Chlorhexidine oral rinses after and between meals help maintain an antiseptic environment in the mouth and mitigate against oral wound infection. Oral antibiotic administration following surgery has been shown to reduce the risk of infection. A liquid diet is instituted immediately after surgery, progressing to a mechanical soft diet at postoperative follow-up. Patients should be counseled that they may experience significant weight loss because of limited caloric intake in the immediate postoperative period, and the importance of adequate nutritional intake should be emphasized. Guiding elastics are used to help maintain the stability of the new occlusion and begin musculoskeletal training, so patients may get accustomed to their new jaw and dental relationships. Every orthognathic surgery patient will require some degree of postsurgical orthodontic therapy to complete their rehabilitation. The length of orthodontic care following orthognathic surgery varies greatly and is largely dependent upon the presurgical plan, the extent of presurgical orthodontic preparation, and the specific endpoints set forth by the orthodontist. Postoperative bleeding is rare, as most bleeding is encountered and controlled during surgery. In unusual circumstances, injury to the internal maxillary artery or the plexus of vessels at the skull base behind the maxilla may manifest following completion of the procedure. In these cases, evaluation and intervention must be immediate and aggressive, potentially involving interventional radiology services or surgical exploration. 22 After mandibular and two-jaw surgery, most patients will experience transient decrease in sensation in the distribution of the inferior alveolar nerve. It is important during the SSO to identify and preserve the nerve as it enters the mandible proximally, throughout its course within its bony canal, and as it exits the mental foramen. If a transection is identified, neurorrhaphy should be performed immediately. Postoperative malocclusion is a rare but serious complication of orthognathic surgery. Technical errors during surgery may predispose a patient to this adverse outcome. The final occlusion should be thoroughly checked with the condyles seated in the glenoid fossae after rigid fixation is achieved. If the occlusion does not exactly correlate with the presurgical plan, rigid fixation should be removed, and the position of one or both jaws must be adjusted. Bony nonunion and malunion are also rare outcomes following orthognathic surgery. Both require reoperation. Repeat osteotomy and bone grafting may be necessary in these situations.

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Summary With appropriate planning and preparation, orthognathic surgery is associated with excellent outcomes, low-risk profiles, and very satisfied patients. A wide range of versatile techniques exist that can be implemented in the treatment of malocclusion, and new technologies allow for detailed VSP and other streamlined perioperative processes that contribute to surgical success. Careful consideration of the impact of planned jaw movements on the position of both skeletal and soft tissue components of the face allows surgeons to achieve desired functional outcomes, optimize facial aesthetics, and meet patient expectations.

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Questions 1. A 30-year-old man presents to your office because he is bothered by his prominent chin. On physical examination, he has class III malocclusion. Cephalometric evaluation shows an SNA of 81° (normal 80–84) and an SNB angle of 83° (normal 78–80). There are no other abnormalities. Which of the following procedures is most appropriate in this patient? a. Setback genioplasty b. SSO and setback c. Le Fort I maxillary advancement d. Two-jaw surgery 2. A skeletally mature patient presents to your office after referral from her orthodontist. She has transverse maxillary deficiency with bilateral posterior crossbite. What is the most appropriate intervention? a. Orthodontic palatal expansion b. SARPE c. Le Fort I advancement d. Bilateral SSO mandibular setback 3. Which of the following orthognathic movements is likely to cause the appearance of facial aging? a. Le Fort I advancement b. Le Fort I with downward repositioning c. Le Fort I with upward repositioning d. Bilateral sagittal split and advancement e. Advancement genioplasty 4. A 22-year-old woman comes to your office with concerns about her lower-third facial appearance, specifically her weak chin. She has no concerns about her midfacial appearance. She has had previous orthodontia and is in class I malocclusion. Her overall facial height is proportional in all views, but on profile, her chin appears weak in an anterior-posterior direction. Cephalometric analysis demonstrates that her SNA angle is 82° (normal 78–82) and her SNB angle is 80° (normal 78– 80). What is the most appropriate surgical management? a. Bilateral sagittal split and advancement b. Two-jaw surgery with maxillary and mandibular advancement c. Vertical lengthening genioplasty and bone grafting d. Horizontal sliding genioplasty and advancement e. Le Fort I setback 5. A 25-year-old man is referred to your office for concerns about lower facial asymmetry. On examination, his maxillary dental midline is in line with his overall facial midline, but his mandibular dental midline is shifted 5 mm to the right. His chin point is in line with his mandibular dental midline. With appropriate orthodontics, which orthognathic procedure would best treat this patient’s lower facial asymmetry? a. SSO with leftward shift alone b. SSO with rightward shift alone c. SSO with leftward shift and sliding genioplasty to the right d. SSO with rightward shift and sliding genioplasty to the left e. Le Fort I osteotomy with rightward shift 1. Answer: b. The patient has prognathism with an abnormal SNB angle. Mandibular osteotomies and setback will address both the patient’s prominent chin and his malocclusion. Given that his SNA

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angle is within the normal range, Le Fort I maxillary advancement is not the ideal choice in this scenario. Likewise, two-jaw surgery is unnecessary with a normal SNA angle and a relatively small overall movement. Setback genioplasty may address the patient’s concerns about his prominent chin, but will not address his malocclusion. 2. Answer: b. The key to this question is that the patient is skeletally mature. This means that the palatal suture is likely to be fused and orthodontic palatal expansion alone is unlikely to correct her transverse maxillary deficiency. Both Le Fort I and bilateral SSOs are incorrect because both primarily address anterior-posterior discrepancies. SARPE involves surgically splitting the palatal suture followed by orthodontic expansion. This will allow transverse expansion of the maxilla without changes in the anterior-posterior direction. 3. Answer: c. All of the movements described expand the facial skeleton except for Le Fort I with upward repositioning (impaction). Le Fort I impaction reduces facial height, but because the existing soft tissue envelope is draped over a smaller skeletal frame, this may result in deeper rhytids and the appearance of facial aging. In contrast, movements that expand the facial skeleton cause the existing soft tissue envelope to be draped over a larger frame, softening and flattening rhytids. 4. Answer: d. The patient described has microgenia, but normal facial height and would benefit from augmenting her chin by advancing it horizontally (a chin implant, although not one of the answer choices, would also be a reasonable option). This patient has normal SNA and SNB angles on cephalometric analysis and is in class I malocclusion; she also has no concerns about her midfacial appearance. These factors all argue against two-jaw surgery with advancements; additionally, this would not change her relative microgenia. Vertical lengthening genioplasty and bone grafting is not indicated because her overall facial height is proportionate (vertical thirds are similar). Le Fort I setback and bilateral sagittal split with advancement would both create malocclusion and neither would address the patient’s weak chin. 5. Answer: a. This patient’s maxillary midline is coincident with his overall facial midline; only the mandibular midline is malpositioned. Although Le Fort I osteotomy and rightward shift could align the dental midlines, this would actually make the patient appear more asymmetric and is, therefore, incorrect. Additionally, the patient’s chin point is coincident with his mandibular dental midline, meaning that moving the mandibular dental midline into the correct position will move the chin point at the same time, rendering genioplasty unnecessary. If the chin point was coincident with the facial midline rather than the mandibular dental midline, a compensatory genioplasty in the opposite direction of the mandibular movement would be needed. This leaves sagittal split alone as the only option, and in this case the patient is already off to the right, so his midline needs to be shifted to the left.

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References Reyneke, JP. Surgical cephalometric prediction tracing for the alteration of the occlusal plane by means of rotation of the maxillomandibular complex. Int J Adult Orthodon Orthognath Surg. 1999;14(1): 55-64. Ricketts, RM. Cephalometric analysis and synthesis. Angle Orthod. 1961;31(3):141-156.This article describes the cephalometric tracings and analysis that have come to be known as a Ricketts analysis for the diagnosis of dentofacial deformities. Ricketts also describes how cephalometric analysis relates to, and is distinct from, treatment planning for orthognathic surgery. Schendel, SA, Eisenfeld, J, Bell, WH, et al. The long face syndrome: vertical maxillary excess. Am J Orthod. 1976;70(4):398-408. Reyneke, JP, Masureik, CJ. Treatment of maxillary deficiency by Le Fort I downsliding technique. J Oral Maxillofac Surg. 1985;43(11):914-916. Wagner, S, Reyneke, JP. The Le Fort I downsliding osteotomy: a study of long-term hard tissue stability. Int J Adult Orthodon Orthognath Surg. 2000;15(1):37-49. Selber, JC, Rosen, HM. Aesthetics of facial skeletal surgery. Clin Plast Surg. 2007;34(3):437-445. Rosen, HM. Facial skeletal expansion: treatment strategies and rationale. Plast Reconstr Surg. 1992;89(5):798-808.This article describes Rosen’s philosophical and clinical preference for skeletal expansion rather than contraction in orthognathic surgery. It emphasizes the paramount importance of aesthetics over orthognathic perfection and illustrates this approach using case examples in which facial disproportion was created or maintained to optimize the aesthetic outcome. Bell, WH. Le Forte I osteotomy for correction of maxillary deformities. J Oral Surg. 1975;33(6):412-426. Trauner, R, Obwegeser, H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Part I. Surgical procedures to correct mandibular prognathism and reshaping of the chin. Oral Surg Oral Med Oral Pathol. 1957;10(7):677-689.In the first of a series of classic articles, the authors describe various mandibular osteotomies that are still in use today, including the sagittal split and inverted L sliding genioplasty technique that are also described. Bell, WH. Surgical correction of mandibular retrognathism. Am J Orthod. 1966;52(7):518-528. Bell, WH. Correction of mandibular prognathism by mandibular setback and advancement genioplasty. Int J Oral Surg. 1981;10(4):221-229. Bell, WH, Jacobs, JD, Legan, HL. Treatment of the class II deep bite by orthodontic and surgical means. Am J Orthod. 1984;85(1):1-20. Al-Moraissi, EA, Ellis, E III. Is there a difference in stability or neurosensory function between bilateral sagittal split osteotomy and intraoral vertical ramus osteotomy for mandibular setback? J Oral Maxillofac Surg. 2015;73(7):1360-1371. Converse, JM, Wood-Smith, D. Horizontal osteotomy of the mandible. Plast Reconstr Surg. 1964;34(5):464-471. Posnick, JC, Choi, E, Chang, RP. Osseous genioplasty in conjunction with bimaxillary orthognathic surgery: a review of 262 consecutive cases. Int J Oral Maxillofac Surg. 2016;45(7):904-913. Trauner, R, Obwegeser, H. The surgical correction of mandibular prognathism and retrognathia with consideration of genioplasty. Part II. Operating methods for microgenia and distoclusion. Oral Surg Oral Med Oral Pathol. 1957;10(8):
 787-792. Bell, WH, Jacobs, JD, Quejada, JG. Simultaneous repositioning of the maxilla, mandible, and chin. Treatment planning and analysis of soft tissues. Am J Orthod. 1986;89(1):28-50.Cephalometric and aesthetic analysis as well as indications for two-jaw orthognathic surgery are described. Case examples illustrate the diagnostic, analytic, and orthodontic and surgical treatment processes. Bell, WH, Sinn, DP, Finn, RA. Cephalometric treatment planning for superior repositioning of the maxilla and concomitant mandibular advancement. J Maxillofac Surg. 1982;10(1):42-49. Brammer, J, Finn, R, Bell, WH, et al. Stability after bimaxillary surgery to correct vertical maxillary excess and mandibular deficiency. J Oral Surg. 1980;38(9):664-670. Park, N, Posnick, JC. Accuracy of analytic model planning in bimaxillary surgery. Int J Oral Maxillofac Surg. 2013;42(7):807-813. Perez, D, Ellis, E III. Sequencing bimaxillary surgery: mandible first. J Oral Maxillofac Surg. 2011;69(8):2217-2224.The article is a commentary on mandible-first two-jaw orthognathic surgery and its advantages over more traditional maxilla-first approaches. Requirements for a mandible-first approach as well as circumstances favoring mandible-first, unique aspects of planning, and disadvantages are also described. Bradley, JP, Elahi, M, Kawamoto, HK. Delayed presentation of pseudoaneurysm after Le Fort I osteotomy. J Craniofac Surg. 2002;13(6):746750.

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CHAPTER 32

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Craniofacial Clefts and Orbital Hypertelorism Jesse A. Goldstein and Joseph E. Losee

Key Points Treat each with a craniofacial cleft and/or hypertelorism individually Soft tissue contours follow the underlying bony abnormality Establishing the brain/nose barrier is critical early in life Definitive surgical intervention for orbital hypertelorism should wait until the orbit has reached maturity (at least 5 to 7 years of age) Maintain medial canthal attachments if possible; if not, resuspend with transnasal wiring No. 7 craniofacial clefts are the most prevalent Orbital hypertelorism is a physical finding, not a syndrome Craniofacial clefts and orbital hypertelorism (OHT) represent two distinct entities that have in common an extreme variation in presentation. They span severity from subtle anomalies of little clinical consequence to the most profound forms of craniofacial disfigurement encountered in plastic surgery. With few exceptions, these entities are rare and result from uncharacterized disruptions during embryogenesis; however, several well-defined syndromes and diagnoses exist whose primary manifestation is hypertelorism or craniofacial clefting. As a whole, these entities should be thought of as part of a phenotypical spectrum and not as those that share a clearly delineated etiopathogenesis. Even so, developing a comprehensive framework for understanding, evaluating, and treating patients with these complex anomalies is crucial to success. This chapter is meant to provide the framework for assessing and categorizing these complex anomalies as well as provide some basic principles of treatment that may be broadly applied.

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Tessier Classification Craniofacial clefts are often referred to as Tessier clefts, a reference to Paul Tessier (1917–2008) who founded the field of craniofacial surgery and developed a system for understanding these diverse entities. 1 The Tessier classification 2 is the most complete and commonly utilized framework today, describing both the soft tissue anomalies and the underlying bony abnormalities. Tessier’s classification was a synthesis of anatomic and clinical study of patients and was developed before the advent of computed tomography (CT). 3 It has withstood the transition into the modern era of imaging including 3D CT and magnetic resonance imaging technologies. The Tessier classification of rare craniofacial clefts centers around the orbits and eyelids, which represent the region of interface between the cranium and the facial structures (Figure 32.1). Therefore, the clefts that occur cephalad to the orbits are defined as cranial clefts, and those occurring caudal to the orbit represent the facial clefts. Tessier’s numbering system helps reinforce this point: facial clefts are numbered 0 to 7, whereas cranial clefts are numbered 8 to 14. Furthermore, cranial and facial clefts often occur in distinct patterns. When Tessier clefts occur in combination, they often include a facial cleft and a cranial cleft such that the sum of the cleft numbers is 14. For example, a midline cleft may begin at the lip and nose (no. 0 cleft) but extend up through the forehead (no. 14 cleft). Other common combinations of craniofacial clefts include 1 and 13, 2 and 12, 3 and 11, etc. (Table 32.1) Craniofacial clefts rarely exhibit the same extent of soft tissue and skeletal involvement. A diagnosis of a craniofacial cleft can be made more reliably based on the skeletal manifestations which are more consistent than the soft tissue manifestations.

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FIGURE 32.1 Tessier classification of craniofacial clefts. Soft tissue clefts are demonstrated on the left. The skeletal clefts are depicted on the right. The facial clefts are numbered 0 through 7 and the cranial clefts are numbered 8 to 14.

TABLE 32.1 Comprehensive List of Craniofacial (Tessier) Clefts With Associated Bony and Soft Tissue Landmarks

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Features of Craniofacial Clefts Median Clefts: No. 0 and No. 14 Clefts Median craniofacial clefts represent a unique form of facial clefting which can be associated with both hypoplasia of midline structures and tissue hyperplasia. The no. 0 clefts define the facial component of the spectrum of median clefts, whereas the no. 14 clefts define the cranial, or frontoethmoidal, component of median clefts. Median clefts can be further divided into hypoplasia or agenesis, dysraphia, and hyperplasia. 4

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Median Craniofacial Hypoplasia Hypoplasia associated with no. 0 clefts can range from small but normal to complete agenesis of the midline facial structures, whereas their extension into a no. 14 cleft can present with mild or severe hypotelorism and central nervous system (CNS) anomalies. Severe forms of median craniofacial hypoplasia fall under the diagnosis of holoprosencephaly and include cyclopia, ethmocephaly with midline proboscis, and cebocephaly, and there is a positive correlation between the severity of the facial findings and degree of CNS anomalies resulting in significantly limited life expectancy or intrauterine demise. In patients with milder forms, assessing CNS anatomy is crucial with CT or magnetic resonance imaging to differentiate between lobar and alobar holoprosencephaly and to determine the integrity of the hypothalamic-pituitary axis.

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Soft Tissue Deficiencies No. 0 clefts can affect the soft tissues of the upper lip and nose and can range from agenesis to subtle hypoplasia. A false median cleft lip may be present with absence of the philtrum and central tubercle. The columella may be narrowed, shortened, or absent, and the nasal tip may lack projection because of a hypoplastic or absent caudal septum. Hypotelorism and midline fusion of the eyebrows can occur in no. 14 clefts.

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Skeletal Deficiencies As with all aspects of craniofacial clefts, the skeletal involvement in no. 0/14 clefts can range from subtle separation between the maxillary central incisors to complete absence of the premaxilla and primary palate resulting in a large central palatal cleft. Hypoplastic nasal structures can also be present including septal, ethmoidal, and nasal bone deficiencies resulting in a flat nasal bridge, hypotelorism, and microcephaly (Figure 32.2). Additionally, intrinsic dental anomalies may also be present including absent or hypoplastic maxillary central incisors or a midline central incisor.

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FIGURE 32.2 No. 0–14 cleft. A. Skeletal involvement demonstrating midline palatal hypoplasia and hypotelorism. B. Patient with midline craniofacial hypoplasia associated with a false medial cleft lip, absent columella, flat nasal bridge, and hypotelorism. C. Skeletal involvement demonstrating midline craniofacial hypertrophy and hypertelorism. D. Patient with midline craniofacial hyperplasia associated with hypertelorism and excess and disorganized nasal cartilage.

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Midline Craniofacial Dysraphia Dysraphia represents a failure of fusion, or cleft, of midline structures without deficiency or excess. The two diagnoses associated with a no. 0/14 cleft are a median cleft lip and an encephalocele.

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Soft Tissue Involvement This includes a true median cleft lip where all central structures are present. These clefts represent an embryological failure of fusion of the paired medial nasal processes and results in a narrow median cleft with present philtral columns. An encephalocele is a herniation of CNS structures including brain and cerebrospinal fluid through a weakened midline space and can result in a mass effect and further separation of normal facial structures.

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Skeletal Involvement True median clefts can result in a midline alveolar cleft and a midline primary palatal cleft, as well as hypertelorism if the cleft extends cephalad toward the orbits. Anterior encephaloceles can be divided into basal encephaloceles, where the CNS herniates through a defect in the cribriform plate or sphenoid bone into the ethmoidal space and frontoethmoidal encephaloceles, where the herniation occurs anterior to the crista galli at the junction of the frontal and ethmoidal bones.

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Midline Craniofacial Hyperplasia The spectrum of midline craniofacial hyperplasia ranges from clinically minor duplication of the nasal septum and subclinical hypertelorism to severe forms of frontonasal dysplasia together with severe hypertelorism and nasal duplication. 5–7

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Soft Tissue Involvement Soft tissue excess may manifest as a widened philtrum, a bifid nasal tip or duplication, and abnormal nasal cartilage as well as widely spaced nasal soft tissue structures (Figure 32.2).

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Skeletal Involvement Skeletal excess in a hyperplastic no. 0/14 cleft can range from a widening of the maxillary alveolar process resulting in a central incisor diastema to a widened and shortened central dental arch resulting in an anterior open bite. A duplicated nasal spine may be present, and the nasal bones and maxillary processes of the maxilla may be flat, broad, and laterally displaced. Hypertelorism and frontal bossing/diastasis may be present because of varying degrees due to widening of the ethmoid sinuses and anterior cranial fossa, while the cribiform plate is low.

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No. 1 Cleft Soft Tissue Involvement No. 1 Tessier clefts can often be confused with common cleft lips, as the cleft passes through Cupid’s bow to the nasal base. The distinguishing feature of a no. 1 cleft, however, is the involvement of the medial nose including notched soft triangle and alar dome. This cleft can extend up the nose, lateral to midline, and be associated with soft tissue furrows and medial canthal displacement resulting in telecanthus (Figure 32.3). The eyelids are unaffected. No. 1 clefts can continue cephalad as no. 13 clefts, which can result in orbital dystopia.

FIGURE 32.3 No. 1 cleft. A. Skeletal involvement is through the piriform aperture just lateral to the nasal spine and septum. The orbit is displaced laterally. B. Patient with a notched alar dome and mild orbital dystopia. (Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Skeletal Involvement An anterior open bite and keel-shaped maxilla are present, whereas a paramedian cleft may extend from between the central and lateral incisor to the nasal floor lateral to the nasal spine. A primary and secondary palatal cleft may be present. The cephalic extension of the cleft occurs between the nasal bone and the frontal process of the maxilla and can result in flattening and widening of the nasal dorsum. Widened ethmoids can result in hypertelorism.

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No. 2 Cleft Soft Tissue Involvement Similar to no. 1 clefts, no. 2 Tessier clefts can also mimic common cleft lips. They are also paramedian, originating at the peak of Cupid’s bow before extending up to the nasal sill. Unlike no. 1 clefts, however, no. 2 clefts pass through the middle third of the ala, lateral to the soft triangle, resulting in a hypoplastic ala rather than a notch. The nose can be broad and flat, and the medial canthus can be displaced. The lacrimal system and eyelids are unaffected (Figure 32.4). No. 2 clefts can continue cephalad as no. 12 clefts, which can lead to orbital dystopia and medial brow distortion.

FIGURE 32.4 No. 2 cleft. Patient with a lateral alar deficiency and mild orbital dystopia. (Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Skeletal Involvement This cleft originates lateral to the lateral maxillary incisor and extends up to the piriform aperture and primary/secondary palate similar to a common cleft lip/palate. Similar to a no. 1 cleft, the cephalic extension of the no. 2 cleft occurs between the nasal bone and the frontal process of the maxilla and can result in flattening and widening of the nasal dorsum as well as ethmoidal involvement and hypertelorism.

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No. 3 Cleft The no. 3 cleft is a common Tessier cleft and is often referred to as a Tessier oro-naso-ocular cleft (Figure 32.5).

FIGURE 32.5 Right no. 3 cleft; left no. 4 cleft. A. Skeletal involvement demonstrates deformity of right medial maxilla and inferior orbital rim/floor with orbital dystopia and left-sided involvement lateral to the piriform extending to the inferior orbital rim/floor with orbital dystopia. B. Patient with deficiency extending from the alveolus into the piriform with microphthalmia and orbital dystopia. C. Patient with mild no. 4 cleft demonstrating cleft lip lateral to the nasal sill and subtle inferior displacement of the medial canthus.

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Soft Tissue Involvement When isolated to the lip, no. 3 clefts manifest as a common cleft lip, starting at Cupid’s bow peak and extending to the lateral nasal sill. The cleft extends through the lateral ala, which can be notched or clefted, to the lower eyelid between the medial canthus and the inferior punctum. There can be a significant soft tissue deficit in the midface with inferior displacement of the lower lid and globe, leading to a risk of exposure keratopathy. The globe may also be microphthalmic in some cases.

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Skeletal Involvement Skeletal involvement of the no. 3 cleft begins at the alveolar process, between the lateral incisor and canine, extending up to the lateral piriform aperture and into the medial orbit. The medial wall of the maxillary sinus is absent. The frontal process of the maxilla is disrupted as the bony component of the cleft terminates in the lacrimal groove in the inferior-medial orbit.

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No. 4 Cleft Soft Tissue Involvement As with other craniofacial clefts, soft tissue involvement in no. 4 clefts presents as a wide spectrum of deformities. 8 The cleft begins lateral to the peak of Cupid’s bow, midway between the commissure and the philtrum. This is the first of the clefts to travel lateral to the nose, although nasal anatomy can still be indirectly displaced superiorly. The cleft extends to the lower lid lateral to the medial canthus, which is displaced inferior-laterally, and can involve the lacrimal system at the level of the punctum and the lacrimal sac. The distance between the lower eyelid and the upper lip is foreshortened and can result in significant corneal exposure (Figure 32.5).

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Skeletal Involvement The skeletal involvement affects the inferior maxilla similarly to a no. 3 cleft; however, the no. 4 cleft courses lateral to the piriform region through the maxillary sinus, including the palate and choanae, superiorly to the infraorbital rim between the frontal process of the maxilla and the infraorbital foramen. The lacrimal system is usually spared. Variable orbital floor defects can be present.

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No. 5 Cleft No. 5 clefts are the least common of the oblique facial clefts.

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Soft Tissue Involvement Soft tissue involvement begins medial to the lateral oral commissure and proceeds cephalad toward the lower eyelid in the middle third. Similar to no. 4 clefts, there is often a soft tissue deficiency between the mouth and the lower lid, resulting in higher risk of corneal exposure (Figure 32.6).

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FIGURE 32.6 Right no. 5 cleft; left no. 6 cleft. The right no. 5 cleft is demonstrated by a subtle soft tissue furrow that begins medial to the oral commissure and extends toward the middle lower lid. The no. 6 cleft begins at the commissure and extends toward the lateral lower lid. (Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Skeletal Involvement The no. 5 cleft affects the alveolus lateral to the canine and extends through the maxillary sinus by encountering the inferolateral orbit lateral to the infraorbital foramen.

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No. 6 Cleft The no. 6 cleft is associated with mild forms of Treacher Collins syndrome and Nager syndrome, both of which present with zygomaticomaxillary dysplasia.

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Soft Tissue Involvement The soft tissue involvement often presents as a vertical cleft or furrow originating in the oral commissure and extending cephalad to the lateral lower eyelid. This can result in inferior displacement of the lateral canthus, ectropion, and an oblique orientation of the palpebral axis, oftentimes referred to as an antimongoloid slant. Colobomas can be present at the inferior lateral eyelid (Figure 32.6).

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Skeletal Involvement Skeletal involvement tracks along the zygomaticomaxillary suture and excludes the alveolar process. The posterior maxillary buttress (pterygomaxillary buttress) can be foreshortened resulting in a steep maxillary occlusal plane and choanal atresia. The cephalad extend of the no. 6 cleft is the lateral orbital floor with a communication with the inferior orbital fissure.

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No. 7 Cleft No. 7 clefts are by far the most common of the craniofacial clefts. When they occur in isolation, they result in isolated macrostomia (Figure 32.7) often associated with a preauricular remnant. Conversely, they can occur as part of a known syndrome such as hemifacial macrosomia or Goldenhar syndrome which are associated with isolated no. 7 clefts, 9–12 or Treacher Collins and Nager syndromes which are associated with no. 6 to 8 craniofacial clefts.

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FIGURE 32.7 Left no. 7; right no. 8 cleft. A. Skeletal involvement demonstrates deformity of the lateral alveolus, extending through the pterygomaxillary junction to the zygomatic arch and involvement of the lateral orbital rim centered around the zygomaticofrontal suture. B. The right soft tissue no. 7 cleft is shown with obliteration of the lateral commissure and a preauricular skin tag. C. Left no. 8 cleft is shown with subtle changes at the lateral canthal region including brow malposition. (B,C. Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Soft Tissue Involvement The no. 7 cleft begins at the lateral commissure and extends to a variable extent posteriorly to the preauricular region. Most commonly, the cleft terminates medial to the masseter. A preauricular remnant may be present as well as varying degrees of microtia. Cranial nerve V may be involved as can the tongue and palate on the affected side.

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Skeletal Involvement The skeletal cleft passes through the pterygomaxillary junction and may affect the ipsilateral posterior maxillary and mandibular ramus, which can be vertically foreshortened contributing to a steel occlusal plane. The zygomatic body is variably dysplastic with an incomplete or absent arch. The cranial base can also be affected leading to asymmetry of the glenoid fossa and sphenoid bone.

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No. 8 Cleft The no. 8 cleft divides the facial clefts from the cranial clefts and is centered around the frontozygomatic suture. It is the lateral most of the cranial clefts. It is associated with several syndromes including Treacher Collins and Goldenhar syndromes.

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Soft Tissue Involvement The no. 8 cleft extends from the lateral canthus laterally to the temporalis region and can be associated with a coloboma of the iris or lateral canthal region. 13 In Goldenhar syndrome, an epibulbar dermoid cyst is present on the globe (Figure 32.7).

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Skeletal Involvement The no. 8 cleft is a cleft in the frontozygomatic suture.

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Treacher Collins and Nager Syndromes Treacher Collins and Nager syndromes are discussed elsewhere in this text. However, it is important to present these anomalies here to demonstrate how this specific syndrome relates to the Tessier classification of craniofacial clefts. It was Tessier who first attributed the no. 6, 7, and 8 cleft to Treacher Collins syndrome. 14,15 The classic findings of Treacher Collins syndrome include zygomatic hypoplasia (no. 6 cleft), vertical pterygomaxillary deficiency with a steep occlusal plane (no. 7 cleft), inferior-lateral decent of the lateral canthus (no. 7 cleft), and absence of the inferior and lateral orbit as zygomatic arch (no. 7 and 8 clefts). Nager syndrome has a similar phenotype to Treacher Collins syndrome but also includes limb anomalies. 16

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No. 9 Cleft The no. 9 cleft is the rarest of the isolated cranial clefts and begins the medial movement of the cranial clefts. This cleft has been termed fronto-sphenoid dysplasia and is the cranial extension of the no. 5 cleft.

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Soft Tissue Involvement Soft tissue involvement includes abnormalities in the lateral third of the upper eyelid and brow. It extends up to the temporoparietal hairline which can be anteriorly displaced with a projection of hair in the temporal region. The orbit may be displaced laterally and microphthalmia may also be present. The frontotemporal branch of the facial nerve can be affected (Figure 32.8).

FIGURE 32.8 Left no. 9; right no. 10 cleft. A. Skeletal involvement of the no. 9 cleft demonstrates disruption of the superolateral orbit and frontotemporal region. Skeletal involvement of the no. 10 cleft originates with the superior orbital fissure and extends through the central supraorbital rim into the frontal bone. B. Patient with no. 9 cleft demonstrating orbital rim, brow, and forehead irregularities. C. Patient with bilateral no. 10 clefts demonstrating soft tissue colobomas of the medial third of the upper eyelid and brown and forehead involvement. (B. Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Skeletal Involvement The no. 9 cleft extends superiorly through the superior-lateral orbit displacing the greater wing of the sphenoid and the squamosal temporal bone. This can lead to posterior rotation of the lateral orbital wall.

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No. 10 Cleft The no. 10 cleft is centered on the middle orbit and cephalic extensions and is a continuation of a no. 4 cleft.

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Soft Tissue Involvement Soft tissue involvement includes the middle third of the upper eyelid and central eyebrow. Eyelid deficiencies are common, ranging from colobomas to complete ablepharon. A paramedian forehead soft tissue furrow may extend to a frontal hair projection in the temporoparietal scalp (see Figure 32.8).

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Skeletal Involvement Skeletal involvement begins at the superior orbit, lateral to the supraorbital foramen, and extends cephalad. An encephalocele may develop through the anterior cranial fossa resulting in inferior-lateral displacement of the orbit and hypertelorism.

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No. 11 Cleft The no. 11 cleft is the cranial extension of the no. 3 facial cleft. 17

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Soft Tissue Involvement This cleft originates in the medial orbit, and as such, the medial upper lid is often involved. Similar to a no. 10 cleft, eyelid involvement may range from a coloboma to ablepharon. The cleft may extend into the eyebrow and up to the frontal hairline with a fingerlike projection of hair extending into the medial third of the forehead (Figure 32.9).

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FIGURE 32.9 No. 11 cleft. Patient with right-sided no. 11 cleft demonstrating involvement of the medial third of the upper lid, canthal involvement, and orbital malposition. (Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Skeletal Involvement The bony involvement of the no. 11 cleft involves the medial third of the orbital rim and may extend cephalad similarly to a no. 10 cleft. If the ethmoid sinus is involved, significant hypertelorism can be seen. The cranial base and anterior cranial fossa are uninvolved.

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No. 12 Cleft The no. 12 cleft is the cranial extension of the no. 2 facial cleft. 18

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Soft Tissue Involvement The soft tissue cleft lies medial to the medial canthus, which is laterally displaced and extends cephalad to the medial eyebrow with effacement of the eyebrow root. A short anterior projection of the hairline occurs just lateral to midline.

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Skeletal Involvement The bony component of the no. 12 cleft originates from the frontal process of the maxilla and extends superiorly. The ethmoid sinuses are widened which contributes to hypertelorism and telecanthus. The anterior and middle cranial fossa may be widened but encephaloceles are uncommon. The cribriform plate and olfactory groove are unaffected.

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No. 13 Cleft The no. 13 cleft represents the paramedian cranial extension of the no. 1 facial cleft.

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Soft Tissue Involvement The eyelid and eyebrow are intact in this cleft; however, the medial brow may be inferiorly displaced. A frontal encephalocele may be present, along with a paramedian V-shaped frontal hair projection (Figure 32.10).

FIGURE 32.10 No. 13 cleft. A. Skeletal involvement occurs between the nasal bone and frontal process of the maxilla and is associated with widened ethmoids and hypertelorism. B. Patient demonstrating right-sided no. 13 cleft with preservation of the lid and canthal structures, orbital dystopia, and frontal soft tissue and bony abnormalities. (B. Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Skeletal Involvement This cleft originates from between the nasal bone and frontal process of the maxilla where an encephalocele may be present leading to cribriform displacement and vertical ocular dystopia. A classic finding of the no. 13 cleft is the involvement of the cribriform plate, leading to widening of the olfactory groove, cribriform plate, and ethmoid sinuses. Especially when bilateral, this involvement can produce some of the most severe forms of hypertelorism encountered.

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No. 30 Cleft The no. 30 cleft is exceedingly rare with few cases reported. 19 It presents as an extension of the no. 0 cleft inferiorly into the mandible and cervical structures (Figure 32.11) and can range in presentation.

FIGURE 32.11 No. 30 cleft. Patient demonstrating a no. 30 cleft with bony and soft tissue deficiency. (Reproduced from Losee, JE, Kirschner, RE. Rare craniofacial defects. In: Comprehensive Cleft Care. Vol 2. 2nd ed. New York, NY: Thieme Medical Publishing; 2016

.)

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Soft Tissue Involvement In microforms/mild forms, a lower lip notch may be the only sign of a no. 30 cleft. In more severe cases, the lip and chin may be completely cleft, with the addition of a bifid tongue, ankyloglossia, or tongue agenesis. There may be diastatic or atrophic cervical strap muscles with scarring and neck contracture.

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Skeletal Involvement Skeletal involvement includes an alveolar cleft between the mandibular central incisors that extends into the symphysis. The hyoid bone may be clefted, or absent, as well as the thyroid cartilage and rarely the sternum.

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Orbital Hypertelorism OHT is an uncommon malformation which results in an abnormally wide spacing of the orbits, eyes, and periorbita. 20 It may be isolated, associated with a craniofacial cleft or encephalocele as detailed above, or one of a variety of findings in any of several craniofacial syndromes. It is important to distinguish hypertelorism from telecanthus (or pseudohypertelorism). Telecanthus is the widening of the intercanthal distance often a result of medial canthal tendon avulsion or nasoorbitalethmoid fracture. In telecanthus, the bony orbits are in a normal position. In contrast, the hyperteloric orbit is entirely displaced and the bony distance between the orbits (interdacryon distance) is increased. In addition to the horizontal vector, orbits can be displaced vertically (orbital dystopia), anteriorly or posteriorly, and rotationally. It is crucial to identify the complete extent of orbital malposition to assist in the diagnosis and correctly identify the most appropriate treatment modality. The classification of hypertelorism is based on the interdacryon distance, sometimes referred to the interorbital distance, which is defined as the distance between the junction points of the contralateral lacrimal bones, frontal processes of the maxilla, and frontal bones. 21 This measurement is best made radiographically or intraoperatively; however, a rough approximation can be made clinically by subtracting 4 to 6 mm from the caliper measurement to account for the soft tissue. In an adult, the average interdacryon distance is 25 mm in a female and 28 mm in a male. First-degree hypertelorism is defined as an interdacryon distance of 30 to 34 mm, second degree is defined as 34 to 40 mm, and third degree is defined as an interdacryon distance of greater than 40 mm. 22,23 In contrast, in a growing child, the distance between the orbits changes over time. Table 32.2 demonstrates the normal interdacryon distance at varying times during development. In children, first-degree hypertelorism is defined as an interdacryon distance 2 to 4 mm greater than normal, second degree is 4 to 8 mm greater than normal, and third degree is more than 8 mm greater than normal (Table 32.2). TABLE 32.2 Normative Interdacryon (Interorbital) Distance by Age Age (years) 1 2 3 5 7 10 12

Interdacryon Distance (mm) 18.5 20.5 21 22 23 ± 4 25 ± 2 26 ± 1

Craniofrontonasal dysplasia is a unique inherited form of hypertelorism associated with the X-linked EFNB1 gene. 24 It occurs in both inherited and sporadic forms; the typical manifestations include unicoronal or bicoronal craniosynostosis, hypertelorism, bifid or absent nasal tip, widow’s peak, and wiry hair. Additionally, patients may have cleft lip and/or palate and limb anomalies including syndactyly.

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Principles of Treatment Craniofacial Clefts Each patient with a craniofacial cleft is unique and should be treated with an individualized plan based on the specific anomalies, functional issues, and social situation. It is helpful to break down various treatment modalities based on the ideal age at which they are performed. For patients with frontonasal dysplasia, frontoethmoidal encephaloceles, or any of the medial cranial clefts (nos. 11–14), early intervention may be warranted to reduce and separate the intracranial compartment from the paranasal sinuses. To avoid the dangerous sequelae of an ascending CNS infection such as meningitis, surgery should be performed as soon as the patient is old enough to tolerate the procedure (>3 months). Additionally, patients with significant ocular involvement including eyelid deficiency or displacement may require earlier intervention if eye lubrication is insufficient to prevent corneal damage. Soft tissue reconstruction of isolated perioral clefts (nos. 0–7) can be performed at 3 to 6 months of age, similar to repairing a common cleft lip deformity. Similarly, palatal involvement should be considered around 9 to 12 months of age to maximize potential for speech development. Nasal anomalies can be treated at the time of perioral cleft repair; however, patients with frontonasal dysplasia and disorganized accessory nasal cartilage may benefit from surgery at an older age to minimize growth restriction. Medial orbital (nos. 3/11 and 4/10) clefts may require dacryocystorhinostomy if symptomatic. Bony anomalies should be reconstructed in a delayed manner unless causing functional impairment. In general, cranial bone grafts are necessary to reconstruct the orbits, facial buttresses, and nose, whereas cancellous iliac crest bone grafts can be used to treat persistent alveolar clefts. Repair of orbital dystopia and hypertelorism should be avoided before school age and preferably performed at orbital maturity (6– 9 years of age).

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Hypertelorism Hypertelorism is not a diagnosis. Rather, it is a physical finding which can occur in a range of abnormalities. When determining the correct treatment, it is crucial to consider patient’s overall diagnosis as well as other pertinent physical findings. For example, hypertelorism secondary to Apert syndrome should be treated in a completely different manner than that caused by a no. 0/14 cleft. When hypertelorism occurs, treatment should focus on safely decreasing the interorbital distance to less than 17 mm by performing a box osteotomy or a facial bipartition. Although these two operations both reduce the interdacryon distance, they differ significantly in the degree of other facial changes they produce. 25–28 A box osteotomy is limited to repositioning the orbits and the zygomas and can effectively narrow the interorbital distance while preserving midfacial and occlusal relationships. It is performed by mobilizing the orbits via a coronal incision, intracranial exposure, and orbital osteotomies in all four walls. Conversely, a facial bipartition procedure is ideal for patients who, in addition to OHT, also have maxillary hypoplasia, a narrow maxillary arch, and malocclusion. The bipartition requires mobilizing the orbits laterally and superiorly and by removing a central wedge of bone from the crista galli extending inferiorly to include the central frontal bone, ethmoids, nasal bones, and nasal septum. A central maxillary osteotomy/ostectomy is made inferior to the piriform and extending to the alveolus to complete the separation of the facial skeleton into two pieces. As the interorbital distance is narrowed, the lower facial skeleton is widened. In both procedures, rigid fixation with titanium miniplates are used to secure the bone segments, medial canthopexies are required to resuspend the soft tissue, and cantilevered bone grafts are used to maintain nasal projection. 29

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Questions 1. The proper assessment of hypertelorism most appropriately includes measurement of which of the following? a. Distance between lacrimal crests b. Distance between medial canthi c. Distance between pupils d. Distance between lateral canthi e. Distance between zygomaticofrontal sutures 2. A one-year-old presents with brachycephaly, bilateral superior orbital rim retrusion with an interorbital distance of 28 mm, and a wide nasal root. Mutation in which of the following genes is associated with these findings: a. FGFR2 b. EFNB1 c. IRF6 d. TWIST e. TCOF1 3. After cleft lip, the most common craniofacial cleft is: a. no. 2 cleft b. no. 15 cleft c. no. 7 cleft d. no. 11 cleft 4. Which of the following disorders is not associated with a 
 craniofacial cleft? a. Hemifacial microsomia b. Treacher Collins syndrome c. Cleft lip/palate d. Ethmocephaly e. Nasofrontal encephalocele 1. Answer: a. OHT is a lateral displacement of the orbits with an increase in the interorbital distance. In patients with OHT, all of the distances in the answer choices are increased; however, OHT is defined by the bony widening between the eyes best measured by the interdacryon distance, or the distance between the anterior lacrimal crests. Pseudohypertelorism, or telecanthus, can be seen after nasoorbitalethmoid fractures and results in an isolated widening of the medial canthi without lateral displacement of the globes. In skeletally mature patients, first-degree hypertelorism is defined as an interdacryon distance greater than 30 mm. 2. Answer: b. The patient described has bicoronal craniosynostosis and hypertelorism (defined as an interorbital difference of greater than a standard deviation over the age-corrected mean; 18.5 mm in a 1-year-old) and nasal anomalies. These findings are typical of patients with craniofrontonasal dysplasia, an X-linked disorder associated with mutations in the EFNB1 gene. Additionally, patients may have cleft lip/cleft palate, curly hair, and syndactyly. FGFR2 is associated with Crouzon, Apert, and Pfeiffer syndromes. IRF6 is the mutation associated with van der Woude syndrome, TCOF1 is associated with Treacher Collins syndrome, and TWIST is associated with Saethre-Chotzen syndrome. None of these syndromes is associated with the constellation of symptoms described earlier. 3. Answer: c. The Tessier rare craniofacial cleft classification describes both bony and soft tissue clefts. The Tessier no. 7 cleft describes a soft tissue cleft which starts at the lateral oral commissure

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and extends to varying extents toward the tragus. It is the most common of the Tessier clefts and is associated with multiple craniofacial syndromes including Treacher Collins syndrome and hemifacial microsomia. 4. Answer: c. Hemifacial microsomia is often associated with a no. 7 (lateral commissure) cleft. Treacher Collins syndrome is associated with no. 6, 7, and 8 clefts. Ethmocephaly is associated with midline craniofacial hypoplasia and no. 14 cleft. Craniofrontonasal dysplasia and nasofrontal encephaloceles are associated with no. 14 or 0/14 clefts. The Tessier (rare craniofacial) cleft classification is not used to describe common facial clefts such as those that occur in unilateral or bilateral cleft lip and/or palate.

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References Wolf, SA. A Man from Héric: The Life and Work of Paul Tessier, MD, Father of Craniofacial Surgery. Lulu Enterprises; 2012. Tessier, P. Anatomical classification of facial, craniofacial, and latero-facial clefts. 
 J Maxillofac Surg. 1976;4:69. Kawamoto, HK Jr. The kaleidoscopic world of rare craniofacial clefts: order out of chaos (Tessier classification). Clin Plast Surg. 1976;3(4):529572. Allam, KA, Wan, DC, Kawamoto, HK, et al. The spectrum of median craniofacial dysplasia. Plast Reconstr Surg. 2011;127(2):812-821. Gaball, CW, Yencha, MW, Kosnik, S. Frontonasal dysplasia. Otolaryngol Head Neck Surg. 2005;133(4):637-638. Guion-Almeida, ML, Richieri-Costa, A, Saavedra, D, Cohen, MM. Frontonasal dysplasia: analysis of 21 cases and literature review. Int J Oral Maxillofac Surg. 1996;25(2):91-97. Jones, MC. Etiology of facial clefts: prospective evaluation of 428 patients. Cleft Palate J. 1988;25(1):16-20. Resnick, JI, Kawamoto, HK. Rare craniofacial clefts: Tessier no. 4 clefts. Plast Reconstr Surg. 1990;85(6):843-849. Stark, RB, Saunders, DE. The first branchial syndrome. The oral-mandibular-auricular syndrome. Plast Reconstr Surg Transpl Bull. 1962;29:229-239. Longacre, JJ. The surgical management of the first and second branchial arch syndrome. Br J Plast Surg. 1965;18:243-253. Converse, JM, Coccaro, PJ, Becker, M, Wood-Smith, D. On hemifacial microsomia: the first and second branchial arch syndrome. Plast Reconstr Surg. 1973;51(3):268-279. Grabb, WC. The first and second branchial arch syndrome. Plast Reconstr Surg. 1965;36(5):485-508. Limaye, SR. Coloboma of the iris and choroid and retinal detachment in oculo-auricular dysplasia (Goldenhar syndrome). Eye Ear Nose Throat Mon. 1972;51(10):384-386. Raulo, Y, Tessier, P. Mandibulo-facial dysostosis: analysis; principles of surgery. Scand J Plast Reconstr Surg. 1981;15(3):251-256. Roddi, R, Vaandrager, JM, van der Meulen, JC. Treacher Collins syndrome: early surgical treatment of orbitomalar malformations. J Craniofac Surg. 1995;6(3):211-217. Halal, F, Herrmann, J, Pallister, PD, et al. Differential diagnosis of Nager acrofacial dysostosis syndrome: report of four patients with Nager syndrome and discussion of other related syndromes. Am J Med Genet. 1983;14(2):209-224. Bodin, F, Salazard, B, Bardot, J, Magalon, G. Craniofacial cleft: a case of Tessier no. 3, 7 and 11 cleft. J Plast Reconstr Aesthet Surg. 2006;59(12):1388-1390. Ozek, C, Gundogan, H, Bilkay, U, et al. Rare craniofacial anomaly: Tessier no. 2 cleft. J Craniofac Surg. 2001;12(4):355-361. Ladani, P, Sailer, HF, Sabnis, R. Tessier 30 symphyseal mandibular cleft: early simultaneous soft and hard tissue correction: a case report. J Craniomaxillofac Surg. 2013;41(8):735-739. Tan, ST, Mulliken, JB. Hypertelorism: nosologic analysis of 90 patients. Plast Reconstr Surg. 1997;99(2):317-327. Tessier, P. Orbital hypertelorism. I. Successive surgical attempts. Material and methods: causes and mechanisms. Scand J Plast Reconstr Surg. 1972;6(2):135-155. Costaras, M, Pruzansky, S, Broadbent, BH. Bony interorbital distance (BIOD), head size, and level of the cribriform plate relative to orbital height: I. Normal standards for age and sex. J Craniofac Genet Dev Biol. 1982;2(1):5-18. Costaras, M, Pruzansky, S. Bony interorbital distance (BIOD), head size, and level of the cribriform plate relative to orbital height: II. Possible pathogenesis of orbital hypertelorism. J Craniofac Genet Dev Biol. 1982;2(1):19-34. Wolfswinkel, EM, Weathers, WM, Correa, B, et al. Craniofrontonasal dysplasia: variability of the frontonasal suture and implications for treatment. J Craniofac Surg. 2013;24(4):1303-1306. Marchac, D, Sati, S, Renier, D, Deschamps-Braly, J, Marchac, A. Hypertelorism correction: what happens with growth? Evaluation of a series of 95 surgical cases. Plast Reconstr Surg. 2012;129(3):713-727. Kawamoto, HK, Heller, JB, Heller, MM, et al. Craniofrontonasal dysplasia: a surgical treatment algorithm. Plast Reconstr Surg. 2007;120(7):1943-1956. McCarthy, JG, La Trenta, GS, Breitbart, AS, et al. Hypertelorism correction in the young child. Plast Reconstr Surg. 1990;86(2):214-225. Tessier, P, Guiot, G, Derome, P. Orbital hypertelorism. II. Definite treatment of orbital hypertelorism (OR.H.) by craniofacial or by extracranial osteotomies. Scand J Plast Reconstr Surg. 1973;7(1):39-58. Wan, DC, Levi, B, Kawamoto, H, et al. Correction of hypertelorbitism: evaluation of relapse on long-term follow-up. J Craniofac Surg. 2012;23(1):113-117.

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CHAPTER 33

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Ear Reconstruction Akira Yamada and Arun K. Gosain

Key Points The understanding of precise location, dimension, and proportion of the normal auricle is the foundation for optimal ear reconstruction. There are four principles in ear reconstruction: proper ear location, well-vascularized thin skin envelope, anatomical 3D framework, and beautiful curves. Team approach to address both hearing and external ear shape from infancy to adulthood will give patients optimal integration to the society. Timely ear molding less than 3 months of age, ideally less than 1 month of age, is a powerful option for miscellaneous ear anomalies to obviate the need for surgery. Current three major options for microtia reconstruction are autogenous rib reconstruction, Medpor reconstruction, and prosthesis. Surgeons should explain to patients the pros and cons of each option. Precise 3D framework is the essential foundation for total auricular construction. Secondary ear reconstruction may require total replacement of 3D framework, new skin flap/fascial flap coverage, and correction of the ear location.

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The Normal Auricle Anatomy The auricle is difficult to reproduce surgically because it is made up of a complexly convoluted frame of delicate elastic cartilage surrounded by a thin skin envelope. Like spiral architecture in the inner ear, the external ear also has a spiral architecture, connecting the basal layer to the top layer. The auricle’s rich vascular supply comes from the superficial temporal anteriorly and posterior auricular vessels posteriorly. The sensory supply to the auricle is mainly derived from the inferiorly coursing greater auricular nerve (C2-C3). Upper portions of the auricle are supplied by lesser occipital (C2-C3) and auriculotemporal nerves (V3) (tragus and crus helicis), whereas the concha region is supplied by a branch of vagal nerve. Arnold nerve (CN 7,9,10) is an auricular branch of vagus nerve that receives contributions from facial nerve and glossopharyngeal nerve. Arnold nerve supplies posterior inferior external auditory canal and meatus, and inferior conchal bowl. This nerve mediates clinical phenomena, such as otalgia. Lymphatic drainage correlates with six embryonic hillocks. The tragus, root of the helix, and superior helix arise from first branchial arch (anterior hillocks 1–3) and drain into parotid nodes. The antihelix, antitragus, and lobule arise from second branchial arch (posterior hillocks 4–6) and drain into cervical nodes.

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Embryology The auricle begins to protrude from the developing face at approximately 3 to 4 months of gestation (Figure 33.1). The auricle arises from two branchial arches: mandibular branchial arch (first) and hyoid branchial arch (second). First branchial arch (anterior hillocks 1–3) contributes the tragus, root of helix, and superior helix (upper third of auricle). Second branchial arch (posterior hillocks 4–6) contributes the rest (antihelix, antitragus, lobule) (lower two-thirds of auricle).

FIGURE 33.1 Embryology of the external ear. A. Hillock formation in an 11-mm human embryo. B. Hillock configuration in a 15-mm embryo at 6 weeks of gestation. C. Adult auricle depicting hillock derivations.

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Location and Dimensions The auricle is located one ear length posterior to the lateral orbital rim, with superior pole level with brow and inferior pole level with alar base. Vertical height of an adult auricle is approximately 55 to 65 mm. Width is approximately 50% to 55% of its length 1 (Figure 33.2). Lateral protrusion of the helix is 1 to 2 cm from the scalp. The long axis tilts posteriorly 15° to 20°. Projection from mastoid to helix: superior 10 to 12 mm; middle 16 to 18 mm; and inferior 20 to 22 mm. The normal auricle is located immediately behind the face mask. Surgeons should avoid placing the new auricle inside the face mask: This is especially important in hemifacial microsomia because the vestige lobule tends to be located anteriorly and inferiorly and may be located inside the face mask. An anthropological study shows that the auricle is normally located approximately 20 mm behind the sideburn. 2 There is a trapezium-shape nonhairbearing skin space, between the sideburn and the auricle in normal anatomy (Figure 33.3). Avoiding placing ear framework in this preauricular trapezium is important to prevent anterior inclination of the auricle.

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FIGURE 33.2 The normal location and dimensions of the auricle, in relation to the surrounding facial anatomy. FH, Frankfurt horizontal line.

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FIGURE 33.3 Nagata-type microtia construction: A. Preoperative view of an 11-year-old girl with lobule-type microtia. B. Harvested ipsilateral six to nine rib cartilage. Note the color of cartilage is white, meaning the perichondrium is completely left intact at the donor site for regeneration. C. 3D Framework with 52 mm type A2 template. D. Appearance at second-stage surgery. Temporoparietal fascia flap is raised, and the cartilage block is fabricated according to thermos-elastic template. E. The final view of the patient 1 year after surgery.

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Miscellaneous Ear Anomalies Cryptotia Cryptotia is a congenital ear deformity in which upper pole of ear cartilage is buried underneath the scalp. The superior auriculocephalic sulcus is absent but can be demonstrated when you pull up the helical pole. Various surgical corrections are reported from Japan, due to the high prevalence of cryptotia, as frequently as 1:400. Nonsurgical ear-molding treatment may be applied if the child is in early neonate stage. The goal of surgical treatment is to create the retroauricular sulcus by skin grafts, Z-plasty, V-Y advancement, or rotation flap. 3 Common cartilage deformity associated with cryptotia is helix-scapha adhesion, which may be addressed by cartilage remodeling techniques.

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Stahl Ear Stahl ear, a rare congenital auricular deformity, is characterized by the third crus extending toward the helical rim. Stahl ear is classified into three types: Type 1: Obtuse-angled bifurcation of antihelix; looks as though superior crus is missing Type 2: Trifurcation of antihelix Type 3: Broad superior crus and broad third crus (protruded scaphoid fossa) Ear molding may work well if ear molding is started in early infancy. Surgical treatment is broadly categorized into two types: cartilage/skin excision and cartilage alteration. Type 1 Stahl ear needs special attention, to reconstruct missing superior crus, by using excised third crus or rib cartilage graft or creating superior crus by sutures or cartilage cutting.

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Constricted Ear Constricted ear is a concept proposed by Tanzer in 1975, 4 and his classification is shown in Table 33.1. In constricted ear, helix and scapha fossa are hooded, and crura of antihelix is flattened in various degrees. One gains an impression that the rim of helix has been tightened. Constricted ear is often referred as cup or lop ear. Tanzer classified constricted ear into three groups based on the severity of defect/deformities. Tanzer group 1: Mild deformities of helix, often called lop ear. Defect involves helical cartilage with minimum skin defect. Musgrave technique is a useful method to expand the helix. Through either anterior or posterior skin incision, multiple cuts were made to the curled cartilage, fan upward and backward, fixed to the curved strut made of concha cartilage graft. The skin is then redraped across the reconstructed framework. For milder constricted ear (group 1,2A), focusing surgical correction to construct helical curve is the reasonable option while keeping the original elastic cartilage framework, avoiding hard rib cartilage framework. When superior crus is deficient, partial helix plus superior crus frame from rib cartilage 5 can normalize the deformity. Tanzer group 2B: Has both skin and cartilage defect in the upper one-third of the auricle. The loss of folding may involve antihelical crura, and hooding is more pronounced. The height of the ear is sharply reduced. Park 6 proposed versatile solution for group 2B constricted ear. For helical skin defect, Park modified the Grotting flap (postauricular flap), creating both skin flap and fascia flap with the same pedicle. For helical cartilage defect, eight rib cartilage is harvested, the helix is fabricated, and the entire length of helix is constructed. Tanzer group 3: Most severe cupping and failure of migration. Brent recommends to treat severe constricted ear as if it is a form of microtia, when the construction is severe enough to produce a height difference of 1.5 cm. Nagata recommends treating severe constricted ear as a concha-type microtia, to replace the defective framework with a full rib cartilage framework. 7 TABLE 33.1 Tanzer Classification of Constricted Ear Group I II IIA IIB III

Description Involvement of helix only Involvement of helix and scapha No supplemental skin needed at margin of auricle Supplemental skin needed at margin of auricle Extreme cupping deformity; often associated with incomplete migration, forward title, stenosis of external auditory canal, and deafness

(From Tanzer, RC. The constricted ear (cup and lop) ear. Plast Reconstr Surg. 1975;55:406.)

Based on the degree of defects, for both skin defects and cartilage defects, the authors’ recommendations for treatment are summarized in Figure 33.4.

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FIGURE 33.4 Recommended strategy for constricted ear. A. Skin augmentation strategy based of the tissue defect severity. B. Cartilage modification strategy based on the severity of defect.

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Ear Molding in Miscellaneous Ear Anomalies Matsuo, who first reported ear molding treatment for congenital ear deformities, states that when the ear deformities are not hypoplastic, nonsurgical correction is easy and reliable. 8 Stahl ear responds well to the nonsurgical correction only during the neonatal period, whereas protruding ears and cryptotia respond until approximately 6 months of age (Matsuo). It is widely believed that the early initiation of molding is more effective because maternal estrogen in the neonate keeps ear cartilage soft and elastic. Most agree that if ear molding is started after 3 months of age, the response tends to be poor. Helixantihelix adhesion responds poorly to the ear molding treatment and may not be the indication of the ear molding. Skin irritation is probably the most frequent complication, possibly due to tape or adhesive.

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Microtia Epidemiology and Pathophysiology Microtia (small ear) is a congenital condition with unknown cause. Prevalence of microtia varies significantly among ethnic groups (0.83–17.4 per 10,000 births) and is higher in Asian countries for unknown reason. 80% to 90% of microtia is unilateral, and 10% to 20% is bilateral. There are more than 18 different microtia-associated syndromes with single-gene or chromosomal aberrations; however, there is no causal genetic mutation confirmed to date. A relatively common syndrome associated with microtia is hemifacial microsomia and Treacher-Collins syndrome. Isolated microtia rarely run in families. TreacherCollins syndrome, inherited in an autosomal dominant fashion, often presents with bilateral microtia.

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Classification Many attempts have been made to classify microtia based on embryogenic development and severity of the deformities. Nagata’s classification is based on surgical correction of the deformity 9–11 : Anotia: Absence of auricular tissue Lobule type: Vestige ear with lobule, without concha, acoustic meatus, and tragus Concha type: Vestige ear with lobule, concha, acoustic meatus, and tragus Small concha type: Vestige lobule with small indentation of concha (need lobule-type construction) Atypical microtia: Cases do not fall into previous categories

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Patient Assessment and Workup About 20% to 60% of children with microtia have associated anomalies or an identifiable syndrome; therefore, individuals with microtia should be examined for other dysmorphic features. Microtia is a common feature of craniofacial microsomia, mandibular dysostoses (eg, Treacher-Collins and Nager syndromes), and Townes-Brocks syndrome, and these conditions should be considered among the differential diagnosis when evaluating an individual with microtia. If there is family history of syndrome, genetic counseling may be necessary.

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Physical Examination Identify the type of microtia, size, dimension, and type of normal auricle, if unilateral. Normal side may not be normal and may have subtle ear deformity such as helix-antihelix adhesion. Evaluate the symmetry of face, facial animation (partial facial paralysis is frequent finding), and dental occlusion. Hemifacial microsomia is often associated with difficult airway for intubation.

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Diagnostic Studies Audiologic testing to determine conductive versus sensorineural defect Temporal bone imaging High-resolution CT scan for evaluating middle ear ossicles to assess the possibilities of future otologic surgery MRI to determine the course of facial nerve, often displaced, especially in the absence of pneumatized mastoid Rule out the presence of cholesteatoma (squamous epithelium trapped in the middle ear), present in 4% to 7% of atresia

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Atresia and Middle Ear Anomalies In bilateral microtia, early and conscientious use of bone-conductive hearing aid is imperative for hearing and speech development. Most of hearing deficits in children with bilateral microtia are managed with hearing aids. Treatments of microtia ideally involve reconstruction of the external ear and the restoration of normal hearing. 12 Hearing impairment in microtia is related to abnormal auditory canal, tympanic membrane, and middle ear. The problem is conduction. Typically, microtia patients have a hearing threshold of 40 to 60 dB on the affected side. By comparison, normal function allows us to hear sounds between 0 and 20 dB. Regarding middle ear surgery for hearing restoration, most surgeons presently feel that potential gains from middle ear surgery in unilateral microtia are outweighed by the potential risks and complications for the surgery, and this surgery should be reserved for bilateral cases. Careful selection of the atresia surgery candidate is important to achieve optimal outcome and more importantly to avoid unnecessary surgery and its complications. Jahrsdoerfer criteria are a widely accepted guideline to select atresia surgery candidates. 13 The bone-anchored hearing aid (BAHA; Cochlear, Mölnlycke, Sweden; and Ponto; Oticon, Kongeballen, Denmark) has been used since 1977, which does not need functioning middle ear or patent canal. In microtia patients, BAHA was initially started to use for bilateral microtia with bilateral conducting hearing loss: Unilateral BAHA is usually placed because a single aid will stimulate both cochlea simultaneously. The drawback of BAHA is the interface between titanium and skin: It may cause skin irritation or infection. BAHA has a retention rate of over 95% on long-term follow-up, with a soft-tissue reaction rate of 30%. 14

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Syndromes Associated With Microtia Craniofacial Microsomia Microtia associated with craniofacial microsomia needs attention for specific characteristics. 15 Dystopic vestige: To achieve symmetry of the vertical dimension of the auricles, dystopic vestige must be transposed backward, and upward, either as a surgery before 3D framework placement, or simultaneous transposition 16 with 3D framework placement. Mistakes are often made to use vestige lobule in the face mask, without transposing it. Low hairline: Low hairline is a part of abnormal hairline most often seen in hemifacial microsomia and Treacher-Collins syndrome. Abnormally low hairline is often associated with missing sideburns, which can confuse surgeons on where to place the new auricle. Avoiding hairline may cause abnormal location of the new auricle too inferiorly. Soft-tissue defect: As a part of manifestation of hemifacial microsomia, microtia is often associated with relatively large depression of soft tissue around the auricular site. Fat grafting may help to improve it. Vascular anomalies: The course of STA is often abnormal. To avoid injury to STA, preoperative Doppler ultrasound tracing of the STA course is advisable.

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Treacher-Collins Syndrome Because a patient with Treacher-Collins syndrome has a relatively smaller face, the size of a new ear has to balance with the smaller face. When you assess microtia in Treacher-Collins syndrome, two specific findings are important not to miss: Low hairline: To eliminate hair on the new auricle, either temporoparietal fascia (TPF) flap or random-pattern fascia flap 17 is necessary to eliminate hair over the framework. Coronal scar: When the patient already has a coronal scar, surgeons should be aware that STA is severed. That means TPF is not available for either low hairline case to cover the anterior surface or for Nagata-type ear elevation to cover the posterior surface. Occipital fascia flap may be indicated.

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Surgical Management History of Microtia Reconstruction Sushuruta (6 BC) was probably the earliest surgeon who performed auricular construction, repairing the earlobe with cheek flap. Tagliacozzi described repair of ear deformities with retroauricular flaps. In 1845, Dieffenbach reported the repair of the middle third of the ear with an advancement flap. This technique may have application today. Early surgical attention focused mainly on traumatic deformities. However, by the end of the 19th century, surgeons began to address congenital defects, in particular prominent ears. The concept of microtia repair began in 1920, when Gillies buried carved costal cartilage under masts skin and elevated it with cervical flap. In 1937, Gillies also used maternal ear cartilage for more than 30 microtic ears; these were found to have progressively resorbed. Peer diced autogenous rib cartilage and placed it in a vitallium ear mold beneath the abdomen in 1948. After 5 months, he retrieved the banked mold, opened it, and harvested the ear framework for microtia repair. Steffensen’s 1955 attempt to use preserved cartilage resulted in progressive resorption of the grafted cartilage. Tanzer, whose excellent results established autogenous construction with rib cartilage, 18 is considered to be the father of modern auricular construction. Surgeons from around the world visited Dartmouth-Hitchcock Medical Center, and autogenous construction spread across the globe. In the United States, Brent succeeded Tanzer in early 1970s, and Brent’s artistry has influenced reconstructive surgeons for more than 40 years until today. Nagata’s two-stage method emerged in the 1990s and has gradually gained popularity, becoming the strongest alternative to Brent’s four-stage method. Autogenous cartilage remains the most reliable material that produces results with the least complications.

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Timing of Surgery The timing of auricular construction is governed by both psychological and physical considerations. From a psychological perspective, it would be ideal to begin construction before the child enters school, but autogenous construction should be postponed until rib growth provides substantial cartilage to permit a quality framework fabrication. Brent begins ear construction at age 6 years, when normal ear has grown to within 6 to 7 mm of its full vertical height and the amount of cartilage is enough for Brent-type framework. Nagata begins auricular construction at the age of 10 years, and chest circumference grows over 60 cm, at the xiphoid level. These two different timings could be explained by the difference of the amount of cartilage required: Nagata-type 3D framework needs larger amount of cartilage from ribs six to nine. In other words, surgeons are less likely to able to fabricate Nagata-type framework at the age 6 years.

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Autogenous Construction The two main techniques described for autogenous auricular construction using a rib cartilage are the Brent and Nagata techniques (see Figure 33.3). Brent technique: Four-stage reconstruction beginning at 6 years of age 19 : Creation and placement of a rib cartilage auricular framework Rotation of the malpositioned ear lobule into the correct position Elevation of the reconstructed auricle and creation of a retroauricular sulcus Deepening of the concha and creation of the tragus Autogenous rib cartilage framework: Rib cartilage framework has evolved from Tanzer-type in the 1950s to anatomically most complete Nagata-type 3D framework architecture (Figure 33.5). 20

Harvesting rib cartilage method: Brent harvested rib cartilage with perichondrium attached to it. Because the perichondrium is the scaffold of cartilage matrix regeneration, after harvesting rib cartilage, chest depression deformities are the usual consequences. Nagata harvests rib cartilage without perichondrium. 32 By leaving 100% perichondrium to the donor site, and bringing back diced leftover cartilage to the donor site, by creating a perichondrium pocket, Nagata stated that chest deformities are less likely to occur. 22,23

FIGURE 33.5 Architecture of 3D framework.

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Synthetic Framework Although silicone breast implants are used, silicone ear framework is discontinued today. Silicone framework, introduced by Cronin in 1966, extrudes, causes infection, and loses definition in the long term. Porous polyethylene implant framework, newer synthetic material, was first introduced by Reinisch in 1991. 24 The advantage of porous polyethylene implant over autogenous construction is that it can be applied to younger children whose costal cartilage are less mature and not ready for autogenous reconstruction. The disadvantage of porous polyethylene framework includes use of TPF flap, long-term risk of alloplastic implant exposure or loss, and compromise of any future autogenous options. Early attempts were associated with a 42% incidence of framework extrusion leading to modifications of the original technique and coverage of the framework using a TPF flap. This drastically reduced the complication rate and is the technique of choice in his opinion. Long-term data to prove sustainability of porous polyethylene implant are not available.

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Prosthesis Osseointegrated auricular prosthetic reconstruction is complementary to other approaches and provides a reasonable alternative to poor autogenous options and poor synthetic framework outcomes. The disadvantages of prosthesis include intermittent soft-tissue problems, long-term maintenance, prosthetic remakes every 2 to 5 years, ongoing cost, compromise of future autogenous options, and need for a compliant patient. 9

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Secondary Total Auricular Reconstruction The cause of unsatisfactory ear reconstruction can be divided into three main categories: inappropriate skin envelope, inappropriate ear framework, and inappropriate ear location. Most unsatisfactory cases have all three components. Therefore, radical total redo of everything (skin envelope, 3D framework, and ear location) may be the solution for the patients/family who are willing to go through the long and challenging surgery. Assessment of the patients is important to know what kind of surgical option would be optimal for the patients. TPF flap is the workhorse for secondary ear reconstruction. 25 The surgeon must assess the presence of STA from the base (near the caudal end of the auricle location) up to the parietal area (10 cm above the upper helix portion), by Doppler ultrasound. If TPF is not available, pedicle-occipital facial flap, or free vascularized fascia flap transfer are the option for the new skin envelope. 26

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Complications of Microtia Construction Complication of both Brent technique and Nagata technique is rare in experienced hands. Most common complication from surgery is that the construct does not look like a normal auricle. Framework problem: Surgeons must understand the basic aesthetic and proportion of the normal auricle to create appropriate 3D framework. Surgeons should receive intense hands-on laboratory training before starting clinical cases. Skin envelope problem: There has been scarce discussion on what is the optimal thickness of the skin flap for ear reconstruction. Too thick skin flap will make ear definition poor; on the other hand, too thin skin flap may die: Surgeons have to walk on a fine line between the two. Nagata stated that proper skin thickness for ear reconstruction is 2 mm. Ear position problem: Various types of ear malposition are possible. Surrounding pathological anatomy influences surgeon’s judgment. To avoid misjudgment of ear positioning, careful assessment of anatomy around the microtia site is important: overall facial symmetry, distance between lateral canthus to the vestige, location of vestige lobule, presence of low hairline. Low hairline is easy to miss and that may cause low-set ear. To avoid hair in the reconstructed ear, ear position may be compromised by some surgeons: Ear may be located too low or inclined forward. Ear positioning in secondary reconstruction is challenging because of inherent and acquired abnormal anatomy around the ear site. Poor definition: Poor definition is one of the most frequent unfavorable outcomes of total ear reconstruction. To create ear definition, skin flaps have to be balanced perfectly with 3D framework, have to have adequate thickness of skin flap—not too thick, not too thin—and must have enough space between cartilage to set in the skin flap. For example, if both helix and antihelix are too wide, there is minimum space between two structures, thus skin flap will not go into that space. Atelectasis: Postoperative pain from rib cartilage harvest may aggravate atelectasis. This can be improved with infusion pumps of local anesthetics. Skin flap necrosis: In the Nagata technique, lobule split technique requires a delicate, meticulous split of the lobule right in the middle. If the lobule was not split in the middle, uneven split may cause partial skin necrosis. To make split lobule more mobile, the split must be performed down to the fascia level. Incomplete, shallow split may cause insufficient rotation and may cause tension to the skin flap that may lead to skin flap necrosis. Relatively large subcutaneous pedicle for posterior skin flap must be preserved to prevent skin flap necrosis. 27 Infection: Immediate postoperative infection after total ear reconstruction is rare (10 mm2 has been shown to correlate with hypernasality. 19 Nasalance (defined as the ratio of nasal sound energy divided by sum of oral and nasal sound) is the acoustic index of nasality that is primarily measured during this assessment. As the patient reads (or repeats) a standardized speech passage, computer-based analysis is done and a nasalance score is calculated (range 0%–100%). Even though a variety of cut-off values for normal versus abnormal are used (depending upon the speech stimulus), in general a higher score suggests more nasality. Nasometry is one of the few tools that indirectly provide objective assessment of velopharyngeal mechanism but the criticism to its use is its oversimplification of the VPD mechanism and its inability to predict the location of gap size. 20

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Surgical Management If a patient is deemed a surgical candidate, then the choice of surgical procedure should be individualized and based on a host of factors. The goal of all surgical procedures is to decrease the area of velopharyngeal port and reduce nasal air escape during phonation. Size of the defect, closure pattern, and lateral wall motion are the three most important anatomic factors that should be considered in selecting an optimal surgical procedure for the treatment of VPI. Figure 34.2 shows an algorithm for choosing the suitable surgical procedure for the treatment of VPI. It is important to keep in mind that functional repairs (see description later) yield a more anatomic local tissue rearrangement of structures in the soft palate, without adding tissue from neighboring areas (e.g., in pharyngeal flap, sphincter pharyngoplasty, or posterior wall augmentation procedures). Hence, functional repairs inherently have less risk of obstructive sleep apnea (OSA) and should be attempted whenever possible to reduce the risk of longterm airway complications as the patient ages.

FIGURE 34.2 An algorithm for choosing the optimal surgical procedure for the treatment of velopharyngeal insufficiency.

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Functional Palatal Lengthening Functional palatal lengthening can be achieved by Furlow palatoplasty, or intervelar veloplasty. The main anatomic objective of these procedures is to achieve lengthening of the soft palate with retropositioning of levator muscle in the velum and closure of a small gap in the VP port. Sommerlad popularized the concept of radical intervelar veloplasty, described as complete dissection of the velar muscle complex off the nasal and oral mucosal layer in the soft palate as far laterally as the hamulus, where tensor tendon is visualized and divided medial to the hamulus. The muscle is then divided from the posterior border of the hard palate and then retropositioned and repaired in at least middle third of the velum (or more posterior to it). 21 Sommerlad prospectively studied pre- and postoperative speech outcomes in 129 patients with previous cleft palate repair, anterior insertion of levator muscle, and symptoms of VPI, who underwent palatal repairs by radical intervelar veloplasty technique and noted significant improvement in hypernasality, nasal air emission, and velopharyngeal gap closure. 22 Sommerlad et al. advocated that radical intervelar veloplasty should be considered as the first-line option in patients with VPI (especially those with levator knee or point of maximum velar excursion on lateral VFS more anteriorly located). However, if the palate is scarred and immobile, then rerepair is unlikely to improve symptoms of VPI and should not be attempted. The more commonly performed palatal lengthening procedure was introduced by Leonard Furlow in 1986. 23 This procedure entails creation of two double opposing Z-plasties of oral and nasal mucosa with attached levator muscle. Lengthening is achieved by the concept of Z-plasty and reorientation of the levator muscle to a more anatomic posterior position, which is achieved by its double opposition technique. A recent study retrospectively analyzed the anatomic and speech changes of 29 patients with VPI in the setting of previous cleft palate repair or submucous cleft and confirmed that Furlow resulted in significant velar elongation, increased acuity of the genu angle, and retropositioning of the levator sling. In their study, Furlow resulted in improvement of the resting genu angle which was noted to be 10° more acute than preoperative assessment. Additionally, speech improvement and the absence of need for reoperation were most consistently associated with tightening of the genu angle. 24 The advantage of functional repair (over more obstructive or nonanatomic surgical procedures for VPI) is that it reduces the long-term distortion of the airway which places patients at a lower risk for OSA, as they grow older and/or gain weight. This reduced risk of OSA is at the cost of up to 30% risk of failure (or incomplete resolution of VPI), which may be a risk worth taking to avoid long-term morbidity of OSA. 21,22,25 However, it is important to counsel patients about the possibility of failure and need for a more obstructive procedure in future if functional repair is selected for the management of VPI. Other methods of palatal lengthening include interpositional buccal flap and V-Y pushback palatoplasty. Next category of surgical procedures aims to physically decrease the area of velopharyngeal port and resulting nasal air escape and hypernasality. These procedures include pharyngeal flap, sphincter pharyngoplasty, or posterior wall augmentation.

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Posterior Pharyngeal Flap Pharyngeal flap was first described by Schoenborn in 1876. This is a rectangular-shaped myomucosal flap, raised from the posterior pharyngeal wall and insetted into the velum. 26 This flap converts a large velopharyngeal port into two small lateral ports by creating a midline obstruction between oral and nasal cavities (Figure 34.3). Even though Schoenborn’s original design for pharyngeal flap was inferiorly based, various modifications of posterior pharyngeal flap have been described in the literature. In general, inferiorly based flaps are considered easier to attach, and superiorly based flap have the advantage of giving a larger flap; however, data are not conclusive on superiority of one flap design over another. 27 Some of the demerits of inferiorly based flap include limitation of its length and possible inferiorly directed pull onto the velum, which is in contradiction to the goals of effective velopharyngeal closure mechanism. Even though theoretically decreasing the port size by virtue of flap attachment into the velum should decrease the symptoms of VPI secondary to all types of ports, pharyngeal flap is best suited for patients with a sagittal or circularly oriented closure patterns. Additionally, adequate lateral wall motion is also important for the success of the flap. 28 Other factors that may play a role in the success of pharyngeal flap are flap width and level of attachment. Flaps that are too wide may be counterproductive by causing symptoms of hyponasality and sleep apnea; on the other hand, flaps that are not wide enough may be ineffective. Width of the flap is generally driven by surgeon experience and supplemented by preoperative diagnostic workup and information gained by videoflouroscopy and/or nasal endoscopy regarding port size, orientation, and lateral pharyngeal wall motion. 29 Pharyngeal flap is ideally inserted at the level of C1 to allow adequate elevation of the velum.

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FIGURE 34.3 Pharyngeal flap.

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Sphincter Pharyngoplasty Sphincter pharyngoplasty procedure was introduced by Hynes in 1950, who described the use of bilateral salpingopharyngeus muscles for decreasing the dimension of velopharyngeal port. 30 Since the first description, several modifications of this procedure have been reported in literature. 31,32 Currently, the most commonly used design of this procedure entails 90° transposition of the superiorly based palatopharyngeal muscles from the posterior tonsillar pillars to the posterior pharyngeal wall (Figure 34.4). It is best suited for a large posterior gap with coronal, circular, or bowtie closure pattern and/or poor lateral wall motion. An advantage of sphincter pharyngoplasty procedure is the ability to adjust the port size postoperatively, if needed by tightening or loosening the muscles.

FIGURE 34.4 Sphincter pharyngoplasty.

There is not enough evidence to suggest the superiority of sphincter pharyngoplasty or pharyngeal flap for the treatment of VPI. 33,34 Large multicenter, randomized, blinded, and prospective studies are required to determine the optimal procedure for VPI secondary to each type, size, and port orientation.

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Posterior Pharyngeal Wall Augmentation Various autologous and alloplastic materials have been reported in the literature with a goal to reduce the size of velopharyngeal port. Some of the synthetic materials used for posterior wall augmentation include silicone, Teflon, proplast, etc. 35 Fat, fascia, cartilage, dermis, and rolled posterior pharyngeal flap are some of the autologous materials that have been used for posterior wall augmentation. 36,37 Infection, resorption, extrusion, migration, and unreliability of the results are some of the reported complications and criticisms of posterior wall augmentation procedures. Another risk associated with posterior wall augmentation with fat is its enlargement with weight gain and the consequent risk of OSA, at which point the grafted fat may be difficult to remove. 36,37

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Complications Complications after surgery for VPI include OSA, bleeding, dehiscence, airway obstruction, injury to anomalous internal carotid artery, and persistent hypernasality, hyponasality, or reoperation. In a 10-year review of perioperative complications following pharyngeal flap surgery, overall complication rate was reported to be 6%. 38 Another series reported a 38% incidence of symptoms of upper airway obstruction acutely after pharyngeal flap surgery, but persistent symptoms beyond five months was only seen in 6% of the patients. 39 Witt et al. reported a 13% incidence of OSA following sphincter pharyngoplasty. 40 Symptoms of OSA can vary from snoring without any airway obstruction to obstruction with desaturation, hence randomized controlled studies comparing complications secondary to various surgical interventions utilized in the management of VPI patients are needed. Another study on salvage of failed pharyngoplasties reported equivalent rates of failure with pharyngeal flap (20%) and sphincter pharyngoplasty (16%) and successful denasalization of speech following revision surgery. 41

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Special Considerations Velopharyngeal Dysfunction and Chromosomal Syndromes Many chromosomal syndromes are associated with VPD. Among the syndromic presentations, 22q11.2 deletion syndrome (sometimes referred to as velocardiofacial or Shprintzen syndrome) is known to be the most common syndrome associated with cleft palate and VPI. These patients commonly have submucous cleft; however, they may have a higher risk of associated VPD compared with patients with submucous cleft in the absence of 22q11.2 deletion syndrome. This higher risk is thought to be multifactorial, and the most commonly reported factor is neuromuscular dysfunction of the muscles of velopharyngeal mechanism. Other contributing factors include increase in the width of space between velum and posterior pharyngeal wall, asymmetric displacement of lateral pharyngeal wall, reduced adenoid size, and intellectual disabilities. Hence, vigilance during interpretation of diagnostic tests such as VFS and nasal endoscopy becomes even more important in the setting of syndromic presentation, so that the accurate diagnosis can be made and precise prognosis of improvement with surgical intervention can be established. During nasal endoscopy, attention should also be paid to the presence of pulsations in the posterior or lateral pharyngeal wall which may suggest medialization of internal carotid arteries. Medial displacement of internal carotid arteries can be frequently seen in patients with 22q11.2 deletion or Kabuki syndrome. 42 Shprintzen and colleagues in their study of magnetic resonance angiography for patients with 22q11.2 deletion syndrome noted anomalies in vertebral, carotid arteries or both, in all patients with 22q11.2 deletion syndrome, highlighting the importance of obtaining imaging prior to the performance of pharyngeal flap surgery in this patient population. 43 Ross and colleagues also studied the risk of medially displaced carotid arteries in this patient population and concluded that a routine superiorly based pharyngoplasty may be safe in 52%, whereas in others it should be custom designed based on the individual anatomy of the patient. 44 Another concern for 22q11.2 deletion and other syndromes with a developmental delay is that these patients may have intellectual disability, making it more challenging for them to relearn and correct some of the articulation errors with speech therapy after surgery. For this reason, in this patient population, physical management of VPI by utilizing pharyngeal flap or sphincter pharyngoplasty may be warranted so that less reliance is placed on patient’s ability to relearn, to control airflow, and to use their tongue, lips, and jaw correctly to make sounds, after surgery. Other syndromes that may present with VPD include Opitz G/BBB syndrome, Kabuki syndrome, and Jacobsen syndrome.

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Submucous Cleft Controversy exists regarding the timing and optimal surgical intervention for submucous cleft (defined as having varying degrees of phenotypic expressions of zona pellucida, notched hard palate, and bifid uvula). In a study of 353 patients with submucous cleft, only 49.8 % were noted to have VPD, with the rest of the patients demonstrating complete or marginal VPD. 45 Hence, it is reasonable to wait on the surgical intervention till the patient is old enough to provide an adequate speech sample for perceptual speech evaluation. If the patient is deemed a surgical candidate, then depending on the size of the defect, it maybe reasonable to start with palatoplasty (either intervelar veloplasty or Furlow repair). Sommerlad and colleagues performed a systemic review of 26 studies analyzing surgical management of VPI in patients with submucous cleft. Speech outcomes were compared following sphincter pharyngoplasty, pharyngeal flap, and palatal reconstruction (Furlow palatoplasty, intravelar veloplasty, and palatal pushback), and little evidence was found to support one intervention over another. 46

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Tonsillectomy and Velopharyngeal Insufficiency The effect of tonsils on VPI is complex. VPI can be associated with superior pole tonsillar hypertrophy, especially when the upper pole extends above the level of the velum, into the lateral port and displaces the palatopharyngeus muscle anteriorly. On the contrary and more importantly, VPI can worsen after tonsillectomy, and hence these cases should be carefully evaluated with NPS prior to any surgical intervention. If tonsillectomy is indicated, then it may be best to perform it prior to the performance of surgical intervention for VPI, and after tonsillectomy, velopharyngeal closure should be carefully reevaluated. Additionally, during tonsillectomy procedure, the posterior tonsillar pillar should be protected, in case sphincter pharyngoplasty is indicated (which uses palatopharyngeus muscle from the posterior tonsillar pillar). 47

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Nonsurgical Management Palatal prosthesis is indicated for patients who have contraindications to surgery or for patients with poor prognosis of improvement with surgery. 48,49 These devices are typically made in coordination with a prosthodontist and a speech pathologist. The device fits along the hard palate and has a posterior extension that pushes the soft palate upwards in a patient with hypomobile velopharyngeal mechanism for closure of the port.

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Prognosis and Outcomes Based on a systemic review with a goal to reach consensus in the literature regarding surgical management of VPD, 71% of patients attained normal resonance and 65% attained normal nasal emission. Additionally, no difference was noted in terms of speech outcomes, sleep apnea, or need for further surgery, for patients treated with pharyngeal flap, sphincter pharyngoplasty, palatoplasty, and posterior pharyngeal wall augmentation. 50 Once the patient undergoes surgery, speech therapy becomes important in the postoperative period again so that the child can relearn and correct the articulation errors with biofeedback and speech therapy.

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Questions 1. 1. A six-year-old boy is brought to the cleft clinic for a follow-up visit. The patient had intravelar veloplasty at 10 months of age. On perceptual speech evaluation, he was noted to have hypernasality and nasal emission. On physical examination, no fistula was noted. Nasal endoscopy showed a large coronal gap with poor lateral wall motion. Which of the following is the most appropriate management? a. Continued speech therapy b. Furlow palatoplasty c. Sphincter pharyngoplasty d. Posterior pharyngeal flap e. Palatal lift prosthesis 2. A six-year-old patient with a history of bilateral complete cleft palate repair in infancy undergoes sphincter pharyngoplasty for her VPI. Which of the following muscles was primarily incorporated during pharyngoplasty for this patient? a. Tensor veli palatini b. LVP c. Palatopharyngeus muscle d. Palatoglossus muscle e. Musculus uvulae 3. A four-year-old patient, adopted from China, is diagnosed with submucous cleft palate. He is noted to have a notch of the posterior hard palate and a bifid uvula. Which of the following is an additional feature that he is likely to have? a. Incomplete cleft lip b. Cleft of the anterior alveolus c. Medialized internal carotid arteries d. Zona pellucida e. Syndactyly 4. A six-year-old boy presented to the multidisciplinary craniofacial team for evaluation of his VPI. He is noted to have Tetralogy of Fallot, submucous cleft palate, learning disabilities, and hypocalcemia. On perceptual speech evaluation, he is noted to have hypernasal speech with nasal air escape. The most likely diagnosis is a. Apert syndrome b. Van der Woude syndrome (VWS) c. 22q11.2 deletion syndrome d. Nager syndrome e. Stickler syndrome 5. A 5-year-old patient with a history of repaired cleft palate at 12 months of age presents to the clinic for evaluation of her VPD. She is noted to have poor intelligibility, hypernasality, and weak pressure consonants on perceptual speech evaluation. She undergoes nasal endoscopy which reveals a moderate to large sized, sagittally oriented gap with good lateral wall motion and limited palatal motion because of scarring. The patient has no contraindications for surgery. Which of the following is the most appropriate treatment for this patient? a. Intervelar veloplasty b. Superiorly based pharyngeal flap c. Posterior wall augmentation with fat

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d. Palatal obturator e. Sphincter pharyngoplasty with transposition of salpingopharyngeus muscle 1. Answer: c. The patient described has VPI because of inadequate closure of the velopharyngeal port. The first step in the evaluation of VPD is perceptual speech assessment, which is usually performed around 3 or 4 years of age. Any nasal emission and/or hypernasality with speech are indicative of inadequate approximation of velum against the posterior pharyngeal wall. Nasoendoscopy provides qualitative assessment of the closure pattern and port size and can be performed at 4 to 5 years of age. Surgical treatment is based on the severity of speech discrepancy and the location and size of port closure defect. A large posterior gap with coronal, circular, or bowtie closure pattern and poor lateral wall motion should be treated with a sphincter pharyngoplasty, where palatopharyngeal muscles in bilateral posterior tonsillar pillars are elevated and rotated through 90°. The flaps are overlapped and sutured to each other and to the posterior pharyngeal wall. Continued speech therapy will not correct hypernasality associated with a large coronal defect. Furlow palatoplasty with its Z-plasty design provides palatal lengthening and is well suited for the management of VPD in patients with unrepaired submucous cleft and with repaired overt clefts. Although it can be done, it is not the best technique for patients in whom the levator muscles are not sagittally oriented, as transposition would disrupt anatomically normal previously reconstructed levator sling. Posterior pharyngeal flap requires raising a myomucosal rectangular flap from the posterior pharyngeal wall and insetting it in the velum. It can be superiorly or posteriorly based and is best suited for sagittal or circular closure patterns. Palatal prosthesis is indicated in cases of failed speech therapy, when surgery is contraindicated. 2. Answer: c. Sphincter pharyngoplasty involves 90° transposition of the palatopharyngeus muscle from the posterior tonsillar pillar and is best suited for a moderate to large coronally oriented gap. TVP originates from the Eustachian tube and the scaphoid fossa of the sphenoid bone, and inserts into the palatal aponeurosis by joining the muscle of the opposite side in the anterior 25% of the soft palate. Its action is to tense the soft palate, in addition to opening the Eustachian tube. LVP takes origin from the petrous part of the temporal bone and decussates with the contralateral levator muscle forming a horizontally oriented sling in the soft palate. It functions to lengthen the velum and elevates it in the posterior direction. Palatoglossus muscles lie in the anterior tonsillar pillars, where the palatopharyngeus muscle is found in the posterior tonsillar pillar. They both serve to depress the soft palate. Musculus uvulae is the only intrinsic muscle of the soft palate and takes origin from the palatal aponeurosis. It likely contributes to the VP closure by providing bulk to it, by acting as a space-occupying structure and a velar extensor. Among the muscles listed, palatopharyngeus muscle is the only muscle that is used in sphincter pharyngoplasty procedure. 3. Answer: d. Patients with submucous cleft tend of have varying degrees of notched hard palate, bifid uvula, and diastasis of the LVP muscle (also known as zona pellucida). This results in VPI in 15% of the cases. Incomplete cleft lip, cleft of the anterior alveolus, medialized internal carotid arteries, and syndactyly are not standard features of a submucous cleft. 4. Answer: c. 22q11.2 deletion syndrome (commonly known as, DiGeorge syndrome, Shprintzen syndrome, velocardiofacial syndrome) is a disorder caused by the deletion mutation on chromosome 22. The typical features of this syndrome include cleft palate, heart defects, recurrent infections, unique facial characteristics, feeding problems, kidney abnormalities, hypoparathyroidism (resulting in hypocalcemia), hearing loss, developmental delay, and learning disabilities. Apert syndrome is an autosomal dominant syndrome characterized by bicoronal synostosis with complex syndactyly, midfacial hypoplasia, exorbitism, etc. Patients with Apert syndrome can have cleft palate and 70% have decreased IQ but they typically do not have hypocalcemia and cardiac abnormalities. VWS is an

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autosomal dominant syndrome characterized by lower lip pits, cleft lip with or without cleft palate, or cleft palate alone. Patients with VWS can have congenital heart problems but do not tend to have hypocalcemia. Patients with Nager acrofacial dysostosis are distinguished by radial-sided limb abnormalities, malar hypoplasia, micrognathia, cleft palate, coloboma, and ear abnormalities. These patients have many other anomalies including renal and cardiac anomalies but do not typically have hypocalcemia. Stickler syndrome is another autosomal dominant syndrome with features of cleft palate, Pierre Robin sequence, ocular malformations, hearing loss, and arthropathies. Patients with Stickler syndrome can have mitral valve prolapse but hypocalcemia is not a typical feature of this syndrome. 5. Answer: b. In a superiorly based pharyngeal flap, a rectangular-shaped myomucosal flap, based superiorly, is raised from the posterior pharyngeal wall and insetted into the velum. This flap converts a large velopharyngeal port into two small lateral ports by creating a midline obstruction between oral and nasal cavities, and it is best suited for moderate to large sized gap that is a sagittally oriented gap with good lateral wall. This patient has a surgical history of cleft palate repair and now has limited palatal motion with scarring, so palatal rerepair with intervelar veloplasty is not likely to help his VPI in the presence of a moderate to large sized gap. Posterior wall augmentation with fat grafting will likely not resolve the VPI secondary to a moderate to large sized gap. Additionally, fat grafting to posterior pharynx carries the risk of increase in size (and resulting obstructive sleep apnea) if the patient gains weight. This patient has no contraindications to surgery so palatal obturator is not the best long-term solution for his VPI. Sphincter pharyngoplasty uses palatopharyngeus muscles and is best suited for a coronally oriented moderate to large sized gap.

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References Drissi, C, Mitrofanoff, M, Talandier, C, et al. Feasibility of dynamic MRI for evaluating velopharyngeal insufficiency in children. Eur Radiol. 2011;21(7):1462-1469. Vadodaria, S, Goodacre, TEE, Anslow, P. Does MRI contribute to the investigation of palatal function? Br J Plast Surg. 2000;53(3):191-199. Mehendale, FV, Birch, MJ, Birkett, L, et al. Surgical management of velopharyngeal incompetence in velocardiofacial syndrome. Cleft Palate Craniofac J. 2004;41(2):124-135. Shprintzen, RJ. Velo-cardio-facial syndrome: 30 years of study. Dev Disabil Res Rev. 2008;14(1):3-10. Kummer, AW. Disorders of resonance and airflow secondary to cleft palate and/or velopharyngeal dysfunction. Semin Speech Lang. 2011;32:141-149. Moon, JB, Smith, AE, Folkins, JW, et al. Coordination of velopharyngeal muscle activity during positioning of the soft palate. Cleft Palate Craniofac J. 1994;31(1):45-55. Inouye, JM, Lin, KY, Perry, JL, Blemker, SS. Contributions of the musculus uvulae to velopharyngeal closure quantified with a 3-dimensional multimuscle computational model. Ann Plast Surg. 2016;77(suppl 1):S70-S75. Croft, CB, Schprintzen, RJ, Rakoff, SJ. Patterns of velopharyngeal valving in normal and cleft palate subjects: a multi-view videofluoroscopic and nasoendoscopic study. Laryngoscope. 1981;91:265-271.The authors examined the velopharyngeal closure pattern on videofluoroscopy and endoscopy and identified five closure patterns in normal and abnormal subjects. These closure patterns are typically reported when describing the orientation of nasopharyngeal gap on nasal endoscopy. Jordan, HN, Schenck, GC, Ellis, C, et al. Examining velopharyngeal closure patterns based on anatomic variables. J Craniofac Surg. 2017;28(1):270-274. Kummer, AW. Evaluation of speech and resonance for children with craniofacial anomalies. Facial Plast Surg Clin North Am. 2016;24(4):445451. Chapman, KL, Baylis, A, Trost-Cardamone, J, et al. The Americleft Speech Project: a training and reliability study. Cleft Palate Craniofac J. 2016;53(1):93-108. Ysunza, PA, Repetto, GM, Pamplona, MC, et al. Current controversies in diagnosis and management of cleft palate and velopharyngeal insufficiency. Biomed Res Int. 2015;2015:196240. Skolnick, ML. Videofluoroscopic examination of the velopharyngeal portal during phonation in lateral and base projections: a new technique for studying the mechanics of closure. Cleft Palate J. 1970;7:803-816. Perry, JL, Sutton, BP, Kuehn, DP, Gamage, JK. Using MRI for assessing velopharyngeal structures and function. Cleft Palate Craniofac J. 2014;51:476-485. Kao, DS, Soltysik, DA, Hyde, JS, et al. Magnetic resonance imaging as an aid in the dynamic assessment of the velopharyngeal mechanism in children. Plast Reconstr Surg. 2008;122:572-577. Tatum, SA III, Chang, J, Havkin, N, Shprintzen, RJ. Pharyngeal flap and the internal carotid in velocardiofacial syndrome. Arch Facial Plast Surg. 2002;4(2):73-80. Warren, DW, Dubois, AB. A pressure-flow technique for measuring velopharyngeal orifice area during continuous speech. Cleft Palate J. 1964;16:52-71.The authors popularized the concept of nasometry, which allows measurement of oral and nasal air pressure and flow and calculation of velopharyngeal port size. D’Antonio, LL. Evaluation and management of velopharyngeal dysfunction: a speech pathologist’s viewpoint. Probl Plast Reconstr Surg. 1992;2:86-111. Warren, DW, Dalston, RM, Trier, WC, Holder, MB. A pressure-flow technique for quantifying temporal patterns of palatopharyngeal closure. Cleft Palate J. 1985;22(1):11-19. Naran, S, Ford, M, Losee, JE. What’s new in cleft palate and velopharyngeal dysfunction management? Plast Reconstr Surg. 2017;139(6):1343e1355e. Sommerlad, BC, Henley, M, Birch, M, et al. Cleft palate re-repair—a clinical and radiographic study of 32 consecutive cases. Br J Plast Surg. 1994;47(6):406-410. Sommerlad, BC, Mehendale, FV, Birch, MJ, et al. Palate re-repair revisited. Cleft Palate Craniofac J. 2002;39(3):295-307. Furlow, LT. Cleft palate repair by double opposing Z-plasty. Plast Reconstr Surg. 1986;78:724-736.In 1986, Leonard Furlow introduced the Furlow palatoplasty procedure. This procedure entails creation of two double opposing Z-plasties of oral and nasal mucosa with attached levator muscle. Pet, MA, Marty-Grames, L, Blount-Stahl , et al. The Furlow palatoplasty for velopharyngeal dysfunction: velopharyngeal changes, speech improvements, and where they intersect. Cleft Palate Craniofac J. 2015;52(1):12-22. Perkins, JA, Lewis, CW, Gruss, JS, et al. Furlow palatoplasty for management of velopharyngeal insufficiency: a prospective study of 148 consecutive patients. Plast Reconstr Surg. 2005;116:72-80. Schoenborn, D. Uber eine neue methode der staphylorraphies. Arch F Klin Chir. 1876;19:528-531.Pharyngeal flap was first described by Schoenborn in 1876. This is a rectangular-shaped myomucosal flap, raised from the posterior pharyngeal wall and insetted into the velum. Whitaker, LA, Randall, P, Graham, WP III, et al. A prospective and randomized series comparing superiorly and inferiorly based posterior pharyngeal flaps. Cleft Palate J. 1972;9:304-311. Argamaso, RV, Shprintzen, RJ, Strauch, B, et al. The role of lateral pharyngeal wall movement in pharyngeal flap surgery. Plast Reconstr Surg. 1980;66:214-219.

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Boutros, S, Cutting, C. The lateral port control pharyngeal flap: a thirty-year evolution and followup. Plast Surg Int. 2013;2013:237308. Hynes, W. Pharyngoplasty by muscle transplantation. Br J Plast Surg. 1950;3:
 128-135.The Sphincter pharyngoplasty procedure was introduced by Hynes in 1950, where he described the use of bilateral salpingopharyngeus muscles for decreasing the dimension of velopharyngeal port. Orticochea, M. Construction of a dynamic muscle sphincter in cleft palates. Plast Reconstr Surg. 1968;41:323-327. Jackson, IT, Silverton, JS. The sphincter pharyngoplasty as a secondary procedure in cleft palates. Plast Reconstr Surg. 1977;59:518-554. Abyholm, F, D’Antonio, L, Davidson Ward, SL, et al. Pharyngeal flap and sphincterplasty for velopharyngeal insufficiency have equal outcome at 1 year postoperatively: results of a randomized trial. Cleft Palate Craniofac J. 2005;42:501-511. Ysunza, A, Pamplona, C, Ramírez, E, et al. Velopharyngeal surgery: a prospective randomized study of pharyngeal flaps and sphincter pharyngoplasties. Plast Reconstr Surg. 2002;110:1401-1407. Lewy, R, Cole, R, Wepman, J. Teflon injection in the correction of velopharyngeal insufficiency. Ann Otol Rhinol Laryngol. 1965;74(3):874-879. Lau, D, Oppenheimer, AJ, Buchman, SR, et al. Posterior pharyngeal fat grafting for velopharyngeal insufficiency. Cleft Palate Craniofac J. 2013;50(1):51-58. Lypka, M, Bidros, R, Rizvi, M, et al. Posterior pharyngeal augmentation in the treatment of velopharyngeal insufficiency: a 40-year experience. Ann Plast Surg. 2010;65(1):48-51. Hofer, SO, Dhar, BK, Robinson, PH, et al. A 10-year review of perioperative complications in pharyngeal flap surgery. Plast Reconstr Surg. 2002;110(6):1393-1397.In a 10-year review of perioperative complications following pharyngeal flap surgery, the overall complication rate was reported to be 6%. Lesavoy, MA1, Borud, LJ, Thorson, T, et al. Upper airway obstruction after pharyngeal flap surgery. Ann Plast Surg. 1996;36(1):26-30. Witt, PD, Marsh, JL, Muntz, HR, et al. Acute obstructive sleep apnea as a complication of sphincter pharyngoplasty. Cleft Palate Craniofac J. 1996;33(3):183-189. Witt, PD, Myckatyn, T, Marsh, JL. Salvaging the failed pharyngoplasty: intervention outcome. Cleft Palate Craniofac J. 1998;35(5):447-453.A study on salvage of failed pharyngoplasties reported equivalent rates of failure with pharyngeal flap (20%) and sphincter pharyngoplasty (16%) and successful denasalization of speech following revision surgery. Ysunza, A, Pamplona, MC, Molina, F, Hernández, A. Surgical planning for restoring velopharyngeal function in velocardiofacial syndrome. Int J Pediatr Otorhinolaryngol. 2009;73(11):1572-1575. Mitnick, RJ, Bello, JA, Golding-Kushner, KJ, et al. The use of magnetic resonance angiography prior to pharyngeal flap surgery in patients with velocardiofacial syndrome. Plast Reconstr Surg. 1996;97:908-919. Ross, DA, Witzel, MA, Armstrong, DC, Thompson, HG. Is pharyngoplasty a risk in velocardiofacial syndrome? An assessment of medially displaced carotid arteries. Plast Reconstr Surg. 1996;98:1182-1190. Heng, Y, Chunli, G, Bing, S, et al. Velopharyngeal closure pattern and speech performance among submucous cleft palate patients. Hua Xi Kou Qiang Yi Xue Za Zhi. 2017;35(3):296-300.In a study of 353 patients with submucous cleft, only 49.8% were noted to have velopharyngeal dysfunction, with the rest of the patients demonstrating complete or marginal VPD. Gilleard, O, Sell, D, Ghanem, A, et al. Submucous cleft palate: a systematic review of surgical management based on perceptual and instrumental analysis. Cleft Palate Craniofac J. 2014;51(6):686-695.The authors performed a systemic review of 26 studies analyzing surgical management of velopharyngeal insufficiency in patients with submucous cleft. Speech outcomes were compared following sphincter pharyngoplasty, pharyngeal flap, and palatal reconstruction (Furlow palatoplasty, intravelar veloplasty, and palatal ‘pushback’) and little evidence was found to support one intervention over another. Paulson, LM, Macarthur, CJ, Beaulieu, KB, et al. Speech outcomes after tonsillectomy in patients with known velopharyngeal insufficiency. Int J Otolaryngol. 2012;2012:912767. Raj, N, Raj, V, Aeran, H. Interim palatal lift prosthesis as a constituent of multidisciplinary approach in the treatment of velopharyngeal incompetence. J Adv Prosthodont. 2012;4:243-247. Aboloyoun, A, Ghorab, S, Farooq, MU. Palatal lifting prosthesis and velopharyngeal insufficiency: preliminary report. Acta Med Acad. 2013;42:55-60. de Blacam, C, Smith, S, Orr, D. Surgery for velopharyngeal dysfunction: a systematic review of interventions and outcomes. Cleft Palate Craniofac J. 2018;55(3):405-422.In a systemic review regarding surgical management of velopharyngeal dysfunction, 70.7% of patients attained normal resonance and 65.3% attained normal nasal emission. Additionally, no difference was noted in terms of speech outcomes, sleep apnea, or need for further surgery for patients treated with pharyngeal flap, sphincter pharyngoplasty, palatoplasty, and posterior pharyngeal wall augmentation.

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CHAPTER 35

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Craniofacial Tumors and Conditions James P. Bradley and Justine C. Lee

Key Points Fibrous dysplasia, a benign, spongy bone disorder, may be monostotic (single area of bone involvement) or polyostotic (multiple involved bony areas) and treated with operative recontour burring or with partial resection and bone graft reconstruction. Parry-Romberg syndrome, a progressive, acquired atrophy of the soft (skin/fat) and hard tissues (cartilage/bone) of the face requires, depending on severity of the case, fat grafting, free adipofascial flap, or even bony reconstruction. Treacher Collins syndrome, a congenital bilateral deficiency of orbitozygomatic, mandibular, and ear regions (Tessier no. 6, 7, and 8 clefts), may require staged reconstruction with bone grafts/eyelid switch flaps for orbital reconstruction, total ear reconstruction for microtia, and mandibular ramus distraction or orthognathic surgery for mandibular abnormalities. Neurofibromatosis of the periphery (NF-1) or centrally (NF-2) is an autosomal dominant disorder that causes (usually) benign growths within nerves and may require resection and the sacrificing of involved nerves. Pierre Robin sequence, a congenital anomaly with a triad of manifestations: micrognathia, glossoptosis, and upper airway obstruction, may require early operative intervention in severe cases with glossopexy or mandibular distraction to avoid a tracheostomy. Moebius syndrome is characterized by bilateral absence of cranial nerves VI and VII resulting in mask facies and inability to lateral deviate the eye and may be treated with functional muscle transfers to give oral commissure animation. Dermoid cysts are benign inclusion cysts typically located in the lateral supraorbital rim; but central lesions require imaging to rule out intracranial extension that would require an intra- and extracranial approach for resection.

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Fibrous Dysplasia Definition and Clinical Findings Fibrous dysplasia is a benign anomaly of the bone characterized by replacement of normal bone with fibro-osseous tissue. It is the most common craniofacial tumor encountered by plastic surgeons. 1 Fibrous dysplasia ranges from mild to severe and presents with monostotic or polyostotic distribution. 2,3 Skull involvement occurs in 27% of monostotic patients and up to 50% of polyostotic patients. Clinical manifestations of fibrous dysplasia depend on the location, duration, and the extent of disease. Craniofacial fibrous dysplasia most commonly begins in childhood then progresses through adolescence. It was previously thought that the disease progression halted after childhood, but this is not universally true; the disease frequently continues well into adulthood. 2 Anatomic location of the monostotic disease in the craniofacial skeleton most often affects the frontal and sphenoid bones and the maxilla 3,4 (Figure 35.1). Signs and symptoms of craniofacial disease are diverse and may include swelling of the affected side (most commonly), facial pain, headaches, cranial nerve (CN) palsies, anosmia, deafness, blindness, malocclusion with tooth displacement, diplopia, proptosis, and orbital dystopia. 3,5

FIGURE 35.1 Fibrous dysplasia limited to zygomatic maxillary complex (monostotic). A. Preoperative right oblique image. B. 3D model depicting fibrous dysplasia mass (arrow). C. Postoperative right oblique image after limited resection, cranial bone graft to orbital rim/arch, and alveolar recontouring. (Courtesy of J.P. Bradley.)

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Etiology and Pathogenesis Fibrous dysplasia occurs as a result of abnormal activity of the bone forming mesenchyme with an arrest of bone maturation in the woven bone stage. 3 Normal bone matrix is replaced by fibroblastic proliferation and there are resultant irregular trabeculae of partially calcified osteoid. 2 Fibrous dysplasia is caused by somatic activating mutations in the alpha subunit of the stimulatory G protein encoded by the GNAS gene. 2 A subset of patients have an associated endocrinopathy called McCune-Albright syndrome. 6,7 This condition includes precocious puberty, café au lait spots, and other endocrinopathies due to the hyperactivity of various endocrine glands. 6,7 Cherubism or familial fibrous dysplasia is a selflimited disease of the maxilla and mandible in children. This genetic giant cell disorder differs from other forms of fibrous dysplasia; in that, it typically regresses without operation and leaves no deformity. 3 A histologic biopsy should be sent at the time of surgical exploration of fibrous dysplasia (especially for polyostotic cases) because malignant transformation may be seen in 3.2% of patients. When regions of fibrous dysplasia undergo cystic or malignant degeneration, rapid enlargement and mass effect are typically seen. 2,8 In cases of malignant degeneration, fibrous dysplasia most commonly transforms to osteosarcoma, and occasionally to chondrosarcoma or fibrosarcoma. 3,8 Diagnosis of fibrous dysplasia depends on a combination of clinical, radiographic, and histological criteria, as diagnosis based on any individual factor alone can be difficult (exclusive of McCune-Albright syndrome). 2 The typical plain radiographic appearance is of radiolucent lytic lesions with a homogenous ground-glass appearance and ill-defined borders. However, this nonspecific appearance makes it difficult to differentiate from other conditions such as ossifying fibroma and Paget disease. Computerized tomography (CT) provides substantially better radiographic information. Fibrous dysplasia has a groundglass pattern (56%), homogeneously dense pattern (23%), or a cystic variety (21%). In addition to improved diagnostic information, CT also improves operative planning by evaluating the extent of disease, particularly in evaluating the extent of optic nerve canal involvement.

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Treatment and Complications Management protocols for the surgical treatment of craniofacial fibrous dysplasia differ. On the radical end, complete excision of all diseased bone with reconstruction is advocated, whereas on the more conservative end, skeletal reshaping with burring to restore normal skeletal morphology is performed. 2,9 Between these two surgical protocol extremes, limited resection (without sacrificing or injuring vital structures) with osseous reconstruction is offered (Figure 35.2). Chen and Nordhoff based their treatment approach to the occurrence in four designated zones in the craniofacial skeleton 2 : Total excision for zone 1 (fronto-orbital, zygomatic, and upper maxillary regions) Conservative excision (contouring) for Zone 2 (hair-bearing cranium), Zone 3 (the central cranial base), and Zone 4 (the tooth-bearing regions of the maxillary alveolus and mandible).

FIGURE 35.2 Fibrous dysplasia involving the left orbit, temporal, and zygomatic, regions (polyostotic). A. Preoperative frontal image demonstrating vertical dystopia and temporal fullness. B. Postoperative frontal image improvement after orbital box repositioning and recontouring of temporal bone. (Courtesy of H.K. Kawamoto.)

When comparing limited resection with reconstruction to bone contouring, patients undergoing resection had a lower recurrence rate and required fewer total operations but had a slightly increased postoperative complication rate. 9 Medical adjuncts for fibrous dysplasia hold an adjunctive role only and include bisphosphonates, steroids, and tamoxifen. 2 Radiotherapy has no role in treatment of fibrous dysplasia and should be avoided. Optic nerve decompression for optic canal involvement is controversial. Optic canal decompression without any vision loss is generally deemed too risky even with radiographic evidence of involvement.

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2,10

However, when vision loss is first noted, optic canal decompression is advised. The outcome of optic nerve decompression ranges from (1) halting vision loss, (2) improvement in vision, to (3) worsening in vision. 2,9

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Parry-Romberg Syndrome Definition and Clinical Findings Parry-Romberg syndrome is characterized as a progressive hemifacial hypoplasia with regional fat atrophy, medial canthal malpositioning, enophthalmos, dystopia, and skin hyperpigmentation. 11 It manifests as unilateral atrophy of the subcutaneous facial fat in the paramedial area with equal frequency on both sides of the face. Atrophy of the skin, muscle, fascia, cartilage, and bone may follow (Figure 35.3). The most evident sign is loss of fullness in 3-D parameters (atrophy of orbital, palpebral, zygomatic, and masseter muscles). The classic linear vertical deficiency is called coup de sabre sign (or mark of the sword). 12

FIGURE 35.3 Romberg syndrome with left side involvement. A. Preoperative image shows C-shaped linear coup de sabre deficiency. B. Postoperative image shows correction after serial fat grafting, septorhinoplasty, and lateral canthoplasty. (Courtesy of H.K. Kawamoto.)

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Etiology and Pathogenesis Parry-Romberg syndrome results in progressive hemifacial atrophy and may be highly variable. Although primarily characterized by soft tissue involvement including fat, skin, muscle, and connective tissue, in more severe cases, bony, ophthalmological, and/or neurological involvement occurs (Figure 35.4). Onset can vary from infancy, to early or mid-childhood, to adolescence, or even adulthood. Rate of progression of disease is also unpredictable and may vary. Some (but not all) cases are believed to undergo remission or burnout after puberty. 13

FIGURE 35.4 Romberg syndrome with left side involvement. A. Preoperative image shows both hard and soft tissue disruption with left vertical orbital dystopia, nasal deviation, and skin changes. B. Postoperative image shows correction after left orbital box elevation, lateral canthoplasty, septorhinoplasty, fat grafting, and face-lift. (Courtesy of J.P. Bradley.)

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Treatment and Complications Current treatment options to fill deficient tissues include fat or dermal grafts, dermal fillers (hyaluronic acid or calcium hydroxyapatite), bone and/or cartilage grafts, and/or free tissue transplantation. 11 Many authors advocate waiting for the disease to reach a stable phase after facial growth completion in late adolescence before beginning surgical procedures. 14 Burnout of disease may not occur for 10 years or more. By contrast, children living with the deformity, while waiting for surgical correction, may have psychosocial difficulties at home and school. Patients with mild to moderate deformity are typically treated with serial fat grafting procedures because of the effectiveness and low risk. Fat grafting is preferred to injection of silicone and other synthetic injectables because of higher rates of infection, seroma, capsule formation, exposure, migration, and longterm scar formation. The take of fat grafting in the diseased Romberg region is less than fat graft take in normal regions. 11 Interestingly, the fat graft take improves in subsequent fat grafting procedures for Romberg patients. This improved take is thought to be due to improved vascular milieu of the grafted bed. For skeletally mature patients with severe deformity, dermal fat grafts or adipofascial free flaps (such as a parascapular or inframammary extended circumflex scapular [IMECS] flaps) are accepted alternatives 14 (Figure 35.5). The back region provides better adipose-fascial fill for facial contouring than that of other free flaps. Although excellent results may be obtained with an IMECS flap, this is a major procedure compared with fat grafting, and subsequent revisions or debulking procedures are typically necessary. In more severe manifestations of the disease, skeletal reconstruction and soft tissue rearrangement are required to restore anatomic landmarks and facial symmetry.

FIGURE 35.5 Romberg syndrome with left side involvement. A. Preoperative image shows significant soft tissue atrophy, nasal deviation, and skin changes. B. Postoperative image shows correction after IMECS flap, lateral canthoplasty, and

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composite graft to nose. (Courtesy of H.K. Kawamoto and S.W. Seibert.)

In summary, Romberg patients required multiple corrective surgeries but showed improvements even when beginning before puberty. Fat graft take is poorer in diseased regions compared with normal regions, but the procedure is still beneficial. For severe Romberg deformities, soft and hard tissue reconstruction is necessary to improve symmetry.

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Treacher Collins Syndrome Definition and Clinical Findings Treacher Collins syndrome (TCS) is generally characterized by bilaterally symmetrical dysostosis of craniofacial structures derived from the first and second branchial arches. 15 Although there is a wide variation in phenotypic expression, common clinical features include hypoplasia of the zygomatic complex and the mandible, antimongoloid slanting of palpebral fissures, coloboma of the lower eyelids, complete or partial cleft palate, and atresia of external ear canals with abnormalities of the external ears accompanied by conductive hearing loss 15-17 (Figure 35.6).

FIGURE 35.6 Treacher Collins syndrome. A. Preoperative image shows bilateral symmetric malar deficiency, down-slanting lateral canthus. B. Postoperative image shows correction after cranial bone grafting to zygomatic arches, lateral orbital wall, and upper to lower eyelid switch flaps. (Courtesy of J.P. Bradley.)

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Etiology and Pathogenesis Genetic, physical, and transcript mapping techniques have demonstrated that approximately 93% of TCS is caused by loss-of-function mutations in the TCOF1 gene (for Treacle) located on chromosome 5 (5q3233.1). 18,19 TCS resulting from mutations in the TCOF1 gene is inherited in an autosomal dominant fashion, with only 40% of patients inheriting a mutated copy of the gene and 60% of cases arising from de novo mutagenesis. 19,20 On a cellular basis, TCOF1 knockout mice have a diminished number of migrating neural crest cells from extensive apoptosis and decreased proliferation.

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Treatment and Complications The treatment of TCS usually begins during infancy (when airway management at birth may be required), continues during mid-childhood (with bilateral total ear reconstruction and malar/orbital bony and soft tissue reconstruction), and is completed at facial maturity (with orthognathic procedures and a septorhinoplasty) (Figure 35.7). 16,17 In the newborn, severe airway obstruction may require a tracheostomy (the standard). If obstruction is limited to the tongue base and epiglottis, mandibular distraction can be effective in the newborn age or at a later age if sleep apnea develops. Choanal atresia, obstructing the posterior nasopharyngeal airway, may also need to be treated with dilatation or bony removal. Before 2 years of age, other procedures may be required, including cleft lip repair, cleft palate repair, macrostomia (Tessier no. 7 cleft), or removal of preauricular skin tags. In addition, optimizing hearing with BAHA (bone-anchored hearing apparatus) is beneficial in early childhood.

FIGURE 35.7 Treacher Collins syndrome. A. Preoperative image shows bilateral anterior open-bite malocclusion and symmetric malar deficiency. B. Postoperative image shows correction after bilateral mandibular distraction (for tracheostomy removal), cranial bone grafting to zygomatic arches, lateral orbital wall, and upper to lower eyelid switch flaps. (Courtesy of J.P. Bradley.)

In mid-childhood (ages 6–9 years of age), corrective procedures may include 16 : mandibular distraction lengthening malar, zygomatic, and eyelid reconstruction total external ear reconstruction Both distraction and total ear reconstruction require staged procedures in which fat grafting may be added at each stage. 21 This addition of soft tissue to the malar region helps while waiting on malar reconstruction, especially when adverse psychosocial peer experiences are occurring. For mandibular distraction, a vertical vector is recommended to correct the short ramus; strong guiding

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elastics are used to close the open bite and improve the obtuse gonial angle. Relapse of this abnormal mandibular morphologic shape has been noted in long-term follow-up from the strong genioglossal muscle pull. Relapse and malocclusion may be addressed later during an orthognathic procedure. For total ear reconstruction, the two-stage Firmin technique is preferred unless there is paucity of skin as in a very low lobule or anotia. 16 For these patients, the four-stage Brent technique may be used. Laser hair removal is performed for low-set hairlines and preauricular sideburns before first-stage ear reconstruction. Malar/orbital reconstruction should not be attempted too early to avoid premature resorption of bone grafts. At age 8 to 12 years, malar/orbital reconstruction may be undertaken with full-thickness parietal skull bone grafts for the zygomatic arch and lateral orbit, with split thickness grafts for the orbital floor, and with simultaneous upper to lower eyelid switch flaps with lateral canthopexies. 22 After facial skeletal maturity (16–18 years), correction of residual jaw abnormalities using orthognathic techniques and a septorhinoplasty are performed. Although a common procedure to close an open bite is Le Fort I posterior impaction, for the Treacher Collins patient, this will likely worsen the airway and aesthetics because of the short cranial base and abnormal mandible. Tessier described l’integrale procedure combining a Le Fort II osteotomy, bilateral mandibular advancement, orbital bone grafting, and genioplasty for the severe, uncorrected form of TCS with airway compromise. With distraction osteogenesis, similar osseous movements may be performed while reducing the relapse. 23 Genioplasty distraction with hyoid advancement has also been used for airway improvement and reduces relapse from genioglossal downward pull. 24 In summary, TCS remains a difficult entity to treat, often requiring multiple-staged procedures throughout childhood for functional and aesthetic improvements.

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Neurofibromatosis Definition and Clinical Findings Neurofibromatoses are a common group of conditions separated into five types, of which type I and type II are the most relevant for plastic surgery. Neurofibromas are benign peripheral nerve sheath tumors and may appear as discreet masses or as diffuse, plexiform masses without distinct borders. Clinical manifestations of neurofibromatosis are detected at birth in about 40% of patients, and over 60% have manifestations by the second year of life starting with café au lait spots. Café au lait spots are pigmented macules present in over 99% of patients with neurofibromatosis. They are frequently present at birth and increase in size in childhood. Cutaneous neurofibromas appear around puberty and increase throughout life. Approximately one-third of patients develop plexiform neurofibromas and about 6% may develop malignancy. Neurologic problems occur in 10%, scoliosis in 5%, learning disabilities in 25%, and intellectual developmental delay in 8% to 9%. In young children, macrocephaly without hydrocephalus, short stature, hypertelorism, and thoracic abnormalities are frequently found. Malignant peripheral nerve sheath tumors, also called neurosarcoma or neurofibrosarcoma, may develop in patients, particularly those with plexiform neurofibromas. The lifetime risk of development is 5% to 10% with the mean age of diagnosis at 41 years of age. Pain is the most reliable sign of malignant transformation. Neurofibromatosis, type I (NF1): NF1 accounts for 90% of all cases. Clinical diagnosis is suspected when six or more café au lait spots, cutaneous neurofibromas, and melanocytic hamartomas projecting from the surface of the iris (Lisch nodules) are found. 25 Neurofibromatosis, type II (NF2): NF2 is characterized by bilateral acoustic neuromas with hearing loss usually present as a teenager or young adult. Café au lait spots and cutaneous neurofibromas are present but usually less common than NF1. Plexiform neurofibromas and central nervous system tumors may also be present occasionally. Craniofacial plexiform neurofibromas: Craniofacial involvement in neurofibromatosis is a significant reconstructive challenge, as it is likely to be plexiform in nature with widespread destruction of facial structures and potential intracranial extension. Two types of craniofacial neurofibromas are generally considered separately: Orbitotemporal neurofibromas Plexiform neurofibromas resulting in hemifacial hypertrophy The specific variety of neurofibromas localized to the orbitotemporal region involves the orbit, the eyelids, and the temporal area (Figure 35.8). It may have an intracranial component associated with headaches and seizures. 26 Manifested during childhood with lid swelling, it becomes worse over time with severe involvement of the subcutaneous tissues of the eyelids and variable degrees of ptosis and proptosis of the globe (see Figure 35.8). In the most severe of cases, involvement of the globe leads to blindness. The skeletal changes in orbitotemporal neurofibromas consist of an absence of the greater wing of the sphenoid and a defect of the posterolateral wall of the orbit or an enlargement of the superior orbital fissure. The orbit is enlarged and hypoplasia of the supraorbital and infraorbital rims is present. The zygoma is hypoplastic and the orbital floor is inferiorly positioned.

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FIGURE 35.8 Neurofibromatosis type 1: left orbital involvement. A. Preoperative image shows vertical dystopia; patient had pulsatile globe. B. Postoperative image shows correction after left orbital box osteotomy with elevation and orbital roof reconstruction. C. Preoperative coronal CT scan depicts absent orbital roof (arrow). D. Postoperative coronal CT scan depicts titanium plate reconstruction of orbital roof (arrow). (Courtesy of J.P. Bradley and J.C. Lee.)

A second type of craniofacial involvement by plexiform neurofibromas results in a unilateral overgrowth of face because of diffuse proliferation of Schwann cells and axons associated with bony hypertrophy. This type typically forms from the trigeminal, facial, or glossopharyngeal nerves.

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Etiology and Pathogenesis Neurofibromatosis occurs in 1 in 2500 to 3000 births. NF1 is caused by mutations in neurofibromin, a tumor suppressor gene on chromosome 17q, and inherited in an autosomal dominant manner. NF2 is caused by mutations in the neurofibromin-2, a tumor suppressor gene on chromosome 22q.

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Treatment and Complications Treatment of craniofacial neurofibromatosis is complex due to the variability in presentations and destructive nature of the tumors. Orbitotemporal neurofibromas associated with sphenoid wing dysplasia and plexiform neurofibromas involving the soft tissue of the face are the two main classifications of the types of neurofibromas addressed. Because surgery cannot cure the process, the goal of surgical resection is to debulk and lessen the visual impact of the deformity.

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Orbitotemporal Plexiform Neurofibromas An algorithm for the treatment of orbitotemporal neurofibromas has been described in detail by Jackson. 26 In the presence of orbital soft tissue involvement without significant bony involvement and intact vision, resection of the neurofibroma through a supratarsal incision may proceed. If the neurofibroma is found to be a discreet mass, dissection and complete resection should be undertaken. However, if there is more widespread involvement of the intraconal tissues, partial resection must be undertaken with every effort to preserve vision. A bony defect of the orbit may be found in the orbital roof which should be reconstructed at the same time to prevent enlargement of the defect due to prolapse of the intracranial contents. Although bone grafts are usually the best choice for reconstruction of most osseous defects, in the orbital roof region, resorption of the graft is common because of the pulsatile intracranial contents. Thus, in this particular location, alloplast (titanium or methylmethacrylate) should be used. Shortening of the levator aponeurosis may be necessary at the time of closure to account for the reduction of proptosis of the globe from neurofibroma resection. In addition to reconstruction of the orbital roof, vertical orbital dystopia may be present with inferior displacement of the orbit due to a mass effect from the neurofibroma. When this occurs, an orbital box repositioning may be necessary. In the most severe of presentations, the neurofibroma is present in the temporal area and the orbit with pulsating exophthalmos because of a massive bony defect. In such cases, vision is not present. Neurosurgical involvement is necessary to reduce the temporal lobe back into the middle cranial fossa. Resection is performed with globe exenteration and reconstruction of the bony defect in preparation for prosthesis. A recent Australian study focused on visual outcomes demonstrated that vision loss and amblyopia are common in this cohort. 27

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Facial Plexiform Neurofibromas With Hemifacial Hypertrophy Similar to the orbitotemporal neurofibromas, consideration for significant bleeding should be taken into account. In the treatment of hemifacial hypertrophy, it is necessary to sacrifice a certain amount of normal soft tissue structures, as it is not possible to separate the neurofibroma from unaffected tissues. One method of soft tissue excision was proposed based on transposition of aesthetic units from the contralateral normal side to the affected side. 28 Following transposition, the remaining tissue is excised en bloc with incisions hidden in the areas such as the nasolabial fold. Underlying bony abnormalities are also found, thus frequently requiring bone grafting for reconstruction of the mandible, maxilla, or zygoma as necessary. 29

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Pierre Robin Sequence Definition and Clinical Findings Pierre Robin sequence (PRS) describes a triad of manifestations in neonates that included micrognathia, glossoptosis, and upper airway obstruction; cleft palate deformity is an associated abnormality but not a requirement for the sequence. 30 Because PRS has been associated with other anomalies, it is often divided into: PRS: isolated (Figure 35.9) PRS plus: with comorbidities, Stickler, 22q deletion Syndromic PRS: Treacher Collins syndrome, Nager syndrome (Figure 35.10)

FIGURE 35.9 Pierre Robin sequence (isolated) in a 6-week-old boy. A. Preoperative image shows significant micrognathia (workup revealed upper airway obstruction). B. Postoperative image shows mandibular position improvement after bilateral mandibular distraction (and relief of airway obstruction). (Courtesy of J.P. Bradley.)

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Etiology and Pathogenesis When genetic syndromes or deformational factors disrupt prenatal growth, micrognathia ensues and causes the retropositioning of the tongue. If this process occurs before the eighth week of gestation, closure 
 of the palatal shelves is prevented, thereby resulting in the formation of 
 a U-shaped cleft palate. 31 When PRS occurs in isolation, in utero deformational factors such as intrauterine growth restriction are generally considered to be important. Although neonates born with PRS may have clinically significant symptoms, a portion of children may escape surgical intervention because of postnatal mandibular catchup growth. This phenomenon is generally more common to patients with isolated PRS, likely because of the release of interference by deformational intrauterine factors after delivery. However, some patients treated conservatively continued to have respiratory disturbances throughout life. 32

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Treatment and Complications The most critical consequence of PRS is upper airway obstruction in the neonatal period. The severity of airway obstruction may not always correlate with the degree of anatomic deformity (micrognathia). An algorithmic workup is often warranted to determine the degree of tongue-based obstruction and indication for surgical treatment to maintain airway patency. 32 In the mildest of circumstances, side or prone positioning may be sufficient to prevent respiratory compromise. These mild PRS cases must still be monitored closely. When cleft palate exists, delay in the repair is recommended (at 18 months or more, as opposed to 10–12 months). In patients who cannot maintain airway patency with positioning alone, intubation using a nasopharyngeal tube or an endotracheal tube may be necessary. In neonates who require endotracheal intubation for survival, a surgical procedure is virtually universal to extubate the child. 33 The current surgical armamentarium for relief of airway obstruction includes glossopexy, subperiosteal mandibular stripping, mandibular distraction, and tracheostomy. In PRS, retrodisplacement of the mandibular attachment of the genioglossus diminishes the ability to hold the tongue out of the pharyngeal airway. Although glossopexy has the ability to temporarily relieve obstruction with anterior movement of the tongue, this procedure depends on sufficient mandibular catch-up growth for long-term reversal of airway obstruction. In addition, glossopexy does not address the core anatomical disturbance. When considering neonatal mandibular distraction for PRS patients, a decision tree model or management algorithm is recommended (Figure 35.11). 32 Patients who exhibit other abnormalities such as central apnea, multilevel airway obstruction, neurologic compromise, or severe airway edema from reflux are precluded from mandibular distraction. Outcome studies on neonatal mandibular distraction have shown improvements in oxygen saturation, apneic events, reflux, and feeding in neonates who received mandibular distraction. 34 In patients who are not eligible for distraction based on the management algorithm, a standard tracheostomy is performed. These tracheostomy patients will need decannulation at a later age after growth and resolve their airway abnormalities. Mandibular distraction and laryngotracheal reconstruction may be needed before tracheostomy removal. Skeletally mature, untreated PRS patients may require mandibular advancement with a sagittal split osteotomy for class II malocclusion after orthodontic preparation.

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FIGURE 35.10 Syndromic Pierre Robin sequence (Nager Syndrome) in a 3-month-old boy. A. Preoperative image shows significant micrognathia (workup revealed upper airway obstruction). B. Postoperative image shows correction of chin point (and improvement in airway). (Courtesy of J.P. Bradley.)

The reported complications of mandibular distraction are respiratory failure, relapse, nerve injury, tooth injury, infection, incorrect distraction vector, and device failure. 35 These complications can be minimized with the use of proper operative indications and perioperative protocols including appropriate rate (2 mm), length (15–30 mm), and extubation times (after 7 days). In syndromic PRS patients, there is a higher rate of temporomandibular joint ankylosis after distraction. 36 Elastic condylar unloading reduces the risk of these ankylosis events. Neonatal morbidity and mortality associated with PRS have significantly decreased with improved nonsurgical and surgical methods for airway protection. With the understanding that improved outcomes occur with mandibular distraction in a management algorithm, the majority of severely micrognathic patients are no longer destined to tracheostomies. The challenge to institutions is to implement and optimize systematic methods for evaluation and treatment for PRS neonates to achieve timely, consistent, and cost-effective outcomes.

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Moebius Syndrome Definition and Clinical Findings In 1888 and 1892, Moebius classically described combined palsies of the abducens (CN VI) and facial (CN VII) nerves as a composite entity. 37 This description was later expanded by others to include other CNs, limb abnormalities, chest wall defects, and developmental delay. The typical craniofacial manifestations of Moebius syndrome include mask-like facies, bilateral facial paralysis, and the inability to abduct the globes (palsy of the abducens or sixth CN) (Figure 35.12). Despite the classic description, there are variable presentations for Moebius syndrome including incomplete or unilateral facial palsy. Several other CNs have also been associated with Moebius syndrome, most frequently the third, fifth, ninth, and twelfth. Clinically, paralysis of the orbicularis oculi is the first sign of Moebius syndrome detected in the neonate, prompting consultation by pediatricians and neonatologists. 38 Ptosis, nystagmus, strabismus, epicanthal folds, hypertelorbitism, and lagophthalmos are all frequently manifested. The nasal root is frequently widened. The mouth opening is usually small and the commissures are downturned. Intraoral manifestations include tongue hypoplasia, oligodontia, mandibular hypoplasia, cleft palate, and poor palatal mobility associated with difficulties in feeding and speech. Feeding difficulties may resolve over time.

FIGURE 35.11 Pierre Robin sequence decision-tree model (algorithm) for all infants admitted to the pediatric intensive care unit (PICU) with upper airway obstruction. Mild obstruction is treated as an outpatient with monitoring. Moderate/severe obstruction undergoes multidisciplinary consultations and tests (sleep study, direct laryngoscopy, reflux study). Infants with central apnea, airway lesions (other than tongue-based obstruction), or severe reflux undergo a tracheostomy. All other infants have internal mandibular distraction.

In addition to craniofacial manifestations, both trunk and limb differences may be found. Absence or hypoplasia of the sternal head of the pectoralis major is a common finding. 39 Moebius combined with Poland syndrome has been reported in combination in 15% to 20% of cases. 40 Scoliosis is also found in

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approximately 14% of cases. 40 Limb abnormalities occur in over half of all patients diagnosed with Moebius syndrome. The most common abnormality is clubfoot in 40% to 50% of patients followed by limb reduction abnormalities in approximately 20% of patients. Intellectual developmental delay occurs in 10% to 30% of patients with Moebius syndrome and ranges in severity. Autism has been associated with Moebius syndrome. Motor delay, independent of the limb abnormalities, and speech delay are frequently seen.

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Etiology and Pathogenesis The prevalence of Moebius syndrome is estimated at 1 in 50,000 with equal distribution between male and female. Although the pathogenesis is not well understood, both environmental and genetic relationships have been described. The correlation between Moebius syndrome and misoprostol, a synthetic prostaglandin E1 analogue, was described in Brazil in the early 1990s. 41 Within 96 infants with Moebius syndrome identified in the Brazilian multicenter study, 49% of the mothers had taken misoprostol during the first trimester of pregnancy. Moebius syndrome may also be related to genetic causes inherited in an autosomal dominant, autosomal recessive, or X-linked pattern. Four genetic loci have been identified (MBS1-4) located on chromosomes 13q, 1p, 3p, and 10q, respectively.

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Treatment and Complications Reconstructive surgery in Moebius syndrome is a multidisciplinary endeavor requiring plastic surgery, ophthalmology, and orthopedic surgery. The main procedures performed by the latter two specialties are strabismus correction and clubfoot correction. For plastic surgery, the primary reconstructive procedure for the treatment of Moebius syndrome is facial reanimation for smile restoration. The ability to reconstruct facial motion using functional muscle transfers has undergone a renaissance age over the past 40 years. In the treatment of Moebius patients, the majority of patients suffer from bilateral complete paralysis. Thus, functional muscle transfers frequently require innervation by nonfacial nerves such as the masseteric nerve. In the absence of suitable facial nerves as the donor innervator, functional muscle transfers for reanimation are typically performed in one stage. 42,43 The most commonly used one-stage procedure is the innervated, partial gracilis free muscle flap. Preoperatively, the new nasolabial fold is marked on the face and a vector connecting the modiolus and the cephaloauricular junction at the root of the helix is marked, mimicking the pull of the zygomaticus major muscle. Intraoperatively, a preauricular incision is made and a dissection is performed in a sub-SMAS plane to the new nasolabial fold and the modiolus. The masseteric nerve is then identified and dissected within an area bordered by the zygomatic arch, coronoid process of the mandible, sigmoid notch, and condyle of the mandible. Dissection is carried out through the parotid and between the superficial and middle heads of the masseter muscle, upon where the nerve is visualized and coapted with the anterior branch of the obturator nerve from the gracilis muscle flap. The harvested partial gracilis muscle is then inset to the insertion on the new nasolabial fold and modiolus and to the origin at the deep temporal fascia following the premarked vector. Microsurgical anastomoses of the vascular supply of the gracilis muscle are performed last, typically to the facial vessels. Alternatively, if CN V is functional, lengthening temporalis myoplasty or Labbe procedure may be performed. 44 In this procedure, the nasolabial fold is marked out preoperatively. Intraoperatively, a coronal incision is made, a scalp flap is elevated, and the temporalis muscle is dissected immediately on the deep temporal fascia down to the zygomatic arch. Subperiosteal dissection is then carried over the zygomatic arch and osteotomized for access. Next, the temporalis aponeurosis is incised 1 cm below the temporal crest and the muscle is dissected away from the bone preserving the temporal nerve and vessels. To inset the muscle, the new nasolabial fold is incised and dissected down to the coronoid process. The temporalis tendon is detached from the coronoid process and sutured to the new nasolabial fold. The temporalis muscle is then stretched and resuspended to the remaining strip of aponeurosis. Although static procedures for smile restoration are not generally considered standard of care for Moebius syndrome, auxiliary static procedures for the treatment of lagophthalmos are common and beneficial for globe protection. The mechanism of lagophthalmos in Moebius syndrome is due to the lack of opposition of the levator palpebrae muscle by the paralyzed orbicularis oculi muscle. Although a number of modalities have been described to treat lagophthalmos, the most common and widely used is the placement of a gold or platinum weight in the upper eyelid. Preoperatively, an appropriate weight is estimated by taping the weight on the patient’s eyelid. Intraoperatively, an incision is made within the supratarsal fold and dissection is carried out through the orbicularis oculi muscle. Two positions have been described for the weight placement: (1) pretarsal and (2) postseptal. 45 In the pretarsal position, the weight is secured to the tarsus underneath the orbicularis oculi muscle. Although this is the classic placement position, there are complications such as entropion and visibility associated with pretarsal weight placement. In the postseptal position, the septum is incised and the weight is placed immediately superior to the tarsus. In this position, complications are diminished; however, the weight chosen should be 0.2 g heavier than the preoperatively estimated weight.

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Quantifiable complications such as hematoma and flap failure in facial reanimation are rare. However, qualitative and aesthetic issues such as incomplete correction, lack of strength in smile, asymmetry, and lack of spontaneity are frequently present. The recent advent of more objective methods of analysis such as the FACE-gram, an automated, objective assessment of facial movement, will likely assist in assessing surgical outcomes. 46

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Dermoid Cyst Definition and Clinical Findings Congenital facial dermoid cysts are benign, developmental malformations formed by inclusion of ectodermal elements. 47,48 Dermoid cysts are differentiated from the typical epidermoid cysts by the presence of mature adnexal structures such as hair and glands. Because of the process of formation, dermoid cysts are frequently, if not always, associated with some type of skeletal abnormality. Dermoid cysts are more common in females than in males. Craniofacial dermoid cysts can be generally divided into lateral and midline. Lateral cysts may be further subdivided into the frontotemporal region and the orbit. By far, lateral dermoid cysts of the frontotemporal region are the most common type of craniofacial dermoids with the majority near the lateral eyebrow (Figure 35.13). The lesion is usually deep to the skin such that there is usually no evidence of sinus ostia. The lesions are typically firm and present as a discreet nodule. Dermoids within this region are rarely associated with intracranial extension and thus do not warrant imaging before surgical resection without additional clinical suspicion.

FIGURE 35.12 Moebius syndrome in a 10-year-old patient. A. Preoperative image (when asked to smile) shows mask faces with no expression. B. Postoperative image (2 years) shows correction after bilateral lengthening temporalis myoplasty. (Courtesy of P.D. Nguyen.)

The orbit is the second anatomical subdivision of lateral cysts and accounts for the second most common area for dermoid cysts of the face. Extraocular mobility is typically not affected by orbital cysts; however, depending on the size, visual obstruction may occur (see Figure 35.13.A). Unlike epidermoid cysts, dermoid cysts are frequently found with skeletal abnormalities. Although the skeletal anomaly in the lateral brow dermoids is simple depressions within the frontal bone, orbital dermoids frequently traverse sutures, such as the frontozygomatic suture (see Figure 35.13.B). In such cases, the dermoid has an

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intraorbital component and an extraorbital component. Unlike lateral orbital cysts, the midline dermoid cysts may have more extensive and potentially intracranial involvement. The estimated incidence of intracranial involvement ranges around 19% of all nasal dermoids. 49 Midline dermoids may be found in the upper, middle, or lower face. In all cases, because of the potential for intracranial extension, a CT scan and/or MRI is necessary to define the limits of the dermoid. Within the nasoethmoid region, the external clinical manifestations may be particularly mild. A small punctum, bulge of the glabella, or widening of the nasal dorsum may be seen. However, mild clinical presentations may portend extensive involvement of internal structures and intracranial involvement. Additionally, unlike the lateral dermoids, midline dermoids have a higher propensity to display puncta and sinus ostia. Owing to the presence of adnexal structures, dermoid cysts have the capability of enlarging over time. Although rare, complications of dermoid cysts include infection, with several instances of calvarial osteomyelitis reported in the literature. 47

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Etiology and Pathogenesis Dermoid cysts are most often found as isolated entities and very rarely found in families. Formation of dermoid cysts is found at the embryologic fusion planes. For example, the lateral brow dermoid is found at the frontotemporal suture; the lateral orbital dermoid is found at the frontozygomatic suture; and the nasoglabellar suture is found at the frontonasal junction. In the circumstances of intracranial extension of dermoid sinuses and cysts, the development can be traced back to 8 weeks of gestation. During this time, the developing nasal and frontal bones are separated by dural extensions through the fonticulus nasofrontalis anteriorly and through the frontal bones into the prenasal space inferiorly. As the frontal bones grow, the dura migrates into the cranium and the fonticulus nasofrontalis fuses with the foramen cecum to become the cribriform plate. When this process is incomplete, the dura remains extracranial and becomes a cyst or sinus.

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Treatment and Complications Surgery is the only treatment available for dermoids. In lateral dermoids of the frontotemporal or orbital region, excision can be approached with an incision directly over the dermoid or hidden in the supratarsal fold. Because the embryologic origins of the cyst formation, dissection of the cyst should be through the soft tissues to the periosteum; this dissection is distinguished from that of the dissection of a simple epidermal cyst. Additionally, a skeletal depression will be frequently found underneath the cyst. In nasal dermoids, diagnosis requires imaging with an initial fine-cut CT scan. The two signs on CT scan suggestive of intracranial extension are a patent foramen cecum and a bifid crista galli. If either finding is present or suspicious for intracranial extension, an MRI should be performed next. If the MRI is negative, simple excision may be performed as above for glabellar dermoids. In nasal dermoids positioned more inferiorly, an open rhinoplasty approach should be considered. If the MRI is positive for intracranial extension, excision of the dermoid requires neurosurgical involvement. Coronal incision access is used for the frontal craniotomy. Dissection of the cyst requires an osteotomy of the frontal bone which may be performed in the keystone technique with paramedian osteotomies of the frontal and nasal bones. 50 By removing this V-shaped piece of bone, the dermoid cyst can be better visualized for full excision. Complications for extracranial dermoid excisions are rare but may include incomplete excision, recurrence, or infection. Resection of dermoids with intracranial extension may be complicated with osteomyelitis, incomplete resection, or cerebrospinal fluid leak.

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Questions 1. A 40-year-old woman diagnosed with fibrous dysplasia is noted on CT scan to have extension of the abnormal osseous growth into the greater wing of the sphenoid bone close to the optic nerve. Which statement about treatment decision is true? a. Optic nerve decompression should be performed with definitive radiographic evidence of fibrous dysplasia around or near the optic nerve. b. Optic nerve decompression may result in worsening of vision because of heat injury and therefore should not be performed. c. Optic nerve decompression should be performed when there is the beginning of visual changes. d. Bisphosphonates, steroids, and tamoxifen are the treatment of choice when visual changes occur because surgery is too risky. 2. For patients with Pierre Robin sequence (PRS), both mandibular distraction and glossopexy address upper airway obstruction with improvement in which of the following? a. Laryngomalacia b. Tracheomalacia c. Vascular webs d. Retroposition of the tongue base e. Chin position 3. Which of the following about the treatment of Parry-Romberg syndrome is true? a. The fat grafting for the Romberg patients is not advised because the take in the diseased Romberg region is less than the take in normal regions for cosmetic procedures. b. The classic coup de sabre sign means there is deeper, bony involvement and osseous correction will also be needed. c. Because Romberg disease burns out in puberty, observation is recommended, as most cases improve over time without treatment. d. For adults with severe soft tissue deficiencies, the parascapular free flap is recommended over the anterolateral thigh free flap because of the better adipose-fascial fill and sculpting. e. Dermal fat grafts have fallen out of favor because of the high infection rate. 4. For Treacher Collins syndrome, orbitomalar reconstruction should not be attempted too early because: a. premature absorption of orbital zygomatic bone grafts may occur. b. zygomatic body growth should be completed before custom implant placement. c. correction of malocclusion should be the paramount concern. d. all stages of total ear reconstruction should be completed first. e. bone graft take is more reliable at an older age. 5. Which is true in facial plexiform neurofibromas with hemifacial hypertrophy? a. The buccal fat is typically the most involved and should be radically resected. b. Multiple small resections are often recommended for large tumors to avoid bleeding and injury to vital structures. c. It is sometimes necessary to resect all the soft tissue between the skin and bone including the facial nerve and perform a reanimation procedure. d. All aesthetic units are distorted by large tumor masses so do not need to be considered. e. When considering risk/benefit, face transplantation is ultimately recommended for the best overall result.

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1. Answer: c. Optic nerve decompression for optic canal involvement is controversial but should be reserved for patients with both definitive radiographic evidence of fibrous dysplasia around or near the optic nerve and the beginning of visual changes. Optic nerve decompression is deemed too risky with normal vision even with radiographic evidence of involvement. 2. Answer: d. PRS is a manifestation of triad of micrognathia, glossoptosis, and upper airway obstruction. Both mandibular distraction and glossopexy (tongue-lip adhesion) improve the retroposition of the tongue base. Laryngomalacia, tracheomalacia, and vascular webs may all obstruct the airway but neither mandibular distraction nor glossopexy will correct these lesions. The retroposition of the chin, seen in PRS, will be improved by mandibular distraction lengthening, not tongue-lip adhesion. 3. Answer: d. Although fat graft take in Romberg regions is diminished, it is still a worthwhile treatment. The coup de sabre sign may just involve skin and fat hypoplasia but not necessarily bone. Unlike hemangioma cases, Romberg hypoplasia does not get better with time. The back region provides better adipose-fascial fill for facial contouring than that of other free flaps. 4. Answer: a. If orbitomalar bone graft reconstruction is performed before the age of 8 to 10 years, premature bone absorption is likely. Alloplastic implants are not recommended for Treacher Collins reconstruction in children. Malocclusion and ear reconstruction issues are independent of the timing of orbitomalar reconstruction. Even with good initial bone healing and bone graft take, absorption can still occur if performed early. 5. Answer: c. In the treatment of hemifacial hypertrophy, it is often necessary to sacrifice a certain amount of normal soft tissue structures and even the facial nerve, as it is usually poorly functioning and not possible to separate from the neurofibroma. Thus, smaller procedures with a goal of saving the facial nerve may be unrewarding. For severe cases, face transplantation has been performed but carries long-term risks associated with immunosuppression.

FIGURE 35.13 Dermoid cyst right lateral orbit. A. Preoperative image shows 2 cm mass. B. 3D CT scan shows erosion of lateral orbit from dermoid mass (arrow). C. CT scan coronal view shows dermoid mass distorting bone from lateral orbital rim (arrow). (Courtesy of J.C. Lee.)

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References Cohen, SR, Bartlett, SP, Whitaker, LA. Reconstruction of late craniofacial deformities after irradiation of the head and face during childhood. Plast Reconstr Surg. 1990;86:229-237. Chen, YR, Chang, CN, Tan, YC. Craniofacial fibrous dysplasia: an update. Chang Gung Med J. 2006;29:543-549.This up-to-date review documents the variation of fibrous dysplasia involvement as mild to severe in the craniofacial skeleton. This center has a broad experience and documents their care protocols in treating this disorder and dealing with monostotic and polyostotic cases. Weinstein, LS, Shenker, A, Gejman, PV, et al. Activating mutations of the stimulatory G protein in the McCune-Albright syndrome. N Engl J Med. 1991;325:1688-1695. Posnick, JC. Fibrous dysplasia of the craniomaxillofacial region: current clinical perspectives. Br J Oral Maxillofac Surg. 1998;36:264-273. Moore, AT, Buncic, JR, Munro, IR. Fibrous dysplasia of the orbit in childhood: clinical features and management. Ophthalmology. 1985;92:1220. Sassin, JF, Rosenberg, RN. Neurological complications of fibrous dysplasia of the skull. Arch Neurol. 1968;18:363-369. Hunt, JA, Hobar, PC. Common craniofacial anomalies: conditions of craniofacial atrophy/hypoplasia and neoplasia. Plast Reconstr Surg. 2003;111:1497-1508. Simpson, AH, Creasy, TS, Williamson, DM, et al. Cystic degeneration of fibrous dysplasia masquerading as sarcoma. J Bone Joint Surg Br. 1989;71:434-436. Gabbay, JS, Yuan, JT, Andrews, BT, et al. Fibrous dysplasia of the zygomaticomaxillary region: outcomes of surgical intervention. Plast Reconstr Surg. 2013;131:1329-1338.This article compares surgical strategy for a known region of involvement (zygomatic maxillary complex) for fibrous dysplasia. This comparative study showed that near-total excision with bone graft reconstruction had decreased recurrence but was more morbid than in situ contouring with a bur. Chen, YR, Breidahl, A, Chang, CN. Optic nerve decompression in fibrous dysplasia: indications, efficacy, and safety. Plast Reconstr Surg. 1997;99:22-30. Slack, GC, Tabit, CJ, Allam, KA, et al. Parry-Romberg reconstruction: optimal timing for hard and soft tissue procedures. J Craniofac Surg. 2012;23:S27-S31.For Parry-Romberg, both hard and soft tissue reconstruction is needed in moderate to severe cases, and this article illustrates how an accepted treatment strategy is beneficial for patients. Most staged reconstruction involves soft tissue and fat/dermal grafts; however, osteotomies and bone grafting is sometimes needed. Stone, J. Parry-Romberg syndrome: a global survey of 205 patients using the Internet. Neurology. 2003;61:674-676. Gorlin, RCN, Hennekam, R. Syndromes with unusual facies: well-known syndromes. In: Syndromes of the Head and Neck. 4th ed. New York, NY: Oxford University Press; 2001:977-1038. Saadeh, P, Reavey, PL, Siebert, JW. A soft-tissue approach to midfacial hypoplasia associated with Treacher Collins syndrome. Ann Plast Surg. 2006;56:522-525.This article documents a microsurgical solution to soft tissue fill with a parascapular (or IMECS) flap after hard tissue reconstruction. Kumar, A. Treacher-Collins syndrome. In: Thaller, SR , Garri, JI , eds. Craniofacial Surgery. New York, NY: CRC Press; 2008:273-281. Trainor, PA, Dixon, J, Dixon, MJ. Treacher Collins syndrome: etiology, pathogenesis and prevention. Eur J Hum Genet. 2009;17:275-283. Posnick, JC, Tiwana, PS, Costello, BJ. Treacher Collins syndrome: comprehensive evaluation and treatment. Oral Maxillofac Surg Clin North Am. 2004;16:503-523.Treacher Collins reconstruction is multistaged and challenging, and this paper offers acceptable evaluation and treatment that is time-tested and accepted by multidisciplinary teams. Trainor, PA. Craniofacial birth defects: the role of neural crest cells in the etiology and pathogenesis of Treacher Collins syndrome and the potential for prevention. Am J Med Genet A. 2010;152a:2984-2994. Dai, J, Si, J, Wang, M, et al. Tcof1-related molecular networks in Treacher Collins syndrome. J Craniofac Surg. 2016;27:1420-1426. Splendore, A, Jabs, EW, Felix, TM, Passos-Bueno, MR. Parental origin of mutations in sporadic cases of Treacher Collins syndrome. Eur J Hum Genet. 2003;11:718-722. Konofaos, P, Arnaud, E. Early fat grafting for augmentation of orbitozygomatic region in Treacher Collins syndrome. J Craniofac Surg. 2015;26:1258-1260. Fan, KL, Federico, C, Kawamoto, HK, Bradley, JP. Optimizing the timing and technique of Treacher Collins orbital malar reconstruction. J Craniofac Surg. 2012;23:2033-2037.This comparative outcomes study is one of the few that critically looks at the timing of bone graft reconstruction for the malar region. It discusses the psychosocial balance with timing of surgery to avoid reoperations. If in-lay cranial bone grafting is performed less than 5 years of age, it will resorb. Hopper, RA, Kapadia, H, Susarla, S, et al. Counterclockwise craniofacial distraction osteogenesis (C3DO) for tracheostomy-dependent children with Treacher Collins syndrome. Plast Reconstr Surg. 2018;142(2):447-457.Mandibular distraction and orthognathic reconstruction is challenging with Treacher Collins patients because of the abnormal mandibular shape and short cranial base. This paper illustrates a unique way of using distraction osteogenesis to lengthen the posterior midface and mandible with a counterclockwise rotation . Heller, JB, Gabbay, JS, Kwan, D, et al. Genioplasty distraction osteogenesis and hyoid advancement for correction of upper airway obstruction in patients with Treacher Collins and Nager syndromes. Plast Reconstr Surg. 2006;117:2389-2398. Hennekam, RCM, Gorlin, RJ, Allanson, JE, Krantz, ID. Gorlin’s Syndromes of the Head and Neck. Neurofibromatosis. 5th ed. New York, NY: Oxford University Press; 2010. Jackson, IT, Carbonnel, A, Potparic, Z, Shaw, K. Orbitotemporal neurofibromatosis: classification and treatment. Plast Reconstr Surg.

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1993;92:1-11. Greenwell, TH, Anderson, PJ, Madge, SK, et al. Long-term visual outcomes in patients with orbitotemporal neurofibromatosis. Clin Exp Ophthalmol. 2014;42:266-270. Hivelin, M, Wolkenstein, P, Lepage, C, et al. Facial aesthetic unit remodeling procedure for neurofibromatosis type 1 hemifacial hypertrophy: report on 33 consecutive adult patients. Plast Reconstr Surg. 2010;125:1197-1207. Munro, IR, Martin, RD. The management of gigantic benign craniofacial tumors: the reverse facial osteotomy. Plast Reconstr Surg. 1980;65:776-785. Robin, P. Glossoptosis due to atresia and hypotrophy of the mandible. Am J Dis Child. 1934;48:541-547. Hanson, JW, Smith, DW. U-shaped palatal defect in the Robin anomalad: developmental and clinical relevance. J Pediatr. 1975;87:30-33. Vyas, RM, Dipple, KM, Head, C, et al. Management of neonatal upper airway obstruction: decreased morbidity by utilizing a decision tree model with mandibular distraction osteogenesis. J Neonat Perinat Med. 2008;1:21-29.Neonatal mandibular distraction for airway obstruction is an effective treatment, but determining the indications for this procedure may be challenging. This algorithm study proves that a multidisciplinary team may treat neonatal upper airway obstruction with the correct modality when the evaluations are performed immediately and carefully. Izadi, K, Yellon, R, Mandell, DL, et al. Correction of upper airway obstruction in the newborn with internal mandibular distraction osteogenesis. J Craniofac Surg. 2003;14:493-499. Kohan, E, Hazany, S, Roostaeian, J, et al. Economic advantages to a distraction decision tree model for management of neonatal upper airway obstruction. Plast Reconstr Surg. 2010;126:1652-1664. Mofid, MM, Manson, PN, Robertson, BC, et al. Craniofacial distraction osteogenesis: a review of 3278 cases. Plast Reconstr Surg. 2001;108:1103-1114. Fan, K, Andrews, BT, Liao, E, et al. Protection of the temporomandibular joint during syndromic neonatal mandibular distraction using condylar unloading. Plast Reconstr Surg. 2012;129:1151-1161. Hennekam, RCM, Gorlin, RJ, Allanson, JE, Krantz, ID. Gorlin’s Syndromes of the Head and Neck. Moebius Syndrome. New York, NY: Oxford University Press; 2010. Terzis, JK, Noah, EM. Möbius and Möbius-like patients: etiology, diagnosis, and treatment options. Clin Plast Surg. 2002;29:497-514.This article documents the important diagnosis and technical details in dealing with and treating Möebius patients. McGillivray, BC, Lowry, RB. Poland syndrome in British Columbia: incidence and reproductive experience of affected persons. Am J Med Genet. 1977;1:65-74. McClure, P, Kilinc, E, Oishi, S, et al. Mobius syndrome: a 35-year single institution experience. J Pediatr Orthop. 2017;37:e446-e449. Pastuszak, AL, Schüler, L, Speck-Martins, CE, et al. Use of misoprostol during pregnancy and Möbius’ syndrome in infants. N Engl J Med. 1998;338:1881-1885. Rozen, SM. Facial reanimation: basic surgical tools and creation of an effective toolbox for treating patients with facial paralysis. Part A functional muscle transfers in the long-term facial palsy patient. Plast Reconstr Surg. 2017;139:469-471. Rozen, S. Facial palsy in children and young adults. In: Lee, JC , ed. Craniosynostosis and Rare Craniofacial Clefts. New York, NY: Nova Science Publishers; 2016:223-247. Labbé, D, Huault, M. Lengthening temporalis myoplasty and lip reanimation. Plast Reconstr Surg. 2000;105:1289-1297.This article documents a better option for facial reanimation for many patients. It describes the details of the lengthening temporalis myoplasty procedure and outcomes. Rozen, S, Lehrman, C. Upper eyelid postseptal weight placement for treatment of paralytic lagophthalmos. Plast Reconstr Surg. 2013;131:1253-1265. Bhama, PK, Weinberg, JS, Lindsay, RW, et al. Objective outcomes analysis following microvascular gracilis transfer for facial reanimation: a review of 10 years’ experience. JAMA Facial Plast Surg. 2014;16:85-92. New, GB, Erich, JB. Dermoid cysts of the head and neck. Surg Gynecol Obstet. 1937;65:48-55. Bartlett, SP, Lin, KY, Grossman, R, Katowitz, J. The surgical management of orbitofacial dermoids in the pediatric patient. Plast Reconstr Surg. 1993;91:1208-1215.
 This article presents a clear process for treating dermoids in the head and neck region in the pediatric population, going over the need for imaging, the surgical approach, and ususual variants. Pensler, JM, Bauer, BS, Naidich, TP. Craniofacial dermoids. Plast Reconstr Surg. 1988;82:953-958. van Aalst, JA, Luerssen, TG, Whitehead, WE, Havlik, RJ. “Keystone” approach for intracranial nasofrontal dermoid sinuses. Plast Reconstr Surg. 2005;116:13-19.

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PA R T I V

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Head and Neck 36. Facial Fractures and Soft Tissue Injuries 37. Head and Neck Cancer and Salivary Gland Tumors 38. Reconstruction of the Scalp, Forehead, Calvarium, Skull Base, and Midface 39. Reconstruction of the Eyelids, Correction of Ptosis, and Canthoplasty 40. Nasal Reconstruction 41. Reconstruction of Acquired Lip and Cheek Deformities 42. Facial Paralysis 43. Mandible Reconstruction 44. Reconstruction of the Oral Cavity, Pharynx, and Esophagus

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CHAPTER 36

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Facial Fractures and Soft Tissue Injuries Christine M. Jones and John A. van Aalst

Key Points The patient with facial fractures is a trauma patient and requires a comprehensive evaluation for calvarial, intracranial, and cervical spine injuries. Impending optic nerve injury can be recognized early by examining for red desaturation. Entrapment of the extraocular muscles and septal hematoma are two surgical emergencies in facial trauma. Restoration of facial height, width, and projection is accomplished through rebuilding the facial buttresses in the vertical, horizontal, and sagittal dimensions. Achieving normal occlusion is of primary importance in the reduction of maxillary and mandibular fractures. Sequencing should build from known to unknown in panfacial fractures in a top-down, bottom-up, or inside-out fashion. Facial trauma is one of the most common reasons for consultation with a plastic surgeon; an estimated 407,000 emergency department visits occur annually for facial fractures alone. 1 Appropriate evaluation and treatment is a fundamental skill for trainees. The principles learned in approaching and stabilizing fractures serve as a foundation for building more advanced concepts in soft tissue handling and orthognathic surgery.

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Concepts in Facial Trauma Mechanisms of injury vary and patients must first be considered from a comprehensive trauma standpoint. Each patient must undergo a thorough trauma evaluation for concomitant injuries, beginning with airway assessment, breathing, and circulation. Over 45% of patients with facial fractures have concomitant intracranial injury and nearly 10% have cervical spine injuries. 2 With areas of thin bone and sinuses, the face is designed to act as a shock absorber to help prevent trauma to these critical neurologic structures.

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Stability of the Craniofacial Skeleton The height, width, and projection of the facial skeleton is stabilized by facial buttresses, which are areas of thick bone that act as scaffolds in the vertical and horizontal dimensions (Table 36.1). Horizontal facial buttresses are divided into coronal and sagittal types (Figure 36.1). Fractures extending through these buttresses are more likely to be clinically significant; proper reduction restores alignment and stability in these areas. Whereas the frontal bone and mandible display stability in each plane, the midface lacks sagittal support, lending it particularly susceptible to flattening after attempts at reconstruction, especially centrally. 3 TABLE 36.1 Buttresses of the Craniofacial Skeleton 3,4 Buttress Vertical Orbital Nasofrontal Zygomatic Pterygomaxillary Mandible Horizontal Coronal Supraorbital Infraorbital rim Transverse maxillary Mandible Sagittal Frontal bone Zygomatic arch LeFort I segment Mandibular body

Purpose Maintain facial height

Maintain facial width

Maintain facial projection

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FIGURE 36.1 Buttresses of the craniofacial skeleton are divided into vertical (A,B) and horizontal (C,D) supports. Horizontal buttresses are further subdivided into coronal (C) and sagittal (D) types.

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Facial Examination To avoid missing injuries, the face should be systematically examined through inspection, palpation, and evaluation of range of motion. Beginning in the upper third, the scalp should be inspected for lacerations and foreign bodies. Scalp lacerations are obscured by hair, positioning, or cervical collars and can bleed significantly. Moving onto the face, the soft tissue, including the auricle, external auditory canal, and nose, including the septum, are inspected for lacerations and foreign bodies. Prompt recognition of both auricular and septal hematomas is critical. Examination progresses to systematic palpation of bony prominences to determine the presence of step-offs, instability, or crepitus; sites of examination include the supraorbital ridge, lateral orbital walls, infraorbital rims, nasal bones, zygomatic arches, maxilla, and mandible. Maxillary stability is determined by stabilizing the head at the nasofrontal junction with one hand and using the examining hand to rock the maxillary alveolus in a forward-backward and mediallateral motion (Figure 36.2).

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FIGURE 36.2 Testing maxillary stability helps diagnose LeFort I, II, or III fractures. The face is stabilized at the forehead while the dominant hand grasps the anterior maxilla and attempts to displace it in an anteroposterior (A) and lateral direction (B).

Ocular examination begins with inspection of the conjunctiva for hemorrhage, assessment of the lids and

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canaliculi for lacerations, inspection for foreign bodies, and visualization of penetrating injuries. Pupillary examination is performed with a flashlight to compare pupillary size at rest and direct and consensual responses to light. The swinging flashlight test distinguishes afferent pupillary defects from an oculomotor nerve injury: an eye that has lost vision will lack the ability to constrict with direct light but will still display a consensual response when light is shone in the opposite pupil. Extraocular muscle excursion should be examined by asking the patient to look in each of the cardinal directions. In an unresponsive patient, forced duction testing rules out entrapment (Figure 36.3). Monocular and binocular vision is examined; the presence of diplopia is recorded. Because red desaturation is one of the earliest signs of visual loss, each patient is asked to compare a red object with both the affected and unaffected eye. A brief visual field examination reveals the presence of gross field cuts. Globe position is examined for early enophthalmos, which reliably indicates the need for orbital floor fracture correction because swelling usually masks enophthalmos in the acute setting.

FIGURE 36.3 To test for entrapment in an unresponsive patient, several drops of ophthalmic tetracaine are instilled into each eye. The bulbar conjunctiva is grasped with toothed forceps near the inferior fornix and the globe is rotated upward, downward, medially, and laterally. Excursion is compared with the contralateral side.

Moving to the middle third, the nasal septum is examined for boggy mucosal swelling, indicative of a septal hematoma. An otoscope is useful for this step if a nasal speculum is not available. Hematoma can be distinguished from septal deviation by probing with forceps and assessing for ballotability. The temporomandibular joint (TMJ), positioned directly anterior to the tragus and under the zygomatic arch, is evaluated for tenderness or deformity. The articular disc can be assessed by palpating anteriorly from within the external auditory canal while the patient gently opens her mouth. Maximal interincisal opening should be recorded. Intraoral lacerations, open fractures, and loose or avulsed teeth should be noted. If a tooth is missing, ensure that it is not retained within the oral cavity where it presents an aspiration risk. Dental hygiene should be noted, as this affects the success of maxillomandibular fixation. The patient’s occlusion is recorded, including the presence of cross-bite or open-bite deformities. Cranial nerve (CN) function is examined by testing sensation to light touch in the V1, V2, and V3

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distributions, comparing sensitivity with the contralateral side and with baseline. Each branch of the facial nerve is tested by asking the patient to raise the eyebrows (temporal branch), close the eyes tightly (zygomatic), puff the cheeks (buccal), smile (marginal mandibular), and purse the lips (cervical). Loss of lip depression while smiling can result from injury to the ipsilateral marginal mandibular nerve or cervical branch, as the platysma (cervical branch innervation) can cofunction with the depressor anguli oris (marginal mandibular innervation) to display a full denture smile. These can be distinguished by asking the patient to evert her lower lip: with a cervical branch injury, eversion is preserved because of intact mentalis function. The tongue should protrude at midline (CN XII), the palate should elevate symmetrically (CN IX, X), hearing should be grossly symmetric (CN VIII), and the shoulders should be able to shrug (CN XI).

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Radiographic Evaluation Thin-slice CT scan should be obtained for patients whose mechanism of injury or examination suggests facial fractures. Cuts should be 1 mm or finer. X-rays are rarely useful. CT scans should be examined in each plane of section to rule out skeletal injuries.

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Regional Blocks Small lacerations are managed by injecting local anesthetic at the site of injury. A 25-gauge needle is used to inject through existing laceration; inject slowly using buffered anesthetic to minimize patient discomfort. Larger areas of the face can be treated with regional blocks (Figure 36.4). 5

FIGURE 36.4 Multiple blocks are available to provide regional anesthesia for the face.

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Access Incisions Numerous incisions are available to access various regions of the facial skeleton (Figure 36.5). 6 Lacerations from the injury can also be used to further improve access. For optimal access to correct bony injuries, edema should be allowed to subside for 7 to 10 days. Scars should be placed in concealed locations whenever possible; the transconjunctival and upper and lower buccal sulcus incisions are good examples. Whenever a skin incision is made, it should be placed in the relaxed skin tension lines (Table 36.2). For access to the midface in particular, multiple simultaneous incisions are often necessary.

FIGURE 36.5 Selected incisions for periorbital and midface skeletal access: coronal (a), Wright (b), upper lid crease (c), transconjunctival (d), lateral canthotomy (e), subciliary (f), subtarsal/midlid (g), infraorbital (h), Lynch (i), and upper buccal sulcus (j).

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TABLE 36.2 Selected Facial Access Incisions Skeletal Access General

Incision

Benefits

Drawbacks

Lacerations

No new facial scars

Frontal bone, midface Orbital floor

Bicoronal

Wide access to frontal bone and midface

Limited control over which parts of skeleton are accessible Conspicuous scar

Transconjunctival, preseptal Transconjunctival, post-septal Subciliary Subtarsal Infraorbital Gillies

Hidden; avoids protrusion of orbital fat

Tedious dissection through lower lid

Hidden; ease

Orbital fat must be retracted during surgery

Scar blends with resting tension lines Scar blends with resting tension lines Ease Hidden in scalp

High risk of ectropion High risk of ectropion Conspicuous scar, risk of ectropion Utility limited to arch alone; blind

Upper buccal sulcus Lower buccal sulcus

Ease, affords wide access, hidden

Risk of gingival retrusion

Wide applications

Risdon

Lower risk of infection, easier reduction for highly comminuted fractures, edentulous patients, poor oral hygiene

Risk of mental nerve injury; higher risk of infection for highly comminuted fractures or poor oral hygiene Risk of marginal mandibular nerve injury; conspicuous scar

Zygomatic arch Midface Mandible

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Antibiotic Prophylaxis Evidence supporting the use of perioperative antibiotics for the treatment of facial fractures is of low quality. However, routine antibiotic prescription is a common practice, with penicillin, cephalosporins, and clindamycin being the most commonly prescribed antimicrobials. 7,8 In a seminal article, two perioperative doses of cefazolin reduced infection risk from 42% to 8.9%. 9 Current literature supports the use of perioperative antibiotics (beginning < 60 minutes prior to incision and ending within 24 hours) for operative facial fractures, especially those that involve transmucosal access incisions with cleancontaminated surgical fields. 7,10 However, data describing use of antibiotics beyond this time period is inconclusive. Although infection is rare, it can have serious consequences. Transmigration of sinus bacteria into the periorbital soft tissue can result in orbital cellulitis, leading to optic neuritis, optic nerve atrophy blindness, cavernous sinus thrombosis, or meningitis. 11 An unclear risk-benefit ratio for the use of antibiotics in facial trauma continues to make this a hotly debated topic.

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Soft Tissue Injuries Plastic surgeons are often consulted for complicated facial lacerations. In these cases, tissue debridement should be limited to only that which is clearly nonviable. The rich vascularity of the face allows partially compromised tissue to survive. Wounds should be meticulously debrided of gravel, glass, or other debris, using loupe magnification if needed. Copious irrigation with normal saline helps prevent infection. Closure should be completed in layers, minimizing buried dissolvable sutures that may incite inflammatory and infectious responses in a contaminated field. Typically, 6-0 nylon or polypropylene suture is used in high-profile areas of the face and 5-0 for more concealed areas. In children, 6-0 plain or fast gut obviates the need for suture removal and provides acceptable appearance. Excellent blood supply to the face results in rapid healing. Permanent sutures should be removed within 5 to 7 days to prevent the train track scars that occur when epithelial cells migrate along sutures that are retained for greater than 7 to 10 days. Accurate tissue reapproximation is the most important step after wound debridement. Key sutures should be placed first in the areas where minor discrepancies of alignment would be most notable, for example, in the eyebrow margin or at the vermillion border.

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Facial Nerve Injury An accurate assessment of facial nerve function should be completed before injecting local anesthetic. Frontal branch injuries are most likely to occur when a laceration crosses the line described by Pitanguy, drawn from a point 0.5 cm inferior to the tragus to a point 1.5 cm superior to the lateral eyebrow. Neurologic deficits from zygomatic and buccal branch injuries are less common, particularly when lacerations occur medial to the lateral canthus because of the arborization that occurs medially, with multiple nerve endings innervating a muscle. Buccal branch injuries are most likely to occur with large, midcheek lacerations. Concomitant parotid duct injuries are common. The marginal mandibular nerve has little redundancy and is most commonly injured as it crosses the inferior border of the midmandibular body. Cervical branch injuries are less common and also exhibit crossover from multiple subbranches. If facial nerve injury is suspected within a laceration, the wound should be explored in an attempt to tag the cut ends proximally and distally. Stimulation of the distal cut end is possible up to 72 hours postinjury; after this period of time, depletion of acetylcholine makes further stimulation impossible.

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Auricular Cartilage Injury Lacerations that penetrate the auricular cartilage must take into account the limited vascularity of the cartilage and the need to restore stability. Nonviable segments of cartilage or skin should be minimally debrided and thoroughly irrigated. The cartilage and skin can usually be reapproximated in a single layer due to the firm adherence of the skin to the cartilage. In adults, 5-0 polypropylene is an appropriate suture choice, with 5-0 fast-absorbing gut reserved for children. Hematoma and chondritis are two major concerns with ear injuries. Hematomas can be seen as ballotable fluid collections between the perichondrium and cartilage. Prompt drainage is essential to avoid necrosis, fibrosis, and deformed neocartilage formation, commonly known as cauliflower ear. After repair of an auricular laceration or drainage of a hematoma, the ear should be bolstered for 5 to 7 days to prevent hematoma formation or recurrence. A roll of petroleum-impregnated gauze placed on either side of the ear and secured in place with polypropylene or nylon mattress sutures serves as an appropriate bolster. Penetrating auricular injuries should receive 7 to 10 days of antibiotic prophylaxis, typically with ciprofloxacin, to prevent chondritis. 12

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Canalicular Injury Lacerations near the medial canthus of the eyelid should raise suspicion for injury to the superior and inferior canaliculi. In these cases, consultation with ophthalmology is warranted. The canaliculi should be probed acutely to determine if injury is present. Suture repair and stenting are commonly used techniques for treatment.

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Septal Hematoma Because cartilage receives its blood supply from the perichondrium, any collection of fluid between the perichondrium and the cartilage will lead to cartilage destruction. The septum should always be inspected with a nasal speculum and good lighting to evaluate for hematoma. A septal hematoma will appear as a bulging, fluctuant collection along the septum. The collection should be aspirated with an 18gauge needle or lanced with an 11-blade scalpel, and nasal packing should be placed to prevent fluid reaccumulation.

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Parotid Duct Injury The parotid duct (Stenson duct) travels horizontally within the cheek, allowing the parotid gland to drain intraorally through an opening on the buccal side of the second maxillary molar. Injury should be suspected with lacerations to the cheek, particularly those that injure the buccal branch of the facial nerve, as the nerve and duct travel in close proximity. A high index of suspicion is needed, because no immediate signs of duct injury exist; the injury is usually noted days later when saliva begins draining from the laceration. The intraoral orifice of the parotid duct can be cannulated with a pediatric intravenous catheter and injected with methylene blue or saline to examine for injury. If the duct is lacerated, repair should be conducted over a small-caliber pediatric feeding tube. The tube should be left in place as a stent for 14 days. A subcutaneous drain left in place for 1 week and facial wrap providing external pressure for the first 48 hours may also help prevent sialocele (Figure 36.6). 13

FIGURE 36.6 Suspected parotid duct injuries should be explored and repaired over a catheter if possible. (Adapted with permission from Lewkowicz, AA, Hasson, O, Nahleili, O. Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg. 2002;60:676-

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680.)

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Skeletal Injuries Upper Facial Fractures Frontal Sinus Fractures The frontal bone is a particularly strong structure and is capable of withstanding more force than the other facial bones. For this reason, frontal bone fractures signify high-energy traumatic mechanisms and are often associated with intracranial injury. Pneumatization of the frontal sinus begins around the age of 2 years and is completed by 12 years. Because the bone is thicker in childhood, frontal sinus fractures are not commonly seen. In adults, management of frontal sinus fractures depends on whether the fracture extends through the anterior or posterior table or both, the degree of displacement, and the likelihood of nasofrontal outflow tract obstruction (Figure 36.7).

FIGURE 36.7 Management of frontal sinus fractures. NFOT, nasofrontal outflow tract. (Reproduced with permission from Rodriguez, ED, Stanwix, MG, Nam, AJ, et al. Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques. Plast Reconstr Surg. 2008;122:1850-1866.)

Fractures of the anterior table may lead to visible or palpable contour irregularities of the forehead or instability of the supraorbital bar. Posterior table fractures have the potential for dural tear, cerebrospinal fluid leak, persistent pneumocephalus, or meningitis. The nasofrontal outflow tract courses from the inferomedial frontal sinus in the most anterior and superior extent of the anterior ethmoidal complex to exit in the middle nasal meatus at the hiatus semilunaris. The nasofrontal outflow tract is likely to be injured with fractures to the inferomedial frontal bone and the floor of the sinus. The tract may become obstructed with injury, leading to abscess or

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sinusitis. Evaluation of the fracture pattern and location on CT scan will indicate the likelihood of nasofrontal tract involvement. Nasofrontal outflow tract involvement with obstruction is strongly correlated with a higher degree of fracture displacement. 14 Several options for management exist. Nonoperative observation should include serial examinations and CT scans to evaluate for mucocele or persistent pneumocephalus. Obliteration requires surgical curettage of the sinus mucosa, burring of the sinus bone to remove any invaginations of mucosa, surgical occlusion of the nasofrontal ducts, and placement of bone, muscle, fat, pericranial, or galeal flaps. Cranialization is performed by removing the posterior table so the sinus and the anterior cranial fossa are contiguous. The sinus mucosa must be carefully curetted, the inner portion of the anterior table bone burred away, and the nasofrontal duct occluded with bone graft. The brain is allowed to fill what was formerly the frontal sinus space over subsequent months. Nondisplaced fractures of the anterior table or combined anterior and posterior tables without nasofrontal outflow tract obstruction should be observed. Displaced fractures of only the anterior table generally require operative reduction and fixation with low-profile miniplates to restore forehead contour. In posterior table fractures, the degree of displacement and presence of a cerebrospinal fuild (CSF) leak dictate management. Displaced fractures carry a higher risk of dural tear, CSF leak, and meningitis. These complications are minimized with obliteration for less severe fractures or cranialization for more displaced or comminuted fractures. With obstruction of the nasofrontal outflow tract in either anterior or posterior table fractures, the sinus must be obliterated or cranialized regardless of the degree of fracture displacement. 14

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Complications Abscesses can occur in acute or delayed fashion and can range from subcutaneous to intracranial. These are managed with repeat surgical debridement and obliteration or cranialization. Mucoceles result from the indolent overgrowth of residual basilar sinus mucosa from the diploic veins of Breschet, which are small mucosal crypts that invaginate into the bone. Mucoceles typically present in a delayed fashion with chronic headaches, mass effect, visual disturbance, nasal obstruction, or erosion of the frontal bone. Mucoceles are difficult to treat; therefore, prevention is of primary importance.

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Midfacial Fractures Orbital Fractures The orbit is a thin-walled, conical, bony box in which the globe rests. Its structure is designed to support the vertical and sagittal position of the globe, and to absorb blunt trauma to the upper midface to prevent globe injury. With fractures to the medial wall or floor, the orbital space becomes contiguous with the ethmoid or maxillary sinus, respectively, and the position of the globe may change. Fractures often increase orbital volume, causing diplopia when the globe descends (vertical dystopia) or becomes positioned deeper within the orbital cavity (enophthalmos). Particularly in children, greenstick fractures of the floor can occur, allowing the inferior rectus muscle to prolapse into the maxillary sinus with the bony fragment snapping back up into near original position because of periosteal recoil. This muscular entrapment is a surgical emergency because the prolapsed portion of the muscle quickly becomes ischemic. If the muscle is not released within 6 to 8 hours, it will become fibrotic with a high risk of permanent diplopia. Retrobulbar hematoma can acutely increase intraorbital pressure and quickly lead to optic nerve damage if not promptly diagnosed. Superior orbital fissure and orbital apex syndromes can be associated with direct injury from fractured bone fragments or with the subsequent retrobulbar hemorrhage (Figure 36.8; Table 36.3). Surgical reduction of these posterior fracture fragments is generally met with limited success. Because the compression is often from soft tissue, treatment is primarily medical, using high-dose corticosteroids. Some cases may resolve spontaneously as edema subsides. 15

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FIGURE 36.8 In this patient with a small fracture of the orbital roof and lateral wall, the bone fragment caused orbital apex syndrome with resultant blindness.

TABLE 36.3 Sequelae of Injuries to Periorbital Structures Associated With Orbital Fractures Clinical Case Entrapment Superior orbital fissure (SOF) syndrome

Orbital apex syndrome

Presentation Pain during attempted upward gaze Ptosis Proptosis Ophthalmoplegia Pupillary dilation, with loss of direct and consensual light reflexes Loss of forehead sensation Loss of corneal sensation Same as SOF syndrome, with the addition of blindness

Structures Involved Inferior oblique CN III to levator palpebrae superioris CN III; loss of retraction forces and bulge of flaccid extraocular muscles CN III, IV, VI Parasympathetic fibers of CN III V1 supratrochlear and supraorbital nerves V1 nasociliary branch Same as SOF syndrome, with the additional involvement of optic nerve (CN II)

Orbital fractures should be suspected with any substantial blunt trauma to the face, including a fall from standing, blow to the face, or motor vehicle collision. Facial CT is the only method of ensuring accurate diagnosis. Alignment of the orbital floor should be evaluated on coronal and sagittal cuts, and the dimensions of the fracture in the anteroposterior and mediolateral directions should be measured. The extraocular muscles can be examined on soft tissue windows to evaluate for entrapment; however, the only way to accurately diagnose entrapment is by physical exam. Diplopia is the primary surgical indication in orbital floor and medial wall fractures. Diplopia is more likely to occur with larger fractures exceeding 1 to 2 cm2. 16,17 Often, when examined in the emergency room, patients have already developed substantial periorbital edema masking the enophthalmos and vertical dystopia that will result over time. Patients should be reexamined in 7 to 10 days, after the swelling has subsided, to determine need for surgical intervention. Once an incision is selected (Figure 36.9), dissection proceeds to the infraorbital rim; the periosteum of the orbital floor and involved medial wall is lifted. At this point, an elevator can be used to identify the borders of the fracture and a rim of stable bone surrounding the fracture (Figure 36.10). The optic nerve is located approximately 32 to 42 mm posterior to the infraorbital rim 18 ; as dissection proceeds deeper into the orbit, caution is used to avoid nerve injury. The elevator can be periodically removed to check the position of its tip by grasping it at the infraorbital rim and measuring the distance from the tip to the surgeon’s fingertip.

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FIGURE 36.9 Cross-sectional view of incisions for orbital floor exploration.

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FIGURE 36.10 When identifying the borders of an orbital floor fracture, an elevator can be used to palpate medially, laterally, and posteriorly for a stable rim of bone.

A plate should be selected based upon fracture characteristics (Table 36.4). Complete coverage of the defect is needed for larger fractures; an anatomic titanium plate with medial extension is often appropriate for orbital floor fractures extending into the medial wall. TABLE 36.4 Options for Orbital Implants19 Type Autologous bone

Benefit Biocompatible

Drawback Requires additional surgery at donor site Unpredictable resorption Inflexible; difficult to contour

Silastic sheets, silicone Porous polyethylene

FlexibleEasy to use Forms capsule prone to infection, seroma, cysts, and sinus tracts

FlexibleEasy to useTissue ingrowth Reduces foreign body reaction

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Risk of infection Difficult removal with tissue ingrowth

Titanium

Rigid, yet malleableAble to osseointegrate

Risk of infection

With orbital roof fractures, the most pertinent concern is risk of a growing skull fracture in children who have years of craniofacial growth ahead of them. Pulsation of the dura at the site of the fracture may impair normal bone healing, allowing the fracture to expand with growth. In adults, indications for reduction of orbital roof fractures are limited to patients with dural tears or orbital apex syndrome that does not respond to medical therapy.

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Complications Continued diplopia can result from inadequate reduction, or more specifically, inadequate restoration of orbital volume. The orbital fat that prolapses into the maxillary sinus must be lifted back into the orbit before placement of the plate to properly support the normal position of the globe. Diplopia can also result from fibrosis of extraocular muscles or necrosis of the intraorbital fat from manipulation. 17 Lower eyelid malposition can include ectropion, scleral show, and entropion. Risk of ectropion and scleral show increases with use of a transcutaneous incision; ectropion can complicate 14% of orbital floor repairs approached through a subciliary incision. 20 A Frost stitch, placed through the lower lid tarsus and secured to the forehead, helps elevate the lower lid for the first several days until edema subsides. Although the Frost stitch can prevent acute globe exposure from chemosis, it has not been shown to prevent ectropion. 21

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Zygomaticomaxillary Complex and Zygomatic Arch Fractures Fractures of the zygomaticomaxillary complex (ZMC) are also referred to as tripod fractures. In fact, the zygoma is a tetrapod structure that is stabilized by the zygomaticofrontal suture, zygomaticotemporal suture, zygomaticomaxillary buttress, and the zygomaticosphenoid suture. 22 The zygomatic bone sets the width and projection of the midface. Fractures typically displace the zygoma inferiorly, laterally, and posteriorly, widening and flattening the face. Reduction is of paramount importance to restore midface structure; therefore, most displaced fractures meet operative criteria. In addition, displacement of the zygoma can impinge upon the coronoid process of the mandible and its associated muscles of mastication, causing trismus, a limiting of mandibular excursion. Appropriate reduction alleviates muscular impingement and restores mandibular motion. The ZMC can be approached through transconjunctival and upper buccal sulcus incisions. Sometimes a lateral canthotomy or an upper lid/lateral blepharoplasty incision is necessary as well, depending on the degree of displacement. Reduction can be performed by placing an elevator or curved bone hook under the body of the zygoma via the upper buccal sulcus incision and lifting the bone from its impacted position. Alternatively, a Carroll-Girard bone screw (Figure 36.11) can be inserted percutaneously and used to joy-stick the fracture into the desired position. Alignment must be determined at the zygomaticofrontal, zygomaticomaxillary, and zygomaticosphenoid articulations. Of these, the zygomaticosphenoid buttress is most important in verifying accurate realignment of the zygoma. The zygomaticosphenoid buttress can be visualized through a lateral canthotomy extension of a transconjunctival incision, or through a separate lateral rim incision. The buttresses are then stabilized with titanium miniplates.

FIGURE 36.11 The Carroll-Girard screw can be anchored into the zygoma percutaneously and used to manipulate the bone.

In many cases, ZMC fractures are associated with fractures of the orbital floor. The ZMC must be reduced first, as its alignment will be based on intact bone at the buttresses described above. The orbital floor should then be checked for unmasking or widening of a fracture. Any significant fracture should be repaired as previously described. Isolated fractures of the zygomatic arch are problematic if they are depressed enough to affect facial

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contour or cause trismus. Direct exposure cannot be achieved through limited incisions, given the conspicuous location and close association with the temporal branch of the facial nerve. For badly displaced and comminuted fractures a coronal incision must be used, because this is the only approach for the necessary access for plate fixation. For depressed fractures with inherent stability, a Gillies approach may be used to reduce the fracture. A 2-centimeter horizontal incision is made within the hair-bearing portion of the temporal region 2.5 cm anterior and superior to the helical root, after palpating and avoiding the temporal artery. Dissection proceeds to the deep layer of the deep temporal fascia, which directly overlies the temporalis muscle. The fascia is then incised, exposing the muscle. An elevator is inserted and directed inferiorly, just under the zygomatic arch. Application of manual pressure reduces the fracture through this minimal access technique. Alternatively, the arch can be approached from a 2-centimeter upper buccal sulcus incision (Keen incision) at the base of the zygomaticomaxillary buttress. The incision is made through the mucosa only, allowing an elevator to be passed under the zygomatic arch that is in direct proximity to the incision.

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Nasal Bone Fractures The nasal bones are the most commonly fractured facial bones, 23 accounting for over 55% of facial fractures. 1,23 The nose serves both aesthetic and functional purposes, and dissatisfaction with nasal appearance (13%–32%) and/or nasal airway patency (14%–36%) is high after fracture. 23 Fractures of the cartilaginous septum are particularly prone to nasal deformity and airway obstruction. Even after closed reduction of the nasal bones, in the presence of an incomplete septal fracture, the bones will tend to deviate toward the displaced portion of the septum during the healing process. 24 In addition to restoring architecture of the nasal airway, reduction of the cartilaginous septum counteracts this deforming force of the septum on the nasal bones and improves final alignment. The nasal bones and septum can be reduced under local anesthesia depending on fracture complexity and patient cooperation. Closed nasal reduction under general anesthesia has not been shown to have superior outcomes to that under local anesthetic, 23 but may be more appropriate for anxious or young patients, or more severely displaced fractures. Regardless of the setting, the equipment and technique for closed nasal reduction are the same (Figure 36.12). Local anesthetic is injected within the soft tissue of the nasal dorsum to anesthetize the infratrochlear nerves, around the infraorbital nerve, and along the base of the columella and nasal floor (branches of the anterior and posterior ethmoidal nerves and sphenopalatine ganglion). Nasal pledgets impregnated with a topical vasoconstrictor such as oxymetolazone or cocaine are inserted into each nostril for 10 minutes and vasoconstriction is allowed to occur. To prevent inadvertent intracranial injury, the distance from the external nasal aperture to the displaced nasal bone is measured by holding an elevator on the exterior of the nose and grasping the distal portion of the elevator at the naris. The elevator is then inserted and manual pressure applied while stabilizing the head and palpating the displaced bones externally with the other hand. Once the nasal bones are reduced, the septum can be grasped with Asch forceps and manipulated to its anatomic, median position.

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FIGURE 36.12 Closed nasal reduction can be accomplished with simple tools, including local anesthetic, oxymetolazone- or cocaine-soaked pledgets, bayonet forceps, Killian nasal speculum, Boies elevator, and Asch forceps.

After manipulation of the septum, pressure should be applied to prevent septal hematoma. This can be done by transseptal mattress sutures, or with Vaseline-impregnated gauze packing that is left in place for 24 hours. Alternatively, silicone septal splints, such as Doyle or bivalve splints, can be sutured in place for 5 to 7 days. The nasal dorsum should be stabilized with an external thermoplastic splint. Curing of the thermoplastic material is an exothermic process, so the thin nasal skin should be protected with a layer of surgical tape to prevent skin burns. Because the nasal bones are reduced but not fixated, a too-tight splint may cause bony displacement.

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Nasoorbitoethmoidal Fractures The nasoorbitoethmoidal (NOE) complex is an area of thin bone in the upper midface that encompasses the superior nasal cavity and ethmoidal air cells. It is bordered superiorly by the frontal sinus, cribriform plate, and anterior skull base; anteriorly by the nasal bones, frontal process of the maxilla, and nasal process of the frontal bone; laterally by the lacrimal bone and lamina papyracea of the ethmoid bone; and medially by the septum and the perpendicular plate of the ethmoid. The thin bones of the anterior cranial fossa at the fovea ethmoidalis and the tight dural adhesion at the cribriform plate make NOE fractures particularly susceptible to CSF leak. The medial canthal tendon attaches the tarsal plates and the orbicularis oculi to the medial orbital wall, inserting onto the anterior and posterior lacrimal crests. The medial canthal tendon sets the intercanthal distance and the angle of the palpebral fissure. NOE fractures are often the result of high-impact injuries to the midface. Comminution and instability are typical. Classification is based upon the involvement of the central fragment, or the fragment of bone to which the medial canthal tendon attaches. 25 Class I NOE fractures involve a single central fragment with relative stability (Figure 36.13A). In class II NOE fractures comminution is present, but the medial canthal tendon remains attached to a central fragment that is large enough for stabilization with a miniplate or microplate (Figure 36.13B). Class III fractures are characterized by detachment of the medial canthal tendon from bone, extensive bony loss, or a high degree of bony comminution such that fixation cannot be accomplished with traditional measures (Figure 36.13C).

FIGURE 36.13 Nasoorbitoethmoid fractures can be divided into types I (A), II (B), and III (C).

Management is dictated by the fracture type. Class I fractures are stabilized with miniplates at the frontomaxillary, zygomaticomaxillary, and medial maxillary buttresses. Placement of miniplates for class II fractures is similar to class I, with the addition of miniplates or microplates for stabilization of the central fragment. In some class II and all class III fractures, instability of the medial canthal tendon requires transcanthal wiring. A 3-0 stainless steel wire is passed from a point superior and posterior to the medial canthal attachment through holes drilled to the contralateral medial orbital wall. In some cases, placement of a bone graft is necessary beforehand to attain bony stability sufficient to support the wire. Adequate restoration of the tendon attachment is critically important to avoid alteration of the palpebral fissure or telecanthus. Vertical asymmetry of as little as 2 mm is noticeable at conversational distance. The medial canthi should be positioned no more than 25 mm apart. Transcanthal wires placed anterior to the medial canthal attachment site will not prevent lateral migration of the canthus, thus leading to

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permanent telecanthus and a broad nasal base. Often, multiple surgical approaches are necessary to attain proper fracture reduction. Management of soft tissue edema is of equal importance as bony reduction. Subperiosteal seroma, hematoma, or postoperative edema can lead to permanent soft tissue thickening, which effaces the normal contours of the nasoorbital region. Splinting with a padded metal bolster is recommended. The splint is fixated with transcanthal wires designed for soft tissue support alone. Careful monitoring is required to avoid soft tissue pressure injury during the period of postoperative edema.

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Maxillary Fractures The French surgeon René Le Fort classified three patterns of maxillary fractures that result from blunt trauma to the adult facial skeleton. A key component of each fracture type is the disruption of the ipsilateral pterygoid plates, which are a major source of midfacial stability. The LeFort fracture classification scheme should be used as a guideline, as true fracture patterns are often combinations of the classic patterns and are most accurately described using anatomic terms. Fracture patterns may differ on each side of the face. In these cases, the term hemi-LeFort is often used. LeFort I fractures occur in a horizontal pattern parallel to the occlusal plane, extending from the piriform aperture laterally through the pterygomaxillary junction (Figure 36.14). LeFort II fractures are pyramidal, extending from the pterygomaxillary junction through the zygomaticomaxillary buttress and orbital floor obliquely to the nasofrontal junction. LeFort III fractures are horizontally-oriented fractures through the upper midface that produce a separation of the cranium from the face, termed craniofacial disjunction. These fractures extend from the zygomatic arch, through the pterygomaxillary junction, lateral orbital rim and orbital roof, to the nasofrontal junction.

FIGURE 36.14 A. LeFort I fractures occur transversely across the maxilla. B. LeFort II fractures have a pyramidal pattern. C. LeFort III fractures represent a craniofacial disjunction.

Although LeFort I fractures may be treated through an upper buccal sulcus incision, LeFort II and III fractures benefit from the exposure of a coronal approach. Reduction can be accomplished with Rowe disimpaction forceps. Restoring normal occlusion is the primary goal of reduction; normal facial width, height, and projection should follow secondarily. Facial stability is restored by placing plates along the involved facial buttresses. LeFort fractures are typically the result of high-energy trauma and are rarely isolated fractures. In these cases, sequencing of fracture reduction becomes an important consideration. Palatal fractures usually occur in the sagittal plane, splitting the alveolar ridge between the central incisors or between the lateral incisor and canine. Alternatively, the maxillary tuberosity containing the molars may be split from the rest of the alveolar ridge. Palatal fractures often occur in conjunction with LeFort I fractures. After reduction, stability can be restored anteriorly with a miniplate in the area of the piriform, and posteriorly with a plate across the palatal concavity for maintenance of palatal width.

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Lower Facial Fractures: The Mandible Biomechanics The biomechanical properties of the mandible are the most complex of the facial skeleton. The mandible acts as a curved beam, supported on its ends by the muscular pterygomasseteric sling. The masseter and temporalis function to elevate the mandible and create a strong bite force. The medial and lateral pterygoids protrude the mandible and help with opening, or excursion. The suprahyoid muscles, comprised of the digastric, stylohyoid, mylohyoid, and geniohyoid muscles, function to elevate the hyoid and base of tongue during deglutition, and depress the mandible. In the fractured mandible, the muscles of mastication displace the posterior segment superiorly, whereas the suprahyoid muscles pull the anterior segment inferiorly. 26 During mastication, external downward forces exerted by tooth-to-tooth contacts cause surrounding areas of compression balanced by the tension created either contralaterally or posteriorly by the upward pull of the muscles of mastication. The areas of tension and compression are dependent on the site of mandibular loading. The mandible can also be thought of as a ring structure, articulating with the temporal bone at the TMJs. Similar to opening the rings of a binder, the mandibular ring is often disrupted through faults created in at least two areas. About 1/2 to 2/3 of mandibular fractures involve fractures at multiple sites. 27,28 Commonly, an anterior impact such as in a motor vehicle collision will result in condylar, symphyseal, and parasymphyseal fractures, whereas a lateral impact from assault will fracture the body and contralateral angle. 27

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Principles of Management The most important objective in treating mandibular fractures is restoration of normal occlusion; anatomic reduction is a secondary goal. Stable, nondisplaced fractures may be treated nonoperatively with a soft diet. Sometimes, partially luxated teeth will prevent fracture reduction and will obscure normal occlusion; in these cases, teeth in the line of the fracture must be extracted. Tooth extraction is also recommended whenever the tooth roots are fractured. Given the normal biomechanical loads exerted on the mandible, types of fixation fall into two categories: rigid and functionally stable. In rigid fixation (load-bearing), no micromotion is translated through the fracture site and primary bone healing occurs. This type of fixation bears more mechanical forces of the mandible and is useful if healing is delayed, such as in atrophic bone, bony defects, smokers, poor oral hygiene, or patients with multiple comorbidities. An example is a reconstructive plate applied to the inferior mandibular border. In functionally stable fixation (load-sharing), micromotion is allowed at the fracture site, and a bony callus forms during the process of secondary bone healing. Miniplates rely on the accumulation of bone at the fracture site to share mandibular loading before they become prone to fatigue failure. Examples of load-sharing fixation include a Champy plate along the external oblique ridge, a lower border miniplate with maxillomandibular fixation (MMF), or upper and lower border miniplates with monocortical screw fixation. In addition to plates, MMF uses contact at the apices of the teeth to serve as another point of functionally stable fixation. 28 In the multiply fractured mandible, at least one fracture site should be treated with heavier, more rigid plates due to the increased complexity of biomechanical stress forces. Because of the curved nature of the mandible, locking plates are often desirable. Screws that lock to the plate fixate the plate in the position in which it was placed by the surgeon with lower risk of displacing the fracture fragments. Conversely, nonlocking screws can lag the plate into closer coaptation with the bone. Although the lag concept is useful in other anatomic areas, its use in the mandible can displace the fracture of the curvilinear bone and lead to malocclusion. Non-locking screws are typically only used in oblique mandibular fractures, and lag screws are usually only used at the symphysis.

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Symphyseal and Parasymphyseal Fractures The mandibular symphysis lies between the apices of the central incisors and is characterized by thick bone and short incisor tooth roots. The parasymphysis is defined by the lateral border of the central incisor root and the lateral border of the canine. A fixation technique unique to the symphysis is the placement of two bicortical lag screws in the coronal plane, perpendicular to the line of the fracture. A lower border plate is a common method of symphyseal or parasymphyseal fixation. This can be placed with bicortical screws below the level of the tooth apices for added stability. Rigid fixation can be attained with the addition of an upper border plate with monocortical screws. MMF is usually preferable as an extra point of stability.

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Body and Angle Fractures The mandibular body extends from the lateral canine to the medial border of the third molar. The body conducts the inferior alveolar nerve to the mental foramen, typically located between the first and second premolars where it exits as the mental nerve. The body contains longer tooth roots, the longest of which is the canine. During fracture fixation, avoiding injury to the inferior alveolar nerve and tooth roots is critical. The angle contains the third molars and connects the body with the ramus. The body and angle experience tensile forces along the upper border and compression along the inferior border under axial loads. A neutral zone exists centrally, along the neurovascular canal. Methods of fixation take these biomechanical properties into account (Table 36.5). Fractures of the angle have the highest incidence of complications, particularly in the presence of partially erupted or impacted third molars. 28,29 TABLE 36.5 Options for Mandibular Fixation. By Convention, Plates are Named According to the Outer Diameter of the Screws They Accommodate Region Symphysis, parasymphysis Lower border plate + upper border plate (2.0 mm each) Body

Rigid Fixation Locking reconstructive plate (2.8 mm)

Angle

Condyle, subcondylar region

N/A

Functionally Stable Fixation Two lag screws (2.4 mm)

Lower border plate (2–2.4 mm) + maxillomandibular fixation (MMF) Lower border plate + upper border plate (2 mm each) ± MMF Single monocortical miniplate in the central neutral zone (2 mm) + MMF Champy plate (2 mm tension band across oblique ridge) + MMF Champy plate + lower border plate (2 or 2.4 mm) ± MMF MMF Two miniplates (1.5 or 2 mm)

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Subcondylar and Condylar Fractures Fractures of the condylar head and subcondylar region are common, accounting for 25% to 35% of mandibular fractures in adults. 26 Loss of condylar height presents with early posterior tooth contact ipsilaterally and an anterior open bite. Risks of open treatment include facial nerve palsy, scarring, and inadequate reduction. Due to the high incidence of stiffness with an open approach, condylar and subcondylar fractures are often treated in a closed fashion. Normal occlusion is established and stabilized with MMF for 2 to 3 weeks. Open treatment is best reserved for displaced fractures without comminution and requires specific training and experience on the part of the surgeon.

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Complications Malocclusion can result from insufficient reduction or loss of reduction during the healing process due to inadequate fixation, poor bone quality, or suboptimal patient compliance. This may cause malunion or nonunion. Injury to tooth roots can occur from drilling or placement of bone screws. Facial nerve injury may result from a Risdon incision (marginal mandibular nerve) or condylar approaches (main trunk or any of its branches). Paresthesias can occur if the inferior alveolar or mental nerves are injured; even without transection, neuropraxia is common due to traction of the nerve. Stiffness of the TMJ can result from inadequate seating of the condyle during fixation, condylar head fracture, or prolonged MMF. Hardware infection may be managed with a period of observation and antibiotics with or without surgical irrigation; ideally, hardware removal is delayed until union occurs.

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Panfacial Fractures The definition of panfacial fractures is variable in the literature, at times referring to fractures spanning each third of the face, and at other times indicating fractures involving the maxilla, mandible, and ZMC. 30,31 With panfacial fractures, the face assumes a spherical shape, with loss of vertical height, reduction in anteroposterior projection, and increase in facial width. Extensive facial fractures are the result of highenergy trauma, and comminution is expected. Plastic surgeons must recognize mechanisms of injury that suggest risk of concomitant injuries and consult the trauma team when warranted. Restoration of facial dimensions must build from a stable, known skeletal base as a reference point. This can be sequenced in a top-down, bottom-up, or inside-out fashion. The most common sequence involves rebuilding the skeleton upwards after restoring mandibular stability. Restoring the preinjury occlusion with MMF allows the occlusal subunit to function as one, and ZMC and NOE fractures can be reduced from this reference point. Alternatively, the surgeon can work downwards from a noninjured cranial base and zygomaticofrontal suture. Primary bone grafting may be necessary to replace devitalized or highly comminuted bone.

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Questions 1. A 14-year-old boy presents to the emergency department after an unwitnessed ATV accident in which he was found lying without a helmet on the trail. He complains of jaw pain and his right eye is swollen shut. What is the best next step in management? a. Maxillofacial CT scan with 1.0 mm cuts b. Evaluation of extraocular motions to rule out entrapment c. Adherence to spinal precautions and palpation of the neck for tenderness d. Checking occlusion to compare to the patient’s baseline 2. Which of the following is most likely to lead to late deformity? a. Bilateral subcondylar mandible fractures b. Comminuted nasoorbitoethmoidal fracture with canthal bowstringing c. Nasal bone fracture with septal deviation d. Zygomaticomaxillary complex fracture without displacement at the lateral orbital rim 3. A 23-year-old man presents to the emergency department with multiple stab wounds. His facial lacerations were not fully evaluated during his workup. Which of the following are appropriate combinations of injury location and long-term complications? a. Floor of mouth; Stenson duct leak b. 1 cm inferior to the auricular lobule; lack of ipsilateral lower lip depression while smiling c. Lateral infraorbital rim; inability to elevate ipsilateral eyebrow d. Central and medial lower eyelid; epiphora 4. Which fracture is most likely to require operative intervention? a. Anterior table frontal sinus fracture with obstruction of the nasofrontal duct b. Orbital roof fracture extending into the lateral wall c. Orbital floor fracture 1 cm in diameter in a patient without diplopia d. Concomitant LeFort I and ipsilateral ZMC fractures with normal occlusion 5. A 50-year-old woman sustains panfacial fractures in a high-speed motor vehicle collision in which she was the unrestrained passenger. Which is the most appropriate sequencing of fracture reduction and fixation? a. ZMC, orbital floor, mandibular angle, LeFort I, anterior table of the frontal sinus b. Anterior table of the frontal sinus, LeFort I, mandibular angle, orbital floor, ZMC c. Mandibular angle, LeFort I, ZMC, orbital floor, anterior table of the frontal sinus d. Anterior table of the frontal sinus, orbital floor, ZMC, LeFort I, mandibular angle 6. You are reviewing the postoperative course of your most recent four operative mandible fractures. Which patient is the most likely to have had complications? a. 21-year-old man with right angle fracture sustained during an altercation b. 34-year-old woman with bilateral subcondylar fractures from a motor vehicle accident c. 18-year-old boy with symphyseal fracture after an ATV accident d. 31-year-old man with subcondylar and contralateral body fracture after falling from a roof 1. Answer: c. Many patients whose mechanism of injury is sufficient to produce facial fractures are also at risk of more significant multisystem traumatic injuries. Evaluation must first focus on airway, breathing, circulation, and disability. Almost 10% of patients with facial fractures will have concomitant cervical spine injuries. Protecting the spine in at-risk patients must be a priority until the spine can be cleared. The remaining actions would be appropriate after serious concomitant injuries are ruled out. Priority should be placed on ruling out plastic surgical emergencies, including entrapment of the extraocular muscles which is diagnosed clinically by physical exam. Workup

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would also include a careful examination to determine occlusion status and a maxillofacial CT scan with thin cuts. 2. Answer: b. NOE fractures are notoriously difficult to treat. The central midface lacks sagittal buttresses to support adequate projection, giving the region a high propensity to heal in a depressed position. The medial canthal tendon inserts into the thin bone of the medial orbit and establishes the appropriate intercanthal distance. When canthal bowstringing is present, the surgeon must determine whether the bone fragment to which the medial canthal tendon attaches is stable enough to fixate with miniplates. If the fragment is too small or comminuted transcanthal wiring will be necessary, with or without primary bone grafting. NOE fractures have a high incidence of late deformity. Bilateral subcondylar mandible fractures are commonly treated with maxillomandibular fixation, with the greatest concern of inadequate treatment being a late anterior open bite. Both nasal bone and septal fractures can be reduced and stabilized more easily than the thin bones of the NOE region. The ZMC is unlikely to be displaced if the zygomaticofrontal buttress at the lateral orbital rim remains well aligned. 3. Answer: d. Lacerations of the medial upper or lower eyelid may involve the canalicular system. If canalicular injury is suspected, ophthalmologic consultation is warranted to probe and repair or bypass the ductal system. Untreated canalicular injury may lead to excessive eye tearing, or epiphora. Injury to the parotid duct (Stenson duct) should be suspected with deep cheek lacerations. The duct travels from the anterior parotid gland through the midcheek in close proximity to the buccal branch of the facial nerve to open into the oral cavity adjacent to the second maxillary premolar. A laceration to the floor of the mouth would risk injuring other salivary glands but the Stenson duct. Inability to depress the lower lip while smiling is characteristic of a marginal mandibular nerve injury. This branch of the facial nerve exits with the main trunk from the stylomastoid foramen 1 cm anterior and inferior to the tragal pointer. It is part of the inferior or cervicofacial division that separates from the temporofacial division within the parotid gland and then divides from the cervical branch at the pes anserinus. The nerve travels anteriorly along the mandibular body or 1 to 2 cm below the lower mandibular border to innervate the mentalis and produce lower lip depression. A laceration directly inferior to the lobule would be too posterior to injure this branch. The temporal branch of the facial nerve innervates the frontalis and is responsible for brow elevation. This branch separates from the main trunk as part of the temporofacial division. The temporal branch is at highest risk of injury along a line drawn from 0.5 cm inferior to the tragus to 1.5 cm superior to the lateral eyebrow, known as the Pitanguy line. A laceration at the lateral infraorbital rim would be too medial to injure this branch. 4. Answer: a. Frontal sinus fractures that involve the nasofrontal duct have a high incidence of complications. These fractures should be treated by cranialization or obliteration to avoid mucocele or abscess formation. Orbital roof fractures are often managed nonoperatively, unless they create dural tears and cerebrospinal fluid leaks at the anterior cranial base. Indications for orbital floor repair include diplopia and entrapment. No definitive size cutoff exists over which an operative floor fracture requires fixation, although fractures larger than 1 to 2 cm2 are more likely to be associated with persistent diplopia. Maxillary fractures meet operative criteria if they are displaced or unstable. A primary indication of displacement is malocclusion. Nondisplaced LeFort I and ZMC fractures can be managed with a soft diet and close observation. 5. Answer: c. Panfacial fractures distort many of the landmarks typically used for fracture reduction, so sequencing fracture reduction and fixation is critical. Strategies that build from known to unknown in a top-down or bottom-up fashion are most likely to be successful. In the patient presented, the mandibular condyles can be used as stable reference points to reduce the mandibular angle fracture; then place the patient in MMF and reduce the LeFort I fragment using the teeth as a point of reference. Of note, the ZMC should be reduced and fixated prior to the orbital floor because

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ZMC reduction may change the size and orientation of the orbital floor fracture but not vice versa. In this patient, a top-down strategy would also be effective, but the ZMC must be addressed before the orbital floor fracture. 6. Answer: a. Multiple studies have demonstrated that fractures of the mandibular angle have the highest incidence of complications. The presence of the inferior alveolar nerve, impacted third molars, and opposing muscle forces make this region more challenging to treat. Risk of infection is slightly heightened if a wisdom tooth is present within the fracture line. The other fracture patterns are not specifically associated with an increased risk of complications. Complications are also more likely to be experienced in ballistic injuries, edentulous patients, and smokers.

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References Allareddy, V, Allareddy, V, Nalliah, RP. Epidemiology of facial fracture injuries. J Oral Maxillofac Surg. 2011;69:2613-2618. Mithani, SK, St Hilaire, H, Brooke, BS, et al. Predictable patterns of intracranial and cervical spine injury in craniomaxillofacial trauma: analysis of 4786 patients. Plast Reconstr Surg. 2009;123:1293-1301. Manson, PN, Clark, N, Robertson, B, et al. Subunit principles in midface fractures: the importance of sagittal buttresses, soft-tissue reductions, and sequencing treatment of segmental fractures. Plast Reconstr Surg. 1999;103:1287-1306.The authors present a classic description of how facial buttresses influence the technique and outcome of midfacial fracture reduction. Common pitfalls are addressed with recommendations as to how secondary complications can be avoided. Manson, PN, Hoopes, JE, Su, CT. Structural pillars of the facial skeleton: an approach to the management of Le Fort fractures. Plast Reconstr Surg. 1980;66:54-61. Zide, BM, Swift, R. How to block and tackle the face. Plast Reconstr Surg. 1998;101:840-851. Eppley, BL, Custer, PL, Sadove, AM. Cutaneous approaches to the orbital skeleton and periorbital structures. J Oral Maxillofac Surg. 1990;48:842-854. Mundinger, GS, Borsuk, DE, Okhah, Z, et al. Antibiotics and facial fractures: evidence-based recommendations compared with experiencebased practice. Craniomaxillofac Trauma Reconstr. 2015;8:64-78. Brooke, SM, Goyal, N, Michelotti, BF, et al. A multidisciplinary evaluation of prescribing practices for prophylactic antibiotics in operative and nonoperative facial fractures. J Craniofac Surg. 2015;26:2299-2303. Chole, RA, Yee, J. Antibiotic prophylaxis for facial fractures: a prospective, randomized clinical trial. Arch Otolaryngol Head Neck Surg. 1987;113:1055-1057. Ellis, E. Antibiotics and mandibular fracture update. J Oral Maxillofac Surg. 2016;74:1911-1912. Zix, J, Schaller, B, Iizuka, T, Lieger, O. The role of postoperative prophylactic antibiotics in the treatment of facial fractures: a randomised, double-blind, placebo-controlled pilot clinical study. Part I: orbital fractures in 62 patients. Br J Oral Maxillofac Surg. 2013;51:332-336. Thill, MP, Horoi, M, Ostermann, K, et al. Acute external ear lesions: clinical aspects, assessment, and management. B-ENT. 2016;26:155171.This article provides a detailed, comprehensive approach to auricular hematoma, perichondritis, laceration, and burn with treatment algorithms for each clinical problem. Lewkowicz, AA, Hasson, O, Nahleili, O. Traumatic injuries to the parotid gland and duct. J Oral Maxillofac Surg. 2002;60:676-680.A literature review was conducted to supplant the experience of a single center in treating traumatic injuries to the parotid duct. An algorithm for treatment is proposed. Rodriguez, ED, Stanwix, MG, Nam, AJ, et al. Twenty-six-year experience treating frontal sinus fractures: a novel algorithm based on anatomical fracture pattern and failure of conventional techniques. Plast Reconstr Surg. 2008;122:1850-1866.This article reviews 857 cases of frontal sinus fractures treated at a tertiary hospital. A treatment algorithm is proposed, and the incidence of complications is described within the framework of the proposed algorithm. Chen, CT, Chen, YR. Traumatic superior orbital fissure syndrome: current management. Craniomaxillofac Trauma Reconstr. 2010;3:9-16. Manson, PN, Grivas, A, Rosenbaum, A, et al. Studies on enophthalmos: II. the measurement of orbital injuries and their treatment by quantitative computed tomography. Plast Reconstr Surg. 1986;77:203-214. Chaudry, O, Isakson, M, Franklin, A, Maqusi, S, El Amm, C. Facial fractures: pearls and perspectives. Plast Reconstr Surg. 2018;141:742e758e.This review article discusses concepts in treating facial fractures primarily and managing secondary complications. Multiple videos are available online with further detail on fracture management and surgical techniques. Danko, I, Haug, RH. An experimental investigation of the safe distance for internal orbital dissection. J Oral Maxillofac Surg. 1998;56:749-752. Mok, D, Lessard, L, Cordoba, C, et al. A review of materials currently used in orbital floor reconstruction. Can J Plast Surg. 2004;12:134-140. Al-Moraissi, EA, Thaller, SR, Ellis, E. Subciliary vs. transconjunctival approach for the management of orbital floor and periorbital fractures: a systematic review and meta-analysis. J Craniomaxillofac Surg. 2017;45:1647-1654. Bartsich, S, Yao, CA. Is frosting effective? The role of retention sutures in posttraumatic orbital reconstruction surgery. J Plast Reconstr Aesthet Surg. 2015;68:1683-1686. Lee, EI, Mohan, K, Koshy, JC, Hollier, LH. Optimizing the surgical management of zygomaticomaxillary fractures. Semin Plast Surg. 2010;24:389-397. Basheeth, N, Donnelly, M, Smyth, D, Shandilya, M. Acute nasal fracture management: a prospective study and literature review. Laryngoscope. 2015;125:2677-2684. Rohrich, RJ, Adams, WP. Nasal fracture management: minimizing secondary nasal deformities. Plast Reconstr Surg. 2000;106:266-273. Markowitz, BL, Manson, PN, Sargent, L, et al. Management of the medial canthal tendon in nasoethmoid orbital fractures: the importance of the central fragment in classification and treatment. Plast Reconstr Surg. 1991;125:843-853.This landmark article describes the classification system for NOE fractures and a detailed treatment strategy for reduction and fixation of each type. Morrow, BT, Samson, TD, Schubert, W, Mackay, DR. Evidence-based medicine: mandible fractures. Plast Reconstr Surg. 2014;134:1381-1390. King, RE, Scianna, JM, Petruzzelli, GJ. Mandible fracture patterns: a suburban trauma center experience. Am J Otolaryngol. 2004;25:301-307. Ellis, E, Miles, BA. Fractures of the mandible: a technical perspective. Plast Reconstr Surg. 2007;120:76S-89S.This introductory article describes the biomechanics of the mandible as related to fracture fixation. Techniques of osteosynthesis in each region of the mandible are discussed in detail, along with depictive photographs and radiographs.

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Chuong, R, Donoff, RB, Guralnick, WC. A retrospective analysis of 327 mandibular fractures. J Oral Maxillofac Surg. 1983;41:305-309. He, D, Zhang, Y, Ellis, E. Panfacial fractures: analysis of 33 cases treated late. J Oral Maxillofac Surg. 2007;65:2453-2465. Kelly, KJ, Manson, PN, Vander Kolk, CA, et al. Sequencing LeFort fracture treatment (organization of treatment for a panfacial fracture). J Craniofac Surg. 1990;1:168-178.

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CHAPTER 37

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Head and Neck Cancer and Salivary Gland Tumors Matthew M. Hanasono and Brian A. Moore

Key Points Alcohol and tobacco use are the two most important risk factors for head and neck cancer, particularly cancers of the oral cavity, oropharynx, hypopharynx, and larynx, whereas human papillomavirus is increasingly recognized as a risk factor for oropharyngeal cancer. Treatment for head and neck cancer depends on the location of the tumor and the stage and can include surgery, radiation, chemotherapy, and/or targeted therapy. Cervical lymphadenectomy (neck dissection) is indicated for nodal disease and cancers at high risk for regional spread. About 80% of salivary gland tumors occur in the parotid glands, followed by the submandibular and minor salivary glands, and only about 1% occur in the sublingual glands. About 80% of parotid gland tumors are benign, and the parotid gland is the most common location for salivary gland malignancies; about 50% of submandibular gland tumors and 80% of minor salivary gland tumors are malignant. This chapter will provide an overview to cancer staging and treatment of the upper aerodigestive tract (UADT), including the oral cavity, pharynx, and larynx, and the salivary glands. Although a comprehensive text is not possible in this space, our goal is to provide the reconstructive surgeon with adequate knowledge to communicate with the ablative surgeon and anticipate the surgical defect. Being able to predict the surgical defect helps the reconstructive surgeon to plan the reconstruction appropriately. Furthermore, knowledge of the cancer’s biology and current recommended treatment assists the surgeon to factor in the possible need for adjuvant therapy, such as radiation, as well as get a sense of the patient’s prognosis, both of which may affect choice of reconstructive techniques to be performed.

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Upper Aerodigestive Tract Cancers Over 95% of UADT tumors are squamous cell carcinomas (SCCs). 1 Overall, 5-year survival for these cancers is about 65% but varies substantially based on site, stage, and histologic findings. 2 Other cancers affecting the UADT include salivary gland malignancies, sarcomas, mucosal melanomas, and lymphomas.

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Anatomy The anatomic subsites of the oral cavity include the labial mucosa, buccal mucosa, floor of mouth, alveolar ridge and gingiva, anterior two-thirds of the tongue (anterior to the circumvallate papillae), hard palate, and retromolar trigone (Figure 37.1). The oropharynx lies posterior to the oral cavity and consists of the soft palate, base of tongue (posterior to the circumvallate papillae), palatine tonsils, palatoglossal folds, valleculae, and posterior pharyngeal wall. The nasopharynx is superior to the oropharynx and includes the mucosa over the posterior body of the sphenoid and basilar part of the occipital bone superiorly, the adenoids and pharyngobasilar fascia posteriorly, and the Eustachian tubes and the lateral pharyngeal recesses (fossae of Rosenmüller) laterally. The hypopharynx spans from the hyoid bone down to the inferior cricoid cartilage and includes the piriform sinuses, postcricoid area, and the pharyngeal wall. The larynx comprises the supraglottis, glottis (vocal folds), and subglottis.

FIGURE 37.1 Upper aerodigestive tract (UADT) sites and subsites.

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Incidence and Risk Factors Tobacco is a major risk factor for UADT SCC. A meta-analysis by Gandini et al. 3 found a relative risk of 3.4 for oral cavity and 6.8 for oropharynx SCC in current tobacco smokers compared with nonsmokers. Tobacco and concomitant alcohol consumption synergistically increase the risk 10- to 15-fold. Alcohol has also been shown by many studies to be an independent risk factor. 4 Smokeless tobacco and betel nut also significantly increase the risk for oral cavity cancers. Although lip cancers are included in the oral cavity cancer staging system, they are different in that sun exposure is highly correlated with their development. Leukoplakia (white patches) and erythroplakia (red patches) in the oral cavity are considered premalignant lesions but may harbor dysplasia or malignancy on histology evaluation up to 20% and over 50% of the time, respectively. 4 Besides tobacco and alcohol, human papillomavirus (HPV) has been recognized as a major etiologic factor in SCCs of the oropharynx and is felt to be the cause of the rise in incidence of this cancer over the past 20 years. Recent studies suggest that HPV-associated cancers account for 73% of oropharyngeal SCCs, representing an increase of 225% between 1988 and 2004. 5,6 Compared with patients with HPVnegative tumors, patients with HPV-associated cancers tend to be younger, healthier, and have a better prognosis; middle-aged men with limited to no smoking history constitute the most commonly affected demographic. 7 HPV is the most common sexually transmitted infection, and certain subtypes, most commonly HPV-16, are associated with the development of malignancy in the oropharynx as well as of the cervix and anogenital tract. SCCs of the oropharynx can be tested for HPV positivity using immunohistochemical stains to identify p16 protein (cyclin-dependent kinase 2A, a tumor suppressor protein that is overexpressed in HPV-associated oropharyngeal cancer) or HPV DNA or RNA to help convey prognostic information to the patient. Because of its lower cost and ease of testing, p16 immunohistochemistry has evolved as an acceptable surrogate marker for HPV-associated cancers. 8 HPV vaccination in adults after the diagnosis of HPV-positive oropharyngeal SCC is not felt to be of any benefit, but there is apparent benefit in primary disease prevention if administered to boys and girls according to established guidelines. 7,9 Nasopharyngeal cancer (NPC) is most common in southern China and other parts of Southeast Asia and, in endemic regions, is strongly associated with the presence of Epstein-Barr virus (EBV). Salt-cured fish and meats, rich in nitrosamines, which are popular in some Asian countries, have also been linked to NPC. Tobacco and alcohol use may also be risk factors, but the link is less clear.

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Preoperative Considerations Biopsies, Imaging, and Metastatic Workup Following thorough history and physical examination, suspicious lesions of the UADT should be biopsied. Because of the relatively high risk of synchronous primary cancers, panendoscopy (laryngoscopy, bronchoscopy, and esophagoscopy) is often performed as part of the workup. Computed tomography (CT) helps identify nodal metastases as well as bony invasion, which is important for staging and surgical planning. If there is a question regarding the extent of soft tissue involvement or perineural spread, magnetic resonance imaging (MRI) may be preferred or obtained in addition to CT. Positron emission tomography (PET) and PET-CT may be used to look for distant metastases and second primary cancers. A metastatic workup should include a chest X-ray for early-stage/low-risk lesions or a chest CT or PET scan in advanced-stage cancers, as well as liver function tests.

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Staging In broad terms, small tumors without obvious nodal metastases represent early stage I and II cancers, whereas larger, more extensive tumors and/or the presence of cervical nodal metastases represent advanced stage III and IV cancers. Factors that have been linked to poorer outcomes include advancedtumor stage, increased soft-tissue depth of invasion, presence of nodal metastases, perineural invasion, lymphovascular invasion, and extranodal extension (ENE). 4 These factors are used to guide treatment and provide patients with prognostic information. As a general rule, the presence of nodal metastases reduces survival by 50%, except in HPV-associated (p16-positive) oropharyngeal cancer. 10 The TNM classification, based on the extent of the tumor (T), spread to the lymph nodes (N), and the presence of metastasis (M), is used to communicate information about tumor size and spread as well as provide prognostic data. At the time of this writing, the eighth edition of the American Joint Committee on Cancer (AJCC)/International Union Against Cancer (UICC) staging system has replaced the seventh edition. 11 For oral cavity cancers, the depth of invasion is now incorporated into the T classification because of the negative effect this parameter has on prognosis. Similarly, ENE has a profound adverse effect on the prognosis and is now part of the N classification. Another major difference is the division of oropharyngeal cancer classifications based on HPV positivity, because HPV-associated oropharyngeal cancer is markedly different in prognosis and behavior from non-HPV–associated cancer. Staging based on clinical and pathologic information is denoted by a “c” or “p” because surgical pathologic data, such as the number of involved lymph nodes or microscopic ENE, provide greater detail regarding adverse features with significant prognostic impact.

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Sites Oral Cavity Cancer The oral cavity is the most common site for SCC of the head and neck (Figure 37.2). Most oral cavity cancers are treated surgically with the goal of achieving clear 1 to 2 cm margins. 10 Neck dissection is performed when lymph node metastases are detected or when there is elevated risk of occult lymph node metastases, and there is growing evidence to support sentinel lymph node biopsy for oral cavity malignancies. 12 Radiation can be used as definitive treatment; however, it is not routinely used because of the elevated rates of osteoradionecrosis associated with the higher therapeutic doses required for definitive versus adjuvant treatment. Advanced-stage cancer is usually treated with surgery and adjuvant radiation or combined chemotherapy and radiation when there are adverse findings (e.g., positive margins, locally advanced disease, perineural or lymphovascular invasion, N2 or N3 nodal disease, and ENE). 13–16 Most surgery is performed transorally, except for very posterior lesions, which may require a mandibulotomy or a transcervical approach.

FIGURE 37.2 Cancer of the oral tongue seen on the right lateral tongue.

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Oropharyngeal Cancer Oropharyngeal cancer is distinctly different from oral cavity cancer, although here too SCC predominates, accounting for approximately 90% of cases. 5,7,17 The tonsillar region and base of tongue are the most common sites for oropharyngeal cancer, and specimens should be tested for p16 protein or HPV DNA or RNA for staging. 17 Compared with treatment of oral cavity SCC, management of oropharyngeal SCC is more controversial. For early stage cancers, surgery alone or radiation alone results in comparable overall survival. Radiation has been favored at many centers to preserve speech and swallowing function. 18 However, transoral laser microsurgery (TLM) and transoral robotic surgery (TORS) have emerged as alternatives with improved functional outcomes over traditional open techniques. 19 For advanced cancers, current evidence supports the use of either combined chemotherapy and radiation therapy or surgery. 18 If surgery is performed, it may be followed by adjuvant therapy depending on the pathologic findings and stage.

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Nasopharyngeal Cancer The World Health Organization (WHO) classifies NPC into three subtypes 20 : Type I: Keratinizing squamous cell carcinoma Type II: Nonkeratinizing squamous cell carcinoma Type III: Undifferentiated carcinoma It is type III that accounts for over 95% of nasopharyngeal carcinomas in high-incidence areas, specifically southern China and Southeast Asia, with a strong association with EBV. 20 Presenting symptoms are often confused with benign and infectious processes, potentially leading to late diagnosis, and include a neck mass from nodal metastasis, middle ear effusion with hearing loss (from Eustachian tube obstruction), nasal obstruction, and sore throat. Flexible fiberoptic nasopharyngoscopy is performed to visualize the nasopharynx in patients suspected of NPC. NPC is a radiosensitive malignancy, and radiation therapy to the primary and to the neck with or without concurrent chemotherapy is the mainstay of treatment for all types of NPC. 20,21 Neck dissection is performed for residual neck disease or resectable regional recurrence. Surgery with or without reirradiation is performed for resectable local recurrences. 20 Surgery of nasopharyngeal tumors can be complex because of limited access and perilous because of risk to the optic nerves as well as the internal carotid artery and cavernous sinus. Targeted treatment for NPC with monoclonal antibodies such as cetuximab, pembrolizumab, and nivolumab is being actively investigated. 20,21

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Hypopharyngeal Cancer Hypopharyngeal and laryngeal cancers are often contiguous with each other as well as with the cervical esophagus. Additionally, many of these tumors are multicentric. Early stage hypopharyngeal cancers can be treated by surgery alone or radiation alone with comparable 5-year survival and local disease control. 4 Surgical approaches are most commonly transoral for early stage cancers, including robotic and laser resections, and transcervical for late stage cancers. 22 Advanced-stage piriform sinus cancers usually require a total laryngectomy and pharyngectomy (Figure 37.3). Advanced-stage cancers are given postoperative radiation. Alternately, they may be treated with combined chemotherapy and radiation with surgery reserved for salvage of residual or recurrent disease. As with laryngeal cancer, organ preservation (i.e., larynx preserving) protocols (induction chemotherapy followed by radiation with surgery reserved for salvage or concurrent chemoradiation therapy) have shown equivalent overall survival to the traditional approach of surgery and adjuvant radiation; therefore, many centers favor chemoradiation as the initial treatment for most hypopharyngeal cancers, although the prognosis for hypopharynx cancer remains grim. 22 The prevalence of neck metastases on presentation of hypopharyngeal cancers is 65% to 80%, and hypopharyngeal cancer is associated with the worst prognosis of all UADT SCCs, with an overall 5-year survival of around 35%. 21

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FIGURE 37.3 Laryngopharyngectomy specimen from a patient with hypopharyngeal cancer.

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Laryngeal Cancer Most laryngeal cancers occur in the glottis (64%), followed by the supraglottis (34%), and only rarely in the subglottis (2%). 4 Only about 5% of laryngeal SCCs occur in nonsmokers and nondrinkers. 4 HPV has been reported to be associated with laryngeal cancer but with much less frequency than in oropharyngeal SCC. The incidence and pattern of nodal spread varies with the location of the primary tumor. Lymphatic drainage of the glottis is sparse, and early stage primary cancers rarely spread to the lymph nodes. Also, because hoarseness is an early symptom, most glottic cancers are diagnosed at an early stage. Thus, cancer of the glottic larynx has an excellent average cure rate of 80% to 90%. 4 TLM and TORS can be used for early stage glottic and supraglottic tumors if adequate visualization of the tumor can be achieved. Early stage glottic tumors are frequently treated with TLM or open cordectomy. If there is extension to the arytenoids, then a hemilaryngectomy can be performed. Such surgeries are aimed at preserving the laryngeal functions of phonation and airway protection. Advanced laryngeal cancers are treated with total laryngectomy or combined chemotherapy and radiation therapy. Chemoradiation is usually the preferred initial treatment modality based on the results of the landmark Veterans Administration Laryngeal Cancer Study and subsequent RTOG 91-11 study, which showed comparable survival for patients treated with total laryngectomy versus an organ preservation protocol with surgical salvage. In this study, the laryngeal preservation rate was 67%. 23,24 Subsequent studies have confirmed these findings and have established concurrent chemotherapy with cisplatin and radiation therapy as the standard of care. 25–27 Bulky T4 cancers with either thyroid cartilage penetration or ≥1 cm base of tongue extension are an exception and should be treated with surgery. Also, patients with laryngeal dysfunction prior to treatment should not undergo organ preservation treatments because laryngeal preservation is valuable only if the core functions of breathing, speech, and airway protection during swallowing are preserved. 27

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Unknown Primary Cancer Neck metastases without a primary tumor that can be localized by physical examination or radiographic imaging are known as unknown primary or occult primary cancers. Unknown primary cancers account for 1% to 4% of head and cancers. 28 A painless neck mass in an adult should be considered a malignancy until proven otherwise. Fine-needle aspiration (FNA) is used to confirm the diagnosis. Metastatic UADT SCC is the most common cancer presenting as an unknown primary neck mass, followed by papillary thyroid cancer and cutaneous SCC. 28 The oropharynx is most frequently the origin of cancer in patients presenting with a cervical metastasis and an unknown primary. HPV detected in FNA specimens suggests an oropharyngeal primary, most commonly arising from either the tonsil or base of tongue. Further workup consists of imaging with CT or MRI and panendoscopy with directed biopsies, usually including the nasopharynx, both sides of the base of tongue (including potential lingual tonsillectomy), bilateral tonsillectomies, and both piriform sinuses, although biopsy sites may be selected based on the level(s) of neck disease and can vary slightly from institution to institution. 28,29 When the primary remains unknown despite complete workup, most patients are treated with multimodality therapy, either resection (neck dissection) followed by adjuvant radiation with or without chemotherapy, or primary chemoradiation with or without posttherapeutic neck dissection. Radiation is usually given to both sides of the neck and to the nasopharynx, oropharynx, and hypopharynx/larynx. An exception is early stage cancers (T0N1 and HPV-associated T0N2a without other risk factors), which are usually treated with a single modality consisting of either surgery alone or radiation alone. 28

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Treatment In general, early-stage tumors are treated with single modality therapy and late-stage tumors are treated with multimodality therapy, usually surgery followed by adjuvant radiation with or without chemotherapy with the exceptions noted earlier.

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Surgery Surgery is the mainstay for initial treatment of oral cavity cancer. 10,30 Most oral cavity lesions can be accessed transorally. A mandibulotomy with a lip-splitting incision may be used for very posterior lesions as well as oropharyngeal lesions. Transcervical resection may also be performed for oropharyngeal tumors. TORS is also an option for posterior oral cavity, oropharyngeal, and early-stage hypopharyngeal resections. For most sites, adequate surgical margins are defined in the National Comprehensive Cancer Network (NCCN) guidelines as ≥5 mm or more on final pathology, with close margins defined as anything 20% of occult lymph node metastases. Bilateral neck dissections may be indicated when nodal metastases are present bilaterally or when a large midline primary tumor is present and there is a high probability of bilateral occult metastases (e.g., in the base of the tongue, the supraglottis, or the floor of the mouth). 10,30 RND and MRND are usually reserved for advanced nodal disease and disease extending into level V or invasion of critical structures in the neck. 30

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Adjuvant Therapy As mentioned, surgery with postoperative radiation or combined radiation and chemotherapy has become the accepted treatment for high-stage head and neck cancers and those with adverse prognostic risk factors. 35 During the past decade, intensity-modulated radiation therapy has replaced standard delivery radiotherapy with decreased radiation-associated toxicity, particularly xerostomia. 36 It is an advanced form of radiation therapy that uses multiple radiation beams of varying intensities coming from different angles to precisely irradiate a tumor and avoid or reduce exposure of healthy tissue. More recently, intensity-modulated proton therapy (IMPT) has been used in head and neck cancer. 37 It may further reduce radiation-associated toxicity because of the decreased dose of radiation distal to the planned target. Besides xerostomia, other side effects of all forms of radiation include dermatitis, nausea and vomiting, fatigue, mucosal sores, hoarseness, and loss of taste. 37 Long-term problems may include dental decay, osteoradionecrosis, hypothyroidism, vascular disease, hypopituitarism if the pituitary gland is irradiated, and decreased hearing or vision when the orbits or middle ear/temporal bone are irradiated. 35 Cisplatin is the chemotherapeutic drug most commonly used in head and neck cancer treatment regimens. It may be used alone or may be combined with 5-fluorouracil if given after radiation. Other agents include carboplatin, doxorubicin, epirubicin, paclitaxel, docetaxel, gemcitabine, bleomycin, and methotrexate. Combinations of two or more of these drugs are often used. Cisplatin is associated with neuropathies, especially peripheral neuropathy and hearing loss. Other side effects of chemotherapy agents include hair loss, mouth sores, loss of appetite, nausea and vomiting, diarrhea, immunosuppression, thrombocytopenia, and anemia. 4 Targeted therapy works differently from standard chemotherapy drugs and often has different side effects. Targeted therapies consist of monoclonal antibodies that target specific protein receptors involved in the cancer pathway. Cetuximab effectively targets the epidermal growth factor receptor, a transmembrane tyrosine kinase receptor that is overexpressed in the majority of head and neck cancers and leads to division, angioinvasion, and metastasis through Ras and PI3K. Cetuximab has been demonstrated to be superior to radiation therapy alone and has become an integral component of systemic therapy for UADT SCC, although its efficacy remains undetermined compared with platinbased regimens. 38–40 Recently, immunotherapy with agents targeted against the PD-1 or PD-L1 checkpoint, such as pembrolizumab and nivolumab, has demonstrated prolonged disease-free survival in a subset of patients with recurrent or refractory head and neck cancer. 41,42

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Salivary Gland Tumors Salivary gland tumors represent a diverse group of neoplasms involving the major and minor salivary glands. Tumors may arise from the various myoepithelial, ductal, and acinic components of the gland. Besides salivary gland epithelial neoplasms, the differential diagnosis for swelling in the region of the major glands includes metastatic cutaneous carcinoma (melanoma or SCC), lymphoma, hemangioma, tuberculosis, HIV, and lymphadenopathy. 43

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Anatomy Salivary glands include the parotid, submandibular, and sublingual glands (Figure 37.6). There are 800 to 1000 minor salivary glands located throughout the oral cavity beneath the buccal, labial, and lingual mucosa; the soft palate; the lateral parts of the hard palate; and the floor of the mouth or between muscle fibers of the tongue. The minor salivary glands are 1 to 2 mm in diameter and, unlike the major glands, are not encapsulated by connective tissue, only surrounded by it.

FIGURE 37.6 Anatomy of the major salivary glands, showing the parotid, submandibular, and sublingual glands.

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Incidence and Risk Factors Salivary gland tumors are rare, with fewer than 15 cases per 100,000 individuals annually. 43 About 80% of salivary gland tumors are benign. 43 Primary salivary gland malignancies represent less than 5% of all new head and neck cancers. About 80% of salivary gland tumors occur in the parotid glands, followed by the submandibular and minor salivary glands, and only about 1% occur in the sublingual glands. About 80% of parotid gland tumors are benign, and the parotid gland is the most common location for salivary gland malignancies; about 50% of submandibular gland tumors and 80% of minor salivary gland tumors are malignant. 43 Rapid growth as well as pain and/or paresthesias caused by perineural invasion are associated with malignancy. In the parotid gland, facial paralysis may be indicative of facial nerve invasion of a malignant tumor. Nodal metastases may also be seen in malignant tumors.

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Preoperative Considerations Biopsies, Imaging, and Metastatic Workup Ultrasound, CT, and MRI are commonly used to evaluate salivary gland lesions. Contrast enhancement does not distinguish between benign versus malignant tumors but can delineate the extent of the lesion. Irregular margins, bony invasion, and the presence of metastatic lymph nodes or perineural spread can all be signs of malignancy; perineural spread may be apparent by widening of a nerve or neural foramina/space on CT scan, as well as by asymmetric enhancement or thickening on MRI. PET-CT is helpful for detecting disease recurrence and distant metastases. 44 Ultrasound-guided FNA cytology is widely used but controversial because it has different levels of accuracy based on tumor type. FNA is reported to correctly diagnose tumor type in 61% to 94% of cases and differentiate between benign and malignant tumors in 81% to 98% of cases. 45,46 Because of this lack of complete accuracy, FNA alone should not be used to dictate the extent of surgery, such as radical resection or cervical lymphadenectomy. Some clinicians will choose to observe a lesion that is benign by FNA in patients deemed poor candidates for surgery. In all other patients, surgery is usually indicated for salivary gland neoplasms regardless of FNA results. The challenge for the extirpative surgeon is to correctly determine the appropriate extent of surgical treatment, taking into account not only results from FNA but also the preoperative and intraoperative findings, including those of frozen section examination, which has limitations in terms of making an accurate diagnosis as well. When the exact diagnosis is equivocal, the full scope of treatment should not be determined until final diagnosis has taken place.

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Common Tumor Types Most (≥95%) salivary gland neoplasms are of epithelial origin. 47 The WHO recognizes 11 benign and 22 malignant epithelial subtypes of salivary tumors, which are in turn characterized by marked biologic heterogeneity. 47 High-grade mucoepidermoid carcinomas (MECs), salivary ducts carcinomas, malignant mixed tumors, and high-grade adenocarcinomas have the most aggressive clinical course with early regional and distant metastases. The most common tumors are briefly discussed in the following sections. Metastatic skin cancer (most frequently SCC) is also an increasing concern, particularly, in elderly or immunocompromised patients, such as patients with chronic lymphocytic leukemia or organ transplant recipients. 48

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Pleomorphic Adenoma Pleomorphic adenoma, also known as benign mixed tumor, is the most common salivary gland epithelial tumor in both adults and children and comprises one-half to two-thirds of all benign salivary gland tumors. 49 About 80% of pleomorphic adenomas are found in the parotid gland. 49 Tumors are most common in the fourth to fifth decade. Pleomorphic adenomas are well circumscribed and are grossly lobular and gray in appearance, although myxoid variants are more gelatinous, whereas cellular variants are firm and may appear tan-white. This tumor is histologically characterized by epithelial and connective tissue elements, with stellate and spindle cells interspersed within a myxoid background. Pleomorphic adenomas are treated by surgical excision and are associated with very low recurrence rates (0%–5%). 49,50 Incomplete excision is the main risk for recurrence. For parotid tumors, pseudopodia pose a theoretic risk for recurrence when margins are narrow. Left untreated, up to 15% of pleomorphic adenomas may undergo malignant transformation into a lesion known as carcinoma ex pleomorphic adenoma, which is why resection is recommended. 49

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Warthin Tumor Warthin tumor (papillary cystadenoma lymphomatosum) is the second most common tumor of the parotid gland and is benign. Warthin tumors predominantly occur in males of 50 to 70 years of age, most frequently smokers, and are the most common bilateral salivary gland tumors (5%–14%). 49 The histologic appearance of this tumor is characteristic, consisting of papillary cysts and mucoid fluid as well as nodules of lymphoid tissue. Because of the mitochondrial concentrations in oncocytes, Warthin tumors do not infrequently demonstrate fluorodeoxyglucose uptake on PET scan, potentially leading to a falsepositive study. 50

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Mucoepidermoid Carcinoma MEC is the most common salivary gland malignancy (about 35% of salivary gland cancers) and consists of mucin-secreting, intermediate, and epidermoid cells. 43 The histologic grade (low, intermediate, high) of MEC has prognostic value and dictates the need for adjuvant radiation therapy. Low- and intermediate-grade tumors often present as asymptomatic slow-growing, solitary masses. High-grade tumors may progress rapidly and present with symptoms including pain, nerve deficits, and local soft tissue invasion. Overall survival is 80% to 90% for low- and intermediate-grade tumors, whereas highgrade tumors have an overall survival of 40% to 50% at 5 years. 43,51 Elective node dissection is often recommended for high-grade tumors; however, histologic grade is seldom known preoperatively.

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Acinic Cell Carcinoma Acinic cell carcinoma accounts for 8% to 14% of salivary gland cancers. 43,51 The parotid is the most commonly involved salivary gland and usually presents as a slow-growing solitary mass. Tumor cells have a granular, metachromatic cytoplasm, resembling that seen in the serous acinar cells of salivary glands. Acinic cell carcinomas tend to behave indolently. Survival is 97%, 93%, and 89% at 5, 10, and 15 years, respectively. 51

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Adenoid Cystic Carcinoma Adenoid cystic carcinoma (ACC) is the second most common malignancy of the salivary glands after MEC and exhibits a propensity for perineural invasion. There are three histologic subtypes: cribriform, tubular, and solid. The cribriform pattern has a classic Swiss cheese appearance with cells arranged in nests separated by round or oval spaces. The tubular pattern has a glandular architecture, whereas the solid (or basaloid) pattern has sheets of cells with little or no luminal spaces. 43 ACC shows a slow but relentless progression. Five-year survival is as high as 90%, but 15-year survival is less than 70% and decreases substantially after this with a 20-year survival of 28%. 43,51 ACCs usually have an indolent natural history although high-grade transformation with markedly worse prognosis (median survival of 12–36 months) can occur. 43 The risk for regional spread is low (about 5%–20%), but these cancers have a propensity for local and distant recurrence even 10 to 15 years after initial treatment. 43 Most commonly, spread is to the lungs, bone, and brain. The development of asymptomatic, slowly growing pulmonary metastases can often be observed for years.

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Malignant Mixed Tumors Malignant mixed tumors of the salivary glands include carcinoma ex pleomorphic adenoma (the most common variant), intracapsular carcinoma ex pleomorphic adenoma, metastasizing pleomorphic adenoma, and carcinosarcoma. 51 Carcinoma ex pleomorphic adenoma presents in a preexisting pleomorphic adenoma with accelerated growth and new-onset pain and/or neuropathy. Nodal metastasis may be an early finding. Adjuvant radiation following surgery to the primary site and nodal basins may improve local control rates, although overall survival is poor (about 40% 5-year survival). 51 Intracapsular carcinoma ex pleomorphic adenoma shows evidence of malignancy cytologically but is confined within the capsule of a preexisting pleomorphic adenoma and generally has better prognosis than invasive variants. Metastasizing pleomorphic adenomas show histologic features of benign pleomorphic adenoma but present with distant metastases and local recurrences. Treatment involves surgical resection of the involved sites when possible. Prognosis is favorable despite metastases. Carcinosarcomas are rare and associated with frequent recurrences, distant metastases, and poor overall survival.

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Treatment Complete surgical excision is curative for benign tumors and malignancies when the tumor is small and low grade. Larger tumors and those with aggressive histologic type and/or high grade are usually treated with surgery and adjuvant radiation therapy.

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Parotidectomy A superficial parotidectomy is considered the treatment of choice for benign and most malignant tumors in the superficial lobe of the gland. 43,49 A less than complete superficial parotidectomy that still removes the entire tumor with a negative margin is referred to as a partial parotidectomy. Total parotidectomy, sparing the facial nerve if uninvolved, is indicated for deep lobe tumors and, increasingly, for metastatic cutaneous malignancy (Figure 37.7). 52 Preoperative weakness or invasion based on imaging may require one or more branches of the facial nerve to be sacrificed. The nerve may also need to be sacrificed if preservation would lead to grossly positive margins or tumor spillage. Radical parotidectomy involves total parotidectomy with facial nerve sacrifice. If adjacent structures such as the skin, mandible, or temporal bone are involved, an extended radical parotidectomy may be indicated. Mastoidectomy/lateral temporal bone resection may also be indicated to identify and/or resect the facial nerve proximally if the tumor abuts the mastoid bone or stylomastoid foramen or invades the nerve. 43

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FIGURE 37.7 A total parotidectomy has been performed in which both the superficial and deep lobes of the parotid gland have been removed. The facial nerve (white arrow) is indicated and can be seen arising from the stylomastoid foramen, above of the posterior belly of the digastric muscle.

Enucleation, which requires simple removal of the mass, is not indicated for malignant tumors and is controversial for benign tumors, with some surgeons advocating against it. 43,49 For those who consider enucleation, resection should include the capsule of the tumor (extracapsular enucleation), and it should be reserved for benign superficial tumors less than 4 cm in diameter. 49

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Submandibular, Sublingual, and Minor Salivary Gland Excision Benign neoplasms of the submandibular gland are treated with submandibular gland excision. For malignant lesions, level I lymph nodes and possibly other cervical levels are dissected in continuity. Sublingual gland malignancies are often managed transorally and may include the floor of mouth mucosa if it is involved or close to the tumor. Obtaining negative margins in sublingual gland surgery can be challenging because it is not encapsulated by fascia and may invade the mandible, lingual nerve, or duct of the submandibular gland. 43 Resection of minor salivary gland tumors depends on their location. Wide local excision is usually performed with the goal of achieving clear margins of at least 5 mm. Resection of palatal and base of tongue tumors can affect speech, swallowing, and velopharyngeal competence. 43

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Cervical Lymphadenectomy Known cervical metastases should be treated with cervical lymphadenectomy. In the clinically nodenegative neck, the decision between observation and treatment via elective neck dissection or prophylactic radiation is made based on the likelihood for occult metastases. Risk factors for nodal spread include histological evidence of perineural invasion, lymphovascular invasion, and extracapsular spread, as well as high-grade histologic subtypes. 53,54 The most frequently involved nodal levels primarily depend on the site of the primary tumor.

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Adjuvant Therapy Unresectable locally advanced tumors with skull base or carotid involvement or those occurring in patients who are not able to tolerate surgery may be managed with primary radiation therapy. Undifferentiated and high-grade tumors, advanced-stage tumors, including those with facial nerve and deep lobe involvement, tumors with lymphatic or vascular invasion, and tumors with positive margins are usually treated with surgery and adjuvant radiation therapy to prevent locoregional recurrence. Systemic chemotherapy is considered for patients who have recurrence or metastatic disease who are not candidates for surgical or radiation treatment. 55 Differing histotypes and heterogeneity within histotypes make it difficult to standardize systemic treatment. Methotrexate, cisplatin, paclitaxel, epirubicin, and vinorelbine have been used in advanced salivary gland cancers, although not routinely. 55 Targeted therapy may also have a role in specific salivary gland malignant subtypes, and research is ongoing.

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Questions 1. A 40-year-old man presents with a neck mass that is found to be SCC on FNA biopsy. Subsequent examination demonstrates that he has a tonsillar primary cancer that is positive for HPV on biopsy. Which of the following statements are true regarding HPV-positive oropharyngeal cancer? a. The cancer is contagious. b. The patient should get an HPV vaccination. c. The patient’s spouse should get an HPV vaccination. d. The patient’s children should get HPV vaccinations. e. This cancer is also frequently related to EBV infection. 2. A 60-year-old woman presents with a 1.5 cm SCC of the right lingual mandibular gingiva and an upper cervical neck mass. Full-thickness cortical invasion of the tumor into the mandible is observed on computed tomography (CT) scan. In addition to neck dissection, the most appropriate surgical treatment is: a. Wide local excision b. TORS c. Transoral laser surgery d. Marginal mandibulectomy e. Segmental mandibulectomy 3. A 47-year-old Asian man presents with decreased hearing and a sense of fullness in the right ear of 3 months duration. Otoscopy demonstrates a middle ear effusion. He is otherwise asymptomatic. What is the next appropriate step in management? a. Placement of a pressure equalization tube b. Referral for a hearing aid c. Trial of an oral penicillin d. Fiberoptic examination of the nasopharynx e. Serum blood work for EBV antigens 4. A 40-year-old man presents with a 2 cm mass behind the angle of his right mandible. On examination, he has weakness of his facial muscles on the side of the tumor. A parotidectomy is performed, and pathology demonstrates a mixed population of predominantly poorly differentiated epithelial cells and intermediate cells with occasional mucous-secreting cells and neural invasion. The most likely diagnosis is: a. MEC b. Pleomorphic adenoma c. Warthin tumor d. SCC e. Hemangioma 5. A 55-year-old man presents with a 2.5 cm right lateral oral tongue squamous cell cancer and a single palpably enlarged jugulodigastric lymph node (clinically staged T2N1M0). In addition to partial glossectomy, what is the most appropriate treatment for the metastatic lymph node? a. RND b. MRND c. SND of levels I-III and total parotidectomy d. SND of levels I-IV e. Observation with possible postoperative radiation depending on the final pathology of the tongue tumor

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1. Answer: d. In recent years, HPV has been recognized as an etiologic factor in oropharyngeal SCC. Because such cancers have a more favorable prognosis than HPV-negative cancers, testing FNA biopsies and tumor specimens for HPV is recommended. The cancer cannot be transmitted to another person. Vaccination has no role in treating patients who are already infected and have no current role in cancer treatment. Vaccination is not recommended for adults who have already been sexually active for a number of years. Vaccination is recommended for all adolescents and young adults (not only children of patients with oropharyngeal SCC), aged 9 to 25, ideally prior to the onset of sexual activity. The vaccine provides protection against the four strains for HPV most commonly associated with cervical and oropharyngeal SCC, including HPV-16. EBV is associated with nasopharyngeal carcinoma in endemic regions and has no known association with HPV-related oropharyngeal SCC. 2. Answer: e. For transcortical invasion of the mandible, a segmental mandibulectomy, in which a full-thickness portion of the mandible is excised, is the most appropriate surgical treatment. Marginal mandibulectomy is reserved for cases in which the cancer stops at the periosteum or does not penetrate full-thickness through the cortex of the mandible. Wide local excision, TORS, and transoral laser surgery are not adequate treatment for this lesion. Immediate reconstruction of the mandible with an osteocutaneous free flap is usually indicated, as is postoperative radiation therapy for this advanced-stage cancer. 3. Answer: d. A serous middle ear effusion in an adult should raise the suspicion for an NPC causing Eustachian tube dysfunction. Nasopharyngoscopy with a flexible fiberoptic scope should be performed as the next step in management. NPC is one of the most common cancers in parts of Asia, most notably southern China, and is associated with EBV seropositivity. If no masses are seen, it would be reasonable to try an oral antibiotic but also to continue further workup with an imaging study (CT or MRI) as well as consider biopsy of the nasopharynx. A pressure equalization tube will allow drainage of the effusion and aeration of the middle ear, restoring hearing and making a hearing aid unnecessary. 4. Answer: a. Only about 20% of parotid gland tumors are malignant. Malignant tumors may invade the facial nerve causing facial paralysis. Malignant tumors may also metastasize to the regional lymph nodes and to distant sites. MECs are the most common malignancy of the parotid gland. 5. Answer: d. Based on the clinical diagnosis of a metastatic lymph node to the ipsilateral neck, a cervical lymphadenectomy should be performed. RND includes removal of neck lymph nodes in levels I to V as well as the SCM, IJV, and SAN.

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References American Cancer Society. Cancer Facts and Figures 2013. Atlanta, GA: American Cancer Society; 2013. Porceddu, SV, Veness, MJ, Guminski, A. Non-melanoma cutaneous head and neck cancer and Merkel cell carcinoma: current concepts, advances, and controversies. J Clin Oncol. 2015;33:3338-3345. Gandini, S, Botteri, E, Iodice, S, et al. Tobacco smoking and cancer: a meta-analysis. Int J Cancer. 2008;122:155-164. Belcher, R, Hayes, K, Fedewa, S, Chen, AY. Current treatment of head and neck squamous cell cancer. J Surg Oncol. 2014;110:551-574. Mehanna, H, Oyaleye, O, Licitra, L. Oropharyngeal cancer: is it time to change management according to human papilloma virus status? Curr Opin Otolaryngol Head Neck Surg. 2012;20:120-124. Chaturvedi, AK, Engels, EA, Pfeiffer, RM, et al. Human papillomavirus and rising oropharyngeal cancer incidence in the United States. J Clin Oncol. 2011;29:4294-4301. Deschler, DG, Richmon, JD, Khariwala, SS, et al. The “new” head and neck cancer patient–Young, nonsmoker, nondrinker, and HPV positive: evaluation. Otolaryngol Head Neck Surg. 2014;151(3):375-380. Hayes, DN, Van Waes, C, Seiwert, TY. Genetic landscape of human papillomavirus-associated head and neck cancer and comparison to tobacco-related tumors. J Clin Oncol. 2015;33:3227-3234. Mirghani, H, Jung, AC, Fakhry, C. Primary, secondary and tertiary prevention of human papillomavirus-driven head and neck cancers. Eur J Cancer. 2017;78:105-115. Chinn, SB, Myers, JN. Oral cavity carcinoma: current management, controversies and future directions. J Clin Oncol. 2015:33;3269-3276. Lydiatt, WM, Patel, SG, O’Sullivan, B, et al. Head and neck cancers: major changes in the American Joint Committee on Cancer Eighth Edition Cancer Staging Manual. CA Cancer J Clin. 2017;67:122-137.Significant changes to head and neck cancer staging were introduced in 2017. The most important changes include the creation of a separate staging algorithm for HPV-associated cancer of the oropharynx; changes to the tumor (T) categories for oral cavity, skin, and nasopharynx cancer; and the addition of ENE to the lymph node category (N) in most head and neck subsite classifications. Civantos, FJ, Zitsch, RP, Schuller, DP, et al. Sentinel lymph node biopsy accurately stages the regional lymph nodes for T1-T2 oral squamous cell carcinomas: results of a prospective multi-institutional trial. J Clin Oncol. 2008;28:1395-1400. Bernier, J, Domenge, C, Ozashin, M, et al. Postoperative irradiation with or without concomitant chemotherapy for locally advanced head and neck cancer. N Engl J Med. 2004;350:1945-1952. Cooper, JS, Pajak, TF, Forastiere, AA, et al. Postoperative concurrent radiotherapy and chemotherapy for high-risk squamous cell carcinoma of the head and neck. N Engl J Med. 2004;350:1937-1944. Cooper, JS, Zhang, Q, Pajak, TF, et al. Long-term follow-up of the RTOG 9501/intergroup phase III trial: postoperative concurrent radiation therapy and chemotherapy in high-risk squamous cell carcinoma of the head and neck. Int J Radiat Oncol Biol Phys. 2012;84:1198-1205. Pfister, DG, Spenser, S, Brizel, DM, et al. Head and neck cancers, Version 2.2014. Clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2014;12:1454-1487. Guo, T, Goldenberg, D, Fakhry, C. AHNS Series: do you know your guidelines? Management of head and neck cancer in the era of human papillomavirus. Head Neck. 2017;39:833-839. Parsons, JT, Mendenhall, WM, Stringer, SP, et al. Squamous cell carcinoma of the oropharynx: surgery, radiation therapy, or both. Cancer. 2002;94(11):2967-2980. Holsinger, FC, Ferris, RL. Transoral endoscopic head and neck surgery and its role within the multidisciplinary treatment paradigm of oropharynx cancer: robotics, lasers, and clinical trials. J Clin Oncol. 2015;33:3285-3292. Lee, AW, Ma, BB, Ng, WT, et al. Management of nasopharyngeal carcinoma: current practice and future perspective. J Clin Oncol. 2015;33:3356-3364. Gooi, Z, Richmon, J, Agarwal, N. AHNS series: do you know your guidelines? Principles of treatment for nasopharyngeal cancer a review of the national comprehensive cancer network guidelines. Head Neck. 2017:39;201-205. Dziegielewski, PT, Kang, SY, Ozer, E. Transoral robotic surgery (TORS) for laryngeal and hypopharyngeal cancer. J Surg Oncol. 2015;112:702706. Department of Veterans Affairs Laryngeal Cancer Study Group , Wolf, GT, Fisher, SG, et al. Induction chemotherapy plus radiation compared with surgery plus radiation in patients with advanced laryngeal cancer. N Engl J Med. 1991;324:1685-1690.This landmark study compared induction chemotherapy with definitive radiation therapy with conventional laryngectomy and postoperative radiation for patients with laryngeal cancer. Surgical salvage was performed for chemoradiotherapy-treated patients who recurred locally. Using this strategy, they reported a high rate of laryngeal preservation without compromising overall survival. This study changed the treatment paradigm for laryngeal cancer at many centers throughout the country and across the world. Forastiere, AA, Zhang, Q, Weber, RS, et al. Long-term results of RTOG 91-11: a comparison of three nonsurgical treatment strategies to preserve the larynx in patients with locally advanced larynx cancer. J Clin Oncol. 2013;31:845-852. Forastiere, AA, Weber, RS, Trotti, A. Organ preservation for advanced larynx cancer: issues and outcomes. J Clin Oncol. 2015;33:3262-3268. Chen, AY, Halpern, M. Factors predictive of survival in advanced laryngeal cancer. Arch Otolaryngol Head Neck Surg. 2007;133:1270-1276. Gourin, CG, Conger, BT, Sheils, C, et al. The effect of treatment on survival in patients with advanced laryngeal carcinoma. Laryngoscope. 2009;119:1312-1317. Galloway, TJ, Ridge, JA. Management of squamous cancer metastatic to the cervical nodes with an unknown primary site. J Clin Oncol.

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2015;33:3328-3337. Byrd, JK, Smith, KJ, de Almeida, JR, et al. Transoral robotic surgery and the unknown primary: a cost-effectiveness analysis. Otolaryngol Head Neck Surg. 2014;150(6):976-982. Miller, MC, Goldenberg, D. AHNS series: do you know your guidelines? Principles of surgery for head and neck cancer a review of the National Comprehensive Cancer Network guidelines. Head Neck. 2017;39:791-796. Maxwell, JH, Thompson, LD, Brandwein-Gensler, MS, et al. Early oral tongue squamous cell carcinoma: sampling of margins from tumor bed and worse local control. JAMA Otolarygol Head Neck Surg. 2015;141(12):1104-1110. Mukhija, V, Gupta, S, Jacobson, AS, et al. Selective neck dissection following adjuvant therapy for advanced head and neck cancer. Head Neck. 2009;1(2):183-188. Cheraghlou, S, Otremba, M, Kuo Yu, P, et al. Prognostic value of lymph node yield and density in head and neck malignancies. Otolaryngol Head Neck Surg. 2018;158(6):1016-1023. Schilling, C, Stoeckli, SJ, Haerle, SK, et al. Sentinel European Node Trial (SENT): 3-year results of sentinel node biopsy in oral cancer. Eur J Cancer. 2015;51(18):2777-2784. Gooi, Z, Fakhry, C, Goldenberg, D, et al. AHNS series: do you know your guidelines? Principles of radiation therapy for head and neck cancer a review of the National Comprehensive Cancer Network guidelines. Head Neck. 2016;38:987-992. Chen, WC, Hwang, TZ, Wang, WH, et al. Comparison between conventional and intensity modulated post-operative radiotherapy for stage III and IV oral cavity cancer in terms of treatment results and toxicity. Oral Oncol. 2009;45:505-510.There has been a dramatic rise in oropharyngeal SCC in recent years because of HPV infection. Patients with HPV-related oropharynx cancers are younger and lack traditional risk factors such as tobacco and alcohol use. Biologically, these HPV-related oropharyngeal cancers behave differently, necessitating new treatment algorithms and staging systems. Van de Water, TA, Bijl, HP, Schilstra, C, et al. The potential benefit of radiotherapy with protons in head and neck cancer with respect to normal tissue sparing: a systematic review of literature. Oncologist. 2011;16:366-377. Bonner, JA, Harari, PM, Giralt, J, et al. Radiotherapy plus cetuximab for squamous-cell carcinoma of the head and neck. N Engl J Med. 2006;354:567-578. Buglione, M, Maddalo, M, Corvò, R, et al. Subgroup analysis according to human papillomavirus status and tumor site of a randomized phase II trial comparing cetuximab and cisplatin combined with radiation therapy for locally advanced head and neck cancer. Int J Radiat Oncol Biol Phys. 2017;97(3):462-472. Magrini, SM, Buglione, M, Corvò, R, et al. Cetuximab and radiotherapy versus cisplatin and radiotherapy for locally advanced head and neck cancer: a randomized phase II trial. J Clin Oncol. 2015;34:427-435. Seiwert, TY, Burtness, B, Mehra, R, et al. Safety and clinical activity of pembrolizumab for treatment of recurrent or metastatic squamous cell carcinoma of the head and neck (KEYNOTE-012): an open-label, multi-centre, phase 1b trial. Lancet Oncol. 2016;17:956-965. Ferris, RL, Blumenschein, G Jr, Fayette, J, et al. Nivolumab for recurrent squamous-cell carcinoma of the head and neck. N Engl J Med. 2016;375:1856-1867. Rodriguez, CP, Parvathaneni, U, Méndez, E, Martina, RG. Salivary gland malignancies. Hematol Oncol Clin North Am. 2015;29:1145-1157. Dercle, L, Hartl, D, Rozenblum-Beddok, L, et al. Diagnostic and prognostic value of 18F-FDG PET, CT, and MRI in perineural spread of head and neck malignancies. Eur Radiol. 2018;28(4):1761-1770. Siewert, B, Kruskal, JB, Kelly, D, et al. Utility and safety of ultrasound-guided fine-needle aspiration of salivary gland masses including a cytologist’s review. J Ultrasound Med. 2004;23(6):777-783. Seethala, RR, LiVolsi, VA, Baloch, ZW. Relative accuracy of fine-needle aspiration and frozen section in the diagnosis of lesions of the parotid gland. Head Neck. 2005;27(3):217-223.Use of FNA and frozen section in the diagnosis of salivary gland lesions are a subject of debate because of less than perfect accuracy. FNA was found to have a sensitivity of 86% and specificity of 92%. Frozen section was found to have a sensitivity of 77% and a specificity of 100%. The authors suggest that frozen section may be useful if FNA is nondiagnositc and may confirm or refute malignancy in some cases. Seethala, RR, Stenman, G. Update from the 4th edition of the World Health Organization classification of head and neck tumors: tumors of the salivary gland. Head Neck Pathol. 2017;11:55-67. O’Brien, CJ. The parotid as a metastatic basin for skin cancer. Arch Otolaryngol Head Neck Surg. 2005;131(7):551-555. Zhan, KY, Khaja, SF, Flack, AB, et al. Benign parotid tumors. Otolaryngol Clin North Am. 2016;49:327-342. Rassekh, CH, Cost, JL, Hogg, JP, et al. Positron emission tomography in Warthin’s tumor mimicking malignancy impacts the evaluation of head and neck patients. Am J Otolaryngol. 2015;36(2):259-263. Guzzo, M, Locati, LD, Prott, FJ, et al. Major and minor salivary gland tumors. Crit Rev Oncol Hematol. 2010;74:134-148. Thom, JJ, Moore, EJ, Price, DL, et al. The role of total parotidectomy for metastatic cutaneous squamous cell carcinoma and malignant melanoma. JAMA Otolaryngol Head Neck Surg. 2014;140(6):548-554. Breen, B, Rahimi, S, Brennan. Current management of the neck in salivary gland carcinomas. J Oral Pathol Med. 2017;46:161-166. Wang, YL, Lin, DS, Gan, HL, et al. Predictive index for lymph node management of major salivary gland cancer. Laryngoscope. 2012;122;14971506.This study examines predictive factors for spread of salivary gland cancer to regional lymph nodes. Tumor- and patient-related factors were used to determine the relative risk for lymph node metastases to guide the indications for elective neck dissection. Laurie, SA, Licitra, L. Systemic therapy in the palliative management of advanced salivary gland cancers. J Clin Oncol. 2008;24:2673-2678.

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CHAPTER 38

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Reconstruction of the Scalp, Forehead, Calvarium, Skull Base, and Midface Alexander F. Mericli and Jesse C. Selber, and Matthew M. Hanasono

Key Points Locoregional or free flaps are usually required for scalp defects that include the pericranium. Unlike other head and neck sites, tissue expansion may play a role in reconstruction of the scalp. Resection of skull base tumors may be associated with significant complications including cerebrospinal fluid leak and cranial nerve deficits. The location of the skull base tumor determines the approach to resection and dictates the reconstructive needs. Maxillary defects are usually complex; prosthetics, soft tissue flaps, and/or bone grafts and flaps may play a role in reconstruction. Defects involving the scalp, forehead, calvarium, skull base, and maxilla are among the most challenging reconstructions in our specialty. Although these structures are adjacent anatomically, their reconstructive requirements are vastly different given the multiple specialized functions located within the head and neck. The techniques employed to restore these anatomic regions are complex, nuanced, and frequently necessitate microsurgery. Furthermore, defects involving the calvarium, skull base, and maxilla are especially challenging because of the potential for major, life-threatening complications that may occur should the reconstruction fail, such as brain exposure and neurologic injury, blindness, cerebrospinal fluid (CSF) leak, meningitis, and osteomyelitis.

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Scalp, Forehead, and Calvarium Scalp and forehead tissue is intrinsically inelastic, limiting the application of primary closure and local flaps. Skin grafts are possible when the pericranium is intact, and a variety of local flaps can be designed. There are only three regional flaps (pericranium, temporoparietal fascia, and temporalis muscle), all of which have a limited arc of rotation thereby minimizing their utility; therefore, microvascular free tissue transfer is commonly required for durable reconstruction in this area of the body for sizable defects. Calvarial reconstruction can include alloplastic materials, customized implants, and bone grafting, depending on the circumstances.

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Anatomy The frontalis muscle overlies the frontal bone and is connected to the occipitalis muscle posteriorly, through the galea aponeurotica. The blood supply of the forehead and scalp is robust and consists of the paired supraorbital, supratrochlear, superficial temporal (ST), posterior auricular, and occipital vessels. The sensory nerves are also paired and include the supraorbital, supratrochlear, zygomaticotemporal, auriculotemporal, lesser occipital, and greater occipital nerves. The most clinically significant motor nerve is the temporal branch of the facial nerve, which innervates the frontalis muscle. This branch is located on the deep surface of the temporoparietal fascia and follows a course approximated by a line extending from 0.5 cm inferior to the external auditory meatus to a point 1.5 cm superior to the lateral eyebrow. Dissection in this area is occasionally needed to access the zygomatic arch for reduction and internal fixation or to raise a temporalis muscle flap. To avoid injury to this important nerve, dissection is performed in a plane deep to the superficial layer of the deep temporal fascia. The calvarium is covered by thick periosteum oftentimes called pericranium, which can be utilized as a local flap. Structurally, the calvarium is comprised of three layers: an outer table, a diploic space, and an inner table.

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Forehead and Scalp Reconstruction Nonmicrosurgical Techniques The skin of the scalp is among the thickest in the body, measuring 3 to 8 mm. This thickness, as well as the fibrous galea aponeurotica, limits the pliability of the scalp. Although primary closure with adjacent hair-bearing tissue is the preferred wound closure technique in the appropriate scenario, this approach is typically limited to defects no greater than 3 cm in diameter. Tension should be avoided to prevent skin dehiscence or alopecia. There are several techniques that can be employed to reduce tension when reconstructing a scalp defect via primary repair or adjacent tissue rearrangement. First, the resection can be designed so that the closure is oriented perpendicular to the relaxed skin tension lines; this tends to be in a sagittal direction on the scalp and in a transverse direction on the forehead. Second, wide undermining in the subgaleal layer along the circumference of the defect can reduce tension. Finally, galeal scoring is an adjunctive technique that can increase scalp pliability and reduce closure tension. The scores should be designed in parallel with the leading edge of the flap, be spaced no closer than 1 cm apart, and only divide the galea. Scores deeper than the galea will disrupt the random pattern blood supply of the scalp. Each galeal incision increases the length of the scalp 1.67 mm; therefore, multiple incisions can substantially minimize tension and maximize pliability. 1 If the scalp defect is too wide to permit primary closure and the underlying calvarium is not exposed, the wound can be closed with a split- or full-thickness skin graft. Alternatively, if the calvarium is exposed, burring the outer table with entry into the vascular diploic space can facilitate skin graft adherence. This can be performed immediately or with an intermediate stage using a dermal substitute; however, this often results in an unstable skin graft and is not recommended as a long-term solution or in the context of radiation. In any situation, once healed, the graft will not bear hair. Additionally, because of the difference in thickness between the native scalp and a skin graft, a noticeable contour deformity will be present. One of the central tenets of reconstructive surgery—replacing like with like—is evident in the use of local flaps for scalp reconstruction. This technique will maintain the thickness of the scalp as well as the ability to bear hair. In situations where the calvarium is exposed at the base of the wound, reconstruction with vascularized tissue, such as a local flap, is required. Most local flaps are designed using the rotationadvancement principle and should be oriented to recruit tissue from areas of the scalp with laxity, such as the parietal and temporal regions. The meticulous plastic surgeon will attempt to match hair follicle direction with the flap and will also bevel the incision parallel to the angle of the hair follicles to minimize scar alopecia. In smaller defects, the local flap donor site can be closed primarily (Figure 38.1); however, reconstruction of larger defects may require elevating the local flap in the subgaleal plane and maintaining the pericranium so that the donor site can then be closed with a skin graft (back grafting). The skin graft can then be serially excised secondarily or the remaining scalp tissue expanded and the skin graft excised, to improve appearance. Larger configurations of multiple flaps, such as the Orticochea flap, are well described but unpopular because of the high rate of partial flap necrosis. 2

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FIGURE 38.1 A. A 4-cm diameter defect of the vertex scalp reconstructed with bilateral rotation-advancement flaps. B. The flaps are advanced and the donor site is closed primarily.

Unlike the scalp, additional attention is required when addressing a forehead wound so that the closure does not distort the brow or anterior hairline. This is often at odds with the direction of tissue laxity along the forehead; however, brow or hairline symmetry must never be compromised for primary closure; a local flap or graft, or even a free flap, is preferred. Because the forehead is a visible area as compared with the hair-bearing scalp, color match and incision orientation require careful planning. The aesthetic subunit principle should be followed to make the reconstruction as inconspicuous as possible. 3 Whenever possible, skin grafts should be harvested from a location above the clavicles to achieve a good color match. Incisions should be designed within the transverse forehead rhytids or along the anterior hairline or browline (Figure 38.2). For limited defect size, healing by secondary intention can have a better cosmetic outcome than skin grafting, as can be frequently seen in the treatment of donor defects for forehead flaps. 4 When operating anywhere around the forehead or brow, care should be taken to avoid injury to the temporal branch of the facial nerve. A variety of local flaps have been described for reconstruction of small forehead wounds, such as in the setting of Mohs surgery; these techniques are addressed elsewhere in this book.

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FIGURE 38.2 A,B. 5 cm defect after resection of forehead invasive melanoma. Delayed reconstruction performed after negative final margins. C. Scalp advancement flap to recreate anterior hairline, forehead rotation flap with W-plasty closure of dogear to limit the inferior extent of the scar. D. Retroauricular full-thickness skin graft used to close donor site along temporal scalp/forehead.

Tissue expansion is useful in reconstructing scalp and forehead wounds due to trauma, burns, or congenital lesions. It is less germane in the oncologic setting when there is typically an urgent need for resection, thus eliminating the possibility of pre-expansion prior to resection and reconstruction. Additionally, a history of radiation therapy or the anticipated need for adjuvant radiation precludes the use of tissue expansion, as the associated complication rate is prohibitively high. 5 When appropriately implemented, tissue expansion is a powerful technique in scalp reconstruction, permitting reconstruction of an area up to 50% of the total surface area of the scalp with hair-bearing tissue of a similar thickness. Expanders come in a variety of shapes and sizes, allowing the surgeon to match the desired vector of expansion. Typically, the expander is placed in the subgaleal plane deep to the healthy scalp. The incision used to place the expander should be designed in the area of scalp that will be excised and should be oriented perpendicular to the axis of expansion to help prevent incisional dehiscence and exposure of the device. In large defects, multiple expanders can be placed; ports are typically remote. Regional flaps are, in general, infrequently used in scalp reconstruction because of the limited number of donor flaps in close proximity. The temporoparietal fascial flap and temporalis muscle flap can be used for defects within or adjacent to the temporal area or lateral forehead and are usually combined with a skin graft. The trapezius muscle can be designed as either a muscle or myocutaneous flap and can be used to reconstruct the occipital scalp.

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Microsurgical Techniques Free flap reconstruction of the scalp is necessary when local options or skin grafting are inadequate. This may be because of defect size and depth, the anticipated need for radiation therapy, prior radiation therapy, or extensive scarring from past surgeries. Preoperatively, a thoughtful reconstructive plan should be devised that includes selection of an appropriate flap and options for recipient vessels. Recipient vessels should have a similar caliber as those of the flap and should be in close proximity to the defect. For the scalp, the ST vessels are the typical first-line option. 6 Using the ST vessels is associated with a high flap success rate (96%) and compatibility with a variety of free flaps and defects. 6 The patency of these vessels should be evaluated preoperatively by gently palpating the preauricular area bilaterally to feel a pulse; alternatively, a pencil Doppler ultrasound can be used. There are several technical points that must be understood to achieve success with the ST vessels. The ST artery and vein are located anterior to the ear and represent the distal extent of the external carotid system (Figure 38.3). Ideally, the anastomosis should be performed at the level of the tragal notch where the vessels emerge from the parotid. This portion of the artery has the greatest diameter and least tortuosity. The artery tends to be more superficial and posterior, whereas the vein may exist in a slightly deeper plane and more anterior. The vein is notoriously thin walled and prone to inadvertent twisting, so special care must be observed. Because of these anatomical nuances, many find it helpful to perform the majority of this recipient vessel dissection under the operating microscope or high-power loupe magnification.

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FIGURE 38.3 A. Large scalp defect reconstructed with free latissimus dorsi muscle flap and split-thickness skin graft. Microvascular anastomoses were performed to the superficial temporal artery and vein. B. Note the significant atrophy of the bulky muscle flap and its improved contour after radiation therapy 10 months after surgery. C. The superficial temporal artery and vein are commonly used as recipient vessels in microvascular reconstruction of the scalp. The anastomosis should be performed at the level of the tragal notch, where the vessels emerge from within the parotid gland. D. When insetting a free muscle flap for scalp reconstruction, the native scalp should be undermined circumferentially so that the flap can be inset in a vest-over-pants fashion.

If the ST vessels are not available or insufficient, the neck provides a multitude of options: facial, lingual, superior thyroid, etc. The pedicle length required to travel from the neck to the scalp almost always necessitates the use of a vein graft. Special care must be taken to avoid kinking or twisting the vein graft or pedicle, particularly with head turning. The vein grafts should be placed beneath a widely undermined cutaneous tunnel, and the patient should be prevented from wearing eyeglasses during the immediate postoperative period to avoid compression. Many flaps have been described for use in microsurgical scalp reconstruction 6–8 (Table 38.1). The incidence of cutaneous malignancies located on the scalp is higher in elderly patients and continues to

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rise after age 65 years. Therefore, it is not uncommon for septua- and octogenarians (or older) to require extensive scalp resections. It is important to emphasize that age is not a contraindication to microsurgical scalp reconstruction, as has been demonstrated in several studies. 9,10 Muscle flaps covered with a skin graft as well as fasciocutaneous flaps have been repeatedly and successfully used for scalp reconstruction. Muscle flaps are bulky initially, but will atrophy over time; this effect is accelerated if postoperative radiation is given (see Figure 38.3). Once the flap atrophies, it contours nicely along the underlying skull. When insetting a muscle flap, it is prudent to inset the flap in a vest-over-pants fashion, with the flap tucked under the remaining scalp so that when the flap atrophies, it is less likely to pull away from the native scalp and cause exposure of the skull (see Figure 38.3). Flaps with a skin paddle are thought to be more durable and may be preferred in situations where the flap is covering a cranioplasty. The disadvantage to a skin paddle is that it may require a secondary debulking procedure to improve the contour, as these flaps are less likely to atrophy. TABLE 38.1 Common Flaps Used for microsurgical Scalp Reconstruction Flap Latissimus dorsi

Type Muscle or myocutaneous

Size 25 × 35 cm

Pedicle Thoracodorsal

Serratus anterior

Muscle

10 × 15 cm

Thoracodorsal or lateral thoracic

Rectus abdominis Deep inferior epigastric perforator

Muscle or myocutaneous Fasciocutaneous perforator

25 × 6 cm

Deep inferior epigastric Deep inferior epigastric

Vastus lateralis

Muscle

20 × 10 cm

Descending branch of lateral femoral circumflex

Anterolateral thigh (ALT)

Fasciocutaneous or myocutaneous Fasciocutaneous

20 × 9 cm

15 × 8 cm

Descending branch of lateral femoral circumflex Radial artery

Visceral adipose tissue

25 × 35 cm

Gastroepiploic

Radial forearm

Omentum

40 × 15 cm

Notes Can be combined with the serratus muscle to make a chimeric flap able to resurface a larger area Insertion area of the muscle overlying the pedicle should be transected obliquely to allow for a better, less bulky contour Only inferior 3 or 4 slips are harvested to prevent winging of the scapula Pedicle is on anterior surface of the muscle; care must be taken during exposure

Large surface area Bulky flap limited by patient’s habitus Potentially long pedicle Small muscle flap with limited donor site morbidity May be useful when use of a fasciocutaneous ALT flap is precluded by habitus

Small thin flap for modest defects Long pedicle Similar thickness as native scalp Potential for significant donor site morbidity Can be harvested robotically or laparoscopically Usually atrophies significantly over time Variable skin graft take

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Reconstruction of the Calvarium Resection of primary bone malignancies, bone metastases, osteoradionecrosis, traumatic defects, or soft tissue tumors of the scalp that involve the underlying calvarium can result in a bony defect. The goals of calvarial reconstruction are both functional and cosmetic, protecting the central nervous system as well as restoring the normal contour of the skull. Calvarial reconstruction is usually recommended for any fullthickness defect greater than 6 cm2. 11

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Alloplastic Materials Calvarial reconstruction is most commonly performed using alloplastic materials (Table 38.2). Alloplastic materials are abundant in supply and have no donor site morbidity, but may be more prone to infection than autologous bone grafts, which may preclude their use in infected or irradiated fields. The ideal alloplastic implant is compatible with surrounding bone and soft tissue, resistant to infection, strong, easily shaped, and remains stable over time. Numerous materials have been described, including titanium mesh, polymethyl methacrylate, porous polyethylene, calcium phosphate cement, and polyetheretherketone (PEEK) 12–14 (Figure 38.4). Many biomaterials can be produced using computeraided design/computer-aided modeling (CAD/CAM) techniques to exactly match the dimensions of the existing or anticipated cranial defect. CAD/CAM technology is available for titanium, porous polyethylene, and PEEK implants. 14,15 Lee and colleagues evaluated their extensive experience in oncologic calvarial reconstructions and identified prior surgery, infection, radiation, and concurrent free tissue transfer to be associated with complications. 12 The type of alloplastic material used was not found to be an independent risk factor for complications on multivariate analysis. TABLE 38.2 Alloplastic Materials Used for Calvarial Reconstruction Material

Structure

Structural Integrity Strong Moderate; can be brittle

Infection Risk Low Moderate; becomes encapsulated

Intraoperative Contouring Yes Yes

CAD/CAM

Advantages

Disadvantages

Titanium mesh Polymethyl methacrylate

Metal alloy Acrylicbased resin

Yes No

Readily available

Imaging artifact

Porous polyethylene

Porous hydrocarbon

Strong

Low; pores encourage tissue ingrowth

Yes

Yes

Calcium phosphate

Bone cement putty

Weak

High late infection risk

Yes; moldable

No

Polyetheretherketone

Aromatic polymer

Strong

Moderatebecomes encapsulated

Minimal; edges can be burred

Yes

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Easily moldable intraoperatively Can be combined with titanium plate for increased strength

Cures by exothermic reaction that can damage surrounding tissue Infection risk

Pores mitigate infection risk

Pores removal difficult

Best for small defects Osteoconductive

Brittle Use limited to smaller defects

Radiolucent

Becomes encapsulated Little ability to adjust intraoperatively

make

FIGURE 38.4 A. Titanium mesh calvarial reconstruction. B. Polyetheretherketone cranioplasty.

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Autologous Techniques Autologous reconstruction of the calvarium involves the use of either vascularized or nonvascularized bone. Several options have been described, including split calvarial or iliac grafts, vascularized or nonvascularized rib, and vascularized fibula. 16–18 Split calvarial grafts should be harvested from the parietal bone where the skull is the thickest. The graft site should not extend any further medially than 1.5 cm lateral to midline, to avoid inadvertent injury to the sagittal sinus. Calvarial bone can be harvested using an in situ technique or an extracranial approach. In the in situ technique, a trough is burred around the outline of the graft until the diploic space is reached. A saw or osteotome is then used to remove the outer table of the skull as a graft. The advantage of this technique is that it avoids accessing the intracranial space. Disadvantages include the creation of a depression contour deformity along the skull; additionally, the size of the graft is limited. In the extracranial approach, a craniotomy is performed and a full-thickness section of the calvarium is removed. On the back table, a saw or osteotome is then used to separate the inner and outer tables through the diploic space. The inner table is then plated back onto the donor site, flush with the adjacent calvarium, to avoid a contour depression. The external table is then used as a graft. Because of the need for a craniotomy, the extracranial technique is usually performed by a neurosurgeon. Compared with calvarial bone grafts, larger defects can be repaired using rib. The seventh and eighth ribs are most commonly used; in men, rib graft is harvested through an incision directly over the rib, whereas in women, an inframammary fold incision is better camouflaged. No more than two or three ribs can be harvested, to maintain chest wall stability. Ribs are harvested in a subperiosteal plane to avoid pleural injury. Grafts can be shaped with a rib bender and plated to the calvarium. Gaps between the rib grafts can be filled with either particulate cadaveric allograft bone, calcium phosphate bone cement, or hydroxyapatite putty. Vascularized bone flaps are useful for smaller calvarial defects within a hostile wound bed. Wounds exposed to radiation or chronic infection are particularly good candidates. A serratus anterior or chimeric latissimus-serratus anterior flap can be designed with vascularized rib and covered with a skin graft, thereby reconstructing an osseous and soft tissue defect with a single flap. 19 A chimeric scapular/parascapular flap has also been described for this purpose, but with using a segment of scapula bone for calvarial defect. 20 The ever-versatile free fibula flap has also been described for calvarial reconstruction—specifically for replacing the anterior table of the frontal sinus in the setting of a chronic mucocele. 18

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Management of the Infected Cranioplasty Because of their robust vascularity, infection is fortunately uncommon in the scalp and calvarium. Infection of alloplastic cranioplasties and cranial bone flaps following craniotomy can be clinically challenging and place the patient at risk for meningitis or brain abscess. If there are signs of infection, the patient should first be treated with empiric, broad-spectrum intravenous antibiotics. If there is no significant clinical improvement, the patient may need to have the cranioplasty or bone flap explanted. This is a serious complication because a redo cranioplasty cannot be performed until the infection has fully cleared. During this period of time, the scalp will shrink in size and conform to the concave contour of the bony defect. Furthermore, if treatment of the infected cranioplasty requires debridement of devitalized scalp, there may be a significant soft tissue deficiency. If after removal of the cranioplasty and debridement, the scalp cannot be closed primarily, the patient will require a soft tissue flap. In this situation, a well-vascularized free myocutaneous flap or muscle flap with skin graft is preferable. It is important for the patient to understand that he or she will have no skull in this area and will be vulnerable to intracranial injury during this period of time. Free flaps are purposefully made redundant for later placement of a convex cranioplasty. After the infection has been adequately treated, an elective cranioplasty can be performed by elevating the free flap and scalp off of the dura with the help of a neurosurgeon.

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The Role of Composite Tissue Allograft Transplantation in Reconstruction of the Scalp and Calvarium A recent addition to the reconstructive ladder in the treatment of scalp and calvarial wounds is vascularized composite allograft (VCA) transplantation. 21,22 Although not commonly employed, situations do exist in which VCA is a reasonable reconstructive option. One such scenario includes transplant patients with large, invasive, and diffuse malignancies of the scalp. These are more common than one may think, as invasive skin cancers of the head and neck occur frequently in the transplant population. For these patients, a transplant that includes scalp and calvarium can be based on ST vessels without the addition of alloplastic materials or donor site defects. A recent case involved a patient who was a previous recipient of a kidney-pancreas transplant, who was in need of a second transplant (Figure 38.5). As a result of his longstanding immunosuppression, he developed a leiomyosarcoma of the scalp, treated with excision and radiation therapy. He then developed an unstable scalp wound with underlying osteoradionecrosis of the skull; this chronic wound precluded him from being included on the transplant list for a repeat kidney-pancreas transplant. A single organ donor was acquired for simultaneous transplantation of the kidney, pancreas, skull, and scalp, thereby addressing all needs in one operation. VCA is an emerging field and can be a useful solution to complex problems in select transplant patients with extensive, composite head and neck defects.

FIGURE 38.5 A–C. Vascular composite allograft transplant including scalp and skull. Donor specimen was harvested en block and supplied by the bilateral superficial temporal vessels. D. One-year postoperative result.

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Skull Base Reconstruction Except for lesions removed via an endoscopic approach, reconstruction may play a major role in the treatment of skull base tumors because of the substantial anatomic and functional deficits that can result following resection of various craniofacial structures. Although historically, skull base resections have been associated with poor outcomes, advances in reconstruction, which minimize complications, loss of function, and disfigurement, concomitant with advances in oncologic treatment, have substantially decreased the morbidity resulting from the treatment of these tumors.

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Anatomy The Irish classification system, based on the relationship of the tumor to the anterior, middle, and posterior cranial fossae, is most useful for describing the clinical anatomy of the resection and associated reconstructive options 23 (Figure 38.6). These resections involve removal of skull base bone with or without the removal of the underlying dura.

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FIGURE 38.6 Skull base regions. (Adapted from Irish, JC, Gullane, PJ, Gentili, F, et al. Tumors of the skull base: outcome and survival analysis of 77 cases. Head Neck. 1994;16(1):3-10. Copyright © 1994 Wiley Periodicals, Inc., A Wiley Company. Reprinted by permission of John Wiley & Sons, Inc.)

Region I involves the anterior skull base; these tumors typically arise from in and around the orbits, nose, sinuses, or cribriform plate. Region II involves the lateral skull base; these tumors arise from the infratemporal or pterygopalatine fossae extending to the middle cranial fossa and can include nasopharyngeal carcinoma, juvenile nasopharyngeal angiofibroma, and locally advanced parotid tumors. Region III involves the temporal bone and posterior cranial fossa; these tumors typically arise from the ear, parotid, or temporal bone.

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Reconstructive Approach Cranial nerve deficits should be anticipated based on the location of the tumor and discussed with the patient preoperatively. Possible functional deficits after skull base surgery may include facial nerve paralysis, dysphagia, and dysarthria due to hypoglossal nerve palsy, and/or shoulder asymmetry due to transection of the spinal accessory nerve. If the facial nerve is removed with a portion of the tumor, then consideration should be given to the reconstruction of the nerve gap with an interposition cable graft. Static and dynamic procedures for facial nerve paralysis should be considered. A detailed discussion of treatment for facial nerve paralysis is addressed elsewhere in this book. Given the paucity of local flap options in this anatomic area, free tissue transfer is frequently required for reconstruction. If the ST vessels are no longer present because of previous use, radiation-related changes, or resection, then the neck provides a multitude of recipient options. Unfortunately, the pedicle length required to reach the neck from the skull base may necessitate vein grafts; this should be recognized preoperatively and incorporated into the reconstructive plan prospectively. The need or desire for an orbital or auricular prosthesis should be discussed preoperatively because this may influence flap design and reconstructive staging. Facial prostheses are created by an anaplastologist and can be secured with adhesive or through the use of osseointegrated anchors. Additionally, if the skull base resection includes removal of the middle ear components, an otologist should be involved preoperatively for placement of a bone-anchored hearing aid (BAHA). Osseointegrated implants and BAHAs have a higher failure rate when placed into irradiated bone; therefore, if radiation is anticipated, consideration should be given to immediate placement of the device. Because use of either a regional or free flap may limit the utility of physical examination to detect local recurrence, serial imaging is mandatory for disease surveillance and should be incorporated into the survivorship plan.

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Region I Midline region I tumors are usually resected with an anterior craniofacial approach, resulting in communication of the nasal cavity with the intracranial space. If the defect is small and limited to the upper nasal cavity, the intracranial space can be separated from the sinuses with a pedicled pericranial flap or galea frontalis flap, both of which derive their blood supply from the supratrochlear and supraorbital vessels. In situations where these blood vessels have already been transected, or in larger defects involving the external nose, forehead, and/or orbit, a free flap may be necessary (Figure 38.7). If there is no skin defect and the flap is only needed to separate the intracranial space, then the free flap may be buried and monitored with an implantable Doppler probe. The rectus abdominis, vastus lateralis, and serratus anterior muscle flaps are good options in this situation.

FIGURE 38.7 A. Zone I skull base defect following a left extended orbital exenteration resulting in communication with the anterior cranial fossa. B. Reconstruction with an anterolateral thigh myocutaneous free flap. The muscle (vastus lateralis) is placed against the dural patch to help prevent cerebrospinal fluid leaks and is also used to obliterate possible communication with the nasal cavity and paranasal sinuses. C. Postoperative result.

Lateral region I defects frequently involve orbital exenteration. If the resection spares the medial and inferior walls of the orbit, it is well suited for the eventual use of a prosthesis. To accommodate a prosthesis, the orbit must be resurfaced with a thin, pliable, well-vascularized tissue that will maintain the concave shape of the cavity. This can be achieved with a free radial forearm flap or pedicled temporalis muscle or temporoparietal fascia flap with a skin graft. If the orbital exenteration results in communication with the sinuses or nasal cavity, then a bulkier myocutaneous free flap is preferred. The anterolateral thigh (ALT) and rectus abdominis myocutaneous (RAM) flaps are highly customizable and allow for the design of flap with a variable amount of muscle, tailored to the defect’s requirements. The muscle conforms to the complex geometry of the defect, sealing exposed dura and/or sinonasal cavities. This feature helps to minimize the occurrence of a sinocutaneous fistula; such fistulae are exceedingly difficult to heal owing to persistent pressure from nasal airway.

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Region II Resection of region II tumors, frequently, is performed through an anterior transmaxillary approach. After resection of the middle cranial fossa, the dura will be in direct communication with the nasopharynx; if the resection also necessitates a maxillectomy, then the oral cavity and oropharynx will be in direct communication with the intracranial space as well (Figure 38.8). The temporalis muscle may reach this area but often does not provide adequate bulk, especially after radiation-
 related atrophy occurs. In such cases, a bulky myocutaneous flap, such as the ALT or RAM free flaps, has great utility. When there is no oral mucosal, palatal, or external cheek defect, the skin paddle of the free flap can be deepithelialized and the entire flap buried. The adipodermal component of the flap provides bulk, which is less prone to radiation atrophy than muscle; the muscle component serves as an adequate seal against exposed dura mater. Persistent bulk and volume maintenance is important in these reconstructions to not only maintain facial contour but also to adequately support the skull base so as to prevent herniation of the intracranial contents into the pharynx or oral cavity.

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FIGURE 38.8 A. Zone II skull base defect combined with orbito- and hemipalatomaxillectomy with resection of the middle cranial fossa skull base. B. Multi-paddle free anterolateral thigh myocutaneous free flap with vastus lateralis to resurface the resected skull base. Anastomosed to facial artery, common facial vein, and external jugular vein via vein grafts. C,D. Postoperative result.

As in reconstruction of the maxillectomy defect, if the orbital floor is resected and the globe is spared, then skeletal reconstruction of the orbital floor is mandatory. Failing to reconstruct the orbital floor or performing an inaccurate reconstruction can result in enophthalmos, vertical dystopia, or diplopia. Various alloplastic materials are commercially available; alternatively, an autologous calvarial or iliac crest bone graft can be used. Although autologous grafts can be revascularized, our own experience does

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not support the use of one material over another. 24 However, evidence does strongly emphasize the importance of covering the entire implant or graft with well-vascularized tissue if adjuvant radiation is anticipated. If the globe is removed as well as the bony orbit, as in the case of an orbitomaxillectomy, then reconstruction of the floor is not necessary nor is maintaining a concave orbital cavity. In these situations, the reconstructive priority is filling the volume of the resected orbit and maxilla with vascularized tissue, sealing the exposed dura, and replacing any missing skin (see Figure 38.8).

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Region III Region III defects will often include parotidectomy or a lateral temporal bone resection in addition to removal of a portion of the posterior cranial fossa. Larger, bulky flaps, such as the ALT or RAM, are frequently required; if an oral cavity defect is anticipated, then two skin paddles may be needed. If a lateral temporal bone resection and/or mastoidectomy is performed, well-vascularized muscle is helpful to obliterate the middle ear and seal off any exposed dura and/or exposed mastoid air cells 25,26 (Figure 38.9). If resection of the middle ear is anticipated, upfront BAHA placement should be considered. If the external ear is resected, reconstruction is best addressed separately in a delayed manner. Prosthetic rehabilitation is the mainstay for oncologic auricular reconstruction; these prostheses can be secured with an adhesive or through the use of osseointegrated implants, provided adequate bone stock remains available to stabilize the implants.

FIGURE 38.9 A. Zone III skull base defect following a right lateral temporal bone resection including division of the facial nerve. The defect is reconstructed with an anterolateral thigh myocutaneous free flap, with muscle placed into the deepest portion of the defect and obliterates the Eustachian tube orifice. Several cable nerve grafts were performed in conjunction with static facial reanimation to restore facial nerve function. B,C. Postoperative result. Note return of motor nerve function following cable nerve grafting, approximately 12 months after the reconstruction.

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Postoperative Care and Management of Complications The principal goal of reconstruction of the resected skull base is to separate the aerodigestive tract from the brain and intracranial contents. Consequently, meticulous isolation of the dura and brain by wellvascularized soft tissue flaps is necessary to prevent meningitis, cerebritis, brain abscesses, neurologic injury, and death. Postoperatively, the patient should be maintained on prophylactic intravenous antibiotics with empiric coverage of normal sinonasal flora. If the dura has been resected, consideration should be given for antibiotics that can penetrate the blood-brain barrier. In addition to flap monitoring, frequent neurologic examinations should be conducted. Postoperative computed tomography (CT) or magnetic resonance imaging scans are obtained according to the recommendations of a neurosurgeon. Although it is not uncommon to see intracranial air on imaging in the early postoperative period, increasing pneumocephalus or any change in the clinical neurologic examination should trigger a prompt return to the operating room. Such findings could suggest a number of complications, including infection, flap dehiscence, hematoma, or intracranial bleed. Any concern for a CSF leak should be evaluated and confirmed with a beta-2 transferrin test. Most minor CSF leaks can be effectively treated conservatively with antibiotic prophylaxis and bed rest. Lumbar drains, externalized ventricular drains, or dural repair are more invasive options for recalcitrant leaks. If a portion of the orbit has been reconstructed, visual acuity and extraocular muscle function should be frequently examined postoperatively. Any concern for decreased visual acuity should prompt an ophthalmologic examination and imaging. Impingement of the optic nerve or entrapment of an extraocular muscle by the reconstruction usually requires a return to the operating room.

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Reconstruction After Maxillectomy Management of the maxillectomy defect is a particularly complicated and controversial field within head and neck oncologic reconstruction. Options include the use of prosthetic obturators, soft tissue free flaps, osseous free flaps, alloplastic implants, and autologous grafts. Reconstructive algorithms can be complex and must take into account a variety of considerations. Multiple approaches have been described and differ based on the prioritization of defect characteristics and reconstructive techniques. 27–31 One of the fundamental problems with reconstructing the midface is that the defects created by oncologic resection are highly variable. Such defects usually involve not only the maxillary bones but may also include a number of adjacent facial and cranial bones, as well as soft tissues of the face, palate, and orbit. Several classification systems have been introduced and can be helpful in guiding reconstruction. 27–29

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Anatomy and Nomenclature The maxilla contributes to forming the boundaries for three cavities: the roof of the mouth, the floor and lateral nasal walls, and the floor and medial orbital walls. Each maxilla articulates with the zygomatic, frontal, ethmoid, nasal, lacrimal, palatine, and vomer bones. Many maxillary tumors extend into or arise from the orbit. Therefore, a maxillectomy may be combined with an orbital floor resection or an orbital exenteration. The orbital roof consists of the frontal bone and separates the intracranial contents from the orbit; the floor is made up of the maxilla, palatine, and zygomatic bones; the medial wall consists of the frontal, lacrimal, and ethmoid bones; the lateral wall includes the zygomatic and sphenoid bones. Spiro and colleagues categorized maxillectomies according to the number of walls resected, dividing them into limited, subtotal, and total subtypes. 30 Unfortunately, this algorithm is relatively simplistic and does not help to guide the reconstruction. Although several other classification systems have been described, we prefer a classification system that provides for an anatomic description of the defect 27–29 (Table 38.3). Orbital exenteration, which includes removal of the globe as well as the other orbital contents in contrast to enucleation which refers to globe removal only, may be included with the maxillary resection. TABLE 38.3 Maxillectomy Classification Systems and Reconstructive Techniques Hanasono Suprastructure

Cordeiro I

Brown I

Resection Description Any part of maxilla not including the palate or alveolus

Resection Depiction

Premaxillary

–

–

Central alveolus between canines ± primary palate

Obturator versus osteocutaneous flap (RFOC/FOC)

Unilateral posterior Palatomaxillectomy

IIa

IIb

Alveolus distad to canine, palate, and one or more walls of the maxilla

Obturator versus ALT/RAM/RFF

Unilateral hemipalatomaxillectomy

IIa

IIb

Entire hemipalate and maxilla

ALT/RAM versus FOC

Bilateral

IIb

IId

Bilateral palate and

FOC

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Reconstruction No treatment versus soft tissue flap if skin resected (ALT/RAM/RFF)

palatomaxillectomy

maxilla

Maxillectomy with orbital floor resection

IIIa

IIIb

Any maxillectomy + orbital floor resection

Choice of flap based on maxillectomy defect; orbital floor reconstructed with alloplastic implant versus autologous bone graft (iliac crest versus split calvarial)

Orbitomaxillectomy

IV

V

Any maxillectomy + orbital exenteration

ALT/RAM versus ALT/RAM + FOC versus chimeric scapula osteomyocutaneous flap

ALT, anterolateral thigh; RAM, rectus abdominis myocutaneous.

Medial maxillectomy involves resection of the medial wall of the maxilla and inferior turbinate. This surgery is usually indicated for tumors arising from the lateral nasal wall or lacrimal system. This resection may be performed through a lateral rhinotomy incision or, more recently, endoscopically. Reconstruction is only necessary if the skin of the medial canthal area or lateral nasal sidewall has been removed with the maxilla (Figure 38.10). In this situation, a paramedian forehead flap or radial forearm free flap can be used to resurface the medial canthus skin; a portion of the flap can be de-epithelialized and buried deep to the lateral rhinotomy incision to prevent fistula formation.

FIGURE 38.10 Medial maxillectomy via lateral rhinotomy incision. A. Defect involves resection of skin overlying the medial canthus and superior lateral nasal sidewall as well as medial maxillary wall. B. Reconstructed with paramedical forehead flap; distal aspect of flap de-epithelialized and buried to reinforce the inferior aspect of the incision. C. Postoperative result after

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pedicle transection and radiation therapy.

Suprastructure maxillectomies involve the orbital floor but do not involve the palate. In these cases, the orbital floor is reconstructed with an alloplast such as titanium mesh or bone graft from the calvarium or ilium. The nonvascularized orbital floor reconstruction and cheek are supported by a bulky soft tissue free flap with a de-epithelialized skin paddle, such as the ALT or RAM free flaps, or a pedicled temporalis muscle flap if the reach and volume appear to be adequate for the defect. If facial skin is also resected, cheek reconstruction becomes necessary and is usually best accomplished using a myocutaneous free flap, such as the ALT or RAM. For maxillectomies that involve removal of some or all of the palate, the amount of hard and soft palate resected, as well as the plan for dental restoration, will dictate whether a prosthetic obturator is indicated or if a flap should be performed. Okay and colleagues provide a set of guidelines based on what defects are compatible with a prosthetic obturator. 32 In general, palatoalveolar defects that spare both canine teeth can be successfully treated with an obturator (Table 38.3). In these cases, cantilever forces resulting in unstable prosthetic retention are minimized because of the favorable root morphology of the canine adjacent to the obturator and the generous arch length provided by the remaining alveolus. Obturators are inappropriate for maxillectomy defects that include a concurrent resection of the skull base, orbital floor, orbital contents, or facial skin, regardless of the remaining dentition and alveolar arch. Additionally, some patients may not like certain features of an obturator, such as the fact that it must be removed and cleaned regularly and periodically adjusted or replaced for fit, wear and tear, and/or fungal colonization. When an obturator cannot be used either because of defect geometry or patient preference, a soft tissue free flap can be used to replace the missing palate and support the soft tissues of the face for palatoalveolar defects posterior to the canine tooth. The ALT or RAM free flaps are well suited for this indication. In obese patients, the radial forearm fasciocutaneous flap can be used. In any palatal defect reconstructed with a flap, meticulous surgical technique must be practiced when insetting the flap to the remaining palate. We recommend resecting additional palatal mucosa so that the flap-palate seam is positioned over bone, thus minimizing the chance of an oronasal fistula should an incisional dehiscence occur. When reconstructing any variety of midface defect with a free flap, achieving adequate pedicle length can be challenging. In general, either the ST vessels or any branch from the external carotid artery in the neck will serve as an adequate recipient. The vein corresponding to the selected recipient artery, or an end-toside anastomosis to the internal jugular vein, will suffice for drainage. If a neck recipient is used, the pedicle will need to be tunneled from the midface, where the flap is inset, into the neck. This is typically done through a subcutaneous tunnel within the cheek and over the mandible into the neck. This should prevent injury to the distal branches of the facial nerve; care should be taken to avoid Stensen duct when creating the tunnel. When designing the flap, every effort should be made to design the skin paddle as distal as possible from the pedicle to maximize length. If the pedicle cannot reach the chosen recipient, then an interposition vein graft should be used to lengthen the pedicle. It is difficult to use an obturator when the palatal-alveolar defect extends mesial to the ipsilateral canine tooth. In this geometry, there are greater cantilever forces acting on the prosthesis, which must also rely on less dentition for retention. There are a variety of flap options for reconstruction following hemipalatomaxillectomy, which results in a defect that extends to the midline. Soft tissue free flaps, such as the ALT or RAM, will provide adequate bulk to obliterate the maxillary sinus, support the cheek, and provide skin for reconstruction of the palatal defect (Figure 38.11). Unfortunately, they do not provide a rigid skeletal framework. Over time, this may contribute to loss of anterior maxillary projection on the side of the flap. Although surgery is usually more technically challenging, osteocutaneous free flaps can provide skeletal support and also facilitate dental rehabilitation via osseointegrated implants; we prefer

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this reconstructive technique for hemipalatomaxillectomy defects in highly functional, compliant patients with good oncologic prognosis (Figure 38.12). One caveat is that we have found that placement of osseointegrated implants in an irradiated bone flap is prohibitively dangerous, associated with a high rate of infection, osteoradionecrosis, and loss of the reconstruction. Therefore, if an osteocutaneous free flap is used for reconstruction and the patient receives postoperative radiation therapy, then one of the main purposes for using a bony reconstruction is obviated. In such cases, temporary placement of an obturator or soft tissue flap followed by delayed conversion to an osseous flap after radiation therapy is an option.

FIGURE 38.11 A. Posterior palatomaxillectomy defect. B. Anterolateral thigh perforator flap harvest. C. Closure of the palatomaxillary defect. D. Postoperative result showing good facial symmetry.

FIGURE 38.12 A. Left hemipalatomaxillectomy defect. B. A fibula osteocutaneous free flap was chosen so that osseointegrated implants could later be placed for dental restoration. C. Postoperative result, showing fibula skin paddle used to close the palatal defect.

Premaxillary defects usually arise from resection of lip or nasal pathologies. Most defects are relatively small and amenable to obturation alone. However, if the patient does not prefer an obturator, reconstruction must be performed to support the upper lip and nasal tip, replace the nasal floor and primary hard palate, and serve as a site for future dental implantation. Although the bony defect is relatively small, it can be challenging to reconstruct. An osteocutaneous free radial forearm or fibula flap

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can be used to replace the missing alveolus, serve as a rigid skeletal framework to support the lip and nose, and replace the resected palate. A premaxillary maxillectomy is one of the rare circumstances in which an osteocutaneous radial forearm flap can be considered a first-line option. Ahmad and colleagues provide an excellent description of their experience and surgical technique for using this flap for this particular defect. 33 A prosthetic obturator is not an option for bilateral palatomaxillectomy defects because of lack of support, and soft tissue flaps lack the rigidity to prevent midfacial collapse. 31,32 These defects require bony reconstruction to maintain midface height, width, and projection, as well as to house dental implants. A bilateral palatomaxillectomy requires a long length of bone, typically 14 to 16 cm, making the fibula the most appropriate choice. The leg that is ipsilateral to the side of the planned microvascular anastomosis is selected for fibula harvest. When the bony defect extends more laterally or posteriorly on one side than another, that side is usually preferred for the anastomosis because of the closer proximity to the neck. Alternatively, the side of the neck with better recipient blood vessels, if any, is used. In any bilateral palatomaxillectomy reconstruction, there is a strong possibility of requiring vein grafts to reach the recipient vasculature; this should be anticipated and planned appropriately. Typically, the fibula flap is shaped similarly to the Greek letter omega in the transverse plane (Figure 38.13). This configuration approximates the width and projection of the native maxilla. The lateral portions of the fibula replace the anterior wall of the maxillary sinus and malar eminence, if resected. The width of the fibula bone replaces the midfacial height. The middle portion of the flap restores the anterior projection and alveolus. A portion of soleus or flexor hallucis longus muscle is included with the fibula flap to fill the maxillary sinus. The skin paddle is designed to reconstruct the palatal defect.

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FIGURE 38.13 A. Computer modeling of a fibula reconstruction for a bilateral palatomaxillectomy defect. B. Fibula free flap after osteotomies for reconstruction of a bilateral palatomaxillectomy defect. C. The fibula can accommodate osseointegrated implants for dental restoration.

There are a number of CAD/CAM systems available to assist with osseous flap planning, such as that required for maxillectomy reconstruction (see Figure 38.13). 34 For these highly complex, challenging surgeries, CAD/CAM and the advent of virtual surgical planning can improve accuracy of the reconstruction and reduce operative time. Using preoperative CT scans of the facial skeleton combined with a CT angiogram of the lower extremity, the exact location and angles of the osteotomies can be preplanned and designed according to the location of the patient’s fibula perforators. These data are then translated to three-dimensionally printed cutting guides for both the fibula and the maxilla for an accurate and precise fit. Recently, using this same CT data, technology has been developed to create a milled titanium plate, corresponding to the exact shape of the reconstruction. CAD/CAM can increase the accuracy of the reconstruction, better approximating the patient’s premorbid occlusion and craniofacial

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dimensions, translating to a better functional and cosmetic result. Dental restoration with osseointegrated implants is performed 3 to 6 months after flap reconstruction. In patients with significant subcutaneous adipose tissue in the flap skin paddle, thinning of the flap is usually performed concurrently with implant placement. Removal of a portion of the plate or screws may be necessary for the fibula to accommodate the implants; therefore, bony union of the fibula at all osteotomy sites and to the native facial skeleton must be confirmed preoperatively.

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Maxillectomy With Orbital Floor Defect The orbital floor can be successfully reconstructed with a variety of alloplastic materials as well as autologous bone grafts, most commonly harvested from either the iliac crest or outer table of the calvarium. Many surgeons believe that bone grafts are more resistant to radiation-induced complications; however, our own experience does not support their use over alloplasts. 24,28 Kirby and colleagues found that bone grafts were more likely to be complicated by orbital dystopia and enophthalmos compared with alloplastic materials. 35 Indeed, shaping an autologous graft is more challenging than shaping titanium mesh; this feature likely contributed to the adverse outcomes discussed in this paper. When using a fibula osteocutaneous free flap to reconstruct a hemipalatomaxillectomy or bilateral palatomaxillectomy with an orbital floor defect, we will include soleus or flexor hallucis longus muscle to support the alloplast or bone graft. We believe it is imperative that the reconstructed orbital floor be in direct continuity with well-vascularized tissue to minimize complications.

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Maxillectomy With Orbital Exenteration When an orbital exenteration is performed in isolation and no aspects of the maxilla or skull base are removed, and there is no history of radiation or no anticipation of radiation, the reconstruction can be very simple. In this situation, the goal is to provide a deep, concave orbit lined with durable skin able to accept a prosthesis. A split-thickness skin graft lining the orbital cavity fulfills these criteria well. It may be helpful to allow for a period of secondary intention healing and dressing changes to build granulation tissue, prior to placing the skin graft. Other options include a local flap such as a temporalis muscle or temporoparietal fascia flap with a skin graft or a thin fasciocutaneous free flap such as a radial forearm flap. The temporalis muscle flap is thin enough to permit a secure prosthesis fit but results in a depression at the donor site. Such a depression can be easily corrected with either fat grafting or placement of a high-
 density porous polyethylene implant. 36 Rotation of either of these flaps may require removal of the lateral orbital wall to achieve the length needed to reach the medial aspect of the orbit; this also creates a significant contour deformity. The complexity of the reconstruction increases significantly when the inferior, medial, or superior walls of the orbit have been removed. In this more complicated scenario, the primary goals of reconstruction are to line the orbital cavity with durable tissue, to exclude the nasal or sinus cavities, and to protect the brain when the orbital roof has been removed. If the bony resection is limited, the radial forearm free flap may still be a reliable option; this thin flap will accommodate an orbital prosthesis without revision surgery. In cases when the bony resection is more extensive, such as an orbitomaxillectomy, a bulky flap is preferred. The ALT or RAM flaps are good options in this scenario. Either flap can be designed with both a muscle component and fasciocutaneous segment; the muscle is used to fill the sinuses, thus preventing infection with sinonasal flora or fistula formation, and the skin portion is used to resurface the orbit. The added flap bulk is also required to restore midfacial volume and cheek contour. The orbital contour is usually convex in these cases, and the reconstruction will require a revision at a later date if an orbital prosthesis is desired. Defects involving both an orbital exenteration and a palatomaxillectomy are best reconstructed with flaps with multiple skin paddles to close these three defects (orbit, cheek/sinuses, and palate). Both the RAM and ALT are good choices. In cases where the perforator anatomy is not compatible with multiple separate skin paddles, a portion of the flap can be de-epithelialized for reconstruction of multiple surfaces. It is the authors’ preference to leave a noncutaneous flap surface facing the nasal cavity to spontaneously mucosalize around a soft silicone nasopharyngeal trumpet; this process takes 2 to 3 weeks.

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Questions 1. A 57-year-old man presents with a 6 cm ameloblastoma of the hard palate. He undergoes bilateral maxillectomy, including total removal of his hard palate and alveolar ridge. What is the most appropriate reconstructive technique? a. Prosthetic obturator b. Temporalis muscle pedicled flap c. Iliac crest bone graft d. ALT free flap e. Fibula osteocutaneous free flap 2. A 92-year-old man is diagnosed with diffuse squamous cell carcinoma of the scalp, metastatic to the cervical lymph nodes. He is healthy other than the fact that he has a BMI of 35 and requires corrective lenses in order to achieve normal vision. A 20-cm diameter excision, including the pericranium, of the scalp and cervical lymphadenectomy is planned. What is the most appropriate method of reconstruction? a. Latissimus dorsi myocutaneous flap with anastomosis to the ST vessels b. Vascularized composite tissue allograft of the scalp with anastomosis to the bilateral terminal external carotid arteries and end-to-side anastomosis to the internal jugular veins c. Latissimus dorsi muscle flap and skin graft with anastomosis to the ST vessels d. ALT fasciocutaneous flap to facial vessels e. Vastus lateralis muscle flap and skin graft with anastomosis to the ST vessels 3. A 37-year-old woman is diagnosed with osteosarcoma of the skull. The lesion has eroded through the scalp and the patient has been treated preoperatively with radiation. A 7 cm2 diameter craniectomy and scalp resection is planned. The neurosurgeon tells you he is very worried about recurrence. What is the most appropriate material for the reconstruction of the calvarium? a. PEEK b. Titanium mesh c. No calvarial reconstruction necessary d. Bone allograft with bone morphogenic protein e. Calcium phosphate 4. A 42-year-old man undergoes resection of the anterior skull base to remove an esthesioneuroblastoma. He has a history of a significant laceration to the left preauricular area. The skull base surgeon reconstructs the missing anterior cranial fossa with a pedicled pericranium flap. Postoperatively, the patient develops CSF rhinorrhea. He is placed on prophylactic antibiotics with his head of bed elevated, but the leak persists even after 5 days. The neurosurgeons place a lumbar drain, but clear fluid continues to drain through the patient’s nose. The plastic surgeon is consulted for recommendations. What is the most reasonable treatment option? a. Continue conservative management b. Return to the operating room for exploration, dural repair by neurosurgery, and re-inset of the pericranial flap c. Return to the operating room for exploration, dural repair by neurosurgery, and resurfacing the resected skull base with a buried vastus lateralis muscle flap. d. Return to the operating room for exploration, dural repair by neurosurgery, and resurfacing the resected skull base with a pedicled left temporalis major muscle flap e. Return to the operating room for exploration, dural repair by neurosurgery, and resurfacing the resected skull base with a free buried omentum flap

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5. A 67-year-old man with an HbA1c of 11 mg/dL, dialysis-depended end-stage renal disease, and an ejection fraction of 20% is diagnosed with a squamous cell carcinoma eroding through the hard palate. An infrastructure palatomaxillectomy is planned with resection of the hard palate and left maxillary alveolus. The ipsilateral canine tooth and all teeth mesial to it will be spared. What is the most appropriate method of reconstruction? a. Free fibula osteocutaneous flap b. Radial forearm osteocutaneous flap c. Radial forearm fasciocutaneous flap d. Prosthetic obturator e. ALT flap 1. Answer: e. Several techniques are used in palatomaxillary reconstruction. Palatal obturators are acceptable for small defects. However, prosthetic retention can be difficult or impossible in sizable defects, particularly when there are few teeth to stabilize the prosthesis. The temporalis muscle flap can be rotated into the oral cavity and is useful for closing isolated defects of the midpalate. However, this flap would not provide the structural support necessary to maintain the shape of the midface. Iliac crest bone grafts stabilized with titanium hardware can be used for some posttraumatic defects but are prone to infection, extrusion, and nonunion in radiated patients, particularly when the defect is as extensive as this one. The ALT free flap can close the palatal defect and restore shape to the cheek in patients with a unilateral maxillectomy. However, in anterior and bilateral defects, such as this one, a myocutaneous free flap, like the temporalis muscle flap, would not restore the height, width, and projection of the anterior midface. The fibula osteocutaneous free flap and other vascularized bone flaps can be shaped to restore the skeletal support of the midface in extensive, bilateral maxillary defects. The skin paddle of the flap can be used to close the palatal defect to restore speech and swallowing function. Also, the fibula osteocutaneous free flap can accept osseointegrated implants for dental restoration because of the good quality of bone stock associated with this flap. 2. Answer: c. The extent of the planned resection will require a free tissue transfer because of lack of available locoregional options. A skin graft alone would be inappropriate considering the anticipated resection will include the pericranium. Using a latissimus myocutaneous flap for a 20-cm wide defect is possible, but the donor site would not be able to close primarily, requiring a skin graft. Additionally, with a BMI of 35, the thickness of the skin paddle would likely require multiple revisionary procedures to achieve an acceptable appearance; it is best to avoid procedures that will necessitate revision in the elderly. An ALT fasciocutaneous flap or vastus lateralis muscle flap will not be large enough to fully reconstruct the defect. The ST vessels are the recipient vessels of choice in any scalp reconstruction. Any patient that wears glasses should be instructed to not wear them postoperatively to avoid inadvertent pedicle compression. The facial vessels will likely be exposed, considering the need for a neck dissection in this patient. However, a vein graft is likely necessary to achieve the required pedicle length to reach the neck; if the ST vessels are adequate and available, they are preferred. 3. Answer: a. Titanium mesh is an effective material for craniectomy reconstruction; however, it is associated with significant imaging artifact, marking radiologic surveillance of disease recurrence challenging. Any calvarial defect greater than 6 cm2 should be reconstructed. PEEK implants are radiolucent and can be customized to the patient, based on the planned resection and preoperative imaging data. In this scenario, given the other available answer choices, a PEEK reconstruction is most appropriate. Bone morphogenic protein is a morphogen and should be avoided in cases of malignancy. Calcium phosphate is useful for smaller calvarial defects; however, it carries a high late infection risk; therefore, it should be avoided in this patient with a history of preoperative radiation.

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4. Answer: c. The CSF leak is unlikely to resolve with continued conservative management at this point. Re-inset of the pericranial flap is unwise considering it failed in initially preventing the leak. Although a temporalis muscle flap may reach the anterior skull base, the patient’s prior left preauricular injury may be damaging the muscle’s blood supply, obviating its use as a flap. The vastus lateralis muscle flap is a good option in this scenario; it is well vascularized and conforms to the shape of the skull base, easily sealing off the intracranial space from the sinonasal cavity. The muscle can be buried and monitored with an implantable Doppler probe. The omentum could be used; however, few plastic surgeons would consider it a first-line option given the need for a laparotomy to harvest it. 5. Answer: d. This patient with multiple medical comorbidities is not a good candidate for a free tissue transfer. An obturator is an excellent option for reconstruction of limited palatal defects. The extent of the remaining alveolar dentition is sufficient to counteract the substantial cantilever forces that will be imparted to the obturator.

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References Raposio, E, Santi, P, Nordström, RE. Effects of galeotomies on scalp flaps. Ann Plast Surg. 1998;41:17-21. Orticochea, M. Four flap scalp reconstruction technique. Br J Plast Surg. 1967;20:159-171. Muresan, C, Hui-Chou, HG, Dorafshar, AH, et al. Forehead reconstruction with microvascular flaps: utility of aesthetic subunits. J Reconstr Microsurg. 2012;28:319-326. Menick, FJ. A 10-year experience in nasal reconstruction with the three-stage forehead flap. Plast Reconstr Surg. 2002;109:1839-1855. Kane, WJ, McCaffrey, TV, Wang, TD, Koval, TM. The effect of tissue expansion on previously irradiated skin. Arch Otolaryngol Head Neck Surg. 1992;118:419-426. Hansen, SL, Foster, RD, Dosanjh, AS, Mathes, SJ, Hoffman, WY, Leon, P. Superficial temporal artery and vein as recipient vessels for facial and scalp microsurgical reconstruction. Plast Reconstr Surg. 2007;120:1879-1884.The superficial temporal artery and vein have historically not been considered adequate for microsurgical reconstruction and have rarely been described as recipient vessels. The authors demonstrate that the superficial temporal artery and vein for scalp and face reconstruction are reliable and safe and state that they should be considered as primary recipient vessels in microsurgical reconstruction of the upper two-thirds of the face and/or scalp. Hussussian, CJ, Reece, GP. Microsurgical scalp reconstruction in the patient with cancer. Plast Reconstr Surg. 2002;109:1828-1834. Sosin, M, De la Cruz, C, Bojovic, B, et al. Microsurgical reconstruction of complex scalp defects: an appraisal of flap selection and the timing of complications. 
 J Craniofac Surg. 2015;26:1186-1191. Sosin, M, Schultz, BD, De La Cruz, C, et al. Microsurgical scalp reconstruction in the elderly: a systematic review and pooled analysis of the current data. Plast Reconstr Surg. 2015;135:856-866. Simunovic, F, Eisenhardt, SU, Penna, V, et al. Microsurgical reconstruction of oncological scalp defects in the elderly. J Plast Reconstr Aesthet Surg. 2016;69:912-919. Chao, AH, Yu, P, Skoracki, RJ, et al. Microsurgical reconstruction of composite scalp and calvarial defects in patients with cancer: a 10-year experience. Head Neck. 2012;34:1759-1764. Lee, EI, Chao, AH, Skoracki, RJ, Yu, P, DeMonte, F, Hanasono, MM. Outcomes of calvarial reconstruction in cancer patients. Plast Reconstr Surg. 2014;133:675-682.Retrospective review of 289 calvarial reconstructions in cancer patients. The authors demonstrate a similar complication profile in a variety of alloplasts with the exception of calcium phosphate, which was found to have a high infection rate. Rubin, JP, Yaremchuk, MJ. Complications and toxicities of implantable biomaterials used in facial reconstructive and aesthetic surgery: a comprehensive review of the literature. Plast Reconstr Surg. 1997;100:1336-1353. Hanasono, MM, Goel, N, DeMonte, F. Calvarial reconstruction with polyetheretherketone implants. Ann Plast Surg. 2009;62:653-655. Kumar, AR, Bradley, JP, Harshbarger, R, et al. Warfare-related craniectomy defect reconstruction: early success using custom alloplast implants. Plast Reconstr Surg. 2011;127:1279-1287. Moreira-Gonzalez, A, Jackson, IT, Miyawaki, T, et al. Clinical outcome in cranioplasty: critical review in long-term follow-up. J Craniofac Surg. 2003;14:144-153. Netscher, D, Alford, EL, Wigoda, P, Cohen, V. Free composite myo-osseous flap with serratus anterior and rib: indications in head and neck reconstruction. Head Neck. 1998;20:106-112. Sinno, S, Rodriguez, ED. Definitive management of persistent frontal sinus infections and mucocele with a vascularized free fibula flap. Plast Reconstr Surg. 2017;139:170-175. Lee, JW, Hsueh, YY, Lee, JS. Composite skull and dura defect reconstruction using combined latissimus dorsi musculocutaneous and serratus anterior muscle-rib free flap coupled with vascularized galea transfer: a case report. Microsurgery. 2010;30:632-635. Hasan, Z, Gore, SM, Ch’ng, S, et al. Options for configuring the scapular free flap in maxillary, mandibular, and calvarial reconstruction. Plast Reconstr Surg. 2013;132:645-655. Selber, JC, Chang, EI, Clemens, MW, et al. Simultaneous scalp, skull, kidney, and pancreas transplant from a single donor. Plast Reconstr Surg. 2016;137:1851-1861.The first report of a simultaneous scalp, skull, kidney, and pancreas transplant from a single donor. The case was successful and established vascularized composite tissue allograft reconstruction of the scalp and skull as a potential option in the appropriate clinical scenario. Sosin, M, Ceradini, DJ, Levine, JP, et al. Total face, eyelids, ears, scalp, and skeletal subunit transplant: a reconstructive solution for the full face and total scalp burn. Plast Reconstr Surg. 2016;138:205-219. Irish, J, Gullane, PJ, Gentili, F, et al. Tumors of the skull base: outcome and survival analysis of 77 cases. Head Neck. 1994;16:3-10.This seminal article introduces the classification schema commonly used when describing skull base resections and reconstructions. Hanasono, MM, Lee, JC, Yang, JS, et al. An algorithmic approach to reconstructive surgery and prosthetic rehabilitation after orbital exenteration. Plast Reconstr Surg. 2009;123:98-105. Rosenthal, EL, King, K, McGrew, BM, et al. Evolution of a paradigm for free tissue transfer reconstruction of lateral temporal bone defects. Head Neck. 2008;30:589-594. Hanasono, MM, Silva, AK, Yu, P, Skoracki, RJ, Sturgis, EM, Gidley, PW. Comprehensive management of temporal bone defects after oncologic resection. Laryngoscope. 2012;122:2663-2669. Brown, JS, Shaw, RJ. Reconstruction of the maxilla and midface: introducing a new classification. Lancet Oncol. 2010;11:1001-1008.Seminal article introducing a widely accepted maxillectomy classification system. Hanasono, MM, Silva, AK, Yu, P, Skoracki, RJ. A comprehensive algorithm for oncologic maxillary reconstruction. Plast Reconstr Surg. 2013;131:47-60.Seminal article describing an anatomic description and classification system for maxillectomy defects, as well as reconstructive options

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organized by defect classification. Cordeiro, PG, Santamaria, E. A classification system and algorithm for reconstruction of maxillectomy and midfacial defects. Plast Reconstr Surg. 2000;105:2331-2346.Seminal article describing an important classification system for maxillectomy defects. It establishes that free tissue transfer provides the most effective and reliable form of immediate reconstruction for complex maxillectomy defects. Spiro, RH, Strong, EW, Shah, JP. Maxillectomy and its classification. Head Neck. 1997;19(4):309-314. Moreno, MA, Skoracki, RJ, Hanna, EY, Hanasono, MM. Microvascular free flap reconstruction versus palatal obturation for maxillectomy defects. Head Neck. 2010;32:860-868. Okay, DJ, Genden, E, Buchbinder, D, Urken, M. Prosthodontic guideline for surgical reconstruction of the maxilla: a classification system of defects. J Prosthet Dent. 2001;86:352-363. Ahmad, FI, Means, C, Labby, AB, et al. Osteocutaneous radial forearm free flap in nonmandible head and neck reconstruction. Head Neck. 2017;39:1888-1893. Chang, EI, Hanasono, MM. State-of-the-art reconstruction of midface and facial deformities. J Surg Oncol. 2016;113:962-970. Kirby, EJ, Turner, JB, Davenport, DL, Vasconez, HC. Orbital floor fractures: outcomes of reconstruction. Ann Plast Surg. 2011;66:508-512. Mericli, AF, Gampper, TJ. Treatment of postsurgical temporal hollowing with high-density porous polyethylene. J Craniofac Surg. 2014;25:563-567.

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CHAPTER 39

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Reconstruction of the Eyelids, Correction of Ptosis, and Canthoplasty Benjamin P. Erickson and Derrick C. Wan

Key Points Comprehensive understanding of eyelid anatomy, coupled with careful assessment of individual patient factors, guides diagnosis, and selection of appropriate procedures. Divide upper and lower eyelid defects into anterior lamellar (partial-thickness and full-thickness defects), then by size to select reconstructive options. Full-thickness defects are reconstructed in layers, restoring a mucosalized posterior lining, structural support layer, and anterior skin/muscle layer. At least one lamella must have an intact blood supply. Avoid undue vertical tension while appropriately correcting horizontal laxity to minimize the risk of postoperative eyelid malposition. When necessary, use a wedge excision with the apex pointing away from the lid margin to approximate a pentagon to avoid dog-ears and notching. Repair of eyelid ptosis requires an understanding of the possible etiologies and full preoperative evaluation, including assessment of lid position and levator function. Lower eyelid malposition and lid laxity can be treated with a lateral canthoplasty (division of the canthus and repositioning) or canthopexy (redirection of intact canthal tendon). Procedures to shorten and provide lower eyelid support depend on the severity of lid laxity. The eyelids are complex lamellar structures that function to protect the anterior globe from injury and maintain ocular surface integrity. They also aid in regulating light exposure to the eye and distribute the tear film over the cornea during blinking. Primary goals of any surgical procedure to reconstruct or modify the eyelids must focus on establishing or preserving a stable structure with adequate height and functional closure, and on maintaining a nonkeratinized mucosal posterior surface to avoid abrasion to the underlying cornea. Restoration of symmetry and appearance remain secondary goals. Understanding the anatomic architecture of the upper and lower eyelid is critical to achieving satisfactory functional and cosmetic outcomes.

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Eyelid Anatomy Lamellar Structure and Surface Anatomy The upper and lower eyelids are composed of the skin, minimal subcutaneous tissue, orbicularis oculi muscle, submuscular areolar tissue, a fibrous layer consisting of orbital septum and tarsal plate, retroseptal fat pads, lid retractors, and conjunctiva (Figure 39.1). For conceptual purposes, however, these structures are divided into anterior and posterior lamellae, with the tarsofascial layer in between. The upper eyelid extends from the lid margin inferiorly to the eyebrow superiorly, which demarcates it from the forehead. The natural curvature of the lid is generated by the shape of the tarsal plate as well as coaptation to the curvature of the globe beneath. In the upper lid, a skin crease can be found approximately 8 to 9 mm superior to the eyelid margin in men and 9 to 11 mm in women, though in the Asians this lid crease can be found significantly lower. The inferior eyelid extends from the lid margin superiorly to the malar fold below, which runs from the medial canthal region inferomedially to the nasojugal fold and serves to delimit the lower lid from the cheek. A lower eyelid fold, particularly in children, can also be found approximately 3 to 5 mm from the lid margin.

FIGURE 39.1 Cross-sectional schematic of upper (A) and lower (B) eyelid anatomy.

With the eye open, the palpebral fissure measures 28 to 30 mm in length and approximately 9 mm in height. The highest point of the upper lid is typically found just medial to the center of the pupil, with the lid margin resting 1 to 2 mm below the superior limbus in adults. The lowest point of the lower eyelid can be found lateral to the center of the pupil, with the margin at the inferior limbus. Finally, in Caucasians, the lateral canthus is positioned 2 mm higher than the medial canthus, whereas in Asians this can be found 3 mm higher.

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Eyelid Skin The skin of the upper and lower eyelids is among the thinnest in the body, measuring less than 1 mm thick. A greater number of sebaceous glands can be found in the nasal portion of the lids, making these regions smoother and oilier than temporal eyelid skin. There is relatively minimal subcutaneous fat in the eyelids, which can mostly be found beneath preorbital and preseptal skin. Beneath pretarsal skin, as well as laterally over the medial and lateral canthal ligaments, the underlying fat is absent. This anatomic relationship facilitates motility, but also contributes to disproportionate redundancy with aging. Of note, descent of the brow fat pad into the lateral upper lid is common, and it should not be confused with retroseptal fat.

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Eyelid Muscles Muscles of the eyelids can be divided into protractors, which close the eyes, and retractors, which open them. The orbicularis oculi muscle is the primary protractor and is divided into orbital, preseptal, and pretarsal portions. Fibers of the orbital portion originate from the medial orbital margin and medial canthal tendon and sweep around the orbit in horseshoe fashion to insert back on the medial canthus. The preseptal and pretarsal subunits originate from the medial canthal tendon and insert on the lateral horizontal raphe. The orbital subunit functions in forced closure, whereas the preseptal and pretarsal subunits are employed for blinking and voluntary winking. Temporal, zygomatic, and buccal branches of the facial nerve innervate the muscle from the undersurface. Eyelid retractors consist of the levator palpebrae superioris and Müller muscle in the upper lid, and capsulopalpebral fascia in the lower lid. The levator palpebrae superioris arises from the orbital apex and terminates in an aponeurosis, which fuses with the orbital septum anteriorly prior to attaching to the superior tarsal plate posteriorly. It is innervated by the oculomotor nerve and serves as the principal upper lid retractor. An anterior extension from the levator can be found inserting into the pretarsal orbicularis oculi muscle and skin, forming a skin crease in the upper eyelid. Dehiscence of the levator muscle from the tarsal plate with age or trauma results in blepharoptosis and elevation of the lid crease. In concert with the levator palpebrae superioris, the sympathetically innervated Müller muscle contributes an additional 2 to 3 mm lid elevation. It originates from the undersurface of the levator muscle and inserts on the superior margin of the tarsal plate. With decreased sympathetic tone, as in Horner syndrome, loss of this muscle function results in mild ptosis. In the lower eyelid, fascial extensions of the inferior rectus muscle continue anterosuperiorly to form the capsulopalpebral fascia. This primarily inserts on the inferior border of the lower tarsal plate, though minor fibers also insert on the conjunctiva of the inferior fornix, facilitating lower lid descent with downward gaze. Analogous to the upper eyelid, sympathetically innervated fibers are intimately involved with the posterior surface of the capsulopalpebral fascia, although they are typically not identifiable as a distinct anatomical layer. The orbital septum in the lower eyelid also fuses with the capsulopalpebral fascia in similar fashion to the upper lid.

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Orbital Septum The orbital septum is a thin layer of connective tissue that separates the eyelid from the anterior orbit. It is continuous with the periosteum along the orbital rim (arcus marginalis) and attaches to the tarsal plates through fusion with the levator palpebrae superioris in the upper lid and capsulopalpebral fascia in the lower lid. Variable indistinct fusion, however, can result in more prominent orbital fat projection in different ethnicities, and with age, thinning of the septum can also lead to more noticeable fat descent. The orbital septum has considerable laxity, but scarring of the septum from trauma or surgical intervention can precipitate lid retraction.

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Fat Pads Adipose tissue in the upper eyelid is divided into two components, the central (preaponeurotic) fat pad and the medial fat pad. The central fat pad is broad and yellow secondary to higher levels of carotenoids and is found in between the orbital septum and levator aponeurosis. The medial fat pad, which is more pale yellow or white in color, is located in the same plane and is separated from the central fat pad by the trochlea of the superior oblique muscle. Finally, the lacrimal gland occupies the lateral compartment in the upper eyelid. It is firmer to palpation, pink in color, and may become more prominent on upper lid examination with age due to prolapse. The lower eyelid contains three retroseptal fat compartments known as the lateral, central, and nasal fat pads. The inferior oblique muscle separates the medial and central fat pads, whereas the arcuate expansion extending from the capsulopalpebral fascia separates the medial and lateral fat pads. As the fat pads reside behind the septum, insertion of this fascial layer outside the orbital rim laterally creates the recess of Eisner into which a portion of the lateral fat pad sits. Because of the intimate association of the inferior oblique muscle with lower lid fat, injury to this muscle during surgical dissection can result in torsional diplopia.

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Tarsoligamentous Sling The tarsal plates comprise the fibrous skeleton of the upper and lower eyelids and provide structural integrity. The superior tarsal plate is typically 10 to 12 mm in height centrally, narrowing medially, and laterally to assume a crescentic shape. The inferior tarsal plate is more rectangular and measures approximately 4 mm in height centrally. The maximum thickness is 1 mm and each tarsus is approximately 30 mm long. Within the upper and lower eyelid, tarsus can be found 25 to 40 sebaceous meibomian glands. These empty at the lid margin posterior to the gray line and are responsible for the oily layer of the tear film. Each tarsus tapers medially and laterally, joining to form canthal tendons. Together with the tarsal plates, they form the tarsoligamentous sling, which maintains lid-globe apposition. The medial canthal tendon is intricately related to the orbicularis oculi muscle and splits to form anterior and posterior limbs that insert into the anterior and posterior lacrimal crest, respectively. The lateral canthal tendon passes deep to the orbital septum and inserts 2 mm posterior to the lateral orbital rim on a bony prominence known as Whitnall tubercle. Proper attachment of canthal tendons both medially and laterally is responsible for preserving sharp canthal angles and maintaining lid-globe apposition.

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Conjunctiva The conjunctiva is a smooth, translucent, nonkeratinized mucous membrane that can be divided into palpebral, forniceal, and bulbar components. The palpebral conjunctiva lines the posterior surface of the upper and lower eyelid and is firmly adherent to the tarsal plates. This continues into the upper and lower fornices where there is redundant tissue to facilitate free motility of the eye. Beyond the forniceal conjunctiva, reflection anteriorly forms the bulbar conjunctiva which coats the surface of the globe. Goblet cells within the conjunctiva produce mucin, whereas accessory lacrimal glands are responsible for basal secretion of aqueous tears. Conjunctival tissue loss can result in lid malposition and limitation in ocular motility, and decreased mucin or tear production can increase risk for ocular surface injury.

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Lacrimal System The lacrimal glands are situated in the superolateral region of each orbit and are responsible for reflex secretion of the aqueous layer of the tear film. Two lobes can be found, separated by the levator aponeurosis, with the orbital lobe residing within the lacrimal fossa and the smaller palpebral portion close to the eye along the inner surface of the eyelid. Aqueous tears drain into the superolateral fornix via ductules and the wiper-blade action of the orbicularis oculi and tarsal plates pushes tears medially. In the normal setting, tears pass over the surface of the globe to reach lacrimal puncta at the inner corner of eyelids. These then pass tears through lacrimal canaliculi and ducts into the lacrimal sac, which turns into the nasolacrimal duct to provide drainage into the inferior nasal meatus. The lacrimal sac sits within the lacrimal fossa which is enveloped by the orbicularis oculi and medial canthal tendon. Contraction of the orbicularis muscle during blinking drives the pumping mechanism of the lacrimal sac, which draw tears into the puncta and propels them through the nasolacrimal duct. Decreased tear production can lead to keratoconjunctivitis sicca, with persistent dryness and burning of the eyes, whereas excess tear production with disruption of the lacrimal drainage system at any level may result in epiphora, or overflow of tears onto the face.

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Blood Supply and Lymphatics The eyelids contain a rich anastomotic blood supply derived from both the internal and external carotid arteries. The internal carotid arterial supply arises from terminal branches of the ophthalmic artery, which supply the medial palpebral vessel directly and the lateral palpebral vessel via the lacrimal artery. In the upper eyelid, a marginal arcade can be found on the anterior tarsal surface, approximately 2 to 4 mm above the lid margin. A second peripheral arcade can be found above the tarsal plate on the anterior surface of the Müller muscle, which can be susceptible to injury during eyelid surgery. In the lower eyelid, only one, more rudimentary arcade can be found approximately 2 mm below the inferior tarsal margin. External carotid artery supply arises from anastomotic branches of the angular artery, the superficial temporal artery, and the maxillary artery. Rich lymphatic drainage can be found for the eyelids and the conjunctiva. The lateral two-thirds of the upper lid and lateral half of the lower lid drain primarily through the preauricular lymph nodes, whereas the medial portion of the upper and lower lid drain through the submandibular lymph nodes. Persistent lymphedema of the eyelids can be functionally and cosmetically debilitating, with high rates of recurrence after surgical revision, but is fortunately a rare complication.

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Preoperative and Postoperative Considerations Defects of the upper or lower eyelids can result from congenital anomalies, trauma, or tumor resection. Irrespective of etiology, however, structures of the eyelid, including skin, muscle, tarsoligamentous sling, and conjunctiva must be fully evaluated and, if deficient, must be addressed in operative planning. Evaluation with respect to location and extent of tissue involvement (partial- or full-thickness) may also help to guide reconstructive planning. For congenital defects, such as with colobomas seen in paramedian clefts, Treacher Collins syndrome, or Goldenhar syndrome, a full evaluation for other associated anomalies must be performed. For postoncologic resection defects, knowledge of the histologic diagnosis and resection margin status should be obtained prior to proceeding with reconstruction. Along with these concerns, a full ophthalmologic history and examination should be performed. Prior ocular injuries, surgery, or history of inflammation may alter anatomic relationships and need to be recognized prior to surgery to reduce risk of postoperative complications. Malposition of the eyelid can be seen with entropion, ectropion, or lid retraction. A snap-back test is crucial for evaluation of laxity in the setting of eyelid malposition. The lower eyelid is pulled down and away from the globe to determine how long it takes to return to the original position without blinking. In the normal lower eyelid (Grade 0), it should spring back immediately to the original position, whereas a delay is observed with lid laxity. Grade I laxity is observed with 2 to 3 second delay, Grade II laxity with 4 to 5 seconds delay, and Grade III laxity with >5 seconds delay and return to position with blinking. Finally, with Grade IV laxity, frank ectropion is maintained without return to the original position. Importantly, though lid laxity must be addressed in successful periocular Mohs reconstruction, preoperative laxity may be beneficial and should therefore be treated conservatively until after definitive excision and repair is planned. The patient must also be evaluated prior to surgery for signs and symptoms of dry eye or blepharitis, as these may be exacerbated postoperatively. Adequate tear film production can be assessed with a Schirmer’s test, in which a filter paper strip is inserted into the lower sulcus for 5 minutes to measure moisture. Tear production is considered to be diminished with less than 15 mm in the absence of a topical anesthetic and with 5 to 10 mm when a topical anesthetic is given. Alternatively, tear production can also be evaluated by administering fluorescein eye drops to determine whether there is interpalpebral staining of the cornea. For patients with excess tear accumulation or epiphora, a dye disappearance test or dilation and irrigation can be performed. While under sedation and anesthetic, a No. 00 Bowman probe can also be passed through the lacrimal drainage system to determine the precise locus of obstruction. Typical distances in an adult are 8 to 10 mm to the common canaliculus, 10 to 12 mm to the lacrimal sac, and 24 mm to the proximal end of the nasolacrimal duct.

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Upper Eyelid Reconstruction Defects of the upper eyelid may arise from various causes, but tissue loss following tumor resection is the most common indication for reconstruction. Mohs micrographic surgery is frequently employed in the periorbital region, and this technique provides increased certainty of negative margins prior to reconstruction. Less frequently, substantial tissue deficit arising from developmental anomalies or trauma may need to be addressed. As the upper eyelid covers a greater portion of the cornea, it serves a more important role in globe protection than the lower eyelid. Consequently, eyelid reconstruction is indicated in all but a few instances, such as when small defects 2 mm) can be addressed with this approach, and further softening of the nasolabial folds can be achieved with targeting the zygomaticus muscles.

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Neck Visible bands in the neck resulting from platysma muscle attenuation can be a source of dissatisfaction for patients. Patients are evaluated by asking them to clench their necks and show their lower teeth. Hyperactive platysmal bands in the superficial subdermal space can be visualized and are the target of treatment. Numerous approaches to treating platysma bands with botulinum toxin have been reported with varying doses techniques. 28,29 It is well accepted that patients with excess skin laxity in the neck are not good candidates for this procedure as they have minimal overall improvement. In a recent study, patients were injected with botulinum toxin along the inferior border of the mandible and with the platysmal bands using a mean dose of 124.9 units. 30 The authors noted a significant improvement using this technique; however, some express concern given the high dose needed for effect and the potential risks of dysphagia and salivary gland dysfunction. Other more conservative approaches include direct platysmal band injection with 20 units of botulinum toxin. 29 Again, patient selection through proper physical examination is paramount for success in this approach.

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Noncosmetic Uses Axillary Hyperhidrosis Hyperhidrosis is characterized by the excessive sweating without any specific cause and can be socially stigmatizing for patients. The axilla, palms, and soles are the most common sites for hyperhidrosis. A variety of topical agents have been used for hyperhidrosis as well as surgical sympathectomy, all with formidable downsides. In 2001, a multicenter trial utilizing botulinum toxin injections for axillary hyperhidrosis was performed. 31 In this randomized double-blinded study, participants received 200 units of botulinum toxin injected into one axilla in comparison to placebo injections into the other. Within 2 weeks, there was a noticeable drop in sweat production from the treatment side. This effect continued for 24 weeks, and patients were highly likely to recommend this treatment to other patients. Further validating this technique was a modeled comparison study between endoscopic thoracic sympathectomy and intradermal botulinum toxin published in 2016. 32 The authors concluded that treatment costs reached an equivalence at 13 years, yet because of the low risk of botulinum toxin injections, they would recommend this over surgical sympathectomy. With this approach, the duration of effect is typically 7 months, and high patient satisfaction is typical. 33 Although side effects remain somewhat uncommon in most studies, a low rate of compensatory sweating in other areas was noted to occur with some regularity. 34,35

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Chronic Migraines An emerging treatment for chronic migraines lies in the neurolysis of sensory nerves of the head, which can be achieved by both surgical (decompression, neurolysis, and ablation) and chemical (BoNT injection) means. Chronic migraines affect over 3 million people in the US population and are distinguished from episodic migraine by a distinct frequency, epidemiology, pathophysiology, and response to treatment. 19 The effectiveness of BoNTs was incidentally discovered by William Binder, a facial plastic surgeon, who was conducting studies with Botox for aesthetic applications and noted a correlation between pericranial injections and alleviation of migraine symptoms. 36 He published the first open-label clinical trial on Botox for chronic migraines in 2000. 37 The pathophysiology of chronic migraines is incompletely understood, and the knowledge base surrounding this issue exceeds the scope of this chapter. The current model of the disease process is based on abnormal excitability in both central and peripheral neurons, particularly in the trigeminal neurovascular bundles. 19 It is thought that peripheral sensitization occurs, in which the threshold of sensory neurons responses to external stimuli is altered because of various maladaptive processes, and the neurons become hyperexcitable. Botox is thought to interrupt both neurotransmitter and neuropeptide release from sensory neurons, which interrupts signal transmission to the central nervous system and mitigates the effects of peripheral sensitization. Two phase III clinical trials were conducted that led to FDA approval of Botox for chronic migraines. The Phase III REsearch Evaluating Migraine Prophylaxis Therapy (PREEMPT 1 38 ) and PREEMPT 2 trials 39 consisted of a multicenter, randomized, double-blind, placebo-controlled clinical trial of Botox for chronic migraines in both North America and Europe. The pooled analysis of 1384 patients randomized to Botox or placebo demonstrated that Botox significantly reduced the number of headache days per month (−8.4 days for Botox and −6.6 days for placebo, P < 0.001, 95% CI −2.52 to −1.13), as well as frequency of migraine days, moderate or severe headache days, cumulative hours of headaches, and other measures of migraine severity and frequency. Safety analysis from the trials also revealed no new concerns, with the percentage of adverse events similar between treatment and control groups. Botox is currently indicated for the treatment of chronic migraines, defined as at least 15 days per month with headaches that last 4 hours or longer. The recommended dosage is 155 units administered intramuscularly, divided between seven sites in the head and neck: corrugators (5 U each side), procerus (5 U), frontalis (5 U each side), temporalis (5 U each side), occipitalis (15 U each side), cervical paraspinal muscles (10 U each side), and trapezius (15 U each side).

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Upper Extremity Vasospastic Disorders Patients with Raynaud phenomenon have abnormal vascular function in the hand who may develop chronic pain and ulceration. Botulinum toxin injections are a promising nonsurgical option for these difficult-to-manage patients. Prior to injection, patients should undergo vascular imaging studies to rule out occlusive disease. Neumeister et al. demonstrated improvements in hand pain, hand blood flow, and healing of chronic ulceration in a retrospective study evaluating the efficacy of botulinum toxin for patients suffering with Raynaud condition. 40 In this study, 50–100 units of Botox was injected into the palm directed toward the neurovascular bundles of the digits, and many patients demonstrated longterm relief of symptoms. Likewise, a study by Fregene et al. demonstrated similar improvements with pain and blood flow to the hand in patients with Raynaud conditions undergoing 100 unit Botox injections to the palm. 41 Side effects from this approach can include recurrence of pain and intrinsic muscle weakness. 40-42

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Hypertrophic Scarring A fascinating application of BoNT lies in the treatment and prevention of hypertrophic scars. Because wound tension is known to lead to an exuberant and potentially pathologic fibrotic response, chemical paralysis of muscles surrounding a wound may reduce tension during the critical healing period. Although only smaller studies have been performed to date, a 2016 meta-analysis showed statistically significant differences in both scar width and patient satisfaction with the use of botulinum toxin type A 43 for head and neck scars. Future studies are needed to flesh out the clinical utility and generalizability of this practice.

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Contraindications and Warnings The absolute contraindications for BoNTs are only two: hypersensitivity to any BoNT preparation (including any component of the preparation) and infection at the injection site. However, there are a number of warnings and precautions issued by the FDA, as well as potential drug interactions of which the practitioner should be aware. The dosages of BoNTs, even of the same toxin family (e.g., OnabotulinumtoxinA and AbobotulinumtoxinA, or Botox and Dysport), are not interchangeable and cannot be compared. As described earlier, movement of toxin beyond the site of injection is always a concern, particularly when injecting the toxin around the airway muscles as is performed for spasticity. Although ongoing controversy exists about the retrograde migration of BoNTs to the central nervous systems (see above), no adverse events have been reported during dermatologic uses of BoNTs. The practitioner should be especially careful when treating patients with cardiovascular disease or neuromuscular disorders (e.g., myasthenia gravis or Lambert-Eaton), who should be monitored after treatment.

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Adverse Effects As with any medical intervention, the side effects of treatment must be well understood by the clinicians prior to application. Distant spread of the effects of botulinum toxin may occur following local infections. These effects are reported to include generalized muscle weakness, diplopia, eyelid ptosis, dysphagia, dysphonia, urinary incontinence, and breathing difficulties. Symptoms may occur hours or even weeks after injection and are most common in children being treated for spasticity. Spread of the toxin effect during facial dermatologic treatments is unlikely when labeled doses are used. For Botox, this includes 20 units for glabellar lines, 24 units for lateral canthal lines, 40 units for forehead lines, 44 units for simultaneous lateral canthal and glabellar lines, and 64 units for simultaneous lateral canthal, glabellar, and forehead lines. Finally, treatment with botulinum toxin is contraindicated when there is an active infection at the injection site. Hypersensitivity to botulinum injections can occur and may include anaphylaxis and other forms of immediate allergic reactions. Botulism-like symptoms have been reported in patients undergoing BoNT injections for dystonia, 44 hyperhidrosis, 45 and blepharospasm. 46 These symptoms included dry eyes and mouth, gastrointestinal disturbances, dysphagia, hoarseness, and breathing difficulties. Notably, it is suspected that an underlying condition of myasthenia gravis was not recognized in these patients, 46 and none of the patients received the drug for aesthetic indications. Dosages of the drugs were also far higher than used for typical aesthetic indications: 6.25 to 32 U/kg of Botox and 388 to 625 U/kg of MyoBloc. Nonetheless, practitioners injecting BoNTs for plastic surgery indications must be aware of the potential for serious adverse events, particularly in patients with preexisting cardiovascular conditions or compromised respiratory function.

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Acknowledgments The authors thank Andre Marshall, MD, for his assistance with Figure 47.1.

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Questions 1. A 44-year-old woman presents with unilateral ptosis 1 week after undergoing botulinum toxin injection for glabellar rhytids. Which of the following is the most likely explanation for this finding? a. Horner syndrome b. Corrugator paralysis c. Levator palpebrae superioris paralysis d. Orbicularis oculi paralysis e. Incomplete administration of toxin 2. A 49-year-old woman presents to your clinic with dissatisfaction of fine rhytids radiating outward from the lateral canthus. Twelve units of Botox are injected intramuscularly in regions of the lateral orbicularis oculi muscle on each side. The procedure is uncomplicated, although 3 days later the patient calls to state that she has minor bruising in the area and has no visible improvement in the rhytids. Which of the following factors is most likely contributing to the lack of effect? a. Injection of improper anatomic region b. Inadequate dosage of injected toxin c. Failure to recognize underlying comorbidity d. Inadequate time for effect e. Wrong depth of injection 3. A 25-year-old man reports migraine headaches that persist more than half the day and occur most days of the month. Symptoms are present diffusely, but predominantly localized to the frontal, temporal, and occipital regions. Ten units of Botox are injected intramuscularly in both the frontalis and temporalis muscles. Which of the following factors is most likely to contribute to a weaker effect of treatment? a. Frequency of migraines b. Insufficient injection into the frontalis and temporalis muscles c. Lack of injection into other pericranial muscles d. a, b, and c e. b and c 1. Answer: c. The levator palpebrae superioris muscle is innervated by the superior division of the ipsilateral oculomotor nerve (cranial nerve III). Its function is to elevate and retract the upper eyelid. Loss of innervation, which may occur from botulinum toxin administration or trauma, will cause blepharoptosis. Although this is considered an adverse event in aesthetic botulinum toxin administration, purposeful levator chemodenervation has been used as a strategy to protect the cornea after facial nerve paralysis–induced lagophthalmos. Although ptosis may also result from inadvertent chemodenervation of the superior tarsal muscle (Müller muscle), Horner syndrome is defined by the classic constellation of ptosis, miosis, and anhidrosis. The latter symptoms are not present in this patient. Horner syndrome is due to lesions in the ipsilateral sympathetic pathway responsible for innervating the superior tarsal muscle. Symptoms can arise from the lesion at any point in the sympathetic nerve pathway including the hypothalamospinal tract, sympathetic trunk of the thoracic spinal cord, sympathetic chain, internal carotid plexus, or superior cervical ganglion. Botulinum toxin injected would not be expected to interrupt sympathetic nerve transmission at these locations. Corrugator paralysis is an anticipated and desirable effect of botulinum toxin injection for glabellar rhytids. Orbicularis oculi paralysis would result from facial nerve (cranial nerve VII) paralysis and cause lagophthalmos, an inability to close the eye. Incomplete administration of toxin would result in persistent rhytids and would not be expected to cause ptosis.

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2. Answer: d. BoNTs typically demonstrate an effect between 3 and 7 days postinjection and persist for 4 to 6 months. If no visible improvement is seen after 3 days, the best course of action is to reassure the patient and reassess in another week. The correct anatomic region for lateral canthal lines (Crow’s feet) is in the lateral orbicularis oculi region, within the muscle, as was done in this patient. A total of 24 units are recommended for lateral canthal lines (12 on each side). The injection sites for this area start in the lateral orbicularis oculi muscle, just temporal to the lateral orbital rim. The next areas are 1 cm superior and 1 cm inferior with a 30-degree angle toward the midline. A comorbidity that predisposes the patient to poor effect of the toxin is unlikely. Minor bruising is a common phenomenon after injections and usually resolves without intervention. 3. Answer: c. The recommended administration of Botox for chronic migraines is 155 units divided between seven sites on the head and neck (see text for specific dosages). The frontalis and temporalis muscles comprise two of these sites, which should both receive 5 units of toxin on each side, as was done for this patient. However, the patient’s diffuse symptoms suggest that complete coverage of the seven sites is appropriate. Chronic migraines are defined as those occurring more frequently than 15 days per month with symptoms lasting at least 4 hours per episode. The patient in this question qualifies for this diagnosis and should benefit from Botox therapy.

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References Erbguth, FJ. Historical notes on botulism, Clostridium botulinum, botulinum toxin, and the idea of the therapeutic use of the toxin. Mov Disord. 2004;19(S8):S2-S6. Patil, S, Willett, O, Thompkins, T, et al. Botulinum toxin: pharmacology and therapeutic roles in pain states. Curr Pain Headache Rep. 2016;20(3):15. Erbguth, FJ, Naumann, M. Historical aspects of botulinum toxin: Justinus Kerner (1786–1862) and the “sausage poison.” Neurology. 1999;53(8):1850-1853. Sterba, JP. The history of botulism. New York Times. April 28, 1982. Pirazzini, M, Rossetto, O, Eleopra, R, Montecucco, C. Botulinum neurotoxins: biology, pharmacology, and toxicology. Pharmacol Rev. 2017;69(2):200-235. Scott, AB, Rosenbaum, A, Collins, CC. Pharmacologic weakening of extraocular muscles. Invest Ophthalmol. 1973;12(12):924-927. Scott, AB. Botulinum toxin injection into extraocular muscles as an alternative to strabismus surgery. J Pediatr Ophthalmol Strabismus. 1980;17(1):21-25. Carruthers, JD, Carruthers, JA. Treatment of glabellar frown lines with C. botulinum-A exotoxin. J Dermatol Surg Oncol. 1992;18(1):17-21.This publication represents the first report of BoNTs for facial rhytids (in this case glabellar lines). This article reflects the author’s experience injecting BoNT for essential blepharospasm, and the serendipitous observation that glabellar lines were also reduced. Giordano, CN, Matarasso, SL, Ozog, DM. Injectable and topical neurotoxins in dermatology: basic science, anatomy, and therapeutic agents. J Am Acad Dermatol. 2017;76(6):1013-1024. Peck, MW, Smith, TJ, Anniballi, F, et al. Historical perspectives and guidelines for botulinum neurotoxin subtype nomenclature. Toxins. 2017;9(1):38. Jankovic, J. Botulinum toxin: state of the art. Mov Disord. 2017;285(8):1059. Wortzman, MS, Pickett, A. The science and manufacturing behind botulinum neurotoxin type A-ABO in clinical use. Aesthet Surg J. 2009;29(6 suppl):S34-S42. Tang-Liu, DD, Aoki, KR, Dolly, JO, et al. Intramuscular injection of 125I-botulinum neurotoxin-complex versus 125I-botulinum-free neurotoxin: time course of tissue distribution. Toxicon. 2003;42(5):461-469. Castaneda, JR, Jankovic, J, Comella, C, et al. Diffusion, spread, and migration of botulinum toxin. Mov Disord. 2013;28(13):1775-1783. Carli, L, Montecucco, C, Rossetto, O. Assay of diffusion of different botulinum neurotoxin type a formulations injected in the mouse leg. Muscle Nerve. 2009;40(3):374-380. Restani, L, Giribaldi, F, Manich, M, et al. Botulinum neurotoxins A and E undergo retrograde axonal transport in primary motor neurons. PLoS Pathog. 2012;8(12):e1003087. Mas, M, Li, S, Francisco, G. Centrally mediated late motor recovery after botulinum toxin injection: case reports and a review of current evidence. J Rehabil Med. 2017;49(8):609-619. Frevert, J. Pharmaceutical, biological, and clinical properties of botulinum neurotoxin type A products. Drugs Res Dev. 2015;15(1):1-9. Whitcup, SM, Turkel, CC, DeGryse, RE, Brin, MF. Development of onabotulinumtoxinA for chronic migraine. Ann NY Acad Sci. 2014;1329(1):67-80. Carruthers, JD, Lowe, NJ, Menter, MA, et al. Double-blind, placebo-controlled study of the safety and efficacy of botulinum toxin type A for patients with glabellar lines. Plast Reconstr Surg. 2003;112(suppl):21S-30S.This publication reports on the first major clinical trial of botulinum toxin A for glabellar lines. The trial involved blinded administration of the toxin and placebo. Results were evaluated by blinded physicians and patients. Both physician and patient ratings were significantly greater for the BoNT group over the placebo group, which peaked at 30 days after injection. Guo, Y, Lu, Y, Liu, T, et al. Efficacy and safety of botulinum toxin type A in the treatment of glabellar lines: a meta-analysis of randomized, placebo-controlled, double-blind trials. Plast Reconstr Surg. 2015;136(3):310e-318e. Carruthers, A, Kiene, K, Carruthers, J. Botulinum A exotoxin use in clinical dermatology. J Am Acad Dermatol. 1996;34(5):788-797. Fagien, S, Carruthers, JDA. A comprehensive review of patient-reported satisfaction with botulinum toxin type A for aesthetic procedures. Plast Reconstr Surg. 2008;122(6):1915-1925. Uygur, S, Eryilmaz, T, Bulam, H, Yavuzer, R, Latifoglu, O. The quantitative effect of botulinum toxin A over brow height. J Craniofac Surg. 2013;24(4):1285-1287. Gordin, EA, Luginbuhl, AL, Ortlip, T, et al. Subcutaneous vs intramuscular botulinum toxin: split-face randomized study. JAMA Facial Plast Surg. 2014;16(3):193-198. Rubin, LR. The anatomy of a smile: its importance in the treatment of facial paralysis. Plast Reconstr Surg. 1974;53(4):384-387.This article describes three smile patterns (“Mona Lisa,” “canine,” and “gummy”) and the impact that each muscle has on the resulting appearance. The Mona Lisa smile, for instance, involves the zygomaticus major muscles drawing the oral commissure upwards and outwards, along with elevation of the upper lip. Nasr, MW, Jabbour, SF, Sidaoui, JA, et al. Botulinum toxin for the treatment of excessive gingival display: a systematic review. Aesthet Surg J. 2015;36(1):82-88. Matarasso, A, Matarasso, SL, Brandt, FS, Bellman, B. Botulinum A exotoxin for the management of platysma bands. Plast Reconstr Surg. 1999;103(2):645-652. Kane, MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A. Plast Reconstr Surg. 1999;103(2):656-663.

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Jabbour, SF, Kechichian, EG, Awaida, CJ, et al. Botulinum toxin for neck rejuvenation: assessing efficacy and redefining patient selection. Plast Reconstr Surg. 2017;140(1):9e-17e. Heckmann, M, Ceballos-Baumann, AO, Plewig, G. Botulinum toxin A for axillary hyperhidrosis (excessive sweating). N Engl J Med. 2001;344(7):488-493. Gibbons, JP, Nugent, E, O’Donohoe, N, et al. Experience with botulinum toxin therapy for axillary hyperhidrosis and comparison to modelled data for endoscopic thoracic. Surgeon. 2016;14(5):260-264. Rosen, R, Stewart, T. Results of a 10-year follow-up study of botulinum toxin A therapy for primary axillary hyperhidrosis in Australia. Intern Med J. 2018;48(3):343-347. Naumann, M, Lowe, NJ. Botulinum toxin type A in treatment of bilateral primary axillary hyperhidrosis: randomised, parallel group, double blind, placebo controlled trial. BMJ. 2001;323(7313):596-599. Scamoni, S, Valdatta, L, Frigo, C, et al. Treatment of primary axillary hyperhidrosis with botulinum toxin type a: our experience in 50 patients from 2007 to 2010. ISRN Dermatol. 2012;2012(5):1-5. Binder, WJ, Blitzer, A, Brin, MF. Treatment of hyperfunctional lines of the face with botulinum toxin A. Dermatol Surg. 1998;24(11):1198-1205. Binder, WJ, Brin, MF, Blitzer, A, et al. Botulinum toxin type A (Botox) for treatment of migraine headaches: an open-label study. Otolaryngol Head Neck Surg. 2016;123(6):669-676. Dodick, DW, Turkel, CC, DeGryse, RE, et al. Onabotulinumtoxin A for treatment of chronic migraine: pooled results from the double-blind, randomized, placebo-controlled phases of the PREEMPT clinical program. Headache. 2010;50(6):921-936.This publication details the results of the PREEMPT 1 trial, which demonstrated improvement in headache scores of patients receiving onabotulinumtoxinA versus placebo. A total of 1384 adults were randomized. Those receiving the toxin reported a significant decrease in the number of headache days (–8.4 versus –6.6, P < 0.001) versus those receiving placebo. Diener, HC, Dodick, DW, Aurora, SK, et al. Onabotulinumtoxin A for treatment of chronic migraine: results from the double-blind, randomized, placebo-controlled phase of the PREEMPT 2 trial. Cephalalgia. 2010;30(7):804-814.The PREEMPT 2 trial was the second in a pair of studies evaluating the effect of onabotulinumtoxinA for treatment of chronic migraines. Like the PREEMPT 1 trial, this publication reported a significant a statistically significant reduction in frequency of headache days (the primary endpoint) in patients receiving toxin versus placebo. The PREEMPT 1 and 2 trials laid the evidence-based foundation for the clinical use of BoNTs for chronic migraines. Neumeister, MW, Chambers, CB, Herron, MS, et al. Botox therapy for ischemic digits. Plast Reconstr Surg. 2009;124(1):191-201. Fregene, A, Ditmars, D, Siddiqui, A. Botulinum toxin type A: a treatment option for digital ischemia in patients with Raynaud’s phenomenon. J Hand Surg. 2009;34(3):446-452. Eickhoff, JC, Smith, JK, Landau, ME, Edison, JD. Iatrogenic Thenar eminence atrophy after Botox A injection for secondary raynaud phenomenon. J Clin Rheumatol. 2016;22(7):396-397. Zhang, D-Z, Liu, X-Y, Xiao, W-L, Xu, Y-X. Botulinum toxin type A and the prevention of hypertrophic scars on the maxillofacial area and neck: a meta-analysis of randomized controlled trials. PLoS One. 2016;11(3):e0151627. Bhatia, KP, Münchau, A, Thompson, PD, et al. Generalised muscular weakness after botulinum toxin injections for dystonia: a report of three cases. J Neurol Neurosurg Psych. 1999;67(1):90-93. Tugnoli, V, Eleopra, R, Quatrale, R, et al. Botulism-like syndrome after botulinum toxin type A injections for focal hyperhidrosis. Br J Dermatol. 2002;147(4):808-809. Omprakash, HM, Rajendran, SC. Botulinum toxin deaths: what is the fact? J Cutan Aesthet Surg. 2008;1(2):95.

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CHAPTER 48

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Fat Grafting in Plastic Surgery Edward I. Chang

Key Points Harvesting techniques have not been proven to increase fat graft take; however, the yield can vary based on handheld suction or power-assisted suction. In general, the less manipulation of the fat graft, the better the viability. Fat graft take following injection is never 100%, and therefore the process of fat grafting often needs to be repeated. The technique for injection is critical for maximizing outcomes and minimizing complications. Fat grafting into the breast following oncologic resection has not been associated with increased risks for tumor recurrence. Although early animal studies demonstrated potential benefits of adipose-derived stem cells in wound healing, the true clinical application of these has yet to be recognized. The technique of autologous fat injection has grown in popularity over the years and has permeated nearly all aspects of plastic surgery. The first recorded use of fat grafting was performed in 1893 by Gustav Neuber who transferred autologous fat to correct periorbital scars. 1,2 However, since its first description, the use of autologous fat was fraught with controversy particularly when injecting into the breast. Concerns regarding breast cancer and possibilities of compromising detection of breast cancer prompted the American Society of Plastic and Reconstructive Surgeons to issue a formal statement cautioning the routine use of lipofilling. 3 Since this declaration, over a decade has passed before the concept witnessed a rebirth with the Coleman technique that ushered an emergence of novel applications and growing technologies by expanding its use in all aspects of plastic and reconstructive surgery. 4-8 One of the defining characteristics of the field of plastic surgery is that it is not limited to a particular anatomic region and as such, the application of autologous fat grafting has also found utility in all areas of the body. The use of autologous fat, now termed fat grafting or lipofilling, has been described for cosmetic augmentation and rejuvenation of the face as well as reconstruction of facial deformities and for both cosmetic and reconstructive procedures over the entire body including the breast, gluteal region, and extremities. Although there are a number of synthetic tissue substitutes available, autologous fat represents one of the most popular fillers available to plastic and reconstructive surgeons.

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Indications Even before the American Society of Plastic Surgeons issued a new declaration regarding the safety of autologous fat transfer, using autologous fat as a filler was growing in popularity. 9 The concept of fillers is well accepted in the field of plastic surgery, and autologous fat is simply another filler that should be in the armamentarium of plastic surgeons. For most patients, there are ample donor sites with sufficient adiposity to provide injectable fat that can be obtained with low cost and also provides the added benefit of contouring and sculpting the donor site. The use of autologous fat grafting focuses on harvesting fat from one donor site and transferring the fat to a desired location for volume augmentation. Not surprising, fat grafting has found broad applications both in the cosmetic arena as well as in reconstructive operations. Plastic surgeons have employed lipofilling in facial rejuvenation and lip and cheek augmentation. 10-12 However, its applications and successes in facial plastic surgery have since been expanded into cosmetic augmentation of other anatomic regions, particularly the gluteal region, the calf, and even for penile enlargement. 13-16 Not surprisingly, the concept of lipofilling as a natural filler and volume enhancer was immediately adopted for breast augmentation. Studies have demonstrated long-term efficacy in maintaining breast volume using autologous fat grafting. 17-19 The use of negative pressure systems such as BRAVA to augment vascularization and engrafting of autologous fat has also been reported, although it has not been widely adopted. 20,21 Lipofilling of the breast introduces a number of considerations and concerns that are unique to the breast. There is little doubt that the fat grafting can add volume to the breast, which obviates the need for a foreign body and the other potential complications associated with a breast implant. However, fat grafting does introduce questions regarding the ability to monitor and image the breast for malignancy and especially in the setting of breast reconstruction. Nonetheless, the use of autologous fat grafting has found some of its greatest uses in plastic surgery not only in breast reconstruction but also in reconstruction of head and neck defects as well as for burns and scars. 22-24 The most widely used reconstructive application for fat grafting is for breast reconstruction. 25 Studies have demonstrated excellent volume retention, efficacy, and safety of autologous fat grafting for breast cancer patients without increased risks of recurrence. 26-29 Further studies focusing on patientreported outcomes have also confirmed high patient satisfaction with lipofilling both as an adjunct in mastectomy reconstruction as well as for reconstruction of partial mastectomy defects in the setting of breast conservation. 29-31

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Surgical Technique Given the increasing utilization of autologous fat grafting, there are a number of variables that are involved in maximizing the take of the fat graft as well as acquiring the best quality fat for injection. These variables can be classified as technical variables and patient-
 related variables; however, within these broader categories, there are a number of components that also need to be considered including tumescent solution, harvest technique, processing technique, and injection technique. From the perspective of patient factors, there are also a number of considerations including the most optimal donor site and body habitus include body mass index, comorbidities, and smoking. 32,33 Studies examining the wetting solution demonstrated a negative impact on adipocyte viability with the use of lidocaine. Because most grafts undergo a processing step that often includes washing the harvested fat, the effects of lidocaine are mitigated. 34 Another study found contradictory findings and demonstrated no impact of lidocaine or epinephrine or prilocaine on fat graft viability. 35 The technique for aspiration and injection has also been examined as a factor that could potentially impact fat graft viability to exert mechanical stress and pressure on the adipocytes. Studies found aspiration via handheld or with mechanical suction and centrifugation have little impact on fat graft viability; however, injection via slow, controlled pressure to minimize the shear stress and forces on adipocytes does improve adipocyte viability. 36,37 These additional steps are important to separate the adipocytes from the other constituents comprising the lipoaspirate. Although some believe there are benefits in preserving the potential growth factors contained in aspirate, there are also nonviable cells that have undergone cell lysis during the harvesting, liquefied fat, and hematocyte component comprised of blood cells and other contaminants. Others believe that one of the most valuable components of the lipoaspirate is the stromal cell fraction containing the adipose derive stem cells and other pluripotent stem cells that can enhance tissue recovery or augment fat graft take. A number of products and devices that will be described in the subsequent section have since come to market to streamline this process to maximize both efficiency and fat graft yield. Aside from the technical aspects of autologous fat grafting, studies also aimed to examine patient-related factors that may influence graft yield and viability. Patient factors such as age have been found to have an impact on fat graft viability, and in general, younger patients tend to have superior fat viability compared to older patients. Interestingly, obesity was also found to be a factor; although a larger amount of fat can theoretically be harvested from a patient with a higher body mass index, the viability of the fat is actually compromised in obese patients. Finally, the ideal location of the donor site has also been an area of tremendous debate and investigation. Although some studies demonstrated the greatest yield and viability of adipocytes from the medial thigh, larger and more comprehensive studies have not found any significant benefits comparing one donor site to another. 38-40

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Fat Graft Processing Given the increasing popularity and applications for autologous fat transfer and lipofilling in plastic surgery, it is not surprising that commercialized products have emerged on the market to improve the adipocyte yield, enhance adipose-derived stem cell concentration, and maximize the efficiency of the process. In its original description, the autologous fat was harvested via syringe aspiration and then separated from the other constituents using centrifugation. 40,41 Most studies examining this process found this technique to be simple and atraumatic to the adipocytes; however, this is a relatively labor-intensive method for harvesting autologous fat graft. A number of other devices have been introduced to the market to streamline the harvesting and processing of the fat graft and have demonstrated tremendous potential with promising results. Some devices can be attached to power-assisted suction that decreases the energy expenditure in obtaining the fat graft and allow the fat graft to be washed while contained within a closed system to minimize risks of contamination or exposure to air. Another device utilizes centripetal forces to isolate the injectable fat from other contaminants and constituents of the lipoaspirate. One device passes the aspirate through a filtration system that separates the fat from the other components. All systems claim to provide superior adipocyte viability, fat graft yield, and stem cell composition, but no unbiased studies are available that have demonstrated superior outcomes compared to the traditional handheld syringe aspiration and centrifugation technique. Nonetheless, the increasing industry involvement in device development is a clear indication of the growing popularity and potential of lipofilling and fat grafting. 41-43 Another trademark device that has been marketed to improve the take and engraftment of the injected fat cells is the BRAVA system. This device is solely promoted for lipofilling of the breast and is based on the premise that negative pressure applied to a recipient bed enhances the vascularity of the recipient site by promoting angiogenesis, which will support large volumes of fat. The product has merit because negative pressure wound dressings have been shown to increase neovascularization of wound, promoting granulation tissue and maximizing the wound healing process.

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Complications As with any surgical procedure, there are potential complications, and autologous fat grafting is no different. Although sound judgment and proper technique are paramount in avoiding complications, complications can occur either in the recipient site or the donor site. With regards to the recipient site, there are always risks of fat necrosis as fat retention following fat grafting is never 100%. Studies vary tremendously based on the percentage of viable adipocytes following fat grafting, but range from 50% to 70%. 44,45 The remaining injected fat often is reabsorbed; however, in other circumstances, it can lead to oil cysts or fat necrosis that can be palpable and cause discomfort or deformity for patients. This can be particularly worrisome in patients undergoing breast reconstruction because a palpable mass in the breast may require further diagnostic testing and potentially biopsies to confirm the mass is benign. 46,47 Although this can also occur in the face, the most dreaded complication following lipofilling of the face is blindness, which results if the fat graft is injected under pressure or while advancing the cannula leading essentially to a fat embolism in the ophthalmic or central retinal artery. 48,49 For these reasons, the fat graft should always be injected without excessive force and always while withdrawing the cannula.

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Controversial Issues As previously discussed, the stromal cell fraction of the lipoaspirate contains adipose-derived stem cells that can have tremendous potential benefits predominantly shown in animal models demonstrating improved angiogenesis and fat graft retention. Anecdotally, reconstructive surgeons noted improvements in tissue quality particularly following radiation and perhaps dramatic improvements in facial rejuvenation. These remarkable results can be attributed to the stem cell component of the autologous fat graft but remain to be proven. Another area of great concern regarding lipofilling is the potential risk that adipose-derived stem cells and the associated angiogenesis can impact recurrence in patients who have undergone autologous fat transfer for breast cancer reconstruction. Complications with fat necrosis and oil cysts may mimic breast cancer, and imaging studies and a biopsy may be warranted to rule out recurrent disease. However, no studies have demonstrated a direct correlation with lipofilling and breast cancer recurrence. Large casecontrolled studies comparing patients who underwent fat grafting to a control cohort of breast cancer patients demonstrated lipofilling to be a safe and effective technique in breast reconstruction without any association with breast cancer recurrence. 50-52

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Summary Fat grafting is a powerful tool for volume augmentation both in cosmetic as well as reconstructive plastic surgery. Although a number of different techniques are available for harvesting and processing of the harvested fat, none are proven to provide superior outcomes or increased fat graft viability or fat graft take. There is no clinical evidence to correlate increased risks of breast cancer recurrence with lipofilling or autologous fat grafting into the breast.

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Questions 1. A 54-year-old woman underwent fat grafting to her breasts and had the fat graft harvested from her abdomen, hips, and flanks using tumescent fluid and suction-assisted cannulas. The patient wakes up from anesthesia and is disoriented, with slurred speech, and complaining of vertigo and tinnitus. What is the most appropriate next step in treatment? a. Electrocardiogram b. Administer intravenous intralipid c. Ativan intravascular injection d. Morphine intramuscular injection e. Computed tomography (CT) scan of the head with and without contrast 2. A 62-year-old woman with a prior mastopexy and abdominoplasty undergoes an upper outer quadrantectomy for ductal carcinoma in situ and completed postoperative radiation 8 months earlier. She has a noticeable contour deformity from the resection in the upper pole of the breast. She is interested in reconstruction. Which is the most appropriate means of reconstruction? a. Lipofilling b. Shaped silicone breast implant c. Pedicle thoracodorsal artery perforator flap d. Free superficial inferior epigastric artery flap e. Free omental flap 3. A 65-year-old man presents for facial rejuvenation and undergoes a rhytidectomy with a superficial musculoaponeurotic system plication, upper lid blepharoplasty, and autologous fat grafting. The fat is harvested from the abdomen, love handles, and flanks using tumescent solution. In the recovery room, the patient is complaining of severe abdominal pain. On examination, the pain is diffuse with guarding but no appreciable mass effect or significant bruising. What is the most appropriate next step in management? a. Observation and trial of clear liquids b. Narcotic pain medication c. Abdominal binder and compression dressing d. CT scan with and without intravenous contrast e. Emergent reoperation 4. A 43-year-old man presents to the emergency center 1 day after autologous fat grafting to his calves for augmentation. The fat was harvested from the abdomen, hips, and flanks and processed through the Coleman technique and injected into both calves. A total of 120 cc was injected into the right side and 90 cc was injected into the left calf. The patient is having severe pain in both calves, more on the left than the right. There is postoperative swelling without evidence of a hematoma, with paresthesias and strongly palpable pulses on in both the dorsalis pedis and posterior tibial of both feet. What is the next most important step in the management of the patient? a. Operating room for fasciotomies b. Operating room for liposuction of calves c. Interventional Radiology angiogram and angioplasty d. Ultrasound to rule out deep vein thrombosis e. Compression wrapping and elevation 5. A lawyer contacts you regarding a patient who underwent lipofilling to augment her breasts and is very displeased with her result 5 months following the operation. The lawyer states that there is asymmetry and lack of fullness in the upper portions of both breasts with insufficient cleavage to the

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patient’s liking. The lawyer examined the operative notes and states that the fat graft was harvested from the abdomen, flanks, and upper arm and that 280 cc were injected into both breasts. The patient was reasonably pleased with the initial result but now feels that the breasts are not much different than prior to her fat grafting. What is the best explanation for the findings? a. The plastic surgeon did not use tumescent solution. b. A stem cell augmenting system should have been used. c. The fat graft should have been harvested from the medial thigh. d. A breast implant is always needed to supplement the procedure. e. Some fat graft failed to survive the transfer. 6. A 54-year-old woman underwent bilateral skin-sparing mastectomies for a right-sided breast cancer treated with adjuvant chemotherapy and hormonal therapy. She then had reconstruction with shaped silicone implants and presents for autologous fat grafting to provide more upper pole fullness. Two years following three rounds of lipofilling to the upper pole, the patient was found to have a fluid collection with a nodule measuring 2.1 cm in the upper pole of the right breast. An ultrasound-guided biopsy demonstrates atypical cells with enlarged irregular nuclei and high mitotic figures. What is the diagnosis? a. Fat necrosis from fat grafting b. Oil cysts from resorbed fat graft c. Breast implant–associated anaplastic large cell lymphoma d. Recurrent invasive ductal carcinoma e. Second primary invasive lobular carcinoma 1. Answer: b. The clinical presentation for this patient suggests that she had tumescent solution– assisted liposuction, which typically contains epinephrine and lidocaine in an isotonic solution. The symptoms presented are consistent with lidocaine toxicity. The next step in treatment is administration of intravenous intralipids to prevent the progression of toxicity, which includes seizures and arrhythmias. 2. Answer: c. For a partial mastectomy defect that involves a significant portion of the breast, lipofilling is an option but would likely require multiple rounds of autologous fat grafting to achieve a reasonable result, which is less optimal for a 62-year-old woman with prior radiation. A shaped implant would likely not provide her with the fullness in the upper pole, and a free tissue transfer would be an aggressive reconstruction for a partial mastectomy defect. Healthy vascularized tissue in the form of a local pedicle flap can provide sufficient volume in a single stage operation without the need for a free tissue transfer. 3. Answer: d. A patient with severe pain following liposuction for autologous fat grafting using the abdominal donor site should not be managed conservatively with observation or pain medication. Pain that is out of proportion to physical examination should raise the concern for puncturing the abdominal wall with a possible vascular injury or bowel injury. The most appropriate next step would be an imaging study to look for free air or active bleeding. Taking the patient back for exploration is likely necessary, but a CT scan should be performed prior to a return to the operating room. 4. Answer: a. The clinical picture presented is most consistent with compartment syndrome of the lower extremities following autologous fat grafting to the calves. The symptoms of pain, paresthesias with persistent pulses, is most consistent with compartment syndrome, which warrants immediate decompression with fasciotomies to prevent further ischemic damage and morbidity. 5. Answer: e. There is always some resorption of the fat graft following lipofilling as the take is never 100%. The different modalities for processing, use of wetting solutions, and the fat graft donor sites have not proved to be relevant in maximizing fat graft survival and take. The loss of volume from the

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initial postoperative period can be because of a combination of resolution from swelling and resorption of a portion of the fat graft. 6. Answer: c. There is no evidence to suggest that lipofilling is associated with recurrent breast cancer or an increased risk for developing breast cancer. A patient who has had shaped textured silicone implants and develops a delayed seroma with an associated mass should be suspected of having breast implant–associated anaplastic large cell lymphoma. The diagnosis is confirmed with staining for CD30, and the patient should be referred appropriately for proper treatment.

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References Billings, E Jr, May, JW Jr. Historical review and present status of free fat graft autotransplantation in plastic and reconstructive surgery. Plast Reconstr Surg. 1989;83(2):368-381. Ersek, RA, Chang, P, Salisbury, MA. Lipo layering of autologous fat: an improved technique with promising results. Plast Reconstr Surg. 1998;101(3):820-826. Report on autologous fat transplantation: ASPRS Ad-Hoc Committee on new procedures, September 30, 1987. Plast Surg Nurs. 1987;7(4):140141. Ellenbogen, R. Free autogenous pearl fat grafts in the face: a preliminary report of a rediscovered technique. Ann Plast Surg. 1986;16(3):179194. Hartrampf, CR Jr, Bennett, GK. Autologous fat from liposuction for breast augmentation. Plast Reconstr Surg. 1987;80(4):646 Coleman, WP III. Autologous fat transplantation. Plast Reconstr Surg. 1991;88(4):736. Coleman, SR. Facial recontouring with lipostructure. Clin Plast Surg. 1997;24(2):
 347-367. Coleman, SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 suppl):108S-120S.The study was one of the earliest studies that brought the resurgence of lipofilling and fat grafting into the modern era. While described much earlier, the concept of fat grafting gained in popularity with increasing applications, research, and innovations following based on the findings and contribution of this paper. Gutowski, KA; ASPS Fat Graft Task Force . Current applications and safety of autologous fat grafts: a report of the ASPS fat graft task force. Plast Reconstr Surg. 2009;124(1):272-280.This study provides the ASPS evaluation regarding the introduction and safety of fat grafting. Although more recent studies have confirmed the findings of the ASPS task force, this study remains a landmark review of the emerging technology and safety of fat grafting. Pezeshk, RA, Stark, RY, Small, KH, et al. Role of autologous fat transfer to the superficial fat compartments for perioral rejuvenation. Plast Reconstr Surg. 2015;136(3):301e-309e. Marten, TJ, Elyassnia, D. Fat grafting in facial rejuvenation. Clin Plast Surg. 2015;42(2):219-252. Charles-de-Sá, L, Gontijo-de-Amorim, NF, Maeda Takiya, C, et al. Antiaging treatment of the facial skin by fat graft and adipose-derived stem cells. Plast Reconstr Surg. 2015;135(4):999-1009. Sinno, S, Chang, JB, Brownstone, ND, et al. Determining the safety and efficacy of gluteal augmentation: a systematic review of outcomes and complications. Plast Reconstr Surg. 2016;137(4):1151-1156. Rosique, RG, Rosique, MJ, De Moraes, CG. Gluteoplasty with autologous fat tissue: experience with 106 consecutive cases. Plast Reconstr Surg. 2015;135(5):1381-1389. Mundinger, GS, Vogel, JE. Calf augmentation and reshaping with autologous fat grafting. Aesthet Surg J. 2016;36(2):211-220. Kang, DH, Chung, JH, Kim, YJ, et al. Efficacy and safety of penile girth enhancement by autologous fat injection for patients with thin penises. Aesthet Plast Surg. 2012;36(4):813-818. Coleman, SR, Saboeiro, AP. Fat grafting to the breast revisited: safety and efficacy. Plast Reconstr Surg. 2007;119(3):775-785. Kerfant, N, Henry, AS, Hu, W, et al. Subfascial primary breast augmentation with fat grafting: a review of 156 cases. Plast Reconstr Surg. 2017;139(5):1080e-1085e. Serra-Mestre, JM, Fernandez Peñuela, R, Foti, V, et al. Breast cleavage remodeling with fat grafting: a safe way to optimize symmetry and to reduce intermammary distance. Plast Reconstr Surg. 2017;140(5):665e-672e. Khouri, RK, Eisenmann-Klein, M, Cardoso, E, et al. Brava and autologous fat transfer is a safe and effective breast augmentation alternative: results of a 6-year, 81-patient, prospective multicenter study. Plast Reconstr Surg. 2012;129(5):1173-1187.The use of large volume fat grafting and lipofilling for breast reconstruction was popularized and introduced using the BRAVA system. The concept has not only been adopted by numerous other plastic surgeons all over the world, but is responsible for the increasing use in augmentation of other areas of the body. Although this is not the most common or widely used technique for breast reconstruction, the BRAVA device and authors are pioneers in lipofilling increasing the public awareness and interest in fat grafting. Del Vecchio, DA, Bucky, LP. Breast augmentation using preexpansion and autologous fat transplantation: a clinical radiographic study. Plast Reconstr Surg. 2011;127(6):2441-2450. Haddock, NT, Saadeh, PB, Siebert, JW. Achieving aesthetic results in facial reconstructive microsurgery: planning and executing secondary refinements. Plast Reconstr Surg. 2012;130(6):1236-1245. Fredman, R, Edkins, RE, Hultman, CS. Fat grafting for neuropathic pain after severe burns. Ann Plast Surg. 2016;76(suppl 4):S298-S303. Klinger, M, Caviggioli, F, Klinger, FM, et al. Autologous fat graft in scar treatment. J Craniofac Surg. 2013;24(5):1610-1615. Khouri, RK Jr, Khouri, RK. Current clinical applications of fat grafting. Plast Reconstr Surg. 2017;140(3):466e-486e Mirzabeigi, MN, Lanni, M, Chang, CS, et al. Treating breast conservation therapy defects with brava and fat grafting: technique, outcomes, and safety profile. Plast Reconstr Surg. 2017;140(3):372e-381e. Niechajev, I, Sevćuk, O. Long-term results of fat transplantation: clinical and histologic studies. Plast Reconstr Surg. 1994;94(3):496-506 Katzel, EB, Bucky, LP. Fat grafting to the breast: clinical applications and outcomes for reconstructive surgery. Plast Reconstr Surg. 2017;140:69S-76S. de Blacam, C, Momoh, AO, Colakoglu, S, et al. Evaluation of clinical outcomes and aesthetic results after autologous fat grafting for contour deformities of the reconstructed breast. Plast Reconstr Surg. 2011;128(5):411e-418e.

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Bennett, KG, Qi, J, Kim, HM, et al. Association of fat grafting with patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. 2017;152(10):944-950. Komorowska-Timek, E, Turfe, Z, Davis, AT. Outcomes of prosthetic reconstruction of irradiated and nonirradiated breasts with fat grafting. Plast Reconstr Surg. 2017;139(1):1e-9e. Sinno, S, Wilson, S, Brownstone, N, Levine, SM. Current thoughts on fat grafting: using the evidence to determine fact or fiction. Plast Reconstr Surg. 2016;137(3):818-824. Nguyen, A, Pasyk, KA, Bouvier, TN, et al. Comparative study of survival of autologous adipose tissue taken and transplanted by different techniques. Plast Reconstr Surg. 1990;85(3):378-386; Moore, JH Jr, Kolaczynski, JW, Morales, LM, et al. Viability of fat obtained by syringe suction lipectomy: effects of local anesthesia with lidocaine. Aesthet Plast Surg. 1995;19(4):335-339. Livaoğlu, M, Buruk, CK, Uraloğlu, M, et al. Effects of lidocaine plus epinephrine and prilocaine on autologous fat graft survival. J Craniofac Surg. 2012;23(4):1015-1018. Lee, JH, Kirkham, JC, McCormack, MC, et al. The effect of pressure and shear on autologous fat grafting. Plast Reconstr Surg. 2013;131(5):1125-1136. Rohrich, RJ, Sorokin, ES, Brown, SA. In search of improved fat transfer viability: a quantitative analysis of the role of centrifugation and harvest site. Plast Reconstr Surg. 2004;113(1):391-395. Geissler, PJ, Davis, K, Roostaeian, J, et al. Improving fat transfer viability: the role of aging, body mass index, and harvest site. Plast Reconstr Surg. 2014;134(2):227-232. Strong, AL, Cederna, PS, Rubin, JP, et al. The current state of fat grafting: a review of harvesting, processing, and injection techniques. Plast Reconstr Surg. 2015;136(4):897-912. Gir, P, Brown, SA, Oni, G, et al. Fat grafting: evidence-based review on autologous fat harvesting, processing, reinjection, and storage. Plast Reconstr Surg. 2012;130(1):249-258.With the increasing use of fat grafting in all aspect of plastic and reconstructive surgery, there is an increasing need and interest in optimizing outcomes. There are a number of important details that can impact fat graft yield and take, and few studies have provided such a comprehensive analysis of the different factors. References 39 and 40 are landmark studies in demonstrating which factors are important in maximizing fat graft yield and retention. Fisher, C, Grahovac, TL, Schafer, ME, et al. Comparison of harvest and processing techniques for fat grafting and adipose stem cell isolation. Plast Reconstr Surg. 2013;132(2):351-361. Aronowitz, JA, Ellenhorn, JD. Adipose stromal vascular fraction isolation: a head-to-head comparison of four commercial cell separation systems. Plast Reconstr Surg. 2013;132(6):932e-939e. Zhu, M, Cohen, SR, Hicok, KC, et al. Comparison of three different fat graft preparation methods: gravity separation, centrifugation, and simultaneous washing with filtration in a closed system. Plast Reconstr Surg. 2013;131(4):873-880. Harrison, BL, Malafa, M, Davis, K, Rohrich, RJ. The discordant histology of grafted fat: a systematic review of the literature. Plast Reconstr Surg. 2015;135(3):542e-555e. Herly, M, Ørholt, M, Glovinski, PV, et al. Quantifying long-term retention of excised fat grafts: a longitudinal, retrospective cohort study of 108 patients followed for up to 8.4 years. Plast Reconstr Surg. 2017;139(5):1223-1232. Kim, HY, Jung, BK, Lew, DH, Lee, DW. Autologous fat graft in the reconstructed breast: fat absorption rate and safety based on sonographic identification. Arch Plast Surg. 2014;41(6):740-747. Parikh, RP, Doren, EL, Mooney, B, et al. Differentiating fat necrosis from recurrent malignancy in fat-grafted breasts: an imaging classification system to guide management. Plast Reconstr Surg. 2012;130(4):761-772. Carruthers, JD, Fagien, S, Rohrich, RJ, et al. Blindness caused by cosmetic filler injection: a review of cause and therapy. Plast Reconstr Surg. 2014;134(6):1197-1201. Kim, SM, Kim, YS, Hong, JW, et al. An analysis of the experiences of 62 patients with moderate complications after full-face fat injection for augmentation. Plast Reconstr Surg. 2012;129(6):1359-1368. Kronowitz, SJ, Mandujano, CC, Liu, J, et al. Lipofilling of the breast does not increase the risk of recurrence of breast cancer: a matched controlled study. Plast Reconstr Surg. 2016;137(2):385-393. Petit, JY, Maisonneuve, P, Rotmensz, N, et al. Fat grafting after invasive breast cancer: a matched case-control study. Plast Reconstr Surg. 2017;139(6):1292-1296. Cohen, O, Lam, G, Karp, N, Choi, M. Determining the oncologic safety of autologous fat grafting as a reconstructive modality: an institutional review of breast cancer recurrence rates and surgical outcomes. Plast Reconstr Surg. 2017;140(3):382e-392e.

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CHAPTER 49

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Forehead and Brow Rejuvenation Alan Matarasso and Darren M. Smith

Key Points The forehead should be considered in any complete evaluation of the aging face. Changes in skin and muscle tone, volume, and activity contribute to the appearance of aging. Several techniques are available to treat this region. Successful treatment of the aging brow begins with an individualized, problem-based approach. Goals in brow rejuvenation can be summarized as restoring eyebrow height, maximizing symmetry, and minimizing the visual impact of rhytids. Forehead rejuvenation can be a powerful addition to other procedures such as a facelift for global facial rejuvenation. It is common practice to focus more on the aging of the lower two facial thirds than on the uppermost facial third during an assessment of the aging face. This bias is further reflected by a parallel imbalance in the literature. This disproportionate distribution of clinical and academic interest is unfortunate, given the critical role the brow plays in interpersonal communication and overall facial appearance. Aging of the brow (progressive descent, deepening of rhytids, and upper lid hooding) classically connotes an angry or tired appearance. 1 Indeed, the eyes have been called the window of the soul, and as coined by the senior author, the brow is the curtain of emotion. Restoration of the brow to a rejuvenated state reverses this stigmatized default faces and instead frees the individual to express joy, surprise, and confusion with their upper facial third. Additionally, the proper position and tensioning of the brow has a significant effect on the appearance of adjacent structures. Consider, for example, the effects of a heavy brow on exaggerating dermatochalasis of the upper eyelids. It has also been noted that sagging glabellar skin can make the nose appear foreshortened; this phenomenon, in combination with a nasal tip elongated with age, can give the illusion of a nose situated too low on the face. 2 Several approaches to the aging brow have evolved since the early 20th century, ranging from the least invasive (neurotoxin) to the most invasive (open brow lift). In our experience, invasiveness is not a proxy for effectiveness in brow lifting. Instead, the practitioner should assess the anatomical basis for the patient’s presenting complaint and identify the appropriate intervention or set of interventions using a problem-based treatment plan. This plan must consider not only the brow but also surrounding structures to ensure that the upper facial third is rejuvenated as a cohesive expressive unit; unresolved dermatochalasis, for example, will undercut the most perfectly executed brow lift. Conversely, the forehead should be considered when assessing other elements of the upper face. An isolated upper blepharoplasty performed in the presence of brow ptosis can over time worsen that problem, as frontalis tone decreases with the elimination of the compensatory stimulus provided by hanging upper lid skin, resulting in increased brow ptosis. Moreover, the proper approach must account not only for the patient’s pathology but also for his or her desired outcome. For example, a publicly photographed female may benefit from more aggressive muscle interruption or resection to achieve a smoother brow; in contrast, an actor may be better off preserving more motility (less aggressive muscle intervention) to maximize remaining facial expression at the expense of a smoother brow. 2

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History Aesthetic surgery of the brow has evolved considerably over time, as chronicled in detail by Paul 3 and summarized here. The earliest description of surgical brow rejuvenation can be credited to Passot in 1919 with his direct forehead skin excision designed to correct brow ptosis. 3 The idea of frontalis and corrugator modification to decrease muscle activity and thereby efface overlying dynamic rhytids gained favor in the 1960s. 4,5 Pitanguy expanded on these principles in the late 1970s and described his approach to coronal brow lifting, entailing wide exposure with muscle-weakening maneuvers and orbital rim softtissue release. 6 As more sophisticated techniques evolved, the indications for brow rejuvenation procedures expanded to include glabellar hyperactivity, transverse brow rhytids, upper eyelid aesthetics, and lateral brow laxity. 7 Until the mid-1990s, the coronal approach remained the form of brow lifting of choice. The mid-to-late 1990s saw the introduction of the endoscopic brow lift. 8,9 The open coronal procedure, though successful, lost favor primarily because of patient and surgeon resistance to the long incision and other issues, such as the potential for alopecia. Additionally, an increase in the popularity and effectiveness of neurotomies which addressed two of the more frequent complaints of patients seeking upper forehead rejuvenation—glabellar and forehead rhytids—further eroded the utility of open coronal techniques. 10 Additionally, brow lift procedures in general have always engendered notable reluctance by patients concerned with creating a look of surprise. With interest waning in the coronal approach, practitioners began focusing on improving internal fixation methods for use with the endoscopic technique. Brow lifting went on to inspire more disagreement over a standard technique than most other facial rejuvenation operations. The endoscopic brow lift ultimately created some consternation with many surgeons, as definitive strategies to obtain fixation were not forthcoming, concerns over longevity of its results lingered, and the inability to apply this method to the high-forehead patient persisted. In the context of these issues, alternative approaches to brow rejuvenation, including the lateral subcutaneous temporal brow lift (LTL) came to fruition. Our technique evolved from a biplanar dissection in a subperiosteal and subcutaneous plane before taking its current form as a lateral subcutaneous brow lift. Ultimately, the authors found the lateral temporal lift (with or without a corrugator excision as indicated) to offer the benefits of previous approaches with reduced morbidity, shorter incisions, no fixation device issues, reliable brow elevation, and consistent longevity.

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Anatomy The normal anatomy of the forehead can be discussed in terms of skin, muscle, the innervation of that muscle, and fat. The skin of the brow is quite thin and tightly adherent, facilitating its transmission of the actions of the underlying muscles of facial expression. Surface landmarks are useful in assessing the degree of pathology present. The intersection of a vertical line drawn at the alar base and the supraorbital rim represents the medial extent of the brow. The brow extends laterally to an oblique line extending from the alar base through the lateral canthus. According to classic standards of beauty, the brow peaks (0.5–1 cm above the rim in women and at the height of the rim in men) at the junction of the middle and lateral third of its width, approximately at the lateral limbus. 1 By some standards in fashion, it may be more desirable for the brow to reach its vertical peak closer to the lateral canthus. 11 The forehead musculature demonstrates the same agonist-antagonist configuration found throughout the body. 9 In the brow, these opposing forces take the form of the depressors (corrugators, procerus, orbicularis oculi) acting as a unified force to draw the brow inferiorly whereas the elevator (the frontalis) works to raise the brow. It is subtle variations in the strength of contractions that result in varying net vectors of skin motion and thereby the multitude of facial expressions produced or enhanced by brow appearance. The muscles of the brow are innervated by the temporal branch of the facial nerve, and this is the only motor nerve at risk during a brow lifting procedure. The temporal branch runs in the temporoparietal fascia and can be avoided by adhering to the deep temporal fascia during dissection and remaining more than 1.5 cm above the lateral orbital rim. Staying in the subcutaneous plane while dissecting the forehead avoids any possibility of motor nerve injury. The first two branches of the trigeminal nerve, the supraorbital nerve and the supratrochlear nerve, supply sensory innervation to the brow. The supraorbital nerve exits the supraorbital foramen in the midpupillary line. The supraorbital foramen can often be palpated and marked on the skin to assist in efforts to avoid the nerve during dissection. The supratrochlear nerve fibers are found in the substance of the corrugator muscle approximately 8 to 12 mm medial to the supraorbital nerve (Figure 49.1). The supraorbital nerve plays a far more significant role in brow innervation than the supratrochlear nerve. In the lateral temporal brow lift, these nerves should not be at risk.

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FIGURE 49.1 This dissection demonstrates the relationship of the corrugator (being dissected with the scissor) to the supraorbital nerve (at the fingertip). The retractor is at the nasal root.

There is minimal adiposity in the brow. Therefore, fat plays little role in the aging process of the brow, and volume redistribution does not enter into the discussion of brow rejuvenation techniques. This observation does not apply laterally as the brow gives way to the temple. Temporal hollowing can indeed play a significant role in aging the face, and volumetric restoration of this region with techniques ranging from autologous fat grafting to injection of various fillers can be an important part of a comprehensive rejuvenation strategy for the upper facial third. Additionally, the lateral temporal fat pad can descend and contribute to a ptotic brow appearance. Finally, with reference to endoscopic brow lift techniques, mention must be made of the sentinel vein, a structure that lies 1.5 cm superior and lateral to the lateral canthus. 12 The sentinel vein represents an important landmark, as it can be used to establish the position of the temporal branch of the facial nerve (1 cm lateral and inferior to the sentinel vein) as well as the temporal line of fusion at the temporal crest. 1 This anatomic background accounts for the changes in appearance associated with the aging brow. As gravity and the relatively stronger depressor muscles overpower the weaker brow elevators, a frownmuscle imbalance results in glabellar creases and central forehead furrows. 13 Compensatory frontalis hypertrophy may result, yielding transverse forehead rhytids. Therefore, it is interesting to note that whereas in the neck and midface it is skin laxity and loss of adipose volume that are the dominant forces in the aging process, muscle activity and imbalance of that activity over time play a greater role in the appearance of the brow in aging. 9 This explains why unlike antiaging procedures of the face and neck which are aimed at excising excess skin and repositioning or revolumizing underlying fat, brow rejuvenation procedures are focused more on rebalancing the underlying muscle equilibrium and

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repositioning ptotic tissue. This distinction does begin to fade further from the midline, as the frontalis muscle is attenuated at its lateral extent. This anatomical fact, together with the weaker attachments of skin to periosteum found in this region, accounts for early lateral brow laxity. 14,15 This laxity manifests as lateral orbital hooding and contributes to the formation of crow’s feet. 1 Also of note, one must also consider the equilibrium that is present between the elevators and depressors of the brow when performing an evaluation for dermatochalasis. If the frontalis is being relied upon to compensate for upper eyelid ptosis, and an upper blepharoplasty is performed without regard for the state of the brow musculature, the appearance of the brow can be adversely impacted. An isolated upper blepharoplasty in the presence of brow ptosis may remove the stimulus for frontalis-based brow elevation and exacerbate glabellar furrows and eyebrow malposition because of unbalanced depressor activity. The presence of compensated brow ptosis must also be ruled out prior to performing an upper blepharoplasty. The examiner should be alerted to the presence of this condition when there are significant horizontal forehead rhytids at rest. These lines are indicative of a requirement for frontalis contraction to maintain brow height at baseline. The diagnosis of compensated brow ptosis is confirmed by having the patient close his or her eyes. If the frontalis relaxes and the brow drops, compensated brow ptosis is present. In addition, the patient should be examined for upper eyelid ptosis, which frontalis hyperactivity can camouflage. Isolated brow lifting procedures can unmask unrecognized upper eyelid ptosis and contribute to an appearance of deep set eyes.

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Management of the Aging Brow Correctable problems of the aging brow include forehead rhytids, glabellar creases (corrugator muscle hypertrophy), lateral brow laxity, and brow ptosis (including congenital and senescent subtypes). Congenital brow ptosis is beyond the scope of this chapter, which is addressed in discussions of congenital facial palsies. The senior author previously introduced an algorithm designed to aid in decision-making for brow rejuvenation from a perspective that considers the gamut of possible surgical and nonsurgical interventions with respect to the underlying anatomical problem at hand. 7 The following review of approaches to the aging brow takes its origins from the thought processes initially set forth in this algorithm. The options discussed below range from noninvasive (neuromodulators) to open approaches. Neuromodulators are indicated in the treatment of isolated dynamic rhytids of the brow. There is also a preventive role for neuromodulators in deterring the eventual formation of static brow rhytids. The three neuromodulators currently in common use are botulinum toxin serotype A and include Botox (onabotulinumtoxin A, Dublin, Ireland), Dysport (abobotulinumtoxin A, Galderma, Lausanne, Switzerland), and Xeomin (incobotulinumtoxin A, Merz, Frankfurt, Germany). These products are all based on botulinum toxin’s capacity to prevent nerves from releasing the neurotransmitter acetylcholine. Acetylcholine is the neurotransmitter responsible for mediating contraction of the muscles of facial expression. The inhibition of acetylcholine release, in turn, weakens contraction of the target muscles and thereby softens overlying dynamic rhytids. In the upper face, neuromodulators are most frequently used at the glabella, the forehead, and the lateral canthal lines, or crow’s feet. Vertical glabellar rhytids are caused by horizontal contractions of the corrugators, whereas transverse forehead rhytids are caused by vertical contractions of the frontalis, and radial lateral canthal rhytids are caused by concentric contractions of the orbicularis oculi. Decreasing motion in the underlying muscles with a neuromodulator softens the appearance of the corresponding rhytids running perpendicular to the axis of muscle contraction. The frozen appearance of complete paralysis is generally to be avoided, whereas measured softening of these rhytids is preferable. Though recommended doses by region are widely published, the key to an excellent outcome lies in understanding an individual patient’s desires, prior experience, and understanding the patient’s anatomy well enough to deliver a dose compatible with inducing a degree of paralysis consistent with those desires. One technique useful for beginning injectors is to employ a planned two-stage injection technique. At the first stage of treatment, a low dose of the desired neuromodulator is injected. The patient is seen back for a second visit once the initial dose has had time to reach maximal efficacy (10 days to 2 weeks is a reasonable window for this visit). The need for an additional neuromodulator is assessed at this visit, taking the patient’s degree of residual muscle activity and his or her desired outcome into account. An additional neuromodulator is administered at this second stage as needed on the basis of this examination. The practitioner then knows the total dose required to reach a desired outcome for a given patient. This dose can be repeated in one session generally at 3 months later when the first treatment (delivered in two sessions) has worn off. Although botulinum toxin’s effectiveness generally wears off gradually, efficacy is more rapidly lost in males. It is critical to ensure appropriate dosing and placement of neuromodulators to achieve the desired effect and avoid adverse outcomes. Perhaps, the most common complication to occur with administration of a neuromodulator to the forehead is the dropped brow in which the eyebrows sag and brow (and often upper eyelid) ptosis is exaggerated. This results from placement of either too much neuromodulators, a proper dose of neuromodulator placed too far inferiorly, or a combination of both scenarios such that the frontalis is no longer properly tensioned to maintain the brow at an appropriate height. When brow ptosis is present, a surgical brow lifting procedure is required. The concept of a chemical

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brow lift produces minimal brow elevation and is based on deactivating the depressors (corrugators, orbicularis oculi, and central frontalis muscles) while preserving sufficient muscle function to allow emotive facial expression. An open brow lift represents a reliable method to gain wide exposure and comprehensively address the anatomical problems responsible for aging brow appearance. It is generally done via a coronal (gull-wing) approach or modified centrally to the widow’s peak hairline (anterior approach) in patients with a wide forehead. The latter approach will improve the appearance of a wide forehead. The choice of incision in an open brow lift is determined by the patient’s forehead morphology. In patients with a wide forehead, defined as greater than 5 to 6 cm from hairline to brow, a hairline incision is used. In patients with normal brow width, a coronal incision is utilized and excess tissue is excised from the hair-bearing scalp. Markings are made with the patient sitting upright. We use the landmarks noted above to mark the location of the nerves (motor and sensory), followed by the planned incision. It is helpful to mark the rhytids because they can become effaced by infiltration with local anesthetic solution, changes in position, decreased tone with anesthesia, and swelling. Either sedation or general anesthesia with infiltration of local anesthesia is utilized. We do not shave or trim any scalp hair. The incision is made as marked to the subgaleal plane in the central scalp and to the deep temporal fascia lateral to the line of temporal fusion. The scalp flap is elevated anteriorly using a combination of scalpel and finger dissection. Electrocautery is used cautiously in the vicinity of hair follicles. This plane of dissection is continued until 3 cm above the supraorbital rim, at which point the subperiosteal plane is sharply accessed with a knife and periosteal elevator, thereby staying deep to the temporal branch of the facial nerve. The supraorbital nerves are preserved. The corrugator muscles are resected carefully while dissecting and preserving the supratrochlear nerves. In patients with hyperactive frontalis muscles, a wedge of frontalis is marked and excised between the supraorbital nerves to preserve underlying fat. Connell has stated that it is important to perform this maneuver evenly and avoid completely denuded regions interposed with areas of untouched muscle, which would result in “islands of immobility surrounded by angry seas of muscle hyperactivity.” The anterior flap is carefully draped over the incision to determine the appropriate degree of resection. The wound is closed with staples in the temporal hair and in two layers centrally. With increasing familiarity and better anatomical understanding, the endoscopic brow lift evolved into an operation most believe capable of addressing the same issues that were previously the exclusive domain of open procedures. The endoscopic approach is especially suited to individuals with a low brow position, as the forehead with properly toned musculature can be expected, after wide elevation, to redrape to a favorably cephalic position with disruption of the depressors and incision of the periosteum for brow elevation. Further advantages of this technique are attributed to patients who are more apt to accept this procedure with its reduced scar burden, decreased risk of scalp paresthesias, and diminished postoperative edema. 1,16 Many variations on this procedure have evolved. That presented here is the technical sequence preferred by the authors. 9 Again, markings are made with the patient sitting upright. The nerves, planned incisions, and rhytids can be marked. Local anesthesia is injected with or without the use of systemic anesthesia. The first incision is oriented vertically (this orientation minimizes the chance of nerve injury) in the hairline at the midline of the nose and is 3 cm in length. This is carried to the subgaleal plane. An incision is made on each side of the scalp lateral to the course of the supraorbital nerves, approximately at the superior extent of the temporalis muscle. These are carried down to the deep temporal fascia. This approach allows access to the forehead subgaleal plane as dissection is carried medially across the temporal crest. After the incisions are made, the dissection is continued anteriorly from each port to 2 cm proximal to the superior orbital rim and posteriorly as far as necessary to permit the requisite amount of skin redraping. The pockets from each dissection are then connected with one another. The subperiosteal plane is entered sharply, and the endoscope is then introduced into the cavity with overhead lights turned off. Periosteal elevators are employed to develop a subperiosteal plane. The muscles comprising

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the depressor apparatus including the orbicularis oculi, the procerus, and the corrugators are sectioned with a Takahashi forceps aided by electrocautery and external traction sutures. The eyebrow-supraorbital rim relationship is used as a reference as the skin is mobilized and redraped cephalically. Several modalities of skin fixation have been described, encompassing both external (e.g., bolster sutures) and internal (e.g., fibrin glue or calvarial fixation) techniques. Calvarial fixation techniques include cortical tunnel fixation and anchoring devices. In the cortical tunnel technique, a guarded drill is used to create monocortical tunnels (Figure 49.2) through which sutures are passed to anchor the scalp flap. Anchoring devices, alternatively, are attached to the calvarium and provide a point of fixation for the scalp flap (e.g., MicroAire’s [Charlottesville, Virginia] Endotine device). Though multiple strategies of scalp flap fixation exist, most would agree that the periosteum reattaches to the mobilized scalp flap rapidly regardless of the method of fixation that is employed.

FIGURE 49.2 Cross-section of the outer table of the frontal bone. A guarded drill is used to create tunnels (direction of drilling indicated by arrows) that are angled such that they connect and allow for passage of a suture.

Although the endoscopic brow lift effectively addresses central forehead and glabellar rhytids, lateral ptosis and crow’s feet are not as readily addressed with this procedure. 1 Therefore, a conscious effort must be made in designing these procedures to provide maximal lateral lift when indicated. Moreover, a high hairline or an acutely sloped forehead can make this procedure technically difficult to perform because of the curvature of the skull and the necessary vectors. 2 The degree of muscle disruption necessary to achieve the desired result can be more difficult to judge with the endoscopic approach, predisposing those starting with the procedure to be prone to corrugator over-resection and resultant widening of the space between the eyebrows. The lateral temporal subcutaneous brow lift has evolved to become the authors’ technique of choice for managing the aging lateral brow. The lateral temporal lift can be used reliably to achieve a significant improvement in brow ptosis with minimal morbidity. A medial subgaleal brow lift with corrugator muscle excision and procerus disruption can be done alone or in combination with a lateral temporal brow lift in patients with a low medial brow. Lateral temporal brow lift markings are designed as follows. In the sitting position, the midline of the forehead is marked (the widow’s peak is a good landmark if present). The midpupillary line, approximately 3.5 cm lateral to the midline, is then marked. After an extensive discussion of incision placement based on patient preference, brow pattern, hair density, and forehead width, an elliptical incision is demarcated that is 4 to 5 cm in length and 2 to 2.5 cm in width. The closer the incision is to the eyebrow and less ptotic the brow, the narrower is the planned excision. Conversely, the more ptotic the

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brow or farther away the incision is from the eyebrow, the wider the excision (Figure 49.3). The long axis of the ellipse generally runs parallel to the brow and is verified prior to surgery with the patient in the sitting position.

FIGURE 49.3 The curved arrows and corresponding hashed lines indicate possible incision positions. The red arrow and incision correspond to positioning in a lower brow (5–6 cm). The ellipse (green) represents the skin excision, and the purple shading represents the area of undermining.

At the beginning of the procedure, the field is injected with a lidocaine and epinephrine-containing solution. The ellipse is preexcised (Figure 49.4). Dissection begins sharply toward the brow and ensues by

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finger-assisted (wrapped in gauze) dissection medially, laterally, and inferiorly. Scissor dissection is used as necessary at points of adherence. The dimensions of the dissection are confirmed, and hemostasis is obtained by electrocautery. The pocket is packed with a lidocaine with epinephrine-soaked gauze, and the procedure is repeated on the opposite side. At this point, we return to the first side and reinspect for hemostasis. After hemostasis is ensured, we prefer to spray Tisseel fibrin glue (Baxter International, Deerfield, IL) into the pocket, although this is not an essential component of the procedure (Figure 49.5). The wound edges are approximated, and gentle pressure is held on the flap for 3 minutes to allow the Tisseel to set. The wound is then closed with 3-0 monoderm Quill (Surgical Specialties Corporation, Tijuana, Mexico) and interrupted Prolene (Ethicon, New Brunswick, NJ) sutures. No dressing is used (Figure 49.6).

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FIGURE 49.4 The skin ellipse has been preexcised.

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FIGURE 49.5 Fibrin glue is sprayed into the pocket, exposed here with a lighted retractor.

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FIGURE 49.6 The appearance of the lateral temporal lift incision (arrows) immediately after closure.

We have found this procedure to be reliable and safe over a decade-long experience encompassing more than 400 consecutive patients undergoing lateral temporal lifts as described here (Figures 49.7 and 49.8). 17 We have followed these patients for between 1 and 10 years. Those treated with this procedure were uniformly pleased with the results. The lateral temporal lift produces long-lasting results, with only one patient in this series requiring correction of relapse. Scar revisions were necessary in two patients. Late fluid collections containing serous fluid and old blood were identified in 3% of patients. These collections generally did not require a return to the operating room and could be aspirated in the office. Skin ischemia and necrosis occurred in two patients after the procedure. The incision from the lateral temporal

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lift heals quite well, and the resulting scars are often nearly imperceptible.

FIGURE 49.7 A 42-year-old woman is shown before and after a lateral temporal lift and upper and lower blepharoplasty.

FIGURE 49.8 A 70-year-old woman is shown before and after a lateral temporal lift, facelift, and upper blepharoplasty.

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Summary The aging forehead represents something of a paradox in aesthetic surgery. The upper facial third is critically important in facial expression, and the rhytids and ptosis associated with aging dramatically impact the ability of the brow to accurately express an individual’s intended emotions. However, despite the forehead’s important role in emotional communication and its great susceptibility to the passage of time, rejuvenation of the brow can be overlooked or minimized in consultations for facial rejuvenation. Similarly, the frequency with which the aging brow and strategies for its management are addressed in the literature pales in comparison to explorations of senescence and rejuvenation of the face’s lower twothirds. There are numerous options available to the surgeon looking to treat the aging brow. This includes surgical procedures and injectables that can be efficacious in addressing brow rhytids. These strategies may be used to address the aging brow alone or as part of a broader approach to facial rejuvenation. Ultimately, as in all procedures designed to reverse the changes of facial aging, it is an understanding of regional anatomy, the forces at play responsible for age-related changes, and the individual patient’s desired outcome that are the ingredients essential to choosing and implementing an appropriate treatment plan for brow rejuvenation and achieving patient satisfaction.

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Questions 1. Performing an isolated upper blepharoplasty in the context of brow ptosis is inadvisable primarily because: a. The brow ptosis will remain uncorrected. b. The brow ptosis may worsen. c. Compensated lower lid ptosis may be unmasked. d. A Spock-like configuration of the brows may result. e. It is difficult to accurately plan the upper lid skin excision in the setting of brow ptosis. 2. Deep horizontal forehead rhytids at rest should alert the examiner to the possible presence of: a. Chronic frontalis over-treatment with botulinum toxin b. Dermal pathology requiring evaluation by a dermatologist c. Congenital brow furrows d. Compensated brow ptosis e. A hyperhydrotic brow 3. The temporal branch of the facial nerve can be most practically avoided during brow rejuvenation procedures by: a. Adhering to the deep temporal fascia during dissection b. Dissecting in the temporoparietal fascia c. Dissecting in the superficial temporal fascia d. Using a nerve stimulator during dissection e. Meticulous intramuscular dissection 4. In a lateral temporal brow lift, a patient with a narrower brow: a. Should always have a hairline incision b. Should always have an incision in the hair-bearing scalp c. Should have their incision placed based on a conversation with the patient to assess his or her preference and an evaluation of brow pattern, hair density, and forehead width d. Is more likely to have hypertrophic corrugator muscles e. Is less likely to have hypertrophic corrugator muscles 5. The supratrochlear nerves: a. Run in the substance of the frontalis muscles and are the dominant source of brow sensation b. Run in the substance of the frontalis muscles and the supraorbital nerve is the dominant source of brow sensation c. Run in the substance of the corrugator muscles and are the dominant source of brow sensation d. Run in the substance of the corrugator muscles and the supraorbital nerve is the dominant source of brow sensation e. Have a sensory and motor component 1. Answer: b. Hanging upper lid skin can provide a compensatory stimulus of frontalis contraction. In the ptotic brow, eliminating this compensatory stimulus may cause frontalis relaxation and worsening of the brow ptosis. There is no relevant phenomenon called compensated lower lid ptosis. A Spock-like appearance results from unbalanced disruption of medial brow elevators, not isolated upper lid blepharoplasty. 2. Answer: d. Significant horizontal brow rhytids at rest could indicate that the frontalis is chronically contracting to compensate for a ptotic brow. This condition should be tested for in individuals with this presentation prior to upper blepharoplasty. The test is performed by having the patient close his or her eyes. If the brow drops, compensated brow ptosis is present. Chronic

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botulinum treatment would likely smooth brow rhytids. Dermatologic evaluation is not necessitated by this condition. Congenital brow furrows are not a commonly recognized occurrence. A hyperhydrotic brow is not related to the presence of brow rhytids. 3. Answer: a. The temporal branch of the facial nerve runs in the temporoparietal fascia (synonymous with the superficial temporal fascia). Dissecting in either of these planes risks damage to the nerve. Adhering to the deep temporal fascia during dissection is safe as the nerve runs superficial to this plane. Utilizing a nerve stimulator during dissection is unnecessary for this procedure given the clear anatomical relationships. The temporal branch of the facial nerve does not have an intramuscular course in the field of a brow lift. 4. Answer: c. Although a patient with a narrower brow would likely benefit from an incision in the hair-bearing scalp, the factors mentioned in answer c must be taken into account. The degree of hypertrophy of the corrugator muscles is not related to the width of the brow. 5. Answer: d. The supratrochlear nerves run through the corrugators and should be avoided during corrugator resection. The supraorbital nerve is the dominant source of brow sensation. The supratrochlear nerve does not have a motor component.

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References Codner, MA, Kikkawa, DO, Korn, BS, Pacella, SJ. Blepharoplasty and brow lift. Plast Reconstr Surg. 2010;126:1e-17e.This excellent article provides an anatomy-based approach to identifying problems and their solution in managing signs of aging in the upper facial third. Connell, BF, Lambros, VS, Neurohr, GH. The forehead lift: techniques to avoid complications and produce optimal results. Aesthetic Plast Surg. 1989;13:217-237. Paul, MD. The evolution of the brow lift in aesthetic plastic surgery. Plast Reconstr Surg. 2001;108:1409-1424. Marino, H, Gandolfo, E. Treatment of forehead wrinkles. Prensa Medica Argentina. 1964;51:1368. Uchida, JI. A method of frontal rhytidectomy. Plast Reconstr Surg. 1965;35:218-222. Pitanguy, I. Section of the frontalis-procerus-corrugator aponeurosis in the correction of frontal and glabellar wrinkles. Ann Plast Surg. 1979;2:422-427.This seminal article clearly addresses the importance of muscle release in treating brow rhytids. The author’s technique and experience are discussed. Matarasso, A, Hutchinson, OH. Evaluating rejuvenation of the forehead and brow: an algorithm for selecting the appropriate technique. Plast Reconstr Surg. 2000;106:687-694.The aging brow is addressed from a functional anatomical perspective, and the management algorithm presented offers an excellent framework for considering strategies to address the changes of aging in this region. Matarasso, A, Matarasso, SL. Endoscopic surgical correction of glabellar creases. Dermatol Surg. 1995;21:695-700. Matarasso, A. Endoscopically assisted forehead-brow rhytidoplasty: theory and practice. Aesthetic Plast Surg. 1995;19:141-147. Matarasso, A, Terino, EO. Forehead-brow rhytidoplasty: reassessing the goals. Plast Reconstr Surg. 1994;93:1378-1389. Daniel, RK, Tirkanits, B. Endoscopic forehead lift: an operative technique. Plast Reconstr Surg. 1996;98:1148-1157. Trinei, FA, Januszkiewicz, J, Nahai, F. The sentinel vein: an important reference point for surgery in the temporal region. Plast Reconstr Surg. 1998;101:27-32. Duchenne de Boulogne, GB. The Mechanism of Human Facial Expression. 
 New York, NY: Cambridge University Press; 1990. Gasperoni, C, Salgarello, M, Gargani, G. Subperiosteal lateral browlift and its relationship to upper blepharoplasty. Aesthetic Plast Surg. 1993;17:243-246. Lemke, BN, Stasior, OG. The anatomy of eyebrow ptosis. Arch Ophthalmol. 1982;100:981-986. Mackay, GJ, Nahai, F. The endoscopic forehead lift. Operative techniques. Plast Reconstr Surg. 1995;2:137-144. Matarasso, A, Smith, DM. The lateral temporal subcutaneous brow lift: a method for consistent, stable brow rejuvenation. ISAPS News. 2016;10:35.This article presents the technique of brow rejuvenation preferred by the authors of this chapter.

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CHAPTER 50

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Blepharoplasty Sheri Slezak and Katherine E. Duncan

Key Points Functional assessment of the aging eye must check for visual acuity, eyelid ptosis, dry eyes, history of refractive surgery, asymmetry, thyroid disease, and eyelid tone. Cosmetic assessment of the aging eye should include the skin, brow, cheek, and tear trough as well as upper and lower lid skin redundancy, fat prominence, and muscle function. Upper lid blepharoplasty includes skin resection and limited or no muscle and fat excision. Fat is preserved or added rather that resected to avoid superior sulcus hollowing. Ancillary brow procedures may be needed. Lower lid blepharoplasty is performed through transcutaneous or transconjunctival incisions and resects minimal skin. It resects, repositions, releases, or adds fat, with lid support techniques as needed. The eyelid-cheek junction is modified as indicated. Ancillary procedures to orbital rejuvenation may include browlift, onabotulinum toxin, peels, laser, or fillers. Complications following upper lid surgery are rare but include lagophthalmos and dry eye. Lower lid surgery carries more risk, including ectropion, corneal abrasion, exposure keratopathy or dry eyes, diplopia, and chemosis. A retrobulbar hemorrhage can result in pain, proptosis, and vision loss and is a surgical emergency. The eyes are a focal point of beauty and expression: art and literature is replete with images that allude to the importance of the eye. Saint Jerome said that “The face is the mirror of the mind, and eyes without speaking confess the secrets of the heart,” Henry Thoreau wrote that “The eye is the jewel of the body,” and Ralph Waldo Emerson said that “One of the most wonderful things in nature is a glance of the eye; it transcends speech; it is the bodily symbol of identity.” We endow the eye with far more than its physiology: it is the pathway to the mind and the soul. Although 20/20 vision is desirable, the eye is also admired for its color, shape, expressiveness, lashes, and size. Therefore, it is not surprising that males and females of diverse backgrounds desire to change the appearance of their eyes to enhance their beauty and to avoid the signs of aging that are so evident around the eyes. Periorbital aging causes predictable changes in the skin, fat, muscle, and bone. The brows descend, producing a sad or fatigued appearance. There is excessive skin in the upper lid that may cover the lid crease or the eyelashes and may obstruct the upper visual field. Lateral hooding due to excess skin and brow ptosis can cause a frowning look. The lacrimal gland may descend from attenuated ligaments. Fat may atrophy, producing superior sulcus hollowing, or the fat pads may herniate and protrude. The lower lids may become lax with increasing scleral show. The pretarsal roll in the lower lid descends and flattens. The septum attenuates and bulging of the lower eyelid fat is seen. Malar bulging with attenuated skin and muscle can be seen as the midface descends. The tear trough becomes more pronounced and the lateral canthus may become lax, causing lid malposition and rounding of the lateral commissure (Figure 50.1).

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FIGURE 50.1 Characteristic signs of aging in the eyes. The blue arrow marks the orbitomalar ligament, the black arrow the zygomaticofacial ligament, and the yellow arrow the nasojugal groove.

Blepharoplasty can reverse many of these undesired effects and restore the periorbital area to a more youthful state. Blepharoplasty is among the most common aesthetic procedures performed. According to American Society of Plastic Surgeons statistics, 209,571 blepharoplasties were performed in 2017, the 4th leading cosmetic procedure for plastic surgeons. Blepharoplasties are performed also by ophthalmologists and otolaryngologists, making it one of the most common aesthetic procedures. The goal of blepharoplasty is to restore a more youthful appearance without any compromise of physiologic function. Many successful techniques have been described and refined over time, and techniques vary with the patient’s particular anatomy. Outcomes are usually excellent, and patients are happy with their improved aesthetics.

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Anatomy Correction of the orbital aging process requires a firm knowledge of normal and abnormal anatomy. Different patients may demonstrate varying anatomical problems and concerns. The upper and lower eyelids surround the palpebral fissure and meet at the medial and lateral canthi. The lateral canthus is 2 mm higher than the medial canthus. With the eye in primary position, the margin of the upper eyelid should cover the superior 1 to 2 mm of the cornea whereas the margin of the lower eyelid is usually within 2 mm of the inferior border of the cornea. The brow should sit at the level of the supraorbital rim in men and above the rim in women. The peak of the brow is at the junction of middle and lateral thirds of the brow (Figure 50.2).

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FIGURE 50.2 Surface anatomy of the upper eyelid, eyelid folds, and canthal tilt.

The most superficial layer of the upper and lower eyelids is skin. Eyelid skin is one of the thinnest in the body with little subcutaneous tissue. The orbicularis muscle is immediately under this layer of skin and is responsible for closure of the eyelids. It is innervated by the facial nerve (mnemonic OO7). The muscle consists of three concentric circles: pretarsal, preseptal, and orbital. The pretarsal portion is important for involuntary blinking. The preseptal and orbital portions of the orbicularis are involved with voluntary blinking and forced eyelid closure. The orbital portion of the orbicularis can cause brow depression in the upper lid, and attenuation of this muscle can contribute to festoons in the lower lid (Figure 50.3).

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FIGURE 50.3 Muscle contributions to the medial canthus. The complex origin of the deep and superficial heads of the canthal portion of the orbicularis muscle.

The orbital septum is contiguous with the periosteum of the orbit, and delineates the preseptal and postseptal space. Posterior to the bands of orbital septum are the fat pads of the orbit. Fat pads serve to cushion the eye, promoting smooth movement of the eyelids and eye muscles within the orbit. The upper lid has two fat compartments, the central and medial (or nasal) fat pad, separated by the superior oblique extraocular muscle. The medial fat pad is lighter in color than the central fat pad and sits near the supratrochlear nerve and vessels. Laterally, in a shallow fossa of the frontal bone lies the two lobes of the lacrimal gland (orbital and palpebral). When the ligaments that connect the glands to the bone (Sommering ligaments) attenuate, the palpebral lobe can cause a prominent fullness in the lateral upper lid fold (Figure 50.4).

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FIGURE 50.4 Anatomy of the orbital fat pads and the interpad septae that are addressed during blepharoplasty.

The main retractors of the upper eyelids, the levator muscle and Müller muscle are posterior to the fat pads. The levator is innervated by cranial nerve III and Müller muscle is innervated by the sympathetic nervous system. The levator muscle has anterior fiber projections into the skin and orbicularis just above the tarsal plate, and this defines the lid crease. Typically, the lid crease is found 6 to 10 mm above the lid margin, near the most superior aspect of the tarsal plate. The lid crease is generally lower in men (6– 8 mm) than women (8–10 mm; Figure 50.5).

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FIGURE 50.5 Layers of the upper eyelid: orbicularis muscle (A), fat compartments (B), and levator muscle and tendon (C).

The tarsus, or tarsal plate, is the cytoskeleton structure of the eyelid. It is made up of connective tissue and Meibomian glands, which secrete an oil that prevents evaporation of the eye’s tear film. The tarsus is usually 8 to 10 mm in height in the upper lid. The levator aponeurosis inserts onto the anterior surface of the tarsus. The palpebral conjunctiva is the most posterior layer of the eyelids continuous with the bulbar conjunctiva, forming the mucosal layer of the ocular surface. The superior tarsal conjunctiva contains an abundant number of goblet cells responsible for forming the mucous layer of the tear film. The lower eyelid anatomy is similar to the upper eyelids, although some differences exist. The tarsal plate of the lower eyelid is shorter, only 3 to 4 mm in height. There are three orbital fat compartments in the lower lid: the lateral, central, and medial fat pads. The medial and central fat pads are divided by the inferior oblique extraocular muscle. The lower eyelid retractors include the capsulopalpebral fascia and inferior tarsal muscle, and are analogous to the levator and Müller muscle of the upper eyelid (Figure 50.6).

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FIGURE 50.6 Cross section of the lower lid demonstrating the anterior and posterior lamella.

The orbital fat pads behind the septum are separated from the inferior fat pad by the orbitomalar ligament, which stretches from the bone through the muscle and attaches to the orbicularis and skin. The medial portion of this arc is called the tear trough or nasojugal groove and extends inferolaterally from the medial canthus to approximately the midpupillary line, where it connects with the orbitomalar ligament. The tear trough ligament is an osteocutaneous ligament between the palpebral and orbital portions of the orbicularis oculi muscle. A tear trough may become more prominent with age, as the tissue above this area is protruding (from fat pad herniation) and the area below it is descending (from malar fat pad descent or subcutaneous thinning; Figure 50.7).

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FIGURE 50.7 Lower lid ligaments. A. Surface anatomy of the tear trough deformity and midfacial aging. B. Three-dimensional anatomy of malar bags created by edematous soft tissue that is surrounded by the orbicularis oculi, the malar periosteum, and the zygomaticocutaneous and orbitomalar ligaments.

Beneath the orbitomalar ligament is the prezygomatic space where the suborbicularis oculi fat resides. The inferior border of the prezygomatic space is defined by the zygomatical-facial (or cutaneous) ligament, which forms attachments from the bone to the dermis. This usually represents the lower edge of the orbicularis. Inferior to this ligament, the malar fat is present anterior to the facial muscles. This is the area where fat, excess skin, muscle, edema, and lymphatic swelling can cause malar mounds and festoons. Malar mounds are defined as chronic soft tissue edema between the infraorbital rim and the midcheek. If chronically and severely swollen, then the skin and muscle in this area may elongate and form permanent cascades called festoons (Figure 50.8).

FIGURE 50.8 Lower lid fat compartments. A. Anatomy of the deep supporting structures of the posterior lamella, including the

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tarsoligamentous sling and the medial and lateral horns of the levator muscle. B. Three fat compartments in the periorbital region include the orbital, SOOF (suborbicularis oculi fat), and malar fat pads.

The lateral canthus is dense connective tissue running from the tarsus to the lateral orbit. It has a deep limb that attaches to a tubercle 1.5 mm posterior to the lateral orbital rim (Whitnall tubercle) as well as a superficial limb, which inserts on the rim. The tendon is approximately 10 mm in length. The medial canthus has a large anterior limb and a small posterior limb, inserting on the anterior or posterior lacrimal crest, respectively. They surround the lacrimal sac (Figure 50.9).

FIGURE 50.9 Anatomy of the deep supporting structures of the posterior lamella, including the tarsoligamentous sling, the medial and lateral horns of the levator muscle, medial and lateral canthi, and Whitnall and Lockwood ligaments.

The vascular supply of the eyelids is formed by the anastomoses of the branches of the internal and external carotid arteries. The marginal arcade is usually found 2 to 3 mm from the lid margin on the anterior surface of the tarsus. The upper lid has an additional peripheral arcade, found on the anterior surface of the Müller muscle. The marginal arcade ought to be avoided during injection of local anesthetics to avoid a hematoma. The venous drainage follows the same pattern. The Asian eyelid differs significantly from Caucasian anatomy. The upper lid crease may be absent, low,

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or present only laterally because of lack of connections between the skin and levator. A medial epicanthal fold may be present, and the upper tarsus may be shorter. The Asian upper lid has more fullness because of preaponeurotic fat that extends more caudally, and there is an upward lateral canthus tilt.

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Preoperative Evaluation Patients seek blepharoplasty for many reasons. They complain of excess skin, fatty bags, wrinkles, and dark circles. They may have reduced visual fields and a tired or angry appearance. General aesthetic goals include a crisp upper crease with pretarsal show of 3 to 6 mm, a full orbital sulcus, and a brow in good position. Aesthetic features of the lower lid include pretarsal muscle fullness with a smooth lidcheek junction, and a well-defined almond-shaped lateral commissure. Determining the patient’s motivations for surgery, goals and expectations is crucial to the success of any surgical intervention. For example, patients who are interested in restoring function will generally be satisfied with removal of vision-obstructing excess skin only; whereas, patients who want to improve their appearance may require a greater amount of skin removal, removal of prolapsed fat, and greater attention to symmetry to meet expectations. It is important to impart to the patient a clear understanding of what goals and expectations can and cannot be achieved with surgery. Patients with unrealistic selfimage or who are not capable of understanding the limitations of the procedure are poor surgical candidates. Preoperative evaluation of the patient begins with taking a careful history. It is important to specifically ask about visual problems, ophthalmology visits, and prior refractive surgery. Blepharoplasty should not be considered within 6 months of refractive surgery as this predisposes the patient to dry eyes. The use of neurotoxin and/or fillers should be elicited as this can alter the physical examination. Specific questioning about coagulopathies, blood thinning medicines, herbal medicines, thyroid disease, allergies, high blood pressure, and glaucoma is required. Dry eye history is elicited by asking about blurry vision that clears with blinking, a burning or irritating feeling, conjunctival injection, the sensation of a foreign body in the eye, or frequent use of artificial tears. Physical examination of the patient should focus on the structure, function, and appearance of the eyelids, eyebrows, cheeks, and forehead. Symmetry of the two eyes is also evaluated. This is very important as there is always some degree of asymmetry, but patients do not always recognize this preoperatively. Postoperatively, however, the patient may detect the smallest of differences. A preoperative picture is helpful in every patient, so that the presurgical state can be reviewed. Careful attention should be given to the position of the eyebrows. The normal brow position in men is along the superior orbital rim. In females, the eyebrow sits slightly higher than the orbital rim, especially in the mid lateral area. Descent of the eyebrow position is an age related change than can make dermatochalasis more severe, and this can be treated surgically with a brow lifting procedure. When assessing eyelid and eyebrow position, it is important that the frontalis muscle is relaxed. Patients may compensate for eyebrow and eyelid ptosis by contracting the frontalis muscle, which can lead to subjective complaints of fatigue and heaviness of the eyelids. The position of the eyelid margin should then be assessed. If the margin of the eyelid is more than 2 mm and lower than the superior limbus, the patient may have eyelid ptosis, typically caused by dehiscence or stretching of the levator aponeurosis. The margin to reflex distance (MRD1) can also be noted. This is the measurement in millimeters from the light reflex on the patient’s cornea to the level of the center of the upper eyelid margin, with the patient gazing in the primary position. If the margin to reflex distance is 2 mm or less, the patient is considered to have visually significant ptosis. If present, ptosis can be corrected at the time of blepharoplasty. The amount of excess skin of the upper eyelid (dermatochalasis) should be assessed. If it overhangs the lid margin or sits on the eyelashes of the upper lid, it may be visually significant. Attention should also be given to any medial or lateral bulging: this may represent fat or lacrimal gland prolapse. Fat herniation can be accentuated by pushing gently on the globe. In contrast to upper eyelid blepharoplasty, lower eyelid blepharoplasty is generally cosmetic. In assessing a patient for lower lid blepharoplasty, it is important to evaluate the amount of excess skin present, the

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presence of orbital fat prolapse, and the tear trough appearance. The position of the lower lid is recorded relative to the limbus. The degree of lower eyelid laxity is assessed by a snap back test. This is done by distracting the lower lid inferiorly from the globe and seeing how quickly it returns to its original position. A normal lid will snap back into its normal position instantaneously. A delay of 2 to 5 seconds for the lid to return to its native state or the need to blink to return to normal state is indicative of abnormal laxity. A lid distraction test pulls the lower lid from the globe anteriorly, and a distance of greater than 6 mm is considered abnormal. A squint test delineates the function of the lower orbicularis. The patient squeezes the eyelids tightly together and the orbicularis contracts. This gives the surgeon a sense of the muscle tone and location of fat (Figure 50.10).

FIGURE 50.10 A. Snap back test. B. Distraction test.

The position of the globe relative to the orbital rim in noted. If the globe is more anterior than the orbital rim, this is called a positive vector and may suggest thyroid disease or a patient prone to dry eye problems. If the globe is posterior to the rim, this is called a negative vector. Lastly, examination of the ocular surface for dryness is important as this can be exacerbated by surgical interventions. If patient complaints or exam findings suggest dryness, an objective test such as the Schirmer test can assess for quantity of tears present. This is done by placing a 5 by 35 mm strip of filter paper in the lateral conjunctival cul-de-sac, and waiting 5 minutes. Normal eyes show 10 or more mm of wetting of the filter paper. In clinical practice, Schirmer testing is infrequently used. Staining of the ocular surface with fluorescein dye and examination under blue light reveals punctate staining corneal erosions in patients with dry eyes. This examination is more efficient in identifying patients with dry eye and is preformed routinely in ophthalmology offices. A visual acuity examination of each eye individually should be performed. The presence or absence of the Bell phenomenon is also noted. This is done by forcibly holding the eyelids open as the patient tries to close them, and seeing if the globe rolls up to protect the cornea. Absence of this reflex puts the eye at risk for dryness and ulceration if postoperative lagophthalmos is present (Table 50.1). TABLE 50.1 Common Eyelid Terminology Anterior lamella—Skin and orbicularis Posterior lamella—Tarsus and conjunctiva Lower lid retractors—Made up of the capsulopalpebral fascia (a fibrous extension from the inferior rectus that inserts onto the inferior

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tarsus) and inferior tarsal muscle. Support normal lower lid position and provide 3–4 mm of inferior displacement of the lower lid margin with downgaze Orbitomalar ligament—Cutaneous crease at the level of the orbital rim. Also called the orbicularis retaining ligament Arcus marginalis—Thickening of the orbital septum where it fuses with the periosteum of the orbital rim Lockwood ligament—Suspensory ligament that runs horizontally along the inferior orbit and supports the globe Whitnall ligament—Dense white band of fibrous tissue running horizontally along the superior orbit. Supports the structures in this area and acts as a fulcrum for the levator muscle Whitnall tubercle—Small elevation of the zygomatic bone just inside the lateral orbital rim that serves as the attachment point for the lateral canthal tendon, the lateral horn of the levator aponeurosis, the check ligament of the lateral rectus and Lockwood ligament Suborbicularis oculi fat (SOOF)—Fat pad deep to the orbicularis oculi overlying the maxillary and zygomatic periosteum. Descends with aging Retro-orbicularis oculi fat (ROOF)—Fat pad deep to the brow, which may also descend with aging Dermatochalasis—Excess skin of the upper or lower eyelid, and may obstruct the upper visual field Blepharochalasis—Excess skin caused by repeated episodes of edema Steatoblepharon—Excess or protruding fat Canthopexy—Tightening of canthus by suturing Canthoplasty—Tightening of eyelid by division of the canthus and reinsertion Ectropion—Outward turning of the eyelid margin, caused by aging, cicatrices, paralysis, or mechanical Entropion—Inward turning of the eyelid margin, which can result in trichiasis (rubbing of the lashes against the eye) and corneal abrasions, due to age, cicatrices, or spasticity Epiphora—Excessive tearing, often a result of a blockage in the nasolacrimal system Festoon—Excessive skin and muscle with swelling below the orbitomalar ligament from long-term edema

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Operative Technique In the past, operative techniques included aggressive fat and skin removal but this led to an unnatural, hollowed appearance. Modern techniques rely on a careful diagnosis of the patient, restoration of more youthful anatomy, and preservation of fat.

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Upper Lid Techniques Repair of dermatochalasis and ptosis can offer functional as well as aesthetic improvement. Functional benefits are noted for an MRD1 of 2 mm or less measured in primary gaze, superior visual field loss of 12 degrees or 24%, and downgaze ptosis impairing reading documented by MRD1 of 2 mm or less measured in downgaze. Improved qualitative findings have also been noted in patient-reported functional impairment from upper eyelid droop, head tilt induced by visual field impairment, and interference with occupational duties resulting from visual impairment caused by the upper lids. The steps of the basic upper eyelid blepharoplasty are outlined next. Additional procedures involving the correction of brow ptosis or eyelid blepharoptosis are described elsewhere in this book.

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Markings Mark the patient in the sitting position. First, identify the natural upper lid crease. If the brow is ptotic, fix it in the intended position to mark. Less skin is taken if concomitant brow lift is performed. Measure the position of the lid crease centrally on each side with calipers. This should fall between 6 and 10 mm above the eyelid margin centrally. Men are in the lower range, and women will be on the upper range. The medial and lateral crease is generally 4 to 5 mm above the lid margin. If the position of the lid crease is different on each side, choose one crease height and mark symmetric incisions for each eyelid. If the crease is not obvious, manually move the eyelid up and down to better visualize the crease. The lateral edge of the mark should be extended to the orbital rim along a crow’s foot crease, but no more than 10 mm beyond the canthus. Typically, one would want to place this 4 to 5 mm above the lateral canthus to avoid a lower lid incision. Placement of the incision along the lid crease results in a hidden scar. The medial marking should not extend beyond the punctum to avoid webbing. After the lid crease has been marked, with the eyelids closed, use a smooth fine tipped forceps to pinch the excess skin. One tip of the forceps will grasp the skin along the marked lid crease, whereas the other end of the forceps is used to grasp the superior extent of the excess skin. Repeat this maneuver at several points along the eyelid and connect the points to outline the upper limit of skin to be removed. Eyelashes should just evert with this pinch. There should always be at least 10 mm of skin left below the brow. The superior extent line is then connected to the lid crease marking medially and laterally. The shape of the excision can be an ellipse or a scalpel shape with more lateral resection. A safe rule of thumb is that skin resection should preserve a brow to margin distance of at least 20 mm (Figure 50.11).

FIGURE 50.11 Upper eyelid markings.

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Anesthesia Inject subcutaneous anesthetic superficially in the area to be resected. Upper lid blepharoplasty alone is generally done under local anesthesia but additional procedures or patients’ characteristics may dictate the use of intravenous (IV) sedation or general anesthesia.

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Skin Resection Incise the skin along the marked incision lines with a no. 15 blade. Some surgeons prefer to use a CO2 laser or Colorado microdissection needle to incise the skin. Excise the marked area of skin by taking care to excise skin only and leaving the orbicularis intact.

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Muscle Resection Although not always needed, removal of muscle may be done to decrease fullness or to create a crisp supratarsal fold. A strip of 3 to 5 mm is removed, and cautery is used to achieve hemostasis from the muscle vessels.

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Fat Removal Fat removal may or may not be needed. If needed, the orbicularis and septum are opened with scissors or cautery to expose the fat pads. Gentle pressure on the globe will further prolapse the fat. The medial orbital fat pad typically requires debulking more often than the central pad. The fat can be resected with needle tip cautery or by clamping the fat with a hemostat, excising it and then cauterizing the cut end. Great care is taken to avoid any traction on the fat as this can lead to bleeding posterior to the septum and a retro-orbital hemorrhage. Aggressive fat debulking of the eyelids can result in a hollowed appearance and has fallen out of favor. Minimal conservative fat removal is recommended. Some patients have a prominent fat fad under the lateral third of the brow, which is below the orbicularis. This is called retro-orbicularis oculi fat and can be resected at the time of blepharoplasty. Dissection is carried out superiorly beneath the orbicularis where the fat is resected. Browpexy may also be performed in this space by placing sutures to secure the lateral orbicularis and brow to the periosteum at the desired position at or above the superior orbital rim.

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Lacrimal Gland A prolapsed lacrimal gland presents as a mass below the brow and lateral orbital rim. Double armed sutures can be used to engage the inferior tip of the gland and secure it to the periosteum just inside the superior orbital rim at the lacrimal fossa. Excision of the gland tissue should be avoided, as this can lead to dry eye.

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Skin Closure Many different skin closures are successful; running or interrupted sutures and absorbable and nonabsorbable sutures can be used. Fine suture (6-0 to 8-0 suture) is used in a single layer, and sutures are typically removed 7 days after surgery (Figure 50.12).

FIGURE 50.12 Upper lid blepharoplasty: preoperative (A) and postoperative (B).

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Lower Lid Techniques Unlike upper eyelid blepharoplasty, there are multiple approaches to a lower eyelid blepharoplasty. Variation in patient anatomy will influence the chosen technique. Older patients with excess skin may warrant a transcutaneous lower eyelid blepharoplasty. If lower eyelid laxity is also present, a lower eyelid tightening procedure (i.e., lateral tarsal strip) can be performed at the same time. Patients with fat prolapse or tear trough deformity and minimal excess skin can be approached with a transconjunctival lower lid blepharoplasty with fat excision or redraping. Different surgeons prefer different techniques.

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Markings A subciliary skin incision is marked 2 mm below the lower eyelid lashes. The marking is extended inferotemporally along a crow’s foot crease to the lateral orbital rim. The lower incision should be 5 to 7 mm inferior to the upper lid incision. The location and the planned amount of fat pad resection is noted or marked. Fat pad anatomy can be better visualized by gentle pressure on the globe. The tear trough is marked.

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Anesthesia and Shields Various surgeons use local, IV sedation, or general anesthesia. A corneal shield may be used for lower lid surgery to protect the globe.

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Transcutaneous Approach The marked subciliary incision is made with a knife or sharp scissors. The incision is then stairstepped so that the muscle incision is made 5 mm below the lashes to spare the pretarsal orbicularis. A skin-muscle flap is dissected inferiorly to below the orbital rim. The orbitomalar ligament is completely released so that the skin is no longer fixed to the bone.

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Fat Removal, Relocation, and Augmentation The orbital septum may be opened with iris scissors or cautery to expose the lower eyelid fat pads. Fat may then be resected in a similar fashion as was described in the upper eyelid blepharoplasty or can be redraped over the inferior orbital rim to address any tear trough deformity. It may also be harvested to use as free fat grafts. Care must be taken to avoid injury to the inferior oblique muscle that divides the nasal and central fat pads.

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Skin/Muscle Resection The skin-muscle flap is then redraped superiorly and laterally and any excess overlapping skin and muscle is excised. It is important to be conservative in the amount of skin resected because this can cause retraction of the lower eyelid. Generally, only a few mm of skin is excised. Vicryl suture is used to resuspend the orbicularis to the soft tissue and periosteum in the area of the lateral orbital rim to provide mechanical support for the lower lid and prevent ectropion.

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Lateral Canthal Tightening If the patient was found to have significant lower eyelid laxity during the preoperative evaluation, they are at higher risk for ectropion with any skin resection and a lateral canthal tightening procedure should be performed. A canthopexy can be used for mild laxity. This is performed by placing a mattress suture through the edge of the tarsal ligament or tarsal plate and securing it to the periosteum inside the lateral orbital rim. A canthoplasty or lateral tarsal strip addresses moderate to severe lower lid laxity. A canthoplasty divides the tarsal ligament and reinserts it. In a lateral tarsal strip, the lid is redraped laterally. The anterior lamella and lid margin in the area of excess lid overlapping the lateral canthus is separated from the tarsus, and the extra lateral tarsus is removed. A mattress suture is then placed through the new lateral end of the shortened tarsus and secured to the periosteum. When placing the periosteal stitch, it is important to ensure proper height of the lateral canthus (2 mm above the medial canthus).

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Closure Close the skin with running fine suture (6-0 to 8-0). Sutures are removed in 7 days (Figure 50.13).

FIGURE 50.13 Four-lid blepharoplasty: preoperative (A) and postoperative (B).

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Transconjunctival Approach The lower eyelid is retracted anteriorly to expose the palpebral conjunctiva. A scalpel or cutting cautery is used to incise the conjunctiva just below the tarsal plate. The lower eyelid retractors are divided. Dissection proceeds inferiorly, between the septum and orbicularis, to expose the fat pads and orbital rim. The orbital malar ligament is completely released. Fat resection or relocation proceeds as earlier. Some surgeons use a lower conjunctival incision, at about 4 to 5 mm below the tarsus, and go directly into the fat pads. Lateral canthal support is generally not needed in a transconjunctival approach, as the orbicularis is not weakened by division. If necessary, a small pinch of pretarsal skin can be resected. The conjunctival incision can be closed with two or three interrupted absorbable sutures or may be left open after the procedure. Adjunct procedures, such as browlift, peels, laser, fillers, and muscle denervation can be added at the time of blepharoplasty or can be performed later in the office. Severe festoons may require muscle resection, redraping, or suspension along with midface lift, liposuction, or direct excision.

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Postoperative Care Patients are advised to elevate their heads and apply cool compresses or ice to the eyelids for the first 24 to 48 hours. They may apply antibiotic ointment to the surgical incisions twice daily for 1 week. Patients should avoid strenuous activity or bending below the waist for 2 weeks. Nonabsorbable sutures can be removed 7 days after surgery. Patients should expect postoperative swelling and bruising to persist for up to 2 weeks after surgery.

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Complications Fortunately, complications are rare in blepharoplasty, but when present, can be devastating both aesthetically and functionally. A full discussion of possible complications with documentation in the record is prudent for every patient. Complications can be divided into acute and long-term risks.

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Acute Complications

Orbital Hematoma The most feared complication of eyelid surgery is hemorrhage behind the orbital septum, which can result in an orbital compartment syndrome and vision loss. Although rare, this needs immediate attention. It generally happens in the operating room or in the first 24 hours postop and presents as severe pain, pressure, and decreased vision. Examination is diagnostic as there is proptosis, limitation of extraocular movements, and increased intraorbital pressure. This complication can be averted by careful tissue handling to avoid traction of the fat pads and careful hemostasis of the base of the fat pad. Preoperative considerations such as control of hypertension and the avoidance of aspirin and blood thinners can decrease this risk as well. In the case of vision threatening hematomas, treatment is directed at urgent opening of the incision for evacuation of the hematoma. A lateral canthotomy can be performed to relieve intraorbital pressure. If the patient has developed vision loss, high-dose IV steroids should be initiated to maximize visual recovery. Operative drainage of the hematoma is a surgical emergency. Small eyelid hematomas without vision changes can be treated conservatively with elevation and ice.

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Corneal Abrasion The patient presents immediately postoperatively with severe eye pain, tearing, and blurred vision with a foreign body sensation. Ophthalmology consultation may use fluorescein and a Wood’s lamp to document an abrasion. Abrasions are treated with frequent use of ophthalmic antibiotic ointment. The use of scleral shields can help prevent this problem. Pain beyond 24 hours requires further ophthalmologic evaluation.

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Lagophthalmos Mild postoperative lagophthalmos (inability to completely close the eyes) is common and typically resolves in the first few days after surgery. This can be managed with lubrication of the eyes. If is present beyond the first week, it can typically be managed with ointment and massage of the upper eyelids. Persistent lagophthalmos is usually the result of aggressive skin removal or scarring of the orbital septum. Reoperation with lysis of scar tissue and/or skin grafting may be required in severe cases.

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Chemosis Conjunctival edema is common after surgery and is usually self-limited. Artificial tears and a steroid eyedrop/ointment can be prescribed if the swelling is severe. Topical ophthalmic steroid use should always be temporary or monitored by an ophthalmologist as it can lead to elevated intraocular pressures and glaucoma with long-term use.

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Infection Infection is rare because of the excellent vascularity of the face. Eyelid surgery is considered clean surgery and antibiotics are not generally used. Erythema and purulent discharge should be treated with antibiotics and culture, and computed tomography may be necessary to evaluate for an orbital abscess.

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Corneal Exposure/Dry Eye Dryness can be transient in the postoperative period and can be corrected with aggressive use of artificial tears and lubricating ointments.

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Diplopia The superior and inferior oblique muscles are the most commonly injured extraocular muscles in upper and lower blepharoplasty, respectively. They can be injured either during fat resection, transconjunctival dissection, or by traction. Diplopia is usually transient and is managed conservatively. Should it persists, ophthalmologic evaluation is needed. Strabismus surgery or prism glasses may be used to correct persistent diplopia.

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Epiphora Tearing can result from irritation, inflammation, or rarely injury to the puncta or the canalicular pump system. An altered lid position may also cause tearing. Tearing is usually transient.

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Long-Term Complications

Asymmetry Asymmetry of the lid position or contour can occur in the immediate postoperative period as a result of swelling and should be monitored initially. Asymmetry of the upper lid creases can be avoided by careful and equal marking of the eyelid crease at the beginning of the procedure as well as uniform dissection of fat.

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Lid Malposition Ptosis of the upper eyelids can occur because of injury to the levator aponeurosis if surgical dissection was carried too deep into the eyelid structures. Complications of lower eyelid blepharoplasty include lower eyelid retraction, ectropion, and inferior scleral show. These typically occur when there is excessive removal of skin and muscle. Upward massage of the lids can be attempted in the acute postoperative period. Persistent ectropion and/or retraction may require surgical revision with skin grafting.

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Dry Eye Syndrome Ocular surface irritation and dryness can persist despite good position of the lids and short-term use of artificial tears. In these situations, it would be most appropriate to refer the patient to an ophthalmologist for further evaluation and management.

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Unsightly Scars Careful camouflage of the incisions in the upper crease and close to the lower eyelid are key to avoid a noticeable scar. Medial scar extension can cause noticeable webbing.

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Outcomes Interestingly, there are few outcome studies from the patients’ point of view. One outcome study used the Face Q. They reported that the most common patient-reported adverse effects after eyelid surgery included obvious, noticeable, or uneven scars (37%); dry eyes (35%), eye irritation (itching or redness) (33%); and excessive tearing (25%). This is significantly different from physician-reported complications, although global satisfaction is generally positive. Fortunately, most adverse effects are self-limited and fully resolve.

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Conclusion Blepharoplasty is a procedure that can improve both the function and the aesthetics of the eyelids. It is a short operation, often under local anesthesia, with generally acceptable risk. Success of the procedure is dependent on a detailed understanding of the eyelid anatomy as well as careful preoperative evaluation and planning. Meticulous surgical technique helps the surgeon to attain the desired goals while avoiding postoperative complications. Long-lasting improvement and satisfied patients make blepharoplasty a popular operation in men and women of many age groups.

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Questions 1. A 56-year-old woman who desires a blepharoplasty is evaluated for ptosis. With the eye in primary gaze, the margin of the upper lid should not be lower than which of the following positions? a. 1 to 2 mm above the superior limbus b. The level of the superior limbus c. 1 to 2 mm below the superior limbus d. The level of the superior pupil 2. A 39-year-old woman comes to the office complaining of dark circles under her lower eyelids that make her look tired. Physical examination shows a prominent tear trough. What is the anatomic basis of the tear trough? a. Prominence of the orbital rim following ptosis of the malar fat pad b. Osteocutaneous ligament between the palpebral and orbital parts of the orbicularis oculi c. Herniation of the medial fat compartment over the arcus marginalis d. Depression between the orbicularis oculi and levator labii superioris 3. As compared with an upper lid blepharoplasty with orbicularis muscle resection, a muscle sparing upper lid blepharoplasty results in which of the following? a. Less lagophthalmos b. Faster recurrence of blepharochalasis c. A superior aesthetic result d. More dry eye symptoms 4. A 49-year-old man complains of double vision 2 weeks after a four-lid blepharoplasty. On examination, he has vertical diplopia in primary gaze, and it increases in adducted upgaze. An injury to which of the following muscles is probable? a. Superior oblique b. Inferior oblique c. Inferior rectus d. Superior rectus 5. Three days after a four-lid blepharoplasty, a patient complains of excessive tearing. Physical findings include normal lid position and mild globe irritation without abrasion. The most appropriate next step in management is a. Observation b. Jones I test c. Anticholinergic drops d. Pensieve test 6. Canthoplasty is differentiated from canthopexy by which of the following? a. Disinsertion of the lateral canthus b. Tightening of the canthus c. Corrects lower lid laxity d. Use of suture fixation 7. A 69-year-old woman who underwent a four-lid blepharoplasty complains of left eye pain, pressure, and decreased vision in the recovery room. Examination shows left eye proptosis, limitation of extraocular movements, and increased intraorbital pressure. A retrobulbar hematoma is suspected. The sutures are released. Which of the following is the next most appropriate step? a. Steroid bolus b. Anterior compartment paracentesis

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c. CO2 inhalation d. Lateral canthotomy 8. The threshold for adding a lid-supporting procedure to a lower lid blepharoplasty is a lower lid distraction test of which of the following? a. 4 mm b. 6 mm c. 8 mm d. 10 mm 1. Answer: c. The normal eyelid is 1 to 2 mm below the superior limbus. A lid that is lower than this needs to be recognized as ptotic, and this can be addressed surgically at the time of blepharoplasty. A higher lid position suggests thyroid disease. 2. Answer: b. The tear trough ligament is an osteocutaneous ligament between the palpebral and orbital portions of the muscle. It extends inferolaterally from the medial canthus to approximately the midpupillary line, where it connects with the orbitomalar ligament. 3. Answer: a. If muscle is not resected, there is less retraction, and lagophthalmos is less likely. Recurrence, outcome, and dry eye symptoms are equivalent. 4. Answer: b. The inferior oblique arises from the orbital surface of the maxilla, lateral to the lacrimal sac and inserts into the scleral surface. Its primary action is extorsion (external rotation); secondary action is elevation; tertiary action is abduction. The field of maximal inferior oblique elevation is in the adducted position. A superior rectus palsy would present with limitation of upgaze in abduction, and a superior oblique injury would have limited downgaze in adduction. An inferior rectus palsy would limit abducted downgaze. 5. Answer: a. Acute tearing is usually self-limited and will resolve within weeks. Prolonged tearing may be due to poor lid position or, rarely, an injured canalicular system. A Jones test evaluates lacrimal outflow by placing fluorescein into the conjunctiva and then testing for it in the inferior nasal meatus. 6. Answer: a. A canthoplasty divides the canthus before reinserting it. Both procedures tighten the canthus by suture fixation and are used to correct lid laxity. 7. Answer: d. A lateral canthotomy should be done immediately to decrease pressure. Other treatments such as steroids, mannitol, beta blockers, and acetazolamide all take longer to lower pressure and are secondary measures. 8. Answer: b. A distraction of the lid from the globe of more than 6 mm is indicative of poor lid tone, and lower blepharoplasty alone will cause ectropion. A canthopexy, canthoplasty, or lateral tarsal strip is needed.

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BIBLIOGRAPHY Cahill, KV, Bradley, EA, Meyer, DR, et al. Functional indications for upper eyelid ptosis and blepharoplasty surgery: a report by the American Academy of Ophthalmology. Ophthalmology. 2011;118(12):2510.A review of 13 studies that demonstrate the improvement in vision, peripheral vision, and quality of life activities with repair of upper lid dermatochalasis and blepharoptosis. Damasceno, RW, Cariello, AJ, Cardoso, EB, et al. Upper blepharoplasty with or without resection of the orbicularis oculi muscle: a randomized double blind left right study. Ophthal Plast Reconstr Surg. 2011;27:195. Drolet, BG Sullivan, PK. Evidence based medicine medicine: blepharoplasty. Plast Reconstr Surg. 2014;133:1195. Espinoza, GM, Holds, JB. Evaluation and treatment of the tear trough deformity in lower. Blepharoplasty Semin Plast Surg. 2007;21:57. Faigen, S. Advanced rejuvenation upper blepharoplasty. Plast Reconstr Surg. 2002;110:278. Fleury, CM, Schwitzer, JA, Hung, RW, Baker, SB. Adverse event incidences following facial plastic surgery procedures: incorporating FACEQ data to improve patient preparation. Plast Recosntr Surg. 2018;141:28e. Ghabrial, R, Lisman, R, Kane, M, et al. Diplopia following transconjunctival blepharoplasty. Plast Reconstr Surg. 1998;102:1219. Hashem, AM, Couto, RA, Waltzman, JT, et al. Evidence-based medicine: a graded approach to lower lid blepharoplasty. Plast Reconstr Surg. 2017;139(1):139e-150e.Accurate diagnosis of the problems in the lower lids is used for a graded, individualized correction of fat excess, tear trough, lidcheek junction abnormalities. Hoorntje, LE, Lei, BV, Stollenwerck, GA, Kon, MJ. Resecting orbicularis oculi muscle in upper eyelid blepharoplasty: a review of the literature. Plast Reconstr Aesthet Surg. 2010;63(5):787-792. Jindal, K, Sarcia, M, Codner, M. Functional considerations in aesthetic eyelid surgery. Plast Reconstr Surg. 2014;134:1154. Kiang, L, Deptula, P, Mazhar, M, et al. Muscle-sparing blepharoplasty: a prospective left-right comparative study. Arch Plast Surg. 2014;41(5):576-583.A randomized prospective study of 22 patients with skin-only upper lip blepharoplasty on one side and muscle-skin resection on the other. Kiranantawar, K, Suhk, JH, Nguyen, AH. The Asian eyelid: relevant anatomy. Semin Plast Surg. 2015;29:158.Thorough discussion of the various types of Asian eye anatomy variations in crease, skin, fat, and epicanthal folds. Korn, BS, Kikkawa, DO, Cohen, SR. Transcutaneous lower eyelid blepharoplasty with orbitomalar suspension: retrospective review of 212 consecutive cases. Plast Reconstr Surg. 2010;125(1):315-323. Kpodzo, DS, Nahai, FC, McCord, CD. Malar mounds and festoons: review of current management. Aesthet Surg J. 2014;34(2):235.Reviews the terminology and anatomy of mounds and festoons, and gives a treatment algorithm for these difficult problems. Friedland, JA, Lalonde, D, Rohrich, R. An evidence-based approach to blepharoplasty. Plast Reconstr Surg. 2010;126:2222. Lellli, GJ, Lisman, RD. Blepharoplasty complications. Plast Reconstr Surg. 2010;125:1007. LoPiccolo, MC, Mahmoud, BH, Liu, A, et al. Evaluation of orbicularis oculi muscle stripping on the cosmetic outcome of upper lid blepharoplasty: a randomized, controlled study. Dermatol Surg. 2013;39:739. Miranda, SG, Codner, MA. Micro free orbital fat grafts to the tear trough deformity during lower blepharoplasty. Plast Reconstr Surg. 2017;139:1335. Muzaffar, AR, Mendelson, BC, Adams, WP Jr. Surgical anatomy of the ligamentous attachments of the lower lid and lateral canthus. Plast Reconstr Surg. 2002;110(3):873.Excellent cadaver study that describes the anatomy of the orbicularis retaining ligament (also called the orbitomalar ligament) and discusses its implications in the aging eyelid. Pacella, S, Codner, M. Minor complications after blepharoplasty: dry eyes, chemosis, granulomas, ptosis, and scleral show. Plast Reconstr Surg. 2010;125:709. Ramil, M. Fat grafting in hollow upper eyelids and volumetric upper blepharoplasty. Plast Reconstr Surg. 2017;140:889. Rohrich, R, Pezeshk, R, Sieber, D. The six step lower blepharoplasty: using fractionated fat to enhance blending of the lid cheek junction. Plast Reconstr Surg. 2017;139:1381.A step-by-step guide to a lower lid blepharoplasty with additional video demonstrations. Tonnard, PL, Verpaele, AM, Zeltzer, AA. Augmentation blepharoplasty: a review of 500 consecutive patients. Aesthet Surg J. 2013;33(3):341.The modern concept of fat replacement rather than resection is highlighted here as fat obtained by liposuction is used as micrografts in 500 consecutive upper and lower blepharoplasties. Wong, CH, Mendelson, B. Extended transconjunctival lower lid blepharoplasty with release of the tear trough ligament and fat redistribution. Plast Reconstr Surg. 2017;140:273. Zoumalan, CI, Roostaeian, J. Simplifying blepharoplasty. Plast Reconstr Surg. 2017;137:196e.

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CHAPTER 51

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Facelift and Necklift Gabriele C. Miotto and Foad Nahai

Key Points Facial anatomy as it is applied to facial rejuvenation Patient evaluation by thorough history, physical examination in the preoperative planning; safety checklist Surgical technique selection and different applications Postoperative care and patient management Common complications and adequate management strategies for good results and patient satisfaction Facial aging is a multifactorial process involving the skin, soft tissues, and facial skeleton. The major goal of facial rejuvenation is to restore smooth contours and soft transitions between facial units. As the face ages there are predictable surface, volume, and positional changes acting as landmarks for soft tissue manipulation and repositioning. Facial skeleton work is limited in facelift. Soft tissue augmentation with autologous fat transfer can significantly improve structural bony deficiencies and is included frequently to enhance results in facial rejuvenation surgery. 1,2

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Anatomy Skin Intrinsic and extrinsic factors contribute to aging of the skin. Intrinsic factors such as epidermal thinning, dermal elastosis, decreased elasticity, and decreased collagen production are hallmarks of normal aging. Chronic UVA exposure, smoking, radiation, and chronic diseases are extrinsic factors that accelerate skin aging. Permanent skin wrinkling and dark spots are visual characteristics of photoaging. They are best treated through skin care and resurfacing procedures such as chemical peels and lasers. Skin wrinkling with dynamic movements is best treated with neuromodulators or selective muscle ablation procedures, such as corrugator muscle resection. Facelifting techniques have little effect on skin texture, elasticity, and discoloration, but they improve folds resulting from tissue shifting and descent.

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Retaining Ligaments and Fat Compartments Described by Furnas in 1989, retaining ligaments are fibrous structures in predictable locations of the face connecting bone to the overlying facial skin, crossing all layers of soft tissue. Alghoul and Codner reviewed and clarified the nomenclature of the retaining ligaments of the face by integrating earlier descriptions. 3 Retaining ligaments are landmarks for facial rejuvenation procedures as they separate facial fat compartment, are intimately related to the branches of the facial nerve, and are structural components of facial support and aged appearance (Figure 51.1). Laxity of the ligaments and fat compartment deflation create visible surface depressions and creases seen with aging.

FIGURE 51.1 The retaining ligaments of the face and different nomenclatures since the initial description by Furnas in 1989. (Adapted from Alghoul, M, Codner, MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33(6):769-782. Reproduced by permission of The American Society for Aesthetic Plastic Surgery, Inc.)

The facial fat compartments are pockets of facial adipose tissue confined within a relatively impermeable membrane (the septum). Fat compartments are divided into superficial and deep in relationship to the superficial musculoaponeurotic system (SMAS). 4 They exist in the forehead, periocular, cheek, and perioral areas, and are separated by retaining ligaments and septa that determine the location of the fat

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compartments. and/or refilled.

5

During facelift, the deep and superficial cheek compartments may be repositioned

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Superficial Musculoaponeurotic System and Mimetic Muscles The term superficial musculoaponeurotic system (SMAS) was popularized by Mitz and Peyronie in 1976, describing the SMAS as a superficial fascia investing the face and the superficial mimetic muscles. It is contiguous with the galea aponeurotica, the temporoparietal fascia, parotid masseteric fascia, platysma muscle, and superficial cervical fascia. The SMAS is an important anatomical structure for facial rejuvenation and is often divided into mobile and fixed SMAS. The fixed SMAS is firm and lateral over the parotid gland. The mobile SMAS is softer and medial, over to the zygomatic and masseteric retaining ligaments toward the central face. The mobilization and suspension of the mobile SMAS to the fixed SMAS is an essential step in any SMAS facelift. It lifts and repositions descended facial tissues. The SMAS lies on top of the deep facial fascia, a layer protecting the branches of the facial nerve. Sub-SMAS dissections may result in facial nerve injury if the deep fascia is violated. The mimetic muscles of the face are arranged in layers according to their origin and insertion. The superficial mimetic muscles include the zygomaticus major and minor, levator labii superioris, risorius, depressor anguli oris, orbicularis oculi, and orbicularis oris. The deeper facial muscles include the buccinator, mentalis, and depressor labii. The most superficial layer of muscles is intimately related to the medial extension of the SMAS. Traction and suspension of the SMAS will also suspend the muscles.

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Motor and Sensory Nerves The facial nerve (seventh cranial nerve) innervates the mimetic muscles and has five main branches: temporal, zygomatic, buccal, mandibular, and cervical. The facial nerve emerges from the stylomastoid foramen and enters the parotid gland where it branches. Within the parotid gland, the branches of the facial nerves are deeply located, deep to the parotid fascia, and they become more superficial at the anterior boarder of the gland. The facial nerve branches transition from the deep superficial fascia through SMAS fusion zones and retaining ligaments. They run as deep as possible until they reach the edge of the muscles they innervate. 6 The facial nerve usually innervates the superficial mimetic muscles through their deep surfaces (the zygomaticus major and minor, levator labii superioris, risorius, depressor anguli oris, orbicularis oculi, and orbicularis oris) and the deeper facial muscles such as the buccinator, mentalis, and depressor labii, from the superficial surface. Facial nerve injury is rare in facelift surgery with an estimated incidence of below 1%. Permanent loss of function from injury is estimated to be around 0.1% in most cases. The trigeminal nerve (fifth cranial nerve) is the sensory nerve of the face. The great auricular nerve is a nerve of the cervical plexus (C2, C3) that provides the dominant sensory innervation to the ear (lobule, concha, and posterior auricle). It is also the most common nerve injured in facelift surgery. 7 These are known as “zones of danger” of the face, where the main nerves are most vulnerable to injury during face and necklift dissections (Figure 51.2). 8

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FIGURE 51.2 Zones of danger for nerve injury during face and necklift. The eight zones are indicated and correspond to both sensory and motor nerve danger areas. (1) The frontal branch is vulnerable to injury as it crosses the zygomatic arch 2.5 cm anterior to the external auditory meatus deep into the temporoparietal fascia. (2) The zygomatic branch is vulnerable during the zygomatic retaining ligaments release. (3) The buccal branch is vulnerable during dissection at the anterior edge of the parotid

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and during buccal fat pad manipulation. (4) The marginal mandibular branch is vulnerable during lateral platysma work and submental dissections as it exits the parotid inferiorly and runs along the mandibular angle. (5) The great auricular nerve branch is vulnerable when dissecting the posterior neck, as it emerges at the posterior border of the sternocleidomastoid muscle, about 6.5 cm inferior to the exterior auditory canal. (6) The supraorbital and supratrochlear nerves are vulnerable during brow lifts and dissections along the supraorbital rim, such as during transpalpebral corrugator resections. (7) The infraorbital nerve is vulnerable during deep dissections of the midface in subperiostal or supraperiostal midfacelift. (8) The mental nerve is vulnerable during deep fat grafting injection in the prejowl sulci and during chin augmentation procedures. (Adapted by permission from Seckel, BR. Facial danger zones: avoiding nerve injury in facial plastic surgery. Can J Plast Surg. 1994;2(2):59-66. Copyright © 1994 SAGE Publications.)

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Vascular Supply The main blood supply to the soft tissues of the face comes from branches of the external carotid artery and internal jugular vein (Figure 51.3). The main arterial supply to the central face is the facial artery. The facial artery branches off the external carotid in the neck and crosses over the mandible approximately 3 cm from its angle to run into the face, deep into the mimetic muscles. Its branches are the submental artery, upper and lower labial arteries, angular artery, and nasal artery. This rich arterial network allows for the elevation of a facelift flap. The infraorbital artery, another branch of the external carotid artery (from the maxillary artery), also supplies the medial cheek and lower lid. The lateral face is supplied by the transverse facial artery. The transverse facial artery branches off the superficial temporal artery at the level of the external auditory meatus and travels anteriorly supplying the lateral face and lateral orbital area. The territories of the facial artery and transverse facial artery overlap in the cheek. The superficial temporal artery provides blood supply to the lateral forehead and scalp.

FIGURE 51.3 Vascular supply to the face.

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The facial vein provides the main venous drainage of the face. It runs parallel to and behind the facial artery and flows into the internal jugular vein. The internal carotid artery and vein also contribute to the vascular supply of the face, mainly in the periocular area and forehead through the supratrochlear and supraorbital vessels.

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Patient Evaluation Good results in facial surgery rely on facial analysis and understanding of the patient’s anatomy, including morphology and the extent of aging. Aesthetic analysis is done by dividing the face into horizontal thirds and vertical fifths (Figure 51.4). It includes assessment of the skin surface, facial volume, and position of facial structures. The neck is included in the lower horizontal third of the facial analysis, because neck aging is also addressed with a facial rejuvenation surgery. Differences in width and length of each side of the face should be noted. The volume and position of tissues will define the need for asymmetrical undermining and SMAS elevation, or a combination of a facelift with fat grafting. 9

FIGURE 51.4 Upper third (periorbital zone) starts at the hairline (trichion) to mid cheek. Middle third (perioral zone) starts at the mid cheek (line over zygomatic arches) to the chin (mentum). Lower third goes from the mentum to the sternal notch and upper border of the clavicles. Lines crossing the inner and lateral canthus divide the face into vertical fifths.

Evaluation of the skin includes skin type, pigment changes, wrinkles, elasticity, and thickness. Dyschromias are common concerns for patients looking for facial rejuvenation and the choice of skin resurfacing often depends on the skin type. Poor skin elasticity and severe degree of wrinkling should alert the surgeon that a combination of surgery and resurfacing procedures would provide the best results. The Fitzpatrick classification is a useful guide for planning skin-resurfacing procedures. 10 Patients with Fitzpatrick skin type I–III are generally good candidates for skin resurfacing procedures such as dermabrasion, with lower risk of postinflammatory hyperpigmentation, hypopigmentation, and blotchiness. For patients with skin types IV–VI, the risks are weighed against potential benefits, and other treatments (nonablative laser rejuvenation, microneedling, and superficial chemical peels) may be considered. Special consideration should be given to certain skin pathologies. Patients diagnosed with cutis laxa, a rare connective tissue disorder that presents with varied degrees of loose hypoelastic skin throughout the body, are candidates for elective aesthetic surgery because there is no underlying issue with wound healing. Patients with genetic connective tissue disorders such as Ehlers-Danlos syndrome, pseudoxanthoma elasticum, elastoderma, progeria, and Werner syndrome have limited and

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unpredictable wound healing and should not undergo elective procedures. 11

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Anesthesia Evaluation Preoperative evaluation is performed by a thorough history and physical examination with the assistance of the anesthesia team. According to the American Society of Anesthesiology preoperative evaluation guidelines, preoperative tests should not be ordered routinely but may be required for purposes of guiding or optimizing perioperative management of selected patients. 12 If the patient has chronic medical issues, the preoperative evaluation may include an ECG, clearance from a specialist, X-rays, and adjustment of current medications. Secondary facelift patients are usually older and may require a more extensive preoperative evaluation and management in the postoperative period. Identification of highrisk patients for VTE events is done with the use of a modified Caprini risk assessment scale as proposed by the American Society of Plastic Surgery. 13 Perioperative pneumatic compression pump and early ambulation are useful for all facelift patients. For patients with Caprini scores higher than 7, 40 mg of subcutaneous enoxaparin is used as a single dose 8 to 12 hours postoperatively or extended to a week of treatment according to preoperative clinical evaluation.

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Facelift Techniques Incisions Facelift and necklift techniques include periauricular skin incisions, varying degrees of skin undermining, and different SMAS manipulation maneuvers. Incisions in front of the ear extend from the base of the ear lobe, into the pretragal or retrotragal area, and then transition along the hairline or into the temporal scalp. Incisions behind the ear are placed just anterior to the retroauricular crease and usually curve posteriorly at the level of the tragus into the hairline or into the occipital scalp (Figure 51.5). The term short-scar facelift was coined by Baker, referring to a limited incision length around the ear for patients who do not have severe skin laxity in the neck. 14

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FIGURE 51.5 The most common variations in the preauricular and postauricular scar placement for facelift and necklift surgery.

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Skin-only Lifts Subcutaneous lifts rely on the undermining of the skin flap only to improve facial aging. They have been used for over a century and have evolved from a limited undermining in the periauricular area to an extensive skin undermining releasing the main retaining ligaments in a superficial plane. Skin traction repositions the facial tissues and follows a superolateral vector of pull. Skin lifts are not universally popular as most surgeons prefer SMAS manipulation because of the tension that is placed adjacent to or in the suture line. 1,2

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SMAS Procedures Dual-plane Approach A dual-plane approach includes undermining of the skin flap and the superficial musculoaponeurotic system (SMAS) separately. It facilitates SMAS and the skin modification in different vectors. The soft tissue support of a dual plane approach is at the SMAS level rather than at the skin. The elevation vector of the SMAS is usually superolateral, and the vector of the skin redraping is usually posterolateral. The SMAS can be elevated as a flap (high SMAS technique), can be resected (SMASectomy), or can be plicated with or without tissue stacking (Figure 51.6). In the high SMAS technique, the SMAS flap is elevated at or above the zygomatic arch with medial dissection with at least partial transection of the zygomatic and masseteric-cutaneous ligaments for full mobilization of the cheek and jaw line. The platysma-cutaneous ligaments are preserved for proper elevation and fixation of the SMAS and to prevent the lateral sweep deformity. The subcutaneous undermining accompanies the SMAS undermining and extends anteriorly to include the area of the mandibular ligaments and the neck 15,16 (Figure 51.7).

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FIGURE 51.6 The different vectors of traction of the SMAS flap during a high-SMAS facelift. Vertical vector is used for elevation of midface, jowls, and neck. Lateral vector can be used for elevation of jowls and neck only.

The lateral SMASectomy technique was popularized by Baker and includes resection of a diagonal strip of SMAS from the malar eminence to the angle of the mandible, parallel to the nasolabial fold with posterior SMAS plication. The edges of the fix and mobile SMAS are brought together with sutures for elevation of the jowls and cheek 17 (Figure 51.8).

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FIGURE 51.7 Preoperative (left) and 3-year follow-up (right) photos of a woman in her 60s who underwent a high SMAS face and necklift with anterior platysmaplasty and partial platysma transection, upper and lower blepharoplasty, and lateral brow lift.

In the SMAS plication technique, there is no flap elevation or resection of SMAS. The edges of the fixed and mobile SMAS are simply plicated together with sutures. The vectors can be diagonally oriented such as in the lateral SMASectomy technique or vertically oriented, such as in the high SMAS technique, depending on the desired outcome. The SMAS stacking procedure proposed by Rohrich includes a limited lateral SMAS dissection and stacking of the SMAS during plication for volume increase in the lateral cheek. In the minimal access cranial suspension lift (MACS lift) developed by Tonnard, large purse-string suture

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loops are used to suspend the SMAS platysma in a cranial position instead of using the traditional individual plication sutures placed parallel to the nasolabial fold. 18,19

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Deep Plane (Composite) Approach The deep plane approach repositions the SMAS and skin as a single unit. The skin flap dissection in front of the ear is limited and there the transition into a skin–SMAS flap starts laterally, over the deep parotid fascia. 20 The skin–SMAS composite flap is suspended as a single structure in a superolateral vector. This composite flap is thick and has robust vascularization, being a good option for patients with potential would healing issues, such as smokers and diabetic patients. The critics of this technique point out that the skin of the neck is usually shifted into the facial skin, and adjustments of the skin and SMAS flaps cannot be performed independently and can cause artificial facial contour.

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FIGURE 51.8 Location of the lateral SMASectomy, which extends from the tail of the parotid to the lateral canthus.

In selected patients, other facial sub-SMAS procedures are needed to adjust facial volume and shape. 8 These include buccal fat pad excision or suspension and trimming of the parotid gland to reshape the

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face. Buccal fat pad may be approached through the mouth, through the temple, or through the subSMAS dissection. There is a close relationship between the buccal fat pad and branches of the facial nerve and the parotid duct.

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Fat Grafting Fat grafting is used to improve facial appearance by volumetric enhancement of deflated areas. Fat integrates well with facial tissues and when used in conjunction with a facelift, it can enhance the overall results. The most common fat injection locations are the midface, temporal fossa, periocular and perioral areas. Facial lines can also be treated with fat injections. Facial fat grafting should be performed by avoiding bolus injections or the use of large particle sizes. The most common fat grafting techniques and tools were developed by Coleman and Tonnard, and consist of small size harvesting and injection cannulas. Harvesting cannulas vary from 2.1 to 2.4 mm in diameter, and injection cannulas vary from 1.2 to 0.7 mm. 21,22 Microfat is a term that was coined by Tonnard and is defined as fat harvested in small particle sizes utilizing tumescent infiltration and small gauge harvesting cannulas (2.0–2.4 mm). Microfat can be used for facial volume restoration and is the preferred method used by the authors for volumization. Nanofat is a fat grafting derivate from emulsification of microfat. There are no viable fat cells in the nanofat solution. Adipose stromal cells are preserved in nanofat preparations and have been credited for the restorative skin effects seen with the nanofat use. Nanofat should not be used for volume enhancement, but as an adjuvant to skin quality improvement. Preparation of the fat through decanting, straining, washing, or centrifugation procedures seems to be equally effective for fat survival. Time from harvesting to injection seems to be the crucial point for optimal fat intake. The quicker the fat injected after harvesting the better the result. 24 Exact fat grafting survival is still uncertain, with reported rates of fat grafting survival varying from 40% to 80%. Therefore, overcorrection is necessary for long results. The use of fat grafting can enhance results, but increase operating room time, postoperative bruising, and swelling. Obtaining fat from multiple sites may be needed for thin patients and may help prevent donor site deformities.

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Neck Contouring Techniques Necklifts can be performed in isolation or combined with a facelift, and all facelift procedures will have some effect on the neck (Table 51.1). The goal of neck rejuvenation is to modify and improve the submental area and cervicomental angle. Depending on the patient’s anatomy and morphology, the surgical options may include single or combined strategies that reduce the fat, remove skin, or modify the muscles and deeper structures of the neck. TABLE 51.1 Decision Making and Patient Selection for Treating the Aging Neck Skin Good elasticity Good elasticity Laxity

Fat Yes Yes Yes/no

Platysma Laxity ± 
 Subplatysma Volume None Yes Yes/no

Treatment Liposuction Submental necklift Necklift Anterior neck resection

The most common surgical techniques for neck rejuvenation are liposuction for superficial fat contouring, platysmaplasty for muscle and fascia plication and reshaping, subplatysmal work for treatment of the subplatysmal fat excess, digastric muscles and submandibular glands, lateral skin excision of the neck flap, or direct anterior neck resection.

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Liposuction The neck contains fat in the subcutaneous tissue between the skin and platysma muscle and in the deep plane under the platysma, between the platysma medial borders, and above the digastric muscles. To differentiate between subcutaneous fat and deep fat during the clinical exam, the submental fat is pinched and the patient is asked to grimace to contract the platysma muscle. If the amount of fat does not change with contraction, it indicates that most of the fat is subcutaneous and liposuction is a good option for fat removal. If the fat pinch diminishes upon contraction, most of the fat is subplatysmal requiring an open neck procedure to remove the fat. The amount of fat in each plane varies according to patient’s weight and anatomy and is usually more abundant in the central submental area. Liposuction can be used to remove superficial fat between the skin and platysma. Used in isolation for neck reshaping, it is ideal for patients who have good skin tone and elasticity. Liposuction is also combined with necklift procedures. All liposuction modalities such as suction assisted liposuction (SAL), power-assisted liposuction (PAL), ultrasound-assisted liposuction (UAL), and laser-assisted liposuction (LAL) can be used. Small cannulas (size 2–3) are recommended to prevent excessive resection of fat and surface irregularities.

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Platysmaplasty and Subplatysmal Procedures The platysma is a pair of superficial muscle of the neck that originates from the pectoralis major muscle fascia and inserts into the mentum and the inferior mandibular border. Its fibers ascend into the lower face connecting to the depressor anguli oris and to the orbicularis oris. It is the extension of the SMAS in the lower face and neck. Within the submental area, the anatomy and the level of midline decussation between the muscles varies greatly from individual to individual. Cardoso de Castro classifies the platysma decussation into Type 1, 2, and 3. Type 1 is the most common (75%) with limited submental decussation. Type 2 (15%) shows decussation from the mandibular symphysis to the thyroid cartilage and Type 3 (10%) shows no decussation. Stuzin discussed the importance of the platysma retaining ligaments in the aging neck. These ligaments are a series of fibrous bands connecting the mandibular symphysis to the thyroid and once attenuated contribute to platysma descent, band formation, and the oblique cervical angle of the aging neck. Platysma work is indicated in patients with neck laxity and the presence of platysma bands. Submental necklifting consists in treatment of the central neck through a submental incision. The submental necklift may be performed in isolation or in combination with a facelift. The submental incision is placed just posterior to the submental crease, with subsequent flap elevation with scissors or electrocautery, liposuction or direct resection of the subcutaneous fat if necessary, and a combination of central platysma plication (anterior platysmaplasty) with or without transection of the medial platysma borders. The extension of the transection usually depends on the thickness and location of the bands and helps with neck reshaping. 20 Anterior platysmaplasty consists of suturing the medial platysma borders from the submental area to the thyroid cartilage for tightening of the neck. The borders of the muscle can be simply approximated or overlapped with or without transverse partial or complete platysma transection to weaken the platysma bands. Transections usually start centrally at the level of the cricoid cartilage and extends laterally, but this maneuver can also be performed from lateral to medial through the facelift incision. Absorbable and permanent sutures may be used for plication through simple or continuous running sutures. Other structures that influence the neck shape and aesthetics are located deep into the platysma muscle, such as the subplatysmal fat, the anterior belly of the digastric muscles, and the submandibular glands. The digastric muscles are paired and have an anterior and a posterior belly. The anterior bellies extend from the posterior mandibular symphysis to the lesser cornu of the hyoid bone. The anterior belly and posterior belly of each digastric muscle form two sides of the submental triangles. The submandibular glands are located in the submental triangles and can produce a visible bulge in the lateral neck. The facial artery and vein and the marginal mandibular branch of the facial nerve crosses the gland superficially outside its capsule. The safest approach to the gland is intracapsular resection to avoid neurovascular injury. To access these deep structures, the surgeon should elevate the central platysma borders. Partial but not complete subplatysmal fat is known to avoid submental depression. When prominent, the anterior belly of the digastric can be partially or totally excised without noticeable loss of function. Enlarged submandibular glands can be visualized laterally to the anterior belly of the digastric muscles. The superficial lobe of the gland is exposed into the operating field by an Allis forceps or a strong suture placement through the gland. The capsule is incised with needle-tip cautery, and the gland excess resected piecemeal until ideal contour of the submandibular area is achieved. Thorough gland hemostasis is important to avoid hematoma in this area and the risk of airway obstruction.

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Direct Anterior Neck Resection Direct resection of the submental skin and fat excess with or without platysmaplasty is an option for neck rejuvenation in selected patients. Good candidates for direct neck resection are usually males or older patients of both genders who tolerate a central and more visible scar, who are not suitable for longer operations or prefer a less extensive procedure. In an anterior neck, the superficial and deep planes of the neck can be resected. Different incision designs have been proposed and straight resections are avoided to prevent banding and scar contraction. Most incision patterns are variations of z-plasty in the midline. Visible scars, hypertrophic scars, and long lasting scar erythema are some of the downsides of this approach.

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Postoperative Management The use of drains under the skin flap is a common practice for neck and facelift. Small size Jackson-Pratt drains to bulb suction are usually left on each side of the face for 24 h after surgery. Drains have not shown to prevent hematomas or seromas but are advocated by many authors to help decrease the amount of swelling and bruising after a facelift and help the patient return quickly to social activities. 15 Facial dressings and head wrapping are commonly used after face and necklifts and removed 24 h after surgery. After this, a compressive, nonbinding chin strap or garment is recommended for a couple of weeks. Head elevation during sleep can help with swelling, as well as low salt intake in the postoperative period.

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Complications Face and necklifts are considered safe procedures with a low overall complication rates. According to a 2016 large prospective cohort study by Gupta et al., the incidence of facelift complications that need hospitalization within 30 days of surgery is 1.8%. Hematoma (1.1%) and infection (0.3%) were most common. The same study found male gender an independent factor for hematoma. Body mass index >= 25 and combined procedures increased the infection risk. 25 Hematoma is the most common early complication of a face and necklift and it usually occurs in the first 24 to 48 h after surgery. The overall incidence of all (minor-large) postoperative hematoma is variable due to lack of consistent classification, usually reported to be 4% to 8% for men and 1% to 3% for women. Minor hematoma is defined as a collection of blood that does not require surgical evacuation but is amenable to treatment by bedside aspiration, with volumes under 30 cc. An expanding hematoma is a serious complication with an incidence of 1.8% that requires immediate recognition and treatment due to impending risk of skin necrosis, airway obstruction, and death. Minor hematomas can lead to persistent face and neck edema, nerve compression, skin necrosis, and unpleasant aesthetic results. Several strategies have been proposed to decrease the incidence of post facelift hematoma. Strict blood pressure control in the operating room (SBP < 150 mm Hg) is a widely recognized preventive intervention. Antihypertensive clonidine has been used successfully in the postoperative period to keep SBP under 140 mm Hg. The use of fibrin glue, absence of epinephrine in the local anesthetic solutions, and compressive dressings have been reported to be beneficial but are not completely effective in preventing hematomas. A few recent studies have demonstrated that the use of quilting sutures is a promising strategy in prevention of hematoma in the face by reducing the rate of hematoma to zero in the published series. 26 Injuries to motor and sensory facial nerves are also acute complications of face and necklift. The great auricular nerve is the most commonly injured nerve and will lead to numbness of the lower part of the ear and earlobe. Its superficial location on the sternocleidomastoid muscle surface places the nerve at risk of transection during the neck flap dissection. Nerve compression by sutures during platysma suspension can also cause numbness and chronic pain. 7 Injury to the marginal mandibular branch of the facial nerve results in weakness of the ipsilateral lower lip depressors (denervation of the depressor anguli oris). It also affects the ipsilateral mentalis muscle. Neurapraxia is more common than complete nerve transection in this area, and can return within a few days to 3 to 6 months. Another common cause of nerve dysfunction in the immediate postoperative period is temporary paralysis of the facial nerves due to injection of local anesthetic in the dissected areas. It usually takes a few hours for the local anesthetic to wear off. Smoking can increase the chance of skin necrosis and poor wound healing after cosmetic surgery. 27-29 Rees found that the incidence of skin slough after facelift was 7.5% in smokers compared to 2.5% in nonsmokers. A recent systematic review and meta-analysis by Rohrich shows that at least 4 weeks of abstinence from smoking reduces respiratory and wound-healing complications. Skin necrosis is initially managed with local wound care. They can heal as wide or hypertrophic scars, and further treatments with steroid injections or excision of the scars and flap readvancement are common treatments. Poor wound healing can be a consequence of poorly planned incisions, too much tension placed on the skin during closure, or poor healing characteristics related to ethnicity (Asians, African Americans). The “pixie ear” deformity is a known tell-tale sign of previous facelift. It is caused by tethering and forward rotation of the base of the lobule due to excessive tension during wound closure and distortion of natural axis of rotation of the lobule. Other tell-tale signs of previous facelifts are “joker lines”, “lateral sweep”, postauricular banding, facial deformities related to abnormal SMAS and skin traction, suturing points, or noncorrection of facial deflation.

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Secondary facelifts have similar complications to a primary procedure, and the timing for a secondary facelift is in average a decade after the first procedure. Secondary facelift patients are older and usually have thinner tissues. Ancillary procedures such as skin resurfacing and fat grafting are often added to secondary facelifts to improve outcomes. Beale at al proposed the “five Rs” or tenets for performing a sound secondary rhytidectomy: (1) resect skin/scar, (2) release abnormal vectors, (3) refill by fat grafting, (4) reshape with SMAS procedures, and (5) redrape skin. 30

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Questions 1. A 62-year-old healthy woman comes to the office for her preoperative visit in preparation for her facelift surgery in 2 weeks. You explain the risks and benefits of the surgery, and she asks what the most common complication of a facelift is. What do you answer? a. Facial nerve injury b. Skin necrosis c. Seroma d. Hematoma e. Infection 2. A 59-year-old woman comes back to the office for follow-up 3 months after surgery. She is pleased with the aesthetic results but refers complete numbness of the left earlobe. Which nerve was most likely injured during the surgical procedure? a. Posterior auricular nerve b. Spinal accessory nerve c. Cervical branch of the facial nerve d. Great auricular nerve e Mandibular branch of the facial nerve 3. During the 2-week follow-up visit of a patient submitted to a high SMAS face and necklift, you noticed a 3 × 4 cm dark patch of skin in the left postrauricular area adjacent the retroauricular suture line. There is no redness or secretion in the area. Which of the following is the most appropriate next step to manage this patient? a. Placement of a negative pressure treatment b. Wide debridement c. Debridement and full thickness skin graft d. Local wound care e. Oral antibiotics for a week 4. Hematoma is a common complication of facelift surgery. Which of the follow options is a known risk factor for this complication? a. Operation performed in an office-based facility b. Hyperthyroidism c. Loose surgical dressing d. History of previous hematoma e. Male gender 5. Six months after a primary facelift with SMASectomy, a 70-year-old man comes back for followup. He was overweight and has lost 15 lb since surgery. Now he complains of midface hollowing, depressed temporal area and visible marionette lines. On examination, there is deflation of temples, midface, and perioral area with good tension on the skin. What is an appropriate option for improving this patient’s concerns? a. SMAS plication procedure b. Chemical peels c. Placement of cheek implants d. Laser resurfacing e. Fat grafting to the face 1. Answer: d. The most common complication of a facelift is a hematoma, with an incidence that

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varies from 1% to 8% in most series. Hematoma that requires surgical evacuation in the operating room has an incidence of 1.8% according to a large prospective study from Gupta et al. Minor hematomas can be drained at the bedside and are likely underreported. Facial nerve injury, skin necrosis, seroma, and infection are not the most common complications of a facelift. Infection is the second most common complication that requires hospital admission within 30 days of surgery. 1,25 2. Answer: d. The overall incidence of nerve injury in facelift surgery is low. Transection of the great auricular nerve is the most frequent nerve injury of facelift surgery, with an estimated incidence of up to 2.6%. Common symptoms associated with great auricular nerve injury are numbness of the earlobe, concha, and posterior auricle or focal pain in case of nerve entrapment from suture placement around the nerve or from neuroma formation. The nerve is located about 6.5 cm inferior to the external auditory canal on the surface of the sternocleidomastoid muscle. 6,7 3. Answer: d. Minor wound issues are known complications of facelifts. The initial treatment is daily local wound care without debridement. In the absence of infection, the eschar will act as a biological dressing and reepithelialization occurs with minor consequences, most commonly wide or hypertrophic scars. Unfavorable scars can be further treated with steroid injections, local resection, or flap readvancement to improve tension upon closure. 1,2 4. Answer: e. According to a 2016 large prospective cohort study by Gupta et al., the incidence of facelift complications that need hospitalization within 30 days of surgery is 1.8%. Hematoma (1.1%) and infection (0.3%) were most common. This same study found male gender an independent factor for hematoma. The same study showed that operations performed in an office-based facility have less risk of hematoma and infection. Surgical dressing, use of drains, and a history of previous hematoma are not risk factors for hematoma after facelift. 1,2,25 5. Answer: e. Facial aging, weight loss, and systemic diseases can cause facial deflation. When there is minimal or no skin laxity associated with facial deflation as in this case, fat grafting is a good option to improve facial deflation by itself. It can be used in combination with a facelift (lift and fill technique). The most common fat injection locations are the midface, the temporal fossa, the periocular, and the perioral areas. Facial lines can also be treated with fat injections. Facial fat grafting should be performed with a proper technique, avoiding bolus injections or the use of large particle sizes. Synthetic fillers such as hyaluronic acid fillers can also be used to improve facial deflation. 5,9,21,22

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References Mustoe, T, Park, E. Evidence-based medicine face lift. Plast Reconstr Surg. 2014;
 133:1206. Wan, D, Small, KH, Barton, FE. Face Lift. Plast Reconstr Surg. 2015;136:676e-689e. Alghoul, M, Codner, MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33(6):769–782. Mitz, V, Peyronie, M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;58:80–88. Rohrich, R, Pessa, J. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121(5):1804–1809. Roostaeian, J, Rohrich, RJ, Stuzin, JM. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg. 2015;135(5):1318–1327. Rohrich, RJ, Taylor, NS, Ahmad, J, Lu, A, Pessa, JE. Great auricular nerve injury, the “subauricular band” phenomenon, and the periauricular adipose compartments. Plast Reconstr Surg. 2011;127(2):835–843. Seckel, BR. Facial danger zones: avoiding nerve injury in facial plastic surgery. Can J Plast Surg. 1994;2(2):59–66. Rohrich, RJ, Pessa, JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–2212. Fitzpatrick, TB. The validity and practicality of sun-reactive skin types I through VI. Arch Dermatol. 1988;124(6):869–871. Nahas, FX, Sterman, S, Gemperli, R, Ferreira, MC. The role of plastic surgery in congenital cutis laxa: a 10-year follow-up. Plast Reconstr Surg. 1999;104(4):1174–1178; discussion 1179. Practice advisory for preanesthesia evaluation: an updated report by the american society of anesthesiologists task force on preanesthesia evaluation. Anesthesiology. 2012;116(3):522–538. Wilkins, EG, Pannucci, CJ, Bailey, SH, et al. Preliminary report on the PSEF Venous Thromboembolism Prevention Study(VTEPS): validation of the Caprini Risk Assessment Model in plastic and reconstructive surgery patients. Plast Reconstruc Surg. 2011;126(4):107. Baker, DC. Minimal incision rhytidectomy (short scar face lift) with lateral SMASectomy: evolution and application. Aesthet Surg J. 2001;21:14–26. Marten, TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek and midface. Clin Plast Surg. 2008;35(4):569–603. Trussler, AP, Stephan, P, Hatef, D, Schaverien, M, Meade, R, Barton, FE. The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique. Plast Reconstr Surg. 2010;125:1221–1229. Baker, DC. Lateral SMASectomy. Plast Reconstr Surg. 1997;100:509–513. Saylan, Z. The S-lift for facial rejuvenation. Int J Cosmet Surg. 1999;7:18–23. Tonnard, P, Verpaele, A, Monstrey, S, et al. Minimal access cranial suspension lift: 
 a modified S-lift. Plast Reconstr Surg. 2002;109:2074–2086. Stuzin, JM, Feldman, JJ, Baker, DC, Marten, TJ. Cervical contouring in face lift. Aesthet Surg J. 2002;22(6):541–548. Coleman, SR. Structural fat grafting: more than a permanent filler. Plast Reconstr Surg. 2006;118(3 suppl):108s–120s. Tonnard, P, Verpaele, A, Peeters, G, et al. Nanofat grafting: basic research and clinical application. Plast Reconstr Surg. 2013;132(4):1017–1026. Sinno, S, Wilson, S, Brownstone, N, Levine, SM. Current thoughts on fat grafting: using the evidence to determine fact or fiction. Plast Reconstr Surg. 2016;137(3):818–824. Rohrich, RJ, Ghavami, A, Constantine, FC, Unger, J, Mojallal, A. Lift-and-fill face lift: integrating the fat compartments. Plast Reconstr Surg. 2014;133:756e-767e. Gupta v, Winocour J, Shi H, Shack RB, Grotting JC, Higdon KK. Preoperative risk factors and complication rates in facelift: analysis of 11,300 patients. Aesthet Surg J. 2016;36(1):1–13. Neto, JC, Rodriguez, DE, Boles, FM. Reducing the incidence of hematomas in cervicofacial rhytidectomy: new external quilting sutures and other ancillary procedures. Aesthet Plast Surg. 2013;37(5):1034–1039. Krueger, JK, Rohrich, RJ. Clearing the smoke: the scientific rationale for tobacco abstention with plastic surgery. Plast Reconstr Surg. 2001;108:1063-1073; discussion 1074–1077. Rees, TD, Liverett, DM, Guy, CL. The effect of cigarette smoking on skin-flap survival in the face lift patient. Plast Reconstr Surg. 1984;73(6):911–915. Wong, J, Lam, DP, Abrishami, A, Chan, MT, Chung, F. Short-term preoperative smoking cessation and postoperative complications: a systematic review and meta-analysis. Can J Anaesth. 2012;59(3):268–279. Beale, EW, Rasko, Y, Rohrich, RJ. A 20-year experience with secondary rhytidectomy: a review of technique, longevity, and outcomes. Plast Reconstr Surg. 2013;131(3):625-634.

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Seminal articles Mitz, V, Peyronie, M. The superficial musculo-aponeurotic system (SMAS) in the parotid and cheek area. 1976. Plast Reconstr Surg. 58:80–88. The first detailed anatomic description of the superficial facial fascia. The authors called it the superficial musculo-aponeurotic system, stablishing the acronym SMAS in facial surgery Alghoul, M, Codner, MA. Retaining ligaments of the face: review of anatomy and clinical applications. Aesthet Surg J. 2013;33(6):769– 782.Review article that clarifies the anatomy and nomenclature of the retaining ligaments of the face and its importance in facial rejuvenation surgery. Marten, TJ. High SMAS facelift: combined single flap lifting of the jawline, cheek and midface. Clin Plast Surg. 2008;35(4):569–603. Comprehensive description of the high-SMAS flap surgical anatomy and technique for face and neck rejuvenation. Gupta, v, Winocour, J, Shi, H, Shack, RB, Grotting, JC, Higdon, KK. Preoperative risk factors and complication rates in facelift: analysis of 11,300 patients. Aesthet Surg J. 2016;36(1):1–13. Large prospective study with current data evaluating risk factors and complication in face lift patients. Rohrich, RJ, Pessa, JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–2212. Facial deflation is an important feature of facial aging. The authors describe the fat compartments of the face and its implications in facial rejuvenation surgery.

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CHAPTER 52

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Rhinoplasty Robert H. Gilman and Jeremy Warner

Key Points Nasal surgery requires accurate evaluation, assessment, and treatment of both aesthetic and functional components. Rhinoplasty surgery can be approached through both open and closed approaches, and there are a number of factors that will direct the surgeon on the most appropriate approach. Thorough knowledge of the functional aspects of nasal surgery is critical to prevent postoperative functional airway issues. There is a range of technical maneuvers available, from basic to complex, for safe and effective rhinoplasty, septorhinoplasty, and revision rhinoplasty. The rhinoplasty surgeon will need to have knowledge of both short-term and long-term facets of the healing process. Although rhinoplasty and revision rhinoplasty share many commonalities, there are specific issues with revision rhinoplasty surgery that the surgeon must be aware of.

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Terminology Table 52.1 contains terms associated with rhinoplasty. TABLE 52.1 Terminology Associated with Rhinoplasty Alae/ala: The outer skin of the nostrils from the nostril margin to the skin overlying the alar cartilage making up the lateral surface of the external nose and composed of fibrofatty tissue Alar groove: The transition between the alae and the lateral nasal sidewalls, defined by a shadow or crease Anatomic dome: The area of transition between the medial and lateral crura of the alar/lower lateral cartilage. The anatomic dome usually but not always corresponds to the most projecting point of the nasal tip (the clinical dome). Anterior septal angle: The junction of the caudal septum and the dorsal septum Anterior: Toward the forward surfaces on lateral view Cartilage-splitting incision: Intranasal incision within the body of the lower lateral cartilage Caudal septum: The caudal most portion of the cartilaginous septum Caudal: Toward the nostrils or the same as inferior when referring to the nose Cephalic: Toward the root or radix of the nose for the same as superior when referring to the nose Clinical dome: The apparent point(s) of maximum projection of the tip Columella: The anatomic columnar structure of the nose that includes the paired lower medial crura of the lower lateral cartilages and its surrounding soft tissues. Columellar labial angle: Formed by the angle between the columella and the upper lip. This angle is not dependent on the nasal base position, as in the nasolabial angle. Columellar lobular angle: The angle formed at the junction of the columella and the infratip lobule. The angle is usually 35°–45° in females and 0°–35° in males. Dorsal aesthetic lines: Imaginary lines starting at the medial edge of the brows and tracing a gentle curve down the lateral side of the dorsum to the tip-defining points. Dorsal: Along and toward the bridge of the nose, either on anterior-posterior or anterior on a lateral view External nasal valve: Corresponds to the support of the nostril with deep inspiration. A competent valve will keep the nostril open during deep inspiration Hemitransfixion incision: An incision along one side of the caudal septum, not going through and through only Infratip lobule: Transition area between the tip (domes) and the columella Intercartilaginous incision: Intranasal incision between the upper and lower lateral cartilages Internal nasal valve: Supportive functional opening within the nasal cavity at the junction of the lower lateral and upper lateral cartilages (scroll area), the angle of which is defined by the septum and the upper lateral cartilage as it diverges from the septum. An angle of less than 15° may contribute to a greater tendency for valvular insufficiency on inspiration. Keystone area: The area where the bone structures meets the cartilage structures along the dorsum of the nose Lateral alar crus (crura): Lateral wing of the alar cartilage Lower lateral cartilages: Paired cartilage structure of the nasal tip also known as the alar cartilage and composed of the medial and lateral crura and dome. It gives support to the nostrils and the external nasal valve and gives rise the tip shape Marginal incision: An incision caudal to the lower lateral cartilage Medial alar crus (crura): medial wing of the alar cartilage Menton: The most inferior point of the mandible/chin as seen on lateral view of a cephalogram Nasal horizontal facial plane: Corresponds to the Frankfort Horizontal line, the plane defined by a 90° plane from the vertical facial plane, with the line drawn from the inferior portion of the external auditory canal to the bony inferior orbital rim Nasal pyramid: Corresponds to the bony structure of the upper nose, pyramidal in shape Nasal septum: The anatomic structure that separates the nasal airway into two separate nasal cavities, with a portion being cartilaginous and a portion being bony Nasal turbinate: Intranasal mass structures consisting of mucosa, erectile tissue, and thin bone, which helps to humidify and control the flow of air as it passes through the nose. Of the three turbinates located on each side, the inferior turbinate is the most important. Nasolabial angle: Formed by a line drawn through the anterior and posterior ends of the nostril and vertical facial plane. The angle is usually 95°–100° in females and 90°–95° in males. Pogonion: The most anterior projection of the mandible as seen on a cephalogram Pyriform aperture: Area of the bony midface that corresponds to the nasal cavity opening Radix: The area deepest point of transition of the bony forehead to the bony upper nose Scroll area: The area where the cephalic edge of the lower lateral cartilage interlocks with the caudal edge of the upper lateral cartilage. Sesamoid cartilages: Accessory lateral cartilage structures lying between just lateral to the lower lateral cartilages and the pyriform aperture. Soft triangle/facet: On basal view, the area of transition between the columella and the nostril rim, corresponding to the area just caudal to the domes where there is no cartilaginous structure Stomion: Midpoint of the oral fissure with the lips closed

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Supratip: The area just above the tip or the transition area between the dorsum and tip Tip: Includes the paired alar cartilages (lower lateral cartilages), tip complex, columella, and nostrils Tip-defining points: Refers to the light reflex on the outer skin corresponding to the structural paired cartilaginous domes. Ideally, they are paired, symmetrical, and distinct. Tip projection: Refers to how far the nasal tip projects from the face. There are multiple ways to determine tip projection. One of the more common ways is to measure two lines: (A) the length from the nasal base crease to the tip on lateral view and (B) the length of nose on lateral view from radix to nasal tip. Line A should be about 0.67 the length of B (B divided by A = 0.67). Tip rotation: Refers to the angle of rotation of the nasal tip. There are multiple ways to measure tip rotation. One of the more common ways is to draw a line from the alar base crease to the nasal tip and compare this angle to the vertical facial plane. Transcolumellar incision: Incision used in an open rhinoplasty approach, along the mid columella, to allow nasal flap elevation. Most surgeons use either a “stairstep” or an “inverted V” Transfixion incision: A through-and-through incision that is made along both sides of the caudal septum Upper lateral cartilages: Paired cartilages along the middle third of the structural nose, extending from the septum medially to the pyriform bones laterally and from the cephalic border of the lower lateral cartilage to the nasal bone. The nasal bone overlaps the cephalic edge of the upper lateral cartilage. Vertical facial plane: Defined by a 90° plane from the Frankfort horizontal

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Nasal Anatomy (Figure 52.1)

FIGURE 52.1 Nasal anatomy. A. Nasal septum. B. Lateral view. C. Anterior-posterior view. D. Internal side wall.

Skin: Thicker over the upper and lower third of the nose and thinner over the middle third muscleosseocartilaginous framework Bones: Nasal, frontonasal process, and palatal crest of the maxilla, nasal process of the frontal, perpendicular plate of the ethmoid, vomer Cartilage: Upper lateral and lower lateral, accessory, sesamoid, quadrangular Arterial blood supply (Figure 52.2) External nose Internal carotid-ophthalmic-anterior ethmoid-external nasal branch of anterior ethmoid Lateral nasal External carotid-facial-angular-lateral nasal

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Superior labial-columellar External carotid-maxillary-infraorbital Internal nose Internal carotid-ophthalmic-anterior and posterior ethmoid External carotid-sphenopalatine and greater palatine Angular and labial Venous blood supply Generally follows the arterial supply The nasal veins do not have valves The nasal venous system has direct communication to the cavernous sinus, thus making nasal infections potentially a life-threatening event Nerve supply (Figure 52.3) Trigeminal-ophthalmic-nasociliary-anterior ethmoid: supplies the anterior half of nasal cavity External branch of the anterior ethmoid: supplies the nasal skin from rhinion to tip Posterior ethmoid: supplies the superior half of nasal cavity Infratrochlear: supplies the nasion and bony dorsum Mucosa The vestibule is lined by hair-bearing squamous epithelium up to the level of the caudal margin of the alar cartilage, where it transitions to pseudostratified ciliated columnar respiratory epithelium with abundant seromucinous glands

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FIGURE 52.2 Nasal arterial supply.

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FIGURE 52.3 Nasal nerve supply.

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Functional Nasal Conditions Physiologic: airway obstruction caused by nonanatomic, nonmechanical conditions Allergy External irritants Tobacco Medications Vasomotor rhinitis Rhinitis medicamentosa Nasal sinus disease Sexual or emotional stimulation Hyperthyroidism Pregnancy Anatomic: airway obstruction caused by mechanical or anatomic impingement on the physical airway Congenital or acquired nasal septal deviation Congenital or acquired nasal bony deviation Congenital or acquired nasal cartilage weakness Internal valve collapse External valve collapse Nasal turbinate bone and/or mucosal hypertrophy Nasal polyps Synechiae

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Patient History and Examination Patient Concerns and Goals It is very important to determine exactly why patients seek a consultation for potential nasal surgery. The patient is asked to look at a mirror and describe exactly what they see, what bothers them, and specifically as possible in what ways they would change their nasal appearance. The patient is told that for the purposes of the exam they can assume that anything that they might want changed can be done but they are also told that in reality it may not be possible. It is incumbent upon the surgeon to assess that the patient’s goals are indeed realistic. A patient with a concern that is disproportionate to the actual degree of deformity that is present should be approached with great caution. 1-3

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Aesthetic Nasal History History and nature of any nasal trauma Pretrauma photos when available Emergency department (ED) notes and radiologic exam records when available. Note whether closed reduction or surgical intervention was attempted Operative reports when available Presence of nasal obstructive symptoms related to trauma or disease Constant Intermittent Epistaxis and or rhinorrhea

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History of Previous Nasal Surgery Copy of operative notes when available

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Psychological History Consider psychologic consultation and clearance Be aware of body dysmorphic disease

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Current Medications Medications that can increase nasal obstruction Negative medication interactions Feedback from prescribing medical doctor regarding medication stops for surgery Adequate control of unrelated systemic medical conditions

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History of Bleeding Disorders or Difficulties With Previous Surgeries Hematology consultation when necessary Anesthesia consultation when necessary

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Current Employment Need to factor in recovery time off work Physical labor versus desk job

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Current Physical Activities Time away from vigorous exercise, gym, working out, or running

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Health History Epistaxis Rhinorrhea Allergies Work and home environmental assessment (exposure history) Chronicity, seasonality Medications Previous surgery History of cocaine abuse

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Physical Examination External evaluation Cottle testing Anterior rhinoscopy before and after vasoconstriction Nasoendoscopy (if available) Rhinomanometry (if available)

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Diagnostic Testing CT scanning MRI Allergy testing

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Focused Nasal Examination External Examination Apparent length and projection of the nose Dorsal profile Symmetry of the external nose, including deviations Width of the alar and bony bases Visible and/or palpable bony and/or cartilaginous irregularities Condition of the nasal skin and its thickness or thinness Presence or absence of nasal scars and skin lesions Size, shape, and width of the nostrils Presence of prominent medial crural footplates Degree of columellar show

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Internal Examination Cottle tests for both internal and external valve dysfunction first without and then with vasoconstrictor 4 Anterior rhinoscopy with evaluation of the nasal mucosa, its moisture, and color The presence or absence of discharge The presence or absence of nasal polyps The shape and alignment of the caudal nasal septum and caudal aspect of the nasal turbinates particularly inferior turbinate The presence of any nasal septal perforations The presence of scars or scar contracture along with signs of previous nasal surgery If the patient has had previous nasal surgery palpation of the nasal septum with a Q-stick can identify whether cartilage has been previously removed. If available, nasoendoscopy can be performed under topical anesthesia to better visualize the posterior aspects of the nasal airway including the posterior septum and turbinates.

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Computer Imaging The use of computer imaging can help to determine the types of changes that can reasonably be made, and it is a visual way of demonstrating the surgeon’s concept of the change in the patient’s nose directly to that patient. It is important to stress to the patient that computer-imaged results cannot be construed as a guarantee of that exact result. The computer image is a tool that allows the patient and the surgeon to view the same proposed result at the same time. 5,6

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Nasal Analysis Much has been previously published regarding the ideal nasal aesthetics. 7-9 Byrd analysis looks at idealized relationships between nasal landmarks. Comparison of these idealized measurements with the patient’s actual measurements suggests quantifiable changes that can be made in that patient’s nose. Computer image analysis uses the surgeon’s aesthetic eye to draw the planned change in the patient’s nose and then figure what maneuvers are needed to achieve those changes. At this time, the projection or lack thereof of the chin can be analyzed on the lateral photographs by using either Byrd analysis or computer-imaged change. This is one of the few areas where a procedure not directly mentioned by the patient may be legitimately proposed. The use of computer imaging can be very helpful in this situation to demonstrate the change that can be made by genioplasty. General analytic guidelines have limitations based on variability of ideals presented by racial, age, and gender differences. 10-12 The facial thirds (Figure 52.4A): Transverse lines drawn tangent to the hairline, brow at the level of the supraorbital notch, nasal base, and at the chin (menton) roughly divide the face into thirds. The forehead third shows significant variability because of the differences in forehead height as determined by hairline. The lower third of the face can be subdivided into thirds by adding a horizontal line at 
 the level of the oral commissures (stomion). The upper third defines the upper lip including the Vermillion while the lower two thirds define the lower lip and chin. Attention to these measurements helps the surgeon to assess overall maxillofacial harmony. Underlying facial disharmony should be discussed with patients prior to any facial aesthetic surgery (not just rhinoplasty) to ensure that the patient understands what is beyond the scope of the planned surgery. The facial fifths (Figure 52.4B yellow lines): Vertical lines are drawn tangential to the periphery of the ears on both sides, the lateral canthi on both sides, and the medial canthi on both sides. Ideally, each segment to the face defined by these vertical lines should be of equal width. Midline facial vertical (Figure 52.4B, black line): A line drawn from the midglabella to the menton. This line can be used to help determine nasal symmetry in the anterior-posterior view Dorsal aesthetic lines (Figure 52.5A): These are curved and opposing lines traced from the super orbital ridges curving in toward the keystone area and then flaring slightly as they curve outward toward the tip-defining points. Alar base width (Figure 52.5B): This distance should be roughly equal to the distance between the medial canthi, as in lines labeled a. Bony base width (Figure 52.5B): This distance should be roughly 80% of the distance between the medial canthi, as in lines labeled b. Alar rim orientation (Figure 52.5C): The alar rims should be symmetrical and flare slightly in it inferolateral direction anterior tip assessment: the supratip break, tip-defining points, and columellar lobular angle are used to define two opposing triangles over the tip of the nose. The intersecting bases of these triangles form a horizontal line through the tip-defining points. These triangles should be roughly symmetrical. Gull wing line (Figure 52.5D): A line drawn along the superior border of the ala from one side curving around the columellar to the other side should describe a gentle curve similar to the sweep of a seagull in flight. Opposing equilateral triangles (Figure 52.5E): Draw two equilateral triangles with their bases opposed to one another. The corners of the diamond thus formed are the two tip-defining points—the supratip break and the columellar lobular angle. These structures should ideally be symmetrical. Base view triangle (Figure 52.6): In the worm’s eye view, a triangle is drawn with its base horizontally through the alar bases and its sides, tangent to the lateral nasal walls. This should form an equilateral triangle.

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Lobular to nostril ratio (Figure 52.6): The nostril should be two thirds and the lobule one third of the nasal height in the worm’s eye view. Nostril shape (Figure 52.6): The nostrils should be roughly teardrop shaped with the base wider than the apex and with the axis oriented in a slight medial direction from based apex. Nasal length (Figure 52.7): The apparent length of the nose from radix to tip. This should be approximately the same as the distance from the stomion to the menton. Perceived nasal length: The apparent length of the nose can be changed by changing the position of the nasal frontal angle or the tip-defining point. Decreasing the rotation of the tip and/or elevating the area of the radix thus moving the nasal frontal angle cephalad will give the perception of a longer nose while increasing tip rotation and/or lowering the radix thus moving the nasal frontal angle caudad will give the appearance of shortening the nose. In addition, a more anterior position of the nasal frontal angle can make the nasal tip look less projecting while a more posterior or deeper position for the nasal frontal angle can make the nasal tip look relatively more projecting. Horizontal ideal chin position (Figure 52.8A): A vertical line can be drawn from a point that is one-half the distance between the radix and the nasal tip and tangent to the anterior most projection of the upper lip. The anterior most projection of the lower lip should be about 2 mm posterior to this line. A parallel line dropped from the anterior most projection of the lower lip should be anterior to the anterior projection of the chin in women and should be tangent to the anterior projection of the chin in men. Nasolabial angle (Figure 52.8B): The angle that is formed between the facial vertical line and the line drawn through the most anterior and posterior edges of the nostril. The degree of rotation of the nasal tip is assessed by evaluating the nasolabial angle. The angle is usually 95° to 100° in women and 90° to 95° in men. Nasofrontal angle (Figure 52.8C): This is determined by the angle of intersection of a line from the tip to the radix corresponding the dorsal plane of the nose and a line along the plane of the brows. Analysis of aesthetically pleasing noses reveals angles ranging from 128° to 140° with the ideal for females being 134° and for males being 130°. Columellar lobular angle (Figure 52.8D): This is the angle formed by the intersection of a line drawn tangential to the columella and to the infratip lobule. This angle is ideally 30° to 45°. Supratip break (see Figure 52.8C): A pleasing appearance particularly for the female nose is the presence of a supratip break. This is a slightly greater dorsal angulation between the plane of the nasal dorsum and the plane from the cephalic edge of the dome to the tip-defining point. Tip projection (Figure 52.9): The degree to which the nasal tip extends from the face. This can be measured by drawing a line from the alar cheek junction to the nasal tip, and the distance between these two points should be approximately equal to the distance of the alar base width and should be approximately 0.67 times the radix-to-tip distance or the nasal length (Figure 52.9A). Another measure of tip projection states that 50% to 60% of a line drawn from the alar cheek junction to the tip should lie anterior to a line drawn tangent to the most projecting portion of the upper lip (Figure 52.9B). Finally, the tip projection as measured from the alar base should equal the alar base width (Figure 52.9C). The alar-columellar relationship (Figure 52.10): Two lines are drawn, one through the long axis of the nostril and the other from the alar rim to the columellar rim at the midpoint of the first line. The distance from the alar rim to the first line should be the same as the distance from the columellar rim to the first line. Increase in either of those distances may represent alar retraction or columellar show.

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FIGURE 52.4 A. Facial thirds. B. Facial fifths (yellow lines) and midline facial vertical for symmetry (black line).

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FIGURE 52.5 A. Dorsal aesthetic lines. B. Alar base width (a) and bony base width (b). C. Alar rim orientation. D. Gull wing line. E. Opposing equilateral triangles.

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FIGURE 52.6 Base view/worm’s eye view showing triangle, lobular to nostril ratio, and nostril shape.

FIGURE 52.7 Nasal length. Ideal nasal length is equivalent to the stomiom-to-menton distance. A, ala; M, menton; R, radix; S, stoma; T, tip.

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FIGURE 52.8 A. Ideal chin position. B. Nasolabial angle. C. Nasofrontal angle, dorsal line. D. Columellar lobular angle.

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FIGURE 52.9 A. Tip-to-length ratio. B. Tip projection. C. Tip projection to alar base width.

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FIGURE 52.10 Alar-columellar relationship.

Regardless of which method one uses to analyze the patient’s nose, the idea is to have a specific and detailed operative plan for the procedure prior to entering the operating room.

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Treatment Plan Many nasal surgeries are in fact a combination of procedures for both aesthetic and functional conditions. Aesthetic rhinoplasty unless traceable to documented trauma is seldom covered by insurance, while functional septorhinoplasty or rhinoplasty performed for correction of deformity secondary to documented trauma or disease may be covered by insurance. Prior approval and contemporaneous records are often required for coverage. The combined case, coding and billing, for the covered aspect of the procedure is often computed by timing the portion of the case that is functional in nature. Most surgeons performing aesthetic rhinoplasty require out-of-pocket payment in full for the procedure in advance of the operation. Common functional procedures: Septoplasty/submucous resection Septorhinoplasty Reconstruction of the internal nasal valve Reconstruction of the external nasal valve Nasal turbinate modification Anterior turbinectomy Submucous resection of the inferior turbinate Out fracture of the inferior nasal turbinates Bipolar cautery of the inferior nasal turbinates Endoscopic polypectomy

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Medical Treatment Medical treatment is used in conjunction with surgical treatment or when mechanical airway obstruction is ruled out and includes the following: Systemic antihistamines and decongestants Topical vasoconstrictor, steroid, and antihistamine sprays Allergic desensitization Medication changes; avoidance of medications known to contribute to nasal congestion

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Surgical Treatment Anesthesia Managed anesthesia care Popular in past years when closed, rapid, and often “cookie-cutter” rhinoplasties were performed Requires expertise and experience in sedative of anesthesia by both the anesthesiologist and the surgeon. Not recommended except for very minor revisions

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General Allows the surgeon the time needed to perform the individualized operation that each patient requires. Ensures that the patient is comfortable throughout the operation

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Approach: Considerations

Closed Rhinoplasty No external scar Limited undermining Less postoperative edema Faster recovery Less operative time Difficult to assess and visualize anatomic variations and therefore make an appropriate operative plan More difficult to teach this technique because it does not allow simultaneous visualization by the surgeon and residents or students

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Open Rhinoplasty Three-dimensional binocular visualization Simultaneous visualization by the surgeon, residents, and students More accurate assessment of anatomic variations Requires wider dissection More postoperative edema particularly at the tip Exposure takes more time Possible longer recovery time Columellar scar

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Operative Order The question for operative order is tip then nose versus nose then tip. In closed rhinoplasty, many surgeons would argue that “as goes the tip so goes the nose.” This is a reasonable approach in closed rhinoplasty particularly when there is limited tip suturing and/or grafting. In open rhinoplasty, many surgeons would recommend modification of the tip as the last step in the procedure. Given modern rhinoplasty techniques with multiple tip sutures and grafts, the possibility of disrupting the tip modifications during performance of the remaining portions of the rhinoplasty argues for performing most of the tip modifications later in the procedure.

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Localization and Preparation This can be done prior to washing the face with prep solution. Local anesthesia with epinephrine is ideal to minimize intraoperative bleeding. Typically, 1% lidocaine with epinephrine or 1% lidocaine with epinephrine mixed 50/50 with 0.25% Marcaine without epinephrine is used. Intranasal cottonoids soaked in Afrin or epinephrine 1:1000 are used to decrease bleeding and to shrink the turbinates. The face wash should be nontoxic to the eyes.

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Incisions and Patient Preparation Options for incisions (Figure 52.11): Transcolumellar stairstep with intranasal marginal incisions: standard for open rhinoplasty Cartilage-splitting incision: often used in closed rhinoplasty Intercartilaginous incision: often used in combination with marginal incision to “deliver” cartilage in closed rhinoplasty

FIGURE 52.11 Incisions. The transcolumellar stairstep with intranasal marginal incisions (shown in red) is standard for open rhinoplasty. The cartilage-splitting incision (shown in yellow) is often used in closed rhinoplasty. The intercartilaginous incision (shown in green) is often used in combination with marginal incision to “deliver” cartilage in closed rhinoplasty.

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Marking Outline the proposed transcolumellar incision using methylene blue pen (Figure 52.12). Methylene blue tattoos strategically placed on either side of the proposed incisions can aid in the closure at the end of the case.

FIGURE 52.12 Nasal anatomy and general operative plan outlined on skin.

Optional: Outline the nasal anatomy, including the outline of the upper lateral cartilages, the lower lateral cartilages, and the nasal bones as well as outline the planned incisions and any proposed nasal dorsal

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reduction, proposed placement of grafts, and proposed modification of the lower lateral cartilages, as well as the location of any planned osteotomies. Trim the nasal vibrissae. Use the local solution described above in a 10-cc syringe with a 25 gauge 1.5 inch needle to inject the nose in the intended plane of dissection. When injecting the nasal septum, use a 3-cc syringe with a 20 gauge 1.5-inch needle thus providing better hydraulic advantage and making it easier to dissect the septal mucoperichondrial flap from the cartilage. Place Afrin-soaked cottonoids along the floor of the nose and in the middle meatus and against the roof of the nose to constrict the mucosal vessels and reduce the size of the turbinates. In the past, cocaine in a 4% solution was commonly used because of it being both a vasoconstrictor and a topical anesthetic. It is not necessary nor indicated to use cocaine when performing this operation under general anesthesia. Prep and drape the patient’s face consistent with your institution’s approved method.

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Basic Open Rhinoplasty Opening Mark a transcolumellar stair-step incision (or an inverted V) across the narrowest portion of the columella. We suggest that the stairs step “down” from the operator’s side of the table as it is a little easier to see the opposite nares when making and elevating that portion of the columella flap. Use the tip of a no. 11 scalpel blade to describe the central stair-step right angles. Use the flat of the blade to make the remaining horizontal incision over the medial crura being careful to stay superficial so as not to injure the cartilage, which is immediately under the skin. This incision will intersect at a right angle with a superficial vertical incision that can be made with a no. 15 scalpel blade and that is located just cephalic to the caudal roll of the medial crura. Again, this should be very superficial as this incision overlies the medial crura. The columellar elevation begins in the midline using a no. 4 angled Converse scissors. The elevation continues carefully over the medial crura, dissected as far toward the domes as possible. Everting the left alar rim with a double hook and your middle finger identify the caudal border of the lateral crus and make an incision from just medial to the pyriform up over the dome with care not to violate the soft triangle and joined this incision with the previously made columellar vertical incision. The double hook will have to be moved toward the dome straddling the area of the dome and pushing with the middle finger to see the caudal margin of the alar cartilage. With the assistant retracting the caudal edge of the now exposed lateral crus, use the Converse no. 4 scissors to identify the plane immediately above the perichondrium. In a primary rhinoplasty, you should now be able to use a Q-stick to continue the dissection in this plane with gentle pushing action exposing all of the lateral crus up to and including the domes. Any remaining attachments of the columella flap overlying the dome can be severed with the scissors. Repeating this on the opposite side should allow the dorsal flap to be completely elevated to the level of the upper lateral cartilages. A Q-stick to be used to continue the dissection in this plane over the dorsum of the nose to approximately the level of the nasal bones. The dissection can be completed using a curved Joseph-Peck scissors spreading and elevating just enough to insert an Aufricht retractor. It is important to only elevate enough to allow whatever modifications are planned but not so much as to decrease tissue attachments to the bone thus making it potentially unstable after osteotomies. Staying in this relatively avascular plane immediately above the cartilage and bone will give you good exposure with minimal bleeding (Figure 52.13). At this time, any individual bleeding vessels can be cauterized.

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FIGURE 52.13 Skin elevated.

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Modifying the Dorsum In this case, we will modify the bony dorsum followed by modification of the cartilaginous dorsum. After elevating the periosteum from the nasal bones using a Joseph elevator, a pull rasp is used to take the dorsum down to the desired height. Incremental reduction and frequent checking with the skin redraped and a wet index finger will help to avoid overcorrection. Orientation of the rasp head in exactly the right plane both horizontal and vertical by stabilization through the skin with the operator’s nondominant hand will ensure even takedown of the nasal bones. When proper bony height is achieved, attention is turned to separate the dorsal septum from the medial aspect of the paired upper lateral cartilages. The cartilaginous reduction is begun by exposure of the junction of the upper lateral cartilages with the dorsal nasal septum by means of the creation of a superior Cottle tunnel. The caudal septal angle is exposed with scissors and a mucoperichondrial elevation is begun on one side of the dorsal septum (Figure 52.14). Care is taken to be directly on the glistening bluish cartilage. A mucoperichondrium flap is elevated along the dorsum of the nasal septum using a Cottle elevator. This tunnel is dissected in the cephalic direction at the junction of the septum with the upper lateral cartilage to and just beyond the junction of the perpendicular plate of the ethmoid bone with the undersurface of the nasal bone. By sweeping the mucoperichondrium laterally using the Cottle elevator, the junction of the dorsal septum and medial upper lateral cartilage is defined (Figure 52.15). If a no. 15 scalpel can be placed within the tunnel with its flat surface on the exposed dorsal septum and with the blade oriented dorsally and with the skin protected by the Aufricht retractor, then the upper lateral cartilage can be sharply separated from the dorsal septum from the junction with the nasal bone to its most caudal attachment. Repeating this process on the opposite side will now expose the dorsal septum as well as the medial aspect of the right and left upper lateral cartilages. Each of these structures can be independently trimmed or manipulated at this time. If carefully done, the mucoperichondrium remains intact without communication to the nasal cavity. The dorsal septum can be lowered using angled scissors or a scalpel. The upper lateral cartilages can be trimmed as well or scored and enfolded on themselves to make auto spreader flaps or maintained for resuturing to the dorsal septum. Note that the cartilaginous dorsum can be lowered first followed by lowering the dorsal bone en bloc using an osteotome.

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FIGURE 52.14 Anterior superior septal angle.

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FIGURE 52.15 Elevating superior Cottle tunnels.

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Septoplasty, Caudal Septal Modification, or Septal Cartilage Harvesting If the caudal septum is to be modified to shorten the nose or modify the columella labial angle, mucoperichondrium will need to be elevated from that portion that is to be resected beginning dorsally at the septal angle where previous superior Cottle tunnels were made. At this point, it is a good idea to again inject local anesthetic into the plane of dissection on both sides of the septum. Once exposed on both sides, the caudal septum can be modified with scissors or scalpel. If there is a need for septal cartilage grafting or there is deviation of the quadrangular cartilage that is to be corrected, a complete mucoperichondrial elevation on one side is necessary. In general, the first side to be elevated is that side opposite the operator. The elevation can be done with a Cottle or a Freer elevator being careful to be in the relatively avascular plane directly over the cartilage. If only a small piece of cartilage is necessary, then a limited elevation can be performed. If there is need for more graft material, complete elevation is necessary. At this point, it is important to ensure that a minimum of 1 cm of dorsal and caudal septum is preserved as an L-shaped strut to support the nasal structure. The more that can be left, the stronger the nasal structure. If the continuity of this L-shaped strut is accidentally interrupted, it must be repaired and reinforced with cartilage or polydioxanone suture plate gussets. The cartilage to be harvested or removed can be outlined on the surface of the quadrangular cartilage in methyl and blue pen. A curved septal knife can then be used to incise along the outlined cartilage dorsally and caudally. A Cottle elevator can then be used to carefully elevate the opposite side through these incisions only elevating the opposite side over the cartilage that is to be removed. Once the opposite side is elevated, the remaining incisions can be completed with scissors, scalpel, Ballenger swivel knife, and elevator without perforating the mucoperichondrium. It is important to remember the shape of the quadrangular cartilage particularly where it abuts the junction of the vomer and the perpendicular plate of the ethmoid. There is usually a significant tongue of cartilage in this area that can provide important additional material for grafting. At this point, any additional deviation of either the perpendicular plate of the ethmoid, the vomer or the maxillary crest can be dealt with using a Jantzen-Middleton rongeur. The airway should now be assessed for patency, and when indicated out-fracture of the inferior turbinate, Dennis bipolar cautery of the inferior turbinate or anterior turbinectomy can be done. The flap should be inspected for perforations but unless they are large and/or they communicate with a perforation on the opposite flap at the same level repair is not necessary.

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Spreader Grafts and Flaps Spreader grafts or flaps are useful to prophylactically maintain or to widen the internal valve area when a narrow valve angle is contributing to obstructive symptoms 13,14 (Figure 52.16). Grafts are generally made from harvested septum but may also be made from rib or auricular cartilage. They can also be used to strengthen the dorsal septum as well as to help straighten dorsal septal deviations. They can be stabilized with 30 gauge needles to allow them to be sutured in place flush with the dorsal septum with 5-0 PDS. Excess medial upper lateral cartilage can be folded on itself and sutured in a similar manner.

FIGURE 52.16 A. Spreader grafts. B. Spreader flaps.

Open rhinoplasty allows you to see the nasal tip as it sits in vivo. It is beyond the scope of this chapter to

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provide a comprehensive compendium of all potential tip modifications. 7-9,15,16 The most common tip modifications involve some form of cephalic lateral alar crural resection, intradome and interdome suturing, and/or the placement of a columellar strut. In principle, as much supporting structure of the alar cartilages as possible should be left in place. The alar cartilages should be assessed for their thickness and strength. If the alar cartilages are of sufficient thickness and strength, a cephalic resection leaving an uninterrupted 6 to 8 mm caudal strip of cartilage can be removed (Figure 52.17). If there is unwanted cephalic fullness but the cartilages of questionable strength than the removed cephalic segment can be slid into a pocket made between the nasal mucosa and the remaining caudal cartilage and sutured into position to bolster the lateral alar crus. If there is too much convexity in the segment, the cephalic cartilage can be inverted before being sewn into place thus counteracting the tendency for convexity). If the domes are widely separated or are of unequal height, they can be adjusted by interdomal mattress sutures of 5-0 PDS (Figure 52.18A). The individual domes can be narrowed and accentuated with intradomal (transdomal) mattress sutures of 5-0 PDS (Figure 52.18B). Combination interdomal and intradomal/transdomal sutures can be used to both narrow the individual domes and as well as the interdome distance (Figure 52.18C). Further strengthening of the medial crura for maintenance of projection or to increase projection can be accomplished by the insertion of a columellar strut (Figure 52.19). This can be fashioned from harvested septum and trimmed to be 0.5 cm in width and up to 3 cm or more in length. A tunnel is made with scissors between the medial crura and extending to the nasal spine. The pocket should be made as close to the width of the strut as possible. The strut can be placed in the pocket against the nasal spine and while the assistant holds the domes at the appropriate level the strut can be sewn in a through-and-through fashion to the medial crura with 5-0 PDS mattress sutures with the knot placed internally between the crura. 
 After each maneuver, the skin should be redraped and the contours carefully inspected and palpated with a wet gloved index finger.

FIGURE 52.17 Cephalic lateral crural resection.

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FIGURE 52.18 Dome sutures. A. Transdome suture. B. Intradome sutures. C. Transdome and intradome suture.

FIGURE 52.19 Columellar strut.

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Osteotomies Generally, osteotomies are performed at this time for closing the open roof that is to say the gap between the nasal bones created when the bony dorsum is reduced. 17 The path that the osteotomies will take will depend upon the degree and length of the open roof as well as the desired change in the width of the base of the nasal bones. Medial oblique osteotomies are first performed by insertion of a curve-guarded osteotome at the junction of the septum and nasal bones at the most cephalic aspect of the open roof (Figure 52.20). The osteotomy line is carried in oblique fashion away from the Keystone area for about 5 to 10 mm. This helps to control the position of the osteotomies preventing injury to the Keystone area or the creation of a rocker deformity. Lateral osteotomies can be performed intranasally using a curveguarded osteotome after elevation of the periosteum overlying the nasal bone-cheek junction or using a 2 mm osteotome through an external percutaneous approach. The osteotomy is begun slightly higher on the pyriform lip preserving a triangle of bone along the pyriform, the Webster triangle, where the lateral most aspect of the alar cartilage anchor and provide stability to the nasal valve. If the bony bases are to be narrowed, the osteotomies are carried from this position staying low on the nasal bones (low to low) to the level of the previously made medial oblique osteotomy. Gentle inward digital pressure will green stick fracture the remaining bridge of nasal bone between the end of the medial oblique and lateral osteotomies. If narrowing of the nasal bony base is not indicated, then the osteotomy can curve in a more dorsal direction, low to high, joining and closing the open roof directly (Figure 52.21). Lateral osteotomies can also be performed using a percutaneous 2-mm osteotome. A small puncture is made through the skin in the natural skin tension line, and then the osteotomy is made along the same lines as described for the intranasal curved osteotome by walking the 2-mm osteotome along its desired path with gentle taps from the mallet. An advantage of the 2-mm osteotome is that the periosteum is not elevated and therefore remains intact on both the nasal and the facial side of the bone adding stability to that bony segment.

FIGURE 52.20 Medial oblique osteotomies.

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FIGURE 52.21 Osteotomies and the Webster triangle (blue). A. Low to high. B. Low to low.

The disadvantage is the necessity for an external puncture though experience has shown that these punctures are virtually invisible once healed.

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Final Inspection and Closure Throughout the procedure, the nose should be assessed by observation and comparison to the operative plan. Palpation of the nose using a wet gloved index finger slid along the dorsum should reveal smooth contours without defects. Any residual bony defects should be treated with further rasping using a diamond rasp, while any cartilaginous irregularities should be smooth with a scalpel. Further options for dealing with and “fine tuning” remaining problem areas will be dealt with later in this chapter. Prior to closing the incisions, the nasal septal flaps are quilted using a 4-0 plain catgut suture passing it back and forth from one side to the other through and through from the caudal septum as far posteriorly as possible in several rows. This is the best way to prevent septal hematoma. Intranasal incisions are closed with interrupted 5-0 chromic in the same way as in the closed rhinoplasty. The transcolumellar incision is closed very carefully with interrupted 6-0 fast absorbing plain catgut suture, which is then reinforced with skin glue. A careful and meticulous closure of the transcolumellar incision should result in a virtually invisible scar once fully healed. If alar base modifications are planned, they can be performed once the nasal incisions have been closed completely. Alar base modifications include alar base narrowing, nostril size adjustments, alar flare reduction, alar hooding reduction, and alar margin grafting to adjust the position of the alar position on both anterior-posterior and lateral views. 12,18 When both nasal septal surgery and turbinate modification are done, a Doyle septal splint is placed in each nostril and suture to the membranous columella with a 3-0 Prolene through-and-through suture. The purpose of this splint is not to prevent septal hematoma but rather to provide insulation preventing the formation of synechiae between the septum and the inferior turbinate. Finally, the nose is taped, and a thermoplastic splint is applied (Figure 52.22).

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FIGURE 52.22 Thermoplastic splint.

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Basic Closed Rhinoplasty Tip Delivery Method A combination of a marginal incision along the caudal border of the lateral alar crus and an intercartilaginous incision at the junction of the cephalic alar crus and the upper lateral cartilages and continued with a transfixion incision at the caudal and cephalic margin of the medial alar crus will allow the total delivery of the dome and lateral alar crura into the nostril for subsequent manipulation. This maneuver is repeated on both sides and allows for increased visualization of the alar cartilages. The bucket handle dissection of the cartilages can be stabilized for manipulation or trimming by passing the handle of a Neivert double ball retractor beneath. The exposure of the domes can allow for moderate manipulation in this area as well.

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Tip Cartilage-Splitting Method An intracartilaginous incision is made at the point where the planned cephalic resection of the lateral alar crus begins. It is carried through the nasal vestibular skin and through the cartilage. The vestibular skin can then be dissected from the nasal side of the cephalic alar cartilage, which can then be separated from its attachment to the upper lateral cartilage and removed.

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Dorsal Elevation and Reduction Once the tip is modified, a curved Joseph-Peck scissors can then be used to elevate the nasal dorsum over the cartilage and bone. The plane of dissection should be immediately superficial to the perichondrium and periosteum. Care to stay in this plane will result in a relatively bloodless dissection. The dissection should be wide enough to allow the insertion of a Aufricht retractor for visualization of the dorsum but should be limited to only that needed to make the planned dorsal modifications. A Joseph elevator can then be used to elevate the periosteum over the nasal bones to allow reduction by rasp or osteotome. If the rasp is to be used the bony modification is done at this point followed by reduction of the cartilaginous dorsum. If an osteotome is to be used to lower the bony dorsum, then modification of the cartilaginous dorsum is done first. Many surgeons prefer the rasp, because it allows a more incremental reduction of the dorsum and is less likely to result in accidental overcorrection. The cartilaginous reduction is begun by exposure of the junction of the upper lateral cartilages with the dorsal nasal septum by means of the creation of a superior Cottle tunnel. Through the previously made transfixion incision at the junction of the caudal septum and medial alar crura a mucoperichondrium flap is elevated along the dorsum of the nasal septum using a Cottle elevator. This tunnel is dissected in his cephalic direction at the junction of the septum with the upper lateral cartilage to and just beyond the junction of the perpendicular plate of the ethmoid bone with the undersurface of the nasal bone. By sweeping the mucoperichondrium laterally using the Cottle elevator, the junction point is defined. A no. 15 scalpel can then be placed within the tunnel with its flat surface on the exposed dorsal septum and with the blade oriented dorsally and with the skin protected by the Aufricht retractor, the upper lateral cartilage can be sharply separated from the dorsal septum from the junction with the nasal bone to its most caudal attachment. Repeating this process on the opposite side will now expose the dorsal septum as well as the medial aspect of the right and left upper lateral cartilages. Each of these structures can be independently trimmed or manipulated at this time. If carefully done, the mucoperichondrium remains intact without communication to the nasal cavity. The dorsal septum can be lowered using angled scissors or a scalpel. The upper lateral cartilages can be trimmed or left in place for later use as auto spreader flaps.

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Septoplasty If correction of septal deviations or harvesting of septal cartilage to use for grafting is indicated, then this should be done at this time after the dorsal profile has been set. Using the previously made transfixion incision, a mucopericondrial flap is elevated in the same manner as described for open rhinoplasty. In closed rhinoplasty, where visualization is more difficult, an inferior Cottle tunnel can aid in the elevation of the mucoperichondrial flap along the junction of the quadrangular cartilage and the Vomer. A Freer or McKenty elevator is used to elevate the periosteum along the medial surface of the floor of the nose and the lateral surface of the Vomer up to the attachments at the cartilage-Vomer junction. Scissors can then be used to cut the attachments between the cartilage and the vomer from caudal to cephalic under direct vision therefore minimizing the risk of flap perforation. Once exposed on one side, the modifications can proceed as described for open rhinoplasty.

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Spreader Grafts and Flaps These can be placed in a manner similar to that described in the open rhinoplasty section. Exposure is more limited, and placement and fixation are more difficult in the closed rhinoplasty.

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Tip Modification Tip modifications are considerably more difficult in the closed rhinoplasty though virtually any modification done in the open setting can be done in the closed rhinoplasty. The authors encourage using the open approach until the surgeon has gained considerable experience.

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Osteotomies Osteotomies are also performed as described for open rhinoplasty.

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Final Inspection and Closure The intranasal incisions are now closed with interrupted 5-0 chromic suture. The nasal dorsum is cleansed with saline, dried, and then treated with Mastisol, and then Steri-Strips are placed in such a way as to try to eliminate any dead space between the skin and the refined cartilage and bone. Finally, a thermoplastic splint is applied. Routine nasal packing is not necessary. 19,20 A Doyle internal splint may be desirable when both septoplasty and anterior turbinectomy are performed to prevent synechia.

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Advanced Maneuvers Advanced rhinoplasty maneuvers include the following: Septal extension grafts Onlay grafts Rim grafts Tip grafts Dome grafts Shield graft/infratip grafts Supratip graft Lateral crural strut grafts Lateral crural spreader grafts Tip diverging grafts Tip width-control grafts Lateral crural shaping sutures to increase external convexity or concavity Through-and-through suturing to narrow the columellar base with or without footplate resection Columella to septum anchoring sutures Alar base excisions to decrease flare or narrow the base

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Revision Rhinoplasty The principles for approaching revision rhinoplasty are the same as those for primary rhinoplasty: careful analysis, diagnosis of the problem, and application of appropriate surgical maneuvers. Revision surgery often involves reconstructive principles because the presenting anatomy is no longer standard. There will be scar tissue encountered during dissection and distorted, missing, and possibly extra nasal tissue or alloplastic implants discovered. Additional cartilage sources, including rib or ear cartilage and bone sources including outer table of the calvarium may be necessary. The guiding principle of revision surgery is that regardless of the deformity encountered, the revision surgeon must be prepared to use all tools available to make the anatomical structures as normal as possible to achieve satisfactory appearance and function. Revision rhinoplasty patients also require greater attention to the psychological aspects involved, as these patients tend to be more anxious about repeating another surgery and risking another disappointing outcome. It is important to obtain the operative records of previous surgeries whenever possible. Bear in mind that not all operative reports are entirely accurate. Preoperative CT scans and office-based nasoendoscopy when available can be helpful as can endoscopy in the OR just prior to the procedure. Common presenting deformities in revision rhinoplasty include a residual dorsal hump, an overprojected nose, a crooked dorsum, a crooked and asymmetric tip, and an overdone “pinched” tip. Other common problems encountered are an overresected dorsum (saddle nose deformity), alar retraction, dorsal asymmetry, visual or palpable irregularities, and a widened dorsum. In addition, one may encounter functional nasal obstruction that is either new or was not optimally dealt with in previous surgery. Given the numerous possible deformities, addressing every problem is beyond the scope of this chapter. The goal is to use whatever tools necessary to fix the problem and create a “normal” structural appearance and normal function. Often, structures need to be reconstructed using strong normal cartilage, which can include residual septal cartilage, previously placed grafts that have been removed during the revisional surgery, rib cartilage, or ear cartilage. Variously prepared allograft materials have also found their way into complex nasal revisional surgery. Extra care is needed in dissecting the skin flap from the underlying skeleton as tenacious scar tissue may be encountered the dissection through which can lead to accidental perforation of the skin flap. Dorsal humps may need to be shaved down using rasps or power burrs if necessary. Repeat osteotomies can create better symmetry in nasal bones but may also lead to comminution and instability. Crooked dorsal septal cartilage may need to be straightened and reinforced using strong cartilage batten grafts applied to one or both sides. The tip can be reconstructed using a variety of means, including grafts to reinforce or replace the lower lateral cartilages and tip grafts to create a more normal looking symmetric tip. Suture can be used to achieve these goals and can also be used to narrow a wide middle third (with care taken not to 
 create a functional problem in the internal nasal valve). Revision septoplasty, anterior turbinate reduction, turbinate cautery, turbinate 
 out-fracture, and internal nasal valve reconstruction using spreader grafts and/or lateral crural strut grafts may be necessary to reconstruct functional airway problems.

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Complications Bleeding Septal hematoma Infection New or persistent obstruction Scarring/skin loss Aesthetic irregularities

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Patient Outcomes Patient outcomes are critically important with any surgery. Measuring individual outcomes quality depends on close and thorough follow-up for at least 1 year if not longer, asking patients questions about their satisfaction with their results, excellent standardized photography at every patient visit, and surgeon dedication to reviewing preoperative photographs and 1 year follow-up photographs in conjunction with the surgical operative report to determine if the operative plan and postoperative treatment were appropriate. 5,21 Many variables affect the result of rhinoplasty surgery, and it is incumbent upon the surgeon to critically analyze his or her results and patient satisfaction to obtain the most optimal outcomes. Objective patient-related outcome (PRO) scales have been developed; however, the perfect qualitative validated scale remains elusive. PRO scales with acronyms such as SCHNOS, NOSE, SNOT, RHINO, and Face-Q are available to the rhinoplasty surgeon but vary in their usefulness. An ideal PRO scale should be validated, reproducible, and easy to administer. 22-27

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Questions The patient is a 27-year-old man who presents to you with two complaints concerning his nose: dislike for the appearance of his nose and nearly complete obstruction of his left nasal airway. He states that he has broken his nose at least two times playing collegiate rugby. He was seen the first time in the ED where a closed reduction was attempted after X-rays confirmed a fracture. He states that his nose has been crooked ever since and that his nasal breathing, though problematic his whole life has been much worse since that trauma. He did not seek medical attention after his second nasal trauma. He denies any known inhalant allergies, takes no medication, denies using nasal sprays or having had any previous nasal surgery other than the attempted reduction in the ED. When asked to be specific about his nasal appearance, he states that he does not like the crookedness of his nose, nor is he happy with the prominent dorsal hump. He is fine with the appearance of the tip of the nose. His family history is unremarkable, as is his review of systems. Focused nasal exam reveals a moderately large and projecting nose with a prominent nasal dorsal bony and cartilaginous hump. The nose shows a significant C-shaped deformity concave to the right. He has a narrow supratip and a wide and boxy tip. His skin is intermediate in thickness. His caudal septum presents in his left nostril. He has marked septal deviation to the left with near total obstruction of the left nasal airway. There is a significant spur of the junction of the quadrangular septal cartilage and the vomer extending into the right nasal airway. He has significant enlargement of the right nasal turbinate and moderate enlargement of the left. He has a sharply positive Cottle test on the right and minimal improvement on the left. You devise a treatment plan, which you go over at length and in detail with the patient. 1. You propose an open septorhinoplasty to be done in the hospital under a general anesthetic as an outpatient. Which of the following statements is most accurate regarding the osteotomies in your surgical plan? a. He will require osteotomies to straighten his nose and correct the incompetent internal nasal valve. b. He will require osteotomies to close an open roof deformity and straighten the nose. c. He will require osteotomies to narrow the nasal bases and straighten the nose. d. He will require oseotomies to close an open roof deformity and straighten the nasal septum. e. Low to high osteotomies would be ideal to correct the bony asymmetry. 2. You perform the septorhinoplasty using an open approach, transcolumellar stair-step incision. To surgically treat the exam finding of a positive Cottle test, which of the following would you perform? a. Quadrangular septal cartilage and bony septum excision b. Bilateral inferior turbinate submucosal resection and outfracture c. Cartilage spreader graft placement between the septum and upper lateral cartilage on the right side d. Cartilage spreader graft placement between the septum and upper lateral cartilage on the left side e. Cartilage lateral crural strut graft placement under each lower lateral crura 3. You perform the septorhinoplasty using an open approach, transcolumellar stair-step incision. Given the marked septal deviation preoperatively, dissection around the deviation was difficult and fractures within the septum from previous trauma presented difficulty in elevating the septal mucoperichondrial flaps. Following completion of septal cartilaginous and bony resection, you note perforations in the septal flaps on both sides. You decide that suture repair of the perforations are not necessary for which of the following reasons?

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a. Septal perforations always heal on their own and close secondarily. b. The opposing perforations are anterior. c. The opposing perforations are posterior. d. The perforations will close with spreader graft placement. e. The perforations on each side are not opposing. 4. The patient you just treated was happy with the results of his rhinoplasty and refers his 22-yearold sister to you for revision rhinoplasty. She has no functional nasal concerns and her nasal history and exam are unremarkable for any breathing disturbance. Her concern is a residual prominent nasal dorsal hump, and she feels that her tip is still too projecting and too bulbous. Her primary rhinoplasty surgery was 3 years ago. You receive a copy of her original operative report, and there is no mention of septal cartilage harvest. You do a nasofacial analysis and find that her tip projection is 70% of her radix-to-tip length and her nasolabial angle is 100°. Your operative plan and consent process should include which of the following? a. Reduction of the bony and cartilaginous nasal dorsum and tip suturing to better define the domes with no change to the nasal labial angle, tip deprojection, and septal cartilage harvest for columellar strut grafting b. Reduction of the bony and cartilaginous nasal dorsum and tip suturing to better define the domes, increasing the nasal labial angle, tip deprojection c. Reduction of the bony and cartilaginous nasal dorsum and tip suturing to better define the domes with no change to the nasal labial angle, tip deprojection, septal cartilage harvest for columellar strut grafting, and possible ear or rib cartilage graft harvest d. Reduction of the bony and cartilaginous nasal dorsum and tip grafting to better define the domes with no change to the nasal labial angle, tip deprojection, and septal cartilage harvest for columellar strut grafting e. Reduction of the bony and cartilaginous nasal dorsum and tip grafting to better define the domes with no change to the nasal labial angle, tip deprojection, septal cartilage harvest for columellar strut grafting, and possible ear or rib cartilage graft harvest 5. You perform revision rhinoplasty on the 22-year-old woman in the previous question in the operating room under general anesthesia. Which of the following is not accurate regarding optimal patient outcome assessment? a. The patient should be followed for 1 year after surgery to assess the final result. b. Standard photographs should be taken at only at the 1-year postoperative visit for comparison. c. Functional assessment should be made at each postoperative visit. d. The patient should be asked directly about satisfaction with the procedure at each postoperative visit. e. Given the reproducible validity of objective patient reported outcomes scales, it is critically important to use them with every patient. 1. Answer: b. Two indications for performing osteotomies are to straighten the nose and to close and open roof deformity after the bony hump is rasped. As he has a C-shaped deformity and crooked nose from his trauma, and because the plan would include rasping of the dorsal bony hump to correct his dissatisfaction cosmetically, answer #2 would be most accurate. Osteotomies are not performed to correct incompetent nasal valves or to straighten the septum. Low-to-high osteotomies are used to prevent further narrowing of the nasal bone bases, not to correct nasal bone asymmetry. 2. Answer: c. A positive Cottle test reveals incompetent unilateral internal nasal valve or bilateral internal nasal valves. In this case, the patient had relief of Cottle test on the right side only. Spreader graft placement on the right side is indicated to open the angle of the internal nasal valve on the

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affected side. Surgery on the septum or turbinates will not treat the internal valve problem. Lateral crural strut grafts are used to treat external nasal valve incompetence. 3. Answer: e. Perforation of one or both sides of the septal mucoperichondrium may occur during septoplasty, especially when dissection is exceptionally difficult. Unilateral perforations do not require suture closure. Perforations that are nonopposing will not heal with a persistent open perforation. Tears in the mucosa that are opposing must be closed with suture on each side to prevent a persistent open perforation that can lead to bleeding, crusting, whistling, and functional airflow issues. 4. Answer: c. The patient’s concerns are residual hump deformity and an overprojected bulbous nasal tip. The plan should include bony and cartilaginous hump reduction, tip suturing to better define the domes of the tip and reduce bulbosity, and deprojection of the tip. Deprojection of the tip will require columellar strut grafting to resupport the new position of the tip. A columellar strut graft can be fashioned from septal, rib, or ear cartilage. Even though the previous operative report does not mention previous septal cartilage harvest, operative reports are not always accurate. Therefore, the operative plan and informed consent for all revision rhinoplasty patients should include the possibility of ear or rib cartilage harvest. 5. Answer: b. Patients should be followed postoperatively for at least 1 year after rhinoplasty surgery. Standard photographs should be taken at each postoperative visit throughout the year to track and document the patient’s progress. Asking the patient about their satisfaction at all time points, as well as surgeon assessment of both functional and aesthetic outcomes, is critical to evaluate the overall results. Objective patient reported outcome scales can sometimes be useful in the postoperative setting, but the scales available today may be difficult to administer and the perfect validated scale remains elusive.

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References Constantian, MB. Four common anatomic variants that predispose to unfavorable rhinoplasty results: a study based on 150 consecutive secondary rhinoplasties. Plast Reconstr Surg. 2000;105:316. Constantian, MB, Lin, CP. Why some patients are unhappy. Part 1. Relationship of preoperative nasal deformity to number of operations and a history of abuse or neglect. Plast Reconstr Surg. 2014;134(4):823-835. Constantian, MB, Lin, CP. Why some patients are unhappy. Part 2. Relationship of nasal shape and trauma history to surgical success. Plast Reconstr Surg. 2014;134(4):836-851.References 2 and 3 are paired articles by Constantian and Lin that provide insight into the recognition of the body dysmorphic patient. They should be read by anyone interested in rhinoplasty. Heinberg, CE, Kern, EB. The Cottle sign: an aid in the physical diagnosis of nasal airflow disturbances. Rhinology. 1973;11:89-94. Guyuron, B. Precision rhinoplasty. Part I: the role of life-size photographs and soft-tissue cephalometric analysis. Plast Reconstr Surg. 1988;81:489-499.First in a set of two articles showing the methodology used by Guyuron as a master rhinoplastic surgeon to obtain consistently good results, Mehta, U, Mazhar, K, Frankel, AS. Accuracy of preoperative computer imaging in rhinoplasty. Arch Facial Plast Surg. 2010;12(6):394-398. Daniel, RK. Rhinoplasty: creating an aesthetic tip. Plast Reconstr Surg. 1987;
 80:775. Rohrich, RJ, Adams, WP Jr, Deuber, MA. Graduated approach to tip refinement and projection. In: Gunter, JP , Rohrich, R , Adams , eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:333. Toriumi, D. New concepts in nasal tip contouring. Arch Facial Plast Surg. 2006;8:156-185. Byrd, HS, Hobar, PC. Rhinoplasty: a practical guide for surgical planning. Plast Reconstr Surg. 1993;91:642-654.Describes Byrd’s method for mathematically analyzing nasal anatomic relationships based on measurements of a particular population judged as having attractive noses. Chauhan, N, Alexander, AJ, Sepehr, A, Adamson, PA. Patient complaints with primary versus revision rhinoplasty: analysis and practice implications. Aesthet Surg J. 2011;31:775. Gunter, JP, Hackney, FL. Clinical assessment and facial analysis. In: Gunter, JP , Rohrich, RJ , Adams, WP Jr , eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:53. Rohrich, RJ, Hollier, LH. Use of spreader grafts in the external approach to rhinoplasty. Clin Plast Surg. 1996;23(2):255-262. Sheen, JH. Spreader graft: a method of reconstructing the roof of the middle nasal vault following rhinoplasty. Plast Reconstr Surg. 1984;73(2):230-239.An early presentation of spreader grafts by their inventor. Adamson, PA, Funk, E. Nasal tip dynamics. Facial Plast Surg Clin North Am. 2009;17:29-40. Hewell, TS, Tardy, ME. Nasal tip refinement. Facial Plast Surg. 1984;1:87. Sullivan, PK, Harshbarger, RJ, Oneal, RM. Nasal osteotomies. In: Gunter, JP , Rohrich, RJ , Adams, WP Jr , eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:595. Gunter, JP, Rohrich, RJ, Friedman, RM, et al. Importance of the alar-columellar relationship. In: Gunter, JP , Rohrich, RJ , Adams, WP Jr , eds. Dallas Rhinoplasty: Nasal Surgery by the Masters. St Louis, MO: Quality Medical Publishing; 2002:105. Guyuron, B. Is packing after septorhinoplasty necessary? A randomized study. Plast Reconstr Surg. 1989;84(1):41-44. Mansfield, CJ, Peterson, MB. Toxic shock syndrome: associated with nasal packing. Clin Pediatr (Phila). 1989;28:443-445. Guyuron, B. Precision rhinoplasty. Part II: prediction. Plast Reconstr Surg. 1988;81:500-505.Second in a set of two articles showing the methodology used by Guyuron as a master rhinoplastic surgeon to obtain consistently good results, Klassen, AF, Cano, SJ, East, CA, et al. Development and psychometric evaluation of the FACE-Q scales for patients undergoing rhinoplasty. JAMA Facial Plast Surg. 2016;18(1):27-35. Kosowski, TR, McCarthy, C, Reavey, PL, et al. A systematic review of patient-
 reported outcome measures after facial cosmetic surgery and/or nonsurgical facial rejuvenation. Plast Reconstr Surg. 2009;123(6):1819-1827. Menger, DJ, Richard, W, Swart, KM, et al. Does functional septorhinoplasty provide improvement of the nasal passage in validated patientreported outcome measures? ORL J Otorhinolaryngol Relat Spec. 2015;77(3):123-131. Rhee, JS, Sullivan, CD, Frank, DO, et al. A systemic review of patient-reported nasal obstruction scores: defining normative and symptomatic ranges in surgical patients. JAMA Facial Plast Surg. 2014;16(3):219-225. Schwitzer, JA, Sher, SR, Fan, KL, et al. Assessing patient reported satisfaction with appearance and quality of life following rhinoplasty using the FACE-Q appraisal scales. Plast Reconstr Surg. 2015;135(5):830e-837e. Stewart, MG, Witsell, DL, Smith, TL, et al. Development and validation of the Nasal Obstruction Symptom Evaluation (NOSE) scale. Otolaryngol Head Neck Surg. 2004;130(2):157-163.One of the first validated patient-reported outcome measured instruments for functional septorhinoplasty.

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CHAPTER 53

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Otoplasty Arin K. Greene

Key Points Ear anomalies can be characterized by having excess structures, deficient parts, or adequate components that need to be rearranged. Ear molding may correct some anomalies during the neonatal period. Most otoplasty procedures are best performed ≥3 years old when most ear growth is completed. Otoplasty should aim to achieve symmetry on frontal view. Simple otoplasty techniques are considered before more complicated reconstructive procedures. About 50% of newborns have an auricular deformity that persists in 33% by 1 month old 1 ; as many as 84% of deformities continue to improve over the first year of life. 2 An exception is prominent ears, which increase from birth to 1 year old, suggesting that postnatal deformation can contribute to this condition (e.g., infant sleep position may push the ear outward). 1,2 Half of children have a bilateral deformity, and when deformity is unilateral, the right and left sides are affected equally. 1 No difference in the prevalence or type of ear deformity exists among males and females. 1 A helical anomaly/constricted ear is the most common disorder at birth (15%). 1 Vaginal delivery and increased birth weight increase the risk of ear anomalies, likely due to forces on the ear causing deformations. 1 Otoplasty is used to reconstruct several types of ear abnormalities. The primary morbidity of an ear deformity is psychosocial. Ear anomalies do not affect hearing and thus insurance companies often do not cover the procedure. Correction of some deformities (e.g., cryptotia) can facilitate the use of eyeglasses. In the pediatric population, ear anomalies can be particularly worrisome for families because they often have to pay for the procedure, and they are subjecting their child to general anesthesia for a “cosmetic” problem. Consequently, surgeons treating ear anomalies should be well trained on the subject and ensure that patients and families have reasonable expectations. The ears are particularly tolerant of asymmetry because of their lateral position over the temporal bones. The full appearance of the ears cannot be appreciated on frontal view. To compare the ears, an individual must look at one ear first and then change positions to see the contralateral side. Consequently, it is most important to have the ears as symmetrical as possible on frontal view. Because most ear anomalies cause a “cosmetic” problem, patients and families can be focused on minor asymmetries. It is important that families understand that asymmetries between the ears are common in the general population 3,4 and that there will be some asymmetry following the procedure.

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Diagnosis Diagnosis of an ear anomaly is made by physical examination. Ear abnormalities can be broadly separated into malformations (absence of part of the ear) or deformations (fully developed ear but misshapen). The surgeon should be able to identify the abnormality and list reconstructive options. I approach the management of ear anomalies by dividing them into three categories: Excess components—treated by excision Deficient parts—managed by addition of tissues Adequate structures that are malformed—treated by rearrangement of tissues The surgeon must understand normal ear anatomy and can use the contralateral ear, if normal, as a guide (Figure 53.1). The axis of the ear is angled approximately 20° more posterior than a vertical line. The top of the helix is at the level of the eyebrow and the lobule is at the base of the columella. The height of the ear is 6.5 (±1) cm, and its width is 4.0 (±0.5 cm). 5,6 It is located one ear length (6–7 cm) posterior to the lateral canthus. Although several measurements for abnormal protrusion from the mastoid have been described, I use greater than 18 mm at the top of the helix and 21 mm at the midhelix. 3

FIGURE 53.1 Ear anatomy.

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Nonoperative Treatment A window exists during the neonatal period when the ear can be molded. 7 Because some anomalies improve during the first week of life, molding should not be initiated until at least 1 week old to allow for possible spontaneous correction. 8 Ideally, molding is started between 1 and 3 weeks old when maternal estrogens in the child facilitate cartilage manipulation. The ear can be molded using wire and tape or a commercially available system (Figure 53.2). 8,9 Unfortunately, patients often are referred after the window to mold their ears has passed. At 6 weeks old, estrogens in the child equal that of an adult and if ear molding is initiated after this time, patients are likely to have a poor response. 9 If the mother is breast-feeding, initiation of ear molding can be attempted up to 8 to 10 weeks old. After 12 weeks old, ear molding is not effective. 9 The ear deformity that is most amenable to molding is a prominent ear. The antihelical fold is recreated to set back the ear. A mildly constricted ear with overhanging helical cartilage can be improved by lifting the helical cartilage into better alignment. A Stahl deformity can be corrected by flattening the abnormal crus.

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FIGURE 53.2 Ear molding. A. Two methods of ear molding. Wire and tape (left) and a commercially available system (right). B. Before (left) and after (right) molding of a prominent ear deformity. C. Before (left) and after (right) molding of a mildly constricted ear.

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Timing of Operative Treatment The primary indication for otoplasty is to improve the patient’s self-esteem. Cryptotia and moderate/severe constricted ears can inhibit the ability to wear eyeglasses. Timing of intervention falls into three categories: infancy, 3 to 4 years old, and late childhood or adolescence. Simple excisions of excess structures can be performed during infancy with local anesthesia. Parents having children with preauricular cartilage remnants usually are eager to remove them as soon as possible. Most are small and able to be excised using local anesthesia in the office, as early as 4 to 6 weeks old. After 12 months old, however, it is difficult to restrain an awake child and I will perform the procedure in the operating room with sedation or wait until the child is old enough to cooperate in the clinic. If a child has an ear deformity that cannot be corrected simply using local anesthesia, then I prefer general anesthesia. Because long-term memory and self-esteem begin to form at approximately 4 year old, many parents decide to correct an ear anomaly when the child is between 3 and 4 years old. At this time, the ear has achieved 85% of its size and the risk of scar limiting ear growth is reduced. 6,10 Most ear growth is completed by 6 years old. 6,10 Although data have shown that operating on ears before 3 years old does not inhibit growth, 11 I prefer to wait until at least 3 years old because (1) the ear is larger to facilitate the procedure and (2) it is not urgent to intervene before this time because memory and self-esteem have not yet formed. An advantage of early intervention is that children tolerate the procedure more favorably than older patients who are more anxious about the operation and are busier with activities such as sports and school. If an individual has a mild deformity that he/she may not want to have improved, then it is prudent to wait until they are older to determine if they become bothered by it. Some families choose to wait to correct a significant ear anomaly until the child is old enough to participate in the decision to have the procedure. Children between 5 and 8 years old typically are bothered by a deformity, but fear of the operation outweighs their desire to improve their appearance. At 9 to 10 years old, the child’s interest in correcting the anomaly begins to outweigh the anxiety about the operation. Girls typically present later than boys, because they are better able to camouflage their deformity with hair. Males often will grow their hair long to hide their ear.

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Prominent Ear Approximately 5% of the population has a prominent ear caused by an absent or weak antihelical fold and/or overgrown concha (Figure 53.3). 1,2 Most patients will require recreation of the antihelical fold and setback of the concha. Rarely, a patient will have a normal antihelix and only require a procedure on the concha. Similarly, an individual may have a normal concha and only require formation of the antihelical fold. The prominence of the auricle can be evaluated by considering the upper, middle, and lower thirds of the ear. Although all patients will need to have the upper and/or middle third of the ear setback, 25% of patients in my practice will benefit from having their lobule setback as well. Three-fourths of patients in my experience undergo bilateral setback otoplasty, whereas one-fourth of individuals have prominence of only one ear.

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FIGURE 53.3 Otoplasty for a prominent ear. A. Preoperative view illustrating the absence of the antihelical fold and overgrown conchal bowl. B. Postoperative appearance.

Although setback otoplasty is a clean case, I give one dose of intraoperative antibiotics because I am placing permanent foreign bodies (merseline sutures) and exposing cartilage. I do not prescribe postoperative antibiotics. After the patient is under general anesthesia, I measure the distance of the ears to the mastoid from the most prominent part of the superior helix and from the midhelix at the level of

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the root. I favor measurements because it improves the likelihood of symmetry between the ears and also reduces the risk of overcorrection. The ear is folded and the position of the antihelical fold is marked. Local anesthetic with epinephrine is infiltrated to hydrodissect the skin off the cartilage to facilitate suture placement. A posterior skin excision is performed at the junction of the ear and mastoid skin. The incision in this location is hidden in the natural crease. I perform a skin excision because it facilitates the procedure by enhancing exposure, and once the ear is set back, there is sufficient skin to reapproximate.

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Superior Third Techniques to set back the superior third of the ear require strengthening or recreation of the antihelical fold by (1) placement of scapha-concha sutures (Mustarde technique), 12 or (2) cartilage scoring (Stenstrom technique) 13 (Figure 53.4). I prefer scapha-concha sutures because it gives greater control and more predictability compared to scoring the cartilage. In addition, scoring the cartilage can cause damage to the cartilage and contour abnormalities. In an adult with very stiff cartilage, scoring may be considered as an adjunct to weaken the cartilage to facilitate its bending during the placement of sutures. The ear is folded, and the position of the antihelical fold is marked. Intraoperatively, a 27 gauge needle is used to transpose the position of the antihelical fold to the posterior cartilage. I typically place three or four 4-0 Mersilene mattress sutures to recreate the fold. It is important not to pull the sutures too tight that can cause the ear to be positioned too close to the mastoid and create an unnatural sharp antihelical fold. On front view, the antihelix should have a gentle curve and the helix should be visible behind the antihelix. I measure the distance from the most superior point of the helix to the mastoid and achieve a distance of 15 mm (±3 mm). Occasionally, the superior third remains prominent despite scapha-concha sutures. In this situation, one or two sutures can be placed from the scapha to the temporal fascia or conchal cartilage. Alternatively, scapha and helical cartilage can be excised. 14

FIGURE 53.4 Illustration of operative methods to reduce the prominence of an ear. Anterior (A) and posterior (B) views showing the position of scapha-concha sutures to strengthen the antihelical fold and set-back the superior 1/3 of the ear (3 lines) as well as concha excision to reduce the prominence of the middle 1/3 of the ear (black ovals). The outline at the junction of the ear and mastoid on the posterior view represents the skin excision performed to access the ear cartilage.

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Middle Third Options to set back the middle third of the ear include excision of concha or concha-mastoid sutures (Furnas technique). 15,16 I prefer a cartilage excision because it reduces the risk of recurrence and weakens the area to facilitate the antihelix contour provided by the scapha-concha sutures. 16 I have found that suturing the hard cartilage to the weak mastoid fascia/periosteum has an increased risk of recurrence of prominence because of suture dehiscence and/or stretching of tissue. I measure the distance from the midhelix at the level of the root to the mastoid and attempt to achieve a distance 18 (±3 mm). An approximately 2.0 to 2.5 cm long piece of superior conchal cartilage is removed just below the scaphaconcha sutures. Depending on the amount of prominence, the width of the area can be 2 to 7 mm. The cartilage defect is repaired with interrupted 4-0 PDS suture. A line of excess skin may be present anteriorly, but this flattens over time. If more than a 7 mm width of cartilage is removed, then it is possible that the excess skin anteriorly might be bothersome to the patient and require excision. Care must be taken to not overcorrect the middle third of the ear to prevent a telephone deformity.

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Lower Third Lobule prominence is present in approximately one-fourth of patients and is often not appreciated preoperatively. 17 If the lobule remains prominent after setting back the superior and middle third of the ear, I first place a Mersilene suture through the area of the tail of the helix to the base of the conchal bowl. Another option is to extend 
 the conchal cartilage excision inferiorly. A posterior lobule skin excision also can be performed. 16,18 Finally, a suture can be placed from the posterior lobule to the conchal cartilage. 18,19 The goal is to prevent the appearance of a hockey stick appearance of the ear.

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Closure Before closing the incision, I ensure that the helix has a straight contour, a telephone deformity is not present, and the superior helix is visible beyond the antihelix. I also perform repeat measurements; the superior distance of the helix to the mastoid must be 15 (±3 mm) and the middle distance 18 (±3 mm). These measurements should have a difference of ≤2 mm between the ears to ensure adequate symmetry. It is important that the ear is not approximated too close to the mastoid that can cause a deformity. The incision is closed using interrupted 5-0 Vicryl suture followed by a running 6-0 Chromic suture. Cyanoacrylate glue and a Steri-Strip are placed.

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Postoperative Care I place a head-wrap (large piece of cotton over the ear followed by a gauze wrap) that is worn for up to 1 week until the first clinic appointment. I do not attempt to place pressure on the ear with bolster sutures or pieces of cotton soaked in mineral oil. Patients then are instructed to wear a soft head band at night for 6 weeks postoperatively to prevent accidental anterior displacement of the ear that could dehisce the antihelical sutures causing recurrent prominence. Six weeks postoperatively scar tissue is strong enough to maintain the shape of the ear.

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Constricted Ear A wide spectrum of constricted (e.g., lop, cup) ear anomalies exist. They range from minor helical problems to a variant of microtia and consist of (1) lidding of the helix, (2) prominence, and/or (3) reduced size from deficient structures. If possible, I prefer to manage these deformities as low on the reconstructive latter as possible before considering cartilage grafts and retroauricular flaps. Minor deformities of the helix can be improved with simple excisions (Figure 53.5). Moderately constricted ears that contain a sufficient amount of structures may be improved using techniques employed for prominent ear deformities (Figure 53.6). Generally, the primary morbidity of a constricted ear is that it is prominent. If the ear is set back by strengthening the antihelical fold and placing sutures from the cartilage to the mastoid and temporal fascia to lengthen the vertical dimension of ear, the appearance of the child can be significantly improved. Severely constricted ears that approximate conchal-type microtia require partial or total auricular construction using cartilage grafts (Figure 53.7).

FIGURE 53.5 Correction of a mildly constricted ear. A. Preoperative image shows abnormal helix covering a portion of the superior crus of the antihelix. B. Outline for soft-tissue and cartilage excision. C. Intraoperative view following removal of cartilage. D. Immediate postoperative appearance.

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FIGURE 53.6 Treatment of a moderately constricted ear. A. Preoperative image shows a cupped ear with reduced vertical height and deficient helix and antihelix. B. Postoperative view after placement of scapha-concha, concha-mastoid, and scaphatemporal sutures.

FIGURE 53.7 Reconstruction of a severely constricted ear with the absence of the lobule and part of the helix, concha, and antihelix. A. Preoperative appearance. B. Following first-stage advancement of a retroauricular flap to add soft tissue to the middle and lower one-third of the ear. The upper one-third of the ear was set back using scapha-concha sutures to recreate the antihelical fold. C. Appearance after staged placement of a conchal cartilage graft harvested from the contralateral ear. The outline of the graft is illustrated by the blue marking. D. Appearance after completing the reconstruction. The lower third of the ear containing the cartilage graft was separated from the retroauricular area using local flaps.

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Cryptotia Patients with cryptotia have a superior helix that is attached to the postauricular skin without a sulcus. In addition to causing a deformity, patients have difficulty wearing eyeglasses. Many techniques have been described to reconstruct the anomaly, including local flaps, skin grafts, and tissue expansion. I prefer using a one-stage V-Y advancement flap from the scalp to recreate the retroauricular sulcus. 20 This leaves a hidden scar behind the ear and in the hairline (Figure 53.8). Occasionally, the helical cartilage may be significantly deformed and require scoring, sutures, and/or grafts to improve its shape.

FIGURE 53.8 Correction of cryptotia. A. Preoperative appearance. B. The normal components of the helix are identified by pulling the ear outward. C. Outline of the V-Y advancement flap to recreate the retroauricular sulcus. D. Flap raised. E. After advancement of the flap and closure of the donor site. F. Postoperative view.

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Stahl Deformity This abnormality describes the presence of a third crus of the antihelix that can cause the helix to have a pointed appearance. Usually, the anomaly is minor and does not cause psychosocial morbidity. Operative intervention may be indicated to treat a severe deformity. The anomaly is improved surgically through an anterior incision at the junction of the helix and scapha. The anterior skin is elevated, and the abnormal crus is resected (Figure 53.9). 21 If the superior crus of the antihelix is missing, then the excised crus can be grafted or rotated to reconstruct this structure. Occasionally, patients may have a prominent ear deformity as well requiring setback otoplasty techniques.

FIGURE 53.9 Correction of a Stahl deformity.% A. Preoperative view illustrating the abnormal one third crus of the antihelix and a pointed appearance of the helix. B. Intraoperative image of the incision along the junction of the helix and scaphoid fossa exposing the abnormal crus. C. Following resection of the abnormal cartilage. D. Postoperative appearance illustrates improved contour of the helix and scaphoid fossa.

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Accessory Cartilage Accessory cartilage in the preauricular area is the most common ear anomaly. I prefer to remove the tissue during the neonatal period using local anesthesia in the office to obviate general anesthesia. If an infant has a large lesion with a wide cartilage base that cannot be easily excised and closed, the procedure is performed in the operating room. Patients who present after 12 months old as well are managed in the operating room because it is difficult to restrain the child in the clinic.

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Lobule Abnormalities Split Ear Lobe This deformity results from an earring being pulled through the lobule. The cleft is rapidly epithelialized preventing the edges from reapproximating. Split ear lobes in older children and adolescents can be repaired with local anesthesia; young children require general anesthesia. The cleft is de-epithelialized and approximated using absorbable sutures in a straight line. The end of the cleft is closed with a mattress suture for eversion to prevent a notch from scar contraction. The scar can be repierced 3 months later when it has achieved its maximal strength. The advantages of repiercing along the scar are that the scar is camouflaged and if the earring pulls through again, a second scar is not formed. The disadvantage of piercing the scar is that it is not as strong as the adjacent lobule and thus has a higher risk of pulling through again.

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Keloid The ear lobe has a greater risk of forming keloid scars from piercings, compared to other parts of the ear. Keloids are managed with pressure, corticosteroid injection, and/or resection. Small lesions can be treated with pressure only. Patients are advised to wear a clip-on earring or purchase a pressure earring designed for keloids. The pressure device is worn at night when sleeping. A pressure earring is a good first-line intervention for minor keloids in young children who are less tolerant of undergoing a corticosteroid injection in the clinic. Older children can be managed with serial triamcinolone injections in addition to the pressure earring. Large keloids are best managed with resection because pressure/injections will only give minimal improvement and the patient will continue to have a significant deformity. Families are educated that resection is exponentially more traumatic to the ear than the piercing that caused the keloid. Consequently, without close follow-up and the use of postoperative compression and corticosteroid injections, the keloid will return and can be worse. After resecting the keloid, the patient wears a pressure earring beginning 2 weeks following the procedure at night. Four weeks postoperatively, the patient returns for monthly evaluations and possible corticosteroid injections. After 6 months, the patient follows up as needed. Although radiation has been described as a treatment for keloids, I have not had a patient require this intervention.

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Congenital Deficiency The most common lobule deficiency is a cleft that causes a deformity and obviates the ability to place earrings. The cleft is deepithelialized and corrected by advancing the tissue to form a lobule (Figure 53.10). Rarely, a patient can have an absent lobule on the spectrum of microtia. The lobule can be constructed using staged skin flaps from the adjacent neck, or by placing a conchal cartilage graft. I have found that using cartilage gives the most favorable outcome (see Figure 53.7).

FIGURE 53.10 Congenital lobule deficiency. A. Preoperative view. B. Outline of flap and area of de-epithelialization. C. Prior to flap advancement. D. Following inset of the flap.

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Complications Rarely, a skin abrasion or full-thickness wound can occur with ear molding; molding is discontinued until the area has healed. The most common problem is an unfavorable “cosmetic” outcome. Infection, hematoma, extrusion of sutures, or wound dehiscence is uncommon. Before reconstructing an ear, patients/parents must have reasonable expectations. The ears are tolerant to asymmetry, and the primary goal is to improve their appearance on frontal view.

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Summary Otoplasty is based on principles. The surgeon must be able to identify the deformity and determine if there are excess structures, deficient structures, or adequate structures that need to be rearranged. Although many options often exist to improve a specific type of ear deformity, the simplest technique often is preferred.

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Questions 1. A 5-year-old girl has an ear anomaly showing poor definition of the superior helix without a retroauricular sulcus. Which of the following is the most likely diagnosis? a. Microtia b. Prominent ear c. Stahl ear d. Cryptotia e. Constricted ear 2. A 5-year-old boy has an ear anomaly showing a pointed helix and a third crus of the antihelix. Which of the following is the most likely diagnosis? a. Microtia b. Prominent ear c. Stahl ear d. Cryptotia e. Constricted ear 3. Which of the following is the most ideal time to initiate nonsurgical molding to correct a prominent ear deformity? a. 1 month b. 3 months c. 6 months d. 12 months e. 24 months 4. Which operative technique is used to recreate the antihelical fold in a patient with a prominent ear? a. Cartilage graft b. Cartilage excision c. Mustarde sutures d. Furnas sutures e. Postauricular flap 5. Which operative technique is used to set back the middle third of the ear in a patient with a prominent ear? a. Cartilage graft b. Cartilage excision c. Mustarde sutures d. Stenstrom technique e. Postauricular flap 1. Answer: d. The patient has cryptotia because the superior helix of the ear is buried underneath the scalp skin. 2. Answer: c. The patient’s anomaly described is a Stahl deformity. 3. Answer: a. Circulating maternal estrogens in newborns allows the molding of ear cartilage. Moreover, 1 to 3 weeks is the ideal time to initiate ear molding because the younger the patient, the more malleable the ear and the more likely the patient will have a favorable outcome. Ear molding cannot be started at 3 months old or later. 4. Answer: c. Mustarde sutures (also known as scapha-concha sutures) are used to recreate the antihelical fold. Another method to establish the antihelix is to abrade the anterior aspect of the

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cartilage (Stenstrom technique). A cartilage graft commonly is used to reconstruct deficient areas of the helix. Cartilage excision minimizes the prominence of the middle third of the ear by reducing the size of the concha. Furnas sutures also decrease the prominence of the concha by suturing the concha to the mastoid fascia and periosteum. A postauricular flap is used to cover exposed areas of helical cartilage. 5. Answer: b. Cartilage excision minimizes the prominence of the middle third of the ear by reducing the size of the concha. Mustarde sutures (also known as scapha-concha sutures) are used to recreate the antihelical fold. Another method to establish the antihelix is to abrade the anterior aspect of the cartilage (Stenstrom technique). A cartilage graft commonly is used to reconstruct deficient areas of the helix. Stenstrom technique is the scoring of cartilage to make it bend and is a technique used to strengthen the antihelical fold and set back the superior third of the ear. A postauricular flap is used to cover exposed areas of helical cartilage.

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References Zhao, H, Ma, L, Qi, X, et al. A morphometric study of the newborn ear and an analysis of factors related to congenital auricular deformities. Plast Reconstr Surg. 2017;140(1):147-155.This was a prospective study of 1500 newborns performed at 7 and 30 days of life. Ear anomalies and risk factors were documented as well as the maturation of ear deformities over time. The investigation provided epidemiological data about the incidence and natural history of ear anomalies. Matsuo, K, Hayashi, R, Kiyono, M, et al. Nonsurgical correction of congenital auricular deformities. Clin Plast Surg. 1990;17(2):383-395. Driessen, JP, Borgstein, JA, Vuyk, HD. Defining the protruding ear. J Craniofac Surg. 2011;22:2102-2108. Shokrollahi, K, Manning, S, Sadri, A, et al. The prominent antihelix and helix—the myth of the ‘overcorrected’ ear in otoplasty. Ann Plast Surg. 2015;74(suppl 4):S259-S263. Tolleth, H. Artistic anatomy, dimensions, and proportions of the external ear. Clin Plast Surg. 1978;5(3):337-345. Bauer, BS. Nonmicrotia. In: Bentz, M , Bauer, BS , Zucker , eds. Principles and Practice of Pediatric Plastic Surgery. New York, NY: Thieme; 2016. Matsuo, K, Hirose, T, Tomono, T, et al. Nonsurgical correction of congenital auricular deformities in the early neonate: a preliminary report. Plast Reconstr Surg. 1984;73(1):38-51.This was the first report for ear molding of auricular anomalies in newborns. This observation lead to the development of commercially produced ear-molding devices and decreased the need for operative otoplasty in children. Byrd, HS, Langevin, CJ, Ghidoni, LA. Ear molding in newborn infants with auricular deformities. Plast Reconstr Surg. 2010;126:1191-1200. Tan, ST, Abramson, DL, MacDonald, DM, Mulliken, JB. Molding therapy for infants with deformational auricular anomalies. Ann Plast Surg. 1997;38:263-268. Adamson, JE, Horton, CE, Crawford, HH. The growth pattern of the external ear. Plast Reconstr Surg. 1965;36(4):466-470. Gosain, AK, Kumar, A, Huang, G. Prominent ears in children younger than 4 years of age: what is the appropriate timing for otoplasty? Plast Reconstr Surg. 2004;114(5):1042-1054.This study prospectively studied 12 patients who underwent otoplasty for prominent ears between 9 months and 3 years old. The length of the surgically corrected and the normal contralateral ears were the same at follow-up (range 2–7 years). This investigation showed that otoplasty can be performed in early childhood without inhibiting ear growth. Mustarde, JC. Correction of prominent ears using buried mattress sutures. Clin Plast Surg. 1978;5:459-464. Stenstrom, SJ, Heftner, J. The Stenstrom otoplasty. Clin Plast Surg. 1978;5:465-470. Sinno, S, Chang, JB, Thorne, CH. Precision in otoplasty: combining reduction otoplasty with traditional otoplasty. Plast Reconstr Surg. 2015;135(5):1342-1348. Furnas, DW. Correction of prominent ears by conchamastoid sutures. Plast Reconstr Surg. 1968;42(3):189-193. Bauer, BS, Song, DH, Aitken, ME. Combined otoplasty technique: chondrocutaneous conchal resection as the cornerstone to correction of the prominent ear. Plast Reconstr Surg. 2002;110(4):1033-1040.The authors present a surgical technique that is a fundamental component of many otoplasty procedures. They describe the resection of conchal cartilage that enables the setback of the middle third of the ear as well as facilitates the formation of the antihelical fold with scapha-concha sutures. Ungarelli, LF, de Andrade, CZ, Marques, EG, et al. Diagnosis and prevalence of prominent lobules in otoplasty: analysis of 120 patients with prominent ears. Aesthet Plast Surg. 2016;40(5):645-651. Thorne, CH, Wilkes, G. Ear deformities, otoplasty, and ear reconstruction. Plast Reconstr Surg. 2012;129:701e-716e. Gosain, AK, Recinos, RF. A novel approach to correction of the prominent lobule during otoplasty. Plast Reconstr Surg. 2003;112(2):575-583. Cho, BC, Han, KH. Surgical correction of cryptotia with V-Y advancement of a temporal triangular flap. Plast Reconstr Surg. 2005;115(6):15701581.The authors present a technique for the correction of cryptotia that uses a one-stage V-Y advancement flap from the postauricular area. This procedure obviates the need for skin grafts or tissue expansion to recreate the sulcus. Kaplan, H, Hudson, D. A novel surgical method of repair for Stahl’s ear: a case report and review of current treatments modalities. Plast Reconstr Surg. 1999;103:566-569.

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CHAPTER 54

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Facial Skeletal Augmentation With Implants and Osseous Genioplasty Paul D. Durand and Christopher C. Surek, and James E. Zins

Key Points Proper preoperative assessment and planning are crucial prior to attempting any modification of the facial skeleton. The subperiosteal plane is typically preferred for implant placement. Incisions should be planned away from the implant pocket. Two most commonly used materials for facial skeletal augmentation are solid silicone and porous polyethylene. Rigid fixation minimizes implant malposition and reduces risk of infection. Skeletal augmentation should not be viewed as a substitute for soft tissue suspension. Horizontal osteotomies should be placed at least 5 mm caudal to the canines to avoid tooth root injury as well as to reduce risk of mental nerve injury. Mental nerve exits the mandible through the mental foramen, which is located between the first and second premolars. Placement of intraoral incision should be 1 cm anterior to the gingivolabial sulcus, allowing for proper wound closure. Using a submental incision for alloplastic augmentation genioplasty may reduce risk of infection, wound dehiscence, and implant migration.

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Facial Skeletal Augmentation With Implants Preoperative Evaluation As in any preoperative assessment, a thorough physical examination is of paramount importance. Aesthetic concerns and expectations should then be discussed. Reviewing photos of the patient’s front, oblique, and profile proves to be particularly useful for both the surgeon and patient. The facial skeleton should be assessed for asymmetry and dysmorphology. Minor modifications of the facial skeleton can significantly accentuate areas of mild asymmetry. Established anthropometric measurements of balanced faces can provide the surgeon with some objective basis that can be used in deciding what areas need to be augmented or reduced and to what extent. 1 Recent advances in preoperative evaluation including 3D CT scanning, stereolithographic modeling, 3D printing, and a variety of other software programs are available. Nevertheless, posteroanterior and lateral cephalometric radiographs and panoramic x-rays can be particularly useful when planning augmentation of the chin and mandible. Skeletal dimensions in relation to soft-tissue thickness can be assessed.

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Alloplastic Materials Aesthetic facial skeletal augmentation is generally performed with alloplastic implants. An ideal implant material is one that is biocompatible and has minimal interaction with the surrounding tissues, such that its morphology is maintained after placement. In contrast, skeletal augmentation with autogenous bone can remodel, in time affecting its size and shape. 2,3 The host tissue response includes some level of capsule formation around the implant being placed. The most important determinant of the degree of this response is the material in the outer surface of the implant. Porous implants typically result in less robust capsule formation compared to smooth implants. Implant migration and adjacent bone erosion also tend to be lower in porous implants. 4,5 Solid silicone implants offer several advantages over other materials—they can be effortlessly carved to achieve a desired shape and size, as well as be easily fixated with screws or sutures. Incidence of infection, although low regardless of the implant type, has been reported to be lower when silicone implants are used. 6

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Positioning and Immobilization Implant placement is described in both supraperiosteal and subperiosteal planes (Figure 54.1). The subperiosteal pocket dissection is preferred as it involves a plane of dissection that is bloodless and safe relative to surrounding neurovascular structures. Regardless of the area being augmented and the type of implant used, proper immobilization of the device can provide a more accurate, reproducible result. A major advantage of screw fixation over the other methods (e.g., sutures) relates to more accurate final contour because gaps between host bone and the implant are eliminated.

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FIGURE 54.1 Location of various facial implants for skeletal augmentation.

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Midface Augmentation Most aesthetic facial augmentation occurs in the middle and lower thirds of the face. Augmentation of the midface can be divided in four major areas: malar, submalar, paranasal, and infraorbital rim.

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Malar The malar area is a frequent area of alloplastic augmentation. Full cheeks and prominent malar bones are associated with youth and attractiveness. Patients seeking augmentation of this area can either have normal anatomy or a true skeletal deficiency of the midface such as congenital deformities. 7 Such distinction is important, as in the latter case; malar augmentation alone can be insufficient to address the aesthetic issue at hand. Finally, skeletal augmentation should not be seen as equivalent to soft-tissue augmentation and resuspension; these are two separate entities that when used appropriately can have a synergistic effect. Incision placement for insertion of malar implants can vary and include the intraoral, coronal, or eyelid routes, all of which have been described. 7 An intraoral approach is preferred as it provides good exposure and avoids any external scars. When performing an upper sulcus incision, sufficient labial tissue should be left on either side to allow for a secure, two layered watertight closure. After careful identification of the infraorbital nerve, dissection is carried out in the subperiosteal plane over the malar eminence and onto the zygomatic arch. The pocket size can be tailored to the implant being used and its desired aesthetic outcome. Screw fixation provides for more freedom in pocket dissection and thus greater exposure at the time of implant insertion. Careful carving of the implant on its posterior surface and rigid fixation minimize visibility and malposition.

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Paranasal Deficiency of midface projection can either be congenital or acquired. It is present in individuals who have undergone cleft surgery, traumatic facial fractures, or due to developmental deformities. In patients with a relatively normal occlusion, deficient midface projection can be corrected with facial implants. By increasing nasal base projection, paranasal augmentation serves to open the nasolabial angle and effaces the depth of the nasolabial fold. When properly placed, paranasal implants can simulate the visual effect of LeFort I advancement. 8 Paranasal augmentation is done intraorally. To avoid placing incisions directly over the implant, the upper gingival buccal sulcus incision is made just lateral to the piriform aperture. As with malar augmentation, dissection is carried out subperiosteally, while the nearby infraorbital nerve is identified and protected. Screw fixation minimizes asymmetries and malposition. When screw fixation is employed, care should be taken to avoid the root of the canine. Compromise of the nasal airway can occur if implants are positioned over the piriform aperture. 8,9

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Infraorbital Rim The morphology of the infraorbital rim skeleton plays a crucial role in supporting soft tissue of the lower eyelids and cheeks. Lack of projection of this skeletal component can be responsible for premature descent of such structures and result in early facial aging. A characteristic “negative” vector, in which the most anterior projection of the globe lies anterior to the lower lid and malar eminence, is commonly noted in these individuals (Figure 54.2). This finding is associated with significant risk of lower eyelid malposition after blepharoplasty. Augmentation of the infraorbital rim can decrease the incidence of lower lid malposition by reversing the “negative” vector. 10,11

FIGURE 54.2 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. A. Positive vector relationship. In a youthful face with normal globe-to-skeletal rim relations, 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. B. 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. C. “Reversed” negative vector relationship. Alloplastic augmentation of the infraorbital rim can reverse the negative vector.

Various types of incision can be used for insertion of infraorbital rim implants, including subciliary skin and skin-muscle flap incisions. If a transconjunctival incision is used, it can be lengthened with a lateral canthotomy. Better exposure of the midface skeleton can be obtained by incorporating an intraoral sulcus incision. Dissection is carried out in a subperiosteal plane. Infraorbital rim implants can be carved to tailor lateral and medial extension depending on the specific area to be augmented. Screw fixation is beneficial in this area to avoid implant malposition. Prior to closure, malar soft tissue should be resuspended over the secured implant. 11

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Temporal Augmentation The deepest portion of the temporal fossa is the anterior inferior fossa, which is the sphenoid bone contribution. 12 Facial aging, trauma including previous surgery, weight change, and a variety of other causes can lead to soft-tissue deficiency of muscle and fat in the temporal fossa. Yaremchuk used polymethylmethacrylate (PMMA) to fill up temporal depressions. If a previous reconstructive surgery was performed in the temporal area, access is gained through the old scar and the PMMA is placed over the deficient muscle. To prevent implant motion, titanium screws are secured along the lateral orbital rim. If patients have not had surgery or have had the temple used as a remote access to other regions of the face (i.e., subperiosteal facelift), then the implant is placed beneath the temporalis muscle though an incision in the temporal hair-bearing scalp. 12,13

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Mandibular Augmentation Chin Augmentation of the chin area can have a profound effect on the facial profile. In an ideal face, the upper lip should be projecting 2 mm beyond the lower lip, whereas the lower lip should be projecting the same distance beyond the chin. 14 Riedel’s line is a rapid means of assessing the adequacy of chin projection. A line is drawn tangential to the upper lip and lower lip and the chin should fall on this line (Figure 54.3). Men tend to have larger, more projected chins compared to women. Placing too large of an implant in a woman can have an unattractive masculinizing effect and should be avoided. 14–16

FIGURE 54.3 Riedel line.

An ideal chin implant is one that augments the mentum while merging laterally with the anterior aspect of the mandibular body. As with skeletal augmentation of other facial areas, implant materials used are either porous or smooth (see Alloplastic Materials section). Extended porous implants have limited

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flexibility and are typically designed in two pieces to allow placement through a reduced incision. 16 Chin implant insertion can be performed through a submental or an intraoral incision (Figure 54.4). However, we use the submental incision exclusively. The intraoral incision avoids an external scar but provides limited exposure of the anterior mandible. In addition, the intraoral incision is associated with superior malposition of the implant and soft-tissue ptosis, and in our opinion it should be avoided. 16 This is usually secondary to improper mentalis muscle repair at the time of wound closure and results in a witch’s chin deformity. 17 Regardless of the incision being used, care should be taken to identify and protect the mental nerves during subperiosteal dissection.

FIGURE 54.4 Representation of a preferred technique for chin augmentation. Through a submental approach, a two-piece porous polyethylene implant is fixed to the skeleton with titanium screws. This maneuver immobilizes the implant and obliterates any gaps between the implant and the underlying bone. The implant is being contoured to provide an imperceptible implant-native mandible transition.

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Other (Body/Angle/Ramus) Although chin augmentation remains the most popular type of mandibular augmentation, certain patient populations may benefit from augmentation of other areas. Yaremchuk identifies two main groups of patients who usually seek such enhancement. The first group includes individuals who display normal mandibular dimensions in relation to other facial thirds. They perceive a wider lower face as more attractive and want to emulate the more angular lower face seen in models and actors. The other group includes those who have an actual deficiency of the mandibular skeleton. They may have a normal occlusion or may have had malocclusion previously corrected by orthodontics alone. In these patients, mandibular augmentation of the ramus and body is often paired with an extended chin implant to address poor mental projection. 18 An intraoral mucosal incision provides adequate exposure of the mandibular ramus and body in the subperiosteal plane. It can be extended anteriorly if concomitant chin augmentation is being performed. Care must be taken to identify and visualize the mental foramen. Screw fixation of the implants can either be done intraorally or through a percutaneous incision for trocar placement (Figures 54.5 and 54.6). A suction drain is usually placed in the operative site which exits through the postauricular area. 18

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FIGURE 54.5 A. Intraoperative photograph following placement of polyethylene gonial angle implant through an intraoral buccal sulcus incision. The periosteum is stripped and the implant is contoured to the appropriate shape and taper. The implant was fixed in place using two screws flush with bone by two titanium screws, one into the gonial angle and the other cephalic in the mandibular ramus. B. An intraoperative photograph demonstrating the location of the buccal sulcus incision that was utilized

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to perform gonial angle implant placement. It is important to leave an adequate mucosal cuff on the lingual side of the incision in order to get a good watertight closure. This photo is taken at the end of the operation demonstrating a multilayered closure.

FIGURE 54.6 A, B. An 18-year-old female had a chin implant placed for sagittal microgenia by another surgeon: preprocedure (left) and 4 months postprocedure (right) photographs. C, D. At age 22, the patient was not satisfied with the aesthetic result, so the chin implant was removed and horizontal advancement genioplasty for sagittal and vertical microgenia was performed: preprocedure (left) and 11 months postprocedure (right) photographs. E, F. At 23, the patient underwent gonial angle implant placement and mandibular fat grafting for jawline contour augmentation: preprocedure (left) and postprocedure (right) photographs. The postprocedure photo is 7 months following the gonial angle implant placement and 4 months following mandibular fat grafting.

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Complications in Alloplastic (Implant) Augmentation Alloplastic implant complications include infection, migration, malposition, and asymmetry. Serious complications after alloplastic augmentation of the facial skeleton are rare. Bone resorption of adjacent areas has been reported and is associated with solid implants. Bone resorption is significantly less likely with porous implants. 19 In his series of 162 patients, Yaremchuk reported an acute infection rate for implants of 2%. The total reoperation rate was 10% and mostly due to implant malposition, asymmetry, or displeasing contours. If implant infection does occur, antibiotic treatment alone is usually not sufficient. In such cases, implant removal is recommended along with an antibiotic regimen. Implants can be replaced at 12 months after infection cessation. 19

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Osseous Genioplasty The horizontal genioplasty remains as the second most commonly performed osteotomy of the facial skeleton, next to rhinoplasty. 20 Compared to prosthetic chin implants, osseous genioplasty allows for a more powerful and versatile alteration of chin morphology and shape. This includes not only correction of sagittal deficiency, but also can include vertical lengthening, reduction, and correction of asymmetries.

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Anatomy To ensure a safe and predictable result in osseous genioplasty, knowledge of muscle attachments and adjacent neurovascular structures is important. The three muscles that attach to the anterior plane of the chin include: mentalis, depressor angularis, and depressor labii inferioris. Equally important are muscle attachments on the lingual aspect of the chin, which include mylohyoid, geniohyoid, and genioglossus. It is the latter group that contains the perforating branches responsible for maintaining blood supply of the caudal chin segment following elevation of the anterior periosteum and horizontal osteotomy. An important structure that is vulnerable to injury during soft-
 tissue dissection and osteotomy is the mental nerve. A continuation of the inferior alveolar nerve, it exits the mandible via the mental foramen. The latter is located in the vertical plane between the first and second mandibular premolars. To avoid injury to the mental nerve, the horizontal osteotomy should be planned at least 5 mm caudal to the foramen in a caudal-oblique angle. The mental nerve makes a gentle curve as it approaches the mental foramen. Therefore it lies caudal to the foramen distally and can be injured if a bone cut is made just below the foramen. 21,22

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Limitations of Alloplastic (Implant) Augmentation Those favoring alloplastic augmentation over osseous genioplasty cite several theoretical advantages including: technical ease, less pain, and a relatively low complication risk. Conversely, the horizontal genioplasty offers potential correction in multiple planes, anterior, posterior, and vertical. Alloplastic augmentation with chin implants can be effective in correcting mild to moderate volume deficiencies in the sagittal plane. Major limitations of alloplastic methods occur when trying to correct vertical excess or any asymmetries of the anterior mandible. Furthermore, osseous genioplasty is more amenable to surgical revision if such a condition is indicated. In the latter, soft tissue of the chin has not been degloved and there is no scar capsule formation to address. 16,23

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Preoperative Evaluation and Indications It is important to note that genioplasty is performed solely to address chin disharmony and should not be seen as a replacement to orthognathic surgery. Proper preoperative evaluation should include a complete history and physical examination with special attention to the occlusion. Specific complaints and cosmetic objectives need to be discussed with the patient. The surgeon should also inquire about previous orthodontic treatments or prior orthognathic surgery. Comorbid conditions and anesthetic contraindications are to be weighed in the decision to perform surgery.

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Physical Examination Physical examination should include appreciation of chin projection, symmetry, and vertical length. In assessing the vertical dimension of the chin, the lower third of the face should be subdivided using a line passing through the stomion (Figure 54.7). The distance from the stomion to the menton should be twice the length of the distance between the subnasale and the stomion.

FIGURE 54.7 Lower facial third division.

Chin projection is better assessed in the profile view using Riedel’s plane. In the latter, a line is drawn tangential to the upper and lower lip (see Figure 54.3). In a balanced face, this line should touch the most prominent anterior portion of the pogonion. Chin position in relation to Riedel’s plane dictates the amount of horizontal microgenia or macrogenia present. 20,24 The lower lip, and not the other structures in the mid and upper face, determines the extent to which the chin should be advanced. 20 In the sagittal dimension, it is always preferable to undercorrect than overcorrect, resulting in an aesthetically displeasing outcome. When advancing the chin, the ratio of soft tissue to skeletal displacement is generally 3:2. Conversely, the response of soft tissue to a posteriorly repositioned chin is less predictable and typically 0.5:1. 20,24 Labiomental groove depth should also be evaluated when determining if a patient is a good candidate for osseous genioplasty; it should measure 4 mm in women and 6 mm in men. Sagittal advancement or vertical shortening of the symphyseal segment would result in deepening of the labiomental groove. Conversely, vertical lengthening softens the labiomental crease (Figure 54.8). In the setting of a long lower face and a deep labiomental fold, correction should include orthognathic surgery rather than osseous genioplasty alone. 20

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FIGURE 54.8 Preprocedure (left) and postprocedure (right) photographs of a 55-year-old man who underwent vertical lengthening genioplasty. Note the improvement in lower vertical faical height and softening of the labiomental crease. The postprocedure photo is 2.5 years after the operation.

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An intraoral examination should be performed to evaluate occlusion and presence of any significant periodontal disease. The majority of individuals requesting aesthetic enlargement of the chin have class II malocclusion secondary to mandibular retrognathia. Although prior orthodontic treatment can convert class II malocclusion into type I, it corrects the underlying skeletal problems. 20 Routine workup includes a lateral cephalometric and panoramic x-ray and frontal, profile, and oblique photographs at a minimum.

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Surgical Technique Operative Approach Although osseous genioplasty can be performed under local anesthesia with intravenous sedation, general anesthesia with either orotracheal or nasotracheal intubation is recommended. Prior to incision, the chin is infiltrated using xylocaine with epinephrine solution. An incision is planned at least 1 cm away from the mandibular buccal sulcus and is 2 to 4 cm in length. The mentalis muscle is exposed after incising the mucosa and submucosa. Maintaining a 1 cm cuff of mucosa and mentalis in the gingival side of incision will facilitate later muscle repair and incision closure. After muscle division, subperiosteal dissection of the anterior mandibular symphysis is performed. Inferior dissection is performed only far enough for sufficient exposure to performing the osteotomy and subsequent fixation. Complete degloving of the symphysis is not preferred as reattachment of soft tissues can be unpredictable, increasing the risk for a witch’s chin deformity. 17 Exposure is carried laterally until both mental nerves are visualized and posteriorly to the inferior border of the mandible, but not further. Prior to performing any osteotomies, the chin midline is marked with a bone bur for proper positioning of symphyseal bone segments at the time of fixation. Horizontal osteotomy should be performed using a reciprocating saw at least 4 mm below the mental foramina to avoid nerve injury. Retractors can be used to protect the nerves. The osteotomy is then carried as far posteriorly as possible to prevent excessive visibility of step-offs in the inferior mandible border. If extensive anterior movement of the chin segment is anticipated, it might be necessary to detach the anterior belly of the digastric muscles from the lingual surface. After proper mobilization is achieved, fixation of the bone segment is performed with either plate and screws or wires (Figure 54.9). 22,23 A temporary drill hole and wire through the anterior surface of the mobilized segment allows easy handling of the osteotomy.

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FIGURE 54.9 Intraoperative photograph demonstrating screw and plate fixation of a horizontal advancement genioplasty.

Osteotomy patterns vary depending on the type of chin deformity to be corrected (Figure 54.10). For vertical shortening of the chin, two parallel horizontal osteotomies with removal of the intervening bone segment are used. The inferior cut is always made first for ease of handling. Conversely, if vertical elongation is needed, interposing blocks of bone substitute can be inserted into the osteotomy gap previously created. 22,23 A gap of less than 5 mm needs no interposition implant.

FIGURE 54.10 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 angulation of this osteotomy allows forward advancement of the chin without any vertical changes. B. Simultaneous advancement and vertical reduction 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 includes blocks of porous hydroxyapatite. D. Lateral shifting of the symphyseal segment to restore lower face symmetry.

After appropriate bony fixation is obtained, the wound is irrigated with either dilute povidone-iodine solution or antibiotic irrigation. Mentalis muscle is then reattached using interrupted sutures, a crucial step in preventing soft-tissue ptosis and a witch’s chin deformity. 17 Mucosa is then repaired using chromic sutures until watertight closure is achieved.

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Complications in Osseous Genioplasty Wound dehiscence and infection are rare after osseous genioplasty. In the setting of a dehiscence without infection and with no loose or exposed hardware, most resolve without intervention. If infection is suspected and bone fixation is not loose, localized debridement and irrigation followed by antibiotics serve to avoid unnecessary removal of hardware. Because this is a vascularized osteotomy, the bone is not at risk. Hematomas should be promptly evacuated to prevent abscess formation. More than half of all patients undergoing osseous genioplasty will have some degree of temporary neurosensory loss. Most of these are due to traction and should return days to weeks after the operation. If the nerve is cut during surgery, it should be repaired. Dental complications can also occur. Root exposure can occur if incision is placed too close to the gingiva and is most likely in patients with gingival resorption. It presents as a caudal retraction of gingival tissue and results in exposure of the sensitive portion of teeth. Gingival grafting might be needed to treat such a complication. Tooth devitalization is probably one of the most serious complications after osseous genioplasty and can be avoided by placing the osteotomy at least 30 mm caudal to the occlusal edge of the mandibular canines. 22 Soft-tissue ptosis is usually secondary to improper mentalis muscle repair at the time of wound closure and results in a witch chin’s deformity. It can be corrected by excising soft tissue through an elliptical incision in the submental area. Lower lip retraction resulting in increased lower incisor show can also occur secondary to improper mentalis muscle repair. Correction can be achieved through an intraoral incision and cephalically suspending anterior periosteum. 17,25

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Questions 1. Riedel’s plane corresponds with a line connecting the most projected points of the upper and lower lip to what structure? a. Nasal tip b. Labiomental crease c. Pogonion d. Base of nasal ala 2. Inadequate reapproximation of the mentalis muscle following genioplasty surgery can lead to what deformity? a. Inability to depress the oral commissure b. Inability to pucker lips c. “Witch’s chin” abnormality d. Decreased ability to suck from a straw 3. Which of the following tooth root apexes is at greatest risk for damage during osteotomy at the time of sliding genioplasty? a. Bicuspid b. Central incisor c. Lateral incisor d. Canine e. First molar 4. A 22-year-old man is evaluated for lower facial asymmetry. He is scheduled to undergo sliding genioplasty. At the time of osteotomy, the nerve more likely to be injured exits mandible adjacent to what landmark? a. Canines b. Between lateral and central incisors c. Between second and third molar d. Between first and second premolars e. Between lateral incisors and canines 5. A 34-year-old woman with class I occlusion comes for orthognathic evaluation. She is displeased with her lower face profile. On examination, isolated retrogenia and moderate vertical mandibular excess are noted. Which is the most appropriate genioplasty for this particular patient? a. Advancement with horizontal osteotomy only b. Advancement with inferiorly angled osteotomy c. Alloplastic augmentation, extraoral approach d. Alloplastic augmentation, intraoral approach e. Advancement with horizontal osteotomy and downgrafting 1. Answer: c. Riedel’s line is a rapid means of assessing the adequacy of chin projection. A line is drawn tangential to the upper lip and lower lip and the chin should fall on this line (see Figure 54.3). 2. Answer: c. During wound closure in genioplasty, the mentalis muscle is then reattached using interrupted sutures; this is a crucial step in preventing soft-tissue ptosis and a witch’s chin deformity. If this deformity occurs, it can be corrected by excising soft tissue through an elliptical incision in the submental area. 3. Answer: d. The canine tooth root is the longest tooth root and therefore is at risk during sliding genioplasty. Tooth devitalization is probably one of the most serious complications after osseous genioplasty and can be avoided by placing the osteotomy at least 30 mm caudal to the occlusal edge

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of the mandibular canines. 4. Answer: d. The mental foramen is located between the first and second premolars. Note that the mental nerve makes a gentle curve as it approaches the mental foramen. Therefore, it lies caudal to the foramen distally and can be injured if a bone cut is made just below the foramen. Horizontal osteotomy should be performed using a reciprocating saw at least 4 mm below the mental foramina in order to avoid nerve injury. 5. Answer: b. This patient has microgenia and therefore needs horizontal advancement. Given that she has vertical excess of the mandible, an angled osteotomy, and possible wedge excision can be performed to help normalize vertical height of the mandible. Patients with retrogenia and vertical mandibular deficiency would be best suited for genioplasty and downgrafting to increase vertical mandibular height (answer e). Patients with normal mandible vertical height and isolated microgenia would receive a horizontal advancement without vertical height manipulation.

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References Farkas, LG, Kolar, JC. Anthropometrics and art in the aesthetics of women’s faces. Clin Plast Surg. 1987;14:599.Classic article exploring the importance of anthropometric dimensions in female face aesthetics. Chen, NT, Glowacki, J, Bucky, LP, et al. The roles of revascularization and resorption on endurance of craniofacial onlay bone grafts in the rabbit. Plast Reconstr Surg. 1994;93:714. Saulacic, N, Bosshardt, DD, Jensen, SS, et al. Impact of bone graft harvesting techniques on bone formation and graft resorption: a histomorphometric study in the mandibles of minipigs. Clin Oral Implants Res. 2015;26(4):383-391. Maas, CS, Merwin, GE, Wilson, J, et al. Comparison of biomaterials for facial bone augmentation. Arch Otolaryngol Head Neck Surg. 1990;116:551-556. Yaremchuk, MJ, Chen, YC. Enlarging the deficient mandible. Aesth Surg J. 2007;27(5):539-550. Carboni, A, Gasparini, G, Perugini, M, et al. Evaluation of homologous bone graft versus biomaterials in the aesthetic restoration of the middle third of the face. Minerva Chir. 2002;57(3):283-287. Whitaker, LA. Aesthetic augmentation of the malar midface structures. Plast Reconstr Surg. 1987;80:337.Another classic article that reviews various preoperative and technical aspects of facial aesthetic augmentation with a focus on the midface. Yaremchuk, MJ, Israeli, D. Paranasal implants—correct midface concavity. Plast Reconstr Surg. 1998;102:1676-1684. Yaremchuk, MJ. Secondary malar implant surgery. Plast Reconstr Surg. 2008;121:620.Offers a complete examination of how to deal with implantrelated complications of the malar area, with a focus on secondary revision surgery. Jelks, GW, Jelks, EB. The influence of orbital and eyelid anatomy on the palpebral aperture. Clin Plast Surg. 1991;18:193. Yaremchuk, MJ. Infraorbital rim augmentation. Plast Reconstr Surg. 2001;107:1585. Vaca, EE, Purnell, CA, Gosain, AK, Alghoul, MS. Postoperative temporal hollowing: is there a surgical approach that prevents this complication? A systematic review and anatomic illustration. J Plast Reconstr Aesthet Surg. 2017:70(3):401-415. Gordon, CR, Yaremchuk, MJ. Temporal augmentation with methyl methacrylate? Aesthet Surg J. 2011;31(7):827-833. McCarthy, JG, Ruff, GL. The chin. Clin Plast Surg. 1988;15:125. Flowers, RS. Alloplastic augmentation of the anterior mandible. Clin Plast Surg. 1991:18:107-137. Yaremchuk, MJ. Improving aesthetic outcomes after alloplastic chin augmentation. Plast Reconstr Surg. 2003:112(5):1422-1432. Zide, BM. The mentalis muscle: an essential component of chin and lower lip position. Plast Reconstr Surg. 1989;83:413.Emphasizes the importance of properly repairing the mentalis muscle when using an intraoral approach. Describes technique and potential pitfalls. Yaremchuk, MJ. Mandibular augmentation. Plast Reconstr Surg. 2000;106:697. Yaremchuk, MJ. Facial skeletal reconstruction using porous polyethylene implants. Plast Reconstr Surg. 2003;111(6):1818-1827.Extensive single surgeon experience of 162 patients undergoing facial skeletal augmentation. An excellent review of potential complications and their management. Rosen, HM. Aesthetic guidelines in genioplasty: the role of facial disproportion. Plast Reconstr Surg. 1995;95:463. Hwang, K, Lee, W, Song, Y, Chung, I. Vulnerability of the inferior alveolar nerve and mental nerve during genioplasty: an anatomic study. J Craniofac Surg. 2005;16(1):10-14. Ousterhout, D. Sliding genioplasty: avoiding mental nerve injuries. J Craniofac Surg. 1996:7(4):297-298. Sawkat, S, Havlik, RJ. An evidence-based approach to genioplasty. Plast Reconstr Surg. 2011:127(2):898-904. Michelow, B, Guyuron, B. The chin: skeletal and soft-tissue components. Plast Reconstr Surg. 1995;95(3):473-478. Chashu, G, Blinder, D, Taicher, S, Chaushu, S. The effect of precise reattachment of the mentalis muscle on the soft tissue response to genioplasty. J Oral Maxillofac Surg. 2001;59(5):510-516.

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PA R T V I

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Breast 55. Augmentation Mammoplasty, Mastopexy, and Mastopexy-Augmentation 56. Breast Reduction 57. Gynecomastia 58. Breast Cancer: Current Trends in Screening, Patient Evaluation, and Treatment 59. Breast Reconstruction: Prosthetic Techniques 60. Breast Reconstruction: Autologous Flap Techniques 61. Reconstruction of the Nipple-Areolar Complex 62. Congenital Anomalies of the Breast: Tuberous Breasts, Poland Syndrome, and Asymmetry

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CHAPTER 55

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Augmentation Mammoplasty, Mastopexy, and Mastopexy-Augmentation Ali A. Qureshi and Terence M. Myckatyn

Key Points Breast augmentation can be performed with implants in the subglandular, subfascial, and submuscular planes with the primary goal to increase the size of the breast. Fat grafting can be used alone or as an adjunct procedure for breast augmentation. Breast implants can be saline or silicone, smooth or textured, round or anatomic. These devices can rupture or form capsules that lead to capsule contracture and distortion of the breast. Mastopexy aims to change the shape of a breast that has become ptotic or involuted as result of age, hormonal changes, or weight loss by altering the skin and parenchyma of the breast. Management of capsular contracture or rupture of a prosthetic device can present a unique set of challenges and often requires operative intervention. A new pocket may need to be created or adjunct materials like acellular dermal matrices may be helpful. Mastopexy-augmentation can be performed as a single-stage procedure to alter both the size and shape of the breast at the same operation and presents a unique set of challenges.

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Augmentation Mammoplasty Augmentation mammoplasty or breast augmentation (BA) continues to be one of the most commonly performed aesthetic breast procedures in the United States. 1 The primary goal of the surgery is to increase the size of the breast, but there are simultaneous changes to the shape of the gland and nippleareola complex (NAC) position. Thoughtful planning and use of devices individualized for the patient help the surgeon to achieve a patient’s goals. Although historically BA has been performed with a prosthetic device, advances in flap design and fat grafting have led to a paradigm shift where now BA can be performed almost exclusively with a patient’s own tissue if desired.

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Preoperative Assessment The consultation for BA, like that for any aesthetic procedure, is an art and a science. It requires a thoughtful assessment and understanding of a woman’s goals for the size and shape of her breasts. This must be complemented by the surgeon’s evaluation of objective parameters of anatomy and tissue dynamics. Together, the subjective assessment of expectations and objective physical examination creates an individualized plan for a patient seeking BA. The astute surgeon is aware, and communicates to the patient, that not only will BA affect the size of the breast, but also the overall gland shape and position of the NAC. After any aesthetic breast procedure, the breast will continue to age and patients should be warned that further procedures may be necessary in the future if they desire restoration of a youthful breast. Patient’s seeking BA have often invested a large amount of time in thinking about their ideal breast size and shape. They have researched implants, planes of implant placement, and incisions, and have explored the experiences of friends, family, and internet bloggers before seeing a plastic surgeon in consultation. It is not uncommon for a BA candidate to have met with other plastic surgeons in consultation and continue to search until she finds the “right” surgeon who has the skill, results, reputation, or price point that fits with her expectations. The artful history taker will be able to elicit this and tailor a unique surgical plan using all the information available. Clinical intuition and experience of the surgeon cannot be underestimated. Unrealistic expectations or indications of psychologic instability should raise a red flag to the provider; surgeons should have a low threshold for a second or even third consultation prior to offering surgery, if at all. The main goal is to increase the volume of the breast and centralize the nipple on the breast mound. The breast mound should reside completely or largely above the inframammary fold (IMF) although this can vary with age. Upper pole fullness and specifically superomedial fullness is generally desired. Asking a patient to bring photographs of augmented breasts that she finds desirable and undesirable can help the surgeon understand the patient’s aesthetic expectation for her own breasts. When a potential BA candidate mentions a “natural look,” it is important to inquire further and clarify what characteristics of the breast create a “natural look” in the eyes of the patient. Often, but not always, it is equated with a sloped upper pole that transition to the curve of the lower two-thirds of the breast. Some women may desire a convex upper pole and have an “augmented” look that is “natural” to them. Clear communication of expectations of outcomes in and out of clothes is also important. A thorough medical and surgical history should be obtained. Candidates should be asked about their current bra size and desired cup size. Patients with a history of prior BA and complications necessitating a revision are different than those seeking a primary BA. For example, it would be useful to know if a patient has had a previous breast reduction surgery or radiation because of breast cancer. Additionally, it is important for a surgeon to understand a patient’s hobbies and interests. Patients who are highly athletic and perform weight training or yoga for example may be less amenable to submuscular placement of an implant because of animation deformity or changes to the pectoralis muscle. Physical examination before BA should be systematic and include an assessment of the chest wall. The chest wall is the foundation upon which a prosthetic device will sit, and chest wall asymmetries or abnormalities recognized preoperatively can allow for better operative correction. This is especially true in women who have a history of congenital chest wall abnormalities or scoliosis. Standard measurements before BA include base width (BW), sternal notch to nipple distance (SN-N), nipple to inframammary fold (N-IMF), NAC diameter, and internipple distance (Figure 55.1). Base width can be measured from the medial aspect of the breast footprint to the anterior axillary fold. Tissue quality should also be assessed. This can be done by measuring the pinch thickness of the breast, particularly in the upper pole where involution can be easily appreciated. Generally, 2 cm of pinch thickness is considered the

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minimum necessary for placement of an implant in the subglandular or subfacial plane. Patients with less than 2 cm of pinch thickness may be better candidates for implant placement behind the pectoralis muscle. The interface between the skin and the breast parenchyma should also be evaluated, as postpartum women or patients with poor dermis due to massive weight loss may have skin that very easily glides over the underlying breast parenchyma. The lower pole of the breast can be constricted in patients with micromastia or mild tuberous breast deformity. Lowering of the IMF and recruitment of upper abdominal skin may be warranted in these patients and should be considered during the evaluation. An assessment of the width of the sternum is a nuance that can help the surgeon talk to a patient about expected superomedial fullness and interbreast distance that will likely persist after augmentation. This distance can be decreased and even lead to symmastia when the implant is placed subglandularly, but is less likely with submuscular placement because the medial pectoralis muscle attachments are left intact and prevent medial migration.

FIGURE 55.1 Key landmarks and measurements for breast augmentation and mastopexy. For both breasts, the sternal notch (SN), nipple (N), and inframammary fold (IMF) are marked. The sternal notch to nipple (SN-N) distance and the nipple to inframammary fold (N-IMF), and internipple distance are key metrics for analyzing nipple position and assessing symmetry between sides. The BW is a key measure for determining the appropriate transverse dimension of a breast implant and chest wall diameter. The nipple-areola complex (NAC) dimensions can affect incision design, particularly for a periareolar or circumvertical mastopexy and may contribute to asymmetry between sides.

According to current epidemiologic studies, one in eight women will get breast cancer. Women with augmented breasts are at no increased risk of breast cancer compared to women with nonaugmented breasts. There is no difference in breast cancer survival rates among women with and without augmented breasts. 2 Women with a history of breast augmentation undergo screening mammography with special implant-displaced or Eklund views to better assess the tissue anterior to the implant. 3 The sensitivity is increased with ultrasound (US) or magnetic resonance imaging (MRI). When silicone implants were

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reintroduced into the market in 2006, the Food and Drug Administration (FDA) recommended screening with MRI for silent ruptures 3 years after placement and then every 2 years thereafter. For women desiring breast augmentation, routine mammographic screening should be performed or reviewed if indicated preoperatively using the US Preventative Services Task Force guidelines based on age over 40 and risk. 4 Assessment of the NAC relative to the IMF is a common way to assess breast ptosis (Figure 55.2). In general, patients who have visible breast skin below the NAC (pseudoptosis or grade I and II ptosis) on a frontal view may be candidates for BA alone. Patients who seek BA who have no visible breast skin below the NAC on a frontal view (grade III ptosis) likely need a mastopexy as well to reposition the NAC on the breast mound.

FIGURE 55.2 Grades of breast ptosis based on the position of the gland and nipple relative to the inframammary fold. (From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)

The location of the breast and its footprint on the chest should be evaluated preoperatively during the consultation. There are several ways to make this assessment. Hall-Findlay describes that a patient can be “high” or “low” breasted based on the location of the breast on the chest wall relative to the clavicle and/or humerus. 5 For example, a patient with an IMF at the junction of the middle and distal thirds of the humerus may be considered “low” breasted whereas another with the IMF at the middle of the humerus may be considered “high” breasted. The location of the pectoralis muscle relative to the breast mound and the IMF should also be assessed. In some women, the pectoralis major muscle and anterior axillary fold are well defined. The pectoralis major’s inferior attachments can be above or below the NAC and at or above the IMF. This can be particularly meaningful when thinking about how a prosthetic device will affect the upper breast border if the implant is placed submuscularly versus subglandularly. For example, a low breasted patient with a pectoralis major muscle attachment that is higher than the NAC may not benefit from subpectoral placement of the breast because the implant will ride high behind the pectoral muscle whereas the NAC will remain in a lower position and not be centered on the implant and augmented breast mound. Patients being evaluated for BA with fat alone or composite BA with fat and an implant should be evaluated for potential donor sites for fat grafting. Common areas include the abdomen, flanks and medial thighs. Finding suitable donor sites and adequate fat can be challenging in women with a low body mass index (BMI) who also have micromastia. Standardized preoperative photographs should be obtained as a way to document and review anatomy

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and asymmetries with the patient. Many times, differences between breasts that are not visible to the patient in the mirror can be more apparent in a photograph. Asymmetries noted preoperatively may require correction, can persist, or become more noticeable after a BA. The impact of asymmetries on the operative plan should be discussed with the patient. Three-dimensional imaging has emerged as a newer technology that can also aid with educating patients. 6 Newer virtual reality simulation technologies have also enhanced the preoperative consultation.

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Augmentation With Implants Breast implants for augmentation vary in composition, shape, and shell texturing. Implants are filled with either saline or silicone. However, even saline filled implants have a silicone outer shell. During the FDA moratorium on silicone implants in the 1990s, saline implants were the only implants available for use. This was reversed in 2002 when silicone implants again became available for use in BA and breast reconstruction largely from combine efforts of plastic surgeons and industry. Silicone implants are considered “off label” when used in women less than 22 years old per the FDA. Just how different saline and silicone implants feel is subjective. A major difference besides cost and feel is that saline and silicone implants differ in how a device rupture is detected. Regardless of type or manufacturer, implant rupture is inevitable. Detection of a rupture in saline implants is fairly straightforward as deflation of the implant and an obvious decrease in an augmented breast indicates a rupture. Silicone implants, including the modern fifth generation cohesive gel implants, differ from the first silicone implants in the 1960s in that the amount of cross-linking of the silicone has increased. First and second generation silicone ruptures led to free floating silicone in the pocket leading to inflammation and silicone granuloma formation. Ruptures of the current fifth generation implants are very different. Silicone ruptures with cohesive gel implants can be detected on mammogram but more often require MRI to confirm a suspected rupture. Often delayed capsular contracture can be due to a silent rupture of a highly cohesive gel implant. Implants can be anatomically shaped or round devices. Different manufacturers have implants of both types with variable dimensions including height, width, projection, and volume. For a round device, height and width will be the same. Therefore, for a given base width with a round device, an implant can vary in volume and projection. Anatomic implants will have variable height, width, volume, and projection and hence, they have many more permutations. This variability and plethora of implant options help the plastic surgeon to customize the BA and even choose different devices for each breast to correct asymmetries. Whether shaped or round implants have a different look is controversial. Some studies have shown that it is not possible to accurately detect a shaped versus round implant in the submuscular plan intraoperatively. 7 Proponents of each type of implant may argue that a round implant has a more round superomedial curve whereas an anatomic implant has a more teardrop look when placed in the subglandular or subfascial plan. Additionally, anatomic implants have been argued to have unique uses in breast reconstruction and tuberous breast deformity, though this is debated. The outer shell of an implant can be either smooth or textured. Textured devices offered by the various implant manufacturers are differentiated by the proprietary methods used to texture the device and surface texture characteristics. Macrotextured devices are characterized by heterogeneously arranged pores with a diameter of 600 to 800 µm and a depth of 150 to 200 µm. Microtextured devices possess a more uniform pore distribution whose diameters range from 70 to 150 µm with a depth of 40 to 100 µm. Pore size and distribution of other textured implant brands run intermediate to the micro- and macrotextured devices. Surface area, pore size, and distribution may play a role in soft tissue integration with the breast implant surface, the organization of myofibroblasts and matrix proteins, and potential for accumulation of bacterial biofilms. 8–10 Textured devices increase friction between the implant and the surrounding tissues that encompass an implant. Anytime a foreign body is placed into a cavity, whether a prosthetic hip in a hip joint or a chin implant in the face, a capsule forms around the device and it happens in the breast around a breast implant. Textured devices have lower rates of capsular contracture, or the formation of a capsule that leads to deformity and/or pain in the breast following BA. This is particularly true when a textured implant is placed in a subglandular or subfascial plane. Textured devices are thought to be less likely to migrate beyond the dissected pocket, but recent data with

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anatomic, textured devices have demonstrated that even these implants can have rotation and malposition necessitating reoperation. 11 Currently, anatomic implants are all textured devices. Round devices can come as either textured or smooth.

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Incisions and Planes for Implant Placement The implant in BA can be placed in different planes using a number of incisions for exposure. Options for planes of implant placement include subglandular, subfascial, submuscular, and dual-plane (Figure 55.3). The subglandular plane is below the breast parenchyma but above the fascia of the pectoralis major muscle. The subfascial plane is below the fascia of the pectoralis muscle and above the muscle itself and is the same plane used by the breast surgeons when they perform mastectomies. The submuscular plane is below the pectoralis muscle superiorly and inferiorly below the pectoralis muscle fascia as it interdigitates with the rectus muscle fascia (Figure 55.4). This is also sometimes referred to as a retropectoral pocket. Dual-plane breast augmentations take advantage of having superior pole coverage with muscle with variable lower pole coverage with breast parenchyma. Dual-plane breast augmentations, as graded I, II, and III, vary by the amount of pectoralis muscle release inferiorly and subsequent amount of contact between the implant and breast parenchyma inferiorly.

FIGURE 55.3 Options for planes of placement of the breast implant include subglandular, subfascial, subpectoral, and dualplane.

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FIGURE 55.4 A–C. Preoperative photographs of a 29-year-old woman with micromastia, and minimal asymmetry in good health for breast augmentation. Three-dimensional image simulation in addition to tissue-based planning was performed to facilitate implant selection. Bilateral 330 cc moderate profile smooth round silicone breast implants were placed using a submuscular approach with inferior release of the pectoralis muscle but fascial preservation. D–F. Two-year postoperative results.

Incision options for BA include IMF, periareolar, and transaxillary approaches. The IMF incision is placed in the desired IMF crease, which may be below the native IMF if the IMF is going to be lowered in a BA. Periareolar incisions are made along the junction of the areola and the breast skin. Transaxillary incisions are made in the hair-bearing region of the axilla.

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Complications Delayed seromas with or without an associated mass should raise suspicion for breast implant-associated anaplastic large cell lymphoma (BIA-ALCL). In line with current National Comprehensive Cancer Network Guidelines, suspicious fluid should be sent with fine needle aspiration and tested as BIA-ALCL fluid is CD30 positive and anaplastic large cell lymphoma kinase (ALK) negative prior to surgical intervention. 12 A PET-CT scan is recommended to visualize a suspicious seroma or mass. Treatment always requires complete capsulectomy, and depending on stage of disease, it may also need adjuvant chemotherapy or immunotherapy. This is a rare disease process, and the understanding of its etiology is rapidly evolving. Revisions rates for BA are largely surgeon dependent. The threshold to perform a revision because of patient complaints or dissatisfaction varies by surgeon. Database studies of complications after BA have shown rates of less than 1% to 2% for hematoma and less than 1% for infection and deep vein thrombosis/pulmonary embolism (DVT/PE). 13 Capsular contracture rates from long-term studies demonstrate variability based on implant manufacturer.

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Capsular Contracture Capsule formation around an implant in any part of the body is a reaction to a foreign body. When the body forms a capsule that distorts the breast and/or causes pain in the breast following BA, this is known as capsular contracture. The Baker classification system is a routine method of categorizing capsular contracture in patients with BA (Table 55.1). It relies on physical examination to assess how soft the augmented breast and whether or not the patient reports pain. Applanation tonometry, adopted for measuring intramammary compliance, and ultrasound elastography represent more modern and quantitative, but less widely adopted techniques for assessing capsular contracture. 14,15 TABLE 55.1 Baker Classification System for Capsular Contracture Baker Grade I II III IV

Physical Examination Soft Palpable, minimal firmness Easily palpable, moderate firmness Firm, distorted

Patient Report of Pain No pain No pain Pain Painful

The etiology of capsular contracture is multifactorial and may differ based on whether capsule contracture occurs early or late. Capsular contractures can occur “early” within 1 year of placement or in a delayed fashion several years later. Historically, smooth devices placed in the subglandular plane have had the highest rates of capsular contracture. Patients with grade III or IV capsular contracture with or without concomitant silicone rupture or silicone granulomas, and those with asymmetry requesting a revision procedure will require operative management. Treatment involves either open capsulectomy or capsulotomy. These can be challenging operations due to silicone rupture, scar formation, thin tissues, and highly vascularized tissue from chronic inflammation. Depending on the plane of the BA, removal of the capsule off the breast parenchyma and/or chest wall can be difficult and techniques including tumescence of the capsule can aid in identifying the correct plane of dissection. Posterior capsulectomy or removal of the capsule of the chest wall should be done with caution as the tissue can be thin and can lead to inadvertent penetration into the thoracic cavity leading to a pneumothorax. Some advocate partial removal or curettage of the posterior capsule for this reason. Closed capsulotomy that involved external, manual compression to break through the capsule is no longer recommended due to risk of implant rupture or possible hematoma formation and incomplete management of the problematic capsule. Medical therapy with leukotriene inhibitors has shown some benefit in preventing and improving capsular contracture. 16 Intraluminal steroids and pocket irrigation with steroids were once performed, but no longer are common practice due to risk of implant rupture, wound dehiscence, and atrophy of tissues. Recurrent capsular contracture often requires placement in an alternative plane or neosubpectoral pocket after a capsulectomy. 17 Acellular dermal matrices (ADM) have also been used in recalcitrant cases of capsular contracture to create an interface between implant and breast tissue. 18

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Implant Rupture Implant rupture can occur regardless of implant fill material. Saline rupture can easily be identified by unilateral deflation and breast asymmetry that occurs suddenly. This can sometimes be preceded by trauma. Silicone rupture can present with the presence of silicone granulomas or can be silent and diagnosed on mammography or MRI. Rupture can be intracapsular or extracapsular. Treatment of rupture often requires removal of one or both implants and any ruptured material in the case of silicone rupture with or without capsulectomy or capsulotomy. This is can be followed by replacement with a new implant.

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Augmentation With Fat and Flaps BA can be performed with fat grafting or autologous tissue. Fat grafting alone can be used to augment a breast. However, with unpredictable rates of long-term fat graft survival, it may be difficult to reliably augment a breast to a desired cup size. More than one surgery or round of fat grafting may be required to achieve a patient’s goals. Composite BA is a procedure in which implant-based BA is combined with fat grafting, often placed in the superior pole to blunt the transition between native tissue and the implant. Fat can be placed laterally and inferiorly when the soft tissue envelope is thin to reduce visible rippling or mask implant palpability. Autologous BA with flaps are common in patients who have had a massive weight loss because they have a paucity of breast tissue, which is often atrophic because of major fluctuations in weight. A number of perforator flaps based on intercostals have been used for this purpose.

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Mastopexy Mastopexy focuses on changing the shape of the breast to one that appears youthful and beautiful; it also addresses descent of the NAC relative to the IMF. 19 Aging, hormonal changes associated with pregnancy, and weight loss can all affect the skin envelope and breast parenchyma. By addressing the outer lamella of the breast (the skin) and/or the inner lamella of the breast (the parenchyma), the discrepancy between the skin and breast tissue can be reduced. Similar to BA, mastopexy is a very common aesthetic breast surgery and can often be combined with augmentation as a single or two-staged procedure. One of the most litigated plastic surgery operations, mastopexy-
 augmentation, has increasingly become safer and more acceptable to well-informed patients.

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Preoperative Assessment Analysis of the breasts and chest wall for mastopexy is similar to that described earlier for BA. An assessment and documentation of breast ptosis is essential. The density of the breasts and superior pole involution should be assessed. Additionally, the interaction between skin and breast parenchyma must be critically evaluated as this may help the surgeon counsel the patient on whether mastopexy alone will help achieve the patient’s results or whether the addition of an implant will also help restore shape, structure, and volume to the breast. If the planned procedure is a secondary mastopexy or mastopexy-augmentation, an attempt to obtain previous operative reports should be made. Scars and examination can provide a roadmap, but operative notes can help provide information to reduce the risk of complications from compromised blood supply to the NAC or parenchyma.

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Surgical Approaches Three major categories of surgical approaches for mastopexy have been described: periareolar, vertical, and Wise pattern. 19 A paradigm shift in mastopexy took place when Benelli demonstrated that skin only mastopexies were not as durable as mastopexies that address the skin and parenchyma by redistributing the parenchyma. 20 Plastic surgeons now understand that by addressing both the outer lamella (skin) and inner lamella (parenchyma), more durable and predictable changes can be achieved in the ptotic, involuted breast. Periareolar mastopexies can be used in patients who have grade I or II ptosis, nipple asymmetry, or widened areola (Figure 55.5). This technique can be used to elevate the nipple no more than 2 cm with an eccentrically designed oval. A variation of the periareolar mastopexy is the crescentic mastopexy in which a crescent is designed only superior to the existing areola. The periareolar mastopexy hides the scar along the areolar-breast junction. Removing skin in a concentric pattern can, however, flatten and reduce breast projection. Scar widening and eventual widening of the areola can occur, but some have advocated the use of a barbed or permanent suture to control this. If there is circumferential full thickness violation of the dermis, decreased nipple sensitivity may occur.

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FIGURE 55.5 Periareolar mastopexy incision placement and final scar location. (From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)

Vertical mastopexies have evolved from reduction mammoplasty techniques described by Lassus, Peixoto, Pitanguy, and Lejour to mention a few. 19 The underlying premise of vertical techniques is to both incorporate ptosis correction with excision of glandular material using a periareolar approach with a vertical component in line with the breast meridian (Figure 55.6). This technique can be used for all grades of breast ptosis. The short-scar periareolar inferior-pedicle reduction (SPAIR) and Hall-Findlay mastopexy techniques are the two vertical mastopexies with the highest surgeon satisfaction. 21

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FIGURE 55.6 Vertical mastopexy incision placement and final scar location. (From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)

Hammond popularized the SPAIR mastopexy that relies on the fourth intercostal perforator or inferior pedicle for blood supply to the nipple. 22 It involves a periareolar closure in a pin-wheel or interlocking pattern, sometimes with a permanent suture. Suspension sutures to the pectoralis fascia can be used to elevate the breast onto a higher position on the chest wall, though the durability of such techniques is hotly debated. The redundant skin inferiorly can be excised in a “J” or “T” pattern. Because weight remains in the inferior portion of the breast, bottoming out remains a shortcoming. The periareolar closure can widen or have pleating that persists. This technique is not typically complemented with implant placement. The Hall-Findlay vertical mastopexy most commonly uses the superomedial or medial pedicles for the NAC based on the second and third intercostal perforators, respectively (Figure 55.7). 23 Different from the SPAIR technique that preserves the inferior pedicle, the inferior pole of breast tissue is excised in the Hall-Findlay technique. The medial and lateral pillars are then sutured together, and this provides

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structural support and buttresses the elevated NAC. By removing weight from the inferior pole of the breast, less gravitational pull will be exerted on the raised NAC and breast. Similar to the SPAIR technique, inferior skin redundancy can be excised as a “J” or “T.” An implant can be placed in the subglandular, subfascial or submuscular planes without concern for blood supply to the NAC as the second and/or third intercoastal perforators travel superficially in the gland and remain undisturbed by an augmentation.

FIGURE 55.7 A–C. Preoperative photographs of a nonsmoking, healthy 51-year-old woman with ptosis and moderate asymmetry in which the right breast was more ptotic, had a lower inframammary fold, and was slightly larger than the left. She was interested in improving breast symmetry, shape, and nipple-areolar positioning. A Hall-Findlay vertical mastopexy was performed with a slight parenchymal reduction and more aggressive nipple-areolar elevation on the right. D–F. Six-month postoperative results.

In general, vertical mastopexies create an inverted breast shape at the end of the procedure with exaggerated upper pole fullness and a sloped inferior pole. Patients should be counseled that it can take weeks to months for the breast and/or implant to settle and for the breast to take on its final appearance. The Wise-pattern or inverted-T mastopexy has been a powerful, traditional method for reducing the discrepancy between skin and breast parenchyma. It can be used for all types of ptosis but carries a large scar burden. It was first described in the 1950s by Wise when he developed templates for a skin only mastopexy. Since that time, the technique has evolved to include parenchymal redistribution and can be used with practically any pedicle for blood supply to the NAC. This versatility makes it popular among surgeons, as it is easily adapted from traditional Wise-pattern inferior-pedicle reduction mammoplasty techniques. Final scars are along the areola, the vertical meridian of the breast, and along the IMF ending up as an inverted-T or anchor pattern (Figure 55.8). This technique has the largest scar burden of any mastopexy method and can experience bottoming out when combined with an inferior pedicle. 21 An implant can be placed in the subglandular, subfascial, or submuscular plane depending on where the blood supply to the NAC is coming from.

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FIGURE 55.8 Wise-pattern or inverted-T mastopexy incision placement and final scar location. (From Qureshi AA, Myckatyn TM, Tenenbaum MM. Madtopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38:374-384.)

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Complications Complications in mastopexy have been found to be around 1% in large database studies, with less than 1% rates for hematoma, infection, and DVT/PE. 13 Survey studies of plastic surgeons reporting complications found suture spitting, excess scarring, and bottoming out to be the most commonly reported complications. 21 Specifically, excess scarring was noted with the periareolar technique, suture spitting with the SPAIR technique, persistent asymmetry with the vertical technique, and bottoming out with the inverted-T or Wise-pattern mastopexy. Revision rates have been reported to be as high as 50% in periareolar approaches.

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Mastopexy-augmentation Single or two-staged mastopexy-augmentation is a powerful way to reshape and add volume to a breast (Figure 55.9). The surgeon must be mindful that there are competing forces at play during this procedure. Mastopexy addresses the skin envelope and shape and often requires removal of skin and parenchyma. In an augmentation, volume is being added or redistributed either with autologous breast tissue, implants, or fat. Caution and planning must be applied as the surgeon keeps in mind the blood supply to the NAC and plane of augmentation. Tension-free closure increases the likelihood of a well-appearing scar.

FIGURE 55.9 A–C. Preoperative photographs of a nonsmoking, healthy 43-year-old woman with grade 1 ptosis who desired increased upper pole fullness, overall breast volume, and elevation of the nipple-areola complex. The patient had reasonable expectations and understood that simultaneous breast augmentation-mastopexy is associated with a higher revision rate than when either procedure is performed alone. She underwent a simultaneous augmentation-mastopexy with bilateral 385 cc moderate profile round textured breast implants placed using a type 2 biplanar approach. D–F. One-year postoperative results.

Single-stage mastopexy-augmentation with implants was once considered a controversial and risky procedure, highlighted in 2003 when Spear published “Augmentation/Mastopexy: Surgeon, Beware.” Although first described in the 1970s, the safety of single-stage mastopexy-augmentation gained traction with large experiences by Stevens and Calobrace et al. who reported revision rates between 8.6% and 23.2%, which was less than the 100% two-operation rate when mastopexy-augmentation was not performed as a single-stage procedure. 24,25 Other studies demonstrated the safety of blood supply and perfusion to the NAC when mastopexy-augmentation was performed with an implant. 26 Meta-analyses of reports of single-stage mastopexy-augmentation have found an overall complication rate of 13% with a reoperation rate of 11%. 27 Two-stage mastopexy-augmentation can also be performed. Some surgeons prefer this method because it allows them to address one issue in the first stage, namely shape or volume and then address the other at a second operation, if even necessary. However, a staged approach commits a patient to two operations and recoveries. There is no consensus of whether augmentation or mastopexy should be performed in a

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two-staged plan. Mastopexy-augmentation has been found to have a complication rate of less than 2% in large database studies with rates of less than 1% for hematoma, infection, and DVT/PE.28

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Questions 1. A 45-year-old woman with whom had a gastric bypass performed 3 years ago has lost 125 lb and currently has a BMI of 29, which has been stable for a year. She is bothered by her grade III ptosis and involuted breasts. She presented for single-stage mastopexy-augmentation and a decision is made to perform a Wise-pattern mastopexy with retropectoral placement of a smooth, round silicone device. Which of the following is the most likely sequela of the procedure? a. Complete nipple necrosis b. Delayed seroma c. Implant rupture and silicone leak d. Lateral malpositioning of the implant e. Symmastia 2. A 33-year-old woman presents for evaluation of nipple asymmetry. She is bothered by the discrepancy between her NAC as the right is 4 cm and the left is 6 cm in width. The left nipple is also 1 cm lower than the right. Which of the following techniques is most suited to correct her asymmetry? a. Breast augmentation with implants b. Circumvertical mastopexy c. Free nipple grafting d. Inverted T-mastopexy e. Periareolar mastopexy 3. A 25-year-old woman presents for evaluation of bilateral breast augmentation. She is interested in a smooth, silicone round device and wants the implant to be placed underneath the breast but not the muscle. Which of the following is she at greatest risk based on the implant type and plane of placement? a. Animation deformity from the pectoralis muscle b. Capsular contracture c. Deflation and subsequent loss of volume d. Superior implant migration e. Widening of the areola 4. A 39-year-old woman with a history of bilateral breast augmentation with textured, silicone anatomic implants 7 years ago presents with asymmetric breast swelling of the left breast with no antecedent trauma. Ultrasound demonstrates a capsule with fluid in the periprosthetic space. Which of the following is the next appropriate step in management? a. Observation b. MRI study of both breasts c. Compression garment with repeat evaluation in 2 weeks d. Ultrasound guided aspiration of fluid and cytology tests for ALK and CD30 e. Surgical exploration with explant and capsulectomy 5. A 62-year-old woman is dissatisfied with the appearance of the size and shape of her breasts. She currently wears a 32B bra and has grade III ptosis. A decision is made to perform a single-stage mastopexy-augmentation. Which of the following is the most likely complication after single-stage mastopexy-augmentation? a. Asymmetry b. Capsular contracture c. Poor scarring

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d. Recurrent ptosis e. Seroma 6. Which of the following best represents the existing Food and Drug Administration recommendation on screening for silent ruptures in silicone implants used for breast augmentation and/or reconstruction? a. MRI annually after placement b. MRI 2 years after placement and then every 2 years thereafter c. MRI 3 years after placement and then every 2 years thereafter d. MRI at 5 years and then as needed e. MRI only if palpable changes in silicone 1. Answer: d. Lateral malposition is a common problem seen in mastopexy-augmentation in the massive weight loss patient population. These patients have attenuated tissues and with placement under the muscle the implant can migrate laterally. Some have advocated the use of acellular dermal matrix or mesh support of the lateral buttress of the augmented breast. Complete nipple necrosis is a devastating and exceedingly rare complication. Delayed seroma can occur but its less likely than implant malposition. Implant rupture and silicone leaks can also occur but it is not higher in massive weight loss patients. Symmastia is unlikely with retropectoral implant placement because the medial pectoralis muscle fibers prevent medial migration of the implants. 2. Answer: e. This is a young woman with NAC asymmetry with regards to diameter as well as nipple position. A periareolar mastopexy can correct the NAC diameter discrepancy and also help elevate a nipple up to 2 cm. Breast augmentation is unlikely to address the underlying problem. The other mastopexy techniques can also correct the nipple asymmetry but are likely to carry a larger scar burden and alter the shape of the breast. Free nipple grafting involves completely removing the NAC and is not appropriate for correction of isolated nipple asymmetry. 3. Answer: b. Subglandularly placed smooth devices are at greatest risk for capsular contracture. This rate can be decreased by using a textured device or placing the implant partially or completely behind the muscle as in a dual-plane or retropectoral augmentation. Animation deformity can occur after placement of an implant placement behind, not in front of, the pectoralis muscle. Deflation is possible and common with saline not silicone implants. Superior implant migration is not a common complication. Areola can widen after an augmentation but that is not the greatest risk associated with this augmentation. 4. Answer: d. A delayed seroma after placement of a texture implant should raise suspicion for BIAALCL. The fluid should be aspirated and sent specifically for ALK and CD30 as the fluid will be ALK negative and CD30 positive. This is the first test that is done in the diagnostic work-up of BIA-ALCL and precedes surgical intervention. If a diagnosis of BIA-ALCL is made (CD30+/ALK-), then a PETCT scan of the chest is indicated to further characterize the mass and fluid collection associated with the implant capsule and breast tissue. The case should be reported to the PROFILE Registry, sponsored by the Plastic Surgery Foundation, which tracks BIA-ALCL cases. Treatment will be dictated based on staging thereafter and will require surgical exploration with explant and complete capsulectomy. The capsule should be sent for pathology. Observation, further imaging, and compression garment placement are not appropriate next steps. 5. Answer: d. In a meta-analysis by Khavinin et al., pooled complication rates in aesthetic breast surgery were examined. Recurrent ptosis was the most commonly encountered complication after single stage mastopexy augmentation at 5.2%. This was followed by poor scarring (3.74%), capsular contracture (2.97%), asymmetry (2.94%), and seroma (1.42%). 6. Answer: c. The current FDA recommendation is for an MRI to be performed 3 years after placement and then every 2 years thereafter. The purpose of this is to identify silent ruptures of the

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implant that would otherwise go unnoticed.

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Acknowledgments The authors thank Drs. W. Grant Stevens, Andrea E. Van Pelt, and Adrian M. Przybyla, who wrote the chapter on mastopexy and mastopexy-augmentation and Dr. Steven A. Teitelbaum who wrote the chapter on breast augmentation in the 7th edition of this book.

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References American Society of Plastic Surgeons. Cosmetic Surgery National Data Bank Statistics. 2016:1-26. Bryant, H, Brasher, P. Breast implants and breast cancer—reanalysis of a linkage study. N Engl J Med. 1995;332(23):1535-1539. Eklund, GW, Busby, RC, Miller, SH, Job, JS. Improved imaging of the augmented breast. AJR Am J Roentgenol 1988;151(3):469-473. Siu, AL; US Preventive Services Task Force . Screening for breast cancer: U.S. Preventive Services Task force recommendation statement. Ann Intern Med. 2016;164(4):279-296. Hall-Findlay, EJ. The three breast dimensions: analysis and effecting change. Plast Reconstr Surg. 2010;125(6):1632-1642.This is an important article on understanding the dimensions of the breast. It describes whether different parameters of the breast can be changed and how. Overschmidt, B, Qureshi, A, Parikh, RP, et al. A prospective evaluation of three dimensional image simulation: patient-reported outcomes and mammometrics in primary breast augmentation. Plast Reconstr Surg. 2018;142(2):133e-144e. Hidalgo, DA, Weinstein, AL. Intraoperative comparison of anatomical versus round implants in breast augmentation: a randomized controlled trial. Plast Reconstr Surg. 2017;139(3):587-596. Wolfram, D, Rainer, C, Niederegger, H, et al. Cellular and molecular composition of fibrous capsules formed around silicone breast implants with special focus on local immune reactions. J Autoimmun. 2004;23(1):81-91. Maxwell, GP, Scheflan, M, Spear, S, et al. Benefits and limitations of macrotextured breast implants and consensus recommendations for optimizing their effectiveness. Aesthet Surg J. 2014;34(6):876-881. Brown, T. Breast implant-associated anaplastic large cell lymphoma in Australia and New Zealand: high-surface-area textured implants are associated with increased risk. Plast Reconstr Surg. 2018;141(1):176e-177e. Sieber, DA, Stark, RY, Chase, S, et al. Clinical evaluation of shaped gel breast implant rotation using high-resolution ultrasound. Aesthet Surg J. 2017;37(3):290-296. Clemens, MW, Horwitz, SM. NCCN Consensus Guidelines for the diagnosis and management of breast implant-associated anaplastic large cell lymphoma. Aesthet Surg J. 2017;37(3):285-289. Gupta, V, Yeslev, M, Winocour, J, et al. Aesthetic breast surgery and concomitant procedures: incidence and risk factors for major complications in 73,608 cases. Aesthet Surg J. 2017;37(5):515-527.This large database study provides invaluable information about complications in aesthetic breast surgery. Prantl, L, Englbrecht, MA, Schoeneich, M, et al. Semiquantitative measurements of capsular contracture with elastography: first results in correlation to Baker Score. Clin Hemorheol Microcirc. 2014;58(4):521-528. Moore, JR. Applanation tonometry of breasts. Plast Reconstr Surg. 1979;63(1):9-12. Graf, R, Ascenco, AS, Freitas Rda, S, et al. Prevention of capsular contracture using leukotriene antagonists. Plast Reconstr Surg. 2015;136(5):592e-596e. Maxwell, GP, Gabriel, A. The neopectoral pocket in revisionary breast surgery. Aesthet Surg J. 2008;28(4):463-467.This is a seminal article for understanding operative management of capsular contracture and/or implant rupture. It describes a reproducible technique of managing the diseased capsular and creation of a new pocket for implant replacement. Maxwell, GP, Gabriel, A. Acellular dermal matrix for reoperative breast augmentation. Plast Reconstr Surg. 2014;134(5):932-938. Qureshi, AA, Myckatyn, TM, Tenenbaum, MM. Mastopexy and mastopexy-augmentation. Aesthet Surg J. 2018;38(4):374-384.This recent review covers surgical steps and approaches for mastopexy and mastopexy-augmentation. Benelli, L. A new periareolar mammoplasty: the “round block” technique. Aesthet Plast Surg. 1990;14(2):93-100. Rohrich, RJ, Gosman, AA, Brown, SA, Reisch, J. Mastopexy preferences: a survey of board-certified plastic surgeons. Plast Reconstr Surg. 2006;118(7):1631-1638. Hammond, DC. Short scar periareolar inferior pedicle reduction (SPAIR) mammoplasty. Plast Reconstr Surg. 1999;103(3):890-901.This landmark article describes the technique of Hammond in the SPAIR procedure. Hall-Findlay, EJ. Pedicles in vertical breast reduction and mastopexy. Clin Plast Surg. 2002;29(3):379-391.This seminal article describes various pedicles and the technique used in a vertical mastopexy by Hall-Findlay. Stevens, WG, Macias, LH, Spring, M, et al. One-stage augmentation mastopexy: a review of 1192 simultaneous breast augmentation and mastopexy procedures in 615 consecutive patients. Aesthet Surg J. 2014;34(5):723-732.This article describes a large series of single-stage mastopexy-augmentation and describes complications and safety profiles. Calobrace, MB, Herdt, DR, Cothron, KJ. Simultaneous augmentation/mastopexy: a retrospective 5-year review of 332 consecutive cases. Plast Reconstr Surg. 2013;131(1):145-156.This article describes a large series of single stage mastopexy-augmentation and describes complications and safety profiles. Swanson, E. Safety of vertical augmentation-mastopexy: prospective evaluation of breast perfusion using laser fluorescence imaging. Aesthet Surg J. 2015;35(8):938-949. Khavanin, N, Jordan, SW, Rambachan, A, Kim, JY. A systematic review of single-stage augmentation-mastopexy. Plast Reconstr Surg. 2014;134(5):922-931. Winocour, J, Gupta, V, Kaoutzanis, C, et al. Venous thromboembolism in the cosmetic patient: analysis of 129,007 patients. Aesthet Surg J. 2017;37(3):337-349.

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CHAPTER 56

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Breast Reduction Paul H. Izenberg and Nicholas L. Berlin

Key Points Integrate anatomic, functional, and aesthetic principles of plastic surgery. Perform thorough physical examination and document findings related to macromastia. Each technique has its own indications and limitations. Preoperative markings and planned resection are essential to achieve consistently good results. Appreciate the desired three-dimensional shape of the breast and underlying neurovascular structures throughout the operation. Counsel patients regarding risks for short-term and long-term complications. Address acute postoperative issues promptly to avoid long-term sequela. The breast reduction procedure demands that the surgeon integrates anatomic, functional, and aesthetic principles into the design and execution of the operation. This chapter will emphasize principles and techniques for surgeons to achieve aesthetically and functionally pleasing results on a routine basis. There have been numerous techniques for breast reduction described in the literature over the past decades, each adding improvements in the reliability, perioperative risk reduction, and the enhancement of the final appearance. This chapter will not attempt to review all of the previously published data. Instead, we will emphasize techniques that have worked well for the senior author in the majority of clinical cases over 40 years of practicing plastic surgery.

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Relevant Anatomy and Physiology The breast is a subcutaneous structure with the strongest attachments to the chest wall medially along the sternum and at the inframammary (IM) fold. The primary blood supply originates from the internal mammary system and its arteries perforate the breast from deep to superficial. The venous drainage is located more superficially. Pedicle design should be based on dominant blood vessels for each specific technique for perfusion and sensation to the nipple-areolar complex (NAC) without compromising the intended shape and underlying breast parenchyma. The superior pedicle approach relies on internal mammary perforators from the second rib intercostal space, whereas the blood supply to the superomedial pedicle originates from both the second and third rib intercostal space. The blood supply to the inferior pedicle is based upon the fourth rib intercostal space. All skin and subcutaneous flaps rely on a network of subdermal venous drainage. Lymphatic pathways parallel the venous drainage and include cutaneous, internal mammary, posterior intercostal, and axillary routes. The lateral branches of the fourth, fifth, and sixth intercostal nerve supply the primary sensation to the NAC. 1,2 Deep and superficial sensory nerve branches allow any full thickness pedicle described to supply sensibility to the NAC without much impact, provided there is careful dissection, limited undermining, and the muscle fascia remains intact.

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Patient History The surgeon must carefully document any symptoms associated with enlarged breasts and attempted nonsurgical approaches to resolve these issues (physical therapy, pain medications, weight loss). Some findings that have been associated with macromastia include occipital headaches, neck pain, shoulder pain, midback and lower back issues, shoulder grooving, intertrigo or skin rashes, sensory changes including upper extremity paresthesias, difficulty participating in recreational activities, work, sleep, illfitting clothes, and anything else that may be attributed to breast hypertrophy. In addition, changes in breast size, as well as previous breast surgery, biopsies, scars, and asymmetries as noted by the patient should be recognized. Document skin lesions, changes with pregnancy, and a personal or family history of cancer (particularly if the family history includes members with breast, colon, prostate cancer or melanoma). If there is any concern for a genetic predisposition for breast cancer, it is recommended that the patient obtain a genetic consultation preoperatively. Consider the potential role of medications that may increase breast size (e.g., hormones, oral contraceptives, and steroids). Additionally, some systemic diseases may affect wound healing, especially related to skin vascularity (e.g., scleroderma, lupus, Raynaud disease, or other connective tissue disorders). Preoperative mammography is not necessary for elective breast reduction before the age at which screening mammography is generally recommended. Unless there are concerning aspects of the patient’s history or examination that call for further investigation, patients should follow the existing clinical practice guidelines that recommend annual screening for patients of certain age groups. 3

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Physical Examination There are multiple aspects of the physical examination that need to be documented for patient selection and surgical planning (Figure 56.1). Furthermore, specific findings in the physical examination may anticipate potential limitations of the procedure in achieving the desired aesthetic result. Therefore, it can be helpful to integrate a standardized checklist into the clinical encounter. Stature: Height and weight are used to calculate total body surface area, which determines the amount of tissue that must be resected based on the Schnur or other scales required for insurance coverage. 4 Shoulder grooving and hyperpigmentation: These findings are typically minimal in younger patients with excellent skin. Scoliosis and chest wall asymmetries: These findings may disguise breast volume or width differences that become more apparent postoperatively and should be discussed with the patient in the preoperative setting. Manubrial projection, pectus excavatum, and pectus carinatum: Breast reduction will not change these abnormalities and may even make them more apparent postoperatively. Soft tissue fullness of the anterior axillary folds and lateral chest: Suction-assisted lipectomy (SAL) may reshape these areas. The effects may be limited in obese patients, especially in those patients with fullness extending posteriorly. Deficient cephalic and medial breast: Emphasize the challenges involved in filling these areas and limit the resection of breast parenchyma in these areas if already deficient. Skin quality: Document scars, skin lesions, striae, or dimpling with motion. Youthful and elastic skin appears to have a greater risk for hypertrophic scarring postoperatively. A vertical approach may reduce this risk. IM fold asymmetries: These may become more apparent to the patient once volume is removed. Intertrigo: Document open wounds, acne, hidradenitis suppurativa, or hyperpigmentation. NAC position: Wide, narrow, or asymmetric nipple positioning can be corrected to a limited degree. Note the position of the NAC relative to: The breast mound The IM fold Current and intended breast meridian Sternal notch Contralateral NAC Papule: Note the size and shape of the papule, including continuous or episodic inversion. It may not improve postoperatively. Complete nipple inversion may be dealt with at the time of the breast reduction if needed. Areola: Document abnormal size, shape, color, and symmetry relative to the contralateral side. Costal margins: Note any abnormal projection and asymmetries, because this may become more noticeable postoperatively. Breast parenchyma: Estimate any volume discrepancies, density (e.g., fatty versus fibrous), estimated volume to be removed, and presence or absence of masses.

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FIGURE 56.1 Key aspects of the physical examination for patients with macromastia. AAL, anterior axillary line; IM, inframammary; NAC, nipple-areolar complex.

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Preoperative Photography Standardized photography of women considering breast reduction is essential for insurance approval, for operative planning, and to identify preoperative asymmetries that may affect the final result (Figure 56.2). Anterior views with arms elevated and at the sides Lateral views with arms elevated and at the sides Optional: oblique views Posterior view (useful for documenting the presence of scoliosis, shoulder grooving, and chest wall asymmetries)

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FIGURE 56.2 Suggested preoperative photography.

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Preoperative Markings Each breast reduction technique is unique and requires variations in markings. We will review a general approach to initial markings. Surgeons generally have two decisions to make: the pedicle type and the pattern of skin resection. Preoperative markings for keyhole pattern technique: 1. Ask patient to stand with arms at her sides. 2. Mark the IM fold and extend this marking medially to a point that is still hidden in the fold. In the midline (at a point corresponding approximately to the breast meridian that will be marked in the next step), make a small peak or upswing of about 1 cm, which may take some tension off the flaps (Figure 56.3). Curve the medial marking cephalically, as this incision tends to straighten postoperatively potentially resulting in visible scarring. Extend the IM fold markings laterally to a point that corresponds with the anterior axillary line, approximately where the breast ends. Avoid extending this mark toward the back chasing skin folds laterally. 3. With a measuring tape hung around the neck or using the midclavicle, mark out the intended breast meridian bilaterally (this may not align with the current nipple position) (Figure 56.4). Carry this line down under the breast crossing the IM fold at the central peak. 4. Mark the new nipple position: This is critical and can be done using a number of techniques (Figure 56.5). The distance from the sternal notch to nipple can vary with height, but an example is that a 5′6″ woman who is a 34/36 C will be about 23 to 24 cm (Table 56.1). This mark should be very close to a hypothetical line that connects laterally to ∼2 cm below the midpoint of the upper arm. And finally, it should be ∼2 cm above the projected IM fold onto the anterior breast. Be sure to compensate modestly for skin elasticity which can cause some postoperative retraction cephalically. All three marks should be very close, and most importantly, the appearance of the final NAC position should appear reasonable. 5. Measure the length of the medial and lateral limbs of the IM fold from the midline peak. Add 1 to 1.5 cm to each distance and transpose this point to the planned corresponding inferior margins of the upper flaps, ∼8 to 9 cm below the new papule position (see Figure 56.3). Adding this horizontal length to the upper flaps reduces tension and may help to avoid wound healing issues at the trifurcation. 6. With a flexible wire keyhole template, place the areolar opening over the new nipple position and open to the previously marked upper flap lengths. Draw the new NAC position and the vertical limbs. The limbs will be ∼5 cm for a small breast and ∼6 to 7 cm for a larger final breast. Extend the upper flap incisions from these points to join the IM fold incision medially and laterally with a gentle S-shaped curve. 7. Finally, mark topographically areas for planned liposuction as needed (lateral chest, anterior axillary fold) and estimate the amount to be removed with suction.

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FIGURE 56.3 How to mark the inframammary (IM) fold and determine lengths of upper flap incisions. Extend mark medially and laterally to points that are still hidden in fold and curve cephalically. At the breast meridian, make a small peak of about 1 cm to reduce tension on the final closure. Measure the length of the medial and lateral limbs of the IM fold. Add 1 to 1.5 cm to each distance and transpose to the corresponding inferior margins of the upper flaps, 8 to 9 cm below the new papule position.

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FIGURE 56.4 How to find the intended breast meridian with a measuring tape hung around the neck. IMF, inframammary fold; NAC, nipple-areolar complex.

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FIGURE 56.5 Three approaches to marking the new papule location. (1) Mark about 2 cm below the midpoint of the upper arm on the meridian. (2) Mark about 2 cm above the transposed position of the inframammary (IM) fold. (3) Refer to Table 56.1 for example sternal notch-to-nipple distances based on desired brasserie size. Remember to compensate for skin elasticity.

TABLE 56.1 Normative Values of Common Preoperative Breast Measurements [Reported in Inches (centimeters)] Measurement B Sternal notch to nipple (left)

32 C 7.8 (19.9)

D 8.2 (20.8)

Sternal notch to nipple (right)

8.1 (20.4)

8.3 (21.1)

Nipple to nipple

7.9 (20.0)

8.0 (20.3)

IMF to nipple

3.3 (8.4)

3.8 (9.7)

B 9.6 (24.4) 9.5 (24.1) 8.4 (21.4) 4.0 (10.2)

34 C 8.3 (21.0) 8.3 (21.1) 8.1 (20.7) 3.5 (8.9)

D 8.8 (22.4) 8.9 (22.5) 8.3 (21.0) 4.0 (10.2)

B 9.9 (25.1) 9.8 (25.0) 8.6 (21.8) 4.3 (10.9)

36 C 8.7 (22.1) 8.6 (21.8) 8.4 (21.3) 3.8 (9.7)

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D 9.4 (24.0) 9.4 (23.9) 8.6 (21.7) 4.3 (10.9)

B 10.2 (25.9) 10.2 (25.9) 8.7 (22.2) 4.5 (11.4)

38 C 9.1 (23.1) 9.1 (22.5) 8.6 (21.9) 4.0 (10.2)

D 10.1 (25.6) 9.9 (25.2) 8.8 (22.4) 4.5 (11.4)

10.5 (26.6) 10.6 (26.8) 8.9 (22.5) 4.8 (12.2)

Areolar width

1.8 (4.6)

2.0 (5.2)

Breast width

5.8 (14.7)

5.8 (14.7)

2.1 (5.3) 6.2 (15.7)

1.9 (4.7) 5.9 (15.0)

2.0 (5.3) 6.0 (15.2)

2.1 (5.3) 6.4 (16.3)

1.9 (4.9) 5.9 (15.0)

Values obtained from a study of 30 women for each breast size by Robert Oneal, MD, Denis Lee, and Art Rathjen. IMF, inframammary fold.

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2.0 (5.1) 6.2 (15.7)

2.1 (5.3) 6.6 (16.8)

2.0 (5.0) 6.0 (15.2)

2.1 (5.2) 6.4 (16.3)

2.1 (5.4) 6.8 (17.3)

Inferior Pedicle Technique This technique may be considered for breasts in which the NAC falls significantly below the triangle formed by the planned vertical flaps. It can be done in very large breasts, but size can be a limiting factor and the amputation/free nipple graft technique may be considered. After prepping and draping the patient in the usual manner, reinforce your markings at the IM fold. Mark out the new areolar size (3.0–5.0 cm depending on final breast size) with the breast under some mild tension. Design the inferior pedicle from about 1 cm above and around the NAC and flare down toward the IM fold medially and laterally. This pedicle base is generally ∼8 to 10 cm or wider. Remeasure and then join the vertical flap incisions in the center of the planned location of the NAC, not fully committing to the final NAC location (Figure 56.6). Tattoo key points for closure with a needle and marking ink including NAC orientation to avoid inadvertent rotation during insetting.

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FIGURE 56.6 The preoperative markings for an inferior pedicle technique with a keyhole pattern skin resection. Note the anticipated flaring of the pedicle shape and tapering of the soft tissues.

If planning to perform SAL laterally, infiltrate with tumescent solution in the intended areas at this time. Placing the breast base under tension, make all planned incisions and deepithelialize the inferior pedicle

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with knife or scissors. Proceed with the SAL. Some surgeons prefer to elevate the upper flaps first. We have found that elevating the inferior pedicle initially works best for us. Make the dermal incisions medially and laterally on the IM fold carrying them about about halfway up the pedicle. Flare this dissection at the IM fold away from the pedicle to leave some added volume and to preserve NAC sensation. Now complete the incision around top of the pedicle and dissect toward the chest wall following natural tissue planes of the breast parenchyma (Wuringer’s Planes) and avoiding larger vessels at the pedicle base. 5,6 Carry this dissection to the chest wall without injury to the muscle fascia. Proceed to elevate the medial and lateral flaps. Incise down to the breast capsule along the flap margins, and at the flap corners, tack the capsule to the dermis to assist in avoiding stripping the soft tissues from the overlying dermis, thus protecting blood supply to the skin edges (Figure 56.7). Trim and taper the flaps as needed for shaping the breast and removing the needed volume. Try to limit the resection from the medial flap, as this area is frequently already deficient. Once the flaps are elevated, remove the breast from the chest wall en bloc leaving the pectoralis fascia intact and avoiding injury to the blood supply of the pedicle. Weigh the specimen. Consider dividing and labeling as central, medial, and lateral so as to be able to help localize any pathology if inadvertently found.

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FIGURE 56.7 Elevation of the upper flaps and suturing the breast capsule to the dermis at the corners to prevent stripping the soft tissues from the overlying dermis.

Divide the dermis at the base of the inferior pedicle to assist in closure. After hemostasis, staple the flaps into position, sit the patient up, and if available, hold a sterilized bra of the planned postoperative breast

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cup size in position to assess the size and to determine asymmetries (Figure 56.8). Return the patient to supine position, and if necessary, release staples and resect additional tissue as indicated. Once both sides are symmetric volumes, restaple, sit up, and mark the new NAC position measuring from the sternal notch with a suture with patient as vertical as possible. They should be symmetric. Modify the NAC position if needed. Excise the skin for the new NAC position, bring the NAC to the skin surface, and confirm that the NAC is not rotated. You can remove some additional volume from the NAC defect if needed. Drains are placed prior to closure for 24 hours only if large amounts of tumescent fluid were used for lateral SAL or if a large potential dead space persists. This is usually not necessary.

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FIGURE 56.8 The inferior pedicle is then brought into position and the upper flaps are brought down and stapled at the meridian. Confirm the correct orientation of the nipple-areolar complex based upon preoperative markings.

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Superomedial Pedicle Technique This technique (popularized by Hall-Findley and others) 7 has increased in popularity over the last two to three decades and continues to be a primary approach for many surgeons in moderate-size breasts. Adapting from the more classic inferior pedicle approach is not an easy transition but well worth the effort. It does require a substantially different three-dimensional understanding and visualization of the planned tissue rearrangement. The resection in the superior and superomedial pedicle approach is mostly from the lower and lateral poles where many volumetric issues exist with breast hypertrophy. The final breast shape can be additionally controlled with some deeper breast pillar sutures to assist in coning the tissues. The marking of these patients is similar to the inferior pedicle approach using a keyhole pattern. Theoretically, using this technique reduces the risk for bottoming out over time as more lower and lateral pole tissues are resected. There is minimal resection of upper and medial breast tissue, which, along with rotation of the pedicle cephalically, may help to increase upper breast fullness. After prepping and draping the patient, reinforce the markings at the IM fold and sweep up about 1 cm at the breast meridian (to reduce tension at the T-junction). Staple the inferior corners of the new NAC position together to mark the areola because it is incised initially. Mark out the new areola size with the breast on mild tension at the base. Release the staples and design a superomedial pedicle from just below the 3-o’clock position on the right (9-o’clock on the left) and extending the pedicle around the NAC inferiorly and laterally with ∼1 cm margins. If necessary, the lower portion of the pedicle extends a bit beyond the tip of the medial flap to maintain a wider pedicle base (Figure 56.9). This base is ∼8 to 10 cm in diameter. Mark key points for closure including the orientation of the areola. Note that the NAC will eventually rotate ∼90°.

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FIGURE 56.9 The preoperative markings for a superomedial pedicle technique with a keyhole pattern skin resection. Note that the position of the nipple-areolar complex is generally within or just below the vertical limbs of the keyhole pattern.

Infiltrate for SAL if indicated. With the breast base under tension, perform all planned incisions including

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the new NAC position, and deepithelialize the superomedial pedicle. Proceed with SAL. Make incisions along the caudal border of the medial flap directly down to chest wall, leaving the pectoralis fascia intact. Continue incisions around the superomedial pedicle up to the new NAC position by avoiding any undermining of the pedicle. The pedicle should rotate easily. Incise along the medial and lateral thirds of the IM fold directly down to chest wall, but in the central third bevel cephalically to allow some soft tissue to remain to fill potential dead space that may persist after superomedial pedicle rotation. Dissect around the new NAC position ∼1.5 to 2 cm into the breast tissue and then bevel caudally to create a platform for the rotated NAC to rest on. Incise along the vertical and horizontal aspects of the lateral flap, leaving at least 3 cm of thickness to the flap at the tip. Taper the dissection cephalically along the lateral flap (Figure 56.10). This resection is important for reduction of lateral fullness and achieving coning. Resect the specimen from the chest wall en bloc, leaving the pectoralis fascia intact. Weigh the specimen. Divide into medial, central, and lateral aspects for pathology. Carefully incise the dermis at the base of the pedicle for ease of rotation into the new NAC position.

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FIGURE 56.10 The relative thicknesses of the dissection of the superomedial pedicle and upper flaps, leaving a support shelf of breast tissue below the new nipple-areolar complex position for projection.

Place pillar sutures (2-0 absorbable) in the deep tissues of the vertical limbs of the tips of the medial and

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lateral flaps. These are placed ∼2 to 3 cm below the flap corners and should assist in coning the breast when tied without skin distortion (Figure 56.11). A second pillar suture can be placed slightly more superficially. Approximate the skin edges with staples, advancing the upper flaps on the IM fold to avoid dog-ears medially and laterally. Staple the vertical incision. In the sitting position check for symmetry, volume, and position on the chest wall. Modify as necessary. The NAC position has already been determined and can only be minimally changed. After confirming that the NAC is oriented correctly, staple it into position.

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FIGURE 56.11 The upper flaps are then sutured together with pillar sutures and the superomedial pedicle is rotated about 90°. Confirm the correct orientation of the new nipple-areolar complex position with the preoperative markings.

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Superomedial Pedicle With Vertical Skin Resection In patients with good skin elasticity, small to moderate amounts of planned tissue resection, and a reasonable distance between the papule and IM fold, a vertical skin resection approach may be used that will eliminate the transverse IM incisions. This approach relies upon lower pole skin contraction after elevating thin flaps down to the IM fold. Resection of breast tissue under the skin flaps is identical to the resection of breast tissue performed for the superomedial pedicle with a keyhole pattern. The vertical approach can significantly decrease the risk for hypertrophic scarring medially and laterally. A full understanding of the superomedial pedicle keyhole approach allows transitioning to this technique more easily. If the NAC is positioned high in the superior aspect of the keyhole pattern, the surgeon may want to consider using a superior pedicle. 8

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Preoperative Markings The surgeon must be familiar with the key differences in the surgical markings for the vertical approach. Mark the breast in a similar manner to the standard superomedial pedicle reduction with a keyhole pattern, except just dot the transverse incisions at the IM fold and the medial and lateral flaps. These marks create a reference on the surface where the resection will be performed underneath the thin skin flaps (also called ghost areas). Extend down the vertical limbs beyond the transition point to the medial and lateral flaps of the keyhole pattern. The vertical limbs will continue caudally to ∼3 to 4 cm above the IM fold and join in a gentle curve. The breast tissue will be resected caudally to this point to level of the IM fold. The scar will shorten as the tissues heal and the breast will drop down to a new higher IM fold, leaving just a vertical scar below the NAC.

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Operative Technique Once on the table, reinforce and remeasure the lines previously described. The superomedial pedicle and the new position and size of the NAC will be marked. The key points will be tattooed as in previous markings. The incisions are made by avoiding the dotted transverse and IM incisions of the previously described keyhole pattern. Deepithelialize the superomedial pedicle as usual and then begin by undermining the ghost areas between the dotted lines down to the IM fold (Figure 56.12). The skin flaps should be thin with minimal fat, but avoiding injury to the dermis. In patients with very thin subcutaneous tissue overlying the breast, dissection may proceed directly on the breast capsule. Once the undermining is completed under the ghost areas, the breast resection is identical to the instructions in the previously described technique for the superomedial pedicle, but with less skin resection.

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FIGURE 56.12 The intended resection of tissues and the ghost areas above the medial and lateral areas of breast tissue resection.

After the resection of breast tissue, place the pillar sutures in the usual location in the upper flaps and

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rotate the NAC into position. The vertical incision is closed in either a single or a double layer. Do not attempt to shorten the incision during the closure for the first 2 cm below the NAC. This will place the 6o’clock position of the NAC under tension caudally and distort its shape. Shorten the incision with a cinching closure beginning about 2 cm below the NAC (Figure 56.13). Barbed sutures may be helpful. It may also be beneficial to hold the skin at the inferior apex of the vertical limbs with a hook retractor during the closure. The final resulting caudal fullness that persists in many cases can be purse stringed or just closed. This redundant tissue can be dressed with a small temporary bolster of Vaseline gauze held by tape for 7 to 10 days.

FIGURE 56.13 Distribute the redundant tissue during the closure of the vertical approach inferiorly to avoid distorting the shape of the nipple-areolar complex postoperatively.

There is the possibility of this residual redundancy needing some eventual resection transversely under local anesthesia, but the surgeon should wait at least 4 to 6 months as it frequently resolves on its own.

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Amputation/Free Nipple Graft If the anticipated length of the inferior pedicle or superomedial pedicle raises concern of potential vascular compromise of the NAC, consider an amputation/free nipple graft technique. 9 This approach is generally ideal for patients with macromastia of excessive proportions that may limit pedicle viability, final aesthetics, and planned reduction goals. Generally, this refers to patients with a nipple to IM fold distance >20 cm. This technique may also be appropriate if there are breast scars that cross planned skin flaps or pedicles. This approach may also be preferred in the setting of a history of previous reduction mammoplasty of known or unknown technique, a history of radiation or for patients with systemic vascular issues due to connective tissue disorders, with an extensive smoking history, or autoimmune disorders. This technique allows the surgeon to achieve an excellent result with some projection and volume. Counsel the patient regarding the loss of NAC sensation and the risks of NAC graft failure. Even with these limitations, it is important for plastic surgeons to be able to utilize this technique.

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Preoperative Markings The preoperative markings are identical to the standard keyhole pattern described earlier (Figure 56.14). Because this technique is usually performed in the setting of very heavy breasts, remember to correct for the elasticity of the upper skin by lowering the final nipple position markings as needed. The major difference from previously described markings is that the width of the vertical portions of the keyhole may change once the resection is completed. The length of these vertical limbs should be 6 to 7 cm depending on the final size considered. Also, plan to leave a mound of lower breast tissue at the IM fold, which improves final projection.

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FIGURE 56.14 Preoperative markings for amputation/free nipple graft with suction-assisted lipectomy and depiction of the nipple-areolar complex harvested as a full-thickness graft.

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Operative Technique With the breast under mild tension, remove the NAC as full-thickness graft. It may be easier to keep the NAC thin to reduce the time needed to perform defatting. Also consider amputation of the tip of the nipple papule in circumstances where the length of the papule exceeds 1 cm to help it to survive as a fullthickness graft. Place it on a labeled moist sponge on the back table to prevent operating room staff from accidentally discarding it. Deepithelialize a small lower flap along the IM fold (Figure 56.15). Incise down to the chest at the IM fold tapering cephalically over this small mound. The upper flap is incised along the caudal edge directly down to the chest wall, avoiding any undermining.

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FIGURE 56.15 Following resection of breast tissue and deepithelialization of a central triangle. The new nipple-areolar complex position should then be confirmed and prepared for the full-thickness skin graft and bolster.

The breast tissue that was amputated will then be resected and weighed. Staple the upper incision to the lower advancing from the medial and lateral corners of the upper flaps centrally. The flaps should come together at the planned vertical marks but, depending on the size of the remaining breast, this triangle may need to be enlarged or reduced to achieve good approximation of the skin edges. Staple the vertical limbs together and assess the new breast size and shape. Mark out the new vertical limbs as needed, remove staples, and now deepithelialize the triangle.

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Restaple the skin edges together again, and in the sitting position, mark the new NAC positions symmetrically and very thinly deepithelialize this area. After closing the horizontal and vertical incisions, secure the NAC grafts to their new positions with tie-over bolsters (Figure 56.16). Drains are not necessary. SAL laterally can help contour as needed.

FIGURE 56.16 Final closure with a tie-over bolster for the amputation/free nipple graft technique.

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Suction-Assisted Lipectomy This technique is helpful ideally for treating limited macromastia in circumstances when the breast tissue contains a high proportion of fatty tissue, the planned reduction would not require significant excision of overlying skin, and the skin has good elasticity. 10 For more dense breasts, modified suction equipment (i.e., ultrasonic, reciprocating, laser assisted) may be more helpful. We consider this for limited asymmetries, small reductions, and previous reductions with asymmetry needing additional volume removal, or for patients who have undergone previous reductions of unknown techniques and are not candidates for amputation with free nipple grafts. This procedure may be performed in a single or a staged manner that may include mastopexy after successful SAL.

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Postoperative Complications ( FIGURE 56.17)

FIGURE 56.17 Potential complications following breast reduction.

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Acute Complications Hematoma Estimated to occur in up to 4% of cases. 11 It is important to recognize a hematoma early as it may result in vascular compromise to the NAC. Although surgical drains may initiate an earlier diagnosis, they will not prevent a hematoma from occurring. A small, localized hematoma can be directly drained or allowed to liquefy and then evacuated with a large bore needle or fat harvesting cannula in 1 to 2 weeks postoperatively.

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Delayed Wound Healing Estimated to occur in 10% of cases. Usually occurs at the lower skin trifurcation (T-junction), but may also occur along any incision lines. It may be due to the flaps closed too tightly over the remaining mound or in patients with any history of scars, or active smoking. It is not uncommon for mild epidermolysis to occur, which is treated with conservative wound care. To prevent wound healing complications, consider tacking the dermis to the breast capsule at the flap corners with absorbable sutures to avoid stripping the underlying blood supply.

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Seroma Leaving a small mound of breast tissue at the midline along the IM fold in the superomedial pedicle breast reduction approach helps to avoid this complication. If significant SAL of the lateral breast is performed, consider leaving a surgical drain overnight which helps remove residual tumescent fluid.

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Vascular Compromise If the breast reduction is designed and executed correctly, this is a rare complication involving the NAC and hopefully only temporary after the pedicle elevation, positioning, and rotation. It can be difficult to evaluate if local anesthetic with epinephrine was used during the case. Try to identify the underlying cause for vascular compromise and release sutures as needed to avoid necrosis and loss of the NAC. Assess the NAC for proper rotation or consider additional reduction of breast to decrease intrinsic pressure. Vascular compromise also can result in fat necrosis and fibrosis, thus potentially leading to the need for future biopsies or operative interventions. Removal of the NAC as a full-thickness graft and regrafting can be done but has limited results. History of radiation therapy, Raynaud disease, scleroderma, and smoking increases risk for vascular compromise.

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Long-term Complications Asymmetry Identify and point out asymmetries to the patient preoperatively, including chest wall, costal margins, manubrium, IM folds, or anticipated discrepancies in the amount of breast volume that will be resected. Furthermore, try to predict the volume discrepancies between the breasts preoperatively. Intraoperatively, sit the patient up to determine symmetry by visual inspection and palpation. Use of a sterile bra in the operating room helps to recognize volume differences. Preoperative breast asymmetries will be more obvious after a symmetrical resection. Small to medium differences may be treated postoperatively with SAL.

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Fibrosis and Fat Necrosis Fibrosis may resolve with time and massage and generally is not visible. This finding may cause anxiety for the patient and lead to unnecessary testing or breast biopsies. Fibrosis and fat necrosis may also affect future mammography. Occasionally an area of firmness may be an inclusion cyst, which is a result of inadequate deepithelialization of the pedicle.

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Inability to Breastfeed The impact of breast reduction on ability to breastfeed postoperatively appears largely related to preservation of the subareolar parenchyma. Rates of successful breastfeeding range from 5 cm), four or more involved lymph nodes, positive or close margins, and those with locally advanced breast cancer. The 2014 American Society of Clinical Oncology guidelines recommend axillary lymph node dissection for patients who have three or more metastatic sentinel lymph nodes on sentinel lymph node biopsy (SLNB) or who have one or two metastatic lymph nodes on SLNB but who do not desire whole-breast irradiation. Oncologic factors suggestive of suitable cases for nipple-
 sparing mastectomies include tumors >2 cm from the nipple and no clinical involvement of the skin or nipple. In breast cancer patients who have undergone mastectomy, there is no difference in survival in patients receiving chemotherapy within 4 to 8 weeks of surgery.

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Introduction Breast cancer is the most common malignancy diagnosed worldwide; currently, it is the leading cause of cancer-related death in women. 1 It is estimated that in 2017 there were 252,710 Americans diagnosed with invasive breast cancer and 40,610 died of the disease. The lifetime risk of women developing breast cancer is approximately 12.4%, or 1 in 8 women. Over the last 10 years, the incidence of new female breast cancer cases has been relatively stable. Most women are diagnosed between 55 and 64 years old. The average 5-year survival rate is 89.7% and patients with higher disease stage have decreased 5-year survival. Death rates have been falling at an average rate of 1.8% per year. 2 The Women’s Health and Cancer Rights Act of 1998 increased access to reconstructive services for women with breast cancer. Since that time, an increased proportion of women have undergone reconstructive procedures by plastic surgeons. In the United States, there has been a nearly 20% increase in rates of reconstruction from 1998 to 2007. During the same time period, there was an increasing proportion of implant-based breast reconstruction compared with autologous-based breast reconstruction and higher rates of bilateral mastectomy. 3,4

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Risk Factors Although the etiology of most breast cancer is unknown, risk factors have been clearly defined. These include female gender, increasing patient age, family history of breast cancer at a young age, early menarche, late menopause, older age at first live childbirth, prolonged hormone replacement therapy, previous exposure to therapeutic chest wall irradiation, benign proliferative breast disease, increased mammographic density, and genetic mutations. Aside from gender, increasing age and genetic mutations are the only substantial risk factors. The National Cancer Institute (NCI) and National Surgical Adjuvant Breast and Bowel Project (NSABP) have developed the Breast Cancer Risk Assessment Tool that can help women to estimate their risk of developing invasive breast cancer (https://www.cancer.gov/bcrisktool/). This tool is also known as the Gail Model. The model uses a women’s history of prior breast malignancy, gene mutations, age, age to menarche, age at the time of her first live birth of child, family history, history of breast biopsy, and race/ethnicity to calculate 5 year and lifetime risk of developing breast cancer. The Gail Model has only been validated for women in the United States who are screened regularly for breast cancer. Hereditary breast cancer accounts for up to 20% of breast cancer cases. More common syndromic breast cancer susceptibility genes include BRCA 1 and 2, TP53 (Li-Fraumeni syndrome), PTEN (Cowden syndrome), CDH1 (hereditary diffuse gastric cancer syndrome) STK11 (Peutz-Jeghers syndrome), mismatch repair genes (Lynch syndrome), and NF1 (Neurofibromatosis 1). More common nonsyndromic breast cancer susceptibility genes include PALB2, CHEK2, and ATM. Genetic testing should be performed if a patient has a known mutation in a breast cancer susceptibility gene, if there are two or more primary breast cancers on the same side of the family (in the same person or two separate individuals), if there is one or more ovarian cancers on the same side of the family, if there is a first- or second-degree relative who was diagnosed with breast cancer before the age of 45 years, or male breast cancer. 5 Patients with strong family history of breast cancer or known genetic predisposition should always be seen in coordination with a certified genetic counselor. The BRCA1 and BRCA2 genes are autosomal dominant tumor suppressor genes that help to repair damaged DNA. BRCA 1 and 2 gene mutations account for 20% to 40% of the hereditary breast cancers. Women with the BRCA1 mutation have a 55% to 65% risk of developing breast cancer and a 39% chance of developing ovarian cancer by age 70 years. In contrast, women with the BRCA2 mutation have a slightly lower risk of 45% for developing breast cancer and 11% to 17% chance of developing ovarian cancer by age 70 years. In addition to breast and ovarian cancers, patients with the BRCA gene mutation are also at higher risk for fallopian tube, peritoneal, prostate, and pancreatic cancer. Although tests are helpful for identifying known genetic risk factors, those who have significant family history may have genetic mutations that have not yet been formally identified. 6,7

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Types of Breast Cancer The most common types of breast cancer include ductal carcinoma in situ (DCIS), invasive ductal carcinoma, and invasive lobular carcinoma. In situ, or noninvasive, cancers increase a patient’s risk for developing invasive cancer. DCIS can transform into invasive cancer. Lobular carcinoma in situ (LCIS) does not transform into invasive disease but instead increases one’s risk by 7 to 12 times for developing invasive cancer in either breast. 8,9 Other less common types of breast cancer include inflammatory breast cancer, Paget disease, Phyllodes tumor, and angiosarcoma.

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Screening The updated American Cancer Society guidelines of 2015 recommend that women with an average risk of breast cancer should undergo regular screening mammography starting at age 45 years. Women between the ages of 45 and 54 years are recommended to have annual screening mammography whereas women at the age of 55 years and older are recommended to have biennial screening mammography. Screening mammography is recommended to continue for as long as the patient has a life expectancy of 10 years or longer. In contrary to previous guidelines, no regular clinical breast examinations for breast cancer are recommended for average-risk women at any age. 10 Mammography is the standard imaging technique for breast cancer screening. Other screening modalities such as MRI are only indicated for patients with higher-than-average risk of developing breast cancer.

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Staging Tumor classification using the TNM staging system outlined by the American Joint Committee on Cancer (AJCC) is used to assist in prognosis and treatment of breast cancer. This system is built upon the extent of disease for the tumor (T), status of the regional lymph nodes (N), and presence of distant metastases (M). More recently, the AJCC has also added tumor grade, HER2, estrogen receptor (ER), progesterone receptor (PR), and genomic assays as part of the breast cancer staging system. 11 Early-stage breast cancer (stages I–II) is disease that is confined to the breast without extension to the chest wall or locoregional lymph nodes. Early-stage breast cancer is usually treated surgically and in selected patients with radiotherapy. Breast cancers that are stage III and above require locoregional control usually consisting of surgery and adjuvant systemic therapy. 12 Surveillance, Epidemiology, and End Results Program data from 2007 to 2013 showed that women with stage 0 or stage 1 breast cancer have a 5-year relative survival rate of nearly 100%. Women with stage II breast cancer have a 5-year relative survival rate of approximately 93%. Women with stage III and stage IV breast cancers have poorer prognoses with 5-year relative survival rates of 72% and 22%, respectively. 13

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Work-Up An abnormal palpable breast mass or new mammographic finding is usually followed by an ultrasonic examination that can differentiate between solid and cystic breast masses. Ultrasound can also be used to detect lymph nodes that are suspicious for axillary metastases. The primary tumor is then evaluated by an image guided biopsy that, if found to be positive for malignancy, is treated with surgery. Although breast MRIs are generally more sensitive than mammography or ultrasonography, they have not been found to improve overall survival outcomes or improve locoregional recurrence rates. 14-17

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Surgical Treatment Improved local control is causally associated with improved breast cancer survival. 18 The surgical treatment of breast cancer has evolved. The first surgical treatment of breast cancer was the radical mastectomy that was popularized by William Halstead at the end of the nineteenth century. Since then, there has been a trend toward increasingly less invasive surgical management of breast cancer. Since the introduction of the radical mastectomy, other techniques, such as the modified radical mastectomy, partial mastectomy, skin-sparing mastectomy (SSM), and nipple-sparing mastectomy (NSM), have been developed. Although traditional surgical management has been used to treat the breast affected by cancer, there has also been an increasing trend toward risk reducing procedures such as contralateral prophylactic mastectomies.

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Breast Conservation Therapy Breast conservation therapy (BCT) couples surgical excision of the tumor with local radiotherapy. BCT is appropriate for early stage breast cancer and has been shown to provide equivalent overall survival rates compared to total mastectomy while still preserving the breast. 18 Despite similar survival rates, BCT has a reported positive margin incidence rate of 20% to 70%. Several techniques have been developed to decrease the positive margin rates including ultrasound needle localization, stereotactic needle localization, bracketing, or taking additional margins. 19

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Neoadjuvant Systemic Therapy Neoadjuvant systemic therapy is indicated for patients with inoperable tumors or if BCT is desired and the tumor size would have otherwise required a mastectomy. Cytotoxic, hormonal, and/or trastuzumab therapy can be used to reduce the amount of tumor burden in the breast and axilla without compromising survival. Although the entire initial tumor bed does not need to be removed, any residual palpable or radiographic lesions should be excised. For those who have complete clinical response, surgical excision is still indicated. 18 Decisions regarding radiation therapy should be based upon maximal stage from prechemotherapy tumor characteristics and/or pathologic stage regardless of the tumor’s response to adjuvant systemic therapy. 20

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Mastectomy The goal of a mastectomy is to remove all breast tissue thus decreasing the risk for cancer recurrence. The anatomic borders of the breast are defined by the midline medially, the latissimus dorsi muscle laterally, the clavicle superiorly, and the insertion of the rectus abdominus muscle inferiorly. Contemporary techniques such as the SSM and the NSM can improve aesthetic outcome. 21 The SSM was first described in June 1991 by Toth and Lappert. This technique is defined by removal of breast tissue with modified minimal incisions leaving as much skin as possible. Contraindications for SSM are inflammatory carcinomas, locally advanced carcinomas, and smoking (relative contraindication). Local recurrence rates after SSM are similar to other forms of mastectomy. 22 The NSM was a natural evolution from the SSM. It is performed by removal of all breast tissue without excision of skin and the nipple-
 areolar complex. Oncologic contraindications for NSM include a 
 tumor to nipple distance of 2 cm), positive lymph nodes, ER-negative and PR-negative tumors, HER-2/neu-positive tumors, and inflammatory breast cancer. Anthracycline-based systemic therapies have been shown to improve survival compared to methotrexate-based regimens but they also have more substantial side effects. Anthracyclines can have associated cardiotoxicity and thus should be used carefully or avoided when treating elderly patients and those with previous cardiac disease. Taxanes in combination with chemotherapy have also been shown to be more effective and thus have become used as standard treatment. 5

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Radiation Therapy Radiotherapy is an important component of local regional disease control. Whole-breast radiation therapy with or without boost to tumor bed is required as a part of BCT and occurs after lumpectomy. Current guidelines also recommend chest wall radiation after mastectomy if tumors are >5 cm, if pathology margins are positive, or if there are positive ALNs. Accelerated partial breast irradiation (APBI) is a technique that provides a more focused field of radiation after complete surgical excision of in-breast disease but is still considered investigational and should be used within the confines of clinical trials. The benefit of APBI is that it can be administered over a 1 to 2 week period as compared to the typical 6 to 7 week period for whole-breast radiation. APBI commonly combines brachytherapy with external-beam photon therapy to the tumor bed. 20

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Hormonal Blockade and Biologic Therapies The relationship between breast cancer and hormone receptors has been well established since the 1950s. Since them, endocrine therapies such as tamoxifen have been used to treat breast cancer. Selective estrogen receptor modulators (SERMs), such as tamoxifen, block estrogen receptors in the breast, and effectively block estrogen activity in breast tissue. Tumors that are progesterone receptor positive often respond similarly to SERMs as ER-positive tumors. Hormonal blockade therapies are not without adverse events. Tamoxifen, while reasonably well tolerated, has been shown to be associated with hot flashes, headaches, menstrual abnormalities, a higher risk for endometrial cancer (cumulative risk 3.1% versus 1.6%), and a twofold increase in the incidence of pulmonary embolism. Current recommendations call for at least 5 years of treatment with a longer course of 10 years having been shown to further reduce recurrence and increase survival. Aromatase inhibitors, such as anastrozole, have been demonstrated to increase disease-free survival, increase time to recurrence, and decrease rates of distant metastases and contralateral breast cancer with fewer adverse side effects compared to tamoxifen in ER-positive postmenopausal women. 5,34-36 Targeted biologic therapies are used to treat patients with HER-2/neu receptor positivity. HER-2/neu receptor positive tumors are known to have a poorer prognosis with high rates of recurrence, relative resistance to hormonal therapy, and resistance to some chemotherapeutics. The monoclonal antibody against HER-2/neu, trastuzumab, has been shown to significantly improve outcomes in HER-2-positive cancers. Current guidelines recommend the use of trastuzumab in patients with HER-2/neu-positive tumors for 1 year. 5

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Questions 1. A 62-year-old female presents with stage II invasive ductal carcinoma. The tumor measures 2.8 cm and is positioned 1.3 cm from her nipple. Clinically, she has no involvement of her axillary lymph nodes. She desires to undergo a NSM. What are her oncologic contraindications to undergoing a NSM? a. Tumor is within 2 cm of her nipple b. Tumor is >2.5 cm in size c. Tumor is consistent with invasive ductal carcinoma d. Patient is older than 60 years of age e. Patient has stage II breast cancer 2. A 53-year-old female presents with stage III, ER/PR-positive, and Her-2/neu-positive right breast cancer. She undergoes a right SSM with placement of a prepectoral tissue expander. Her oncologist has recommended chemotherapy and would like to initiate it as soon as possible. How long after her mastectomy can you delay chemotherapy without impacting her overall survival? a. 8 weeks b. 9 weeks c. 10 weeks d. 12 weeks e. 14 weeks 3. A 56-year-old female comes to your clinic to be evaluated for bilateral mastopexy. She appears to be a good candidate for a mastopexy. She has no personal or family history of breast cancer and denies any new masses in her breasts. Her last mammogram was performed 14 months ago, and there was no evidence of malignancy. How frequently should she have screening mammography? a. Annually b. Every 5 years c. Biennially d. No need for screening mammogram giving her low risk profile e. Every 6 months 4. A 43-year-old female with an extensive family history of breast cancer was recently diagnosed with stage IIA left breast cancer. Her mother was diagnosed with breast cancer at age 46 and her sister was diagnosed at age 42. Genetic testing was performed, and she has no known genetic predisposing for breast cancer. She presents for a NSM with SLNB with a submuscular tissue expander placement. She had no clinically positive nodes preoperatively. Her SLNB demonstrated three positive lymph nodes, and she undergoes an ALND. What are her indications for the ALND? a. Stage IIA breast cancer b. Preoperative history of clinically negative nodes c. Family history of breast cancer d. Greater than 2 positive sentinel lymph nodes e. NSM 5. Patients with the BRCA gene mutations are at increased risk of developing breast and ovarian cancer as well as which of the other cancers listed below? a. Lung cancer b. Pancreatic cancer c. Basal cell carcinoma d. Lymphoma

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e. Glioblastoma 1. Answer: a. NSM is becoming more popular technique. The overall rate of occult nipple malignancy is 11.5%. Characteristics of the primary tumor that increase the risk for occult nipple malignancy include tumor-nipple distance 2, lymph node metastasis, lymphovascular invasion, human epidermal growth receptor-2-positive, estrogen receptor/progesterone receptor-negative, tumor size >5 cm, retroareolar/central location, and multicentric tumors. Reference: Mallon, P, Feron, JG, Couturaud, B, et al. The role of nipple-sparing mastectomy in breast cancer: a comprehensive review of the literature. Plast Reconstr Surg. 2013;131(5):969-984. 2. Answer: a. There is no difference in overall survival when comparing initiation of adjuvant chemotherapy within 4 weeks or within 8 weeks after surgery for patients who have estrogen receptor, progesterone receptor, or HER-2/neu-positive breast cancers. In patients with triple negative breast cancers, initiation of adjuvant chemotherapy within 4 weeks of surgery has been shown to improve overall survival. Reference: Gagliato, Dde M, Gonzalez-Angulo, AM, Lei, Xet al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol. 2014;32(8):735-744. 3. Answer: c. The updated American Cancer Society guidelines of 2015 recommend that women with an average risk of breast cancer should undergo regular screening mammography starting at the age of 45 years. Women between the ages of 45 and 54 years are recommended to have annual screening mammography while women at the age of 55 years and older are recommended to have biennial screening mammography. Screening mammography is recommended to continue for as long as the patient has a life expectancy of 10 years or longer. Reference: Oeffinger, KC, Fontham, ET, Etzioni, R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614. 4. Answer: d. In 2011, the American College of Surgeons Z0011 study was a prospective multicenter randomized trial that showed that for clinical T1–T2 invasive breast cancer patients with clinically negative lymph nodes that a SLNB with one to two positive SLNs was not inferior to a complete ALND for regional control of the axilla. Patients with clinically positive nodes at the time of diagnosis confirmed by FNA or core biopsy or patients who had no sentinel nodes identified (e.g., a failure of the sentinel lymph node mapping procedure) are recommended to have an ALND. Reference: Giuliano, AE, Hunt, KK, Ballman, KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569-575. 5. Answer: b. The BRCA1 and BRCA2 genes are autosomal dominant tumor suppressor genes that help to repair damaged DNA. BRCA 1 and 2 gene mutations account for 20% to 40% of the hereditary breast cancers. Women with the BRCA1 mutation have a 55% to 65% risk of developing breast cancer and a 39% chance of developing ovarian cancer by the age of 70 years. In contrast, women with the BRCA2 mutation have a slightly lower risk of 45% for developing breast cancer and 11% to 17% chance of developing ovarian cancer by the age of 70 years. In addition to breast and ovarian cancers, patients with the BRCA gene mutation are also at higher risk for fallopian tube, peritoneal, prostate, and pancreatic cancer. Reference: https://www.cancer.gov/about-cancer/causes-prevention/genetics/brca-fact-sheet.

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References Network NCC. NCCN Guidelines Version 3.2017 Breast Cancer. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed November 11, 2017. Surveillance E, and End Results Program. Cancer Stat Facts: Female Breast Cancer. https://seer.cancer.gov/statfacts/html/breast.html. Accessed November 11, 2017. Jagsi, R, Jiang, J, Momoh, AO, et al. Trends and variation in use of breast reconstruction in patients with breast cancer undergoing mastectomy in the United States. J Clin Oncol. 2014;32(9):919-926. Kwok, AC, Goodwin, IA, Ying, J, Agarwal, JP. National trends and complication rates after bilateral mastectomy and immediate breast reconstruction from 2005 to 2012. Am J Surg. 2015;210(3):512-516. Matsen, CB, Neumayer, LA. Breast cancer: a review for the general surgeon. JAMA Surgery. 2013;148(10):971-980. NIH NCI. BRCA1 and BRCA2: Cancer Risk and Genetic Testing; 2017. Frey, JD, Salibian, AA, Schnabel, FR, Choi, M, Karp, NS. Non-BRCA1/2 breast cancer susceptibility genes: a new frontier with clinical consequences for plastic surgeons. Plast Reconstr Surg Glob Open. 2017;5(11):e1564. Society AC. Lobular Carcinoma In Situ (LCIS); 2017. Society AC. Types of Breast Cancer; 2017. Oeffinger, KC, Fontham, ET, Etzioni, R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614. Cancer AJCo. Breast cancer. AJCC Cancer Staging Manual. 8th ed.; 2017. Teven, CM, Schmid, DB, Sisco, M, Ward, J, Howard, MA. Systemic therapy for early-stage breast cancer: what the plastic surgeon should know. Eplasty. 2017;17:e7. Society AC. Breast Cancer Survival Rates; 2017. Turnbull, L, Brown, S, Harvey, I, et al. Comparative effectiveness of MRI in breast cancer (COMICE) trial: a randomised controlled trial. Lancet. 2010;375(9714):563-571. Morris, EA. Should we dispense with preoperative breast MRI? Lancet. 2010;375(9714):528-530. Shin, H-C, Han, W, Moon, H-G, et al. Limited value and utility of breast MRI in patients undergoing breast-conserving cancer surgery. Ann Surg Oncol. 2012;19(8):2572-2579. Weber, JJ, Bellin, LS, Milbourn, DE, Verbanac, KM, Wong, JH. Selective preoperative magnetic resonance imaging in women with breast cancer: no reduction in the reoperation rate. Arch Surg. 2012;147(9):834-839. Kaufmann, M, Morrow, M, von Minckwitz, G, Harris, JR. Locoregional treatment of primary breast cancer. Cancer. 2010;116(5):1184-1191. Edwards, SB, Leitman, IM, Wengrofsky, AJ, et al. Identifying factors and techniques to decrease the positive margin rate in partial mastectomies: have we missed the mark? Breast J. 2016;22(3):303-309. Gradishar, WJ, Anderson, BO, Balassanian, R, et al. Invasive breast cancer version 1.2016, NCCN clinical practice guidelines in oncology. J Natl Compr Cancer Netw. 2016;14(3):324-354. Cil, TD, McCready, D. Modern approaches to the surgical management of malignant breast disease: the role of breast conservation, complete mastectomy, skin-and nipple-sparing mastectomy. Clin Plastic Surgery. 2018;45(1):1-11. González, EG, Rancati, AO. Skin-sparing mastectomy. Gland Surg. 2015;4(6):541. Bleicher, RJ, Ruth, K, Sigurdson, ER, et al. Time to surgery and breast cancer survival in the United States. JAMA Oncol. 2016;2(3):330-339. Sanford, RA, Lei, X, Barcenas, CH, et al. Impact of time from completion of neoadjuvant chemotherapy to surgery on survival outcomes in breast cancer patients. Ann Surg Oncol. 2016;23(5):1515-1521. Gagliato, Dde M, Gonzalez-Angulo, AM, Lei, X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol. 2014;32(8):735-744. Whelan, TJ. Use of conventional radiation therapy as part of breast-conserving treatment. J Clin Oncol. 2005;23(8):1718-1725. Buchholz, TA. Radiation therapy for early-stage breast cancer after breast-conserving surgery. New Engl J Med. 2009;360(1):63-70. Punglia, RS, Saito, AM, Neville, BA, Earle, CC, Weeks, JC. Impact of interval from breast conserving surgery to radiotherapy on local recurrence in older women with breast cancer: retrospective cohort analysis. BMJ. 2010;340:c845. Silva, SB, Pereira, AAL, Marta, GN, et al. Clinical impact of adjuvant radiation therapy delay after neoadjuvant chemotherapy in locally advanced breast cancer. Breast. 2018;38:39-44. Rao, R, Euhus, D, Mayo, HG, Balch, C. Axillary node interventions in breast cancer: a systematic review. JAMA. 2013;310(13):1385-1394. Madsen, AH, Haugaard, K, Soerensen, J, et al. Arm morbidity following sentinel lymph node biopsy or axillary lymph node dissection: a study from the Danish Breast Cancer Cooperative Group. Breast. 2008;17(2):138-147. Ozmen, T, Vinyard, AH, Avisar, E. Management of the positive axilla in 2017. Cureus. 2017;9(5). Giuliano, AE, Hunt, KK, Ballman, KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569-575. Burstein, HJ, Temin, S, Anderson, H, et al. Adjuvant endocrine therapy for women with hormone receptor–positive breast cancer: American Society of Clinical Oncology Clinical Practice Guideline focused update. J Clin Oncol. 2014;32(21):2255-2269. Shagufta, Ahmad, I. Tamoxifen a pioneering drug: an update on the therapeutic potential of tamoxifen derivatives. Eur J Med Chem.

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2018;143:515-531. Cuzick, J, Forbes, JF, Sestak, I, et al. Long-term results of tamoxifen prophylaxis for breast cancer—96-month follow-up of the randomized IBIS-I trial. J Natl Cancer Inst. 2007;99(4):272-282.

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Key References Network NCC. NCCN Guidelines Version 3.2017 Breast Cancer. https://www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Accessed November 11, 2017.These are peer reviewed national guidelines for the work-up and treatment of breast cancer. Matsen, CB, Neumayer, LA. Breast cancer: a review for the general surgeon. JAMA Surg. 2013;148(10):971-980.This is a concise review of screening, work-up, and treatment of breast cancer with a focus on pertinent information for a surgeon. Oeffinger, KC, Fontham, ET, Etzioni, R, et al. Breast cancer screening for women at average risk: 2015 guideline update from the American Cancer Society. JAMA. 2015;314(15):1599-1614.These paper outlines the most recent American Cancer Society guidelines for breast cancer screen for women at average risk. Gagliato, Dde M, Gonzalez-Angulo, AM, Lei, X, et al. Clinical impact of delaying initiation of adjuvant chemotherapy in patients with breast cancer. J Clin Oncol. 2014;32(8):735-744.This paper examines the risks of delaying adjuvant chemotherapy. Giuliano, AE, Hunt, KK, Ballman, KV, et al. Axillary dissection vs no axillary dissection in women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial. JAMA. 2011;305(6):569-575.This is also known as the American College of Surgeons Z0011 study. The results of this paper set the standard for how surgeons decide on whether or not to perform an ALND.

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CHAPTER 59

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Breast Reconstruction: Prosthetic Techniques Peter W. Thompson and Grant W. Carlson

Key Points Implant-based reconstruction is the most common method of breast reconstruction employed by plastic surgeons. Advantages of implant-based reconstruction include decreased operative time, no donor site morbidity, and faster patient recovery. Disadvantages include implant-related complications such as infection, capsular contracture, and implant malposition. Prosthetic reconstruction may be performed in an immediate or delayed fashion, in one or two stages. Healthy patients with smaller breasts, early stage breast cancer, and healthy mastectomy skin flaps are the best candidates for immediate and single-stage reconstruction. Acellular dermal matrix in implant-based reconstruction is a useful adjunct to provide total implant coverage while defining and maintaining implant position. Adjuvant radiation therapy significantly increases the rate of complications and reconstructive failure following implant-based reconstruction while decreasing patient-
 reported aesthetic outcomes and quality-of-life measures. Acute complications such as hematoma, infection, and mastectomy skin flap necrosis must be treated quickly and aggressively to avoid implant loss and suboptimal aesthetic outcome. The primary technical goal of breast reconstruction is to recreate a breast mound in the postmastectomy patient. Prosthetic breast reconstruction techniques use tissue expanders and breast implants to accomplish this goal. In 2002, breast reconstruction using prosthetic techniques became the most popular method of immediate breast reconstruction, outpacing autologous methods. According to a survey of the Nationwide Inpatient Sample database, the rate of immediate prosthetic breast reconstructions increased by 11% per year over a period of time from 1998 to 2008, whereas the rate of autologous reconstruction remained stable. 1 The reasons for this trend are likely multifactorial, including the increased prevalence of contralateral prophylactic mastectomy, a favorable operative morbidity profile for prosthetic reconstruction, and changes in patterns of reimbursement for breast reconstruction procedures. 2 In 2016, 81% of breast reconstructive procedures used prosthetic techniques. 3 Prosthetic breast reconstruction techniques, also called implant-based reconstructions, hold certain widely accepted advantages over autologous methods (Table 59.1). First, prosthetic techniques minimize operative and donor site morbidity. The time required to perform placement of an implant or tissue expander is significantly shorter (around 1–1.5 hours) than that required for an autologous flap, which can extend beyond 6 hours of operative time. No dissection of donor site tissue, tunneling into the mastectomy defect or dissection of recipient vessels, is necessary with prosthetic techniques. Prosthetic techniques preserve autologous methods of reconstruction as options for future procedures, should patient preference or necessity determine the need for conversion. Hospital length of stay and patient recovery are generally shorter with prosthetic techniques compared to autologous reconstruction. TABLE 59.1 Advantages and Disadvantages of Implant-Based Reconstruction

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Advantages Shorter operative time Shorter hospital stay Shorter recovery No donor tissue or recipient vessel dissection necessary Disadvantages Implant-related complications (implant infection, capsular contracture, implant malposition, rippling, rupture) Less natural feel compared to autologous tissue Difficult to achieve symmetry in unilateral reconstruction

Prosthetic reconstruction techniques also have several disadvantages compared to autologous methods (see Table 59.1). First, it can be more difficult to match the appearance of an implant reconstruction to a contralateral native breast in the setting of unilateral reconstruction, making symmetry harder to achieve. Second, breast implants and tissue expanders can experience device-related complications including implant infection or exposure, capsular contracture, implant malposition, implant visibility or rippling, and implant rupture. Third, an implant does not behave like normal breast tissue or autologous tissue in look, feel, and development of ptosis over time. For properly selected patients undergoing breast reconstruction, prosthetic techniques have the potential to create an attractive breast mound that can help improve a patient’s psychosocial, physical, and sexual well-being following mastectomy. 4 In this chapter, we highlight some of the different viewpoints concerning timing, technique, and patient selection for implant-based reconstruction.

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Patient Selection for Prosthetic Techniques Successful prosthetic breast reconstruction begins with proper patient selection. Careful attention to patient and oncologic factors in the planning stages of breast reconstruction will ensure an optimal aesthetic outcome with an acceptable complication profile. Risk factors for complications in implant reconstruction include the following: Smoking Obesity (BMI >30) Large breasts Diabetes (Hgb A1C >6.5%) The patient selection process begins with a thorough discussion of patient expectations. One important consideration is the desired postoperative breast volume. Maintaining premastectomy breast volume after reconstruction in a patient with macromastia may be difficult or impossible using prosthetic reconstruction techniques if an appropriately sized implant is not available; in addition, large mastectomy specimen weight was found to be an independent risk factor for implant loss in prosthetic reconstruction. 5 Certain patient comorbidities make the rate of complications following prosthetic reconstruction unacceptably high. It is accepted that smokers have an increased rate of overall complications, tissue necrosis, and need for reoperation in general following plastic surgical procedures 6 ; there is also ample evidence that smoking increases the rate of complications specifically following prosthetic breast reconstruction. An analysis of ACS-NSQIP data demonstrated that active smokers have an odds ratio of four for early tissue expander loss compared to nonsmokers. 7 Two studies from the Memorial SloanKettering Cancer Center demonstrated that smoking more doubles the rate of mastectomy skin flap necrosis, infection, and reconstructive failure in patients undergoing implant-based reconstruction (Figure 59.1). 8,9 The authors also demonstrated a dose-
 response effect for tobacco use, with the incidence of complications increasing with the number of packs per day smoked. 8 Interestingly, although some surgeons recommend smoking cessation for at least a month prior to surgery, there is some evidence that the rate of complications in former smokers, those who stopped smoking 1 month or more before surgery, is similar to the rate of complications in active smokers. 8,9 Patients should be thoroughly educated about the detrimental effects of tobacco, and if active smoking continues, serious consideration should be given to delaying reconstruction.

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FIGURE 59.1 Mastectomy skin flap necrosis. Partial-thickness (A) and full-thickness (B) mastectomy skin flap necrosis following implant-based reconstruction in patients with history of smoking.

Diabetes has been associated with an increased risk of wound healing complications in a variety of surgical procedures, and breast reconstruction is no exception. NSQIP database analysis suggests that diabetes increases the overall 30-day complication rate and the rate of wound healing complications in expander/implant-based reconstruction. 10 In addition, data from Hart et al. suggest that even wellcontrolled diabetes (average preoperative blood glucose 137 mg/dL) increases the 1-year rate of wound healing problems following prosthetic but not autologous reconstruction. 11 In patients with poorly controlled diabetes, referral to diabetic educators and endocrine specialists may be appropriate before consideration of reconstruction. A team-based approach to perioperative glucose management should be undertaken with the goal of preoperative Hgb A1C 30. 13 Similarly, McCarthy et al. demonstrated that patients with BMI >30 were almost seven times more likely to experience reconstructive failure following prosthetic reconstruction than their nonobese counterparts. 9 In addition, device projection may be severely limited in patients with overly thick mastectomy flaps; therefore, obese patients should be counseled that preoperative weight loss will not only decrease their risk of postoperative complications, but also potentially improve the appearance of the final result. Successful patient selection for prosthetic breast reconstruction must also consider oncologic factors. Close communication with the ablative surgeon is extremely important during the planning phase of breast reconstruction to avoid complications and optimize outcomes. The size of the tumor and lymph node status are crucial pieces of information for the reconstructive surgeon; clinical staging helps determine the likely need for adjuvant radiotherapy, which can greatly affect complication rates following implant-based reconstruction. Other important factors to discuss with the ablative surgeon that may influence the choice to pursue implant-based reconstruction include the plan for unilateral versus bilateral mastectomy, and whether a nipple-sparing mastectomy approach is appropriate. A thorough physical exam can help determine if a patient is an appropriate candidate for prosthetic reconstruction. The preoperative breast size must be taken into account; macromastia is not a contraindication to implant-based reconstruction, but does require attention to tailoring of the skin

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envelope, such as with skin-reducing mastectomy methods (Figure 59.2). 14 Examination of potential donor sites is important, as a lack of adequate tissue or volume will immediately disqualify patients from undergoing reconstruction with autologous techniques.

FIGURE 59.2 Skin-reducing mastectomy. Preoperative (A) and postoperative (B) views following skin-reducing mastectomy with implant reconstruction and nipple-areola reconstruction.

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Timing of Prosthetic Reconstruction The plastic surgeon undertaking an implant-based breast reconstruction must decide whether to perform the reconstruction in an immediate fashion (at the time of mastectomy) or delayed fashion (as a staged procedure following recovery from mastectomy and/or adjuvant therapy). Each approach has distinct advantages and disadvantages (Table 59.2). Immediate breast reconstruction, by preserving the original skin envelope and native breast borders, has been purported to optimize aesthetic outcomes and patient satisfaction, 15 while minimizing the negative psychological impact of mastectomy on a patient’s selfimage. 16 In addition, immediate reconstruction potentially minimizes the number of trips to the operating room and recovery downtime. Proponents of delayed prosthetic reconstruction have argued that this approach results in a lower rate of complications including mastectomy skin flap necrosis, capsular contracture, and need for device removal. 17,18 The decision to perform a prosthetic reconstruction in an immediate or delayed fashion should be based on patient factors, oncologic factors, and technical aspects of the mastectomy itself. In general, immediate reconstruction will achieve optimal results in patients with a lower preoperative risk profile (nonsmoker, nonobese) and early stage cancers. Delayed reconstruction is more appropriate in patients with advanced stage cancers in whom close tumor surveillance is needed or adjuvant therapy is likely; in addition, if there is concern about the viability of the mastectomy skin flaps and adequate tissue for device coverage at the time of mastectomy, an intraoperative decision to delay reconstruction may be appropriate (Figure 59.3). 19 TABLE 59.2 Advantages of Immediate and Delayed Prosthetic Reconstruction Immediate Preserves native skin envelope and breast borders Minimizes trips to the operating room Improved psychological and emotional outcome Delayed Decreased risk of complications in setting of patient comorbidities or need for adjuvant radiation Decreased risk of mastectomy skin flap necrosis

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FIGURE 59.3 Delayed placement of tissue expander in breast reconstruction. A. Preoperative view following bilateral mastectomy. B. Following delayed placement of tissue expander and inflation. C. Following exchange for permanent implant and nipple-areola reconstruction.

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Technical Considerations in Implant-Based Reconstruction Single- Versus Two-Stage Reconstruction As previously mentioned, prosthetic breast reconstruction may be completed with either a two-stage (placement of tissue expander followed by exchange for permanent implant) or single-stage (direct placement of permanent implant after mastectomy) approach. A direct-to-implant approach has the obvious advantage of eliminating (1) multiple office visits for device expansion, (2) risk of infection related to expander filling access and manipulation, and (3) second-stage surgery for expander-to-implant exchange. Single-stage implant breast reconstruction can achieve excellent outcomes with acceptable revision rates in properly selected patients, but is technically demanding, requiring precise implant selection and positioning following an often unpredictable extirpative procedure. A quality mastectomy is a major determinant of the success of direct-to-implant reconstruction; a skin-sparing or nipple-sparing mastectomy with appropriate skin flap thickness and viability that preserves the inframammary fold will help avoid the complications of implant malposition, skin flap necrosis and device exposure. Adjuncts such as indocyanine green angiography can provide an objective assessment of skin flap perfusion, and acellular dermal matrix (discussed later) is a useful tool for providing total implant coverage and securing implant position. Patient comorbidities such as diabetes and smoking, need for adjuvant radiation, and increasing premastectomy breast size have all been found to be risk factors for postoperative complications following single-stage reconstruction. 20,21 Few individual studies have demonstrated any significant difference in complication rates between single- and two-stage prosthetic reconstruction; however, in a recent systematic review and head-to-head meta-analysis, Basta et al. found a significantly increased risk of skin flap necrosis, need for reoperation, and reconstructive failure in patients undergoing direct-to-implant reconstruction (OR 1.43, 1.25, and 1.87, respectively). The overall absolute rate of implant loss was 14.4% for single- and 8.7% for two-stage reconstruction. 22

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Acellular Dermal Matrix Acellular dermal matrix (ADM) exists in various forms as human or animal cadaveric, decellularized dermis. It is useful as an adjunct to prosthetic breast reconstruction for its ability to better define the mastectomy space and provide support to soft tissues, essentially acting as a hammock to stabilize the implant or expander device. When used in single- or two-stage reconstruction, ADM can help maintain the device in the optimal position on the chest wall, add definition to the inframammary fold and lateral breast border, and improve lower pole projection (Figure 59.4). In several studies, these advantages have translated into improved aesthetic outcomes as determined by independent observer subjective review, 23 compared to prosthetic reconstruction without ADM or even compared to total submuscular coverage. 24 In the setting of two-stage prosthetic reconstruction, the use of ADM was associated with a higher intraoperative fill volume and shorter time to optimal expansion. 25 There are data suggesting that ADM is useful in both the primary prevention and secondary treatment of capsular contracture. Compared to an expected 5-year capsular contracture rate of between 10% and 30%, multiple series in the recent literature have demonstrated a much lower rate (between 0% and 4%) when ADM is used as an adjunct to prosthetic reconstruction. 23,26,27 Several of the patients in these studies had breast irradiation before or after surgery, suggesting that the use of ADM may ameliorate some of the negative sequelae associated with radiation treatment. These benefits may come at the expense of a higher complication rate; multiple retrospective reviews have demonstrated a higher incidence of acute postoperative complications including infection, seroma, skin flap necrosis, and reconstructive failure in prosthetic reconstructions employing ADM. 28-30 The strength of this data is diminished by selection bias and confounders such as morbid obesity, which is also known to contribute to higher seroma rates. Taken together, most surgeons feel that, in properly selected patients (i.e., normal BMI, nonsmokers), the benefits of ADM use likely outweigh the potential drawbacks.

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FIGURE 59.4 Submuscular placement of tissue expander with acellular dermal matrix for lower pole support and coverage.

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Implant Selection Choice of device is an important component of planning both expander-based and direct-to-implant reconstruction. There are many options for size, shape, and texture of both expanders and permanent implants. There is a more limited range of options in choice of tissue expanders. Most commercially available tissue expanders designed for use in breast reconstruction use a textured surface, a relative anatomic shape for differential filling of the lower pole, and a magnetic port for filling with saline. Expanders are available in different height, projection, capacity, and base width. Among these, base width is the most important parameter for intraoperative device selection; matching the device base width to the width of the breast footprint on the chest wall eliminates dead space and skin redundancy while optimizing the final expansion pocket. Expander capacity is less important, as many expander devices may be filled well beyond their stated maximum volumes. 31 Permanent implants are available in an ever-increasing variety of sizes, shapes, textures, fills, and cohesivity. In general, there are several decisions that must be made when selecting a permanent implant. Most available data directly comparing different types of implant exist in the breast augmentation literature, and must be extrapolated to breast reconstruction.

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Saline Versus Silicone Both saline and silicone have distinct advantages and disadvantages from both the patient and surgeon perspective. It is easier to detect a saline implant rupture. Saline implants require a less rigorous surveillance protocol, but likely have higher rates of implant visibility and rippling. Silicone implants more closely resemble the look and feel of the native breast tissue, but silicone leak or implant rupture may be harder to detect and can lead to capsular contracture; in contrast, saline is physiologically inert and is simply absorbed if there is a leak. Available data suggest that rates of rupture and capsular contracture may be slightly higher in silicone implants than in saline at 10 years following implantation. 32-34 There is also some evidence that patients have improved overall satisfaction as well as self-assessed psychological and sexual function after receiving silicone versus saline implants in breast reconstruction. 35 There is no evidence to support the idea that patients with silicone implants are more likely to develop rare neurologic or connective tissue diseases. 36

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Smooth Versus Textured Textured implants were developed in an attempt to reproduce lower rates of capsular contracture obtained historically with placement of polyurethane-coated devices. In general, rates of capsular contracture do appear to be lower with textured devices, though this difference appears less significant when implants are placed in the submuscular position. 37,38 Again, these data are extrapolated from literature specific to breast augmentation. Another benefit of textured implants includes a more stable position within the pocket, which theoretically decreases lower pole stretch over time. There appears to be a small increase in risk of breast-implant-associated anaplastic large-cell lymphoma (BIA-ALCL) with use of textured devices. This effect may be greatest with macrotextured implants. The overall incidence of this complication is still low (∼1/30,000), but discussion of BIA-ALCL is an important part of the informed consent process. 39

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Round Versus Anatomic Anatomic-shaped implants have been in use for several years and are preferred by some plastic surgeons in breast reconstruction for their ability to better match the device to the original breast footprint following mastectomy. Shaped implants may result in improved upper pole shape and volume, especially in reconstruction of breasts that are taller than they are wide. Placing an anatomic implant is more technically challenging, because without precise pocket control, implant rotation may result. Patients may also report a somewhat firmer feel compared to a softer, round silicone implant. In practice, there has been little detectable difference in patient satisfaction, aesthetic outcome, or complication rates between shaped and round implants in breast reconstruction. Interestingly, blinded expert observers in one study were not routinely able to differentiate which type of implant a patient had received. 40 All currently available anatomic-shaped implants are also textured to limit unwanted implant movement/rotation; therefore, all of the risks and benefits of textured devices also apply to shaped devices.

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Standard Technique for Submuscular, Two-Stage Implant-Based Reconstruction With Acellular Dermal Matrix Procedure begins with assessment of mastectomy cavity, including evaluation of mastectomy skin flap thickness/regularity, hemostasis, and preservation of native breast footprint (i.e., violation of inframammary fold). The breast base width may be measured, and expander size selection is made. Note is made of the mastectomy specimen weight. Indocyanine green angiography may be performed as an adjunct to evaluate mastectomy skin flap viability. If viability or skin quality is a concern, placement of a device is relatively contraindicated and may be deferred to a later time. If native breast borders have been violated, recreation of these natural landmarks such as the lateral breast border and inframammary fold may be accomplished with placement of absorbable sutures. The lateral border of the pectoralis muscle is identified and raised; the submuscular plane is defined superiorly and medially to the sternal origin of the muscle. A lighted retractor or headlamp, long cautery tip, and muscle paralysis help with this step. After the submuscular plane is developed, the inferior origins of the pectoralis muscle along the inframammary fold are divided and released to the level of the sternum. Additional muscle origin along the most inferior portions of the sternum may be divided further if increased lower pole projection is needed or desired. Care is taken to maintain perfect hemostasis when large intercostal and internal mammary artery perforators are encountered. A rectangular or contoured piece of ADM is brought onto the field. Usually, a piece 8 × 16 cm in size is more than sufficient. The ADM is anchored medially at the junction of the muscle and chest wall, and then anchored with interrupted absorbable sutures to the thick fascial attachments of the inframammary fold. Laterally, the ADM is sutured to the chest wall to reapproximate the lateral breast border. Excess ADM is trimmed away, leaving a curvilinear sling along the lower and lateral aspects of the mastectomy cavity. At this point, the cavity is irrigated with antibiotic solution and hemostasis confirmed once again in both the subcutaneous and submuscular space. The previously selected tissue expander is brought onto the field and all air removed from the device. The expander is then inserted into the submuscular space and anchored medially and laterally to the chest wall using the suture tabs on the device (if available). The inferior border of the pectoralis muscle is sutured to the superior border of the ADM sling to prevent window-shading of the muscle. Excess ADM is removed to set the appropriate muscle tension. The device should now be completely covered by the combination of muscle in the upper pole and ADM in the lower pole. Drains are placed in the subcutaneous space and brought out below the lateral aspect of the inframammary fold. One or two drains may be used depending on the amount of dead space. The tissue expander port may now be accessed and the expander filled as desired. After filling the expander, the mastectomy incision may be tailor tacked and a final indocyanine green perfusion assessment performed. If there is a worsening in the appearance of the flaps with the expander in place, volume may be removed from the device, as appropriate, to take pressure off of the skin flaps. The mastectomy incision is meticulously closed in two layers with absorbable monofilament suture. A surgical dressing is applied and the patient is placed in a surgical bra or chest binder. Overnight admission for pain control is standard at our institution.

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Implant-Based Reconstruction in the Setting of Adjuvant Therapy The need for adjuvant or neoadjuvant therapy can complicate the decision to employ prosthetic techniques in breast reconstruction, negatively impacting the ability of the reconstructive surgeon to create an aesthetic and natural appearing breast mound (Figure 59.5). Radiation of a prosthetic device can lead to increased rates of early complications such as infection, seroma, and mastectomy flap necrosis, as well as delayed complications such as capsular contracture, poor aesthetic outcome, and reconstructive failure. The odds ratio of developing any complication following radiation of an implant-based reconstruction is approximately 4.2 compared to no radiation, 41 and the rate of reconstructive failure is generally accepted to be around 20% compared to 3% in those not receiving adjuvant radiotherapy. 42 Compared to radiation of an autologous reconstruction, patients undergoing postmastectomy radiation therapy following implant reconstruction have been shown to have higher rates of overall complications and significantly lower patient-reported quality-of-life scores as determined by the BREAST-Q. 43 However, patient desire for implant-based reconstruction, a shortage of autologous options, or unplanned need for adjuvant therapy may still result in the need to radiate a prosthetic reconstruction. Considerable effort has been devoted to determining the optimal timing and protocol for radiation therapy to minimize complication rate while maximizing aesthetic outcome and patient quality of life.

FIGURE 59.5 Effect of radiation on appearance of reconstructed breast. Preradiation (A) and postradiation (B) views of implant reconstruction, demonstrating skin color change, contraction of skin envelope, and nipple-areola malposition.

When breast reconstruction is undertaken in the setting of adjuvant radiation therapy, the plastic surgeon’s goal of creating an aesthetic, symmetric, and natural appearing breast mound must not overshadow the oncologic goals of local and systemic eradication of breast cancer cells. Further complicating reconstructive planning, the indications for radiotherapy in breast cancer appear to be expanding. In general, postmastectomy radiation is considered in any clinical scenario with an elevated risk of locoregional recurrence. The indications for radiation therapy as outlined by the National Comprehensive Cancer Network (NCCN) are as follows 44 : Radiation indicated Following breast conservation therapy

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Inflammatory breast cancer (may also be considered as neoadjuvant therapy) Any T4 tumor Four or more positive axillary lymph nodes Local or regional recurrence (if radiation not previously administered) Radiation should be strongly considered Tumor >5 cm Between one and three positive axillary lymph nodes Positive margins Radiation may be considered Close margins (2 cm in young patient or with pathologic extensive lymphovascular invasion)

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Timing of Adjuvant Radiation Therapy Following two-stage prosthetic reconstruction (placement of a tissue expander followed by second-stage replacement with a permanent implant), the treatment team must decide whether to administer radiation before or after exchange of the expander for a permanent implant. Multiple studies have addressed the question of timing, comparing outcomes in patients who have received radiation to the expander versus radiation to the permanent implant. Some studies have found an increased rate of reconstructive failure (complication necessitating device removal) when the permanent implant undergoes radiation, 45,46 but others have found no significant difference in the rate of any complication including reconstructive failure. 47 In a 2015 study by Cordeiro et al., radiation of the permanent implant was associated with a higher rate of capsular contracture and subsequently worse aesthetic outcomes. 46 In this same study, however, patient-reported quality-of-life measures were no different between radiation of the expander versus the permanent implant. In the setting of radiation of the tissue expander, increasing the interval of time between completion of radiation and exchange to permanent implant appears to improve outcomes, with intervals ranging from 3 to 8 months. 48,49

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Technical Aspects of Radiation Delivery Other factors that may influence prosthetic reconstructive outcome include the dose and fractionation of radiation delivery, as well as whether treatment is delivered to a fully expanded, partially expanded or fully deflated tissue expander. A full discussion of the data supporting different radiation doses, targets, and delivery methods is beyond the scope of this chapter, except to say that there is significant variability in practice patterns in both the United States and abroad. 50 It is possible that these factors may affect reconstruction success and complication rates in a given practice, and it is important to be familiar with the protocol used in a given institution when evaluating published results. With regard to radiation of tissue expanders, some controversy exists regarding the optimal inflation status at the time of radiation delivery. Some authors argue that attempting to radiate a fully or even partially inflated expander may result in alteration of the dose delivered to the chest wall and internal mammary nodes, and that complete deflation of the expander followed by reexpansion at completion of radiation is preferable. 51 However, with modern techniques and modeling, more recent data seem to suggest that radiation of even a fully inflated expander or permanent implant is safe, does not result in decreased radiation dose administration, and may result in a lower rate of complications compared to radiation of a deflated device. 52 Again, the importance of a team approach is emphasized; detailed discussion and close coordination of care between the plastic surgeon, breast surgeon, and radiation oncologist will help to optimize the patient experience and reconstructive outcome.

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Implant Reconstruction in the Setting of Previous Radiation Treatment Another common clinical scenario is the patient who requires salvage mastectomy following previous breast conservation therapy with local recurrence. In these patients, reported complication rates in patients undergoing breast reconstruction with prosthetic techniques vary widely. One systematic review reported the rate of major complications associated with prosthetic reconstructions of previously irradiated breasts at 49%. 53 The rates of early complications such as infection, seroma, and mastectomy skin flap necrosis are significantly higher in previously radiated patients undergoing prosthetic reconstruction compared to nonirradiated patients. 53-56 In addition, late complications such as capsular contracture and reconstructive failure appear to be two to three times more likely in previously irradiated patients. 57 The well-known chronic tissue effects of radiation such as fibrosis and decreased vascularity are likely to blame for the increased complication rate; the soft tissue envelope of the breast simply does not respond as well to stress or expansion following radiation. Compared to postmastectomy radiation, prosthetic reconstruction of the previously irradiated breast appears to have a similar or slightly worse risk profile. 53,56 Sbitany et al. demonstrated that compared to patients who underwent preoperative radiation, patients with postmastectomy radiation exposure had lower rates of wound breakdown and infections requiring procedures for resolution. 56 Despite the complication rate, in their systematic review, Momoh et al. conclude that the rate of successful completion of prosthetic reconstruction in previously irradiated breasts was 83%. 53 This supports the conclusions of multiple authors that despite a higher rate of complications, prosthetic reconstruction can be effectively accomplished in the previously irradiated breast. 54-56 Attempts to maximize the safety of this approach include a careful clinical assessment of the skin for discoloration, quality and elasticity, as well as the location of previous scars, which may necessitate removal of prohibitive amounts of skin. Interestingly, the use of ADM in previously irradiated patients is not protective against reconstructive failure and may increase the rate of skin flap and infectious complications, perhaps due to its inability to incorporate into a poorly vascularized, irradiated mastectomy flap. 56 Although increasing the time interval between previous irradiation and salvage mastectomy beyond 1 year does not appear to improve the rate of complications, performing the reconstruction in a delayed rather than immediate fashion may result in a lower rate of reconstructive failure. 57 All things considered, undertaking a prosthetic reconstruction in a previously irradiated breast can be done effectively and with acceptable aesthetic outcomes. Patient education should include a frank discussion of the possible postoperative course and a realistic appraisal of expectations. Reconstructive failure and need for conversion to an autologous reconstruction is a realistic potential outcome.

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Effect of Systemic Therapy on Prosthetic Reconstruction Neoadjuvant or adjuvant systemic therapies used in the treatment of breast cancer include chemotherapeutic regimens and hormonal therapies. Chemotherapeutics have varying degrees of myelosuppressive potential, resulting in thrombocytopenia, anemia, and neutropenia. These adverse effects raised concerns about the safety of breast reconstruction in patients receiving chemotherapy either before or after expander or implant placement. Several experimental studies demonstrated an increased rate of wound healing complications in animals receiving specific chemotherapeutic agents, 58,59 however similar results in clinical trials have not been reliably reproduced. On the balance, there is no clear evidence that either neoadjuvant or adjuvant chemotherapy increases complication rates in patients undergoing prosthetic reconstruction, 60-62 but these studies varied in the timing, dose, and regimen of chemotherapy administered. Similarly, there is no evidence that hormonal therapies such as tamoxifen or aromatase inhibitors increase complication rates in prosthetic reconstructions. 63 Many patients who require adjuvant systemic therapy for advanced stage breast cancer will also require radiation therapy; as expected, patients who receive both chemotherapy and radiation also experience radiation-related complication profiles.

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Complications in Implant-Based Reconstruction Hematoma Hematoma is estimated to occur in 2% to 3% of implant-based reconstructions. 23 Acute hematoma is most likely to occur in the first 24 to 48 hours after surgery, and the telltale swelling and ecchymosis are often clinically obvious (Figure 59.6). Surgical drains are not useful for evacuation of blood clots; most hematomas require return to the operating room for evacuation, though finding a single bleeding source at the time of reexploration is rare. Left untreated, even small hematomas can increase the risk of mastectomy skin flap necrosis, capsular contracture, and poor aesthetic outcome.

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FIGURE 59.6 Acute hematoma following nipple-sparing mastectomy.

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Infection The overall rate of infection following implant-based reconstruction was estimated at 7.6% in a recent meta-analysis. 64 Surgical site infections present in a spectrum of severity, from cellulitis involving the incision to frank abscess in the implant pocket with whole breast erythema, swelling and purulent output from the incision and drain (Figure 59.7). Minimal cellulitis may often be managed with empiric outpatient antibiotic therapy, whereas pocket infections often require admission for IV antibiotics, surgical exploration, and implant removal. Implant salvage may be considered in properly selected cases; a recent retrospective review by Reish et al. identified elevated white blood cell count at admission and methicillin-resistant S. aureus (MRSA) infection as predictors of salvage failure. 65 Gram-positive bacteria such as Staphylococcus, Streptococcus, and Propionibacteria are the most common pathogenic organisms in implant-associated infection. 66

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FIGURE 59.7 Infection following implant-based reconstruction. Incisional erythema (A) and whole breast erythema (B) with purulent drain output approximately 3 to 4 weeks following mastectomy and placement of tissue expander.

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Capsular Contracture Capsular contracture is a pathologic process thought to result from chronic inflammation of the periprosthetic capsule, resulting in thickening of the capsule and tightening around the implant (Figure 59.8). The Baker Scale is used to grade severity of capsular contracture: grade 1 is a normal, soft breast; grade 2 is a minimally firm breast; grade 3 capsular contracture results in a visible distortion of the breast, and grade 4 capsular contracture causes a painful breast with severe distortion. Rates of capsular contracture following implant-based reconstruction at 3 years are estimated at between 10% and 13% in core studies from Mentor and Allergan. Hematoma, radiation, silicone rupture, and biofilm formation are all considered to increase the incidence of capsular contracture. Techniques for prevention of capsular contracture attempt to target these risk factors (meticulous sterile technique, hemostasis, and pocket irrigation), but an evidence-based approach to treatment of capsular contracture is lacking. A good summary of the current evidence for capsular contracture management was published by Wan and Rohrich; in general, effective surgical techniques require capsulectomy, implant exchange, change of implant position, and use of ADM. 67

FIGURE 59.8 Severe capsular contracture several years following implant-based reconstruction resulting in pain and implant malposition.

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Implant Malposition or Asymmetry Breast symmetry can be difficult to achieve, particularly in patients with significant premorbid breast asymmetry with respect to both breast size and shape. It is important to point out to the patient any notable asymmetries preoperatively because these may become more apparent after reconstruction. In unilateral reconstruction, contralateral procedures such as breast reduction or mastopexy may be needed to achieve better symmetry. It is important to discuss the likelihood of needing secondary procedures to achieve the best overall result. Implant malposition is a common complication that may result from overdissection of the mastectomy pocket, expansion in an inappropriate vector, poor implant choice, or capsular contracture. Attention to maintaining or recreating the native breast landmarks at the first stage of reconstruction, in particular the inframammary fold and lateral breast border, can help prevent this complication. At the second stage of reconstruction, capsulorrhaphy may be needed to reestablish the optimal implant pocket.

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Postoperative Care Drains Drains are considered a standard though inconvenient part of implant-based reconstruction. Practice patterns vary considerably, but in our practice one or two closed-suction drains are left in the subcutaneous space until output is less than 30 cc over a 24-hour period. Typical drain duration is 1 to 2 weeks. Persistent high output from a drain can sometimes be improved by partially inflating the tissue expander to decrease the amount of dead space.

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Antibiotics The data supporting antibiotic use in implant-based reconstruction are mixed, and practice patterns vary significantly. Whereas some surgeons treat patients with a preoperative dose of antibiotics only, others prefer to treat with oral outpatient therapy until surgical drains are removed. A recent review by Phillips and Halvorson noted that although data seem to support preoperative antibiotic dosing in decreasing the risk of infectious complications, there was insufficient evidence to recommend continuing antibiotics on an outpatient basis. 68

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Questions 1. A 44-year-old woman undergoes immediate right breast reconstruction with placement of a tissue expander in the partial submuscular position. ADM is used to cover the lower pole of the device. Which of the following is not a potential advantage of ADM use in this patient? a. Maintains optimal implant position on the chest wall b. Reduced risk of seroma and implant infection c. Reduced rate of capsular contracture d. Improved definition of inframammary fold and lateral breast border e. Improved aesthetic outcome 2. A 30-year-old fitness instructor comes to clinic to discuss prosthetic breast reconstruction. She would like to know if she is a candidate for single-stage direct-to-implant reconstruction. Which of the following patient characteristics is not a contraindication to single-stage prosthetic reconstruction? a. BMI >30 b. Active smoker c. Thin mastectomy skin flaps d. B-cup breasts prior to mastectomy e. Desire for larger postreconstruction breast size 3. A 38-year-old woman with large breasts comes to clinic to discuss reconstruction after planned mastectomy for a newly diagnosed right breast cancer. Which of the following is not considered an advantage of implant-based reconstructions over autologous reconstruction methods? a. Shorter operative time b. Easier to achieve symmetry with contralateral breast c. Greater long-term patient satisfaction d. Improved control over final reconstructed breast volume e. Both b and c 4. A 45-year-old woman who underwent bilateral breast reconstruction with tissue expanders 3 weeks prior 
 comes to clinic with a warm, swollen, red right breast. Her drain output is cloudy. She has a low-grade temperature. Her WBC is 13. She is admitted for IV antibiotic therapy and attempted implant salvage. Which of the following clinical findings is most predictive of failure of implant salvage? a. Diffuse breast erythema b. Purulent drain output c. Temperature greater than 38.6 d. WBC greater than 13 e. Wound cultures growing methicillin-sensitive staphylococcus. 1. Answer: b. ADM has become a useful adjunct in implant-based breast reconstruction as a reliable method to maintain the implant pocket, specifically by reconstituting the inframammary fold and lateral breast border, thereby maintaining the device in the optimal position on the chest wall. This has been shown in some studies to translate into improved aesthetic results as graded by both surgeon and patient. Evidence from multiple studies demonstrated decreased risk of capsular contracture when ADM is used at the time of reconstruction. Despite this positive effect, several retrospective reviews have demonstrated an increased risk of other complications including seroma and infection with ADM. A recent meta-analysis of ADM use demonstrated no clear increase in incidence of seroma or infection when ADM was used, but there is no evidence that ADM results in a lower incidence of these complications. 2

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2. Answer: d. When considering single-stage implant-based reconstruction following mastectomy, patient selection is key. There are added technical considerations when direct placement of permanent implant is performed that must be considered to obtain the best possible outcome. None of these appears more important than the overall quality and viability of the mastectomy skin flaps. Flaps that are overly thin or that exhibit poor bleeding are more prone to skin necrosis, implant exposure, and reconstructive failure from the added stress of the device, and are therefore a contraindication to single-stage implant reconstruction. Along similar lines, smoking significantly increases the risk of wound complications following direct-to-implant reconstruction, and is a relative contraindication to this technique. Healthy patients without comorbidities such as obesity and diabetes have been shown to have the best outcomes with this technique. The need for revision and complication rates appear to correlate with increasing premastectomy breast size; therefore, patients with small (A or B cup) breasts tend to make the best candidates for a single-stage technique. 3. Answer: e. Implant-based reconstruction techniques have several advantages when compared to autologous reconstructions. Implant-based reconstructions can typically be performed in a much shorter period of time, as they do not require dissection of autologous donor tissue or, as in the case of microsurgical reconstruction, the dissection of recipient vessels. Although the volume of an autologous reconstruction is limited by the quantity of donor tissues, the final volume of an implantbased reconstruction can to a certain extent be controlled by the surgeon, both through tissue expansion and final implant selection. One downside of implant-based reconstruction is the ability to obtain symmetry of the reconstructed breast with contralateral native breast tissue. Over time, as the contralateral breast develops ptosis, asymmetry may become even more evident. The difference in the long-term behavior of an implant reconstruction may partially account for differences in longterm patient satisfaction between prosthetic and autologous methods. There are data that though patient satisfaction initially is no different between prosthetic and autologous reconstruction, over time patients tend to become less satisfied with the appearance of an implant reconstruction whereas their satisfaction with an autologous reconstruction remains relatively constant. 69 4. Answer: d. There is a broad range of severity of surgical site infections following implant-based reconstruction. Although erythema isolated to the mastectomy incision may represent a more superficial process that can be managed with outpatient oral antibiotics, infections involving the implant pocket itself may present with whole breast erythema, purulent drain output, and systemic signs such as fever and leukocytosis. Even in the setting of more severe infections, implant salvage is possible and can be considered for certain properly selected patients. A recent study of nearly 2000 implant reconstructions identified elevated WBC at admission and intraoperative cultures growing MRSA as independent predictors of salvage failure. 65 Diffuse erythema, character of drain output, fever, and methicillin-sensitive Staphylococcus aureus growth were not predictive of need for explantation.

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References Albornoz, CR, Bach, PB, Mehrara, BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131(1):15-23. Farhangkhoee, H, Matros, E, Disa, J. Trends and concepts in post-mastectomy breast reconstruction. J Surg Oncol. 2016;113(8):891-894. 2017 plastic surgery statistics report. Procedural Statistics from the American Society of Plastic Surgeons. 2017. Available from http://www.plasticsurgery.org. Accessed July 19, 2017. Pirro, O, Mestak, O, Vindigni, V, et al. Comparison of patient-reported outcomes after implant versus autologous tissue breast reconstruction using the BREAST-Q. Plast Reconstr Surg Glob Open. 2017;5(1):e1217. Woerdeman, LA, Hage, JJ, Hofland, MM, Rutgers, EJ. A prospective assessment of surgical risk factors in 400 cases of skin-sparing mastectomy and immediate breast reconstruction with implants to establish selection criteria. Plast Reconstr Surg. 2007;119(2):455-463. Coon, D, Tuffaha, S, Christensen, J, Bonawitz, SC. Plastic surgery and smoking: a prospective analysis of incidence, compliance, and complications. Plast Reconstr Surg. 2013;131(2):385-391. Fischer, JP, Nelson, JA, Serletti, JM, Wu, LC. Perioperative risk factors associated with early tissue expander (TE) loss following immediate breast reconstruction (IBR): a review of 9305 patients from the 2005-2010 ACS-NSQIP datasets. J Plast Reconstr Aesthet Surg. 2013;66(11):1504-1512. Goodwin, SJ, McCarthy, CM, Pusic, AL, et al. Complications in smokers after postmastectomy tissue expander/implant breast reconstruction. Ann Plast Surg. 2005;55(1):16-19. McCarthy, CM, Mehrara, BJ, Riedel, E, et al. Predicting complications following expander/implant breast reconstruction: an outcomes analysis based on preoperative clinical risk. Plast Reconstr Surg. 2008;121(6):1886-1892.A large retrospective review examining the impact of individual clinical risk factors on outcomes in implant-based reconstruction. Ibrahim, AM, Shuster, M, Koolen, PG, et al. Analysis of the National Surgical Quality Improvement Program database in 19,100 patients undergoing implant-based breast reconstruction: complication rates with acellular dermal matrix. Plast Reconstr Surg. 2013;132(5):10571066. Hart, A, Funderburk, CD, Chu, CK, et al. The impact of diabetes mellitus on wound healing in breast reconstruction. Ann Plast Surg. 2017;78(3):260-263. Endara, M, Masden, D, Goldstein, J, et al. The role of chronic and perioperative glucose management in high-risk surgical closures: a case for tighter glycemic control. Plast Reconstr Surg. 2013;132(4):996-1004. Huo, J, Smith, BD, Giordano, SH, et al. A comparison of patient-centered economic and clinical outcomes of post-mastectomy breast reconstruction between obese and non-obese patients. Breast. 2016;30:118-124. Dietz, J, Lundgren, P, Veeramani, A, et al. Autologous inferior dermal sling (autoderm) with concomitant skin-envelope reduction mastectomy: an excellent surgical choice for women with macromastia and clinically significant ptosis. Ann Surg Oncol. 2012;19(10):32823288. Drucker-Zertuche, M, Robles-Vidal, C. A 7 year experience with immediate breast reconstruction after skin sparing mastectomy for cancer. Eur J Surg Oncol. 2007;33(2):140-146. Al-Ghazal, SK, Sully, L, Fallowfield, L, Blamey, RW. The psychological impact of immediate rather than delayed breast reconstruction. Eur J Surg Oncol. 2000;26(1):17-19. Sullivan, SR, Fletcher, DR, Isom, CD, Isik, FF. True incidence of all complications following immediate and delayed breast reconstruction. Plast Reconstr Surg. 2008;122(1):19-28. Seth, AK, Silver, HR, Hirsch, EM, et al. Comparison of delayed and immediate tissue expander breast reconstruction in the setting of postmastectomy radiation therapy. Ann Plast Surg. 2015;75(5):503-507. Nahabedian, MY. Implant-based breast reconstruction: strategies to achieve optimal outcomes and minimize complications. J Surg Oncol. 2016;113(8):895-905. Colwell, AS, Damjanovic, B, Zahedi, B, et al. Retrospective review of 331 consecutive immediate single-stage implant reconstructions with acellular dermal matrix: indications, complications, trends, and costs. Plast Reconstr Surg. 2011;128(6):1170-1178. Gdalevitch, P, Ho, A, Genoway, K, et al. Direct-to-implant single-stage immediate breast reconstruction with acellular dermal matrix: predictors of failure. Plast Reconstr Surg. 2014;133(6):738e-747e. Basta, MN, Gerety, PA, Serletti, JM, et al. A systematic review and head-to-head meta-analysis of outcomes following direct-to-implant versus conventional two-stage implant reconstruction. Plast Reconstr Surg. 2015;136(6):1135-1144.A meta-analysis of studies comparing singleversus two-stage implant reconstruction complication rates and outcomes. Vardanian, AJ, Clayton, JL, Roostaeian, J, et al. Comparison of implant-based immediate breast reconstruction with and without acellular dermal matrix. Plast Reconstr Surg. 2011;128(5):403e-410e. Forsberg, CG, Kelly, DA, Wood, BC, et al. Aesthetic outcomes of acellular dermal matrix in tissue expander/implant-based breast reconstruction. Ann Plast Surg. 2014;72(6):S116-S120. Sbitany, H, Serletti, JM. Acellular dermis-assisted prosthetic breast reconstruction: a systematic and critical review of efficacy and associated morbidity. Plast Reconstr Surg. 2011;128(6):1162-1169. Breuing, KH, Colwell, AS. Inferolateral AlloDerm hammock for implant coverage in breast reconstruction. Ann Plast Surg. 2007;59(3):250-255. Salzberg, CA, Ashikari, AY, Berry, C, Hunsicker, LM. Acellular dermal matrix-assisted direct-to-implant breast reconstruction and capsular

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contracture: a 13-year experience. Plast Reconstr Surg. 2016;138(2):329-337. Antony, AK, McCarthy, CM, Cordeiro, PG, et al. Acellular human dermis implantation in 153 immediate two-stage tissue expander breast reconstructions: determining the incidence and significant predictors of complications. Plast Reconstr Surg. 2010;125(6):1606-1614. Chun, YS, Verma, K, Rosen, H, et al. Implant-based breast reconstruction using acellular dermal matrix and the risk of postoperative complications. Plast Reconstr Surg. 2010;125(2):429-436. Lanier, ST, Wang, ED, Chen, JJ, et al. The effect of acellular dermal matrix use on complication rates in tissue expander/implant breast reconstruction. Ann Plast Surg. 2010;64(5):674-678. Treiser, MD, Lahair, T, Carty, MJ. Tissue expander overfilling: achieving new dimensions of customization in breast reconstruction. Plast Reconstr Surg Glob Open. 2016;4(2):e612. Cunningham, BL, Lokeh, A, Gutowski, KA. Saline-filled breast implant safety and efficacy: a multicenter retrospective review. Plast Reconstr Surg. 2000;105(6):2143-2149; discussion 2150–2141. Holmich, LR, Friis, S, Fryzek, JP, et al. Incidence of silicone breast implant rupture. Arch Surg. 2003;138(7):801-806. Rohrich, RJ, Reece, EM. Breast augmentation today: saline versus silicone—what are the facts? Plast Reconstr Surg. 2008;121(2):669-672. Macadam, SA, Ho, AL, Cook, EF Jr, et al. Patient satisfaction and health-related quality of life following breast reconstruction: patientreported outcomes among saline and silicone implant recipients. Plast Reconstr Surg. 2010;125(3):
 761-771. Singh, N, Picha, GJ, Hardas, B, et al. Five-year safety data for more than 55,000 subjects following breast implantation: comparison of rare adverse event rates with silicone implants versus national norms and saline implants. Plast Reconstr Surg. 2017;140(4):666-679. Barnsley, GP, Sigurdson, LJ, Barnsley, SE. Textured surface breast implants in the prevention of capsular contracture among breast augmentation patients: a meta-analysis of randomized controlled trials. Plast Reconstr Surg. 2006;117(7):
 2182-2190. Wong, CH, Samuel, M, Tan, BK, Song, C. Capsular contracture in subglandular breast augmentation with textured versus smooth breast implants: a systematic review. Plast Reconstr Surg. 2006;118(5):1224-1236. Calobrace, MB, Schwartz, MR, Zeidler, KR, et al. Long-term safety of textured and smooth breast implants. Aesthet Surg J. 2017;38(1):38-48. Gahm, J, Edsander-Nord, A, Jurell, G, Wickman, M. No differences in aesthetic outcome or patient satisfaction between anatomically shaped and round expandable implants in bilateral breast reconstructions: a randomized study. Plast Reconstr Surg. 2010;126(5):1419-1427. Barry, M, Kell, MR. Radiotherapy and breast reconstruction: a meta-analysis. Breast Cancer Res Treat. 2011;127(1):15-22. Lam, TC, Hsieh, F, Boyages, J. The effects of postmastectomy adjuvant radiotherapy on immediate two-stage prosthetic breast reconstruction: a systematic review. Plast Reconstr Surg. 2013;132(3):511-518. Jagsi, R, Momoh, AO, Qi, J, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl Cancer Inst. 2018;110(2). doi:10.1093/jnci/djx148. National Comprehensive Cancer Network Clinical Practice Guidelines in Oncology: Breast Cancer. Version 2. Published April 26, 2017; Accessed July 19, 2017. Nava, MB, Pennati, AE, Lozza, L, et al. Outcome of different timings of radiotherapy in implant-based breast reconstructions. Plast Reconstr Surg. 2011;128(2):353-359. Cordeiro, PG, Albornoz, CR, McCormick, B, et al. What is the optimum timing of postmastectomy radiotherapy in two-stage prosthetic reconstruction: radiation to the tissue expander or permanent implant? Plast Reconstr Surg. 2015;135(6):1509-1517.Single surgeon experience looking at both surgeon and patient-reported outcomes following radiation of either the tissue expander or the permanent implant in two-stage reconstruction. Santosa, KB, Chen, X, Qi, J, et al. Postmastectomy radiation therapy and two-stage implant-based breast reconstruction: is there a better time to irradiate? Plast Reconstr Surg. 2016;138(4):761-769. Peled, AW, Foster, RD, Esserman, LJ, et al. Increasing the time to expander-implant exchange after postmastectomy radiation therapy reduces expander-implant failure. Plast Reconstr Surg. 2012;130(3):503-509. Lentz, R, Ng, R, Higgins, SA, et al. Radiation therapy and expander-implant breast reconstruction: an analysis of timing and comparison of complications. Ann Plast Surg. 2013;71(3):269-273. Chen, SA, Hiley, C, Nickleach, D, et al. Breast reconstruction and post-mastectomy radiation practice. Radiat Oncol. 2013;8:45. Kronowitz, SJ, Lam, C, Terefe, W, et al. A multidisciplinary protocol for planned skin-preserving delayed breast reconstruction for patients with locally advanced breast cancer requiring postmastectomy radiation therapy: 3-year follow-up. Plast Reconstr Surg. 2011;127(6):21542166. Woo, KJ, Paik, JM, Bang, SI, et al. The impact of expander inflation/deflation status during adjuvant radiotherapy on the complications of immediate two-stage breast reconstruction. Aesthet Plast Surg. 2017;41(3):551-559. Momoh, AO, Ahmed, R, Kelley, BP, et al. A systematic review of complications of implant-based breast reconstruction with prereconstruction and postreconstruction radiotherapy. Ann Surg Oncol. 2014;21(1):118-124. Persichetti, P, Cagli, B, Simone, P, et al. Implant breast reconstruction after salvage mastectomy in previously irradiated patients. Ann Plast Surg. 2009;62(4):350-354. Cordeiro, PG, Snell, L, Heerdt, A, McCarthy, C. Immediate tissue expander/implast breast reconstruction after salvage mastectomy for cancer recurrence following lumpectomy/irradiation. Plast Reconstr Surg. 2012;129(2):341-350. Sbitany, H, Wang, F, Peled, AW, et al. Immediate implant-based breast reconstruction following total skin-sparing mastectomy: defining the risk of preoperative and postoperative radiation therapy for surgical outcomes. Plast Reconstr Surg. 2014;134(3):396-404.Retrospective review comparing outcomes of immediate reconstruction in setting of premastectomy or postmastectomy radiation. Lee, KT, Mun, GH. Prosthetic breast reconstruction in previously irradiated breasts: a meta-analysis. J Surg Oncol. 2015;112(5):468-475.

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Devereux, DF, Thibault, L, Boretos, J, Brennan, MF. The quantitative and qualitative impairment of wound healing by adriamycin. Cancer. 1979;43(3):932-938. Lawrence, WT, Talbot, TL, Norton, JA. Preoperative or postoperative doxorubicin hydrochloride (adriamycin): which is better for wound healing? Surgery. 1986;100(1):9-13. Caffo, O, Cazzolli, D, Scalet, A, et al. Concurrent adjuvant chemotherapy and immediate breast reconstruction with skin expanders after mastectomy for breast cancer. Breast Cancer Res Treat. 2000;60(3):267-275. Donker, M, Hage, JJ, Woerdeman, LA, et al. Surgical complications of skin sparing mastectomy and immediate prosthetic reconstruction after neoadjuvant chemotherapy for invasive breast cancer. Eur J Surg Oncol. 2012;38(1):25-30. Warren Peled, A, Itakura, K, Foster, RD, et al. Impact of chemotherapy on postoperative complications after mastectomy and immediate breast reconstruction. Arch Surg. 2010;145(9):880-885. Wang, F, Peled, AW, Chin, R, et al. The impact of radiation therapy, lymph node dissection, and hormonal therapy on outcomes of tissue expander-implant exchange in prosthetic breast reconstruction. Plast Reconstr Surg. 2016;137(1):1-9. Zhao, X, Wu, X, Dong, J, et al. A meta-analysis of postoperative complications of tissue expander/implant breast reconstruction using acellular dermal matrix. Aesthet Plast Surg. 2015;39(6):892-901. Reish, RG, Damjanovic, B, Austen, WG Jr, et al. Infection following implant-based reconstruction in 1952 consecutive breast reconstructions: salvage rates and predictors of success. Plast Reconstr Surg. 2013;131(6):1223-1230. Washer, LL, Gutowski, K. Breast implant infections. Infect Dis Clin North Am. 2012;26(1):111-125. Wan, D, Rohrich, RJ. Revisiting the management of capsular contracture in breast augmentation: a systematic review. Plast Reconstr Surg. 2016;137(3):826-841. Phillips, BT, Halvorson, EG. Antibiotic prophylaxis following implant-based breast reconstruction: what is the evidence? Plast Reconstr Surg. 2016;138(4):751-757. Hu, ES, Pusic, AL, Waljee, JF, et al. Patient-reported aesthetic satisfaction with breast reconstruction during the long-term survivorship Period. Plast Reconstr Surg. 2009;124(1):1-8.

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CHAPTER 60

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Breast Reconstruction: Autologous Flap Techniques Shailesh Agarwal and Adeyiza O. Momoh

Key Points Autologous flap breast reconstruction is a mainstay in modern day approach to postmastectomy breast reconstruction. An understanding of the multidisciplinary aspects and components of cancer care is important when formulating a plan for reconstruction Free flap selection is based on surgical history and presence of sufficient tissue at proposed donor site. A variety of flap donor options exist including the abdomen, buttocks, and thighs. Preoperative imaging may elucidate vessel anatomy, but is not always critical. Clinical exam remains the standard for postoperative flap monitoring. Breast reconstruction is a critical component of the comprehensive management of the breast cancer patient. The primary goal of breast reconstruction is to restore a natural appearing form of the breast, with additional benefits in the quality of life experienced after cancer treatment. Breast reconstruction may be performed using implants or tissue derived from the patient (autologous tissue). A number of studies evaluating national reconstruction trends have reported ratios of implant to autologous breast reconstruction in the range of 2:1 to 9:1. 1-4 That a minority of breast reconstruction patients undergo autologous tissue reconstruction is likely due to patient- and nonpatient-related factors. Patient-related factors include a lack of donor site tissue, comorbidities that preclude use of flaps, desire to avoid recovery from the donor site and patient preference. Operative requirements, such as increased operative time, need for specialized instruments, specialized technical training and skills, and greater resources, comprise nonpatient-related factors that impede the utilization of autologous breast reconstruction. 4-6 However, by using autologous tissue, one may obviate the postoperative risks of morbidity associated with implants including infection, rupture, capsular contracture, and malposition. In addition, autologous tissue is generally preferred in patients expecting to receive radiation therapy, or with a history of radiation therapy including radiation previously delivered as part of breast conservation therapy (BCT). 7-10 Finally, quality of life in patients undergoing autologous tissue reconstructions is maintained at a high level over time after completion of reconstruction. 11

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Preoperative Evaluation Breast Cancer Treatment Plan The preoperative evaluation of the patient interested in postmastectomy breast reconstruction includes a thorough history and physical examination. The patient’s goals, including desired breast size, should be discussed in the context of the utility and limitations of the reconstructive options. The oncologic plan should also be reviewed including the possibility of chemotherapy, radiation therapy, and contralateral prophylactic mastectomy (CPM). Tamoxifen increases the likelihood of thrombotic complications. 12 A history of radiation or plan for future radiation delivery may make autologous breast reconstruction more desirable given greater morbidity with radiation and implant reconstruction. 7-10 Often, patients presenting for mastectomy have previously been treated for breast cancer with BCT, which includes whole breast radiation (Figure 60.1). These variables should be considered in decisions made for immediate or delayed breast reconstruction and on the type of reconstruction recommended.

FIGURE 60.1 A patient with a left invasive breast cancer who has undergone breast conservation therapy (BCT—lumpectomy, adjuvant chemotherapy, and radiation) with gross changes to the left breast seen on AP (A), oblique (B) and lateral (C) views.

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Timing of Breast Reconstruction When possible immediate breast reconstruction tends to be preferred by a majority of patients undergoing mastectomies. The decision on immediate or delayed reconstruction in general is influenced by cancer staging, with delayed reconstruction favored in advanced stage cancers that require postmastectomy radiation therapy (PMRT) or close surveillance. Some patients may also opt to wait on reconstruction if the combined process of oncologic treatment and reconstruction seems overwhelming. The need for PMRT, though not an absolute contraindication to immediate reconstruction, tends to be the predominant reason to consider delayed reconstruction. Delayed reconstruction is typically advocated for multiple reasons including the avoidance of untoward effects of radiation on the results of an immediate reconstruction and the potential for delaying oncologic treatment because of complications from reconstruction.

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History and Exam Obtaining an accurate medical and surgical history is critical when evaluating patients for autologous reconstruction. Because autologous operations often require longer operative times, it is imperative to ensure that the patient is medically appropriate for a longer operation from cardiac and pulmonary perspectives. In addition, a history of previous surgeries may impact the use of specific donor sites for autologous breast reconstruction. For instance, previous abdominal operations that compromise abdominal soft tissue blood supply may preclude use of the abdomen as a donor site for reconstruction. A known history of hypercoagulable conditions would be a contraindication to performing a free tissue transfer with an increased risk for vessel thrombosis; pedicled flap options would be possible in this context. Active smoking would be a relative contraindication for performing any autologous flap procedure with increased risk for wound dehiscence and delayed wound healing. Patients are typically counseled to quit smoking for a minimum of 4 weeks before surgery and often preoperatively evaluated with a urine cotinine test. Patient preferences for postreconstruction breast size is also important for operative planning. For example, thin patients with a paucity of abdominal tissue who desire CPM may not be candidates for bilateral breast reconstruction using abdominal tissue alone. In some patients, use of the entire lower abdominal soft tissue in the form of bipedicled or stacked flaps may be required to attain unilateral breast reconstruction of sufficient size. Alternative donor sites such as the buttocks (superior gluteal artery perforator flap), medial thigh (transverse upper gracilis flap), or posterior thigh (profunda artery perforator flap) may also be options for patients with insufficient abdominal tissue. All potential donor sites should be examined for the presence of adequate skin laxity and adipose tissue by inspection for scars, palpation, and pinch testing.

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Perforator and Pedicle Evaluation Although useful for preoperative planning, imaging is not absolutely needed in patients without a surgical history that raises concerns about pedicle compromise. Scans may be necessary to evaluate the thoracodorsal (TD) vessels in patients desiring latissimus dorsi reconstruction who have undergone axillary lymph node dissections, where the status of the TD vessels is unclear. Similar concerns exist and may prompt imaging to confirm an intact pedicle in patients with low and lateral abdominal incisions in patients considered for abdominal free flaps. Computed tomography angiography (CTA) provides information regarding perforator distribution and pedicle course (Figure 60.2). Studies have shown that CTA may reduce operative time for abdominal-based reconstruction, ostensibly by aiding in perforator identification/selection and deep inferior epigastric artery dissection; however, CTA may also lead to increased healthcare costs. 13-19 Alternative imaging techniques have also been studied including duplex ultrasound and MR angiography, although to a lesser extent. Many surgeons who do not implement preoperative imaging may instead use the pencil Doppler to simply confirm perforator location on the abdominal wall. Still others may choose not to perform any initial perforator or pedicle evaluation, but rather begin flap elevation knowing that the abdomen has reliable perforator anatomy.

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FIGURE 60.2 Preoperative CT angiogram of the abdomen (A), identifying perforators (B) and outlining the branching pattern (C) of the abdominal vascular pedicle. Also, valuable in evaluating thoracodorsal vessel patency (D) with a history of axillary lymph node dissection.

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Pedicled Flaps Latissimus Dorsi Flap The latissimus dorsi (LD) myocutaneous flap is a well-established pedicled flap option for breast reconstruction. The LD flap is based on the thoracodorsal vessels, which arises from the subscapular vessels that branch off of the axillary vessels (Figure 60.3). Within the latissimus the thoracodorsal branches into a medial or transverse and a lateral or descending branch, which allow for muscle-sparing procedures with use of part of the LD for reconstruction. The LD flap is a broad muscle that covers a large surface area and can be used with or without a skin paddle for reconstruction. However, the muscle harvested with a skin paddle typically does not provide sufficient volume for breast reconstruction. To achieve a desired breast volume the LD flap is often used in combination with a prosthesis (Figure 60.4). The LD may also be used in setting of salvage procedures to replace compromised mastectomy skin flaps over implants or in cases of failed free-flap breast reconstructions.

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FIGURE 60.3 Thoracodorsal vascular anatomy. (Reproduced with permission from Kung, TA, Momoh, AO. Recipient vessel exposure: internal mammary and thoracodorsal. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 4, Figure 24-1.)

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FIGURE 60.4 A, B. A patient with a history of invasive right breast cancer who has undergone bilateral mastectomies with right chest wall radiation. C, D. Postoperative result after completion of delayed bilateral breast reconstruction with a latissimus dorsi myocutaneous flap and implant on the right and an implant alone on the left. E. Obliquely oriented donor site scar on the right back.

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Pedicled Transverse Rectus Abdominis Myocutaneous (TRAM) Flap The pedicled TRAM flap takes advantage of lower abdominal soft tissue adiposity that is present in many patients and is based on the superior epigastric artery, a continuation of the internal mammary artery (IMA). The pedicled TRAM is elevated with the ipsilateral rectus muscle and tunneled into the mastectomy defect site through the inframammary fold. 20-22 Flap harvest includes fascia overlying the rectus muscle and often requires mesh placement for closure of the donor site. The use of the rectus muscle contributes to weakened abdominal wall strength and an increased risk for abdominal bulge. 23-25 Because the deep inferior epigastric artery system is the more dominant blood supply to the abdominal skin and fat, maneuvers to improve the blood supply (from the superior vasculature) to the flap are sometimes employed. One such maneuver is a delay procedure, which is often performed 2 or 3 weeks before the pedicled TRAM procedure, when the ipsilateral deep inferior epigastric artery is ligated to facilitate the recruitment of choke vessels with perfusion from the superior epigastric vessels. 26 Efforts to avoid donor site morbidity while taking advantage of the more dominant deep inferior epigastric system encouraged the evolution of free tissue transfer options described later.

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Free Flaps Abdomen-Based Flaps Abdomen-based breast reconstruction is the mainstay of autologous microvascular breast reconstruction. The benefits of this well-described reconstructive technique include reliable vascular anatomy, extensive reported clinical experience, reduced donor site morbidity with muscle-sparing/perforator flap options, a long pedicle with similar caliber to recipient vessels, and typically, the presence of sufficient soft tissue for reconstruction. Flap types include the free transverse rectus abdominis musculocutaneous (TRAM), free muscle-sparing TRAM (ms-TRAM), deep inferior epigastric perforator (DIEP), and the superficial inferior epigastric artery (SIEA) perforator flaps. The free TRAM, free ms-TRAM, and DIEP flaps are based on the deep inferior epigastric vessels, which are branches from the external iliac vessels. Perforating vessels from the deep inferior epigastric system perfuse varying aspects or zones of the abdominal wall skin and adipose tissue. The SIEA flap is based on the superficial inferior epigastric vessels, which are branches from the femoral vessels, run superficial to the abdominal wall fascia, and perfuse the abdominal soft tissue in parallel to the deep inferior epigastric system (Figure 60.5); violation of the anterior rectus fascia is avoided with this flap. A small percentage of flaps (less than 10%) are reported to be superficially dominant. 27

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FIGURE 60.5 Superficial inferior epigastric and deep inferior epigastric vascular anatomy.

The operation is performed with the patient in the supine position. For patients who are undergoing immediate breast reconstruction, flap elevation may be performed while the breast surgery team performs the mastectomy. A lenticular design is employed with tissue based around and inferior to the umbilicus (Figure 60.6). Consideration is given for SIEA flap reconstruction whenever possible. Early in the abdominal flap elevation, along the inferior aspect of the designed abdominal flap, generally superficial to the Scarpa fascia and within 5 to 10 cm lateral from the midline, is explored for the SIEA and SIEV (Figure 60.7). 28 SIEA/V vessels that can be used are reported to be present in 30% of patients. 29 In flaps with vessels that are present and of appropriate size (1.5 mm diameter SIEA at the inferior edge of the flap) dissection of the SIEA and SIEV are carried to the femoral vessels. 29 Once adequate perfusion based on the superficial vessels is confirmed, all other perforators from the deep inferior epigastric system are divided. Perfusion of flaps based on the SIEA/SIEV is not reliable across the midline.

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FIGURE 60.6 Preoperative markings for abdominal based flap breast reconstruction. The flap is designed to capture perforators typical localized around the umbilicus (superior marking just above the umbilicus and extending laterally toward the anterior superior iliac spines). Consideration is given for primary closure of the donor site, which determines the position of the lower marking above the pubis.

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FIGURE 60.7 Superficial inferior epigastric artery and vein, at the inferior border of abdominal flap dissected toward the femoral vessels.

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FIGURE 60.8 DIEP flap zones of perfusion.

Most of the perforators required for DIEP flap elevation are located within a 10 cm radius from the umbilicus. 30 These perforators perfuse predictable zones of the lower abdominal soft tissue, with perfusion zones initially described by Hartrampf for TRAM flaps and subsequently modified by Holm for DIEP flaps 22,31 (see Figure 60.8). Zones of perfusion have since been shown to be varying depending on the row of perforators (medial or lateral) selected (Figure 60.8). 30 When reconstructing a single breast, the midline may be crossed to include the zone immediately adjacent to the midline to provide sufficient tissue for symmetry with the contralateral side; for bilateral breast reconstruction, the abdominal tissue is bisected down the midline. The superior abdominal flap is elevated from the superior incision for closure with the inferior incision, which is not undermined. The umbilicus is transposed and delivered through the superior abdominal flap. At the inferior aspect of the flap, even in cases where the SIEA is absent or too small to rely upon, the SIEV if present is dissected out to a length (5–7 cm) for potential use as an alternate flap outflow option. Suprafascial identification of lateral and medial row perforators (over the rectus abdominis muscle) is performed and an ideal perforator or group of perforators are selected. With use of a preoperative CT scans, identification of perforators may be simplified. Perforator row selection may be based on a combination of factors including perforator size, location (central or peripheral) and branching pattern within the adipose tissue of the flap. In addition, perforators considered for exclusion may be clamped temporarily with assessment of flap perfusion by assessing color and capillary refill; perfusion with select perforators clamped may also be assessed with indocyanine green perfusion imaging. Once perforators are selected, the anterior rectus fascia is incised and careful intramuscular dissection of the selected perforators through the rectus muscle is performed down to the deep inferior epigastric vessels (Figure 60.9). If perforators from separate rows (e.g., medial and lateral row) are to be included to improve tissue perfusion, the intervening segment of muscle between the two rows may be harvested with the flap as a muscle-sparing TRAM flap, obviating perforator dissection through the muscle. Complete transection of a segment of the rectus muscle that includes perforators without preserving continuity of any aspects of the rectus muscle constitutes a free TRAM flap. In all three described flaps, the pedicle is traced proximally toward its takeoff from the external iliac vessels. The pedicle, typically consisting of two veins and one artery, is ligated distal to the takeoff from the external iliac vessels. The pedicle is ligated to ensure sufficient vessel length and caliber

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for anastomosis with the internal mammary vessels. In the repair of abdominal fascial defects after flap harvest, primary closure without mesh is often possible with DIEP flap and free ms-TRAM flap harvests. Free TRAM harvests tend to include wide sections of anterior rectus fascia and may require mesh placement, particularly in cases with bilateral flaps.

FIGURE 60.9 DIEP flap with three medial row perforators dissected through the rectus muscle and inclusion of a zone across the midline.

On completion of the microvascular anastomoses, with perfusion reestablished, flaps are shaped on the chest wall to achieve the contour of a breast mound. Varying amounts of skin and adipose tissue are utilized based on existing deficiencies as is encountered in cases of immediate and delayed breast reconstruction (Figures 60.10 and 60.11).

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FIGURE 60.10 A–C. Preoperative views of a patient with a right invasive breast cancer considering bilateral mastectomy and immediate reconstruction. D–F. Postoperative results after immediate bilateral DIEP flap breast reconstruction, with nipple reconstruction and tattooing. G, H. Abdominal donor site before and after reconstruction.

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FIGURE 60.11 A–C. Preoperative views of a patient with a left invasive breast cancer who has undergone a left mastectomy with postmastectomy radiation therapy. She plans on a right contralateral prophylactic mastectomy with bilateral breast reconstruction. D–F. Postoperative results after immediate right and delayed left breast reconstructions. G, H. Abdominal donor site before and after reconstruction.

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Medial Thigh Flaps Medial thigh flaps incorporating the gracilis muscle provide another option for breast reconstruction in patients who have had previous abdominoplasty or abdominal flaps, or insufficient abdominal tissue. 32 The medial circumflex femoral artery, a branch of the profunda femoris artery, serves as the pedicle to the gracilis muscle to support the overlying fat and skin (Figure 60.12). The pedicle is identified in the interval between the gracilis and adductor longus muscles and is traced proximally (Figure 60.13). The skin may be oriented transversely (transverse upper gracilis (TUG) flap), vertically (vertical upper gracilis (VUG) flap) or designed as a combination of both with a bipedicled skin paddle. 32 Although the TUG does not provide as much skin or fat as the VUG, it may provide a more reliable skin paddle. The transverse upper thigh scar is better hidden than the vertical scar; however, excessive tension from closure of the transverse skin paddle donor site may cause labial spreading. Medial thigh flaps are ideal for patients with small- to moderate-sized breast who desire similar-sized reconstruction. The overall availability of sufficient tissue for breast reconstruction is one drawback of medial thigh flaps. In a retrospective study, Park et al. reported a mean weight of 342 g among VUGs and 268 g among TUGs 32 ; however, use of bilateral stacked flaps (bilateral upper gracilis (BUG) flap) may address this concern for patients undergoing unilateral breast reconstruction. 32 One advantage of this form of reconstruction is that flap harvest and breast reconstruction can be performed in one position with the patient supine and the hip externally rotated (thigh frog legged) for flap harvest. However, the length of the vascular pedicle is relatively short, measuring approximately 7 cm and the flap artery is often smaller than recipient arteries used for breast reconstruction (e.g., internal mammary or thoracodorsal vessels). 33

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FIGURE 60.12 Medial circumflex femoral artery and vein anatomy with transversely oriented skin paddle for medial thigh flap. (Reproduced with permission from Momoh, AO. Transverse upper gracilis flap for breast reconstruction. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 4, Figure 28-2.)

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FIGURE 60.13 Medial circumflex femoral vessels extending from the medial border of the gracilis. Vessels are dissected underneath the adductor longus muscle (retracted) to the profunda femoris.

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Posterior Thigh Flaps The profunda artery perforator (PAP) flap uses posterior thigh skin and adipose tissue as an option for breast reconstruction 34 (Figure 60.14). The consistent presence and length of the pedicle—reported to average 10.6 cm—allows for the internal mammary or thoracodorsal vessels to serve as recipient vessels. 35,36 Perforators from the pedicle are located roughly 5 to 6 cm below the gluteal crease, both medial and lateral to the midline of the posterior thigh. 36,37 The flap is designed as a horizontal ellipse with superior incision at or immediately below the gluteal crease; the perforator travels through the adductor magnus. Flap elevation can be performed in the prone position; however, to avoid intraoperative position change and to facilitate a two-team approach, the flap may also be elevated in a lithotomy or frog-leg position (Figure 60.15). Although it has been reported that the horizontally designed PAP flap offers mean weight of 220 g, larger flaps are possible with the PAP designed as a fleur-de-lis (range 340–735 g). 38

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FIGURE 60.14 Profunda artery perforator vascular anatomy with transversely oriented skin paddle for a posterior/medial thighbased flap.

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FIGURE 60.15 A. Supine position with medial thigh marking of flap visible. B. Two perforators dissected underneath the gracilis and thrugh the adductor magnus muscle (both retracted), towards the profunda femoris.

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Gluteal Artery Perforator Flaps The superior or inferior gluteal artery perforator (SGAP or IGAP) flaps are autologous alternatives to abdominal-based flaps for patients who do not have reliable abdominal vascular anatomy due to previous surgery, or who do not have sufficient abdominal tissue to reconstruct breasts of sufficient size. The superior gluteal artery exits the pelvis superior to the piriformis muscle at approximately the point marking the junction of the upper and middle third of a line drawn from the posterior superior iliac spine (PSIS) to the greater trochanter. The inferior gluteal artery exits the pelvis inferior to the piriformis muscle, at approximately the point marking the junction of the upper and middle third of a line drawn from the PSIS to the ischial tuberosity. 39 Perforators are identified preoperatively using CT angiogram and/or Doppler probe. Patients are either positioned lateral or prone and might need position changes for flap elevation and for transfer of the flap to the breast. A skin paddle is designed over anticipated perforators and an adipocutaneous flap is elevated intramuscular perforator dissection (Figure 60.16). One perforator is many times sufficient to support the GAP flap. One advantage provided by use of this flap is the presence of a good amount of adipose tissue for reconstruction even in patients with lower BMIs. However, the length of the vascular pedicle for this flap is relatively short, measuring 5.6 cm on average. 40

FIGURE 60.16 A. Lateral positioning for SGAP flap harvest with flap centered over the upper to middle third of axis from PSIS to greater trochanter. B. Single perforator dissected between gluteal muscle fibers.

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Recipient Vessels The IMA and internal mammary vein (IMV) are the more commonly utilized recipient vessels for free flap breast reconstruction; alternatives are the thoracodorsal artery and vein. The IMA arises from the subclavian artery, run 1 to 2 cm lateral to the sternum, deep to the intercostal muscles and ribs, and are in continuity with the superior epigastric vessels. The internal mammary vessels can be accessed by removal of the third or fourth rib cartilage; the rib level is determined by ease of access and size of the flap pedicle to avoid a significant vessel size mismatch. At the level of the third rib, the IMA generally lies lateral to the IMV. The right and left IMAs are of similar diameter (1.9–2.1 mm) at third and fourth intercostal spaces. The left IMV bifurcates at a higher level than the right IMV (third rib on the left vs. fourth rib on the right). At the level of the third intercostal space, the left IMV is on average smaller than the right (2.5 mm vs. 3 mm). Branches of the IMA and IMV are ligated using clips under Loupe magnification, and further under the microscope if necessary. Alternatively, a rib-sparing approach may be performed if the interspace width is adequate to perform anastomoses. This approach limits vessel exposure and introduces greater technical challenge. Here, the intercostal muscles are elevated to access the internal mammary vessels. Care is taken during internal mammary vessel exposure to avoid injury to the pleura, deep to the vessels, which could result in a pneumothorax. The thoracodorsal vessels arise from the axillary artery and travel along the lateral thoracic wall and into the latissimus dorsi muscle. The vessels are typically identified at the lateral border of a mastectomy defect on the deep surface of the latissimus muscle.

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Microvascular Anastomosis Once flap harvest and recipient vessel exposure is complete, flap vessels are divided rendering the flap ischemic. End-to-end arterial and venous anastomoses are performed either under loupe magnification or using an operating microscope. Arteries are typically hand sewn with fine sutures (8-0 to 10-0 nylon sutures) and veins coupled with a coupling device (Figure 60.17).

FIGURE 60.17 Hand-sewn arterial anastomosis to the IMA. Coupled veins in the background.

After completion of the arterial and venous anastomoses, assessment of perfusion can be determined by confirming capillary refill time (∼2–3 seconds), warmth, and flap edges with bright red bleeding. Handheld Doppler ultrasound may be used to confirm a signal over perforators within the flap and on the external surface of the flap. The external site can then be marked with a suture to facilitate postoperative monitoring as well. Venous outflow can be confirmed based on appearance of the flap—a congested flap typically appears dark and has dark red blood from the edges. The identification of venous congestion without obvious mechanical obstructions within the pedicle and perforators may lead the surgeon to consider augmenting venous outflow through use of the superficial inferior epigastric vein (SIEV).

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Postoperative Free Flap Care and Monitoring Postoperatively, flaps are kept warm with either a blanket with forced warm air over the flap or with control of the room temperature. Flaps are evaluated often, typically every hour for the first 24 hours. Postoperative flap monitoring consists of clinical exam including capillary refill (∼2–3 seconds), color, warmth, and hand-held Doppler signals. Adjuncts to the clinical exam that are often implemented include near-infrared tissue oximetry, implantable arterial Doppler, or venous flow coupler. Tissue oximetry reflects a combination of arterial inflow and venous outflow. The implantable arterial Doppler provides real-time audible information regarding arterial inflow. The venous flow coupler provides realtime audible information regarding venous outflow. Anticoagulation with an antiplatelet agent (Aspirin) and venous thromboembolism (VTE) prophylaxis (subcutaneous heparin or enoxaparin) is typical.

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Flap and Donor Site Complications During the first 24 to 48 hours, vascular compromise may occur due to occlusion of the artery or vein due to thrombus, compression caused by hematoma, or positioning of the vessels (e.g., kinking). Vascular compromise can be identified on the basis of postoperative monitoring techniques described earlier; the rule of thumb is that early vascular compromise necessitates reoperation for salvage. Beyond the early postoperative vascular compromise other flap-related complications include fat necrosis, partial flap loss, wound dehiscence, infections, hematomas, and seromas. Donor site complications also occur and include infection, hematoma, seroma, wound dehiscence, skin flap necrosis, umbilical necrosis, abdominal wall hernias and bulges, medial thigh lymphatic leaks, and unfavorable scars.

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Questions 1. You plan to perform a pedicled TRAM flap for breast reconstruction and would like to physiologically augment blood flow to the flap through the intended pedicle. What can you do to achieve this? a. Ligate the superior epigastric artery 3 weeks before the TRAM procedure b. Ligate the deep inferior epigastric artery 3 weeks before the TRAM procedure c. Ligate the intercostal arteries 3 weeks before the TRAM procedure d. Elevate the entire TRAM flap and then replace it on the abdomen e. Perform an additional microvascular anastomosis 2. A 45-year-old patient with a history of right-sided breast cancer treated with BCT 5 years ago comes to your clinic to discuss reconstructive options to restore size and symmetry. She has a history of abdominoplasty at the age of 35 years. On examination, her left breast is approximately a B-cup bra-size. Her BMI is 30 kg/m2. Which of the following reconstructive options would be most appropriate for her? a. Ipsilateral breast reconstruction with DIEP flap b. Ipsilateral breast reconstruction with latissimus dorsi musculocutaneous flap c. Contralateral breast reduction d. Ipsilateral breast reconstruction with PAP flap e. Silicone implant placement 3. In preparation for microvascular reconstruction of the left breast with a DIEP flap (pedicle: 2.5 mm artery/3.0 mm vein), exposure of the IMA/IMV is planned with a rib cartilage resection. Which rib is the most appropriate to resect? a. Rib 1 b. Rib 2 c. Rib 3 d. Rib 4 e. Rib 5 4. A 37-year-old woman with a genetic predisposition for breast cancer undergoes bilateral nipplesparing prophylactic mastectomies with immediate microvascular breast reconstructions. The flaps are buried and without skin paddles. Which of the following offers you the ability for postoperative monitoring of the flap? a. Transcutaneous tissue oximetry b. Pencil Doppler c. Exam (warmth, color) d. Venous coupler e. Arterial Doppler probe 5. You are in the operating room and performing autologous breast reconstruction with a DIEP flap. Immediately on completion of the arterial and venous anastomoses, you note that both anastomoses are patent, but you also see dark red blood from the edges of the flap. What is the next appropriate action to take? a. Begin intraoperative leeches b. Perform additional venous anastomosis with SIEV from the flap to the retrograde IMV c. Give the flap 5 to 10 minutes to allow for old venous blood to clear d. Take down and redo the venous anastomosis with the IMV e. Initiate an intravenous heparin drip

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1. Answer: b. Ligating the deep inferior epigastric artery several weeks before the TRAM flap is performed is known as a TRAM delay procedure. Studies have shown that this improves flap survival and augments blood flow through the superior epigastric artery. The pedicled TRAM flap is based on the superior epigastric artery. Ligating this artery would render the flap unuseable. Ligating the intercostal arteries would risk causing abdominal necrosis superior and lateral to the TRAM donor site. It would not be reasonable to elevate the entire TRAM flap and then replace it on the abdomen. In addition, this would not augment flow through the superior epigastric artery. Additional microvascular anastomosis can be performed if the superior epigastric artery is injured during flap elevation. In that setting, the DIEA, if left long enough can be used to augment flow. However, this would not augment flow through the pedicle (superior epigastric artery). 2. Answer: d. The PAP flap provides a reasonable alternative to abdominal-based free flaps in patients with a prior history of abdominal surgery, which would place abdominal-based flaps at risk. In this patient with a history of abdominoplasty, an abdominal-based free flap would not be a viable reconstructive strategy. The PAP flap can provide sufficient tissue in patients with B or C-cup breasts. The DIEP flap is no longer an option in patients who have had an abdominoplasty. The latissimus dorsi musculocutaneous flap is not likely to provide sufficient tissue to reconstruct B-cup breasts in this patient. A contralateral breast reduction is unlikely to restore size, one of the concerns for this patient. In many patients, breast reduction is also unlikely to yield symmetry unless additional operations are performed on the ipsilateral side. A silicone implant would be inadvisable in a patient with a history of radiation on the ipsilateral side, which is a part of the BCT protocol. 3. Answer: c. The IMA and particularly the IMV have sufficient size on the left side to match the flap pedicle diameters at rib 3. In addition, if the vessel is injured during exposure, there is an opportunity to obtain sufficient exposure to anastomose proximal on the vessels. On the right side, the veins are slightly larger than they are at the same rib level on the left and as such should be of reasonable size for the described flap at either rib 3 or 4. Rib 1 sits just below the clavicle and resection of this rib would not be appropriate for anastomosis. Rib 2 is still located too far superior for anastomosis between the IMA/IMV and DIEA/DIEV. In addition, if any difficulty is encountered during exposure of the IMA/IMV, use of the second rib does not allow sufficient operative exposure superiorly to perform anastomosis. IMV on the left side can be substantially smaller at ribs 4 and 5. 4. Answer: e. The arterial Doppler probe, or Cook arterial Doppler, is a probe that wraps around the artery distal to the anastomosis and provides audible feedback. If the Doppler no longer provides a signal, the reasons can include thrombosis of the artery or in some circumstances, dislodgement of the probe. Transcutaneous tissue oximetry, pencil Doppler, and physical examination all require exposed skin paddle on the flap to be useful. The venous coupler facilitates the anastomosis and has been shown to reduce operative time. However, it alone does not provide monitoring. However, modifications of the venous coupler include the implantable venous flow coupler with Doppler, which allows for venous monitoring. 5. Answer: c. Giving the flap 5 to 10 minutes to allow for blood inflow through the DIEA-IMA anastomosis will help determine whether the observed dark blood is a symptom of true venous congestion or of stagnant blood in the flap that remained from the flap harvest. If venous congestion persists despite an intact DIEV-IMV anastomosis, additional anastomosis with the SIEV to the retrograde IMV can be performed. Leeches would be typically used postoperatively. However, in the setting of free-flap breast reconstruction, postoperative venous congestion should be treated with operative exploration. Additional SIEV anastomosis to the retrograde IMV would be appropriate if the flap exhibits congestion for a prolonged period of time in the operating room despite a patent DIEV-IMV anastomosis. This would not be the next action to take, however. The DIEV-IMV anastomosis is patent based on the question stem. Therefore, it would not be appropriate to redo the anastomosis at this time. There is no evidence of thrombosis and as such anticoagulation in response

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to the clinical finding would not be indicated.

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References Albornoz, CR, Bach, PB, Mehrara, BJ, et al. A paradigm shift in U.S. breast reconstruction: increasing implant rates. Plast Reconstr Surg. 2013;131:15-23.Cross-sectional study of immediate breast reconstruction trends in a national patient sample. One of the better known contemporary studies that demonstrates rising reconstruction rates following the Women Health and Cancer Rights Act of 1998. Also, a key study that shows a rise in implant use in the United States. Panchal, H, Matros, E. Current trends in postmastectomy breast reconstruction. Plast Reconstr Surg. 2017;140:7S-13S. Barnow, A, Canfield, T, Liao, R, et al. Breast reconstruction among commercially insured women with breast cancer in the United States. Ann Plast Surg. 2018;81:220-227. Sheckter, CC, Panchal, HJ, Razdan, SN, et al. The influence of physician payments on the method of breast reconstruction: a national claims analysis. Plast Reconstr Surg. 2018;142(4):434e-442e. Billig, JI, Lu, Y, Momoh, AO, Chung, KC. A nationwide analysis of cost variation for autologous free flap breast reconstruction. JAMA Surg. 2017;152:1039-1047. Sheckter, CC, Yi, D, Panchal, HJ, et al. Trends in physician payments for breast reconstruction. Plast Reconstr Surg. 2018;141:493e-499e. Jagsi, R, Momoh, AO, Qi, J, et al. Impact of radiotherapy on complications and patient-reported outcomes after breast reconstruction. J Natl Cancer Inst. 2018;110(2):157-165.A multicenter observational study from the Mastectomy Reconstruction Outcomes Consortium (MROC) focusing on postoperative morbidity and patient reported outcomes (PROs) in radiated and nonradiated patients undergoing breast reconstruction. Findings of superior PROs and lower risk of complications with autologous reconstruction in patients receiving postmastecomy radiation therapy. Billig, J, Jagsi, R, Qi, J, et al. Should immediate autologous breast reconstruction be considered in women who require postmastectomy radiation therapy? A Prospective analysis of outcomes. Plast Reconstr Surg. 2017;139:1279-1288. Aliu, O, Zhong, L, Chetta, MD, et al. Comparing health care resource use between implant and autologous reconstruction of the irradiated breast: a national claims-based assessment. Plast Reconstr Surg. 2017;139:1224e-1231e. Chetta, MD, Aliu, O, Zhong, L, et al. Reconstruction of the irradiated breast: a national claims-based assessment of postoperative morbidity. Plast Reconstr Surg. 2017;139:783-792. Santosa, KB, Qi, J, Kim, HM, et al. Long-term patient-reported outcomes in postmastectomy breast reconstruction. JAMA Surg. 2018;153(10):891-899.A multicenter observational study from the Mastectomy Reconstruction Outcomes Consortium (MROC) evaluating long-term patient reported outcomes in patients undergoing implant or autologous breast reconstruction. Patients undergoing autologous breast reconstruction (relative to implant reconstructions) were found to be more satisfied with their breasts, in addition to other specific quality of life measures, 2 years after reconstruction. Kelley, BP, Valero, V, Yi, M, Kronowitz, SJ. Tamoxifen increases the risk of microvascular flap complications in patients undergoing microvascular breast reconstruction. Plast Reconstr Surg. 2012;129:305-314. Agarwal, S, Talia, J, Liu, PS, et al. Determining the cost of incidental findings for patients undergoing preoperative planning for abdominally based perforator free flap breast reconstruction with computed tomographic angiography. Plast Reconstr Surg. 2016;138:804e-810e. Rozen, WM, Ashton, MW, Grinsell, D, et al. Establishing the case for CT angiography in the preoperative imaging of abdominal wall perforators. Microsurgery. 2008;28:306-313. Rozen, WM, Phillips, TJ, Ashton, MW, et al. Preoperative imaging for DIEA perforator flaps: a comparative study of computed tomographic angiography and Doppler ultrasound. Plast Reconstr Surg. 2008;121:1-8. Malhotra, A, Chhaya, N, Nsiah-Sarbeng, P, Mosahebi, A. CT-guided deep inferior epigastric perforator (DIEP) flap localization—better for the patient, the surgeon, and the hospital. Clin Radiol. 2013;68:131-138. Teunis, T, Heerma van Voss, MR, Kon, M, van Maurik, JF. CT-angiography prior to DIEP flap breast reconstruction: a systematic review and meta-analysis. Microsurgery. 2013;33:496-502. Klasson, S, Svensson, H, Malm, K, et al. Preoperative CT angiography versus Doppler ultrasound mapping of abdominal perforator in DIEP breast reconstructions: a randomized prospective study. J Plast Reconstr Aesthet Surg. 2015;68:782-786. Offodile, AC II, Chatterjee, A, Vallejo, S, Fisher, CS, Tchou, JC, Guo, L. A cost-utility analysis of the use of preoperative computed tomographic angiography in abdomen-based perforator flap breast reconstruction. Plast Reconstr Surg. 2015;135:662e-669e. Alderman, AK, Kuzon, WM Jr, Wilkins, EG. A two-year prospective analysis of trunk function in TRAM breast reconstructions. Plast Reconstr Surg. 2006;117:2131-2138. Wilkins, EG, August, DA, Kuzon, WM Jr, et al. Immediate transverse rectus abdominis musculocutaneous flap reconstruction after mastectomy. J Am Coll Surg. 1995;180:177-183. Hartrampf, CR, Scheflan, M, Black, PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg. 1982;69:216-225.A classic article and one of the earlier descriptions of the the pedicled TRAM flap and its vascular anatomy for breast reconstruction. Vyas, RM, Dickinson, BP, Fastekjian, JH, et al. Risk factors for abdominal donor-site morbidity in free flap breast reconstruction. Plast Reconstr Surg. 2008;121:1519-1526. Nahabedian, MY, Dooley, W, Singh, N, Manson, PN. Contour abnormalities of the abdomen after breast reconstruction with abdominal flaps: the role of muscle preservation. Plast Reconstr Surg. 2002;109:91-101. Nahabedian, MY, Manson, PN. Contour abnormalities of the abdomen after transverse rectus abdominis muscle flap breast reconstruction: a multifactorial analysis. Plast Reconstr Surg. 2002;109:81-87. Atisha, D, Alderman, AK, Janiga, T, et al. The efficacy of the surgical delay procedure in pedicle TRAM breast reconstruction. Ann Plast Surg.

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2009;63:383-388. Sbitany, H, Mirzabeigi, MN, Kovach, SJ, et al. Strategies for recognizing and managing intraoperative venous congestion in abdominally based autologous breast reconstruction. Plast Reconstr Surg. 2012;129:809-815. Reardon, CM, O’Ceallaigh, S, O’Sullivan, ST. An anatomical study of the superficial inferior epigastric vessels in humans. Br J Plast Surg. 2004;57:515-519. Spiegel, AJ, Khan, FN. An Intraoperative algorithm for use of the SIEA flap for breast reconstruction. Plast Reconstr Surg. 2007;120:1450-1459. Schaverien, M, Saint-Cyr, M, Arbique, G, Brown, SA. Arterial and venous anatomies of the deep inferior epigastric perforator and superficial inferior epigastric artery flaps. Plast Reconstr Surg. 2008;121:1909-1919.Contemporary cadaver studies of DIEP and SIEA flap zones of perfusion that demonstrate similar perfusion pattens for lateral row perforators and SIEA vascular pedicles, consistent with Holm’s Zones of perfusion. Medial row perforators were found to perfuse in a pattern similar to Zones described by Hartrampf. Holm, C, Mayr, M, Hofter, E, Ninkovic, M. Perfusion zones of the DIEP flap revisited: a clinical study. Plast Reconstr Surg. 2006;117:37-43.An evaluation of DIEP flap zones of perfusion using laser-induced fluorescence that redefined the zones of perfusion as described earlier by Hartrampf. Park, JE, Alkureishi, LW, Song, DH. TUGs into VUGs and friendly BUGs: transforming the gracilis territory into the best secondary breast reconstructive option. Plast Reconstr Surg. 2015;136:447-454. Arnez, ZM, Pogorelec, D, Planinsek, F, Ahcan, U. Breast reconstruction by the free transverse gracilis (TUG) flap. Br J Plast Surg. 2004;57:2026. Allen, RJ, Haddock, NT, Ahn, CY, Sadeghi, A. Breast reconstruction with the profunda artery perforator flap. Plast Reconstr Surg. 2012;129:16e-23e. Saad, A, Sadeghi, A, Allen, RJ. The anatomic basis of the profunda femoris artery perforator flap: a new option for autologous breast reconstruction—a cadaveric and computer tomography angiogram study. J Reconstr Microsurg. 2012;28:381-386. DeLong, MR, Hughes, DB, Bond, JE, et al. A detailed evaluation of the anatomical variations of the profunda artery perforator flap using computed tomographic angiograms. Plast Reconstr Surg. 2014;134:186e-192e. Haddock, NT, Greaney, P, Otterburn, D, et al. Predicting perforator location on preoperative imaging for the profunda artery perforator flap. Microsurgery. 2012;32:507-511. Hunsinger, V, Lhuaire, M, Haddad, K, et al. Medium- and large-sized autologous breast reconstruction using a fleur-de-lys profunda femoris artery perforator flap design: a report comparing results with the horizontal profunda femoris artery perforator flap. J Reconstr Microsurg. 2019;35(1):8-14. LoTempio, MM, Allen, RJ. Breast reconstruction with SGAP and IGAP flaps. Plast Reconstr Surg. 2010;126:393-401. Rad, AN, Flores, JI, Prucz, RB, et al. Clinical experience with the lateral septocutaneous superior gluteal artery perforator flap for autologous breast reconstruction. Microsurgery. 2010;30:339-347.

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CHAPTER 61

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Reconstruction of the Nipple-Areolar Complex Anne C. O’Neill and Toni Zhong

Key Points Reconstruction of the nipple-areolar complex (NAC) is the final step in the breast restoration process and should only be performed when optimal breast symmetry has been achieved. The nipple and areola are reconstructed separately. A number of local flaps have been described for reconstruction of the nipple. Maintaining nipple projection is one of the greatest challenges in NAC reconstruction. Areolar reconstruction can be achieved with pigmented skin grafts or tattooing. Nonsurgical options are also available and can achieve satisfactory reconstitution of the NAC. Reconstruction of the nipple-areolar complex (NAC) is most commonly performed as a component of breast reconstruction following mastectomy for the treatment of cancer. Other indications for NAC reconstruction may include trauma, burns, nipple loss following reduction mammoplasty, or congenital absence of the NAC (athelia) or breast (amastia). Reconstruction of the NAC was first described by Adams in 1944 and was followed by a steady evolution of techniques up to the early 2000s. 1,2 In recent years, however, there has been increasing acceptance of nipple sparing mastectomies, and the demand for NAC reconstruction has consequently declined. 3 Reconstruction of the NAC is usually the final stage in breast reconstruction and so for many women marks the completion of their breast cancer treatment. Although reconstruction of the NAC is a relatively simple procedure, it can make a significant contribution to patient satisfaction and psychosexual well-being. 4,5

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Preoperative Planning The nipple is an elevated structure that projects approximately 5 to 10 mm and arises in pigmented skin known as the areola, which is on average 4.2 to 4.5 cm in diameter. The NAC is a critical landmark of the breast. Other aesthetic components of the breast such as the inframammary fold (IMF), breast meridian, and parenchymal position are frequently assessed in terms of their relationship to the NAC. The NAC is generally situated at the prominence of the breast mound, but there is considerable variation in position, size, color, and texture in individual patients. The ideal NAC position is variably described as 22 to 24 cm from the sternal notch or the level of the midhumerus. In unilateral cases, the size and position of the reconstructed NAC is designed to match the contralateral side. In bilateral cases, the optimal position must be carefully selected, and the breast prominence, the breast meridian, the IMF, and the midline of the chest must be considered. Although some surgeons advocate simultaneous reconstruction of the breast and NAC, most would agree that NAC reconstruction should be performed 3 to 6 months later. 6-8 This enables the reconstructed breast to settle into its final position and allows the surgeon to consider any contralateral balancing procedures that may be required. For the purposes of reconstruction, the nipple and the surrounding areola are generally considered separately.

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Nipple Reconstruction Grafts The nipple share technique was introduced by Millard in 1972 and remains a popular technique in selected patients. 9 A segment of the contralateral natural nipple is harvested and transferred to the reconstructed breast as a composite graft. This technique is most effective in patients with a large contralateral nipple where projection exceeds 5 to 6 mm. It has been reported that composite nipple grafting can provide sensation and erectile function in the reconstructed nipple in some cases. 10 However, many patients are reluctant to have surgery on the normal nipple. The risk of reduced sensation and impaired erectile function at the donor site has limited the popularity of this technique. In an effort to avoid contralateral surgery, banking of the affected nipple at the time of mastectomy has been proposed. However, cryopreservation of the nipple results in tissue damage and loss of pigmentation that adversely affects aesthetic outcomes. 11 The desire to avoid surgery on the contralateral nipple has resulted in a number of alternative donor sites for nipple grafts including labia, earlobe, toe pulp, and skin from the postauricular area, medial thigh, and axilla. 12,13 Although most of these areas provide hyperpigmented skin, they usually fade over time and are a poor match for the contralateral nipple. The popularity of grafting has waned with the advent of a multitude of local flap techniques that eliminate the need for a secondary donor site and the risk of associated morbidity. Grafting remains a favorable option in patients who have thin skin and subcutaneous tissues following alloplastic breast reconstruction.

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Local Flaps The first description of nipple reconstruction using local skin flaps was by Berson in 1946. 14 A recent review by Sisti et al identified 30 subsequently described flap designs that have contributed to the evolution of nipple reconstruction in the intervening 70 years. 15 Nimboriboonporn and Chuthapisith proposed a simple classification system for these techniques that divided them into (1) centrally based flaps, (2) subdermal pedicle local flaps with single pedicle, and (3) subdermal pedicle local flaps with double pedicle. 16 Description of all the described local flap options for nipple reconstruction is beyond the scope of this chapter. The commonest techniques currently in use (skate flap, star flap, and C-V flap) consist of two larger lateral flaps that are approximated to create the circumference of the nipple and a smaller central flap that forms the tip of the nipple (Figure 61.1). Although several more complicated techniques have been described, most surgeons favor modifications of these classic flap designs because of their relative simplicity and the fact that complex designs with multiple incisions may be more prone to complications including contracture and loss of projection.

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FIGURE 61.1 A. Preoperative marking of a C-V flap for nipple reconstruction on a breast mound. Note that the base of the CV flap does not cross the mastectomy incision. B. C-V flaps incised and raised. C. The wings of the C-V flap and the cap of the C-V flap are closed. D. Final C-V flap closure.

The skate flap was among the first simple and effective techniques described and is named for its similarity to a skate fish. 17 It consists of two lateral wing flaps and a central head flap. It incorporates a superior deepithelialized area, which, together with the flap donor areas, accommodates application of a skin graft for reconstruction of the areola. The star flap described by Anton in 1991 is simpler in design than the skate flap and allows primary closure of the donor site. 18 The C-V flap represents a further simplification and has become a popular choice among surgeons with many minor modifications of the design described in the literature. 19-21

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Nipple Projection One of the greatest challenges in nipple reconstruction is achieving sustained projection. 22 Both graft and flap techniques retract over time, with long-term loss of nipple projection reported to be between 40% and 70%. 15 Studies suggest that the reconstructed nipple loses projection in the first 2 years postoperatively, after which time the height remains relatively stable. A good flap design can help minimize contracture of the nipple by providing well-vascularized tissue and reducing the number of incisions and subsequent scars that are subject to contractile forces. Although there have been few studies that directly compare flap techniques, it is though designs that include double wide-based flaps that preserve rich subdermal vascularity may limit postoperative contracture. 16 Incorporation of subcutaneous fat or de-epithelialized dermis into the lateral flaps may increase the bulk of the reconstructed nipple. 20,23 Centrally based flaps such as the quadrapod flap are subject to the highest degree of postoperative retraction. 24 Flap design must anticipate long-term loss of projection, and surgeons should aim to create a nipple that is at least 50% larger than required. Protective dressings or padding is frequently used to prevent local trauma and compression of the nipple in the early postoperative period. Augmentation techniques have been described in an effort to improve nipple projection. The addition of autologous auricular cartilage was advocated in the 1970s. 25 With the advent of microvascular breast reconstruction, costal cartilage was identified as a more accessible autologous material because it could be harvested and banked at the time of the initial breast reconstruction and eliminated the need for additional donor sites. 26 Although cartilage can help maintain projection, its use is associated with relatively high complication rates. Pressure necrosis can lead to ischemia of the flaps with exposure and loss of the cartilage graft. In more recent years, there has been increasing interest in the use of fat as an alternative autologous material. The soft consistency of fat grafts may reduce the risk of flap necrosis, but the impact on long-term nipple projection has yet to be established. 27 Acellular dermal matrix and prefabricated collagen tubes can also be used to support local flap reconstruction, but studies still report significant loss of projection over time. 28,29 Several alloplastic augmentation techniques have also been described including calcium hydroxylapatite, silicone, hyaluronic acid, and polytetrafluoroethylene. 30-32 Alloplastic materials carry the risk of infection and extrusion, making them less attractive than autologous options.

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Areola Reconstruction Skin-Grafting Techniques Skin grafts are commonly used for reconstruction of the areola, as they recreate natural variation in pigmentation and texture that can mimic Montgomery tubercles. The contralateral areola is the ideal source of donor skin but is rarely used unless the patient is undergoing a concomitant balancing breast reduction. Skin is more commonly harvested from areas of increased pigmentation such as the inner thigh, groin, or axilla. Grafting of the areola usually occurs at the same time as nipple reconstruction. An area of deepithelialization can be incorporated into the nipple flap design to accommodate the skin graft. Fading of pigmented skin grafts commonly occurs over time.

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Tattooing Intradermal tattooing has become a popular method of areola reconstruction. 33 It eliminates the need for additional donor sites and allows customization of areolar pigmentation, which optimizes aesthetic outcomes. Tattoo pigments, consisting of iron and titanium oxides, are deposited into the dermis using a dermabrasion technique. One of the commonest problems is fading of the pigment over time and the need for touch-up procedures. 34 The initial tattoo should be darker than required in anticipation of this. Deposition of pigment at the correct dermal level is also important because if it is too superficial, it will slough off in the early postoperative period, but if it is too deep, it will be degraded by macrophage activity. Tattooing is generally performed 6 to 8 weeks after reconstruction of the nipple. It can be challenging to achieve homogenous deposition of pigment in scarred tissues. In an effort to avoid this, some surgeons advocate tattooing of the areola prior to nipple reconstruction. 35 Recent years have seen significant advances in tattoo techniques. Using color shading, a very convincing NAC can be recreated without the need for flaps or grafts. The tattoo simulates the nipple projection through color contrasts and also mimics the texture of a natural areola. 36 Three-dimensional tattooing is generally performed by specialized medical tattoo artists and requires several sessions to achieve the end result.

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Prosthetics Nipple prostheses are an attractive option for patients who wish to avoid further surgery on the reconstructed breast. They may also be recommended in cases where NAC reconstruction might be considered high risk. The prostheses are made of soft silicone and are attached to the breasts using adhesives. They can be customized for color, shape, and texture to provide an exact match to the contralateral NAC.

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Pitfalls and Complications Although NAC reconstruction is relatively simple, it can be associated with significant complications including infection and flap or graft failure. Overall complication rates are lower with flap reconstruction of the nipple and tattooing of the areola, but selection of the optimal reconstruction technique in each individual patient is critical. 15 Particular caution is necessary in patients who have had alloplastic reconstruction with thin skin flaps and those who have had prior radiation. Local flap failure may be more common in these patients, resulting in dehiscence and, in severe cases, exposure of the underlying implant. Malposition of the NAC can compromise the overall aesthetic outcome of breast reconstruction and can be very difficult to correct. Repositioning of the reconstructed NAC usually requires local transposition flaps, which result in additional unfavorable scarring on the breast. Careful initial planning of NAC position and appropriate timing of reconstruction is essential. The commonest complications are loss of projection and fading of pigmentation over time. As these are almost inevitable with all current techniques, they must be anticipated and adjustments should be made to the reconstructive design to accommodate them.

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Questions 1. A 59-year-old woman is planning to undergo a delayed right breast reconstruction with a free deep inferior epigastric perforator (DIEP) flap. She will require a left-sided balancing mastopexy for symmetry. When is the optimal time to perform NAC reconstruction? a. At the time of DIEP breast reconstruction b. 3 months after DIEP breast reconstruction c. At the time of balancing mastopexy d. 3 months after balancing mastopexy 2. All the following materials have been used to augment nipple projection in a reconstructed NAC except: a. Silicone b. Calcium hydroxylapatite c. Hyaluronic acid d. Polyurethane e. Acellular dermal matrix 3. Possible complications following nipple-areolar reconstruction include the following except: a. Nipple malposition b. Loss of projection c. Increase in pigmentation d. Decrease in pigmentation e. Partial or complete nipple necrosis 4. What is the safest method of NAC reconstruction in a patient with a radiated implantreconstructed breast? a. 3D NAC tattooing b. Labial graft c. Nipple share d. C-V flap e. Skate flap with skin graft 5. The following landmarks should be taken into consideration for placement of the NAC reconstruction on the reconstructed breast mound except: a. Position of the opposite native NAC b. IMF c. Midhumeral point d. Breast meridian e. Midclavicular point 1. Answer: d. NAC reconstruction should be the final step in the reconstructive process. Although it is possible to reconstruct the nipple at the time of DIEP, it is difficult to predict the final position especially in delayed breast reconstruction when the flap would be expected to develop increased ptosis over time. Correct positioning of the reconstructed NAC is essential, and both the position of the NAC on the reconstructed breast and its relationship to the contralateral natural NAC must be considered. It is therefore important to perform the mastopexy prior to NAC reconstruction and to allow some time to determine the final position of the natural NAC following the balancing procedure. Nipple malposition can have a significant adverse effect on the final outcome of breast reconstruction. Correction of nipple malposition is difficult and results in additional scarring on the reconstructed breast.

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2. Answer: d. Several alloplastic augmentation techniques have also been described including calcium hydroxylapatite, silicone, hyaluronic acid, and polytetrafluoroethylene. Acellular dermal matrix has been inserted as well to increase nipple projection. Polyurethanes are in the class of compounds called reaction polymers, which include epoxies, unsaturated polyesters, and phenolics. They are not safe for placing into human tissues. 3. Answer: c. A common complication after nipple reconstruction is fading of nipple-areolar pigmentation over time, rather than increase in pigmentation. The decrease in NAC tattoo pigment can occur months to years after the procedure, and this is more commonly observed in patients with fair skin. 4. Answer: a. The safest method of NAC reconstruction in a patient with radiated breast implant reconstruction is 3D tattooing. In all the other methods of NAC reconstruction, incisions have to be placed, a flap has to be recreated, or a recipient bed has to be made to accept the flap or skin graft. In radiated breast tissue, vascularity is compromised, and all the techniques of grafts or flaps that rely on blood supply may be complicated by wound healing problems. Therefore, noninvasive procedures such as 3D tattooing may be the safest choice. 5. Answer: e. In a patient undergoing unilateral NAC reconstruction, the opposite or native position of the NAC must be taken into consideration when designing the placement of the NAC. In a patient undergoing bilateral NAC reconstruction, the caudal-cephalic position of the NAC needs to take into account the mid-humeral point, the IMF, and the sternal notch to reconstructed NAC distance. The medial to lateral position of the NAC needs to be placed along the meridian of the breast mound.

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References Adams, W. Free transplantation of the nipples and areola. Surgery. 1944;15:186-189. Farhadi, J, Maksvytyte, GK, Schaefer, DJ, et al. Reconstruction of the nipple-areola complex: an update. J Plast Reconstr Aesthet Surg. 2006;59(1):40-53. Peled, AW, Wang, F, Foster, RD, et al. Expanding the indications for total skin-sparing mastectomy: is it safe for patients with locally advanced disease? Ann Surg Oncol. 2016;23(1):87-91. Momoh, AO, Colakoglu, S, de Blacam, C, et al. The impact of nipple reconstruction on patient satisfaction in breast reconstruction. Ann Plast Surg. 2012;69(4):389-393.This article demonstrates the effect of nipple-areolar complex reconstruction on overall satisfaction and aesthetic scores in a large series of breast reconstruction patients. Wellisch, DK, Schain, WS, Noone, RB, Little, JW III. The psychological contribution of nipple addition in breast reconstruction. Plast Reconstr Surg. 1987;80(5):699-704. Delay, E, Mojallal, A, Vasseur, C, Delaporte, T. Immediate nipple reconstruction during immediate autologous latissimus breast reconstruction. Plast Reconstr Surg. 2006;118(6):1303-1312. Losken, A, Duggal, CS, Desai, KA, et al. Time to completion of nipple reconstruction: what factors are involved? Ann Plast Surg. 2013;70(5):530-532. El Amm, CA, Sung, JS, Sawan, KT, et al. Immediate nipple reconstruction using the everted umbilicus. Plast Reconstr Surg. 2011;128(2):91e92e. Millard, DR Jr. Nipple and areola reconstruction by split-skin graft from the normal side. Plast Reconstr Surg. 1972;50(4):350-353. Zenn, MR, Garofalo, JA. Unilateral nipple reconstruction with nipple sharing: time for a second look. Plast Reconstr Surg. 2009;123(6):16481653.This article discusses the benefits of the nipple share technique in selected patients and demonstrates that this is an excellent option particularly following alloplastic reconstruction or post radiation where local flaps may have high complication rates. Nakagawa, T, Yano, K, Hosokawa, K. Cryopreserved autologous nipple-areola complex transfer to the reconstructed breast. Plast Reconstr Surg. 2003;111(1):141-147; discussion 8-9. Adams, WM. Labial transplant for correction of loss of the nipple. Plast Reconstr Surg. 1949;4(3):295-298. Klatsky, SA, Manson, PN. Toe pulp free grafts in nipple reconstruction. Plast Reconstr Surg. 1981;68(2):245-248. Berson, MI. Construction of pseudoareola. Surgery. 1946;20(6):808. Sisti, A, Grimaldi, L, Tassinari, J, et al. Nipple-areola complex reconstruction techniques: a literature review. Eur J Surg Oncol. 2016;42(4):441465.The authors provide a detailed review of the many nipple-areolar reconstruction techniques that have been described and the associated risks and benefits. This is the most comprehensive review in the current literature. Nimboriboonporn, A, Chuthapisith, S. Nipple-areola complex reconstruction. Gland Surg. 2014;3(1):35-42.This article provides an excellent review of nipple-areolar reconstruction and presents a useful classification system for flap techniques. It also provides important insights into the mechanism of retraction in the reconstructed nipple. Little, JW, Spear, SL. The finishing touches in nipple-areolar reconstruction. Perspect Plast Surg. 1988;2:1-22. Anton, LE, Hartrampf, CR. Nipple reconstruction with local flaps: star and wrap flaps. Perspect Plast Surg. 1991;5(1):67-78. Losken, A, Mackay, GJ, Bostwick, J III. Nipple reconstruction using the C-V flap technique: a long-term evaluation. Plast Reconstr Surg. 2001;108(2):361-369. Temiz, G, Yesiloglu, N, Sirinoglu, H, Sarici, M. A new modification of C-V flap technique in nipple reconstruction: rolled triangular dermalfat flaps. Aesthet Plast Surg. 2015;39(1):173-175. Witt, P, Dujon, DG. The V-V flap—a simple modification of the C-V flap for nipple reconstruction. J Plast Reconstr Aesthet Surg. 2013;66(7):1009-1010. Zhong, T, Antony, A, Cordeiro, P. Surgical outcomes and nipple projection using the modified skate flap for nipple-areolar reconstruction in a series of 422 implant reconstructions. Ann Plast Surg. 2009;62(5):591-595.This article provides a detailed long-term evaluation of outcomes following nipple-areolar reconstruction using a single technique in a large series of patients. Jamnadas-Khoda, B, Thomas, R, Heppell, S. The ‘cigar roll’ flap for nipple areola complex reconstruction: a novel technique. J Plast Reconstr Aesthet Surg. 2011;64(8):e218-e220. Little, JW 3rd, Munasifi, T, McCulloch, DT. One-stage reconstruction of a projecting nipple: the quadrapod flap. Plast Reconstr Surg. 1983;71(1):126-133. Brent, B, Bostwick, J. Nipple-areola reconstruction with auricular tissues. Plast Reconstr Surg. 1977;60(3):353-361. Mori, H, Uemura, N, Okazaki, M. Nipple reconstruction with banked costal cartilage after vertical-type skin-sparing mastectomy and deep inferior epigastric artery perforator flap. Breast Cancer. 2015;22(1):95-97. Bernard, RW, Beran, SJ. Autologous fat graft in nipple reconstruction. Plast Reconstr Surg. 2003;112(4):964-968. Garramone, CE, Lam, B. Use of AlloDerm in primary nipple reconstruction to improve long-term nipple projection. Plast Reconstr Surg. 2007;119(6):1663-1668. Tierney, BP, Hodde, JP, Changkuon, DI. Biologic collagen cylinder with skate flap technique for nipple reconstruction. Plast Surg Int. 2014;2014:194087. Evans, KK, Rasko, Y, Lenert, J, Olding, M. The use of calcium hydroxylapatite for nipple projection after failed nipple-areolar reconstruction:

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early results. Ann Plast Surg. 2005;55(1):25-29. Lennox, K, Beer, KR. Nipple contouring with hyaluronics postmastectomy. J Drugs Dermatol. 2007;6(10):1030-1033. Wong, RK, Wichterman, L, Parson, SD. Skin sparing nipple reconstruction with polytetrafluoroethylene implant. Ann Plast Surg. 2008;61(3):256-258. Spear, SL, Convit, R, Little, JW III. Intradermal tattoo as an adjunct to nipple-areola reconstruction. Plast Reconstr Surg. 1989;83(5):907-911. Spear, SL, Arias, J. Long-term experience with nipple-areola tattooing. Ann Plast Surg. 1995;35(3):232-236. White, CP, Gdalevitch, P, Strazar, R, et al. Surgical tips: areolar tattoo prior to nipple reconstruction. J Plast Reconstr Aesthet Surg. 2011;64(12):1724-1726. Halvorson, EG, Cormican, M, West, ME, Myers, V. Three-dimensional nipple-areola tattooing: a new technique with superior results. Plast Reconstr Surg. 2014;133(5):1073-1075.

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CHAPTER 62

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Congenital Anomalies of the Breast: Tuberous Breasts, Poland Syndrome, and Asymmetry Kenneth L. Fan and Maurice Y. Nahabedian

Key Points Broadly speaking, pediatric breast disorders may be categorized into hypoplastic, hyperplastic, and deformational. Key moves in correction of tuberous breast deformity are periareolar approach to the breast, with radial scoring of constriction bands to the deep dermal plane as necessary, as well as partial subpectoral implant placement and circumareolar reduction of areola and herniated breast tissue. Classically, Poland syndrome has been treated with a pedicled latissimus flap and implants. In such a scenario, tissue expansion has been undertaken in the first stage to expand deficient breast tissue. A pedicled latissimus flap with implant placement is performed in a second stage. Increasing implant volume can provide an adjunct to camouflage chest wall deformities. Some authors have had success with multiple stages of lipofilling and free flap reconstruction. Gynecomastia requires complete medical workup for concomitant abnormalities in conjunction with medical physicians. At onset during adolescence, 1 year of observation is required as spontaneous regression may occur. Treatment involves liposuction with or without subglandular resection. Congenital breast deformities represent a source of significant anxiety and distress to the pediatric patient and their families. Broadly categorized, pediatric breast disorders can be thought of as hypoplastic, hyperplastic, or deformational as a framework for discussion among plastic surgeons. The first two are discussed in this chapter. The timing of surgical correction is critical as the operative plans must balance growth-related factors in light of the psychological trauma that may result from a persistent deformity. As a result, treatment goals rely on accurate diagnosis, timing, and technique selection in order to provide the best aesthetic result while addressing psychosocial needs.

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Embryology The breast is a modified apocrine sweat gland that commences development at around 6 weeks of life. Paired, proliferating epidermal cells migrate into mesenchymal tissue and form primitive mammary ridges, or milk line that extends ventrally along the embryo, from the axilla to the groin roughly lateral to the midclavicular line (Figure 62.1). Failure of development within this time results in complete absence of the breast. 1 Portions atrophy, except at the fourth intercostal space, which set the foundation for the primary mammary bud. Incomplete regression gives rise to ectopic breast tissue (polymastia) or supernumerary nipples (polythelia). Breast growth consists of ectodermal plaques branching into underlying mesenchyme, which proliferate and canalize to form lactiferous tissue by 8 weeks. 1 The lactiferous ducts open into the surrounding ectoderm, which develops into the areola at 5 months. By 6 months of gestational age, the basic framework and tubular architecture of the breast can be seen. With circulating estrogen and progesterone from the placenta, the lactiferous tissue continues branching into 2 years of life. The normal gland remains quiescent from 2 years until puberty.

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FIGURE 62.1 Embryonic mammary ridges. (Reproduced with permission from Weber, JR, Kelley, JH. Assessing breasts and lymphatic system. In: Weber, JR, Kelley, JH, eds. Health Assessment in Nursing. 5th ed. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2014:396-415. Figure 19-3.)

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At birth, the neonatal mammary tissue is functional. Seventy percent may secrete colostrum because of rise in prolactin. The nipples evert soon after birth because of proliferation of the underlying mesoderm. However, inverted nipples that remain until puberty is not uncommon. By 2 years of age, breast tissue grows at the same rate in the body, so long as estrogen levels are low. Sex hormones heavily influence the development of the breast in morphological stages as described by Tanner. 2 During Tanner stage 1, the breast is prepubertal, without appreciable breast parenchyma and slight nipple elevation. Tanner stage 2 begins with thelarche, around 9.7 years, as the nipple-areolar complex (NAC) widens and the breast and nipple become a small mound. Stage 3 is heralded with a further enlargement, as the breast extends beyond the borders of the areola. The NAC elevates above the breast contour as a secondary mound in stage 4. In stage 5, the breast achieves the final mature size and form.

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Hypoplastic Disorders Breast hypoplasia presents in a wide spectrum of phenotypes reflecting their underlying disease (Figure 62.2). Amazia, the absence of the breast without nipple absence, may occur unilaterally or bilaterally, in isolation or in conjunction with pectoralis hypoplasia. Athelia describes the absence of the NAC. Amastia is the complete absence of the breast unit, including the gland and nipple. Although these terminologies suggest otherwise, these abnormalities often occur together: athelia often occurs in conjunction with amazia.

FIGURE 62.2 Typical appearance of breast hypoplasia.

Accordingly, Trier et al. broadly categorized observed patterns of amastia and its suspected mode of inheritance into three groups: bilateral absence of the breast associated with congenital ectodermal defects, unilateral absence of the breast, and bilateral absence of the breast. 3 In congenital ectodermal defect, a sex-linked recessive disorder, additional abnormalities with the skin and its appendages, the teeth, and nails are present. Unilateral absence of the breast, when combined with pectoralis aplasia or hypoplasia, is considered a variant of Poland syndrome. Genetically inherited bilateral absence of the breast has been described. 1 Management of the hypoplastic/aplastic breasts requires consideration of the patient’s growth and contralateral breast size. Optimal timing is contingent on the deformity and the psychological and physical manifestations. Tissue expanders may be placed in the breast should the deformity cause profound psychosocial effects while the child is growing or if the skin envelope requires expansion.

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Implants, myocutaneous flaps, and autologous fat transfer are viable methods of reconstruction. Careful consideration of familial breast cancer history is mandatory when employing fat transfer techniques. Usually, nipple-areolar reconstruction is undertaken after a breast mound is created. Techniques include local flaps, skin grafts, cartilage grafts, acellular dermal matrices (ADMs), and/or NAC tattooing. 4

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Tuberous Breast First described by Rees and Aston in 1976, the tuberous breast (e.g., tubular breast, herniated areola complex, snoopy breast, constricted breast, lower pole hypoplastic breast, narrow-based breast, domed nipple, and nipple breast) abnormality represents a spectrum of abnormal breast shape (Figure 62.3). 5-7 The term tuberous refers to the similarity in shape to root tubers. 6 Rearing its phenotype only during puberty, the tuberous breast is characterized by 6 : Constricted skin envelope in the vertical and horizontal dimensions Deficiency in the base diameter (breast footprint) Elevated inframammary fold (IMF) Short nipple-to-IMF distance (high, tight fold) Herniation of the breast parenchyma through the areola resulting in enlarged diameter of the NAC. NAC involvement is present in about 50% of cases 8 Parenchymal hypoplasia Asymmetry

FIGURE 62.3 Bilateral type III tuberous breast. Both sides suffer from constricted envelope, deficiency of the base diameter, elevation of the inframammary fold with short nipple to inframammary fold distance, parenchymal hypoplasia, and asymmetry. The left side has more areolar herniation than the right.

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Grolleau proposed the most widely used classification scheme based on the initial work by Von Heimburg 7 (Figure 62.4): Type I Deformity: Only the medial quadrant is absent, the lower medial edge is shaped like an italic S, and the lateral breast is larger in comparison. Type II Deformity: Both lower quadrants are deficient, the areola points down, and the lower pole is constricted. Type III Deformity: All quadrants are deficient, the breast base is constricted both horizontally and vertically, and the breast is shaped like a tubercle.

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FIGURE 62.4 Grolleau classification of tuberous breast deformity. Blue on the right represents missing tissue. A. Type I: Medial quadrant absent. Lateral breast is large in comparison. B. Type II: Both lower quadrants are absent. The areola points down, and the lower pole is constricted. C. Type III: All quadrants are absent. The breast is constricted both in the horizontal and vertical dimension.

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Kolker and Collins further described the three tiers with additional pathologic findings (Table 62.1). 9 TABLE 62.1 Kolker and Collins’ Additions to the Modified Grolleau Classification Type

Base

Inframammary Fold

I

Minor constriction

Normal laterally, minor elevation medially

II

Moderate constriction Severe constriction

Medial and lateral elevation Elevation of the entire fold, or fold absence

III

Skin Envelope Sufficient

Breast Volume

Ptosis

Areola

Minimal deficiency, no deficiency, or hypertrophy

Enlargement

Inferior insufficiency Global insufficiency

Moderate deficiency

Mild, moderate, or severe None or mild

Severe deficiency

Mild ormoderate

Normal, mild, or moderate herniation Severe herniation

(From Kolker, AR, Collins, MS. Tuberous breast deformity: classification and treatment strategy for improving consistency in aesthetic correction. Plast Reconstr Surg. 2015;135(1):73-86.) Several etiologies have been proposed. Grolleau et al. postulated that anomalies in the superficial fascia in the lower pole of the breast lead to strong adherence between the dermis and the muscular plane. 7 During breast development, the growth of the breast cannot overcome this adherence. The peripheral expansion of the breast is restricted, resulting in preferential development forward. When the connective and muscular structure of the areola is weak, as seen in the severe variants, the gland herniates through the NAC. Mandrekas expanded on this with a ring theory by histologically demonstrating a dense constricting ring spanning from the periphery of the NAC to the lower part of the breast representing a thickening of the superficial fascia. 10 He postulated that this condensation of fascia may be caused by the joining of the deep and outer layers of the superficial fascia, which collectively envelope the breast, at a higher level, or a thickening of penetrating suspensory ligaments in the area. The constricting ring prevents normal breast expansion and development, and the breast tissue is forced through the outer layer of the superficial fascia resulting in vertical breast development herniating through the areola. The true incidence of tuberous breast deformity is variable and somewhat unknown. DeLuca-Pytell et al. reported 73% of females presenting for breast augmentation were found to have tuberous breast deformity, with the 60% of breasts having the most severe phenotype (Type III). 8 Ninety-eight percent of the patients with tuberous breasts were asymmetrical in size as well. However, such high incidence is debated, particularly by Zambacos and Mandrekas who report a 7% incidence among those who present for mammoplasty. 11 This discrepancy represents a diagnostic dilemma in tuberous deformity, as milder forms are commonly underappreciated and underdiagnosed. 9

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Surgical Correction of Tuberous Breast Deformity Surgical management of tuberous deformity requires close counseling and management of patient expectations. Although patients have semblance of breast deformity, few fully understand the anatomic deficits present and the challenge of restoration to a near normal appearance. Without proper education, many patients expect outcomes seen with primary breast augmentation. These principles of surgical treatment in tuberous breast deformity are adapted from Brown and Somogyi 12 : Release of the constricted base in both the vertical and horizontal plane from the tethering fibrous attachments and/or bands between the breast parenchyma and deep fascia and pectoralis muscle 6 Restoration of a normal nipple-to-IMF distance through expansion and/or mastopexy and lowering of the IMF Obliteration of the old IMF to avoid a double-bubble deformity Reduction of herniated tissue Correction of areola hypertrophy Restoration of breast volume Correction of breast asymmetry Critical analysis of deficiencies helps formulate a surgical plan. Simply placing an implant will fall short in correcting the tuberous breast (Figure 62.5). Kolker and Collins recently published an algorithm that should be helpful in approaching the tuberous breast deformity (Figure 62.6). 9 In most cases, when the soft tissues are distensible and the size goals are attainable, correction can be performed in a single stage. Two-stage procedures with expanders are reserved for the most severe cases when the lower pole skin is severely deficient, the base/IMF is severely constricted, and/or the patient desires a fuller size. In Kolker and Collins’ series, 8% of total or 30% of Groleau type III tuberous breast required expansion. 9

FIGURE 62.5 A standard augmentation mammoplasty will fall short in correcting the tuberous breast deformity.

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FIGURE 62.6 Treatment algorithm for tuberous breast deformity. (From Kolker, AR, Collins, MS. Tuberous breast deformity: classification and treatment strategy for improving consistency in aesthetic correction. Plast Reconstr Surg. 2015;135(1):73-86.)

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Approach The periareolar incision has become the most widely used as it provides access for the reduction of the areola, to the lower pole subglandular plane, and for radial division of the constriction ring. 4,9,13 It is important to avoid reduction of the areola until the implant is placed or tissue rearrangement is performed because the skin envelope is deficient: what may seem to be excess initially may ultimately not be. The alternative approach to the breast tissue is through an inframammary incision.

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Radial Scoring and Internal Tissue Rearrangement Release of the glandular and breast base constriction with radial scoring is an essential component of surgical correction. Rees and Aston first described radial scoring on the undersurface of the breast for expansion. 5 However, their description did not call for scoring to the deep dermis. For adequate release, bands at the base of the breast parenchyma and along the IMF are radially dissected from deep to the superficial until the deep dermis to the point visual and palpable release of the lower pole (Figure 62.7). 9

FIGURE 62.7 Radial scoring for release of the glandular and native inframammary fold constriction. (From Kolker, AR, Collins, MS. Tuberous breast deformity: classification and treatment strategy for improving consistency in aesthetic correction. Plast Reconstr Surg. 2015;135(1):73-86.)

Several methods of internal tissue rearrangements have been described. Dinner and Dowden advocated full-thickness skin and glandular incisions with transposition flaps, as they considered the skin itself to be constricting. 14 The addition of internal gland reshaping allowed for release of the constricting base and

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redistribution of tissue without external scars or contour abnormalities. 12 Puckett and Concannon 15 as well as Riberio et al. 16 described horizontal transection of the gland with folded-down internal flaps based on the subareolar tissue or posterior chest wall, respectively, to reconstitute the lower pole. Mandrekas and Zambacos utilized a periareolar incision to exteriorize the lower half of the breast. 10 A radial six o’clock incision was made to release the constricting ring, creating pillars to redrape and reconstitute the lower pole. Abbate, Fan, and Nahabedian described a new technique for correction of a tuberous breast with sufficient volume using a central mound mastopexy via an inverted-T incision. 17 The undersurface of the breast was scored to correct the base constriction without violating the central mound perfusion. The parenchymal herniation through the NAC was managed by de-epithelizing the central mound followed by imbrication sutures to create a tight dermal base and minimize the risk for future herniation. The success of these internal rearrangement techniques is contingent on the presence of enough tissue to augment the hypoplastic lower pole. In severe cases, these techniques may be less successful because of the paucity of breast tissue, thus necessitating the use of an implant.

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Implants Volume correction is often required because of the prevalence of asymmetries. Selection of the appropriate implant requires biodimensional planning that includes breast height, width, and tissue compliance. 12 Devices of various projections can be utilized to augment deficiency in the lower pole and maintain expansion of the released constricted base. The use of anatomical implants for tuberous breast can be considered to increase the volume in the lower pole and for tailoring of height, width, and projection. 12 Careful attention needs to be given to the IMF. Extending beyond the intended footprint of the breast during dissection may be difficult to correct. Some surgeons avoid lowering the IMF whenever possible owing to the possibility of implant malposition. 12,18 In patients with less severe tuberous deformities, the IMF is well defined, and further lowering the IMF may be counterproductive. In patients with severe tuberous breasts, correction is mandated because of a short nipple-to-IMF distance. In such situations, effacement of the existing IMF is necessary to avoid the double-bubble deformity by lysing fascial connections between the dermis and superficial fascia. 19 Extending radial scoring to the deep dermis may assist in this endeavor. Algorithms, such as ones borrowed from the breast augmentation literature by Tebbett based on implant volume, 20 Mallucci and Brandford ICE principle, 21 and Per Heden’s Akademikliniken method, 22 can assist in planning the final IMF location. The surgeon may also use cues from the contralateral IMF or the ridges made by the patient’s ideal bra to roughly determine where the IMF will sit. Working backwards from the aforementioned IMF algorithms can help in selecting an implant preoperatively. Correction of asymmetry may be adjusted by varying implant sizes, although some authors remove excess gland from the deepest aspect of the subareolar gland to keep the implant size similar and prevent future herniation. 9 The ideal plane for implant placement is somewhat controversial. The initial descriptions for correction of tuberous breast demonstrated that implant placement should be in the subglandular plane for the prosthesis to shape and expand the constricted breast without tethering of the pectoralis muscle. 9,12 However, subglandular implants have been associated with increased rates of capsular contracture with visible implant margins and rippling in patients because of a paucity of parenchyma. The use of anatomic implants can mitigate these effects, especially when placed in a dual-plane position. In patients with a tuberous breast deformity, a dual-plane III, which is defined as prepectoral undermining to the upper edge of the NAC, is usually performed to redrape the gland over the implant, and expand the parenchymal malposition and the short lower pole skin.

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Mastopexy Following placement of the permanent implant, final determination on the extent of areolar correction is judged. The periareolar incision may be converted to circumareolar mastopexy with an interlocking purse-string suture technique to reduce areolar dimensions. 9,23 When a patient presents with severe ptosis and a less severe tuberous deformity, a circumvertical mastopexy can be performed as needed using a tailor-tack approach. Complications seen in tuberous breast deformity are similar to that observed in mastopexy. Implant insertion with the additional complications from implant malposition and persistence of the fold produces a double-bubble contour. Management of these complications is further discussed in the cited articles. 12,19,24

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Poland Syndrome Poland syndrome, described by Alfred Poland in 1851, is a rare congenital malformation with an incidence of 1 in 7000 to 100,000. 4 Generally cases are unilateral, but bilateral anomalies have been described. Sporadic cases are hallmarked by 2 to 3:1 higher incidence in males, with 60% to 75% affecting the right side (Figure 62.8). 25 Familial cases have equal incidence in sexes and laterality. Classically, Poland syndrome was defined as the absences of the pectoralis major and ipsilateral hand abnormality (Figure 62.9). Hypoplasia or absence of the sternocostal head of the pectoralis major results in the absence of the anterior axillary fold, subclavicular hollowing, and a pathognomonic groove at the junction of the superior anterior axillary line and chest wall. 13 However, current thought is that Poland syndrome comprises hypoplasia/absence of the pectoralis major with at least two of these minor criteria 4,25,26 : Hypoplasia or absence of the breast Absence of the nipple Absence of axillary hair Absence of adjacent muscles (e.g., latissimus dorsi, serratus anterior, external oblique, deltoid, infraspinatus, supraspinatus, and pectoralis minor) Absence of costal cartilage and anterior ribs Absent subcutaneous tissue Axillary webbing Ipsilateral brachydactyly, brachysyndactyly, or amelia

FIGURE 62.8 A. Moderate to severe Poland syndrome in a male patient. Note the lack of anterior axillary fold and sunken chest. B. Moderate Poland deformity in the female patient. Note the lack of anterior axillary fold and subclavicular hollowing. The breast is characterized by hypoplasia, elevated inframammary fold, and superiorly displaced and underdeveloped nippleareolar complex.

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FIGURE 62.9 Anatomic representations of the classic Poland syndrome.

Comprehensive clinical classification is difficult because of the diversity in presentation. The general classification used was introduced by Foucras et al. and categorized the severity of disease to mild, moderate, and severe, as summarized in Table 62.2. 4,6,27 TABLE 62.2 Expanded Classification of Poland Syndrome 27,29 Type

Breast

Nipple Areola

Pectoralis Major

Mild Moderate

Hypoplasia, asymmetry Significant hypoplasia, aplasia, asymmetry Complete aplasia

Small, elevated Hypoplastic, absent Hypoplastic,

Hypoplasia Absent sternocostal head

Thoracic Skeleton None Moderate

Complete absence (including surrounding

Severe

Severe

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absent

musculature)

Breast anomalies among females are variable and range from mild hypoplasia to amastia. 25 Poland syndrome is involved in 14% of breast aplasia. 6 In the mild form, structural abnormalities may only be appreciated radiographically. 28 These patients may be referred to the plastic surgeon for mild asymmetry, without a formal diagnosis. 29 The mild variant of Poland syndrome is more common than the classic full presentation with an incidence of 1 in 16,500 live births. 25 The moderate variant of Poland syndrome represents the classic form and is characterized by hypoplasia of breast parenchyma, high IMF, and an underdeveloped and superiorly displaced NAC, with the absence of the anterior axillary fold. The severe variant of Poland syndrome represents the most challenging to reconstruct and is characterized with a marked deformity of the chest wall with tight chest skin and axillary webbing. 28 Ribiero and colleagues suggested obtaining CT scans to evaluate the structural abnormalities. 29 Cases have been reported in which a prominent posterior fold was evident on clinical examination with compensatory hypertrophy of the teres major that simulated the normal contraction of the latissimus dorsi muscle. 30 The frequency of hand abnormalities with Poland syndrome is 13.5% to 56%; in turn, 10% of syndactyly is a result of Poland syndrome. 25 The spectrum may range from webbing of the fingers, fusion of the carpal bones, absence of phalanges, and syndactyly to shortened forearm and/or upper arms. Aplasia of the ribs and cartilage involving rib segments two to five often leads to severe chest depression in 11% to 25% of patients. Eight percent of patients may have lung herniation. Dextrocardia is present in 5.6% of patients, which rises to 9.6% when the deformity was on the left side. Poland syndrome can be associated with Mobius and Klippel-Feil syndrome. 25 Termed acro-pectoralrenal defect, an association with aplasia of the pectoralis major exists with renal anomalies (e.g., unilateral renal agenesis or duplication of the urinary collecting system). 5 Renal ultrasounds are recommended for all patients with aplasia of the pectoralis. Certain cancers are known to exist with Poland syndrome owing to suppression of homeobox and tumor suppression genes: leukemia, non-Hodgkin lymphoma, cervical cancer, leiomyosarcoma, and lung cancer. Despite being hypoplastic, breast cancer has been reported to occur in patients with Poland syndrome and therefore standard monitoring is required. The etiology of Poland syndrome remains unclear; however, the leading theory suggests by the sixth week of gestation, when the limb bud is adjacent to the chest wall, interruption of the embryonic blood supply results in hypoplasia of the subclavian artery or its branches. 25 The severity and location of the flow impairment dictates the structures compromised (i.e., internal thoracic artery leading to absence of the sternocostal head of the pectoralis major; brachial artery leading to hand anomalies; and suprascapular artery leading to elevation or winging of the scapula, Sprengel deformity).

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Surgical Correction of Poland Syndrome Skeletal deformities should be addressed before breast reconstruction. 13 Significant chest wall depression, inadequate protection of the mediastinum, and paradoxical movement of the chest wall are indications for chest wall reconstruction. 6 When residual chest wall defects persist, custom silicone implants can be considered. Owing to the lack of a pectoralis major as an interposing muscle, placement of a chest wall prosthesis will result in implant-to-implant contact that may increase the likelihood of reconstructive failure. 31 Seyfer et al. reported a 100% complication rate using this technique and eventually abandoned it because of local complications that included migration, contour irregularities, and discomfort. 32 An alternative for the simple chest deformity included using the latissimus dorsi muscle to contour the chest wall followed by placement of a thin mammary prosthesis to correct the subclavicular hollow and to provide a more tolerable feel and appearance. The timing of breast reconstruction for patients with Poland syndrome is another important consideration. It is commonly delayed until late adolescence or adulthood when breast development is complete, with the pedicle latissimus dorsi flap most commonly used. Patients who have completed breast reconstruction during their later years have been shown to have body image disorders that are unalleviated by reconstructive efforts. 33 Therefore, there is a trend toward less invasive modalities such as fat grafting and tissue expander placement at earlier ages to relieve psychosocial morbidity. The breast of the Poland syndrome patient presents several challenges: deficient subcutaneous tissue, contracted skin envelope, deficient subcutaneous tissue, NAC malposition or absence, high IMF, and caliber of recipient vessels if free flap reconstruction is necessary. 6 Combination of modalities as listed below is often necessary for optimal reconstruction in severe cases.

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Fat Grafting The use of lipofilling to correct contour abnormalities has become a cornerstone in treatment of mild Poland deformity. Lipofilling can be used primarily or secondarily with other procedures. Fat grafting has made the correction of mild to moderate contour abnormalities, such as improvement of the subclavicular hollow and absence of the anterior axillary fold, possible in short procedures. 34 Lipofilling can also be used to camouflage chest abnormalities and may obviate the need for custom silicone devices. The low morbidity of this procedure has permitted its safe use in adolescent females at the onset of puberty. Transfers may be staged at 4- to 6-month intervals to simulate natural breast growth. 35 Fat grafting techniques have also been used in patients with a history of breast cancer with long-term followup demonstrating oncologic safety. 36 Although radiographic distortions are possible with fat grafting, modern imaging modalities are able to differentiate between microcalcification due to fat grafting and malignancy.

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Expander and Implant Reconstruction Patients with less severe phenotypes (grade I or mild II) may be managed with prosthetic reconstruction alone. A prerequisite to direct to implant reconstruction is adequate soft-tissue coverage. When there is a soft-tissue deficiency and the IMF is high and tight, placement of tissue expanders can be beneficial. The expansion of the breast lower pole may bring down a superiorly malpositioned NAC. A contralateral symmetry procedure, such as a mastopexy or augmentation, may be required. The primary complication arising from the placement of an implant alone is capsular contracture and is most likely increased because ofsubcutaneous placement. Seyfer’s series treated 15 patients with implants alone, and 6 (40%) required open capsulotomy. 32 In the event of prosthetic failure, autologous tissue may be added to improve outcomes. In a series by Gautam et al., there were 12 cases in which a perforator flap was used in patients with Poland syndrome who had prior implant failure. 37 Although our understanding of prepectoral implant placement using ADMs has improved in patients following mastectomy, there have been no descriptions of use of ADM to secure the implant and to reduce the incidence of capsular contracture in Poland syndrome.

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Autologous Tissue The pedicled latissimus dorsi flap in combination with a prosthetic device has been the most common form of reconstruction in women with Poland syndrome. This can be performed simultaneously or in stages. The staged approach often begins with tissue expansion followed by a latissimus dorsi flap. 13 Seyfer et al. reported a 0% revision rate of patients treated with this technique. The transfer of the latissimus dorsi flap facilitated the creation of an anterior axillary fold and also camouflaged the subclavicular hollow. The latissimus muscle may be reinserted anteriorly on the humerus, simulating the pectoralis major insertion. Although 66% of patients required a contralateral symmetry procedure, the latissimus transfers were well tolerated without upper extremity weakness. The correction of Poland deformity with free tissue transfer is another option when pedicled options are not available. Longaker et al. described their experience using free flaps (eight TRAMs, two SGAPs, one IGAP, and one contralateral TRAM) in nine patients with Poland syndrome. 38 Complications included one flap loss because of venous outflow anomalies in the subscapular system. Gautam et al. described a series of 12 perforator flaps to reduce donor site morbidity. 37 The recipient vessels in all patients were the internal mammary vessels. Success was excellent with no take-backs or flap failures. Dos Santos Costa et al. described using a laparoscopically harvested pedicled omentum flap based completely on the right gastroepiploic artery and tunneled subcutaneously through the IMF. 39 Four to six months are required for volume equalization of the omentum. Eighty percent of patients required additional implants. Huemer utilized myocutaneous gracilis flaps to approach reconstructions. 40 When correction of the infraclavicular territory was necessary, an ipsilateral free gracilis flap was anastomosed to the thoracodorsal vessels. When correcting for breast volume, the free gracilis flap was placed in a retroglandular position and anastomosed to the internal mammary vessels. Because of the incidence of vascular anomalies in the recipient vessels, preoperative angiography should be strongly considered when proceeding with free tissue transfer options. 30 A secondary implant or lipofilling can be considered as needed for additional volume.

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Anterior Thoracic Hypoplasia Anterior thoracic hypoplasia was described by Spear et al. and represents a distinct entity separate from Poland syndrome. 31 Although Poland syndrome has a hallmark of hypoplasia or aplasia of the pectoralis major, anterior thoracic hypoplasia presents with hypoplasia of the ipsilateral breast, superior displacement of the NAC, and posterior displacement of the ribs with sunken chest wall but a normal pectoralis major and sternum position. All patients in his series were treated with a partial submuscular anatomical implant.

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Hyperplastic Disorders Virginal Mammary Hypertrophy Virginal hypertrophy (e.g., juvenile hypertrophy, gigantomastia) of the breast is a rare condition characterized by rapid, excessive, and unyielding proliferation of one or both breasts in the adolescent years for at least 6 months (Figure 62.10). Reports have demonstrated that breasts may grow as large as 13 to 23 kg. 41 Virginal hypertrophy, which occurs after a few months after puberty, is differentiated from prepubertal hypertrophy, which is before puberty and usually bilateral. Associated symptoms include shoulder and neck pain, bra strap grooving, and rashes. The parenchyma is often tender, with thin skin and dilated veins. Although there is no consensus on exact etiology, the leading theories include excess local estrogen production and estrogen end-organ sensitivity. 6 The differential diagnosis includes but is not limited to fibroadenoma, phyllodes tumor, lymphedema, endocrine conditions, rheumatologic diseases, and lymphoma. 42 Optimal management usually requires a team approach with pediatric and medical disciplines involved in making the diagnosis.

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FIGURE 62.10 Bilateral virginal hypertrophy in a 16-year-old girl.

There has been a myriad of medical options for management that have included dydrogesterone, bromocriptine, and medroxyprogesterone; however, tamoxifen administration for 4 months has been shown to be the most effective in retarding or arresting breast growth. Its use is limited by the side effects in the pediatric population, which includes hot flashes, venous thrombosis, osteoporosis, and endometrial hyperplasia. The ultimate treatment, however, remains surgical and most commonly includes reduction mammaplasty and in some cases, mastectomy. Hoppe et al., in the largest systematic review of virginal hypertrophy, demonstrated that recurrence of breast growth is sevenfold higher following a reduction mammaplasty compared with mastectomy. 42 To preserve lactation and aesthetic outcome, most physicians recommend reduction mammaplasty with preservation of the NAC on a vascularized pedicle to avoid the psychologic sequela of a mastectomy in the pediatric patient. It is best to defer reduction mammaplasty until the later years of adolescence to reduce the risk of recurrence and revision surgery. 41,43 In severe cases, early identification is important to minimize the extent of surgery and associated

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morbidity. 4,42 It is important to have in-depth discussions with patients preoperatively to set expectations and review sequela, especially relating to breast feeding. With careful preservation of the subareolar gland, most studies have indicated the rates of breast feeding in patients with breast hypertrophy with and without reduction mammaplasty to be equivalent (∼60%). 44 In both control and operated groups, 34% to 39% of these patients required supplementation of breast milk. Although this was not studied directly in virginal hypertrophy, these statistics are helpful in counseling.

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Giant Fibroadenoma During adolescence, 75% to 95% of breast lesions are fibroadenomas. 41 Generally, they are wellcircumscribed, painless, rubbery, and mobile masses of benign connective tissue and epithelial proliferation. Giant fibroadenoma refers to when the tumor is larger than 5 cm in diameter and/or weighs more than 500 g (Figure 62.11). At this point, skin changes, venous dilation, and in severe instances, skin ulceration of overlying tissue may occur. Ultrasound may reveal a well-circumscribed avascular mass. Although the diagnosis is clinical, confirmation may be obtained with a fine-needle aspiration. 41 Timing is dictated by rate of growth. However, earlier intervention may be necessary to prevent distortion of existing tissue. Treatment involves removing the lesion in the well-demarcated plane. To fill in large cavities, tissue rearrangement techniques are required with consideration to the pedicle and nipple perfusion. Pathologically, fibroadenoma is difficult to distinguish from phyllodes tumor, which has an incidence of less than 1.3%. 6,41 Should a diagnosis of malignant phyllodes tumor be made, consultation with surgical oncology or pediatric surgery is appropriate.

FIGURE 62.11 Giant fibroadenoma.

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Polythelia and Polymastia Polythelia is relatively common and occurs in up to 5.6% of male and female patients along the milk lines. 45 These cases are generally sporadic; however, cases of familial inheritance patterns have been reported. They may be associated with nephrourologic abnormalities and therefore a urinalysis and renal ultrasound is necessary. Excision is typically performed before puberty begins with an elliptical excision. Delay of treatment, especially in females, may require a wider incisional pattern as glandular tissue may become involved. Polymastia, with or without the NAC, may also occur along the embryonic mammary ridges, most commonly in the axilla with a prevalence of 1% to 2%. 46 Although sporadic, familial cases and associated renal abnormalities have been identified. Polymastia differs from ectopic breast tissue, as ectopic breast tissue is outside the mammary ridges. Unlike polythelia, polymastia is usually not identified until after puberty, pregnancy or lactation, and when hormonal influences enlarge the breast tissue. These lesions generally present with discomfort during certain points of the menstrual cycle. This accessory breast tissue may be excised and closed primarily over a drain as needed. If excision is forgone, then screening for malignancy is necessary because breast cancer can occur with the accessory tissue at an equal rate to the natural breast.

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Gynecomastia Gynecomastia is the most common form of breast hypertrophy in men with an overall incidence of 32% to 36% and up to 65% in adolescent males (Figure 62.12). 47 Bilateral disease occurs in 25% to 75% of individuals. Although most cases of gynecomastia during adolescents are idiopathic, the most common cause in those >40 years old is most often drug induced. Idiopathic or physiologic gynecomastia is typically a reflection of the hormonal milieu, with a relative predominance of estrogen. Such times occur with neonates because of circulating maternal estrogen, puberty when there is an excess amount of estradiol versus testosterone, and in the elderly (>65) when both a decline in androgen and aromatization peripherally of testosterone to estrogen occur.

FIGURE 62.12 Bilateral gynecomastia.

Workup of gynecomastia begins with a detailed history and physical examination as outlined by Rohrich. It is necessary to identify pathologic causes that include testicular cancer, pituitary tumors, adrenal tumors, liver disease, paraneoplastic syndrome, Klinefelter syndrome, thyroid disease, renal failure, myotonic dystrophy, human immunodeficiency virus, marijuana use, alcohol, anabolic steroids, and medications (Figure 62.13). 47 Physical examination will help distinguish pseudogynecomastia, for which enlargement is due to fat deposition in light of obesity without glandular hypertrophy.

47

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FIGURE 62.13 Preoperative algorithm for gynecomastia. (From Rohrich, RJ, Ha, RY, Kenkel, JM, Adams, WPJr. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111(2):909-923.)

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Various staging classifications have been described. Simon and Kahn described a classification system based on skin and tissue excess: Grade 1: slight breast enlargement without redundancy, Grade 2A: moderate breast enlargement without skin redundancy, Grade 2B: moderate breast enlargement with marked skin redundancy, and Grade 3: marked breast enlargement and skin redundancy. 48 Webster described a classification based on tissue type 49 : Type I: Presence of glandular tissue Type II: Presence of fatty and glandular mix Type III: Presence of simple fatty tissue Rohrich described the most utilitarian method for classifying gynecomastia, based on the amount and character of breast hypertrophy and degree of ptosis (Table 62.3). 47 TABLE 62.3 Classification and Management of Gynecomastia Classification Grade I  IA

Description Minimal hypertrophy (500 g of breast tissue with grade I ptosis Glandular or fibrous Severe hypertrophy with grade II or III ptosis Glandular or fibrous

Management Ultrasound-assisted liposuction or suction-assisted lipectomy Ultrasound-assisted liposuction

Ultrasound-assisted liposuction or suction-assisted lipectomy Ultrasound-assisted liposuction Ultrasound-assisted liposuction with or without staged excision Ultrasound-assisted liposuction with or without staged excision

(From Rohrich, RJ, Ha, RY, Kenkel, JM, Adams, WPJr. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111(2):909-923.) The onset of gynecomastia is characterized by fibroblastic stromal and ductal proliferation, which may resolve spontaneously. However, when persisting beyond a year, these tissues rarely regress, as stromal fibrosis and hyalinization occur with minimal ductal proliferation. Should a pathologic cause be present, treatment of such agents or disease is required in conjunction with a medical doctor. The risk of breast cancer in patients with gynecomastia remains equivalent when compared with the normal male population. The incidence of breast cancer is 60 times higher in patients with gynecomastia associated with Klinefelter syndrome when compared with the general population and thus necessitates mastectomy. 47 Tamoxifen has been successful in the treatment of glandular gynecomastia in which there is a palpable nodule under the areola. 50 Other medications such as testosterone, danazol, and clomiphene have had limited success. Surgical management is considered for persistent breast enlargement after 1 to 2 years. Techniques have evolved from the classic open approach to the minimally invasive approaches. Liposuction presented a breakthrough when it was introduced as a primary modality over surgical excision, reducing the incidence of postsurgical contour abnormalities and asymmetry. Rohrich advocates use of ultrasoundassisted liposuction as a first-line treatment, arguing that the emulsification of the fat, connective tissue, and skin retraction is advantageous when compared with traditional liposuction. 47 In addition to suctioning in the intermediate fat layer, the subdermal and subareolar regions are suctioned for maximal skin retraction and disruption of the fibroconnective tissues (Figure 62.14). In this study, 87% of men were

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treated with traditional or ultrasound-assisted liposuction alone. In 13%, 6 to 9 months were allowed to elapse for maximal skin retraction before secondary excision was performed.

FIGURE 62.14 Pattern of ultrasound-assisted liposuction. Liposuction ports are made in the lateral inframammary fold crease. Adherent zones in the upper outer quadrants (red), in proximity to the axillary tissue, should be suctioned with caution. (From Stranix, JT, Hazen, A. Gynecomastia. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer Health; 2019.)

Most practitioners perform a single-stage correction, with liposuction and the excision of the subglandular tissue through a partial periareolar approach. Overzealous subareolar resection may lead to a saucer-type deformity under the areola. It is therefore advisable to leave a layer of fibrous tissue under the areola for a smooth contour to avoid this complication. An alternative to excision is to use an arthroscopic shaver to treat the excess subareolar tissue, obviating the need for an incision. 51 In patients with severe gynecomastia, there are several methods by which the excess skin and gland can be managed. These include circumareolar de-epithelialization and gland resection through an inferior transdermic approach, circumvertical reduction pattern, or free nipple graft. 52,53 Postoperatively, compression garments are worn for at least 6 weeks, and heavy exercise should be avoided for 1 month.

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Conclusion Congenital anomalies of the breast represent a rare and diverse set of disorders requiring application of various principles of breast reconstruction with consideration of growth and psychosocial impact. Careful determination of all the deformities present is crucial, and surgeons need to have a frank discussion of goals and the potential impact correction has to the aesthetic and functional (e.g., breast feeding) outcomes. It has become commonplace for early identification of hyperplastic disorders and intervention to limit the extent of surgery and body image disorders, as well as to preserve lactation and optimize aesthetic outcomes. 42 Although correction of hypoplastic breast deformity has traditionally been postponed until late adolescence after growth completed, studies now demonstrate improved psychosocial benefit with the early minimally invasive techniques. 33

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Questions 1. What is the key pathological feature of Poland syndrome? a. Hand abnormalities b. Chest depression c. Hypoplasia or absence of the pectoralis major d. Hypoplastic or absent breast e. Absence of the latissimus dorsi 2. Where is the most common site for polymastia to occur? a. Axillary region b. Underneath the breast c. Near the groin d. On the abdomen 3. An 18-year-old female with a history of tuberous breast deformity comes into your clinic requesting evaluation for unsatisfactory aesthetic appearance. She has had a previous partial submuscular breast augmentation performed by another surgeon. On examination, she appears to have a double-bubble deformity. What key maneuver was missed in the initial operation? a. Complete release of the pectoralis major b. Ablation of the old IMF c. Placement of the implant’s partial submuscular plane d. Radial scoring of the undersurface of the breast 4. A 13-year-old boy with a BMI of 22 presents with bilateral fibrofatty tissue underneath his nipples recalcitrant to exercise regimens for the past 3 months. The lesions have caused him significant distress at the gym and when swimming. A full workup has elicited no pathologic cause. What is the most appropriate next step in management? a. Surgical excision b. Selective estrogen receptor modulators c. Continued weight loss d. Observation and follow-up for 6 to 8 months 5. What tumor is most clinically difficult to distinguish from fibroadenoma? a. Phyllodes tumor b. Intraductal carcinoma c. Fibrocystic lesion d. Intraductal papilloma 1. Answer: c. Poland syndrome represents a highly variable constellation of syndromes revolving around structures supplied by the subclavian vessels. Hypoplasia or absence of the pectoralis major represents the central pathologic finding of Poland syndrome. Additional abnormalities that may be seen include hypoplasia or absence of the breast, absence of the nipple, absence of the axillary hair, absence of adjacent muscles (e.g., latissimus dorsi, serratus anterior, external oblique, deltoid, infraspinatus, supraspinatus, and pectoralis minor), absence of costal cartilage and anterior ribs leading to chest wall abnormality, and upper limb malformations. 2. Answer: a. The most common location of the polymastia is the axillary region. 46 These lesions typically present with pain that may coincide with menstrual cycles or lactation separate from the breast tissue itself. Excision requires preservation of the intercostobrachial and associated nerves. The rate of malignancy is equal, and pathologic examination of the sampling is necessary. 3. Answer: b. Ablation of the old IMF is the key maneuver to eliminate double-bubble deformity. In

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an excellent review of the topic by Handel, he demonstrates the double-bubble deformity is not caused by disruption of an IMF ligament but by failure to fully detach the superficial fascial system from the dermis. 19 The IMF is created by attachment from the superficial fascial system to the dermis. In routine breast augmentations without manipulation of the fold, the implant lies beneath the pectoralis fascia, and the superficial fascia relationships are undisturbed. In the more severe cases of tuberous deformity, owing to the short nipple-to-IMF distance, inferior dissection and displacing the fold to a caudal location is typically necessary. Dissection is continued in a plane underneath the superficial fascia. The superficial fascia and dermis attachments from the old IMF persist with inadequate ablation, resulting in double-bubble deformity. 4. Answer: d. The patient likely suffers from benign pubertal gynecomastia, which may respond spontaneously. Therefore, observation is prudent. Beyond 1 year, the tissue rarely regresses as stromal fibrosis and hyalinization set in. At this point, surgical therapy is indicated. While weight loss is encouraged, suggesting continued weight loss would resolve gynecomastia is inappropriate. 5. Answer: a. Fibroadenoma can be clinically difficult to distinguish from phyllodes tumor. Making such diagnosis may require pathological examination. 41 Histologically, phyllodes tumor shows more stromal proliferation. However, malignant phyllodes tumor has the ability to metastasize and recur locally. These lesions are hallmarked by obvious sarcomatous elements. In adults, surgical treatment requires a 1 cm surgical margin to reduce recurrence rates. There are some who believe the adolescent phyllodes tumor is less aggressive and therefore can be excised with a small rim for a surgical margin.

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References Lin, KY, Nguyen, DB, Williams, RM. Complete breast absence revisited. Plast Reconstr Surg. 2000;106(1):98-101. Marshall, WA, Tanner, JM. Variations in pattern of pubertal changes in girls. Arch Dis Child. 1969;44(235):291-303. Trier, WC. Complete breast absence: case report and review of the literature. Plast Reconstr Surg. 1965;36(4):431-439. Egro, FM, Davison, EH, Namnoum, JD, Shestak, KC. Congenital breast deformities. In: Neligan, P , ed. Plastic Surgery. Vol 2. Philadelphia, PA: Elsevier; 2017. Rees, TD, Aston, SJ. The tuberous breast. Clin Plast Surg. 1976;3(2):339-347.The authors describe the tuberous breast deformity for the first time and postulate reconstruction efforts that now serve the basis of modern techniques. Shestak, KC, Rottgers, SA, Grunwaldt, L, et al. Congenital anomalies of the breast: tuberous breasts, Poland’s syndrome, and asymmetry. In: Thorne, C , ed. Grabb and Smith’s Plastic Surgery. 7th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2014:668-677. Grolleau, JL, Lanfrey, E, Lavigne, B, et al. Breast base anomalies: treatment strategy for tuberous breasts, minor deformities, and asymmetry. Plast Reconstr Surg. 1999;104(7):2040-2048. DeLuca-Pytell, DM, Piazza, RC, Holding, JC, et al. The incidence of tuberous breast deformity in asymmetric and symmetric mammaplasty patients. Plast Reconstr Surg. 2005;116(7):1894-1899. Kolker, AR, Collins, MS. Tuberous breast deformity: classification and treatment strategy for improving consistency in aesthetic correction. Plast Reconstr Surg. 2015;135(1):73-86.This recent article demonstrates a large series (n = 51) on correction of tuberous breast. The authors comprehensively discuss their classification system, their algorithm for correction, and their results. Mandrekas, AD, Zambacos, GJ. Aesthetic reconstruction of the tuberous breast deformity: a 10-year experience. Aesthet Surg J. 2010;30(5):680692. Zambacos, GJ, Mandrekas, AD. The incidence of tuberous breast deformity in asymmetric and symmetric mammaplasty patients. Plast Reconstr Surg. 2006;118(7):1667. Brown, MH, Somogyi, RB. Surgical strategies in the correction of the tuberous breast. Clin Plast Surg. 2015;42(4):531-549. Nahabedian, MY. Breast deformities and mastopexy. Plast Reconstr Surg. 2011;127(4):91e-102e. Dinner, MI, Dowden, RV. The tubular/tuberous breast syndrome. Ann Plast Surg. 1987;19(5):414-420. Puckett, CL, Concannon, MJ. Augmenting the narrow-based breast: the unfurling technique to prevent the double-bubble deformity. Aesthet Plast Surg. 1990;14(1):15-19. Ribeiro, L, Canzi, W, Buss, A Jr, Accorsi, A Jr. Tuberous breast: a new approach. Plast Reconstr Surg. 1998;101(1):42-50. Abbate, OA, Fan, KL, Nahabedian, MY. Central mound mastopexy for the correction of tuberous/tubular breast deformity. Plast Reconstr Surg Glob Open. 2017;5(11):e1545. Swanson, E. Can we really control the inframammary fold (IMF) in breast augmentation? Aesthet Surg J. 2016;36(10):NP313-NP314. Handel, N. The double-bubble deformity: cause, prevention, and treatment. Plast Reconstr Surg. 2013;132(6):1434-1443.This in-depth article reviews the double-bubble deformity in the context of the inframammary fold. The authors describe the pathologic and clinical basis of the IMF, a commonly poorly understood and complicated structure. Tebbetts, JB, Adams, WP. Five critical decisions in breast augmentation using five measurements in 5 minutes: the high five decision support process. Plast Reconstr Surg. 2005;116(7):2005-2016. Mallucci, P, Branford, OA. Design for natural breast augmentation: the ICE principle. Plast Reconstr Surg. 2016;137(6):1728-1737. Heden, P, Jernbeck, J, Hober, M. Breast augmentation with anatomical cohesive gel implants: the world’s largest current experience. Clin Plast Surg. 2001;28(3):531-552. Hammond, DC, Khuthaila, DK, Kim, J. The interlocking Gore-Tex suture for control of areolar diameter and shape. Plast Reconstr Surg. 2007;119(3):804-809. Brown, MH, Somogyi, RB, Aggarwal, S. Secondary breast augmentation. Plast Reconstr Surg. 2016;138(1):119e-135e. Fokin, AA, Robicsek, F. Poland’s syndrome revisited. Ann Thorac Surg. 2002;74(6):2218-2225.This article is the most comprehensive review on the clinical findings and chest reconstruction associated with Poland syndrome. Yiyit, N. Definition of the inclusion criteria of Poland’s syndrome. Ann Thorac Surg. 2014;98(5):1886. Foucras, L, Grolleau-Raoux, JL, Chavoin, JP. [Poland’s syndrome: clinic series and thoraco-mammary reconstruction: report of 27 cases]. Ann Chir Plast Esthet. 2003;48(2):54-66. Namnoum, JD. Breast Reconstruction in patients with Poland syndrome. In: Spear, SL , ed. Surgery of the Breast: Principles and Art. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2011:1416-1424. Ribeiro, RC, Saltz, R, Mangles, MG, Koch, H. Clinical and radiographic Poland syndrome classification: a proposal. Aesthet Surg J. 2009;29(6):494-504. Beer, GM, Kompatscher, P, Hergan, K. Poland’s syndrome and vascular malformations. Br J Plast Surg. 1996;49(7):482-484. Spear, SL, Pelletiere, CV, Lee, ES, Grotting, JC. Anterior thoracic hypoplasia: a separate entity from Poland syndrome. Plast Reconstr Surg. 2004;113(1):69-77. Seyfer, AE, Fox, JP, Hamilton, CG. Poland syndrome: evaluation and treatment of the chest wall in 63 patients. Plast Reconstr Surg. 2010;126(3):902-911.The authors describe their method of correction in 63 patients with Poland syndrome. They outline their methods of correction for each deformity.

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Baldelli, I, Santi, P, Dova, L, et al. Body image disorders and surgical timing in patients affected by Poland syndrome: data analysis of 58 case studies. Plast Reconstr Surg. 2016;137(4):1273-1282. Pinsolle, V, Chichery, A, Grolleau, JL, Chavoin, JP. Autologous fat injection in Poland’s syndrome. J Plast Reconstr Aesthet Surg. 2008;61(7):784-791. Delay, E, Sinna, R, Chekaroua, K, et al. Lipomodeling of Poland’s syndrome: a new treatment of the thoracic deformity. Aesthet Plast Surg. 2010;34(2):218-225. Cohen, O, Lam, G, Karp, N, Choi, M. Determining the oncologic safety of autologous fat grafting as a reconstructive modality: an institutional review of breast cancer recurrence rates and surgical outcomes. Plast Reconstr Surg. 2017;140(3):382e-392e. Gautam, AK, Allen, RJ Jr, LoTempio, MM, et al. Congenital breast deformity reconstruction using perforator flaps. Ann Plast Surg. 2007;58(4):353-358. Longaker, MT, Glat, PM, Colen, LB, Siebert, JW. Reconstruction of breast asymmetry in Poland’s chest-wall deformity using microvascular free flaps. Plast Reconstr Surg. 1997;99(2):429-436. dos Santos Costa, S, Blotta, RM, Mariano, MB, et al. Aesthetic improvements in Poland’s syndrome treatment with omentum flap. Aesthet Plast Surg. 2010;34(5):634-639. Huemer, GM, Puelzl, P, Schoeller, T. Breast and chest wall reconstruction with the transverse musculocutaneous gracilis flap in Poland syndrome. Plast Reconstr Surg. 2012;130(4):779-783. Chang, DS, McGrath, MH. Management of benign tumors of the adolescent breast. Plast Reconstr Surg. 2007;120(1):13e-19e. Hoppe, IC, Patel, PP, Singer-Granick, CJ, Granick, MS. Virginal mammary hypertrophy: a meta-analysis and treatment algorithm. Plast Reconstr Surg. 2011;127(6):2224-2231. van Aalst, JA, Phillips, JD, Sadove, AM. Pediatric chest wall and breast deformities. Plast Reconstr Surg. 2009;124(suppl 1):38e-49e. Cruz, NI, Korchin, L. Lactational performance after breast reduction with different pedicles. Plast Reconstr Surg. 2007;120(1):35-40. Schmidt, H. Supernumerary nipples: prevalence, size, sex and side predilection—a prospective clinical study. Eur J Pediatr. 1998;157(10):821823. Grossl, NA. Supernumerary breast tissue: historical perspectives and clinical features. South Med J. 2000;93(1):29-32. Rohrich, RJ, Ha, RY, Kenkel, JM, Adams, WP Jr. Classification and management of gynecomastia: defining the role of ultrasound-assisted liposuction. Plast Reconstr Surg. 2003;111(2):909-923.In this landmark article, the authors classify gynecomastia, review historical correction, describe algorithm of workup, present treatment plan, and review results. They make a strong case for the use of ultrasound-assisted liposuction in the correction of gynecomastia. Simon, BE, Hoffman, S, Kahn, S. Classification and surgical correction of gynecomastia. Plast Reconstr Surg. 1973;51(1):48-52. Webster, JP. Mastectomy for gynecomastia through a semicircular intra-areolar incision. Ann Surg. 1946;124:557-575. Khan, HN, Rampaul, R, Blamey, RW. Management of physiological gynaecomastia with tamoxifen. Breast. 2004;13(1):61-65. Petty, PM, Solomon, M, Buchel, EW, Tran, NV. Gynecomastia: evolving paradigm of management and comparison of techniques. Plast Reconstr Surg. 2010;125(5):1301-1308. Persichetti, P, Berloco, M, Casadei, RM, et al. Gynecomastia and the complete circumareolar approach in the surgical management of skin redundancy. Plast Reconstr Surg. 2001;107(4):948-954. Hammond, DC. Surgical correction of gynecomastia. Plast Reconstr Surg. 2009;124(suppl 1):61e-68e.

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PA R T V I I

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Body Contouring 63. Principles of Plastic Surgery After Massive Weight Loss 64. Liposuction, Abdominoplasty, and Belt Lipectomy 65. Lower Body Lift and Thighplasty 66. Brachioplasty and Upper Trunk Contouring

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CHAPTER 63

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Principles of Plastic Surgery After Massive Weight Loss Omar E. Beidas and Jeffrey A. Gusenoff, and Ernest K. Manders

Key Points Massive weight loss patients require comprehensive preoperative evaluation and management of expectations. Optimization of patients preoperatively is paramount to minimizing or avoiding complications. Multiple procedures can be performed simultaneously depending on patient priorities and degree of deformities. Staging procedures can minimize operative time and avoid opposite vectors of tension. Although complications following body contouring for the massive weight loss patient are common, most are minor and managed as an outpatient basis. The obesity epidemic in the United States and subsequent popularity in weight loss, whether by means of bariatric surgery or diet and exercise, echeloned a new subspecialty of plastic surgery. Massive weight loss (MWL), commonly defined as a loss of greater than 50% of excess weight above ideal body weight (IBW), has caused an explosion of patients seeking removal of excess skin and fat. This population deserves special consideration, as MWL has been found to be a predictor for wound complications in those undergoing body contouring surgery. 1 A comprehensive evaluation must take a multitude of factors into account to safely and effectively care for the patient. Every patient presents an interesting and unique challenge; therefore, approaches must be tailored to the individual. Attention to detail keeps both surgeon and patient out of trouble. This chapter focuses on the overall assessment and management of the weight loss patient, with procedural details described in Chapters 64–66.

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Preoperative Planning MWL leads to various deformities in all regions of the body, resulting in excess loose skin and fat. Although many medical diseases are improved or even cured by means of weight loss, the redundant skin is a constant reminder of the patient’s former self when looking in the mirror. Common complaints from patients include inability to properly fit in clothing, buildup of moisture in skin folds leading to intertriginous rashes and recurrent infections, and social stigma. Regardless of the weight loss method, patients should be congratulated on their tremendous achievement and reminded that their visit with the plastic surgeon ushers the beginning of the end of their journey. It is imperative that the surgeon performs a careful assessment of any patient who presents for body contouring after MWL to optimize the patient and minimize complications.

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Weight Loss Method Most patients undergo weight loss surgery, some achieve weight loss via diet and exercise, whereas a few resort to medication-induced methods of weight loss. If surgery was performed, it is important to note the type of procedure, whether laparoscopic or open, need for revisions or adjustments, and presence of a subcutaneous port. Weight loss by pharmacologic methods can be risky and unpredictable given the lack of long-term data. Dietary supplements or drugs may not have Food and Drug Administration approval and can have serious untoward effects. Similarly, fad diets do not have enough evidence to substantiate them. Interestingly, complications from body contouring in this population are similar independent of weight loss method. 2

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Weight History History should include the timeline of weight gain and subsequent loss, with particular attention paid to the method of weight loss. Bariatric surgery typically causes a precipitous drop in weight for the first year, thereafter a slow decline. A patient often reaches a nadir then climbs to within 10% of this value before plateauing at this new level. Additional information to obtain at the initial visit is maximum, minimum, and current weights. MWL patients have an almost three-fold increased risk of wound healing complications compared to non-MWL patients, and the risk is highest in those who have lost over 100 pounds. 1 Before enlisting a patient for body contouring after weight loss, weight should remain stable—within 5 kg —for at least 3 months. 3 If a patient is still actively losing weight, or intends to, then he or she should be reevaluated at 3 to 6 month intervals until down to the desired weight. Ideally, patients should be at or close to their goal weight, as results are significantly improved when weight is shed before surgery rather than after.

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Nutritional Assessment Because most patients presenting to the plastic surgeon for body contouring achieve MWL by means of bariatric surgery, it is vital to perform a comprehensive nutritional assessment as part of the evaluation. Diet, including daily protein and liquid intake, should be documented. The American Dietetic Association (ADA) recommends a daily protein intake of 1 to 1.5 g/kg of IBW, or approximately 60 to 80 g for most adults. ADA guidelines suggest 2 L (8 cups, or 64 ounces) of fluid intake per day. It is best that patients eat a healthy-balanced diet and exercise regularly. Given that the stress of surgery can increase energy expenditure up to 25%, 4 patients should be accordingly counseled to increase their daily protein consumption to 75 to 100 g in the perioperative period. This increased protein intake should be maintained for at least 2 weeks preoperatively and 4 weeks postoperatively. Symptoms of chronic malnutrition range in form and severity, including but not limited to fatigue, muscle aches, and peripheral neuropathy. A history of dumping syndrome should be elicited, characterized by postprandial symptoms of abdominal pain, nausea, emesis, and diarrhea. Dumping syndrome is seen mostly in gastric bypass patients and is caused by a rapid emptying of stomach contents into the small intestine. Generally, the solution is to avoid foods with a high sugar content as these are not well-tolerated by the postbariatric surgery patient. If any concerns arise from the patient or physician perspective, the patient should be referred to their bariatric team to address these issues before proceeding with body contouring. As many as 50% of postbariatric surgery patients have at least one elemental or nutritional deficiency as a result, with a greater risk after procedures with a malabsorptive component such as Roux-en-Y gastric bypass surgery. 5-7 Many of these nutrients and vitamins are necessary cofactors for general metabolism and wound healing. 8 Patients who achieved weight loss by surgical means often require supplementation. 9 Therefore, nutritional assessment should include screening of iron, albumin, and vitamins A, B, and D. Iron-deficiency anemia is the most common preoperative deficiency found in the MWL population 10 and is most prevalent in women of childbearing age. 11 Referral to a hematologist to optimize hemoglobin before surgery can avoid need for perioperative transfusion. Not only are low albumin levels associated with poor wound healing, but also levels below 2.1 g/dL are predictive of increased mortality rates postoperatively. 12,13 Vitamin B (thiamin) deficiency should be suspected in any patient with intractable emesis, as late recognition can lead to serious consequences 14,15 (Table 63.1). TABLE 63.1 Common Vitamins and Elements That Require Supplementation After Bariatric Surgery a Vitamin/Mineral

Etiology of Malabsorption

Calcium

Deficient Patients (%) 10,16-19 40%-50%

Iron (Fe)

25%-50%

Decreased gastric acid

Vitamin B1

20%-30%

Decreased oral intake; persistent nausea/vomiting

(thiamin)

Absorption sites (duodenum and jejunum) bypassed

Symptoms/Complications of Deficiency

Muscle weakness/tetany Osteoporosis Microcytic anemia Fatigue Generalized weakness Neurologic manifestations Wernicke encephalopathy Beriberi

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Supplementation Recommendations b Calcium citrate 1500 mg 
 PO daily

Iron sulfate 325 mg PO daily

12 mg PO daily

Vitamin B9

30%-50%

Poor dietary intake

Vitamin B12

10%-15%

Decreased intrinsic factor (produced in antrum of stomach) required for absorption in terminal ileum

PO: 500 µg daily Megaloblastic anemia IM or SQ: 1000 µg Peripheral neuropathy injection monthly

Vitamin D

20%-40%

Poor sun exposure

Ergocalciferol (D2) or Osteoporosis cholecalciferol (D3) 3000 Increased risk of IU PO daily infection, chronic disease

Zinc

20%-40%

Absorption sites (duodenum and jejunum) bypassed

(folate)

Thrombocytopenia Changes in pigmentation or ulceration of skin or mucosa

Decrease immune system function Poor wound healing Hair loss Folate deficiency

500 µg PO daily

10 mg PO daily

a

Signs of deficiency should be screened for at any visit to allow for correction before serious complications arise.

b

These are recommendations for supplementation in a person with already-established normal levels of micronutrients based on the American Society for Metabolic Surgery. 20 In a patient with lower than reference range levels, patients require larger doses and closer monitoring. Recommendations for women attempting to get pregnant or currently pregnant are generally higher. This table is not allencompassing, and there are several other doses and routes of administration for many of these supplements. IM, intramuscular; IU, international units; PO, per os (oral); SQ, subcutaneous.

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Medical Comorbidities It is important to document a patient’s medical comorbidities before and after weight loss, as many conditions will improve if not resolved after achieving a more IBW. Medical diseases such as diabetes, hypertension, hyperlipidemia, gastroesophageal reflux disease, and obstructive sleep apnea, among others, are improved or possibly entirely eliminated. However, these and others may be present and must be optimized before any operative procedure. Principles outlined in Chapter 16 should guide management options, and referrals to specialists made accordingly. It is recommended that a complete blood count be obtained on all patients who have experienced MWL. Although all patients will experience some degree of amelioration in medical conditions, not all will be completely alleviated. Therefore, surgeons treating these patients should be familiar with common disease states with which they may present. The three most common diseases patients present with after MWL are depression (53%), arthritis (41%), and anxiety (27%). 10

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Body Mass Index A crucial factor in determining a patient’s suitability for surgery is body mass index (BMI). Although no threshold exists, BMI should be under or as close to 30 kg/m2 preoperatively, because there is an increased risk of complications in patients who have a BMI above this threshold. Specifically, in the body contouring population, higher BMI at time of presentation is associated with increased complications. 17 Deformities can vary after weight loss so distribution of residual obesity is best evaluated on an individual basis. An example could be performing a patient with a BMI above 40 kg/m2 who has difficulty ambulating secondary to a heavy, hanging panniculus that ulcerates and makes exercise difficult. Patients such as these should be optimized and offered a panniculectomy to motivate further weight loss. Such procedures should be focused and expedited to minimize complications in this patient population.

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Medical, Surgical, and Social History The surgeon must be conscientious that body contouring after weight loss is elective and should remind the patient as such. Even though surgery may be life-changing, it will likely never be life-saving as these patients are unlikely to suffer a mortality if they do not undergo surgery. With that in mind, modifiable risk factors should be maximally optimized before signing a patient up for these operations. Use of nicotine products, as discussed in Chapter 16, is the single most easily modifiable risk factor. It is not advisable to operate on patients actively using any form of nicotine product as these procedures often have lengthy incisions that are at high risk for wound dehiscence or delayed healing. History of previous surgeries should be elicited, and scars in the anatomical region of the procedure should be sought to avoid complications secondary to vascular compromise. Planned surgery on the abdomen should include a thorough examination of the abdominal wall and any potential hernias. Patients who have undergone adjustable gastric band (AGB) procedures should have a subcutaneous port on the abdominal wall, and this may need to be relocated intraoperatively. Given that many of these procedures have a significant scar burden, patients must be willing to accept a trade-off of aesthetic result for a scar. Patients need to understand that there is a delicate balance between scar burden and aesthetic outcome, but certain deformities can only be corrected with a greater scar load.

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Medications Guidelines for management of medications for the body contouring patient in the perioperative period is akin to most patients, and is covered in Chapter 16. Additional care should be taken if patients are actively taking weight-loss drugs. Surgeons must ask about birth control or other hormone medications, as this is pertinent for calculating a Caprini score. The surgeon must be aware of restrictions on postoperative medications in bariatric surgery patients. Patients who have undergone AGB must take oral medications in crushed, liquid, chewable, suspension, or sublingual forms. In those who have had Roux-en-Y gastric bypass, nonsteroidal antiinflammatory drugs are contraindicated due to the perceived risk of ulceration, 21 although this has not been studied.

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Staging Patients presenting after MWL usually have many areas in need of body contouring. It is best to have the patient prioritize the regions they desire corrected and, together with the surgeon, create a plan. Variables that may influence the timing and staging include the number of surgeons, procedure setting, regional laws, and the patient’s financial resources. Procedures may have to be staged to minimize operative time and avoid opposite vectors of skin tightening. Some procedures may be combined safely, whereas certain procedures should not be combined in the same operative setting. 22,23 Given that many of these procedures are not covered by health insurance carriers, patients may space surgeries due to financial implications. Staging may not be a bad option, however, because it allows for minor revisions and corrections of areas previously operated on. Finally, patients generally desire new areas contoured after initial stages and may return to have other body regions corrected. 24 For global body contouring, including procedures on the chest or breast, trunk, upper and lower extremities in a healthy patient without financial constraints, a two-stage approach may be used. A common two-stage practice involves a circumferential trunk procedure and upper body procedure such as either mastopexy or brachioplasty, followed later by the second stage to encompass the other upper body procedure and thigh lift. Unless extraordinary circumstances dictate a more accelerated timeline, surgeries should be spaced with a minimum of 3 months in between to allow for the tissues to heal, assessment of skin relaxation, and improved patient recovery.

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Markings Preoperative markings serve for surgeons either as an estimate that is verified intraoperatively or as the final cutting guide. Therefore, it is critical that the patient understand the markings and final scar placement. An easy approach is to mark the patient in clinic the day before surgery in front of a mirror and show the patient the expected scar location. This allows ample time for marking without interruptions, is less invasive and more comfortable for the patient than the holding area, and provides time for questions.

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Special Considerations Despite being already covered in Chapter 16, perhaps in no other patient is attention to certain perioperative factors as important as the MWL patient, namely venous thromboembolism (VTE) prophylaxis and intraoperative body temperature. For truncal reshaping procedures, some surgeons prefer to prep the patient while in the standing position, then have him or her move onto a sterile draped operating room table. Extremities should be prepped circumferentially for easy movement and access to all areas, permitting liposuction of other regions of the extremity or the excision site itself.

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VTE Prophylaxis Worthy of mention in the patient population is proper management of VTE prophylaxis. Risk of VTE in the post-MWL patient is around 3%, and the risk in those with a BMI over 35 kg/m2 triples to approximately 9%. 25 Although no consensus guidelines exist for the post-MWL patient, the 2005 Caprini score should be used as a reference. At a minimum, either compression stockings or intermittent pneumatic compression devices should be applied throughout the patient’s stay, and patient should be encouraged to ambulate on the evening of surgery.

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Body Temperature Given that hypothermia can increase complications postoperatively and body-contouring procedures often require exposure of a large body surface area, it is critical to take all possible precautions to avoid hypothermia. 26,27 Hypothermia is easier to treat before rather than after it sets in, so appropriate measures should be in place to prevent its occurrence. In addition to the methods described in Chapter 16, certain techniques can be employed in the MWL patient to decrease the risk. One technique involves making a sterile warming blanket sandwich, using a forced air heating pad interposed between two sterile drapes. In this manner, the entire surgical region may be prepped, but any areas not actively being operated on may be covered and warmed without interrupting the flow of the procedure.

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Complications Even though postoperative complications in the MWL population can be quite frequent, fortunately they are usually minor and amenable to treatment on an outpatient basis. Most commonly observed are delayed wound healing and wound dehiscence, underscoring the importance of preoperative nutrition optimization. Wound breakdown should be presumed to be a result of nutritional deficiency until proven otherwise. Another common complication is seroma, which can be decreased with drain use. If drain output continues to preclude removal of drains, chemical sclerosis can be performed. If drains were not used or a seroma appears after drain removal, percutaneous needle aspiration can be done up to three times, after which time placement of a seroma catheter is recommended. Rarely, the patient may require reoperation to excise the seroma cavity. Systemic complications tend to be more serious and can range from VTE to death. Early serious surgical site complications that may require intervention include hematoma, which may require operative drainage; surgical site infection, necessitating oral or intravenous antibiotics; nerve injuries, possibly needing exploration in the operating room. Late surgical site complications include scar widening or hypertrophy, as well as chronic draining wounds or sinus tracts. Surgery on the extremities can lead to lymphedema, with the lower extremities more commonly affected. Postoperative numbness of the surgical site is normally transient and resolves with time. If a nerve injury is identified intraoperatively, it should be repaired. If a patient complains of numbness postoperatively, it is expected to resolve with time, sometimes taking up to a year. However, if a patient reports numbness in a nerve outside of the zone of operation, such as an ulnar nerve neuropathy during abdominoplasty, this is more likely to be related to improper positioning or padding of the nerve intraoperatively. These nerve symptoms generally resolve spontaneously, although patients require reassurance throughout this period. The most feared complication of body contouring surgery is resecting so much tissue that closure becomes impossible with the tissue left behind. This is prevented by use of judicious measuring and resection of tissue. The best practice to avoid this complication is by verifying the marks several times, and by committing to only one margin of resection and raising flaps toward the opposite margin until these edges can be brought together without undue tension.

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Outcomes Studies have shown that, overall, patients who have body contouring after weight loss have better quality of life (QoL) outcome measures as compared to weight loss patients who do not undergo plastic surgery. Body contouring after MWL provides patients with improved self-esteem, social life, work ability, and sexual and physical activity. 28 Specifically, after lower body lift, patients have higher levels of self-
 esteem and self-confidence and feel more attractive. 29 These improved QoL measures persisted for years after plastic surgery.

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Questions 1. A 45-year-old woman presents for abdominoplasty. She has two children delivered via C-section and desires improved abdominal contour. She smokes half a pack of cigarettes a day but is otherwise healthy. Which of the following is the best approach to her operative management? a. Ask her to quit and proceed with surgery next week b. Deny her surgery for her smoking habit c. Proceed with surgery since half a pack of cigarettes a day is not detrimental d. Refer her to another physician willing to operate on smokers e. Wait until she has stopped smoking for 4 weeks and check her urine cotinine before proceeding with surgery 2. A 37-year-old woman presents to your clinic desiring correction of breast ptosis and abdominal skin laxity. She underwent laparoscopic Roux-en-Y gastric bypass surgery 6 months ago and reports her weight has been stable for the past month. Her BMI in your office is 33 kg/m2. She has no other significant medical problems and she would like both procedures at the same stage. What is the best management of this patient? a. Defer surgery until her weight has been stable for a minimum of 3 months b. Defer surgery until she is 1-year postbariatric surgery c. Perform the abdominoplasty first to promote further weight loss, then the mastopexy in a second stage d. Proceed with surgery as soon as possible 3. A 41-year-old man presents after losing 50 kg through diet and exercise. He has gynecomastia as depicted in Figure 63.1. On physical examination, there is significant fibrous tissue in the retroareolar region. What is the best treatment option for this patient?

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FIGURE 63.1

a. Inframammary fold excision with free nipple graft b. Liposuction only c. Periareolar incision, direct excision d. Wise-pattern reduction 4. What is the appropriate antibiotic and dose for preoperative prophylaxis in a 50-year-old man who has no known drug allergies and weighs 128 kg? a. Cefazolin 2 g b. Cefazolin 3 g c. Clindamycin 600 mg d. Clindamycin 900 mg e. Vancomycin 1500 mg 1. Answer: e. Smoking is a modifiable risk factor that can reduce complications after surgery. Nicotine can lead to vasoconstriction and reduced oxygenation of healing tissues, leading to

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increases in wound healing problems and infection. The best option is to counsel the patient to stop and check her urine for smoking 2 weeks before surgery. Urine cotinine tests can take up to 10 days to get the results, so it should not be used close to the surgical date. Many surgeons advise smoking cessation for 4 weeks before and after surgery. Having a smoking policy in place can avoid postoperative complications. 2. Answer: a. Patients who present after MWL, regardless of weight method, should have a stable weight for at least 3 months before undergoing a body contouring procedure. Patients often lose weight and reach plateaus at several points in their weight loss cycle then go on to lose again; therefore, a one-month period is of insufficient length to deem stable. In addition, further weight loss will surely improve this patient’s BMI, perhaps even bringing it below 30 kg/m2, reducing her risk substantially. 3. Answer: a. In a patient with excess bulk and a long nipple to inframammary fold distance such as the one pictured, a direct excision with free nipple graft is needed to remove the tissue and move the nipple-areola complex (NAC) to the proper location on the chest wall. Liposuction only or direct excision would be insufficient to treat the excess tissue or move the NAC to the correct location, or both. A pedicled reduction would be too bulky to fit the pedicle under the skin envelope. 4. Answer: b. The correct dosing for a patient who has no allergy to penicillin or cephalosporins is 2 g in patients under 120 kg of weight and 3 g in patients over 120 kg of weight. Clindamycin 600 mg is no longer recommended, and the standard dose for patients with a true cephalosporin allergy is 900 mg. In special circumstances, including a history of methicillin-resistant Staphylococcus aureus infection, vancomycin 1500 mg should be used.

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References Constantine, RS, Davis, KE, Kenkel, JM. The effect of massive weight loss status, amount of weight loss, and method of weight loss on body contouring outcomes. Aesthet Surg J. 2014;34(4):578-583.This study examined the differences in complication rates between MWL and non-MWL patients undergoing the same procedures. Results from 450 patients showed that those who lost more than 100 lb of weight were in the highest risk category. Chetta, MD, Aliu, O, Tran, BA, et al. Complications in body contouring stratified according to weight loss method. Plast Surg (Oakv). 2016;24(2):103-106. Bond, DS, Phelan, S, Leahey, TM, et al. Weight-loss maintenance in successful weight losers: surgical vs non-surgical methods. Int J Obes (Lond). 2009;33(1):173-180. Van Way, CW III. Nutritional support in the injured patient. Surg Clin North Am. 1991;71(3):537-548. Halverson, JD. Metabolic risk of obesity surgery and long-term follow-up. Am J Clin Nutr. 1992;55(2 suppl):602S-605S. van der Beek, ES, Monpellier, VM, Eland, I, et al. Nutritional deficiencies in gastric bypass patients; incidence, time of occurrence and implications for postoperative surveillance. Obes Surg. 2015;25(5):818-823. Stein, J, Stier, C, Raab, H, Weiner, R. The nutritional and pharmacological consequences of obesity surgery. Aliment Pharmacol Ther. 2014;40(6):582-609. Agha-Mohammadi, S, Hurwitz, DJ. Potential impacts of nutritional deficiency of postbariatric patients on body contouring surgery. Plast Reconstr Surg. 2008;122(6):1901-1914. Austin, RE, Lista, F, Khan, A, Ahmad, J. The impact of protein nutritional supplementation for massive weight loss patients undergoing abdominoplasty. Aesthet Surg J. 2016;36:204-210. Naghshineh, N, O’Brien Coon, D, McTigue, K, et al. Nutritional assessment of bariatric surgery patients presenting for plastic surgery: a prospective analysis. Plast Reconstr Surg. 2010;126(2):602-610.A prospective study examining nutritional status of 100 consecutive patients presenting for plastic surgery after bariatric surgery. Eighty percent of patients had inadequate protein intake. The most common deficiency was iron deficiency anemia, with almost 40% of patients. Zimmermann, MB, Hurrell, RF. Nutritional iron deficiency. Lancet. 2007;370:511-520. Gibbs, J, Cull, W, Henderson, W, et al. Preoperative serum albumin level as a predictor of operative mortality and morbidity: results from the National VA Surgical Risk Study. Arch Surg. 1999;134(1):36-42. Correia, MI, Waitzberg, DL. The impact of malnutrition on morbidity, mortality, length of hospital stay and costs evaluated through a multivariate model analysis. Clin Nutr. 2003;22(3):235-239. Sebastian, JL, V, JM, Tang, LW, Rubin, JP. Thiamine deficiency in a gastric bypass patient leading to acute neurologic compromise after plastic surgery. Surg Obes Relat Dis. 2010;6:105-106. Gardiner, S, Hartzell, T. Thiamine deficiency: a cause of profound hypotension and hypothermia after plastic surgery. Aesthet Surg J. 2015;35(1):NP1-NP3. Carlin, AM, Rao, DS, Meslemani, AM, et al. Prevalence of vitamin D depletion among morbidly obese patients seeking gastric bypass surgery. Surg Obes Relat Dis. 2006;2:98-103. Coon, D, Gusenoff, JA, Kannan, N, et al. Body mass and surgical complications in the postbariatric reconstructive patient: analysis of 511 cases. Ann Surg. 2009;249(3):397-401.A study examining differences between body contouring patients undergoing single versus multiple operations in a single setting. 449 patients were included, and complications were correlated with current and maximum BMIs in the single procedure group, but with change in BMI in the multiple procedure group. Gletsu-Miller, N, Wright, BN. Mineral malnutrition following bariatric surgery. Adv Nutr. 2013;4(5):506-517. Clements, RH, Yellumahanthi, K, Wesley, M, et al. Hyperparathyroidism and vitamin D deficiency after laparoscopic gastric bypass. Am Surg. 2008;74(6):469-474. Parrott, J, Frank, L, Rabena, R, et al. American Society for Metabolic and Bariatric Surgery Integrated Health Nutritional Guidelines for the surgical weight loss patient 2016 update: micronutrients. Surg Obes Relat Dis. 2017;13(5):727-741. Mechanick, JI, Kushner, RF, Sugerman, HJ, et al. American Association of Clinical Endocrinologists, The Obesity Society, and American Society for Metabolic & Bariatric Surgery medical guidelines for clinical practice for the perioperative nutritional, metabolic, and nonsurgical support of the bariatric surgery patient. Surg Obes Relat Dis. 2008;4(5 suppl):S109-S184. Coon, D, Michaels, J IV, Gusenoff, JA, et al. Multiple procedures and staging in the massive weight loss population. Plast Reconstr Surg. 2010;125(2):691-698.Looking at 609 patients undergoing body contouring after MWL, the authors showed that the per-procedure complication rate was the same whether performing one or many procedures in the same stage. Pascal, JF, Le Louarn, C. Remodeling bodylift with high lateral tension. Aesthetic Plast Surg. 2002;26(3):223-230. Song, AY, Rubin, JP, Thomas, V, et al. Body image and quality of life in post massive weight loss body contouring patients. Obesity (Silver Spring). 2006;14(9):1626-1636. Shermak, MA, Chang, DC, Heller, J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg. 2007;119(5):1590-1596.The authors looked at their 10-year experience with 129 patients having body contouring after MWL. BMI was the leading risk factor, and recommendations for prophylaxis are discussed. Kurz, A, Sessler, DI, Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization: study of wound infection and temperature group. N Engl J Med. 1996;334(19):1209-1215.

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Coon, D, Michaels, J IV, Gusenoff, JA, et al. Hypothermia and complications in postbariatric body contouring. Plast Reconstr Surg. 2012;130(2):443-448. Modarressi, A, Balagué, N, Huber, O, et al. Plastic surgery after gastric bypass improves long-term quality of life. Obes Surg. 2013;23(1):24-30. Vierhapper, MF, Pittermann, A, Hacker, S, Kitzinger, HB. Patient satisfaction, body image, and quality of life after lower body lift: a prospective pre- and postoperative long-term survey. Surg Obes Relat Dis. 2017;13(5):882-887.

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CHAPTER 64

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Liposuction, Abdominoplasty, and Belt Lipectomy Terri A. Zomerlei and Jeffrey E. Janis

Key Points Selection of the correct body contouring procedure—liposuction versus skin resection technique—is essential to optimize outcomes. Obtain a thorough personal and family medical history to appropriately calculate the patient’s venous thromboembolism risk and plan mechanical and chemoprophylaxis for prevention of VTE. Perform anatomic-based markings to keep incisions in cosmetically acceptable locations. Be mindful of zones of adherence. Decrease potential complications by proper positioning and padding and preventing hypothermia, calculating local anesthetic dosing, and respecting blood supply and previous scars. Selection of the appropriate body contouring procedure(s) is based on the presence and degree of skin and adipose excess. Body contouring procedures are not strictly for weight reduction and patients should be counseled in this regard.

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Liposuction Liposuction, the surgical aspiration of fat from the subcutaneous plane, is one of the most popular procedures performed by plastic surgeons. The first description of surgically removing fat for body contouring is from the 1920s. Dr. Dujarrier, an obstetrician and surgeon, utilized a uterine curette to remove fat from the knees of a ballerina resulting in catastrophic complications and eventual leg amputation. Modern liposuction became popularized in the 1970s by Drs. Illouz, Fournier, and Otteni. The key advancements and contributions by these surgeons were the use of a wetting solution, blunt cannulas, and negative pressure evacuation. This greatly improved the safety of the procedure. 1

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Patient Selection and Evaluation Suction-assisted lipectomy, or liposuction, is indicated for removal of localized excess adipose tissue or lipodystrophy ideally in areas with good overlying skin quality and minimal excess skin. The patient’s motivation and surgical expectations should be garnered early in the consultation process to sort out those with unrealistic expectations or mental disorders such as body dysmorphic disorder. A thorough medical history should be obtained on all patients. Nonessential supplements and vitamins should be discontinued 3 weeks prior to surgery. Medications that could interfere with lidocaine metabolism (such as psychotropics) should be noted. 2 Patients with a history of nicotine use or poorly controlled diabetes should be counseled on the increased risk of wound healing complications, and strong consideration should be given to deferring their procedures until they have had nicotine cessation for 4 weeks prior to the proposed elective operation (compliance can be tested with a urine cotinine test) and an A1C of less than 7.5. 3,4 In those patients who will be receiving large-volume liposuction (defined as aspiration of greater than 5 L), a complete blood count should be performed preoperatively. In addition, assessing personal and family history of bleeding problems, blood clots, and miscarriages is important. The practitioner should obtain labs and/or hematology consultation as appropriate so that venous thromboembolism (VTE) prevention is optimized. Liposuction should not be offered as a treatment for global obesity or cellulite, and ideally patients should be within 30% or their ideal body weight. 5 Women typically have a gynoid pattern of fat distribution with accumulation in the lower trunk, hips, upper thighs, and buttocks. Men often exhibit an android fat accumulation pattern with increased abdominal girth, thickened torso, and upper abdomen. During examination of the abdomen, particular attention should be paid to any surgical scars that can affect blood supply and also signal possible hernias. 4 A Valsalva maneuver or having the patient perform a small sit-up should reveal the presence of any hernias. Obtain a computed tomography (CT) scan, if needed. During the examination, the presence and extent of a diastasis recti should also be evaluated in addition to assessing the degree of visceral versus external fat. Location of adipose deposits and asymmetries should also be noted and discussed with the patient. Skin quality and quantity should also be assessed noting that those with good skin quality will have more optimal results.

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Pertinent Anatomy Thorough understanding of the pertinent anatomy is essential for effective liposuction treatment. The subcutaneous adipose tissue is supported and separated into compartments and layers by a fibrous network called the superficial fascial system. 6,7 The adipose tissue in a given region can roughly be divided into two layers: Superficial layer: Dense fat, contained within tight septae and adherent to the dermis. This layer is most susceptible to contour irregularities. Deep layer: Loose fat and less compact. This is the safest layer to suction. Zones of adherence are recognized regions in which the subcutaneous tissues are securely adherent to the deep fascia. Liposuction should be avoided or used with extreme caution in these areas as the risk of contour irregularities is high 5 (Figure 64.1): Gluteal crease Lateral gluteal depression Middle medial thigh Distal iliotibial tract Distal posterior thigh

FIGURE 64.1 In addition to surrounding the superficial fat layer, the superficial fascial system sends components through the deep fat compartment attaching to the investing fascia of the underlying musculature. These extensions, where the superficial subcutaneous plane is adherent to the underlying muscle fascia, are collectively called zones of adherence. These zones,

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which include the lateral gluteal depression, the gluteal crease, the distal posterior thigh, middle medial thigh, and inferolateral iliotibial tract, are much more susceptible to contour irregularities.

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Marking, Positioning, and Safety Patients should be marked in the standing position with an indelible marker. Areas to be suctioned are marked with concentric circles in a topographical pattern, typically with an X at the most protuberant point. Zones of adherence are noted and are marked with straight parallel lines or hash marks. Natural creases should be noted, as these will be optimal areas to perform the incisions for liposuction to minimize visibility 5 (see Figure 64.1). Safety is of utmost importance in surgery, and several precautions should be taken with liposuction procedures. 8 With large areas of the body usually exposed for the liposuction procedure, care should be taken to avoid intraoperative hypothermia. Intravenous fluids (IVFs) and wetting solutions should be warmed. Forced warm air blankets should be placed over areas not being suctioned, and the ambient room temperature can be raised. Pressure points should be appropriately padded, as improper pressure on the neurovascular structures in the body can lead to short- or long-term disability. Padding and flexion of the arm and elbow less than 90 degrees and use of an axillary roll in the lateral decubitus position reduces the risk of upper extremity nerve compression. The surgeon should work closely with the anesthesia provider to ensure that the patient’s eyes are protected, the head is supported, and the neck is in a neutral position. In the prone position, a soft hip roll placed beneath the iliac crests aids in elevating treatment areas off the operative table. If the patient will be repositioned during the procedure, close attention should be paid to careful choreography of all details. Body contouring operations such as liposuction and abdominoplasty have a higher incidence of venous thrombotic complications than other plastic surgery procedures. In 2011, the American Society of Plastic Surgeons Venous Thromboembolism Task Force recommended a stepwise approach for plastic surgery patients that includes: 9 Preoperative risk stratification Prevention with mechanical and/or chemoprophylaxis Patient education At minimum, patients undergoing liposuction should have pneumatic compression stockings in place (if the leg is not being treated). The use of chemoprophylaxis will depend on the preoperative risk stratification.

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Wetting Solution and Fluid Management First introduced by Illouz, the advent of the use of wetting solution has greatly improved the safety of liposuction. 1 Wetting solutions can be a variable composition but usually include saline or lactated Ringer’s, lidocaine, epinephrine, and sometimes sodium bicarbonate. The wetting solution has multiple functions and aids with anesthesia, hemostasis, and emulsification of adipocytes. There has been an evolution of wetting solution techniques that have helped decrease blood loss (Table 64.1). 10-12 The desired wetting solution composition and amount is instilled into the treatment area via a fine infiltration cannula through a small stab incision that will also function as the liposuction port. Ideally, the fluid resides at least 7 to 10 minutes in the tissue for optimal vasoconstrictive effect. High lidocaine doses can result in severe systemic complications. Traditionally, maximal lidocaine dosing is 7 mg/kg. In wetting solution, however, much higher doses, up to 35 mg/kg, have been reported as safe. The maximal safe dose of lidocaine should be calculated for each patient. 12-14 TABLE 64.1 Commonly Used Wetting Solution Techniques a Technique Dry Wet Superwet Tumescent

Infiltrate Volume No infiltrate 200–300 mL/area 1 mL infiltrate: 1 mL aspirate To skin turgor 2–3 mL infiltrate: 1 mL aspirate

Estimated Blood Loss (as % of Aspirate Volume) (%) ∼20–40 ∼25 ∼1–4 ∼1

a

The essential difference among these techniques centers on the amount of solution infused into the tissue and the resultant blood loss with aspiration.

Intraoperatively, appropriate fluid administration and balance is critical. 15 This will include IVF administration to replace preoperative deficit and to provide appropriate maintenance fluids, which can vary depending on whether the patient is undergoing large-volume liposuction. Clear communication with anesthesia staff is essential.

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Treatment Types Once the patient has been deemed an appropriate candidate for adipose reduction, technique selection is the next step. Current options for traditional liposuction include suction-assisted liposuction (SAL), power-assisted liposuction (PAL), ultrasound-assisted liposuction (UAL), and laser-assisted liposuction (LAL). SAL is the most frequently utilized modality among plastic surgeons.

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Traditional Liposuction SAL is a two-stage technique that requires infiltration of wetting solution followed by suction evacuation. This technique is popular because of its lower cost of equipment investment, ease of use, and reliability. However, SAL is more labor-intensive and does not perform as well on areas with fibrous fat. PAL is a technique that uses a variable- speed motor that provides oscillation in a reciprocating motion at rates of 4000 to 6000 cycles per minute. Because PAL can break up fibrous fat more readily, this modality can significantly cut down on physician fatigue due to shorter procedure times and employing less physical labor to use. UAL applies ultrasonic energy to break down fat and facilitate suction aspiration. UAL works to emulsify the fat by three mechanisms: 16,17 Mechanical: direct tissue effects by the ultrasound wave; this is the primary mechanism Cavitation: tissue fragments based on the formation and collapse of intracellular microbubbles Thermal: absorption of the ultrasound waves produces heat Treatment with UAL involves three stages: 1. Infiltration of wetting solution 2. Emulsification with ultrasound treatment 3. Evacuation of emulsified fat and final contouring With the use of smaller cannulas and conservative ultrasound application times, the frequently cited complications of UAL (contour deformities and thermal injury) can be avoided. LAL uses a small laser fiber to emulsify fat and tighten skin. A four-step technique is used: 1. 2. 3. 4.

Infiltration Application of energy to the tissue Evacuation Subdermal skin stimulation

This treatment modality is purported to have the benefit of skin tightening. However, several welldesigned studies have failed to show a significant benefit over SAL. 18 Peer-reviewed studies failed to show consistent evidence-based benefits for the use of UAL and LAL over SAL. The aesthetic outcomes, patient satisfaction, and incidences of long-term complications appear to be more related to technique and not technology. As a result, SAL/PAL remains the leading techniques employed. 18 Surgical endpoints for liposuction can be divided into primary and secondary endpoints and depend on the treatment modality used: Primary endpoints SAL/PAL: contour, symmetrical pinch test, and presence of bloody aspirate UAL: loss of tissue resistance, contour, and presence of bloody aspirate Secondary endpoints SAL/PAL/UAL: treatment time and volume

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Cryolipolysis In select patients who prefer to avoid surgery for adipose reduction, treatment with cryolipolysis may be employed. Cryolipolysis is a noninvasive technique to destroy adipose cells through administration of controlled thermal reduction via a specialized machine. 19,20 Because of their susceptibility, exposure of adipose cells to below normal temperatures (+5° to −5°C) results in apoptosis-mediated cell death with preservation of overlying skin integrity. The subsequent inflammatory cascade results in removal of the damaged cells over the course of 3 months. The most common complication following cryolipolysis is hypoesthesia of the treatment area that usually resolves over several months. Other less common complications include surface contour irregularities, chronic pain, and rarely, paradoxical adipose hyperplasia. 21

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Technique Once the wetting solution has been instilled and allowed sufficient time for effect, the liposuction cannula is introduced. The cannula is inserted into the access incision(s) and using even strokes, the cannula is moved in a fanlike pattern. The deep plane is suctioned first, with the dominant hand guiding the liposuction cannula and the nondominant hand overlying the treatment area, providing stereotactic feedback on the cannula location and depth. To mitigate the most frequently cited liposuction complication, contour irregularities, careful attention to technique is important. Cross-hatching or cross-tunneling is the method of using the liposuction cannula via multiple access sites to create intersecting sets of parallel lines over the treated area. This helps to ensure the tissue is suctioned more symmetrically and evenly. In 2016, Wall proposed a multistep process for nonthermal comprehensive fat management that focuses on minimizing tissue injury and prevention of contour irregularities. 22 The SAFE (separation-aspirationfat equalization) liposuction technique is based on the following principles: Optimize fat removal Provide comprehensive means of body contouring Preserve vascular integrity Maximize skin retraction Minimize potential for complications/revisions Briefly, the separation step uses an exploded-tip (basket-tip) cannula with no suction to separate and mechanically emulsify the fat. This step comprises 40% of the operating time and addresses both the superficial and deep fat compartments. Aspiration is then performed with less aggressive cannulas. This step should take approximately another 40% of the procedural time. The last step, fat equalization, again uses an exploded tip without suction. During this step, the fat layer evens out the thicker and thinner areas that may exist. An extension of the SAFE liposuction technique utilizes the aspirated fat to perform expansion vibration liposuction of the gluteal area. 23 This technique utilizes exploded liposuction tip and other nondisposable existing instrumentation. Close attention is given to patient safety and avoiding critical structures when lipofilling.

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Large-Volume Liposuction The ASPS Patient Safety Committee has recommended, when the anticipated lipoaspirate amount is expected to be greater than 5 L, several precautions should be taken. For safety reasons, the procedure should be performed in a hospital setting as opposed to an ambulatory surgical center. In addition, fluid shifts with large-volume liposuction can be significant, and thus specific fluid replacements should be performed. Maintenance IVF should be administered up to 5 L. Every 1 mL of aspirate beyond 5 L should be replaced with 0.25 mL of IVF. Overnight monitoring of fluid balance (based on vital signs and urinary output) should be considered. 24

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Treatment Areas Many areas of the body can be treated with liposuction. The practitioner should keep in mind ideal aesthetic contours based on gender.

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Arms The upper arm can be contoured with liposuction alone or with concomitant brachioplasty to resect excess skin (see Chapter 65). 25 Liposuction of the tissues that will be excised can facilitate dissection of the tissues. Adiposity is usually focused at the posterior third of the arm and can be addressed through access points on the distal radial side of the arm. The ulnar nerve can be superficial near the elbow and could be inadvertently injured during the procedure. In addition, the medial antebrachial nerve pierces the fascia of the arm approximately 14 cm proximal to the medial epicondyle and is susceptible to injury in this area. The ideal aesthetic arm is lean with merging deltoid and biceps convexities.

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Back The back anatomy is characterized by a thick dermis and fibrous, dense fat. Lipodystrophy of the back tends to result in folds, especially inferior to the bra line. Improved contour can be obtained when the fibrous attachments creating the folds are disrupted. The buffalo hump is an enlargement of the dorsocervical fat pad and can be present because of genetics, certain medical conditions, or medication use. In appropriate candidates, this area can be successfully liposuctioned. Because of the dense nature of this fat, UAL is a commonly employed technique for this area.

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Abdomen Lipodystrophy in the abdomen is predominantly in the infraumbilical region. Care must be taken to ensure no hernias are present. In cases of significant excess skin or poor overlying skin quality with poor elasticity, skin resection techniques are indicated. Ideal abdominal contour is gender-dependent, with the female aesthetic having an hourglass figure defined by the flanks and a slight supraumbilical concavity and infraumbilical convexity. Men should have no flare at the iliac crest and the infraumbilical area should be flat. In a leaner patient, improved body contour can be achieved with high definition liposuction or etching. With this method, the fat in the superficial plane is liposuctioned to improve or provide the appearance of muscular definition. This technique can be used in conjunction with focused fat transfer. This technique should be used only by the trained practitioner as there is a high risk for contour irregularities. 26

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Hips/Flanks These areas are treated most often in the prone or lateral decubitus positions. There are gender aesthetic differences and fat distribution tendencies that must be taken into consideration when treating this area. In women, the adipose deposits are commonly in the hip overlying the iliac crest and extending down to the lateral thigh zone of adherence. In contrast, the men tend to have adiposity in the flank or lateral lumbar area.

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Buttocks/Thigh There are also gender differences in the ideal gluteal region aesthetic. Women desire a rounded more protuberant buttock without ptosis that merges with lateral thigh. Male gluteal area aesthetic is flatter and angular with a squared off lateral contour. The fat in the gluteal area is denser and fibrous. The thigh is a difficult area for liposuction because of the circumferential approach that is usually required. In addition, zones of adherence and natural creases (gluteal crease) need to be recognized and appreciated. Overzealous suctioning in the buttock can result in ptosis and in the thigh can lead to unflattering skin redundancy. For this reason, liposuction in these areas should be approached with caution.

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Postoperative Care Following a liposuction procedure, massage excess wetting solution out of access incisions and either close primarily with suture or leave open, if small enough. Absorbent dressings are applied along with a compression garment. The dressing can be changed as needed for drainage and the compression garment should be worn at all times except during showering. Various lengths of time have been proposed for length of time to wear compression garments but most advocate a duration of 2 to 4 weeks.

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Complications Postoperative complications following liposuction can roughly be divided into early and late complications. Patients should be aware that postoperative edema and ecchymosis are an expected side effect of the procedure and occur to varying degrees in all patients.

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Early Complications Inadequate fluid resuscitation: communication with anesthesia team is vital Sinus tachycardia: can develop after administration of wetting solution because of the epinephrine effect Injury to solid organs, bowel, or blood vessels: always be aware of the plane the cannula is in Hypothermia: use warming techniques Skin slough: local wound care VTE: the most common cause of death following liposuction. Risk for this complication increases with large-volume aspirate (>5 L), increased wetting solution infiltration LAST (local anesthetic system toxicity): begins with symptoms of central nervous system excitation such as perioral numbness, lightheaded, and dizziness. Can progress with seizures and cardiac arrest. Calculate safe lidocaine dosing prior to procedure. Treat with ABCs of resuscitation and lipid emulsion infusion. 27

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Late Complications Neurapraxia: motor weakness or sensory disturbance (numbness/pain) after liposuction. Should observe and reassure the patient. Should resolve within 3 to 4 months. Contour irregularities: this is the most common postoperative complication and can occur in up to 20% of patients. Techniques to help prevent include use of small cannulas, multiple access incisions, and cross-tunneling. Treatment of irregularities requires secondary fat equalization and fat grafting to oversuctioned regions, if needed.

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Conclusion Liposuction is artistry as well as surgery. It entails a practical application of anatomic knowledge with precision and craftsmanship and is a skill that can be attained and refined with clinical experience.

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Abdominoplasty Abdominoplasty is a procedure that removes excess skin and fat and, in most cases, restores the rectus muscle to a more anatomical position, creating an abdominal profile that is smoother and firmer. Abdominoplasty outcomes can be optimized and complication reduced with a strong understanding of the anatomy.

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Pertinent Anatomy The abdominal wall is composed of seven layers: Skin Subcutaneous fat (superficial layer of fat—thicker and dense) Scarpa fascia (superficial fascial system) Subscarpal layer (deep layer of fat—less dense) Anterior rectus sheath Muscle Posterior rectus sheath There are four paired muscle groups that comprise the abdominal wall: Rectus abdominis External oblique Internal oblique Transversus abdominis The aponeurotic portion of the oblique muscles and the transversus abdominis envelope the rectus muscles forming the anterior and posterior rectus sheaths. The composition of the anterior and posterior sheaths varies in relation to the arcuate line. The sheaths meet in the midline forming the linea alba. Pregnancy and weight gain can result in a separation of the rectus muscles in the midline termed a diastasis rectus. The vascular perfusion of the abdomen is supplied by the deep epigastric arcade, the superficial epigastric arcade, and contributions of the intercostal and subcostal vessels bilaterally. The regional blood supply to the abdomen is defined by three zones, first elucidated by Huger 28 : Zone I is the midabdomen, supplied by deep superficial and deep inferior epigastric arcades. Zone II is the lower abdomen and is supplied by the superficial and deep circumflex arteries. Zone III is the lateral abdomen and is supplied by the intercostal, subcostal, and lumbar arteries. Prior to abdominoplasty, the major blood supply to the abdomen is from zone I. Following abdominoplasty, zone I blood supply is lost and the abdominoplasty flap is predominantly supplied via zone III segmental perforators with minor collateral flow from zone II. There are several sensory nerves that supply the abdominal wall (Table 64.2). In abdominoplasty, the lateral femoral cutaneous nerve emerges into the superficial plane approximately 2 cm medial to the anterior superior iliac spine (ASIS), and therefore, dissection in this area should be superficial to reduce the risk of meralgia paresthetica, a syndrome characterized by tingling, burning, and numbness in the lateral thigh. TABLE 64.2 Nerves at Risk for Injury During an Abdominoplasty Nerve Lateral femoral cutaneous Iliohypogastric

Danger Zone Passes through inguinal ligament 1 cm medial to ASIS

Ilioinguinal

Lateral aspect of low horizontal incision near inguinal ligament

Intercostal

Plane between the internal oblique and transversus abdominis. Lateral branches

Lateral aspect of low horizontal incision near inguinal ligament

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Symptoms of Injury Numbness/pain along anterolateral thigh Numbness/pain along the inguinal crease and lateral gluteal region Numbness along the medial thigh and scrotum/labia Numbness in abdominal/flank

penetrate fascia at midaxillary line and travel in subcutaneous tissues

dermatome

ASIS, anterior superior iliac spine. The umbilicus is located at or near the midline at the level of the iliac crests. The umbilicus is the central focus of the abdomen. The ideal umbilicus has superior hooding, round or oval shape, is shallow, and has inferior retraction. The blood supply is based on the subdermal plexus, the ligamentum teres remnant, and perforators from the deep inferior epigastric system.

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Patient Selection and Evaluation Pertinent history to obtain from patients seeking abdominoplasty include gravidity and parity history, previous abdominal surgeries (including cesarean sections), history of weight loss/gain, gastrointestinal or respiratory ailments, and tobacco abuse. Patients should be nicotine free for a minimum of 4 weeks prior to and after an abdominoplasty to minimize postoperative complications. Compliance can be tested with a urine cotinine test. 3,4 On examination, assess for the presence of hernias (order a CT if needed) and take note of the excess fat and skin, skin tone and appearance, and the presence of scars. 29,30 Small hernias may be addressed at the time of abdominoplasty depending on the surgeon’s comfort level. The amount and location of excess fat and skin will aid in determining the best technique to address the abdomen. Patients with striae, which represents a thinning or rupture of the dermal layer, must be counseled that an abdominoplasty will remove stria located inferior to the umbilicus but those located supraumbilically may be made worse by the procedure. Scars may limit the movement of the abdominal skin flap and a subcostal scar has potential to compromise the vascular supply to the skin flap. Examination of the patient should also include assessment of myofascial laxity via a diver’s test (worsening lower abdominal fullness with flexion at the waist) and a pinch test (assessing abdominal fullness with the abdomen both relaxed and tensed). When the patient is supine, tensing of the abdominal muscles with a small sit-up should reveal a diastasis rectus if present.

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Marking, Positioning, and Safety Patients should wear an undergarment or swim bottom of choice to their operation so that the incision can be planned with minimal exposure. Anatomical points should be marked including the xiphoid, midline, ASIS, and pubic bone. Previous scars should be marked. The lower excision should be at least 5 to 7 cm above the vulvar commissure and should be below any cesarean scar if possible. The upper marking is made based on pinch test of the abdomen both centrally and laterally. This marking should come down inferior to the ASIS to minimize visibility. Prior to entering the operating room, the operative table should be checked that it is able to flex. The patient should be padded appropriately, and previously described measures to minimize hypothermia should be employed. Sequential compression stocking should be applied. Data accrued by the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF) from 2001 to 2006 indicate abdominoplasty is the procedure with the highest frequency of death due to pulmonary embolism (PE). All patients undergoing abdominoplasty should be carefully risk stratified and at minimal receive sequential compression stockings. 9,31 Any excessive hair can be clipped and the patient is prepped with a wide field ensuring that the umbilicus is free from debris.

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Operative Options and Techniques There are a variety of abdominoplasty techniques that can be employed to improve the contour of the abdomen. Selecting the correct procedure is based upon the examination of the amount and distribution of excess fat and skin, assessment of skin tone and quality, and the presence of a diastasis (Table 64.2).

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Traditional Abdominoplasty In a traditional abdominoplasty, the umbilicus is transposed and the rectus muscles are plicated. A circumumbilical incision is made and dissection is carried down to the rectus sheath. An orientation suture placed in the umbilicus will aid in prevention of twisting at inset. The lower incision is incised and dissection is carried up to the xiphoid, minimizing extensive lateral dissection to preserve blood supply and taking care to keep the disinserted umbilicus intact to the abdominal wall (Figure 64.2A). A marking pen or methylene blue is used to outline the medial edge of the rectus bilaterally. The rectus sheath is then plicated (Figure 64.2B). The bed is flexed at the waist, and the amount of abdominal wall skin that can be safely excised while maintaining a tension-free closure is marked (this may be slightly different than the preoperative estimation). The surgeon can determine where the area of greatest tension will be on the closure based on the patient’s needs. The upper incision is made, the abdomen irrigated, and meticulous hemostasis achieved. To minimize dead space and tension at the closure, a surgical assistant can aid in advancing the abdominal skin flap and progressive tension sutures can be placed. 32 Drains can then be placed; however, some studies have found foregoing drains with the use of progressive tension sutures is safe and without increased risk of seroma formation. 33 The neoumbilicus spot is located on the abdominal skin flap based on the umbilical location on the abdominal wall. A small circular or ovoid opening is made and the umbilicus is reintroduced into the skin flap and secured with several suture layers, keeping in mind ideal umbilical aesthetics and the patient’s body habitus and preference. The closure of the abdomen is performed in multiple layers with sutures in the Scarpa layer, deep dermis, and subcuticular space.

FIGURE 64.2 A. The abdominal flap is dissected up to the xiphoid, minimizing excessive lateral dissection. A stitch in the umbilicus helps with orientation when it is delivered through the new opening in the abdominal flap. B. The edges of the rectus are outlined and plication is performed to restore the muscles to their anatomic position abutting each other on the midline.

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Miniabdominoplasty In the miniabdominoplasty, also referred to as a short-scar abdominoplasty, the surgical goal is to remove a small amount of skin and subcutaneous tissue from the lower abdomen only. The scar is limited and the position of the umbilicus remains unchanged. Usually no plication of the rectus muscles is performed. The option of a short scar can be appealing to younger patients, but dog-ears can be problematic because of the shorter incision. Careful patient selection is crucial for patient satisfaction.

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High Lateral Tension Popularized by Lockwood, the high lateral tension abdominoplasty endorses an oblique vector of pull of the abdominal skin flap. 34 The oblique vector aids in reducing the horizontal epigastric laxity. In this technique, more skin is excised from the abdominal skin flap laterally than centrally. The tension at the line of closure is borne by meticulous closure of the superficial fascial system (Scarpa fascia). 7

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Fleur-de-lis With the fleur-de-lis technique, the standard low horizontal incision is combined with excision of a vertical ellipse of abdominal tissue (Figure 64.3). This procedure is best for a patient who has both horizontal and vertical skin and tissue excess that is commonly the case in a weight loss patient. 35 First described by Dellon, the procedure seeks to restore a more aesthetic abdominal contour. 36 The major disadvantage of this procedure is an additional scar that is on the vertical midline. Care must be taken to only undermine to the degree necessary for skin resection. The addition of liposuction to the lateral abdomen will result in a discontinuous undermining that will aid in increasing excursion of the abdominal skin flap laterally without increasing the risk of vascular compromise to the skin flap.

FIGURE 64.3 In the fleur-de-lis abdominoplasty technique, a horizontal and vertical wedge of tissue is excised in order to address excess tissue in both directions.

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Lipoabdominoplasty Popularized by Saldanha, this abdominoplasty technique substitutes liposuction of the abdominal skin flap in lieu of wide lateral undermining in an effort to preserve perforating vessels and thus the blood supply to the skin. 37 Undermining of the skin flap is limited to the area that will be plicated, and the liposuction with a superwet technique is performed in the areas lateral to the rectus. 38 Liposuctioning of the undermined regions of the flap could result in skin flap necrosis and must be avoided or performed with extreme caution.

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Postoperative Care At the conclusion of the abdominoplasty procedure, the patient will be flexed at the waist. To minimize tension at the closure, the patient should be transferred to a stretcher/bed that is likewise flexed at the waist with the knees elevated (beach-chair position). Most would recommend that the patient maintain a semiflexed position at the waist, even when ambulating, for several weeks duration to minimize tension at the closure. If drains are utilized, the patient and/or a caregiver must be educated on proper drain care. 39 A compression garment is worn by the patient for several weeks duration. The patient should avoid heavy lifting and vigorous activity for up to 6 weeks postoperatively. As described previously, abdominoplasty carries an increased risk of VTE, and thus patients should be encouraged to ambulate early. Low molecular weight heparin or other anticoagulant should be given to those patients deemed to be at higher risk when performing risk stratification. 31

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Scar Management Scars, especially those that are widened or hypertrophic, can be troublesome to patients. Intraoperatively, wound eversion and minimization of excess tension have been proven to improve scar appearance. In addition, the use of dermal sutures with a self-adherent mesh and octyl-2-cyanoacrylate (PRINEO, Ethicon, Raleigh, NC) has been shown to provide equivalent scar results as dermal sutures, and a subcuticular stitch and is more than four times faster to perform. 40 In the presence of hypertrophic scars, there is evidence that the use of pressure garments, scar massage, and pulsed-dye lasers can improve the appearance. 41

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Complications The surgeon’s efforts both preoperatively and intraoperatively should be focused on mitigating any potential complications through careful preparation and technique. Complications of abdominoplasty, however, do occur but are usually minor and may include small areas of wound healing problems, poor scars, and lateral dog-ears. Small areas of wound dehiscence, suture abscess, etc. can frequently be treated with local wound care. Those with widened scars or dog-ears can be treated with minor revisional procedures, usually performed in an office setting several months later. More significant complications can include persistent seroma, areas of flap ischemia, and larger areas of wound dehiscence. Seroma is a common problem with abdominoplasty because of the larger area that is usually undermined. As described previously, the use of progressive tension sutures or quilting sutures has been shown to reduce dead space and in turn lessen the frequency of seroma formation. 32,33 The use of drains and compression garments may also reduce the incidence of seroma. 42 Should the patient develop a seroma, it can frequently be aspirated in an office setting using sterile technique so as not to introduce an infectious nidus to the seroma. Larger areas of wound dehiscence can be allowed to heal via secondary intention and be revised at a later date, or a delayed primary closure may be an option. Vascular compromise of the abdominal skin flap can usually be avoided by minimizing large area of undermining. If necrosis does occur, the wound is treated conservatively and allowed to heal by secondary intention with revision at a later date. The most worrisome complications are those that could prove life-threatening or severely compromise the final aesthetic results. These include VTE and PE, large hematomas, infection, and large areas of flap necrosis. As described previously, abdominoplasty carries with it a relatively high risk of VTE thought to be attributable to the tightening of the abdominal wall, which may increase intra-abdominal pressure. Therefore, all patients should undergo a thorough risk assessment, and mechanical and chemoprophylaxis should be utilized. 31 Patients with any symptoms related VTE or PE such as extremity pain and swelling or shortness of breath should be worked up immediately. Large hematomas should be treated via surgical drainage and meticulous hemostasis. Infection is not a frequent abdominoplasty complication. Areas of cellulitis can be treated expectantly with oral antibiotics. More concerning infections may warrant surgical exploration. Larger areas of skin necrosis should be treated with local wound care and subsequent debridements.

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Conclusion Abdominoplasty is a powerful body contouring technique and requires understanding of the relevant anatomy. A thorough physical examination helps the practitioner tailor the procedure to meet patient’s specific needs. Complications can occur with any surgical procedure. Fortunately, with good patient and procedure selection and meticulous planning and surgical technique many potential complications can be avoided.

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Belt Lipectomy Body contouring procedures address the soft tissue redundancy after weight loss. The popularity of these procedures has increased in conjunction with the number of patients undergoing weight loss procedures. In patients with generalized laxity of the truncal tissues, belt lipectomy is a high yield surgery because it is a circumferential procedure that addressed multiple anatomic areas including the abdomen, back, flanks, and thighs.

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Pertinent Anatomy The surgeon should be familiar with the anatomy of the abdomen (see Abdominoplasty section) and regional blood supply when performing body contouring of the trunk. Zones of fascial adherence are five fixed points that serve as important anatomical landmarks (see T 1). Commonly, in the weight loss patient, zones of adherence as well as a midabdominal fascial thickening are preserved.

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Patient Selection and Evaluation A full history and physical should be performed on all body contouring patients. The medical interview should include questions about the patient’s motivation for surgery and their expectations to identify those who may have body dysmorphic disorder. Other questions include the method of weight loss (i.e., diet and exercise vs. a weight loss surgery). The specific type of weight loss surgery (restrictive vs. malabsorptive) should also be obtained as those with malabsorptive surgeries have specific nutritional needs (see Chapter 63). Weight loss before surgery should be stable for a minimum of 3 months prior to surgical interventions. 43 The patient should be questioned about VTE risk factors so that they can be properly risk stratified, and appropriate mechanical and chemoprophylaxis can be anticipated. 31 Many times, weight loss or bariatric patients have a history of several medical comorbidities. All these should be assessed and specialists should be engaged when appropriate to assess surgical risk and assist with medical optimization. On examination, the skin should be examined for rash, intertrigo, previous incisions, and striae. The thickness and distribution of excess skin and subcutaneous tissue should be evaluated. The abdomen should be examined for the presence of hernias. A CT scan can be ordered if needed. There are a variety of names to describe body contouring procedures. As described by Aly, the belt lipectomy addresses the lower truncal area by removing a wedge of tissue to improve the abdominal contour and create definition between the lumbar area and the buttock. 44 However, with this procedure, the fascial zones of the trunk and lower extremity are not markedly disrupted. This limits the ability of this procedure to substantially address the thighs, and patients with concerns in this area may be better served with a lower body lift (see Chapter 65). 45 The goals of the belt lipectomy are to eliminate the ptotic panniculus to define the waist, eliminate lower back rolls, and elevate the lateral thighs and mons pubis. Proper patient selection is the most important preventative measure available to the surgeon to mitigate the risk of postoperative complications in the body contouring patient; thus a thorough preoperative assessment is crucial.

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Marking, Positioning, and Safety The patient is marked in the standing position. Anatomic landmarks including the anterior and posterior midlines, the suprapubic crease, and the iliac crests are marked. Based on pinch test and anatomic landmarks, the upper and lower incisions are all marked with the anterior superior marking being similar to that for an abdominoplasty and the midline posterior having the narrowest resection width. The posterior markings should be based on pinch test both in the erect and flexed at the waist positions to ensure the area is not overresected. The proposed line of closure is then marked by ensuring that it is at or above the ASIS so the scar can be hidden with undergarments (Figure 64.4). Vertical hash marks through the horizontal markings will assist with realigning the tissues after tissue excision. The markings will be cursory as intraoperative adjustments may need to be made.

FIGURE 64.4 A. Anterior view of the markings for a belt lipectomy. The red line marks the inferior incision. The black mark indicates the proposed superior incision. The green dashed line is a visual indicator of the eventual scar location. B. Lateral view of the marking for a belt lipectomy. Black line marks the upper incision, red indicates the inferior incision, and the green is to visually indicate the eventual scar location.

Based on surgeon preference, patients undergoing belt lipectomy will be repositioned a minimum of twice. Because of intraoperative positioning changes, padding of extremities to prevent neurapraxias is of utmost importance. The operative table should be tested to ensure it is in good working order and the operative team should be well versed in optimizing patient safety through use of padding, positioning, warming, and VTE prevention techniques. 46

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Technique The surgeon should have well-laid plans for their operative approach to minimize operative time. The patient position changes (supine to prone or lateral-lateral-supine) should be anticipated and communicated with the operative team who should be sufficiently equipped to facilitate safe patient turns. Starting in the supine position, the trunk is widely prepped and draped. The umbilicus is incised and freed from the abdominal tissues and the lower abdominal incision is made. The dissection is carried up to the xiphoid similar to that with abdominoplasty with the exception that the lateral area is undermined to a greater degree. Any rectus diastasis is repaired and the abdominal flap is redraped. Progressive tension sutures can be used if desired and/or closed suction drains are placed. The new umbilical location is anatomically determined and the umbilicus is delivered and sutured into place. The anterior abdomen is sutured closed in the standard fashion working some of the excess abdominal tissues laterally. These lateral dog-ears are stapled closed provisionally and the patient is repositioned into the prone or lateral position and appropriately positioned, padded, prepped, and redraped. The posterior incisions are made based on tailor-tacking and a cut as you go technique, if that is the surgeon preference to prevent overresection. The dissection is carried down to the musculofascia. Little to no undermining of the superior or inferior skin flaps is performed. To optimize the superior excursion of the lateral thigh and minimize contour irregularities, this area is liposuctioned in a discontinuous manner to partially disrupt the pelvic rim zone of adherence. The lateral areas and the posterior resection areas are closed over drains. The patient is then repositioned from the prone or lateral position back to the supine beach chair position for extubation and application of compression garments.

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Complications With a proper preoperative assessment and close attention to detail in the operative room, efforts can be made to reduce complications by selecting appropriate patients, avoiding hypothermia, correct positioning, and appropriate VTE prophylaxis. 47-49 In addition, controlling for overresection can minimize tension and wound dehiscence. This is performed by committing to only one incision and the undermining the skin resection estimated by pinch test. Prior to making the resection incision, the skin flap is transposed under the first incision to estimate the safe amount of tissue resection. Despite the surgeon’s best efforts, complications can occur. 49 The outcome can still be controlled with early recognition and prompt steps to remedy concerns. Superficial wound healing problems and minor wound dehiscence are the most common complications that occur with circumferential body contouring procedures such as the belt lipectomy because of the competing tensions of the anterior and posterior incisions. These can almost universally be treated with attentive local wound care. Seromas can also be a troublesome postsurgical complication. Seroma formation can be minimized by only undermining the tissues to the degree necessary for excision and closure. Other measures such as sharp dissection, closed suction drains, and quilting or progressive tension sutures are also proven to reduce seroma rates. 42 If a seroma does occur, it can commonly be treated with serial aspirations in the office of placement of a seroma catheter. Untreated seromas can lead to infections, so these should be treated aggressively. Because of the large tissue surface area, bleeding and hematomas can be a potential complication. Large hematomas should be evacuated. Small hematomas that are not expanding and well drained can be treated expectantly. Skin flap necrosis can also occur in the belt lipectomy patient and this is usually due to excessive tension, previous incisions that compromise regional blood flow, and aggressive liposuction. If this occurs, the area is treated with local wound care and allowed to heal secondarily. A revisional procedure can be performed at a later date. The complication with the most potential for mortality is VTE. Procedures that tighten the abdominal wall, such as recuts plication, are theorized to increase intraabdominal pressure, which affects the compression susceptible venous system. Risk stratification and assertive use of mechanical and chemoprophylaxis is critical. 9,31 Patients should be counseled on the signs and symptoms of VTE so that they can obtain prompt evaluation should they experience these. Belt lipectomy is a circumferential procedure performed following massive weight loss that improves the abdominal contour and laxity, back rolls and buttock, and lateral thigh ptosis. Proper patient selection and optimization is essential to maximize outcomes and prevent complications.

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Questions 1. Several weeks following an abdominoplasty, your patient presents for follow-up and informs you that she was recently evaluated by her primary care physician because of complaints of outer thigh discomfort. She was diagnosed with meralgia paresthetica. Which structure was likely injured during her procedure? a. Iliohypogastric nerve b. Ilioinguinal ligament c. Genitofemoral nerve d. Lateral femoral cutaneous nerve e. Pectineus muscle 2. Following large-volume flank and abdominal liposuction, your patient is taken to the recovery room. While the patient is being transferred to the overnight observation unit, they begin to complain of perioral numbness, develop hypotension, and start seizing. What medication should be administered? a. Phenobarbital b. Dantrolene c. Lipid emulsion d. Phentolamine e. Epinephrine 3. You are performing large-volume liposuction at a local hospital. Which of the following is not an endpoint for liposuction aspiration? a. Pinch test b. Skin laxity c. Aspirate volume d. Skin turgor e. Length of operative time 4. When assessing a patient during consultation for an abdominoplasty, what is the clinical significance of a positive diver’s test? a. The patient has an incisional hernia. b. The patient has excess lower abdominal fat. c. The patient has excess lower abdominal skin. d. The patient has myofascial laxity. e. The patient has a diastasis rectus. 5. Which of the following is true regarding belt lipectomy? a. The postoperative scar is at the same level as with a lower body lift. b. All zones of adherence are left intact. c. More than one patient position on the operative table is necessary. d. The superficial fascial system is not approximated at closure. e. Belt lipectomy has minimal effect on the waist contour. 1. Answer: d. The lateral femoral cutaneous nerve is the most frequently injured nerve during abdominoplasty. Injury to this nerve causes meralgia paresthetica, which is characterized by anterolateral thigh burning, tingling, and numbness. It emerges close to the ASIS, and keeping some fat overlying the musculofascia in this area may prevent nerve injury. The iliohypogastric nerve innervates the suprapubic region. The genitofemoral nerve courses deep into the abdominal wall and originates from L1 to L2. The ilioinguinal ligament is a band that originates from the ASIS and inserts

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on the pubic tubercle. It is formed by the external oblique aponeurosis and is continuous with the fascia lata of the thigh. The pectineus muscle is a flat, quadrangular muscle on the anteromedial thigh. 2. Answer: c. This patient is suffering from lidocaine toxicity or LAST (local anesthetic systemic toxicity). With large-volume aspirates, lidocaine dosage must be carefully calculated and kept below 35 mg/kg. Lidocaine toxicity is best treated with 20% lipid emulsion. The current agreed hypothesis for intravenous lipid emulsion efficacy in treating cardiotoxicity and the effects of lidocaine toxicity is the formation of a lipid sink, that is, an expanded intravascular lipid phase that acts to absorb the offending circulating lipophilic lidocaine toxin, hence reducing the unbound free toxin available to bind to the myocardium. LAST treatment consists of the following steps: Infuse 20% lipid emulsion. (Upper limit is approximately 10–12 mL/kg over the first 30 minutes.) Bolus at 1.5 mL/kg (lean body mass) intravenously over 1 minute. Provide continuous infusion at 0.25 mL/kg per minute. For persistent cardiovascular collapse, repeat bolus up to two times. Double the infusion to 0.5 mL/kg per minute, if remains hypotensive. Continue infusion for at least 10 minutes after circulatory stability is achieved. Phenobarbital is a barbiturate that acts as a nonselective central nervous system depressant and that is used primarily as a sedative hypnotic and also as an anticonvulsant in certain populations. It is not used for adult status epilepticus. Dantrolene is a postsynaptic muscle relaxant that lessens excitationcontraction coupling in muscle cells. It acts by inhibiting Ca2+ ions release from sarcoplasmic reticulum stores by antagonizing ryanodine receptors. It is the primary drug used for the treatment and prevention of malignant hyperthermia, a rare, life-threatening disorder triggered by general anesthesia. Phentolamine is an alpha-1 agonist and results in vasodilation. It can be used to reverse the effects of local anesthetics containing epinephrine. Epinephrine is a direct-acting sympathomimetic drug that acts as an agonist at alpha- and beta-adrenergic receptors. It produces vasoconstriction to counteract the vasodilation and resulting hypotension associated with anaphylaxis and other conditions. 3. Answer: a. When performing liposuction, endpoints include contour, pinch test (pinching the operative area between the thumb and index finger to assure evenness of liposuction), and bloody aspirate. The tone of the skin does not dictate an endpoint for liposuction. Skin turgor and the fountain sign (escape of wetting solution when the infiltration cannula is withdrawn) are endpoints for infiltration of wetting solution. The practice advisory on liposuction released by the ASPS acknowledges that there are no scientific data available to support a specific volume maximum at which point liposuction is no longer safe; with that said, it is important for the surgeon and patient to know that the risk of complications is unavoidably higher as the volume of aspirate and the number of anatomic sites treated increase. Assuming that the patient is tolerating anesthesia and the procedure well, operative length is not an endpoint for liposuction, but should be kept to a reasonable minimum. Close attention to prevent hypothermia, to position and pad the patient appropriately, and to use appropriate deep vein thrombosis prophylaxis will minimize adverse outcomes from a prolonged procedure. 4. Answer: d. To perform a diver’s test, the patient flexes at the waist from a standing position. Presence of a lower abdominal protuberance with flexion that is not present in the erect position indicates laxity of the myofascial system that is most commonly a result of pregnancy. Myofascial laxity can be improved with plication of the rectus muscles. 5. Answer: b. The resultant scar from a belt lipectomy is generally located more superior than that of a lower body lift. With the wedge of tissue being removed located more superior encompassing the abdomen, flanks, and lower back, there is a greater effect on the waist contour. Because of the circumferential nature of the procedure, a minimum of two position changes is necessary during the

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surgery in order to adequately address the abdomen, back, and lateral flank/thigh area. To obtain maximal lift from the belt lipectomy, the zones of adherence of the lateral thighs are discontinuously disrupted with liposuction.

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References Illouz, YG. Body contouring by lipolysis: a 5-year experience with over 3000 cases. Plast Reconstr Surg. 1983;72:591.Illouz’s technique of using a wetting solution, blunt cannulas, and negative pressure aspiration improved the safety of lipolysis and is the foundation of how liposuction is performed today. Illouz also recognized over the course of his experience represented in this paper that deeper liposuction tunnels allowed for a smoother contour and less skin excess. Broughton, G, Crosby, MA, Coleman, J, Rohrich, RJ. Use of herbal supplements and vitamins in plastic surgery: a practical review. Plast Reconstr Surg. 2007;119(3):48e. Harrison, B, Khans, I, Janis, JE. Evidence-based strategies to reduce postoperative complications in plastic surgery. Plast Reconstr Surg. 2016;138:51S. Rinker, B. The evils of nicotine: an evidence-based guide to smoking and plastic surgery. Ann Plast Surg. 2013;70:599. Chia, CT, Neinstein, RM, Theodorou, SJ. Evidence-based medicine: liposuction. Plast Reconstr Surg. 2017;139(1):267e. Markman, B, Barton, FE. Anatomy of the subcutaneous tissue of the trunk and lower extremity. Plast Reconstr Surg. 1987:80:248. Lockwood, TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87:1009. Haeck, PC, Swanson, JA, Gutowski, KA, et al. Evidence-based patient safety advisory: liposuction. Plast Reconstr Surg. 2009;124(suppl 4):28S. Murphy, RX, Alderman, A, Gutowski, KA, et al. Evidence-based practices for thromboembolism prevention: summary of the ASPS Venous Thromboembolism Task Force Report. Plast Reconstr Surg. 2012;130(1):168e-175e. Klein, JA. The tumescent technique for liposuction surgery. Am J Cosmet Surg. 1987;4:263. Rohrich, RJ, Kenkel, JM, Janis, JE, et al. An update on the role of subcutaneous tissue infiltration in suction-assisted lipoplasty. Plast Reconstr Surg. 2003;111:926. Gutowski, KA. Tumescent analgesia in plastic surgery. Plast Reconstr Surg. 2014;134(4 suppl 2):50S-57S. Klein, JA. Tumescent technique for regional anesthesia permits lidocaine doses of 35 mg/kg for liposuction. J Dermatol Surg Oncol. 1990;16:248. Swanson, E. Prospective study of lidocaine, bupivacaine and epinephrine and blood loss in patients undergoing liposuction and abdominoplasty. Plast Reconstr Surg. 2012;130:702. Rohrich, RJ, Leedy, JE, Swamy, R, et al. Fluid resuscitation in liposuction: a retrospective review of 89 consecutive patients. Plast Reconstr Surg. 2006;117:431. Kenkel, JM, Robinson, J, Beran, SJ, et al. The tissue effects of ultrasound assisted lipoplasty. Plast Reconstr Surg. 1998;102:213. Zocchi, ML. Ultrasonic assisted liposuction: technical refinements and clinical evaluations. Clin Plast Surg. 1996;23;575. Prado, A, Andrades, P, Danilla, S, et al. A prospective, randomized, double-blinded, control clinical trila comparing laser-assisted lipoplasty with suction assisted lipoplasty. Plast Reconstr Surg. 2006;118:1032. Ingargiola, MJ, Motakef, S, Chung, MT, et al. Cryolipolysis for fat reduction and body contouring: safety and efficacy of current treatment paradigms. Plast Reconstr Surg. 2015;136(6):1581. Derrick, CO, Shridharani, SM, Broyles, JM. The safety and efficacy of cryolypolysis: a systematic review of available literature. Aesthet Surg J. 2015;35:83. Stroumza, N, Gauhier, N, Senet, P, et al. Paradoxical adipose hyperplasia (PAH) after cryolipolysis. Aesthet Surg J. 2018;38(4):411. Wall, SH Jr, Lee, MR. Separation, aspiration, and fat equalization: SAFE liposuction concepts for comprehensive body contouring. Plast Reconstr Surg. 2016;138(6):1192.This article proposes a comprehensive multistep process toward body contouring aimed at reducing complications and fulfilling aesthetic ideals. Wall and Lee describe detailed steps of the process and a retrospective 5-year review of their liposuction results on 129 patients. Del Vecchio, D, Wall, S Jr. Expansion vibration lipofilling: a new technique in large-volume fat transplantation. Plast Reconstr Surg. 2018;141(5):639. Horton, BJ, Reece, EM, Boughton, G, et al. Patient safety in the office based setting. Plast Reconst Surg. 2006;117(4):61e. Appelt, EA, Janis, JE, Rohrich, RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118(1):237. Steinbrech, DS, Sinno, S. Utilizing the power of fat grafting to obtain a naturally-appearing muscular “6-pack” abdomen. Aesthet Surg J. 2016;36(9):1085. Weinberg, GL. Lipid emulsion infusion: resuscitation for local anesthetic and other drug overdose. Anesthesiology. 2012;117:180. Huger, WE Jr. The anatomic rationale for abdominal lipectomy. Am Surg. 1979;45:612.This anatomic study introduced a simple and reliable regional vascular map of the abdomen. The map is divided into three zones based on regional anatomy. Lipectomy or abdominoplasty alters the normal anatomic blood supply to the superficial abdominal wall. These postsurgical anatomic changes explain tissue survival following the surgery. Buck, DW II, Mustoe, TA. An evidence-based approach to abdominoplasties. Plast Reconstr Surg. 2010;126:2189. Gutowski, KA. Evidence-based medicine: abdominoplasty. Plast Reconstr Surg. 2018;141:286e. Pannucci, CJ. Evidence-based recipes for venous thromboembolism: a practical safety guide. Plast Reconstr Surg. 2017;139:520e. Pollock, H, Pollock, T. Progressive tension sutures: a technique to reduce local complications in abdominoplasty. Plast Reconstr Surg. 2000;105:258. Macias, LH, Kwon, E, Gould, DJ, et al. Decrease in seroma rate after adopting progressive tension sutures without drains: a single surgery center experience of 451 abdominoplasties over 7 years. Aesthet Surg J. 2016;36:1029.

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Lockwood, T. High-lateral tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96:603.In this article, Lockwood introduces his belief that the circumferential trunk is a subunit and provides evidence against two commonly held abdominoplasty principles of that time. Firstly, he challenged the principle that wide undermining of the abdominal flap to the costal margin was necessary by achieving excellent results with widespread liposuction and less flap undermining. Secondly, Lockwood drew attention to the previously neglected lateral abdominal wall tissues and resected excess tissue in this area transferring the tension of closure to the superficial fascial system. Friedman, T, O’Brien Coon, D, Michaels, J, et al. Fleur-de-lis abdominoplasty: a safe alternative to traditional abdominoplasty for the massive weight loss patient. Plast Reconstr Surg. 2010;125:1535. Dellon, AL. Fleur-de-lis abdominoplasty. Aesthet Plast Surg. 1985;9:27.This is the first description of this technique. The author emphasizes the advantages of using both a horizontal and a vertical resection in order to restore a favorable contour to the abdomen. Saldanha, OR, Federisco, R, Daher, PF, et al. Lipoabdominoplasty. Plast Reconstr Surg. 2009;124(3):934. Matarasso, A. Liposuction as an adjunct to a full abdominoplasty. Plast Reconstr Surg. 1995;92:1112. Khansa, I, Khansa, L, Meyerson, J, Janis, JE. Optimal use of surgical drains: evidence-based strategies. Plast Reconstr Surg. 2018;141(6):15421549. Richter, D, Stroff, A, Ramakrishnan, V, et al. A comparison of a new skin closure device and intradermal sutures in the closure of fullthickness surgical incisions. Plast Reconstr Surg. 2012:130(4):843. Khansa, I, Harrison, B, Janis, JE. Evidence-based scar management: how to improve results with technique and technology. Plast Reconstr Surg. 2016;138(3):165S. Janis, JE, Khansa, I, Khansa, L. Strategies for postoperative seroma prevention: a systematic review. Plast Reconst Surg. 2016;138(1):240. Rubin, JP, Nguyen, V, Schwentker, A. Perioperative management of the post-gastric-bypass patient presenting for body contouring. Clin Plast Surg. 2004;31:601. Aly, AS, Cram, AE, Chao, M, et al. Belt lipectomy for circumferential truncal excess: the University of Iowa experience. Plast Reconstr Surg. 2003;111:398. Lockwood, TE. Lower body lift. Aesthet Surg. 2001;21:355. Colwell, AS, Borud, LJ. Optimization of patient safety in post-bariatric body contouring: a current review. Aesthet Surg J. 2008;28;437. Almutairi, K, Gusenoff, JA, Rubin, JP. Body contouring. Plast Reconstr Surg. 2016;137:586e. Hunstad, JP. Body contouring in the obese patient. Clin Plast Surg. 1996;23:647. Fischer, JP, Wes, AM, Serletti, JM, Kovach, SJ. Complications in body contouring procedures: an analysis of 1797 patients from the 2005-2010 American College of Surgeons National Surgical Quality Improvement Program database. Plast Reconstr Surg. 2013;132(6):1411-1420.

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CHAPTER 65

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Lower Body Lift and Thighplasty Omar E. Beidas and J. Peter Rubin

Key Points The lower body lift is a powerful procedure that reshapes the hips, buttocks, and lateral thighs. Because the lower body lift does not address the medial thighs, a medial thighplasty is required to treat the thigh deformity. Together, these two operations contour the lower trunk and thigh in a single stage or in separate stages. The massive weight loss (MWL) patient is left with deformities of varying degrees, with somewhat predictable patterns of excess skin and fat. The lower trunk and thighs can be dramatically improved by combining a lower body lift (LBL) and thighplasty. Although many variations of each of these procedures have been described in the literature, key principles are applied according to each patient’s anatomy and preferences. Importantly, patients must be accepting of long scars in exchange for improved contour, especially for the medial thighs where a vertical scar is necessary to correct the circumferential excess of skin. 1,2 Not every patient presenting after MWL needs an excisional procedure; each patient is assessed individually and an operative plan is created based on the nature of the deformity and the patient’s goals. Moreover, patients who have plateaued at a high BMI or require optimization of medical comorbidities may not be ready for major elective surgery. The Pittsburgh Rating Scale 3 is a useful tool to grade a patient’s deformities and can assist the surgeon with operative planning. Patients with low-grade deformities have excess adipose tissue with adequate skin tone and may be treated with liposuction alone. Patients with high-grade deformities require skin and subcutaneous tissue resection with or without liposuction.

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Approaches to Thigh and Buttock Contouring The LBL was introduced over 25 years ago to treat the ptotic, wrinkled skin and subcutaneous tissue of the abdomen, hips, back, and buttocks. 4 With the understanding of the relevant vectors, Lockwood combined procedures that were typically carried out in multiple stages into a single stage. He introduced the concept of suspending the superficial fascia system (SFS) 5 to anchor the incision and achieve a circumferential correction of the lower trunk. Lockwood referred to this initial technique as the lower body lift #1 (LBL #1)—a combination of abdominoplasty and medial thighplasty—and later developed the lower body lift #2 (LBL #2)—a combination of high-lateral-
 tension abdominoplasty, lateral thigh lift, and buttock lift. LBL #1 is best suited for patients with minimal abdominal laxity and is infrequently applied to the MWL population as many require a significant abdominal resection. However, the LBL #1 may be useful for patients who had a prior abdominoplasty. The LBL #2 is applied for patients with abdominal skin laxity, and this circumferential approach is the most common and familiar variant in current practice. Both variants exert a significant upward lifting effect on the lateral thighs. The actual vector, though primarily vertical, also causes a mild lateral and vertical rotation (outward spiral motion) of the medial thigh tissues. The correction of medial thigh skin laxity from an LBL is small in magnitude, and patients with significant laxity of the medial thigh skin will require a medial thighplasty procedure. The medial thigh lift was introduced in 1957, 6 but not widely adopted; over 20 years elapsed before another specific article about thigh lift was described. 7 Complications associated with the original description included vulvar distortion due to scar migration and early recurrence of ptosis. It was not until Lockwood wrote about anchoring the SFS of the thigh to Colles fascia that thighplasty gained popularity. 8 Thighplasty requires resection of skin and subcutaneous tissue in a longitudinal, transverse, or combined axis. Various incision patterns are described, including a longitudinal medial incision, a longitudinal lateral incision, or a transverse incision in or near the groin crease. 9–11 The transverse thigh lift is also known as a proximal thigh lift, generally reserved for patients with minor deformities. 12 The transverse thigh lift is not the procedure of choice in MWL patients because it can only treat the proximal third of the thigh deformity. It is important to recognize that transverse-only excisions have low power to correct thigh deformities and the force of pull is not transmitted past the proximal third of the thigh. Overly aggressive transverse resection in an attempt to obtain a greater correction of skin laxity can result in labial spreading. The medial vertical thigh lift is better suited for the MWL patient whose excess tissue can be treated along the entire length of the thigh. Lateral vertical thigh excisions are rarely used, but have a role in cases of severe deformities in which both medial and lateral excisions may be of benefit.

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Lower Body Lift Multiple variations of the LBL exist based on the patient’s deformity and desired outcome. An LBL generally needs a more inferior resection, and a belt lipectomy resection is located more superiorly, at the level of the waistline. A belt lipectomy (Chapter 63) tends to emphasize waist shape, directly excising central adiposity of the flanks, and is therefore well suited for the typical android body fat distribution. The more inferior resection pattern of an LBL enables more control of lateral thigh and buttock shape and is better for patients with a gynecoid body type whose excess adiposity is in the hips and thighs. Although the higher incisions of a belt lipectomy give the surgeon better control over the contour of the waist and flank, the lower incisions of the LBL exert a more powerful and direct lifting effect of the lateral thighs for gluteal autoaugmentation with autologous flaps. The more caudal the incision, the more buttock autoaugmentation tissue can be incorporated into the dermoglandular flap. Matching the variant of the procedure to individual body types is the key to optimizing outcomes.

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Patient Evaluation Patients almost never present requesting an LBL. Generally, they highlight their dissatisfaction with the appearance of their abdomen, lateral thighs, and/or buttocks. Many do not realize the LBL is an option until brought up by the surgeon. The first determination that must be made is the lower truncal procedure that will best address the patient’s deformities and meet their goals; both anterior and posterior deformities must be considered. Candidates for LBL are those with circumferential skin laxity when an anterior approach alone will not treat the 360° nature of the deformity. The anterior assessment requires a thorough physical examination of the abdomen. The surgeon must evaluate the patient’s skin quality, excess skin, subcutaneous versus intraabdominal fat distribution, rectus diastasis, hernias, and existing scars. It is vital to pay attention to the location of previous scars when deciding on any areas that may need liposuction or undermining. Patients who have undergone adjustable gastric banding surgery will have a subcutaneous port along the abdominal wall; it is important to note its location as it may be encountered intraoperatively. Posteriorly, the physical examination focuses on the lower back and buttocks. MWL patients have a characteristic appearance of the buttocks, with loss of adiposity, decreased projection, and ptosis, in addition to lengthening of the infragluteal fold. Depending on patient and surgical factors, patients may need clearance from other medical specialists. Although these issues are covered in both Chapters 16 and 63, they are worth repeating as MWL patients and body contouring procedures are independent risk factors for complications. 13–15 Please refer to the two chapters referenced above for appropriate venous thromboembolism prophylaxis, pre- and postoperative antibiotic dosing, intraoperative positioning, maintenance of body temperature, and fluid balance. Figures 65.1 and 65.2 depict a patient of each gender who underwent LBL.

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FIGURE 65.1 A–C. This 35-year-old woman lost 150 lb after gastric bypass surgery and desired body contouring of multiple areas. She underwent a staged approach with lower body lift and brachioplasty followed 3 months later by dermal suspension parenchymal reshaping mastopexy and thighplasty. D–F. Three months postoperative photographs show the first stage of her lower body lift.

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FIGURE 65.2 A–C. A 48-year-old male fitness trainer who lost 100 lb through diet and exercise and desired abdominal contouring. D–F. One year after lower body lift.

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Surgical Technique Markings Markings begin posteriorly by identifying the midline. The patient and surgeon together decide on the optimal scar placement that is in an acceptable location to the patient to address their chief complaint. The superior line—the stable anchor posteriorly—is marked. Vertical lines are drawn at consistent intervals to align the superior and inferior lines. Next, the width of resection is estimated by means of pulling the caudal tissue in a cephalad direction until the skin is taut in appearance. This marks the inferior line of resection. The posterior resection has the appearance of a bow tie, tapered centrally given the strong zone of adherence and flaring laterally where tissue is more lax. To preserve the sacral dimple, the scar should come together in a “V” at the midline. Maximum buttock projection is most aesthetic when located at the transposed horizontal level of the pubic symphysis; therefore, surgical planning should take this into account. If gluteal autoaugmentation is planned, the resection width is adjusted to accommodate the anticipated additional volume. Male and female markings sometimes differ based on the area to be resected, as shown in Figure 65.3.

FIGURE 65.3 Side-by-side pictures to demonstrate the sometimes necessary difference in marking a female versus male for lower body lift (LBL) procedure. A. The woman in Figure 65.1 marked for her LBL. B. The man in Figure 65.2 marked for his LBL with a more cephelad pattern of resection best suited for his specific body type.

Once the posterior markings are complete, they are extended anteriorly, where the inferior line is now the stable anchor. At the midline, the marking is made 7 cm superior to the labial commissure. The marking is carried laterally over the thigh superior to the inguinal ligament to avoid disrupting lymphatic drainage. The superior line anteriorly need not be drawn as it is determined intraoperatively. Areas of liposuction are marked using different color ink.

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Intraoperative Steps Several different techniques have been described for the LBL. At a minimum, 1 intraoperative patient position change is required to access the torso circumferentially, whereas some prefer 2 position changes. If the procedure is to begin in the lateral or prone position, the patient is intubated and a Foley catheter placed while on the stretcher, then the patient is flipped onto the operating room table. The patient is positioned appropriately, all bony prominences are padded, and the head and neck are placed in neutral alignment. All visible lower truncal surfaces are prepped and draped in typical sterile fashion. Alternatively, some surgeons prefer to prep the patient while standing before moving onto a sterile drape on the operating room table. The patient’s trunk is prepped down to the operating room table along with the thighs circumferentially. As previously described, an additional arm board can be placed adjacent to each thigh to be able to abduct them and decrease tension during the posterior closure. 16 A solution of 1:100,000 of epinephrine in normal saline is injected subcutaneously along the markings. The width of resection is verified with a single towel clamp placed across both incisions, as the LBL is one of the few procedures where the surgeon commits to the entire width simultaneously. After waiting approximately 10 minutes, the incision through the dermis is made. The resection is tailored to the patient, and as is often said in a breast reduction, the tissue left behind is more important than the tissue removed. Preservation of gluteal fat pads to ensure adequate gluteal projection is vital to avoid flattening of the buttock shape.

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Thighplasty Both short and long scar versions of this operation exist, and the incision length is determined according to the patient’s preference and soft tissue deformity. In the long scar version, the incision stays medial to the patella before curving inferiorly in a lateral direction. Combined with LBL, thighplasty completely reshapes the lower trunk and thigh circumferentially.

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Patient Evaluation Most patients present in consultation requesting a solution to excess skin in the medial upper thigh that causes chaffing, moisture buildup, and difficulty fitting into clothes. The thigh is assessed in a circumferential fashion to decide on the optimal approach that will address the patient’s excess tissue and meet their expectations. Often, vertical thigh lift is combined with liposuction of the lateral thigh and medial knee to debulk tissue that is not treated by the excision. This is discussed with the patient at the preoperative visit. Before and after pictures are shown in Figure 65.4.

FIGURE 65.4 Preoperative (A,B) and postoperative (C,D) thighplasty.

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Surgical Technique Markings The patient is marked with the patient on a bed, in the supine position, with thighs abducted in frog leg position. The first mark is made 4 cm away from the midline at the level of the mons pubis. In the area of the mons, the incision should stay in or near the proximal thigh crease to avoid scar migration and labial widening. This is then extended within the groin crease to mark the natural line that exists in this region. Next, the adductor longus is marked along its course from groin to knee. A pinch or distraction test is used to determine the estimated width of tissue that will be removed. If significant vertical excess is present, a horizontal incision may have to be incorporated; this is done by means of sliding tissue along the adductor longus superiorly and marking the estimated height of resection. Hatch marks are made for easy reapproximation, and symmetry is verified. Representative markings are shown in Figure 65.5.

FIGURE 65.5 The same patient at her second stage, with markings performed prior to vertical medial thighplasty. A. Anterior and (B, C) oblique views of markings.

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Intraoperative Steps The thigh is prepped circumferentially for access to all areas. This permits liposuction of the excision site as well as other regions, if needed (see Alternate Approach: Excision-Site Liposuction section). The procedure begins with subdermal injection of a 1:100,000 epinephrine solution. Alternatively, the epinephrine can be injected after the patient is intubated to allow for maximum effect and minimize wasted time once the procedure has started. After waiting an appropriate amount of time for the epinephrine to take effect, the anterior incision is made along its length. Dissection proceeds in a plan immediately superficial to the muscular fascia toward the posterior marking. Care must be taken during this step to avoid injury to the saphenous vein, which courses superficially, or lymphatic structures of the groin. The dissection must not proceed past the maximum width of resection or risk raising a flap of tissue that will have to be sewed back down. The preoperative markings are guides and therefore the width of resection may differ from the anticipated width. As the surgeon approaches the posterior margin, the ability to close the elevated tissue is intermittently verified. Once the limit of dissection is reached, the margin of resection is verified by pulling the edges together with a pair of forceps or towel clamp. Perpendicular hash marks are then made to simplify closure, and the posterior incision is infiltrated with epinephrine prior to completing the resection. The wound is irrigated and hemostasis is assured. The SFS of the thigh flap is secured to the Colles fascia using 2-0 absorbable suture to prevent labial distortion. A drain is placed at the base of the wound, exiting lateral to the mons area, and the incision is temporarily closed with staples to mitigate edema. The deep SFS layer is closed with 2-0 absorbable suture and the deep dermis is closed with 3-0 absorbable suture. The skin is closed with 3-0 absorbable suture in the subcuticular layer, and cyanoacrylate glue is used to seal the incision. Lower extremities are wrapped from foot to thigh with a compression bandage.

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Alternate Approach: Excision-Site Liposuction Resection site liposuction as described by Drs. Pascal and Louarn 17 can be applied to thighplasty with comparable results. However, new adopters of this technique should be careful as it requires a commitment to the estimated width of resection and therefore can lead to over-resection. Tumescent solution is infiltrated into the excision site and this area is aggressively lipoaspirated. Alternatively, conservative tumescent followed by liposuction can be performed in an anterior to posterior direction to ensure that the margins of resection can be closed. As much as is feasible, liposuction access sites should be within the safe margin of resection to avoid additional small scars.

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Postoperative Care Patients generally spend one to two nights in the hospital, depending on the concurrent procedure performed. All patients are encouraged to ambulate with assistance on the evening of surgery. While hospitalized, venous thromboembolism prophylaxis is based on a patient’s 2005 Caprini score, a validated tool for use in plastic and reconstructive surgery. 18 A Foley catheter is left in place for one evening until the patient can ambulate and use the bathroom. Showering may begin 24 to 48 hours postoperatively. The morning after surgery, dressings are unwrapped and surgical sites examined for signs of bleeding before discharge from the facility. Perioperative antibiotic use and drain placement is left to the discretion of the surgeon. The patient is seen in clinic within 1 week of surgery for a first postoperative visit. The postoperative dressing is removed to examine the surgical sites. If drains were placed, they are discontinued based on output. Patients are seen weekly until all drains are removed. Compression is maintained for 6 weeks. Patients may use the postoperative medical wrapping or transition to a store-bought compression garment of choice. Lifting is restricted to 5 kg during this same period.

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Complications Common complications with truncal or extremity contouring procedures are usually minor and easily managed on an outpatient basis. Those seen most often are delayed wound healing or wound dehiscence. Another commonly seen complication is a seroma. More serious complications that could require a return to the operating room are hematoma, surgical site infection, and nerve injuries during extremity surgery. Some complications may necessitate revisions, such as scar widening or hypertrophy and chronic wounds or sinus tracts. Recurrent skin laxity is a source of dissatisfaction for the patient and is an unpredictable complication. Systemic complications are generally more worrisome, including but not limited to deep venous thrombosis and pulmonary embolism, which could be fatal. For management of these postoperative problems, refer to Chapter 63.

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Summary Careful planning is the key to successful outcomes in LBL and thigh lift in the MWL population. The surgeon must choose the optimal procedure for the patient’s unique deformity rather than stick to one technique and apply it to all comers. Understanding and being able to manage complications is paramount in the care of these patients.

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Questions 1. A 56-year-old woman presents to clinic after being referred by her bariatric surgeon. She underwent laparoscopic Roux-en-Y 2 years ago. What is the procedure that will best address the deformity shown in Figure 65.6? a. Abdominoplasty b. Lateral thighplasty c. Liposuction d. LBL e. Panniculectomy 2. A 28-year-old man comes to your office after 60-kg weight loss secondary to gastric bypass surgery. He has no major comorbidities and is otherwise healthy. He has an incisional hernia from previous abdominal surgery and is interested in panniculectomy and simultaneous hernia repair. He asks your opinion about a concurrent hernia repair and panniculectomy. What is the appropriate response? a. Both procedures can be safely performed in one operative setting. b. It is best to fix the hernia at a first stage then perform the panniculectomy at a second stage. c. The risk of complications is less when performed together than individually. d. The risk of complications is too high to perform both procedures simultaneously. 3. What is the best treatment option for the patient in Figure 65.7 who has lost 100 lb and presents desiring correction of excess thigh laxity? a. Lateral thighplasty b. Liposuction c. Short scar vertical thighplasty d. Transverse thighplasty e. Vertical thighplasty 4. Which procedure has the highest risk of recurrent skin laxity? a. Abdominoplasty b. Brachioplasty c. Dermal suspension, parenchymal reshaping mastopexy d. LBL e. Thighplasty

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FIGURE 65.6 A. Anterior and (B) posterior view of patient in question 1.

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FIGURE 65.7 Anterior view of patient in question 3.

1. Answer: d. LBL is the only procedure among the choices that will address the lateral thigh laxity present in the patient depicted. None of the other choices alone would address the circumferential deformity present, which is only treated by means of an LBL. 2. Answer: a. Multiple studies have shown the safety of simultaneous panniculectomy or abdominoplasty combined with ventral hernia repair in all patient types (including MWL patients). 19-21 As with all procedures, patient selection and optimization is key, and these operations should not be performed on smokers or poorly controlled diabetics. 3. Answer: e. The best treatment for MWL patients for treatment of excess skin and fat of the thigh is a medial vertical thighplasty. Contouring surgery requires a shaping of the thigh in a cylindrical fashion, which can only be obtained via a longitudinal incision on the extremity. Lateral thighplasty

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may be performed but would place a more visible scar on the outside aspect of the thigh. Liposuction alone would not treat the excess skin present in this patient. A short scar vertical thighplasty would not address the full-length deformity that is present at the knee region. Finally, transverse thighplasty is incorrect as it is a transverse incision that will inadequately treat the distal thigh and is prone to recurrence of laxity. 4. Answer: e. Of all the procedures for massive weight loss patients, thighplasty is the one that is most likely to result in recurrent skin laxity. Unfortunately, this is neither avoidable nor predictable by the surgeon preoperatively.

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References Lockwood, T. High-lateral-tension abdominoplasty with superficial fascial system suspension. Plast Reconstr Surg. 1995;96(3):603-615. Cormenzana, P, Samprón, NM. Circumferential approach to contouring of the trunk. Aesthet Surg J. 2004;24(1):13-23. Song, AY, Jean, RD, Hurwitz, DJ, et al. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;116(5):1535-1544.A classification system designed to grade the deformities of 10 anatomical areas after massive weight loss. The Pittsburgh Rating Scale is a validated measure of contour deformities in MWL patients. Lockwood, T. Lower body lift with superficial fascial system suspension. Plast Reconstr Surg. 1993;92(6):1112-1122. Lockwood, TE. Superficial fascial system (SFS) of the trunk and extremities: a new concept. Plast Reconstr Surg. 1991;87(6):1009-1018. Lewis, JR. The thigh lift. J Int Coll Surg. 1957;27:330-334. Schultz, RC, Feinberg, LA. Medial thigh lift. Ann Plast Surg. 1979;2(5):404-410. Lockwood, TE. Fascial anchoring technique in medial thigh lifts. Plast Reconstr Surg. 1988;82(2):299-304.An important article by Ted Lockwood describing the high-lateral tension abdominoplasty with SFS suspension. Fifty patients underwent this technique with excellent lifting of the inguinal and anterior thigh areas. Spirito, D. Medial thigh lift and DE.C.LI.VE. Aesthetic Plast Surg. 1998;22(4):298-300. Le Louarn, C, Pascal, JF. The concentric medial thigh lift. Aesthetic Plast Surg. 2004;28(1):20-23. Sozer, SO, Agullo, FJ, Palladino, H. Spiral lift: medial and lateral thigh lift with buttock lift and augmentation. Aesthetic Plast Surg. 2008;32(1):120-125. Shermak, MA, Mallalieu, J, Chang, D. Does thighplasty for upper thigh laxity after massive weight loss require a vertical incision? Aesthet Surg J. 2009;29(6):513-522. Shermak, MA, Chang, DC, Heller, J. Factors impacting thromboembolism after bariatric body contouring surgery. Plast Reconstr Surg. 2007;119(5):1590-1596. Kurz, A, Sessler, DI, Lenhardt, R. Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization: Study of Wound Infection and Temperature Group. N Engl J Med. 1996;334(19):1209-1215. Coon, D, Michaels, JV, Gusenoff, JA, et al. Hypothermia and complications in postbariatric body contouring. Plast Reconstr Surg. 2012;130(2):443-448.An article examining effects of intraoperative hypothermia in patients undergoing plastic surgery after bariatric surgery. Results demonstrated that hypothermia is associated with an increased risk of seroma formation and bleeding requiring transfusion. Hurwitz, DJ, Rubin, JP, Risin, M, et al. Correcting the saddlebag deformity in the massive weight loss patient. Plast Reconstr Surg. 2004;114(5):1313-1325. Pascal, JF, Le Louarn, C. Brachioplasty. Aesthetic Plast Surg. 2005;29:423-429. Caprini, JA. Thrombosis risk assessment as a guide to quality patient care. Dis Mon. 2005;51(2–3):70-78.A landmark article by Caprini wherein the first VTE risk-assessment tool was introduced. This study was later validated in the plastic surgery literature by Panucci et al. and is currently the basis for stratifying outpatient plastic surgery procedures. Shermak, MA. Hernia repair and abdominoplasty in gastric bypass patients. Plast Reconstr Surg. 2006;117(4):1145-1150. Moreno-Egea, A, Campillo-Soto, Á, Morales-Cuenca, G. Does abdominoplasty add morbidity to incisional hernia repair? A randomized controlled trial. Surg Innov. 2016;23(5):474-480. Hughes, KC, Weider, L, Fischer, J, et al. Ventral hernia repair with simultaneous panniculectomy. Am Surg. 1996;62(8):678-681.

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CHAPTER 66

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Brachioplasty and Upper Trunk Contouring Amy S. Colwell and Nicole A. Phillips

Key Points Brachioplasty and upper trunk contouring are increasingly performed for patients with redundant skin following massive weight loss. The goals of surgery are to remove redundant skin and restore more normal or enhanced contour. Patient selection centers on optimizing medical conditions and nutrition while accepting realistic expectations of outcomes. Brachioplasty procedures successfully remove redundant skin and fatty tissue from the upper arm. The most common technique leaves a visible scar along the inner aspect of the arm. The patient needs to decide if the benefits of improved contour outweigh the presence of scar. The breast deformity is typically characterized by deflated, ptotic breasts. The surgical procedure of choice is related to the current and desired volume of the breasts and includes breast reduction, mastopexy, augmentation-mastopexy, and less commonly autologous augmentation using intercostal artery perforator (ICAP) flaps. Upper body contouring includes removal of an axillary roll and back skin to tighten the entire upper torso. This is commonly known as a bra-line lift and may be combined with breast and arm contouring. Management of excess skin and fat following massive weight loss (MWL) is an area of growing interest and consumer demand. Given the steady rise in popularity of bariatric procedures, it is not surprising that patients are seeking out body contouring procedures at increasing rates. The American Society for Metabolic and Bariatric Surgery reported 216,000 bariatric procedures in 2016, compared with 158,000 procedures just 5 years earlier. 1 Today’s plastic surgeon should be comfortable with the surgical approaches and perioperative care requirements for patients requesting body contouring procedures. The focus of this chapter, brachioplasty and upper body contouring, highlights the upward trend of patient interest in these procedures. According to data from the American Society for Aesthetic Plastic Surgery, breast lift and brachioplasty have shown the most dramatic increase in cosmetic procedures performed since the society began collecting data nearly 20 years ago. More than 24,000 brachioplasty procedures were reported in 2016, representing an 879% increase since 1997. Breast lift was the fourth most commonly performed procedure in 2016 with over 161,000 procedures performed. The popularity of this surgery has increased 712% compared with 1997 rates. 2 For patients who have successfully lost weight following bariatric surgery or through diet and exercise routines, satisfaction with results can be severely limited by the excess skin and deflated tissue that remains. Although the health benefits of weight loss are undisputed, the psychosocial benefits may lag behind as patients struggle with intertriginous rashes, skin breakdown, difficulty with clothing fit, poor self-image, and functional impairment. The goals of surgery are to restore a more normal contour, achieving improved appearance and function; however, expectations must be frankly discussed with patients prior to surgery, as soft tissues that have been subject to significant weight gain/loss will never recover their pre–weight-gain elasticity and appearance. Patients must fully understand that lengthy scars are the trade-off for improved contour, and that minor complications such as wound dehiscence and seromas are not uncommon. Patients with unreasonable expectations or who are unwilling to accept

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these risks are not good candidates for body contouring procedures. 3 At the initial evaluation, special attention should be paid to certain elements of the patient history. The maximum body mass index (BMI) prior to weight loss should be recorded along with the current BMI. Higher BMI at both time points has been associated with higher complication rates after surgery. 4,5 Timing of body contouring procedures should allow at least 12 months after bariatric surgery and 6 months at a stable weight for patients to achieve metabolic and nutritional homeostasis. If patients have experienced a plateau of weight loss at higher-than-expected BMI, or are suffering from significant nausea, vomiting, or nutritional derangement, referral back to the bariatric surgeon for reevaluation is recommended. 4 Patients with a history of obesity also demonstrate high rates of significant medical comorbidities including cardiac disease, insulin resistance, and obstructive sleep apnea. Risk factors for the aforementioned should be carefully examined, and medical management optimized prior to any planned surgical intervention. Furthermore, if a patient is on chronic anticoagulation, a decision must be made on the safety of being off the medication for the perioperative time period. Finally, the patient’s psychological status and social support network should be ascertained. MWL and outcomes after body contouring procedures can precipitate tremendous changes in self-esteem, image perception, and interpersonal relationships. Ensuring the safety and stability of the patient from a psychological and social perspective should not be overlooked. 4

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Brachioplasty Introduced by Iturraspe and Fernandez in 1954, 6 brachioplasty was designed to tighten and lift the upper arm. Weight fluctuations, aging, and heredity contribute to sagging skin and a droopy appearance of upper arms (Figure 66.1). This excess skin is troubling to patients and has functional consequences including chafing, rashes, and difficulty with clothing fit. No amount of physical exercise will correct an excess of loose skin, and localized adipose deposits can likewise be difficult to target. For these patients, a number of arm contouring procedures have been described, with significant modifications in technique since the original description. 7

FIGURE 66.1 Massive weight loss upper torso deformity. A. The breast deformity is characterized by breast ptosis, lowering of the inframammary fold, upper pole volume loss, and often medialization of the nipples. B. The arm deformity consists of variable amounts of excess skin and adipose tissue. C, D. The axillary and midback deformity likewise contains excess skin, with or without excess fatty tissue deposits.

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Classification schemes are not widely used in clinical practice; however, knowledge of basic systems may facilitate procedure choices and discussions. The first classification of the upper arm deformity, described by Teimourian and Malekzadeh in 1998, divided upper arm findings into four categories 8 : Group 1: Patients with minimal to moderate subcutaneous fat and minimal skin laxity Group 2: Patients with generalized accumulation of subcutaneous fat and moderate skin laxity. The authors suggested management of these patients with liposuction, with the possible addition of a small axillary skin excision Group 3: Patients with excess fat and extensive skin laxity requiring combined liposuction and direct soft-tissue excision Group 4: Patients with minimal excess adiposity but significant skin laxity, requiring brachioplasty without adjunctive liposuction Later classification systems built on and refined this concept. In addition to the degree of skin and fat excess, the algorithmic system introduced by Appelt et al. in 2006 added the variable of location of skin excess 9 : Type I: Patients with relative excess of adipose tissue but good skin quality and tone, for whom liposuction alone was recommended Type II: Patients with minimal to moderate adipose tissue and moderate skin laxity. Excisional brachioplasty techniques were endorsed for this patient population, with a further subdivision into type IIA, IIB, and IIC based on the location of skin excess and the related skin excision pattern Type III: Patients with both significant lipodystrophy and redundant skin laxity fall into three categories: Continued weight loss prior to surgery Staged treatment with initial liposuction followed by excisional brachioplasty Combined liposuction-excisional brachioplasty Type III patients were again subdivided based on location of skin excess, which determines the skin excision pattern for any brachioplasty procedure performed. Another widely accepted classification system described by El Khatib appeared in the literature the following year with five stages of brachial ptosis and management according to adipose deposits and skin laxity. 10

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Related Anatomy The fascial systems of the upper arms provide important landmarks for the surgeon performing liposuction or excisional contouring procedures. The superficial fascial system is found between the superficial and deep layers of subcutaneous fat. Loosening of this layer with age or significant weight fluctuations can contribute to upper arm ptosis; as such, some authors advocate plication of this layer during the closing portion of the procedure. 11 The deep fascial system envelops the musculature, and all major neurovascular structures of the arm lie deep to this layer. Care should be taken to avoid violation of this layer during all aspects of the procedure. Two sensory nerves travel superficial to the deep fascial layer and are thus at risk during brachioplasty procedures: the medial brachial cutaneous nerve and the medial antebrachial cutaneous (MABC) nerve (Figure 66.2). Damage to these nerves results in sensory dysfunction, a well-recognized possible complication of this procedure. Both nerves arise from the medial cord of the brachial plexus. The MABC nerve, which is the more frequently involved of the two, pierces the deep fascia an average of 14 cm proximal to the medial epicondyle and travels with the basilic vein in the superficial plane of the distal half to third of the upper arm. To prevent damage to these sensory nerves, at least 1 cm of fat should be left on the deep brachial fascia of the upper arm if possible. Adjunctive liposuction can also be employed to facilitate atraumatic dissection and lymphatic preservation of lymphatics to decrease seroma formation. To prevent ulnar nerve injury, liposuction access incisions should be avoided at the posteromedial elbow, and caution should be exercised with the liposuction cannula tip in this same region.

FIGURE 66.2 Upper arm anatomy. During upper arm contouring, knowledge of the relevant anatomy is essential. The shaded areas highlight the axilla and posteromedial elbow, which are approached cautiously secondary to the brachial plexus in the axilla and the superficial path of the ulnar nerve distally. The medial antebrachial cutaneous nerve travels with the basilic vein and should be preserved.

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Preoperative Evaluation, Planning, and Marking A thorough history and physical examination must be conducted at the time of the initial evaluation, with special attention paid to weight loss/gain, stability of current weight, tobacco use, medical comorbidities, and nutritional status. Physical examination should include full motor and sensory examinations of the bilateral upper extremities, in addition to assessment of skin quality and tone. Evaluation of the degree of excess skin and adipose tissue forms the basis for operative planning. Importantly, patients must be willing to accept potentially unfavorable scarring in exchange for improved contour. To best determine the degree of excess skin, fat, and ptosis, the patient is asked to stand with the shoulder abducted to 90° and the elbow flexed at 90°. Details of marking and surgical technique specific to each approach are highlighted in the relevant sections.

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Liposuction For patients with minimal skin laxity and a mild to moderate amount of adipose deposits in the upper extremity, liposuction can be performed as a stand-alone technique for upper extremity recontouring. It can also be performed as a staged procedure or as an adjunct to traditional excisional brachioplasty procedures. Traditional, mechanical, and/or ultrasound-assisted liposuction may be employed according to the surgeon’s preference. The patient should stand in the position described above, with shoulders abducted and elbows flexed. Pockets of adipose tissue are marked out and access incisions planned by avoiding areas that must be treated with caution while performing liposuction: the axilla, to avoid damage to branches of the brachial plexus, and the posteromedial elbow, to avoid damage to the ulnar nerve (see Figure 66.2). The operation is performed under local, monitored, or general anesthesia with the patient in the supine position. Arms should be supported on single arm boards, abducted to approximately 80°. Following standard procedures for prepping and draping, tumescent fluid is infiltrated into each arm prior to suction lipectomy. Care should be taken to remain above the deep brachial fascia with the liposuction cannula, leaving a layer of fat over this deep fascial layer to preserve lymphatics and avoid significant contour irregularities. Long, uniform strokes are also recommended to improve outcomes. Liposuction to the bicipital groove is avoided to minimize contour irregularity in this region, which is known anatomically to be relatively devoid of fat. 7,9,12

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Minibrachioplasty (Limited Medial Incision Brachioplasty) For patients with good skin quality but a moderate excess of skin and adipose tissue limited to the proximal one-half to one-third of the upper arm, the minibrachioplasty is a reasonable option to consider. This procedure has little to no benefit for the MWL patient. Preoperative planning should begin with the patient standing in the upright position, with arms resting at his or her sides. The anterior and posterior borders of the axillary skin crease are marked, signaling the boundaries of the planned incision (Figure 66.3). The patient is then asked to stand with the arm raised, shoulder abducted, and elbow flexed. The two points are connected along the axillary fold; this line now defines the planned medial incision. A pinch test is performed to determine the extent of resection, which is generally limited to 3 to 5 cm at its widest point. A vertical dart can be added as needed to correct residual horizontal excess. Hatch marks are placed to assist with realignment at the conclusion of the procedure.

FIGURE 66.3 Minibrachioplasty. For patients with small degrees of skin laxity, with or without excess adiposity, an elliptical incision can be designed in the axilla for skin tightening. This incision may contain a vertical dart (dashed lines) for dog-ear removal or to excise more redundant upper arm skin.

The procedure is performed under local, monitored, or general anesthesia. Setup and liposuction should proceed as described in the previous section. The axillary elliptical incisions are made using a scalpel, and

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then electrocautery is used to raise the tissue in a subcutaneous plane. The medial and lateral skin flaps may be undermined to facilitate closure, but this is typically not necessary. A transverse extension at the midpoint of the incision can be designed to correct a dog-ear or correct for ongoing skin laxity. 7,13

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Extended Brachioplasty An extended brachioplasty is the procedure of choice for patients with significant skin laxity that cannot be corrected by the methods described earlier. Most MWL patients require this technique if they desire improved arm contour. The superior incision is marked approximately one fingerbreadth above the bicipital groove (Figure 66.4). The inferior incision is then determined with the assistance of a pinch test, often resulting in mark placement just posterior to the inferior-most extent of hanging skin. The final inferior mark is rechecked after skin undermining. An extension to the chest wall is often added and is known as an L-brachioplasty with the superior L-point in or near the deltopectoral groove along the anterior axillary line. The distal extension is planned based on the expected amount of tissue resection and confirmed with a pinch test. Care is taken to avoid overresection and prevent breast lateralization.

FIGURE 66.4 Markings for upper body lift. This patient had massive weight loss and desired an improvement in her contour. A. Markings for Wise pattern mastopexy. B. Markings for Wise pattern mastopexy and brachioplasty. C. Side view showing continuity of breast and back markings. D. Bra-line excision of axilla and back.

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The operation is performed under monitored or general anesthesia with the patient in the supine position. Arms should be supported on single arm boards, abducted to approximately 80°. Following standard procedures for prepping and draping, tumescent fluid is infiltrated into each arm if liposuction is going to be used to facilitate the dissection. The amount of tumescent fluid should be minimized, so as to avoid large-volume swelling that may ultimately inhibit the degree of resection. Liposuction is then performed through access incisions placed within the planned area of resection. Liposuction beyond the borders of the planned resection is intentionally limited, as aggressive liposuction of these areas may compromise the remaining soft tissue and lead to postprocedure skin loosening when swelling resolves. The anterior incision is then made, and dissection of the skin flap from anterior to posterior is performed in the honeycomb plane that has been defined by the previous liposuction (Figure 66.5A). Intermittent pinch tests are performed to ensure the accuracy of the preoperative markings and the ability to close the skin once the inferior incision has been made. The final excision of the skin flap and resultant contour are guided by tailor tacking and either segmental resection or alternatively by committing to the entire inferior incision at once (Figure 66.5B). The longitudinal resection of the upper arm tissue is achieved first, and then adjustments are made to the axillary/chest wall component as needed. Three-layer closure of the wound is also performed using absorbable sutures in a sequential fashion, over a drain (Figure 66.5C). Reapproximation of the superficial fascial system importantly helps maintain contour and prevents scar puckering. 14

FIGURE 66.5 Extended brachioplasty technique. A. Liposuction facilitates the dissection plane and leaves fat down on the deep fascia, thus helping to preserve nerves and lymphatics. B. A segmental excision maximizes skin excision without risking the ability to close. C. The incisions are closed in three layers to avoid indentation and scar puckering.

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Postoperative Management, Outcomes, and Complications All patients should be placed into compressive dressings at the end of the procedure, regardless of the selected technique. These compression garments should be worn day and night for at least 6 weeks postoperatively. Drains placed for brachioplasty procedures offload stress on the incisions early and can be removed at the first postoperative visit. Recent studies have demonstrated intact sensory and lymphatic function following brachioplasty employing liposuction for atraumatic dissection of tissue planes. 15 This technique helps preserve the layer of fat above the deep brachial fascia harboring the sensory nerves and lymphatics. Reported complications of the procedure include seroma, hematoma, infection, wound breakdown, slight asymmetries between sides, paresthesias, lymphedema, and unsightly scarring. Risk factors that may increase the chance of overall complications, hematoma, or infection include male gender, BMI >30, and combined procedures. 16 Thoughtful preoperative discussions with patients regarding these risks are critical to ensuring a positive outcome. Patients must be willing to accept these risks to achieve improved contour with decreased volume of the upper arms. Ongoing debate remains over optimal scar placement. An anterior scar placed just below the bicipital groove of the upper arm is well hidden on both anterior and posterior views with the arms at the side. If the incision is instead placed posteriorly, it will be visible when the patient has his or her arm by the side, but it may have the advantage of avoiding the arm sensory nerves with tissue removal. For thick or heavy scarring, which may occur despite optimal scar placement and technique, regular application of silicone sheeting or scar massage may improve scar appearance. 17 With careful planning, thorough preoperative discussions, and careful execution, brachioplasty procedures can achieve significant cosmetic and functional improvements for patients. Risk profiles should be carefully considered prior to proceeding; however, with the right patient and operative technique, satisfactory outcomes should be obtainable (Figure 66.6).

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FIGURE 66.6 Brachioplasty result. The scar is located at the level of the bicipital groove and fades over time.

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Breast Contouring Related Anatomy The medial and lateral borders of the breast are defined by the sternocostal junction and the midaxillary line, respectively. The second intercostal space marks the superior boundary. The inframammary fold (IMF) delineates the inferior border of the breast and is formed by the fusion of the deep and superficial fascia with the dermis. Composed of multiple interconnected subunits, the breast is made of mammary glands and associated adipose tissue, which increases as the glandular component subsides after lactation or during menopause. Each mammary gland consists of a host of secretory lobules, which converge to form lactiferous ducts that drain to the nipple. Layers of deep and superficial fascia support the soft tissues of the breast, as do the suspensory Cooper ligaments. Aging and stretch due to weight loss/gain or breastfeeding can lead to attenuation of these structures, contributing to breast ptosis. Blood supply to the breast must be vigilantly maintained during all contouring procedures. The subdermal plexus provides blood supply to the skin and nipple-areolar complex (NAC). The parenchyma is supported by vascular inflow from perforating branches of the internal mammary artery, the lateral thoracic artery, the thoracodorsal and thoracoacromial arteries, and multiple intercostal perforators. Innervation of the breast is derived from anteromedial and anterolateral branches of the thoracic intercostal nerves, with the fourth intercostal nerve considered the major contributor to the NAC. Lymphatic drainage occurs via superficial and deep lymphatic drainage systems. The subareolar and subdermal regions drain via the superficial lymphatic system to the axillary basin. The deep lymphatic system drains to the axillary nodes as well, but also exhibits connections with a perforating system that drains to the internal mammary nodes. Other node fields that directly drain the breast include the interpectoral, infraclavicular, supraclavicular, and intercostal nodal basins. 18,19

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Preoperative Evaluation, Planning, and Marking The loss of volume and attenuation of soft tissue, skin, and ligamentous support associated with MWL results in deflated, ptotic breasts that little resemble the ideal, youthful breast (see Figure 66.1). Given the resultant superior pole deficiency, lack of lateral breast definition, and associated contour deformities of the axilla or posterior trunk, the MWL patient provides the plastic surgeon with a unique set of challenges when attempting to improve breast contour and volume, as traditional techniques may not sufficiently address these concerns. 20 Additionally, the nipple position in MWL patients is frequently located too medial and the IMF too inferior compared with normal breast anatomy, presenting yet other factors to be considered in surgical design and planning. The breast technique employed largely depends on the current breast volume and desired breast volume 20 (Figure 66.7). Breast ptosis is nearly universal in the weight loss population. If the patient has large breasts and desires smaller breasts, a reduction mammoplasty is performed. If the patient desires to stay the same size, a mastopexy or augmentation mastopexy is offered depending upon the overall size and shape goals. For the patient desiring an increase in breast size, a breast augmentation alone rarely is enough to correct the loose skin and ptosis. Instead, an augmentation mastopexy with implants or autologous tissue is most often chosen. The following breast procedures are covered in separate chapters, but challenges and techniques specific to the MWL population are emphasized in the following sections. As with all patients planned to undergo breast surgery, history of personal or family breast cancer, prior breast procedures, and up-to-date mammography results must be obtained as part of the preoperative workup.

FIGURE 66.7 Breast contouring. Options for breast contouring most commonly involve a mastopexy with shaping sutures. A mastopexy with autologous augmentation using an intercostal artery perforator flap can be considered. Augmentation mastopexy is performed in one or two stages. A. For a one stage approach, access through a vertical incision preserves lower pole breast support. B. Once the implant is placed, the skin is tailor-tacked around the implant for a circumvertical or Wisepattern mastopexy.

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Breast Reduction For the uncommon MWL patient who retains excess breast volume, standard breast reduction techniques can be employed to provide improved breast shape and position on the chest wall. Although all breast reduction techniques may be considered, the superior safety profile of the inferior pedicle should be taken into account, given the lengthy sternal notch-to-nipple distance typical of weight loss patients. A Wise skin pattern is most commonly chosen to reduce the large skin excess. Dermal suspension techniques and pedicle-shaping sutures as used in mastopexy procedures may improve long-term outcomes and patient satisfaction. 20–22

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Mastopexy For patients with sufficient volume, standard mastopexy techniques may be employed with the addition of dermal flaps or pedicle-shaping sutures to provide support and maintain breast shape (see Figure 66.4). The entire Wise pattern is deepithelialized. The lateral most extension of the breast into the axilla may be removed to facilitate a smooth lateral breast border. Skin flaps are then raised approximately 1.5 cm in thickness. The medial and lateral aspects of the deepithelialized breast parenchyma are elevated at the level of the chest wall, maintaining blood supply to the NAC via the preserved 8 to 10 cm inferior and central mound. The inferior pedicle is plicated, leaving 5 to 5.5 cm between the base of the areola and the IMF. Medial, lateral, and superior sections are then tacked to the pectoralis fascia or rib periosteum 20,21 (Figure 66.8).

FIGURE 66.8 Mastopexy with pedicle-shaping sutures. A. An 8 to 10 cm inferior and central pedicle is marked around the breast meridian (dotted area). B. The dermal flap sections are deepithelialized and tacked to the chest wall to support the pedicle shape. C. The shaped pedicle resembles the appearance of an implant; however, it descends more than an implant with healing, resulting in less sustained upper pole fullness.

If the degree of excess skin and ptosis is less severe, a vertical/extended vertical mastopexy with preservation and advancement of the inferior pole tissues can be considered. 23

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Autologous Autoaugmentation An appealing option for the MWL patient interested in improved breast contour and volume is mastopexy with autologous autoaugmentation using an intercostal artery perforator (ICAP) flap/spiral flap. 20,24–26 This procedure can simultaneously address multiple deformities at once, taking advantage of excess axillary and posterior trunk tissue to provide increased superior pole volume, improved lateral breast definition, and correction of axillary/back irregularities. However, the technical challenges of this technique in achieving adequate mobilization of the flap without injuring the ICAPs have made augmentation using an implant a preferred approach. For the ICAP flap, patients are marked for a standard inferior-pedicle Wise-pattern mastopexy with extension into the axillary and back regions. Sentinel to this procedure is preservation of the ICAP(s). A Doppler probe is used to confirm perforator location anterior to the anterior axillary line. The flaps are raised from posterior to anterior in the subfascial plane. To obtain adequate rotation of the flap for inset, perforating vessels from the thoracodorsal system must be sacrificed. The skin flaps and inferior pedicle are defined as per routine, and then the mobilized ICAP flap is rotated around the inferior pedicle and secured to the chest wall medially, superiorly, and laterally. Layered closure is performed over a drain. Inadequate mobilization leads to a boxy breast with lateral fullness. Failure to preserve the intercostal arteries leads to fat necrosis. 20,24–26

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Augmentation Mastopexy For patients who desire more superior fullness, mastopexy with implants is recommended in one or two stages. Owing to the thin, overstretched skin typical of MWL patients, patients are advised to choose a conservative implant size, and two stages may be considered for more predictable results. In one-stage augmentation mastopexy, the implant pocket is approached through a vertical or IMF incision by preserving the superior and medial blood supplies to the breast. A vertical approach is advantageous for easier exposure compared with an IMF incision because the lateral fold is often anatomically low and for preservation of the inferior breast tissue and fold centrally. The implant is placed subpectorally in a dual plane or in a subglandular position, and a circumvertical or Wise-pattern mastopexy is then tailor-tacked around the implant (Figure 66.9).

FIGURE 66.9 Augmentation mastopexy with an implant. A. This patient had breast ptosis and loss of volume. B. She underwent a single-stage augmentation mastopexy with a silicone implant and had a lower body lift at a later date.

In two-stage augmentation mastopexy, the mastopexy is performed first followed by the augmentation procedure 3 to 6 months later. If the inferior blood supply to the nipple is preserved for the mastopexy, care is taken to make a lateral IMF incision for implant placement. If instead the superior/medial blood supply was preserved for the breast lift, the vertical incision may be used to place the implant.

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Axilla and Upper/Middle Back Contouring Excess adiposity and skin laxity of the upper and middle back occurs following MWL or simply as a result of the natural aging process. For patients concerned with the appearance of this region, axillary and back roll excision can be achieved via posterior midback/bra-line lift. This procedure can be performed in conjunction with breast contouring or may be added as a second stage. There are theoretical concerns about opposing vectors if performed at the same time as a belt lipectomy/lower body lift; however, both procedures rely primarily on lifting of the inferior tissues superiorly, so they may be performed together safely and effectively in experienced hands.

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Preoperative Evaluation, Planning, and Marking Evaluation of the degree of excess skin and adipose tissue forms the basis for operative planning. Patients must be willing to accept potentially significant scarring in exchange for improved contour. According to the Pittsburgh Weight Loss Deformity Scale, 27 the posterior trunk can be evaluated according to a four-point scale: Grade 0: Normal contour of the back Grade 1: Excess adiposity or a single fat roll Grade 2: Multiple skin and fat rolls Grade 3: Ptosis of the fat rolls It is useful for female patients to wear a bra in the initial phase of marking, as this can help determine scar placement—ideally hidden by the posterior bra strap. Once bra strap borders have been marked, the bra is removed. For male patients or patients who do not present with an appropriate undergarment, the ideal placement of the final scar should be set at the level of the planned IMF. The superior incision is designed immediately above the planned final scar; the lower incision can be expected to elevate significantly during closure and is based on a pinch test. The incisions extend from the lateral IMF, along the lateral chest wall, to the posterior chest (see Figure 66.4). The bimanual examination defines how far this excision extends. Severe deformities will require a scar that crosses the midline to avoid a dog-ear. However, for less severe deformity, the central skin of the back is preserved and bilateral wedge excisions are performed. Vertical realignment marks may assist with final closure.

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Surgical Technique The procedure is performed under general anesthesia. The patient is placed in the prone position on gel rolls, with arms flexed at the elbow and extended in the superman position. Care is taken to avoid pressure in the axilla. If excess adiposity extends inferior to the planned excision, liposuction is first performed in this area via separate stab incisions. The superior incision is made and carried down through Scarpa fascia using electrocautery (Figure 66.10). The tissue is undermined at the level below Scarpa fascia, leaving fat on the fascia to help prevent seroma. The proposed inferior mark is then rechecked with a pinch test, and the excision is completed. Closure is then performed in three layers over a drain. The wound is dressed with surgical glue and steri strips, covered with tegaderm dressings. The patient is then placed supine for completion of the excision or concurrent surgery of the breast and/or arms.

FIGURE 66.10 Bra-line lift. The excess tissue of the back is removed at a level just below Scarpa fascia.

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A compression bra, vest, or ace wrap should be placed at the conclusion of surgery. Patients should avoid heavy lifting for 6 weeks postoperatively. Drains are removed at the first postoperative visit. The most common complication reported with this procedure is widening of the scar. Wound healing complications, seroma, hematoma, and infection can also occur. 28–32 A postoperative result is depicted in Figure 66.11.

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FIGURE 66.11 Bra-line lift result. This 44-year-old Asian woman had a bra-line lift combined with a lower body lift and augmentation mastopexy. Liposuction was performed of the midback region and flanks below the bra-line lift. The scar remains covered with a bra.

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Combined Surgery The decision on whether to combine one or more surgical procedures into one operative setting depends upon the age, health, and desire of the patient as well as planned operative time and experience of the surgeon. Upper body contouring procedures are not associated with excessive amounts of blood loss. Therefore, an upper body lift including brachioplasty, excision of axillary and back rolls/bra-line lift, and breast contouring can be combined into one operative procedure in many patients. 5 Upper body contouring can also be combined with lower body contouring procedures; however, a total body lift is typically avoided secondary to excessive operative time, blood loss, and morbidity. There are patient advantages in combined surgeries for time off work and overall costs. 5 However, each patient must be evaluated individually to determine the risk/benefit ratio and to determine the optimal procedure for them.

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Questions 1. A 43-year-old woman lost 150 lb through diet and exercise. She had excess skin in her upper arms and underwent a brachioplasty procedure. The patient has persistent numbness in the volar ulnar surface of the forearm. Which nerve was most likely injured during the procedure: a. Intercostobrachial b. Lateral antebrachial cutaneous c. MABC d. Medial brachial cutaneous 2. A 30-year-old woman who has lost 110 lb after gastric bypass presents for evaluation. She is interested in addressing the excess skin of her upper arms, as this causes her significant distress and difficulty with clothing fit. When counseling the patient about the risks of surgery, which of the following is most likely to lead to dissatisfaction with results and reoperation? a. Wound dehiscence b. Hypertrophic scar c. Seroma d. Numbness e. Contour irregularities 3. A 54-year-old woman presents to the office 24 months after gastric bypass surgery. She has lost a total of 170 lb and maintained a stable weight for the past 6 months. Her breasts are characterized by grade 3 nipple ptosis and volume fitting into a C cup bra. She would like to have a more youthful appearance. Which of the following is least likely to offer a satisfactory result? a. Mastopexy b. Mastopexy with autoaugmentation using an ICAP flap c. Breast augmentation alone d. Augmentation mastopexy 4. Which of the following best describes the characteristics most commonly associated with breast appearance following MWL? a. Deflated superior pole, lateralized NAC position, lowered IMF position b. Deflated superior pole, medialized NAC position, lowered IMF position c. Deflated superior pole, medialized NAC, raised IMF position d. Deflated inferior pole, medialized NAC position, lowered IMF position e. Deflated inferior pole, lateralized NAC position, raised IMF position 5. A 60-year-old woman presents for consideration of upper body contouring following previous mastopexy. She is primarily concerned about the appearance of her back and posterior trunk. Physical examination is significant for multiple loose, hanging rolls of skin and soft tissue. Which of the following grades best described this deformity, according to the Pittsburgh Weight Loss Deformity Scale? a. Grade 0 b. Grade 1 c. Grade 2 d. Grade 3 1. Answer: c. The MABC nerve is the most commonly cited sensory nerve injury following brachioplasty. The nerve pierces the deep fascia an average of 14 cm proximal to the medial epicondyle and travels with the basilic vein in the superficial plane of the distal half to third of the upper arm. To prevent this complication, at least 1 cm of fat should be left on the deep brachial fascia

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of the upper arm. 2. Answer: b. The most common reason for patient dissatisfaction or reoperation after brachioplasty is unsightly scarring. Patients undergoing this procedure should understand that they are trading improved contour for a significant scar. Because of the tension forces of the upper extremity, thickening or widening of this scar is not uncommon and may require laser treatment, kenalog injections, or revisional surgery to improve scar appearance. 3. Answer: c. For patients with MWL, the breast deformity nearly uniformly involves breast ptosis. An implant alone would not be expected to lift the nipple position enough for a satisfactory result. A mastopexy is typically involved, with or without augmentation procedures, or as part of a breast reduction to achieve a good result. 4. Answer: b. The loss of volume and attenuation of soft tissue, skin, and ligamentous support associated with MWL results in deflated, ptotic breasts that little resemble the ideal, youthful breast. Characteristic findings include superior pole deficiency, lack of lateral breast definition, medial NAC position, and inferior IMF when compared with normal breast anatomy. 5. Answer: d. According to the Pittsburgh Weight Loss Deformity Scale, the posterior trunk can be evaluated according to a four-point scale. A score of “0” indicates a normal contour of the back. Patients with excess adiposity or a single fat roll are classified as grade 1; multiple skin and fat rolls are classified as grade 2. Ptosis of these rolls represents the most severe stage, grade 3. In this patient with multiple loose, hanging rolls of skin and soft tissue, her physical examination findings would qualify as a grade 3 deformity.

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References American Society for Metabolic and Bariatric Surgery. 2016 Statistics. Available at https://asmbs.org/resources/estimate-of-bariatric-surgerynumbers. Accessed March 22, 2018. American Society for Aesthetic Plastic Surgeons. 2016 Statistics. Available at https://www.surgery.org/sites/default/files/ASAPSStats2016.pdf. Accessed March 22, 2018. Gusenoff, JA, Rubin, JP. Plastic surgery after weight loss: current concepts in massive weight loss surgery. Aesthet Surg J. 2008;28:452-455. Bossert, RP, Rubin, JP. Evaluation of the weight loss patient presenting for plastic surgery consultation. Plast Reconstr Surg. 2012;130:13611369.Based on years of experience with the massive weight loss population, this paper provides an excellent overview of the complex factors that must be considered in the perioperative period. Medical comorbidities and risk factors associated with obesity are reviewed, as are the psychosocial factors that help determine the patient’s candidacy for surgery and chances for a successful outcome. Colwell, AS, Borud, LJ. Optimization of patient safety in postbariatric body contouring: a current review. Aesthet Surg J. 2008;28:437-442.An extensive literature review was performed to examine and present consensus guidelines for preoperative, intraoperative, and postoperative management of the postbariatric body-contouring patient. This study includes an important discussion of the role of venous thromboembolism prophylaxis among this patient population and provides risk stratification guidelines invaluable for patient counseling and surgical planning. Iturraspe, M, Fernandez, JC. Brachial dermolipectomy [in Spanish]. Prensa Med Argent. 1954;41:2432-2436. Shermak, MA. Aesthetic refinements in body contouring in the massive weight loss patient: part 2. Arms. Plast Reconstr Surg. 2014;134:726e735e.Review article examining evolving trends in brachioplasty classification systems and operative techniques. Succinct overview of relevant anatomy, current practice, and reported outcomes. Teimourian, B, Malekzadeh, S. Rejuvenation of the upper arm. Plast Reconstr Surg. 1998;102:545-551. Appelt, EA, Janis, JE, Rohrich, RJ. An algorithmic approach to upper arm contouring. Plast Reconstr Surg. 2006;118:237-246. El Khatib, HA. Classification of brachial ptosis: strategy for treatment. Plast Reconstr Surg. 2007;119:1337-1342. Ferraro, GA, De Francesco, F, Razzano, S, et al. Modified fish-incision technique in brachioplasty: a surgical approach to correct excess skin and fat of the upper arm (restoring the armpit contour). Aesthetic Plast Surg. 2015;39:203-208. de Runz, A, Colson, T, Minetti, C, et al. Liposuction-assisted medial brachioplasty after massive weight loss: an efficient procedure with a high functional benefit. Plast Reconstr Surg. 2015;135:74e-84e. Hill, S, Small, KH, Pezeshk, RA, Rohrich, RJ. Liposuction-assisted short-scar brachioplasty: technical highlights. Plast Reconstr Surg. 2016;138:447e-450e.Technique article detailing markings and surgical approach for minibrachioplasty/limited medial incision brachioplasty. Hurwitz, DJ, Holland, SW. The L brachioplasty: an innovative approach to correct excess tissue of the upper arm, axilla, and lateral chest. Plast Reconstr Surg. 2006;117:403-411.Technique article introducing the indications for L-brachioplasty, as well as design, surgical approach, and expected patient outcomes. Gentileschi, S, Servillo, M, Ferrandina, G, Salgarello, M. Lymphatic and sensory function of the upper limb after brachioplasty in postbariatric massive weight loss patients. Aesthet Surg J. 2017;37:1022-1031. Nyugen, L, Gupta, V, Afshari, A, et al. Incidence and risk factors of major complications in brachioplasty: anaylsis of 2294 patients. Aesthet Surg J. 2016;36:792-803. Meaume, S, Le Pillouer-Prost, A, Richert, B, et al. Management of scars: updated practical guidelines and use of silicones. Eur J Dermatol. 2014;24:435-443. Blumgart, EI, Uren, RF, Nielsen, PM, et al. Lymphatic drainage and tumour prevalence in the breast: a statistical analysis of symmetry, gender, and node field independence. J Anat. 2011;218:652-659. Manca, G, Volterrani, D, Mazzarri, S, et al. Sentinel lymph node mapping in breast cancer: a critical reappraisal of the internal mammary chain issue. Q J Nucl Med Mol Imaging. 2014;58:114-126. Colwell, AS, Driscoll, D, Breuing, KH. Mastopexy techniques after massive weight loss: an algorithmic approach and review of the literature. Ann Plast Surg. 2009;63:28-33.Review article highlighting anatomical changes of the breasts associated with massive weight loss. The authors conduct a literature review examining various techniques for correction of MWL-associated deformities of the breast and offer an algorithmic approach for the management of such. Rubin, JP. Mastopexy after massive weight loss: dermal suspension and total parenchymal reshaping. Aesthet Surg J. 2006;26:214-222.The author presents a technique that achieves improved breast contour and volume using the patient’s own tissues. This technique has the added advantage of correcting the lateral axillary roll frequently seen in patients following massive weight loss. Colwell, AS, Breuing, KH. Improving shape and symmetry in mastopexy with autologous or cadaveric dermal slings. Ann Plast Surg. 2008;61:138-142. Losken, A, Holtz, DJ. Versatility of the superomedial pedicle in managing the massive weight loss breast: the rotation-advancement technique. Plast Reconstr Surg. 2007;120:1060-1068. Kwei, S, Borud, SJ, Lee, BT. Mastopexy with autologous augmentation after massive weight loss: the intercostal artery perforator (ICAP) flap. Ann Plast Surg. 2006;57:361-365.The authors of this technique paper describe the ICAP flap for autologous autoaugmentation. The article includes detailed information regarding indications for the procedure, surgical planning and execution, and expected outcomes. Hamdi, M, Van Landuyt, K, Blondeel, P, et al. Autologous breast augmentation with the lateral intercostal artery perforator flap in massive weight loss patients. J Plast Reconstr Aesthet Surg. 2009;62:65-70. Hamdi, M, Van Landuyt, K, de Frene, B, et al. The versatility of the inter-costal artery perforator (ICAP) flaps. J Plast Reconstr Aesthet Surg.

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2006;59:644-652. Song, AY, Jean, RD, Hurwitz, DJ, et al. A classification of contour deformities after bariatric weight loss: the Pittsburgh Rating Scale. Plast Reconstr Surg. 2005;116:1535-1544.The authors devise a 10-region, 4-point grading scale for the purpose of providing a validated measure of contour deformities following massive weight loss. This scale can assist with communication between providers, preoperative planning, and patient counseling. Hunstad, JP, Repta, R. Bra-line back lift. Plast Reconstr Surg. 2008;122:1225-1228. Hunstad, JP, Khan, PD. The bra-line back lift: a simple approach to correcting severe back rolls. Clin Plast Surg. 2014;41:715-726.The authors review relevant anatomy, preoperative markings, and intraoperative technique for the bra-line back lift. The article is accompanied by clear photographs and a concise overview of postoperative care requirements, possible complications, and outcomes. Shermak, MA. Management of back rolls. Aesthet Surg J. 2008;28:348-356. Soliman, S, Rotemberg, SC, Pace, D, et al. Upper body lift. Clin Plast Surg. 2008;35:107-114. Strauch, B, Rohde, C, Patel, MK, Patel, S. Back contouring in weight loss patients. Plast Reconstr Surg. 2007;120:1692-1696.

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PA R T V I I I

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Hand 67. Functional Anatomy and Principles of Upper Extremity Surgery 68. Hand Infections 69. Soft Tissue Reconstruction of the Upper Extremity and Management of Fingertip and Nail Bed Injuries 70. Management of Compression Neuropathies of the Upper Extremity 71. Principles and Applications of Nerve Transfers 72. Management of Brachial Plexus Injuries 73. Tetraplegia 74. Management of Hand Fractures 75. Management of Wrist Fractures 76. Flexor Tendon Repair and Reconstruction 77. Extensor Tendon Repair and Reconstruction 78. Tenosynovitis Disorders of the Upper Extremity 79. Principles and Applications of Tendon Transfers 80. Ligament Injuries of the Hand 81. Ligament Injuries of the Wrist 82. Management of Mutilating Upper Extremity Injuries 83. Replantation Strategies of the Hand and Upper Extremity 84. Thumb Reconstruction 85. Dupuytren Disease 86. Hand Tumors 87. Treatment of Vascular Disorders of the Hand 88. Comprehensive Management of the Burned Hand 89. Compartment Syndrome of the Upper Extremity 90. Common Congenital Hand Anomalies 91. Upper Limb Amputations and Prosthetics 92. Rheumatoid Arthritis and Inflammatory Arthropathies 93. Osteoarthritis

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CHAPTER 67

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Functional Anatomy and Principles of Upper Extremity Surgery Robert A. Weber and Wendy L. Czerwinski

Key Points The anatomy of the upper extremity follows a form that maximizes its functional output. Understanding the relationship between surface landmarks and underlying anatomy facilitates safe and efficient hand surgery. A standardized template that identifies functional deficits can facilitate the evaluation of a hand surgery patient to arrive at an accurate diagnosis. The restoration of motor and sensory function in the hand is the focus of an upper extremity treatment plan. Patient outcomes can be improved by following the principles of Enhanced Recovery After Surgery.

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Functional Anatomy Form follows function is a particularly useful aphorism when considering the upper extremity. The appearance of the arm is determined by its anatomy, which in turn is a result of the functional demands placed upon it. As such, a way to understand the anatomy of the upper extremity is to think in the following terms: bones, joints, and ligaments function as the foundation, muscles and tendons function as motors, arteries and veins function as fuel, nerves function to control, and the skin and subcutaneous tissues function as the surface interface.

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Bony Foundation The primary function of the upper extremity skeleton is to provide a stable foundation for purposeful movement. The bones anchor the origin and insertion of musculotendinous units. As such, bone injuries often have concomitant musculotendinous injuries. The bones also resist the compressive and bending forces that these muscles produce, so immobilization must relieve the torque and not create tension in the bone. The joints channel the compressive forces into motion; the configuration of the joints and the constraint of the ligaments determine the degrees of freedom. The majority of functional motion in the arm is flexion and extension in the anterior/posterior plane. The metacarpophalangeal (MP), carpometacarpal (CMC), and wrist joints also allow small amounts of rotation in other axes in order to conform to objects and dissipate forces.

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Forearm The radius and ulna have flat surfaces for multiple muscle origins and insertions. The ulna is constrained to flexion and extension at the elbow, whereas the radius can perform these actions and is also able to rotate longitudinally at the elbow and circumduct around the ulna distally, resulting in proximal translation of the distal radius relative to the distal ulna during pronation. This relative shortening of the radius can cause the distal ulna to impact the lunate or triquetrum (Figure 67.1). The primary stability of the distal radioulnar joint (DRUJ) is provided by the triangular fibrocartilage complex (TFCC) (Figure 67.2); the bony configuration of the sigmoid notch of the radius provides 30% of the DRUJ stability.

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FIGURE 67.1 AP radiograph of the hand. a. Location for ulnocarpal impaction due to relative shortening of the radius during pronation. b. Hook of the hamate. c. Head of the MP demonstrating the recesses where the collateral ligaments insert as well as the ball-and-socket like configuration of the joint. d. Bicondylar configuration of the PIP joint adds conformational stability to flexion and extension. e. Thumb CMC joint is a saddle joint, which allows flexion and extension in the AP and radioulnar planes (unlike the other CMC joints) and prohibits axial rotation (unlike the MP joints). Note the natural ulnar deviation at the MP joints.

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FIGURE 67.2 The TFCC is a complex arrangement of seven soft tissue structures of the ulnar wrist. This includes the TFC proper (a meniscus homologue), the dorsal and volar radioulnar ligaments, the three volar ulnocarpal (UC) ligaments (ulnolunate [UL], ulnocapitate, ulnotriquetral [UT]), and the floor of the extensor carpi ulnaris tendon subsheath. The UC ligament sits volar to the UL and UT ligaments.

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Wrist The radius and ulna articulate distally with the carpus. Because there are no tendinous insertions in any of the carpal bones, the osseous shapes as well as the extrinsic and intrinsic ligaments are vital for functional stability. For the purpose of motion, carpal bone arrangement is usually considered as two arched rows with the lunate as the keystone and the scaphoid extending to both rows. Gilula’s arcs represent the curvatures of a ball-within-a-cup configuration of the proximal and distal carpal rows (see Figure 67.1). 1 The hamate bone has a palpable volar hook that is visible on carpal tunnel view radiographs and represents an attachment of the flexor retinaculum, hypothenar muscles, and pisohamate fascia of the Guyon canal (see Figure 67.1). The radiocarpal (RC) and the ulnocarpal (UC) joints are restrained by the joint capsule, the volar radioscaphocapitate ligament (the strongest ligament), the long radiolunate ligament, short radiolunate ligament, and the ligament of Testut. 2 The primary dorsal ligaments consist of the dorsal radiocarpal ligament and dorsal intercarpal ligament. A dorsal carpal surgical exposure with a dorsal ligament sparing capsulotomy attempts to preserve the integrity of these structures, thereby improving postoperative stability and mobility. 3 Intrinsic ligaments provide stability between carpal bones within the proximal and distal rows but not between rows and lead to coordinated flexion and extension of these rows. Disruption of intrinsic ligaments can create various instability patterns such as those seen in greater and lesser arc perilunate injuries. 4

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Hand The metacarpal (MC) bones have a collateral recess radially and ulnarly at their heads for the origin of the proper collateral ligaments (CL) of the metacarpal-phalangeal (MP) joints. These recesses are radiographically visible and serve as excellent insertion points for ideal angulation in placing longitudinal K-wires for fracture fixation (see Figure 67.1). The dorsal convexity of the MC bone results in tension on the dorsal surface with loading, leading to dorsal apex fracture patterns. The MP joints are condyloid in nature, allowing for motion in three planes: flexion/extension, abduction/adduction, and rotation. The volar plate is contiguous with the deep transverse MC ligament, which connects the metacarpal heads and helps maintain the MCs in a slight dorsal arch in the transverse plane. Because the MC head is wider on its volar surface, flexion increases joint stability by tightening the CL and elongating the VP. Thus, the MP joint should be immobilized in flexion to reduce the occurrence of joint contractures. In extension, the MPs are not linear. Instead, there is a 10- to 14-degree natural ulnar deviation, predisposing the finger to ulnar subluxation of the extensor hood and ulnar drift (see Figure 67.1). The carpometacarpal (CMC) joints have limited mobility at the index finger and become progressively more mobile toward the ulnar aspect of the hand, allowing for approximately 30 degrees of flexion/extension at the fourth and fifth with some supination. The phalangeal heads are bicondylar and form interphalangeal uniaxial hinge joints (see Figure 67.1). The interphalangeal (IP) joints have one axis of rotation in flexion and extension due to their bony configuration as well as a complex arrangement of ligaments, volar plate (VP), joint capsule, and a stout extensor mechanism that resists joint dislocation. Small volar checkrein ligaments arising from the proximal phalanx volar ridges to the VP are thought to contribute to flexion contractures, which can arise at the PIP joints. In contrast to the MP joints, the PIP joints should be splinted in full extension. The thumb bones are pronated about 90 degrees and volarly abducted about 45 degrees from the plane of the hand. This configuration is what allows the functions of prehension: tip pinch, chuck pinch, key pinch, and grasp. The thumb’s MP joint is a shallow ball-and-socket, which permits the thumb phalanges to pronate even more than the metacarpal. Soft tissues are more dominant in creating joint support with the addition of the adductor aponeurosis overlying the ulnar CL. The basilar or carpometacarpal (CMC) joint is a saddle or double ginglymus joint allowing for circumductive motion, and the primary stabilizer is the volar beak/oblique ligament (see Figure 67.1). Laxity of this ligament is considered the origin of first CMC articular changes.

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Makers of Movement The musculotendinous systems of the arm create tension, which is transmitted from the origin to insertion. Working primarily as class 3 levers, longitudinal contraction of the muscle results in rotation around the joint axis. The primary motion is flexion and extension, and the flexors are able to generate more force than the extensors. The primary function of the extensors is to place the hand and fingers in a position to be used optimally. The work of the arm is done by the flexors. Repair or reconstruction of a musculotendinous unit requires that the tension forces be transmitted across the injured site in such a way to minimize adherence to adjacent structures.

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Extensors The musculotendinous system can be differentiated into extrinsic muscles originating in the forearm and intrinsic muscles of the hand including the thenar group. The extrinsic extensors, which are in three groups of three, originate from the dorsal-radial surface of the forearm and serve to extend the wrist, thumb, and remaining digits primarily at the MP level with some contribution to IP extension (Figure 67.3). They are all innervated by the radial nerve. At the wrist, they pass deep to an extensor retinaculum organized into six compartments with extensor indicis proprius (EIP) and extensor digiti minimi providing independent extension of the index and small digits and usually lying ulnar to their corresponding extensor digitorum communis (EDC) counterparts. The EIP is a useful donor motor tendon for functional transfers and can be identified by its muscle belly distal most in the dorsal forearm. The juncturae tendinae, which are interconnections between the extensors over the dorsal hand, can confuse diagnosis of tendon disruptions by the ablility to extend fingers with ruptured tendons to neutral posture through the juncturae tendinae.

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FIGURE 67.3 The extrinsic wrist extensors (extensor carpi radialis longus [ECRL], extensor carpi radialis brevis [ECRB], extensor carpi ulnaris [ECU]), thumb extensors (extensor pollicis longus [EPL], abductor pollicis longus [APL], extensor pollicis brevis [EPB]), and finger extensors (extensor digitorum communis [EDC], extensor indicis proprious [EIP], extensor digiti minimi [EDM]) are organized into 6 compartments with EIP and EDM providing independent extension of the index and small digits and

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usually lying ulnar to their corresponding EDC slips. The extrinsic tendons continue over the digit stabilized by the extensor hood. The tendinous system continues and becomes a W over the PIP joint. The tendon inserts as the central slip over the middle phalanx with contributions to the lateral bands which extend distally to the terminal triangular ligament over the DIP joint and inserting just proximal to the germinal matrix. The dorsal and volar interossei and lumbricals are intrinsic muscles contributing to the lateral bands running volar to the MP joint axis.

The extrinsic tendons continue onto the digit stabilized at the MP joint by the extensor hood/sagittal band (see Figure 67.3). Disruption at this level contributes to improper tendon tracking, and the radial-sided laxity seen in inflammatory joint conditions contributes to ulnar drift. There are no extensor insertions on the proximal phalanx. Instead, the sagittal bands transmit tension to the volar plate to pull the proximal phalanx into extension. At the PIP joint, the intrinsic muscles of the hand join the extensor mechanism (see Figure 67.3). They contribute to the lateral bands, which pass volar to the MP joint axis and thus aid in flexion at that joint. The intrinsic insertions then move dorsal to the axis of the PIP joint and function as the primary IP extensors. The PIP and DIP joints will not extend if the intrinsic muscles do not contract.

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Flexors There are 11 extrinsic flexors, 9 of which pass through the carpal canal (Figure 67.4). The majority of flexors are innervated by the median nerve; the ulnar nerve innervates the flexor carpi ulnaris (FCU) and the flexor digitorum profundus (FDP) to the ring and small digits; however, innervation variability exists in the forearm. The flexor tendon sheath extends from the proximal edge of the A1 pulley to the DIP joint, provides tendon nutrition and facilitates glide. Annular pulleys (A1-A5) are numbered from proximal to distal with three compressible cruciate pulleys intervening from A2 to A5. These prevent bowstringing in order to allow for improved excursion/moment arcs at the corresponding joint levels.

FIGURE 67.4 The FDS runs superficial to FDP and FPL in the carpal tunnel but then has a longitudinal splint near its insertion across the PIP joint (Camper’s chiasm), which permits FDP to run superficially to reach the distal.

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Intrinsic Tendons In addition to their contributions to MP flexion and IP extension, the interossei are also responsible for digit adduction and abduction. The first dorsal interosseous muscle is the last innervated muscle by the ulnar nerve; thus, wasting and weakness assessed are often first noted here by Froment’s test. The adductor pollicis (AdP) is responsible for thumb adduction. The thenar group is innervated by the median nerve, whereas the deep head of FPB and the transverse head of the AdP are innervated by the ulnar nerve. Although this group contributes to precise thumb motion, patients with long-standing carpal tunnel syndrome and thenar wasting are often not aware of any functional deficit. The intimate relationship between the intrinsic muscles and the metacarpals is critical to keep in mind. Metacarpal fractures will always have concomitant interosseous muscle damage. As a result, a fracture may heal completely with anatomic configuration, yet the hand may have significant weakness with grip or finger extension due to derangement of the muscles. A similar apposition is present between the phalanges and the flexor/extensor tendons of the finger, wherein a finger fracture can have significant concomitant tendon involvement.

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Fuel and Control The arteries provide metabolic support for the hand, but the majority of blood flow is used for thermoregulation. Within the arm and hand, the arteries and nerves tend to run parallel within a common sheath, protected from compression by the bones and tendons. The neurovascular structures can tolerate some tension and are able to glide longitudinally within the extremity to accommodate the various positions of the bones and joints. Adhesions that restrict gliding can produce pain and interfere with functionality.

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Arteries The brachial artery at the elbow divides into the radial and ulnar arteries in the antecubital fossa. The radial artery runs in a course toward the radial wrist radial to the FCR. There is a larger dorsal branch that passes through the snuffbox to the deep arch in the palm. The small volar branch contributes to the superficial arch. The ulnar artery runs between the FDS and FDP muscle groups and is palpable radial to the FCU. It continues radial to the ulnar nerve through the Guyon canal; its larger volar branch completes the superficial arch, whereas the smaller dorsal branch completes the deep arch. Vascularity to the carpus arises from the posterior and anterior interosseous arteries as well as from the ulnar and radial arteries at the level of the wrist. The common digital arteries arise from the superficial arch, whereas the princeps pollicis artery to the thumb arises from the radial artery portion of the deep arch. Vascular architecture varies from individual to individual, but within every hand, there are numerous redundant arterial interconnections, so disruption of one artery is unlikely to result in terminal ischemia. Nevertheless, arterial supply to the hand or a digit should be examined before deciding to ligate or not to repair an artery.

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Nerves The peripheral nerves originate from the cervical roots and form the brachial plexus. The median, ulnar, and radial nerve branches that terminate in the hand have fairly consistent anatomic relationships. Cranial to caudal nerve roots correspond to proximal to distal motor control, that is, the shoulder girdle is controlled by C5 nerve roots, and the intrinsic muscles of the hand are innervated from C8/T1 roots. Sensory innervation also follows a cranial to caudal pattern; C5 provides sensation to the radial border of the forearm, T1 provides ulnar forearm sensation. The internal topography of peripheral nerves has functional implications. For example, some muscles such as the FCR have multiple innervating fascicles, thereby allowing one of the fascicles to be used as motor nerve transfer. Another example of the functional relevance of internal fascicular anatomy is seen in the median and ulnar nerves at the wrist. The motor branches of those nerves are in a predictable location (the median motor is volar radial, and the ulnar motor is dorsal radial), thereby allowing more accurate nerve repairs or nerve transfers. All the extensors in the arm are innervated by the radial nerve. The elbow flexors are innervated by the musculocutaneous nerve, whereas the wrist and finger flexors are primarily innervated by the median nerve. The ulnar nerve innervates the FCU, the ulnar two FDPs with their associated lumbricals, and all the intrinsics except the thenar muscles. Like the arteries, the location of a peripheral nerve can vary from individual to individual; nevertheless, the ulnar nerve is commonly located adherent to the ulnar artery. The median nerve lies between the superficialis and profundus muscle bellies in the forearm, adherent to the deep surface of the superficialis. This is important to remember when attempting to locate the nerve during trauma exploration. Knowing the functional anatomy of the nerves also allows the surgeon to block the nerves with a local anesthetic for diagnostic and therapeutic purposes.

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Surface Anatomy Understanding how the surface anatomy of the upper extremity (flexion and extension creases, palpable muscle, and bony landmarks) relates to the structures hidden beneath the skin is critical for the management of the hand. The ability to relate what can be seen and palpated to the underlying elements allows effective treatment of those deeper structures with a minimum of damage to the surrounding tissues. Fortunately for the hand surgeon, there are many reliable guides on the surface of the upper extremity.

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Forearm With the elbow flexed at 90 degrees and the wrist in neural pronation, the muscle visible and palpable in the anterolateral portion of the proximal forearm is the brachioradialis (Figure 67.5). The biceps tendon is palpable ulnar to the brachioradialis in the antecubital fossa. The median nerve, anterior interosseous nerve, and the brachial artery are ulnar to the biceps insertion. The extensor wad is dorsal to the brachioradialis.

FIGURE 67.5 Right forearm demonstrating the brachioradialis, extensor wad, palmaris longus tendon, and FCR tendon.

In the distal volar forearm, flexion of the wrist simultaneous with positioning all the finger tips together reveals the palmaris longus tendon, a source of tendon graft. The palmaris longus (PL), used as both a tendon graft and motor tendon transfer, is absent unilaterally in about 15% of the population and bilaterally in 8%. The median nerve is radial to the PL tendon, with the flexor pollicis longus tendon deep to the nerve. All the flexor digitorum superficialis and profundus tendons are ulnar to the PL tendon.

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Volar Hand The volar skin creases provide many landmarks to the musculoskeletal and neurovascular architecture. 5 Figure 67.6 shows the relationship between the major flexion creases and the underlying anatomy. The distal wrist crease lies at the midcarpal joint corresponding to the capitolunate articulation. The distal pole of the scaphoid is distal to the crease. The crease also identifies the proximal edge of the transverse carpal ligament and can be used as a landmark for median nerve blocks. The distal palmar crease overlies the metacarpal necks and is 5 to 8 mm proximal to the metacarpal-phalangeal (MP) joints. This crease should be visible when making volar splints that are intended to immobilize the wrist while allowing MP motion. The misleadingly named MP crease is actually at the same level as the web space and overlies the midportion of the proximal phalanx. The proximal interphalangeal (PIP) and distal interphalangeal (DIP) creases are superficial to the actual joints. They can be used to locate the underlying flexor tendon pulleys. The thenar crease is due to CMC motion and must be visible in any immobilization in which the thumb is allowed to move. The radial digital nerve to the index finger runs deep to the thenar crease. The thumb MP and IP creases overlie the corresponding joints.

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FIGURE 67.6 AP radiograph of the hand with wires on the major hand creases.

Figure 67.7 shows the creases along with the palpable bony landmarks and their relationship to underlying vessels and nerves. 6 The pisiform and hook of the hamate can be used as guides to find the ulnar artery and nerves, and the superficial palmar arch runs transversely across the palm distal to the hamate toward the distal end of the thenar crease. The common digital nerve bifurcates into the digital nerves distal to the distal palmar crease, approximately at the same location where the proper palmar

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arteries divide.

FIGURE 67.7 Volar hand with the palpable pisiform, hook of the hamate, distal pole of the scaphoid, and trapezial ridge identified in black. The transverse carpal ligament (brown) as well as the relationship of the median and ulnar nerves (green) and ulnar artery (red) to the palpable bones are drawn. The arterial branches as well as the nerve branches have a more variable location from hand to hand.

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Dorsal Hand Lister’s tubercle is the key to identifying the important dorsal structures (Figure 67.8). 7 It marks the distal lip of the dorsal radius. Immediately distal to the tubercle is the midportion of the scapholunate ligament, which links the scaphoid and the lunate. The head of the capitate is approximately 1 cm distal to the palpable tubercle. The ulnar surface of the tubercle serves as a pulley for the extensor pollicis longus; the fourth extensor compartment is 1 cm ulnar with its extensor digitorum communis and extensor indicis proprius tendons. The second dorsal extensor compartment with its palpable extensor carpi radialis longus and brevis tendons is on the radial border of the tubercle. Proximal to Lister’s tubercle is the radial metaphysis, a good source of bone graft.

FIGURE 67.8 Dorsal hand with Lister’s tubercle identified (black circle in center) and the underlying bony anatomy drawn (distal radius and ulna and metacarpal bases in black, carpals in purple). The ECRL and ECRB in the second compartment and the EPL in the third compartment are drawn in orange. The extensor retinaculum is drawn in brown.

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Radial Hand The radial styloid, the abductor pollicis longus and extensor pollicis brevis tendons, and the extensor pollicis longus tendon all form the anatomic snuffbox (Figure 67.9). 8 The first dorsal compartment, the artery used in the 1,2 intercarpal radial artery pedicled bone graft, and the sensory branch of the radial nerve all overlie the dorsal radial styloid. The dorsal branch of the radial artery and its venae comitantes are located deep in the snuffbox, easily and reliably identifiable for free flap anastomoses. The thumb CMC joint is the firm bony structure, which creates the distal lid of the snuffbox. The bony floor deep is the distal scaphoid and the trapezium.

FIGURE 67.9 Radial wrist with the bony anatomy drawn (the radial styloid and metacarpal base in black, scaphoid, and trapezium in purple). The EPL and EPB/APL ridges are clearly visible. The dorsal branch of the radial artery (in red) courses diagonally on the surface of the wrist capsule from volar-proximal to dorsal-distal.

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Ulnar Hand The palpable ulnar styloid is the origin of the TFCC as well as the border of the sixth dorsal compartment. The bone palpable 1 cm distal to the styloid is the hamate, and the next bony prominence distal is the base of the little finger metacarpal with its concomitant CMC joint. Analogous to the radial snuffbox configuration, the tendon that is palpable dorsal to the styloid and hamate is the extensor carpi ulnaris tendon while the volar border is the flexor carpi ulnaris tendon.

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Digit The junction of the glabrous and nonglabrous skin marks the midlateral line of a finger (Figure 67.10). Points on this line can be found when the PIP and DIP joints are flexed. Incisions in this line are preferable to minimize scar contractures of the joints. The digital neurovascular bundles and flexor tendon sheath are volar to this line, and the bony phalanges are dorsal, a fact to keep in mind when placing percutaneous K-wires.

FIGURE 67.10 CT cross-section of the proximal phalanx of the thumb, the volar surface is on the top. The dots are at the junction of the glabrous and nonglabrous skin, which is also the midlateral line. The arrows point to the neurovascular bundles in the 2 o’clock and 10 o’clock positions.

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Principles of Upper Extremity Surgery Assessment Hand surgery is a discipline in which the practitioner is still a detective. Many patients present with a general concern of pain, stiffness, numbness, weakness, etc, and it is incumbent upon the hand surgeon to perform a history and physical sufficient to determine the correct diagnosis. A standard template for asking questions is provided in Table 67.1; note the emphasis on functional concerns. There are two particularly important aspects of the patient’s narrative that should be elucidated: those circumstances in which the deficit is noted and the amount of traumatic energy involved. Symptoms specific to a particular motion or job begin to point the surgeon to the affected anatomy. A fracture from a fall has different accompanying injuries and expected outcomes than a fracture incurred during a high-speed collision. TABLE 67.1 Elements of a Hand History History Component History of present illness

General demands on the hand

Medical history

Surgical history 
 and prior treatments Family history

Medications/allergies

Data Collected Time of onset of symptoms Mechanism of injury or inciting event, or nature of repetitive trauma Type of trauma—blunt, sharp, mechanism, hand position, contamination; estimated amount of force/energy involved Duration of symptoms; continual or intermittent Severity of symptoms Factors that worsen and/or improve the symptoms; cold intolerance History of infection Care to date Hand dominance Occupation, hobbies Activity status, walking aids Social status Nicotine use Chronic disease—autoimmune, diabetes Prior hand trauma and outcomes Prior surgical interventions and outcomes—remaining hardware Dupuytren’s contracture Lipomas Congenital conditions Anticoagulation Immunosuppressants Nonsteroidal anti-inflammatory agents Steroids Opioids

Having established a differential diagnosis based on the history, the physical exam is used to hone in on the underlying diagnosis; again, the focus is on function (Table 67.2). It is important to be thorough and examine seemingly uninvolved structures. For example, patients with carpal tunnel syndrome often have thumb CMC arthritis, but unless the arthritic component of their thumb pain is explained prior to surgery, the patient will expect the pain to resolve after carpal tunnel release and be disappointed when it

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does not. In addition, a thorough functional exam may demonstrate other abnormalities that should be addressed. TABLE 67.2 Physical Examination of the Hand Physical Examination Soft tissue appearance

Vascular

Motor

Sensory

Joint range of motion

Bone

Finding General Gross deformity Cascade Congenital anomalies Wounds—dimension, location, contamination, or presence of foreign body Rashes Nail deformities Masses Contractures versus posturing Symmetry Skin color and temperature Atrophic skin changes Allen’s test Capillary refill Flexor and extensor tendon function including forearm musculature Thenar and hypothenar muscle function or atrophy Intrinsic muscle function or atrophy Subjective numbness, comparison for symmetry Provocative nerve tests (e.g., Tinel’s sign, Phalen’s sign) Two-point discrimination Arc of rotation: DIP, PIP, MP Wrist, forearm rotation Elbow Joint stability Angulation/rotational deformity Pain or instability Prominences

Tables 67.1 and 67.2 can also be used to develop a standard history and physical template for use in an electronic medical record. The value of an individually developed standardized evaluation is that repetition allows the clinician to recognize abnormalities and disruptions of patterns better. Subtle diseases are easier to spot in a background of well-understood normal states. Table 67.3 lists the imaging modalities available to hand surgeons. It is important to choose the proper test for the patient. On one hand, magnetic resonance imaging is overly sensitive and not specific enough to use when a diagnosis is unclear. 9 On the other hand, recent advances in ultrasound make it an excellent investigative and therapeutic tool for multiple conditions involving the soft tissues. Fractures and dislocations are best identified with plain radiographs; palpating a suspected fracture site to make a diagnosis causes pain, tissue damage, and is not diagnostic. The new technology now allows for subtraction of hardware artifact in computerized tomography and has significantly improved resolution. TABLE 67.3 Imaging Modalities for Use in the Hand

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Imaging Modality Plain Radiographs Most common, most useful, most cost effective imaging modality

CT

Angiography

Ultrasound

Good for assessing fractures, dislocations, arthritic changes Rule of 2’s: Two views minimum Joint above and below level of injury Injured and contralateral side Before and after treatment Special views (e.g., carpal tunnel view, scaphoid view) Instability series Evaluation of the image—quality of the radiographs, alignment of the skeleton Provides improved bony detail Good for assessing Bone tumors Fracture healing Carpal or fracture alignment

MRI Not to be used as a screening test, only order to evaluate a suspected diagnosis

Bone scan

Evaluation

Provides improved soft tissue detail—ligaments, cartilage, muscle Good for assessing possible bony avascular necrosis T1 Black = fluid and cartilage Gray = tendon and muscle White = bone and fat T2 Black = bone, tendon, ligament, and cartilage White = fluid Three phase assesses vascularity Delayed phase useful for assessing chronic hand pain Provides vascular detail for occlusion, aneurysm, ischemia Magnetic resonance angiography is replacing traditional contrast angiography Identifies and localizes fluid collections (e.g., abscess, ganglion) Localizes radiolucent foreign bodies Identifies ligament and tendon ruptures

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Treatment Once a diagnosis has been made, the patient and surgeon collaborate on choosing a treatment plan. Not all hand patients will require surgery. In fact, most patients seen in a hand clinic will be treated nonoperatively with a combination of immobilization, anti-inflammatory medications, therapeutic modalities, and pain management. In patients who have been sent to see a surgeon and are treated without surgery, it is important to make sure the patient understands that the concerns have been taken seriously and are being appropriately addressed.

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Preoperative Patient education and a discussion about expectations are critical in surgical patients. Enhanced Recovery After Surgery (ERAS) is a multidisciplinary and multimodal approach to the care of a surgical patient. Primary elements of ERAS protocols include preoperative patient education, nutritional optimization, early mobilization, and standardized analgesic and anesthetic regimens. 10 Implementation of the ERAS protocol across surgical specialties has demonstrated the decreased average length of stay, complication rates, readmissions, and costs. 11 There has been much research done on improving outcomes in hand surgery patients, and many institutions are utilizing these strategies to decrease costs and improve patient satisfaction. A comprehensive approach to hand surgery utilizing these strategies is outlined below. Patient education is an important but often overlooked aspect of patient care. A patient’s clear understanding of their diagnosis, perioperative plan, and long-term functional expectations has been shown to improve patient compliance and health outcomes. These are also the key elements of informed consent. Additionally, patient education can benefit the provider by cutting down on unnecessary calls, clinic visits, and medication refills. Providing patients with appropriate educational materials that explain the perioperative course may also reduce patient anxiety and create more reasonable expectations, particularly in the realm of pain control.

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Operative Surgery begins before the patient enters the room. Equipment, positioning, and the anesthetic plan are discussed with operative personnel beforehand and confirmed during the time-out. Surgical site preparation, the operative plan, and subsequent surgical markings should all be performed prior to inflating the tourniquet since the tourniquet time is precious. The safe duration of tourniquet-induced ischemia in the upper extremity is 2 hours, but there are few studies other than Wilgis’ to confirm this time. 12 His study also suggests that the tourniquet time can be extended by releasing the tourniquet and then reinflating it after the blood supply has had time to circulate to prevent reperfusion injury. 13 Forearm tourniquets may be used in hand cases performed under local anesthesia. These are well tolerated by the patient and provide a bloodless field, but they can encroach on the surgical field. 14 Details of specific procedures will be provided in the upcoming chapters, but there are several principles that should be followed when operating on the upper extremity. Incisions should be longitudinal. This minimizes the number of cutaneous nerves that might be transected, allows for wider exposure through simple extension of the incision, and facilitates reexcision of the scar if needed in the future. Transverse incisions at the volar wrist with their attendant stigmata should be avoided. Incisions should not cross flexion creases. A combination of Bruner and midaxial incisions provides good exposure and can incorporate most traumatic lacerations. Incisions should be long enough to do the job. A common cause of struggling during surgery is insufficient exposure. The chief goal of hand surgery is restoration of function; patients will trade an additional 2–4 cm of scar for improved use of the hand. Work from normal to abnormal, known to unknown. Another cause of surgeon distress is the inability to identify structures. The incision should be long enough to expose uninjured, unaffected tissues in order to provide orientation. The temptation to explore a wound through an insufficiently extended traumatic laceration should be resisted. If it does not look right, it will not work right. Incisions that violate the aesthetics of the hand and closures that produce distortions in hand architecture will result in a wound that may heal, but the functional outcome will be suboptimal.

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Postoperative As noted, optimal postoperative outcomes start with following the principles of ERAS preoperatively. The important points of patient education are reviewed with the patient and his or her support system. Proper dressings, elevation, and activity levels are important and should be described in concert with their concomitant procedures. The key elements of any dressing are edema control, protection of repairs, pain minimization, immobilizing parts of anatomy that must not move, and allowing motion in all other locations. Pain management in the upper extremity is an important determinant of recovery and overall function. Insufficient pain control in the acute phase increases inflammation and scarring; concerns about opioid dependence are real, but the role of narcotics and nonsteroidal anti-inflammatory medications in the acute phase should be discussed prior to surgery in order to establish expectations. Medication-adverse patients should be reminded that the use of opioids will be limited, and that it is more important to use appropriate pain medication and move the hand than not use pain medication and not move the hand. One of the most important aspect of postoperative care is the rehabilitation plan. Many hand surgical procedures depend equally on specified hand therapy protocols. The hand surgeon should have an open, well-established line of communication with the hand therapist. The importance of good hand rehabilitation cannot be overstated. In fact, there are numerous procedures in the hand that should not be attempted unless the therapy plan has already been outlined to the patient, compliance has been demonstrated, time off and transportation issues addressed, and insurance coverage for the therapy assured. This last item is important to establish preoperatively because many insurance policies will cover surgery but not rehabilitation. Since form follows function in the hand, a good hand surgeon should master three areas: functional anatomy, basic surgical techniques, and principles of rehabilitation. Knowing the anatomy allows the surgeon to make a correct diagnosis and construct a plan to restore the anatomy to as close to normal as possible. Because all surgeries are composed of the same basic movements, a good surgeon does not have to memorize a series of specific steps but can apply well-established component steps to create a surgical plan that is tailored to the specific needs of the case at hand. Rehabilitation is the process of returning control of the hand back to the patient. People use their hands in infinite ways; the focus of the hand surgeon is to use all the operative and nonoperative modalities available to return injured or diseased structures to their proper configuration so that the patient can carry on effectively with life.

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Questions 1. Surgical exposure of the dorsal carpus should attempt to preserve which of the following anatomic structures? a. Dorsal radiocarpal ligament b. TFCC c. Gilula’s arcs d. Dorsal intracarpal ligament e. Radioscaphocapitate ligament 2. Which of the following is correct regarding the bony anatomy of the metacarpal? a. The condyloid nature of the MP joint allows for motion in two planes, flexion/extension and rotation. b. The MC head is wider on its volar surface contributing to CL tightening in flexion. c. There is a natural radial cant to the MC head of about 10 to 14 degrees. d. The volar plate is contiguous with the superficial transverse MC ligament. e. The volar convexity of the MC lends to dorsal apex fracture patterns. 3. Which of the following anatomic relationships is correct? a. Lister’s tubercle is just proximal to the lunotriquetral joint. b. The palmaris longus is radial to the median nerve. c. The distal palmar crease is at the proximal end of the A1 pulley. d. The web space is at the proximal portion of the proximal phalanx. e. The distal wrist crease is at the level of the DRUJ. 4. Which of the following anatomic relationships is correct? a. The neurovascular bundle in the proximal phalanx is deep to the midlateral line. b. The ulnar artery and nerve are radial to the palpable hook of the hamate. c. The trapezoid can be palpated in the depths of the space between the EPL and EPB tendons. d. The flexor wad is ulnar to the visible brachioradialis muscle. 5. Which of the following imaging modalities is best suited to locate a suspected mesquite thorn deep in the thenar eminence? a. Plain film radiograph b. Ultrasound c. MRI d. CT 6. Which of the following ERAS protocols in hand surgery is false? a. Primary elements of protocols include patient education, nutrition optimization, early mobilization, and standardized analgesic and anesthetic regimens. b. Implementation of ERAS protocols has demonstrated decreased average length of stay but not complication rates. c. ERAS protocols across surgical specialties have been seen to lower readmission rates and hospital costs. d. The use of ERAS protocols in hand surgery specifically has not been well established. 1. Answer: a. The dorsal ligaments consist of the dorsal radiocarpal ligament and dorsal intercarpal ligament, and a surgical exposure of the dorsal carpal bones, such as a dorsal ligament sparing capsulotomy, attempts to preserve the integrity of these structures, thereby improving postoperative stability and mobility. This is a V-shaped flap elevated from the midpoint between the DRUJ and Lister’s tubercle to the tubercle of the Triquetrum and then transversely to the tubercle of the

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scaphoid. This divides the above to noted ligaments along their midsubstance preserving their integrity. The TFCC is a 7 part soft tissue structure which stabilizes the DRUJ. Gilula’s arcs mark the radiographic aspect of the distal and proximal carpal rows. The intracarpal ligaments connect carpal to carpal and are not in the dorsal wrist capsule. The radioscaphocapitate ligament is a volar structure. 2. Answer: b. The MP joints are condyloid in nature allowing for motion in three planes: flexion/extension, abduction/adduction, and rotation. Because the MC head is wider on its volar surface, flexion increases joint stability by tightening the CL and elongation of the VP. Thus, the MP joint should be immobilized in flexion to reduce the occurrence of joint contractures. There is a 10- to 14-degree natural ulnar deviation. As a result, the slight ulnar cant to the MP head predisposes to ulnar subluxation of the extensor hood and ulnar drift. The volar plate is contiguous with the deep transverse MC ligament, which connects the metacarpal heads of the index, long, ring, and little fingers and helps maintain the MCs in a slight dorsal arch in the transverse plane. The dorsal convexity to the MC bone results in tension on the dorsal surface with loading, leading to dorsal apex fracture patterns. 3. Answer: c. Lister’s tubercle is just proximal to the scapholunate ligament and is the radial border of the third dorsal compartment. The palmaris longus is ulnar to the median nerve and serves as a landmark for median nerve blocks. The distal palmar crease is distal to the superficial palmar arch and at the level of the proximal A1 pulleys. The web space is at the mid portion of the proximal phalanx. The distal wrist crease is at the level of the midcarpal joint. 4. Answer: d. The neurovascular bundle in the finger is anterior to the midlateral line. The hook of the hamate, which is palpable in the palm, is radial to the ulnar neurovascular structures. The trapezium is palpable in the depths of the anatomic snuffbox. The origin of the flexor wad is the medial epicondyle, which is ulnar to the origin of the brachioradialis on the humerus. 5. Answer: d. Like most plant thorns, a mesquite thorn is radiolucent and will not be detected using X-rays. MRI will locate the thorn but is expensive and time consuming. Ultrasound is both sensitive and specific, costs much less than an MRI, and can be used during surgery. 6. Answer: b. Primary elements of ERAS protocols include preoperative patient education, nutritional optimization, early mobilization, and standardized analgesic and anesthetic regimens. Implementation of ERAS protocol across surgical specialties has demonstrated decreased average length of stay, complication rates, readmissions, and costs. Although recent research has aimed at improving outcomes in hand surgery, little data are available specific to ERAS protocols.

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References Linscheid, RL, Dobyns, JH, Beabout, JW, Bryan, RS. Traumatic instability of the wrist: diagnosis, classification, and pathomechanics. J Bone Joint Surg Am. 1972;54(8):1612-1632.This is the sentinel article on wrist biomechanics and instability patterns of traumatic conditions. It reviews the diagnosis, classification, and pathomechanics and relates to radiographic findings of carpal angles. Berger, RA, Landsmeer, JMF. The palmar radiocarpal ligaments: a study of adult and fetal human wrist joints. Iowa Orthop J. 1985;5:32-41. Berger, RA, Bishop, AT, Bettinger, PC. New dorsal capsulotomy for the surgical exposure of the wrist. Ann Plast Surg. 1995;35(1):54-59. Mayfield, JK. Patterns of injury to carpal ligaments: a spectrum. Clin Orthop. 1984;187:36-42. Bugbee, WD, Botte, MJ. Surface anatomy of the hand: the relationship between palmar skin creases and osseous anatomy. Clin Orthop Relat Res. 1993;(296):122-126.The volar creases were marked with wires on 50 adult female volunteers. Distance measurements were obtained and analyzed to establish normal anatomic relationships between the creases and radiographic finding. McLean, KM, Sacks, JM, Kuo, YR, et al. Anatomic landmarks to the superficial and deep palmar arches. Plast Reconstr Surg. 2008;121(1):181. Ağır, I, Aytekin, MN, Küçükdurmaz, F, et al. Anatomical localization of Lister’s tubercle and its clinical and surgical importance. Open Orthop J. 2014;8:74-77. Hazani, R, Engineer, NJ, Elston, J, Wilhelmi, BJ. Anatomic landmarks for basal joint injections. Eplasty. 2012;12:e2. Michelotti, BF, Mathews, A, Chung, KC. Appropriateness of the use of magnetic resonance imaging in the diagnosis and treatment of wrist soft tissue injury. Plast Reconstr Surg. 2018;141(2):410-419.A retrospective review of 140 patients who had an upper extremity MRI demonstrated that the results only affected treatment recommendations in 28%. The predictor of impact on treatment was the presence of a specific suspected diagnosis. Kehlet, H, Wilmore, DW. Multimodal strategies to improve surgical outcome. Am J Surg. 2002;183(6):630-641. Ljungqvist, O, Scott, M, Fearon, KC. Enhanced recovery after surgery: a review. JAMA Surg. 2017;152(3):292-298.Enhanced Recovery After Surgery (ERAS) process implementation involves a team consisting of surgeons, anesthetists, an ERAS coordinator (often a nurse or a physician assistant), and staff from units that care for the surgical patient. The care protocol is based on published evidence. The ERAS Society, an international nonprofit professional society that promotes, develops, and implements ERAS programs, publishes updated guidelines for many operations. ERAS protocols have resulted in shorter lengths of hospital stay by 30% to 50% and similar reductions in complications, while readmissions and costs are reduced. The elements of the protocol reduce the stress of the operation to retain anabolic homeostasis. The ERAS Society conducts structured implementation programs that are currently in use in more than 20 countries. Shahryar, N, McEwen, JA, Kragh, JF, et al. Surgical tourniquets in orthopedics. J Bone Joint Surg Br. 2009;91(12):2958-2967.This article reviews the literature regarding tourniquet use including size, pressure, location, and duration. Wilgis, E. Observations on the effects of tourniquet ischemia. J Bone Joint Surg Am. 1971;53(7):1343. Cousins, GR, Gill, SL, Tinning, CG, et al. Arm versus forearm tourniquet for carpal tunnel decompression: which is better? A randomized controlled trial. J Hand Surg Eur. 2015;40(9):961-965.

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CHAPTER 68

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Hand Infections Anne Argenta and William W. Dzwierzynski

Key Points Obtain a thorough history and physical exam; this will guide treatment. Know when urgent surgical intervention is warranted and always be suspicion. Persistent symptoms require further review and workup. Clearance of infection alone will not always result in a functional hand; stiffness and pain must be addressed. The hands play a significant role in the way humans communicate and interact with the external environment. Because of this, the hands are particularly vulnerable to infection. Hand infections present in a variety of ways, but they will uniformly have a better outcome when managed expeditiously. When there is suspicion of infection, it is incumbent on the plastic surgeon to be knowledgeable, efficient, and vigilant.

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Presentation and Workup There are two main players during an infectious process: the insulting pathogen and the body’s defense mechanism. A thorough workup of each will guide appropriate treatment. Important factors to elicit in the history are the duration and progression of symptoms, history of blunt or penetrating trauma, unusual exposures (animals, water, travel, and sick contacts), alleviating or aggravating factors, and systemic symptoms including fever, nausea, malaise, and altered mental status. Prior treatments and tetanus immunization should be documented. The same pathogen may present differently in different individuals. Therefore, the patient’s comorbidities and risk factors, including occupation, must be identified. Diabetes, obesity, intravenous (IV) drug use, malnutrition, human immunodeficiency virus (HIV/AIDS), autoimmune disease, and use of immunosuppressive medication can predispose patients to infection. Patients with these conditions are more susceptible to opportunistic pathogens and require more aggressive monitoring, with a lower threshold for intervention. Patients who use tobacco should be expected to have slower healing. 1 On physical exam, the hand should be inspected for swelling, color changes, focal pain, guarding, puncture wounds, lacerations, and active and passive range of motion (ROM). The location of wounds can influence decision-making. For example, a wound over a joint warrants washout and investigation for joint involvement in the setting of a sterile environment, whereas a wound on the dorsum of the hand can usually safely be washed out and explored at the bedside. Similarly, the location of focal swelling should be documented. The compartments of the hand dictate how an infection may spread and, consequentially, influence incision placement during surgery. Signs of progressing infection, such as pain with passive ROM and ascending lymphangitis, should be noted and be treated. The history and physical exam will guide need for further work up with imaging, cultures, and lab work. Ancillary tests should be used judiciously. Three view X-rays should be done when there is trauma and/or suspicion of foreign body. However, when there are signs of acute rapidly worsening infection, such as with necrotizing fasciitis, imaging will only delay treatment. Computed tomography (CT) and magnetic resonance imaging (MRI) should be reserved for cases where the diagnosis is unclear. A culture or tissue biopsy, if needed, can be taken expeditiously and easily in the emergency department setting before administration of antibiotics, without delaying treatment. Any labs, such as chemistries, complete blood count, and coagulation tests, can be drawn while the physician is examining the patient, thus avoiding treatment delays. A critical step in the workup of hand infection is determining whether a patient needs hospitalization versus outpatient management. Hospitalization is required in patients with ascending lymphangitis, a failed trial of oral antibiotics, systemic symptoms, elevated white blood cell (WBC) count, a reasonable chance of needing operative intervention, or a high risk of not following-up. When an infection is managed as an outpatient, it is imperative to follow up culture results and adjust antibiotics as appropriate.

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General Principles of Treatment Most hand infections are mild and can be managed in the outpatient setting, but the surgeon should have a low threshold for inpatient care, particularly in rapid onset infections or high-risk patients. Fluctuance, purulent drainage, and worsening pain are all indications for surgical management. Knowledge of anatomy optimizes surgical outcome and minimizes complications. Antibiotics are the cornerstone of infection management. Cultures of drainage or tissue should ideally be obtained before any antibiotics are given. The most common infections are a result of inoculation of tissues by bacteria normally found on human skin. Staphylococcus and Streptococcus species are by far the most common and should be covered in initial treatment. A first-generation cephalosporin is usually adequate. Methicillin-resistant Staph aureus (MRSA) is becoming 
 more common as both a hospitalacquired and a community-
 acquired infection. MRSA infections tend to present with more skin necrosis, though cultures should be done to confirm diagnosis. In regions of high MRSA rates and in patients with a history of MRSA or recent hospitalization, empiric coverage with clindamycin, trimethoprim/sulfamethoxazole, a tetracycline (doxycycline or minocycline), or linezolid is indicated. 2 The choice of antibiotic is directed by the patient’s community or hospital antibiogram. Immunocompromised patients are more susceptible to fungal, mycobacteria, and other less common pathogens. A high suspicion or an initial lack of response to standard antibiotic regimens may warrant broad-spectrum coverage and tailoring as culture results are obtained. Tissue culture will be more reliable than culture swabs. Confirm with the laboratory proper sampling and storage protocols for adequate testing of fungal and atypical mycobacteria. Elevation and rest are standard treatment adjuncts for infection and are important components of pain management. Elevation of the hand above the heart level will limit edema. A short period of hand rest for 24 to 48 hours will not have a negative effect on long-term hand function. Hands should be splinted in the position of function (wrist extended 30°, MCP flexed 90°, digits extended) during this rest period. As the acute swelling improves, resumption of ROM exercises is important to limit stiffness and loss of strength. Hand soaks are commonly used in the acute setting and rehabilitation phase, although their efficacy has not been fully established. Multiple solutions have been advocated. The most important principle is to dilute the betadine or chlorhexidine to a level that is nontoxic to healthy tissue. Soaks are generally performed two or three times a day, 5 to 10 minutes per session. Patients often report better pain control and ability to perform ROM exercises when the hand is submerged in warm solution.

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Common Hand Infections Digits Paronychia Paronychias are caused by infection of the skin around the nail fold. Initial violation of the skin barrier is often the result of a hangnail, manicure instruments, or nail biting. Symptoms include swelling, erythema, and pain around the nail plate. Exam should note swelling, discoloration, fluctuance, and drainage. The most common pathogen isolated from culture is Staph aureus. If caught early, treatment comprises hand soaks, oral antibiotics, and hand elevation. A first-generation cephalosporin is usually adequate. If an abscess has formed, as indicated by fluctuance and swelling, incision and drainage (I + D) is required. I + D is performed by incising the skin longitudinally with a no. 11 or 15 blade directly over the most prominent area of swelling, bluntly dissecting the cavity with a hemostat, culturing drainage, and copiously irrigating the wound with saline. When the decompressed cavity is large, a gauze wick is placed in the wound for 24 hours to help prevent reaccumulation and early skin closure. A paronychia may extend into the eponychium; in this case, the eponychial fold will need to be elevated. If purulence is noted under the nail plate, part or the entire nail should be removed. All of this can usually safely be performed under a digital block in the emergency room or clinic. Chronic paronychias present as longstanding induration, pain, erythema along the nail fold, nail plate ridges, elevation of the skin off the nail plate, and occasional drainage. The nail plate may be thickened and discolored due to concomitant onychomycosis. Chronic paronychias are more common in diabetics, immunocompromised patients, women who get manicures, and people who frequently immerse their hand in water (dishwashers, nurses, or swimmers). Antibiotics are less effective and antifungal coverage for Candida albicans with nystatin or itraconazole is generally required, along with marsupialization (excision of semilunar patch of eponychial skin and subcutaneous tissue down to the germinal matrix). Topical gentian violet is a historic treatment for chronic paronychia that is gaining popularity again. 3

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Felon Felons are focal infections within the pulp tissue of the fingertip (Figure 68.1). They are usually initiated by a puncture wound. Because of the extensive septae within the pulp, infection remains localized within a small compartment; this results in abscess formation with throbbing pain, often without visible external swelling until infection is advanced. The most common pathogen is Staphylococcus aureus. Very early presentations may resolve with oral antibiotics alone, but usually a focal abscess has formed by the time of presentation. This requires incision and drainage. Incision should be designed longitudinally over the most prominent point of pain, avoiding damage to neurovascular bundles and unnecessarily long incisions over the pulp, as the scars can become hypersensitive. The cavity should be bluntly probed with a hemostat to break up septae and ensure full drainage, and then irrigated. Placing gauze wick in the incision for 24 to 48 hours will help prevent reaccumulation. I + D in the outpatient setting under digital block is generally adequate. Delay in I + D of these abscesses can result in pulp necrosis, osteomyelitis, or extension of infection into the flexor sheath.

FIGURE 68.1 Felon, presenting in a 12-year-old boy with no recalled history of trauma.

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Flexor Tenosynovitis Flexor tenosynovitis presents as an acutely swollen, painful digit (Figure 68.2). Often, there is history of a puncture wound, animal bite, or scrape on the volar surface of digit. When a pathogen, usually S aureus, inoculates the flexor tendon region and expands, the flexor sheath guides the infection proximally up the sheath, into the hand and forearm. The four identifying characteristics, known as the Kanaval signs, are as follows: Fusiform swelling, or a sausage-shaped digit Digit resting in flexed position Pain with passive extension Tenderness to palpation along the flexor tendon sheath into the palm

FIGURE 68.2 Flexor tenosynovitis, presenting 3 days after a cat bite to the digit.

Untreated infectious tenosynovitis can lead to stiffness, chronic pain, osteomyelitis, and ascending limbthreatening infection. One should have very low threshold for hospitalization and early operative intervention. If caught within 24 to 48 hours with mild or equivocal Kanaval signs, some patients may improve with IV antibiotics, rest, elevation, and inpatient monitoring alone. Broad-spectrum antibiotics should be considered. Anyone presenting with symptoms longer than 48 hours, Kanaval signs, or worsening symptoms with conservative management should undergo surgical decompression in the operating room (OR). A variety of incisions have been described. Most cases can be treated with two incisions: a standard palmar oblique incision over the A1 pulley (as for trigger finger release), and a midaxial, transverse, or Bruner incision at the distal P2 level. Proximally, blunt dissection with tenotomies will expose the A1 pulley, which is

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incised longitudinally to view the flexor tendons. A culture should be taken of any fluid in this area. Distally at the midaxial incision, blunt dissection deep to the neurovascular bundle will expose the flexor sheath distally. A small incision in the sheath should be made to inspect the tendons. Any wounds or focal abscesses in the finger should be debrided and cultured. The flexor sheath is then thoroughly irrigated using a 14 to 18 gauge angiocatheter or a no. 5 pediatric feeding tube attached to a syringe of saline and inserted into the tendon sheath through the proximal incision. Saline is pushed though the sheath and drains out the distal incision until the irrigation is clear. The irrigation system can also be inserted into the sheath from the distal incision, if easier but risks pushing the infected fluid proximally into the palm. At least 1 L is irrigated, ensuring that the saline is flowing well through the entire sheath. If there is significant frank pus, Bruner incisions may be used to connect the proximal and distal incisions for further exposure. The irrigation system is removed at the end of the case or sutured in place for serial irrigations overnight in the hospital room. Retrospective reviews have not demonstrated that continuous irrigation has better outcomes compared to intraoperative irrigation alone. 4 The palmar and midaxial incisions can be left to close by secondary intention or loosely approximated. Extensive Bruner incisions should be loosely tacked together. Postoperatively, the hand should be monitored, elevated, and rested for 24 hours in an inpatient setting. If improving, hand therapy can be started 24 to 48 hours after surgery. If pain and swelling persist, return to the OR is necessary. IV antibiotics are generally continued for 5 to 7 days and tailored by the culture results. Subcutaneous purulence and digit ischemia on presentation are indictors of a poor prognosis. 5

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Hand Cellulitis Cellulitis is the most common hand infection (Figure 68.3). Patients present with diffuse erythema and nonfocal swelling in the extremity. There may be history of a scratch or insect bite. Exam demonstrates generalize warmth, erythema, stiffness, lymphadenopathy, and edema. Patients rarely have one focal area of pain on exam. Staph and Strep species are the most common offenders. If the inciting trauma was caused by an animal scratch, additional bacteria may be involved (Pasturella multocida in dogs and cats; Bartonella henselae in cats). Ascending lymphangitis, elevated WBC, altered mental status, or lack of response to oral antibiotics warrants inpatient admission and IV antibiotics. Erythema should be outlined and dated in permanent marker to monitor progression. High-risk patients should be monitored for septic shock. Surgery is not indicated for cellulitis, but local debridement at the site of inoculation may be necessary if there is tissue necrosis or a localized abscess.

FIGURE 68.3 Cellulitis in a patient with necrotizing fasciitis (dorsal arm view in Figure 68.7).

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Fight Bites Fight bites are caused by penetration of a foreign body, usually a tooth, through a joint capsule, resulting in inoculation of sterile joint space with bacteria (Figure 68.4). Patients typically present to the emergency room with a swollen, painful hand 2 or 3 days after punching another person in the face. Exam findings include pain, erythema, swelling over the dorsal metacarpal-phalangeal joint (MCP) region, a benign appearing scab over the dorsal MCP, and pain with axial loading of the joint. X-rays should be performed if there is suspicion of a retained foreign body or fracture.

FIGURE 68.4 Fight bite, presenting 3 days after assault.

Fight bites require exploration of the wound to rule out joint-space infection, as the MCP joint is violated in 70% of cases. This is best performed in the OR. The wound should be excised in an elliptical fashion. Because the extensor mechanism glides with ROM, punctures in the extensor mechanism may not directly underlie the skin puncture site. The joint should be fully explored during wound exploration to find violations in the extensor mechanism. If violation is suspected, the extensor should be opened either by longitudinally splitting the tendon or by incising between the extensor and sagittal band. Violation of the underlying joint capsule requires capsulotomy. After cultures are taken of the joint fluid, the patient should be started on broad-spectrum antibiotics covering for S aureus and oral flora (Eikenella corrodens and Bacteroides sp. in human bites) and the joint should be thoroughly irrigated with saline. A small gauze wick is placed in the joint space and the overlying capsule, extensor mechanism, and skin is loosely closed. Postoperative inpatient monitoring is advised. Persistent symptoms require return to the OR. Delay in surgical treatment can result in extensive joint destruction (Figure 68.5).

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FIGURE 68.5 A. Delayed presentation of a fight bite to the left middle finger MCP, 7 months after assault. B. X-rays demonstrating joint destruction and osteomyelitis.

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Deep-space Infections Deep-space infections comprise 5% to 15% of all hand infections. 6 Because the hand is compartmentalized by fascial septae, these infections are often naturally confined to predictable locations. A brewing abscess in the thenar region after a puncture wound will be blocked from moving ulnarly toward the small finger by the midpalmar septum. Instead, it travels up flexor pollicis longus into the wrist, where the Parona space allows the infection to cross over to the flexors of the small finger and distally into the ulnar hand, circumventing the mid palm and creating the classic horseshoe abscess. A collar button abscess is an infection originating volar webspace and confined distally, because the strong palmar aponeurosis blocks infection from spreading proximally. Instead, the infection spreads dorsally into the dorsal subcutaneous tissues, forming the classic puckering, swelling, and abducted position of the digits. Patients with deep-space infections will present with pain, swelling, erythema, and increased pain with ROM (Figure 68.6). A CT with contrast, ultrasound, or MRI will help localize and identify the extent of infection when the exam is vague. All deep-space infections require formal I + D and culture, preferably in the OR setting. Care should be taken in designing incisions, ensuring drainage of all areas but avoiding scars over critical structures. Thenar abscesses can be managed with a dorsal incision and dissection between the first dorsal interosseous and adductor pollicis muscles. The midpalmar abscess is accessed with an extended carpal tunnel incision or curved longitudinal incision in the palm. Collar button abscesses generally require volar and dorsal incisions for complete drainage; transverse incisions within the webspace cause adduction contractures and should be avoided. The most commonly isolated pathogens are S aureus and group A Streptococcus. Gauze wicks should be placed in the wound for continued egress of infection. Inpatient monitoring, broad-spectrum IV antibiotics, and early hand therapy are advised.

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FIGURE 68.6 Thenar deep-space infection in an IV drug user.

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Necrotizing Fasciitis Necrotizing fasciitis is one of the few emergent life- and limb-threatening hand infections. Patients present with cellulitis, discoloration, limited ROM, and rapidly ascending pain. Inciting trauma, if any, is often a minor cut or scrape. Immunocompromised patients (diabetics, chronic steroid use), the elderly, and IV drug abusers are more susceptible to necrotizing fasciitis and have higher mortality rates. There are two types of presentations: type 1, involving multiple anaerobic and aerobic bacteria, and type 2, involving group A Streptococcus and Staphylococcus sp. More recently, MRSA has been isolated in up to 39% of cases. 7 Exam reveals erythema, streaking lymphangitis, pain, blistering, and crepitus (Figure 68.7; see Figure 68.3). Signs of hemodynamic instability, such as hypotension, tachycardia, and altered mental status are indicative of septic shock. Stat gram stain should be done without delaying definitive treatment of broadspectrum IV antibiotics, aggressive resuscitation, and emergent operative debridement. A classic sign of necrotizing fasciitis is cloudy dishwasher drainage, due to necrosis of the fascia. Aggressive debridement is vital, as infection spreads rapidly along fascial planes and leads to skin and muscle necrosis. Amputation must be considered in the setting of advanced muscle necrosis and septic shock. Tissue samples should be cultured. Patients should be placed in the intensive care unit if there is any concern of hemodynamic instability. Return to the OR for a second look should occur within 24 to 48 hours. Patients will generally need extensive soft tissue reconstruction once infection is cleared.

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FIGURE 68.7 Necrotizing fasciitis, presenting in a healthy 60-year-old man 4 days after scratching his dorsal hand on a piece of metal (volar arm view in Figure 68.3).

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Wrist Septic Arthritis Similar to a fight bite, septic arthritis of the wrist results from inoculation of the joint with a pathogen. Because joints are avascular immune privileged sites, meaning that they do not mount a strong immune response to infection, infection can rapidly progress to permanent cartilage and bone destruction. These infections can arise from a direct penetrating trauma or from hematogenous spread. S aureus, Streptococcus sp., Haemophilus influenzae (in children), and Neisseria gonorrhoeae are the most common pathogens. Patients present with gradually worsening pain in the wrist, severe pain with ROM, and swelling. A history of trauma, immunosuppression, autoimmune disease, gout, and sexually transmitted disease should all be noted. Exam reveals pain with wrist ROM and axial loading, swelling, warmth around the joint, and often overlying cellulitis. In delayed presentations, X-rays can identify bony erosion (Figure 68.8).

FIGURE 68.8 Advanced septic arthritis and osteomyelitis of the carpus and distal radius in a 50-year-old male with extensive psychiatric history presenting with 7 months of wrist pain. A. Anteroposterior radiograph. B. Oblique view.

Septic arthritis of the wrist must be distinguished from simple cellulitis and from acute flares of gout or pseudogout. The history may provide some clues. Prior flares and patchy calcifications of the wrist joint on X-rays would lean toward autoimmune etiology, whereas history of penetrating trauma, fever, erythema, and lymphangitis would be suspicious for infection. A wrist aspiration and joint fluid analysis will confirm diagnosis. This should only be done in the setting of high suspicion, as aspiration risks

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introduction of pathogen into a joint, creating septic arthritis when it may not have been present initially. To perform a wrist joint aspiration, the 3 to 4 interval on the dorsal wrist is palpated just distal and ulnar to Lister tubercle. The skin is anesthetized, the site sterilized, and the wrist flexed slightly to facilitate entry. A sterile large bore (18–20 gauge) needle is inserted at an angle to avoid the dorsal lip of the distal radius. Ideally, 2 cc of fluid is aspirated. Normal joint fluid is clear or straw colored. The fluid should be sent for crystal analysis and culture, after confirming with the laboratory that the sample is properly packaged for analysis. Although septic arthritis due to N gonorrhoeae can often be treated with IV antibiotics alone, the presence of any other bacterial strain in the joint fluid warrants operative washout and aspiration of frank pus is an indication for urgent surgery. The wrist joint is opened via a longitudinal dorsal skin incision. The wrist capsule can be opened longitudinally or in a ligament-sparing approach to expose the wrist joint. The joint space should be cultured and extensively irrigated with 3 L of saline. Automated pulse lavage is avoided, because the excessive pressure can damage cartilage. The cartilaginous surfaces are inspected. Any frankly necrotic bone is debrided with a rongeur; this is generally only seen in late, advanced cases. The capsule, extensor retinaculum, and skin can be loosely closed, leaving a gauze wick to allow continued egress of bacteria. Arthroscopic wrist washout has been reported to achieve similar results with less postoperative stiffness. 8 Postoperatively, the hand is placed in a wrist splint and elevated for comfort. Patients should be admitted for observation, pain control, and IV antibiotics. One should have a low threshold for a second look in 24 to 48 hours. Once improving, ROM exercises are started while the patient is still admitted.

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Special Cases Fungal, Mycobacterial, or Viral Infections The vast majority of hand infections are bacterial in origin. When infections do not respond rapidly to standard antibiotic regimens, one should consider fungal, mycobacterial or viral sources. These pathogens tend to be more indolent. Chronic paronychia, for example, is usually due to candida infection. Mycobacteria are notoriously difficult to culture; suspicion should be raised for mycobacteria when rice bodies are found at time of debridement or granulomas are found on pathology. Immunocompromised patients and specific patient populations are more susceptible to these less common infections. Hand infections due to Mycobacterium avium-intracellulare are increasing in the HIV population. Mycobacterium marinum tends to affect fisherman and fish handlers; the infection causes indolent progression of papule clusters on the hand and fingers. Pain is variable. The four other most common pathogens associated with water animal exposure are Aeromonas sp., Edwardsiella tarda, Erysipelothrix rhusiopathiae, and Vibrio vulnificus. Sporotrichosis is a fungal infection more common in gardeners who have been pricked by a rose thorn. Coccidioidomycosis in the southwestern United States and histoplasmosis in the midwestern United States are rare fungal causes of synovitis and microabscesses of the hand. Herpetic whitlow is a viral infection due to the herpes simplex virus, which causes a burning sensation for 1 or 2 days, followed by erythema and blistering around the thumb of fingers (Figure 68.9). 
 It is seen more commonly in children, dentists, and other medical professionals exposed to oral secretions, and in immunocompromised patients. Tzanck smear confirms diagnosis. The infection is self-
 limited in 2 to 3 weeks; treatment with oral acyclovir or similar antivirals may be used in severe cases or to speed resolution. Aggressive debridement and unroofing of vesicles is ill-advised and can predispose patients to bacterial superinfection.

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FIGURE 68.9 Herpetic whitlow in a dental hygienist. (Courtesy of Dr James Sanger.)

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Osteomyelitis The ideal time to treat a hand infection is within the first 24 hours. Unfortunately, a lingering infection in the hand, even a simple paronychia, can lead to underlying osteomyelitis if neglected. The standard for diagnosing osteomyelitis is bone biopsy. Any frankly necrotic bone encountered during an I + D should be debrided back to hard, bleeding bone and sent for culture, or it will continue to act as a nidus for further infection. It is prudent to consult an infectious disease (ID) specialist in these cases, to help narrow antibiotics, determine duration, and monitor for any medical side effects caused by the antibiotic use. The ID specialists are often more familiar with community antibiotic resistances and cost comparisons of different antibiotics. Patients with osteomyelitis generally require formal hand therapy to limit stiffness and disuse atrophy of the hand during extended treatment. One must consider the pros and cons of amputation over salvage.

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Drug Abuse IV drug use is an unfortunately common cause for hand infections, either by use of a dirty needle, by introduction of skin bacteria by the needle, or by contamination of the substance injected. When the concern is present, patients should be asked directly about drug habits. Particular attention should be paid to track marks along the forearm or antecubital fossa. Puncture marks within the webspace may indicate direct drug injection into the subcutaneous tissues, an increasingly common form of drug delivery known as skin popping. A recent history of IV drug use should raise suspicion for both cellulitis and deep-space infections. Mixed flora and anaerobic infections are more common in IV drug use. A drug screen and basic laboratory workup should be performed for anesthesia clearance, if needed. Workup for hepatitis C and HIV should be discussed with these high-risk patients.

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Immunocompromised Patients Immunocompromised patients, including those with diabetes, chronic steroid use, HIV, and malnutrition, require special attention. A higher level of vigilance is needed when monitoring infections in this population. Simple infections can progress rapidly to limb-threatening problems. Because this group has a muted immune response, common presentations such as elevated WBC, fever, erythema, or significant pain may not be present. Inpatient observation and serial exams are recommended.

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Problems That Mimic Infection Several problems can masquerade as an infection. Most commonly, inflammatory arthritis flares, including gout and pseudogout, are confused with septic arthritis of the joints. Proper diagnosis is imperative, as treatments differ dramatically. Factors such as recurrent episodic pain, lack of trauma, elevated blood uric acid levels, and calcium deposits in joints on X-rays may indicate gout or pseudogout, but the presence of crystals on joint aspiration must be confirmed. When in doubt, assume a septic joint until proved otherwise. Chronic hand wounds that have been maintained on long courses of antibiotics with minimal improvement warrant further investigation. Any wound present for longer than 6 months should be biopsied to rule out cancer, pyogenic granuloma, or pyoderma gangrenosum. Biopsy incisions should be designed longitudinally to allow extension as needed for a wide excision in the future.

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Optimizing Long-term Outcome The outcome of hand infections is dependent on rapid diagnosis, efficient treatment, and early rehabilitation. Long after the infection has been treated, the body’s inflammatory response may cause residual swelling, stiffness, and pain. As with many other hand conditions, early hand therapy is critical to optimizing function and should, in most cases, be started in the postoperative period while the patient is still in the hospital. When treating hand infections, the ultimate goal is not clearance of infection, but the restoration of a functional hand.

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Questions 1. A 40-year-old homeless diabetic man presents to the emergency room after spontaneous onset of exquisite pain, swelling, and blistering of the dorsal hand 6 hours ago. He is appropriately communicative, tachycardic to the 110s. He has a WBC of 20 and a blood glucose level of 160. On exam, there is blistering and streaking erythema up the forearm and palpable crepitus in the hand and forearm. What is the next step? a. X-ray to rule out trauma b. MRI to rule out abscess c. Emergent surgery d. Tissue biopsy 2. A 35-year-old woman with type 1 diabetes presents with worsening pain over the volar index finger after being bitten by her cat yesterday. She has a 2 mm open wound with expressible purulence over the volar surface of the second phalanx. She has full active ROM of the digit with mild pain, no fusiform swelling, and no pain over the volar P1 and palm. Her WBC is 7, her glycosylated hemoglobin is 9.5, and she is afebrile. What is the next step? a. X-ray to rule out underlying fracture b. I + D of localized abscess and inpatient IV antibiotics c. I + D of abscess and discharge with clindamycin d. Emergent decompression of the flexor sheath 3. A 75-year-old man with rheumatoid arthritis was referred to you for a persistent infection on the dorsal hand. He reports bumping the hand on a metal railing 10 months ago, resulting in an open, intermittently draining 1 × 1 cm wound overlying the dorsal fifth metacarpal. There is mild cloudy drainage and thickened scar tissue along the wound edges, but no exposed tendon or bone. What is the next step? a. Biopsy b. IV antibiotics c. Formal debridement and closure d. Local wound care 1. Answer: c. Patient has signs and symptoms of necrotizing fasciitis, which is limb and life threatening. Treatment involves emergent and often serial debridement, broad-spectrum IV, and supportive inpatient care. A tissue sample can be obtained in the OR. Imaging will delay definite treatment. 2. Answer: b. Patient is a poorly controlled diabetic with a localized infection that has high risk of developing into flexor tenosynovitis. At present, her wound should be I + Ded and cultured. Monitoring as an outpatient or inpatient can be debated, but clindamycin is not an appropriate antibiotic for Pasteurella species, which are most commonly associated with animal bites. At this point, patient does not have flexor tenosynovitis, though she has potential to develop it. 3. Answer: a. A biopsy is the necessary next step to rule out skin cancer, which can masquerade as a chronic infection. The other options are appropriate once cancer has been ruled out.

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References Siverstein, P. Smoking and wound healing. Am J Med. 1992;93(1 suppl A):22S-24S. Liu, C, Bayer, A, Cosgrove, S, et al. Clinical practice guidelines by the infectious diseases society of America for the treatment of methicillinresistant Staphylococcus aureus infections in adults and children. Clin Infect Dis. 2011;52:e18-e55. Merritt, W. The Impecunious Treatment for Chronic Paronychia and Ingrown Toenails: Back to the Future. Presented at American Association of Hand Surgery Annual Meeting; January 21-24; Paradise Island, Bahamas. 2015. Lille, S, Hayakawa, T, Neumeister, M, et al. Continuous postoperative catheter irrigation is not necessary for the treatment of suppurative flexor tenosynovitis. J Hand Surg Br. 2000;25(3):304-307.This study is a multicenter retrospective review of 75 patients that compares intraoperative and continuous postoperative irrigation (standard of care; n = 55) versus intraoperative flush alone (n = 20) for treatment of suppurative tenosynovitis. Outcomes were not statistically different between the two groups. Intraoperative flush alone simplifies treatment, reduces patient discomfort, and allows for earlier postop range of motion exercises. Pang, H, Teoh, L, Yam, A, et al. Factors affecting the prognosis of pyogenic flexor tenosynovitis. J Bone Joint Surg. 2007;89(8):1742-1748. Jebson, PJ. Deep subfascial space infections. Hand Clin. 1998;14(4):557-566. Lee, T, Carrick, M, Scott, B. Incidence and clinical characteristics of methicillin resistant Staphlococcus aureus necrotizing fasciitis in a large urban hospital. Am J Surg. 2007;194(6):809-812. Sammer, D, Shin, A. Comparison of arthroscopic and open treatment of septic arthritis of the wrist. J Bone Joint Surg Am. 2009;91A:13871393.This is a retrospective review out of Mayo clinic that compares open irrigation and debridement (standard of care; n = 19 wrists) versus arthroscopic irrigation and debridement (n = 21 wrists). For isolated septic arthritis of the wrist, arthroscopic treatment resulted in fewer procedures and shorter hospitalization. No differences in procedure number or hospitalization length between the two groups were seen when patients had multiple sites of infection.

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CHAPTER 69

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Soft Tissue Reconstruction of the Upper Extremity and Management of Fingertip and Nail Bed Injuries Sirichai Kamnerdnakta and Kevin C. Chung

Key Points The primary goals of soft tissue reconstruction of the hand are restoration of function and appearance. As opposed to the historical reconstructive ladder approach, reconstructive elevator approach is more suitable for soft tissue defects of the hand, in which the surgeon selects any procedure that will achieve the desired outcomes. Early postoperative mobilization and rehabilitation will achieve maximal functional outcomes. A functional hand should possess a stable wrist and at least two opposing, sensate, and painless digits. One finger should be mobile and opposed with another stable finger, with a space between the digits. In a mutilated hand injury, pedicle flaps can be used to provide coverage in preparation for a microsurgical procedure, such as a toe transfer or microsurgical bone reconstruction. An acceptable hand consists of a thumb and at least three fingers that have supple interphalangeal joint motion, adequate length, and preserved sensibility. 1 However, these minimal conditions are sometimes not achievable in extreme reconstruction cases. In such cases, function is prioritized. The minimal functional requirements include a stable wrist and two opposing, sensate, and painless digits. The two fingers should be separated by a gap and should include one mobile finger, along with an opposing, stable finger. 2 Although the functional requirements should be considered during the development of the reconstruction plan, the surgeon should also aim to achieve optimal appearance of the hand. 3 In particular, the surgeon should consider color and texture match, donor/recipient tissue interface, hairiness, and the size and location of the final scar.

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Principles of Reconstruction One of the fundamental principles of plastic surgery regarding soft tissue reconstruction is the reconstructive ladder, in which surgical decisions are made following a stepwise approach that increases in complexity the higher the ladder goes. The ladder starts with simple primary closure and ends with complex microsurgical free flap surgery. However, modern advancements in plastic surgery suggest a new approach, the reconstructive elevator. With this approach, optimal function and appearance guide the decision that surgeons make regarding reconstruction. 4,5 Starting with the simplest procedure, definite wound closure should be planned expeditiously. The ultimate goal is to obtain primary wound healing to diminish scar formation and lessen the possibility of contracture and stiffness. However, before any definitive wound coverage is done, wound bed preparation is mandatory before any coverage to ensure proper wound healing of the reconstructed defect. Coverage should be delayed until the wound shows stability and clear demarcation of nonviable tissue, with minimal risk of infection. Although temporary, negative pressure wound therapy (NPWT) provides optimal wound dressing during the serial debridement period because it bridges the gap before definite wound closure and promotes healing. Applying NPWT can reduce exudate, improve local tissue perfusion, and lessen swelling. However, surgeons must exercise caution during prolonged application of NPWT because granulation tissue may form over the wound bed and cause scarring over time. 6 NPWT is often used to promote granulation tissue prior to skin grafting in the lower extremities. However, prolonged use in the hand causes contracture and stiffness. If a patient has vital structures that are exposed, the surgeon must consider an immediate flap coverage. Subsequent debridement and irrigation can be performed to ensure viability of the tissue. Once the wound bed has been prepared adequately, a definitive flap can be performed.

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Clinical Consideration An analysis of a defect is crucial prior to initiating any mode of reconstruction. The surgeon should try to preserve the essential structures as much as possible so that they can maintain their own function. The most effective way to preserve the vital components is to consider early soft tissue coverage as the first step in the management of the severed hand. In certain scenarios, single-stage reconstructions are not appropriate (e.g., tendon or nerve reconstruction with substantial bony and soft tissue loss) because the formation of scar and fibrotic tissue will hinder functional recovery. Thus, a staged reconstruction is often better than trying to accomplish too much at the onset of the injury. Each defect requires an individualized treatment protocol. While formulating the treatment plan, the surgeon should consider all relevant factors that could affect the success of the reconstruction 7 (Table 69.1). Although treatment options vary, all reconstructive procedures of the soft tissue envelope of the hand must follow the basic principles of coverage: replacing like with like, restoring function, and preserving sensibility and mobility. For example, in the effort to reconstruct a mutilated hand that requires secondary reconstruction, surgeons prefer the use of a fasciocutaneous flap over a muscle flap. A fasciocutaneous flap is more pliable and has greater gliding capacity, which facilitates tendon gliding without impairment during motion. On the other hand, a muscle flap can adhere to the wound bed and make a secondary procedure more tedious. TABLE 69.1 Influential Factors for Perioperative Considerations Factor Wound Site Side (volar/dorsal) Amount and type of tissue loss Donor site

Flap

Patient

Surgeon

Implications Size

Functional loss Scar location Morbidity Texture Color Volume Hairiness Sensibility Handiness Age Sex Occupation Medical comorbidities Preferences Knowledge Technical skill Preference

Choosing the optimal flap for each individual defect is an important factor of the hand reconstruction. Choices include a pedicle locoregional flap, a distant flap, and a microsurgical free flap, which all abide by the basic principles of coverage. Depending on the origin site, flaps are defined as the following: Local flap: Originates from a site directly adjacent to the defect and is typically completed in a singlestage reconstruction (e.g., V-Y advancement flap or Z-plasty) Regional flap: Originates from areas not adjacent to the defect but is still confined within the ipsilateral limb (e.g., thenar flap, cross-finger flap, radial forearm flap) Distant flap: Originates from areas that are not from the ipsilateral limb of the defect and almost

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always requires two stages for harvest and inset (e.g., groin flap) Surgeons should preferentially consider the use of pedicle locoregional flaps. The defect can be used as a template to simulate the flap design. Pivot point, movement, and length are all factors that should be considered when designing the flap. If a locoregional flap cannot be designed to cover the defect adequately, a distant flap or microvascular free flap is needed. A free flap is advantageous because it requires only one procedure, encourages composite reconstruction, allows mobility, and permits earlier rehabilitation. 8 However, the operation is technically demanding and requires advanced microvascular surgery skills. Unstable patients, including those with multiple comorbidities, are normally not the best candidates for free flaps. Additionally, vessel paucity, mutilating hand injuries, or prior history of free flap failure may be indication for a pedicle distant flap. 9 Common scenarios for which the surgeon should consider performing a pedicle distant flap include coverage of digital stump defects in preparation for toe-to-hand transfer, high-voltage electric injuries with diffused thrombosed vessels, and multiple defects. 10-14

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Modes of Reconstruction for Individual Defects Partial or Full-Thickness Skin Loss Skin Grafts Partial or full-thickness skin defects that do not require additional volume or functional tissue can be covered using a skin graft. Split-thickness skin grafts (STSGs) are more pliable, have an easier “take,” conform better on a convoluted surface, and provide more surface coverage than full-thickness skin grafts (FTSGs). However, a FTSG can restore more durability and sensibility, while it can minimize the risk of contracture. Despite their benefits, there are certain contraindications for skin grafting: Nonvascularized wound bed such as a bare bone or bare tendon defect Exposure of vital structures such as neurovascular bundle Defects that are overlying a joint area Active infectious status Planned secondary reconstruction; tendon graft, nerve graft, implantation, tenolysis, or joint release The most notable contraindication is that grafts can adhere to the underlying structures, making further reconstruction impossible. The palmar and dorsal skins of the hand are functionally and anatomically different. The dorsal skin is thin, pliable, and loose, which facilitates smooth tendon gliding and unrestricted movement of the underlying joints. Conversely, the palmar skin is thick, durable, glabrous, and inelastic, which enables to withstand constant external forces and enhance prehensile function through the formation of skin creases and folds. The thick dermal layer of the glabrous skin is rich in exocrine sweat glands, blood vessels, and sensory nerve endings. Therefore, STSGs are typically used for reconstruction of defects of the dorsum of the hand; whereas, volar skin defects almost always require resurfacing by FTSGs. To obtain similarity of the glabrous volar skin, the donor site of FTSGs is harvested from the hypothenar eminence or instep plantar area.

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Dermal Substitute A dermal substitute, in conjunction with an STSG, will provide better quality, thickness, and pliability in comparison to reconstruction with an STSG alone. 15,16 Dermal substitutes are advantageous because they provide a scaffold for growth of neovascularized tissue from the wound bed. Therefore, a dermal substitute can take on tendons devoid of paratenon, cartilage without perichondrium, and bones without the periosteum. Dermal substitutes require a noninfected and well-vascularized wound bed. However, the amount of vascularized tissue necessary for successful incorporation of dermal substitutes is not well defined. 17 Dermal substitutes are used for the reconstruction of acute and chronic burns of the hand, but it lacks evidence-based support to be used over traditional modes of reconstruction in nonburn-related or traumatic wounds. 18-20 Nonetheless, dermal substitutes are a good alternative if the patient cannot tolerate a prolonged operation or needs a shorter period of immobilization. Soft tissue reconstruction using dermal substitutes may deliver acceptable functional and aesthetic outcomes in select situations. 20,21

However, dermal substitute templates lack many essential components of normal skin, such as hair follicles, sweat glands, or other skin appendages. Furthermore, sensory recovery is unsatisfactory. Injuries that need reconstruction with high sensory demand, such as those in the palm or pulp of the finger, are better suited to be reconstructed with a flap to optimize functional outcomes. Reconstruction of soft tissue defects via dermal substitutes typically requires STSG. In a two-stage reconstruction, split-thickness skin grafting can be done 2 to 3 weeks after dermal substitute placement. NPWT can be used to bridge the wound before definitive skin graft placement. Full-thickness skin grafting with a dermal substitute is not recommended because there is a high metabolic demand of the FTSG, leading to a risk of ischemia and necrosis of the FTSG. 22

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Fingertip Defect The goals of reconstructing a fingertip amputation are to restore the padding of the finger to provide maximum tactile gnosis, preserve the length of the finger, keep an intact nail bed, and minimize downtime. Although replantation achieves optimal appearance and functional results, this is not always possible. Surgeons should consider the following factors while formulating the best treatment method: the location of the injury, the dimension of the defect, and any involved structures, such as bone or tendon. Small fingertip defects that are less than 1 cm2 with minimal bony exposure or nail matrix involvement should be healed by secondary intention. Secondary intention can restore sensation, appearance of the fingertip, and achieve comparable functionality to skin grafts. 23-25 In cases of defects larger than 1 to 1.5 cm2, presence of volar oblique injuries, or the exposure of tendon or bone, the mode of surgical closure will be determined. 26 Defects with the largest dimension of less than 1 cm may indicate reconstruction using local tissue coverage, such as V-Y volar or lateral advancement flaps. The V-Y advancement flap is most suitable for coverage of transverse or dorsal oblique fingertip amputations that have exposed bones but sufficient length and bony support of the nail bed. Previous studies have demonstrated near-normal or normal recovery in sensation for most patients after V-Y flap reconstruction. 27-29 However, larger or composite defects will require more soft tissue, suggesting homodigital, heterodigital, locoregional, or free tissue transfers. The location, geometry, and mechanism of the injury will dictate the mode of reconstruction. The indications and contraindications of the available flaps are in Table 69.2. Although some locoregional flaps do not require a two-stage reconstruction, cross-finger and thenar flaps do. During a two-stage reconstruction, the affected finger is usually restrained for 2 to 3 weeks before a secondary flap division is performed. This waiting period will delay the onset of rehabilitation, possibly resulting in joint stiffness. TABLE 69.2 Flap Options for Fingertip Reconstruction (PIPJ: Proximal Interphalangeal Joint) Flap V-Y advancement flap

Cross-finger flap

Thenar flap

Homodigital island flap

Heterodigital island flap

Indication

Contraindication

Bony exposure defect from a transverse or dorsal oblique fingertip amputation with adequate length and bony support of the nail bed. Amputation is usually a the midportion of the nail bed.

Insufficient tissue on the volar area, such as a volar oblique amputation. Amputation injury proximal to the lanula.

Volar soft tissue defects with exposed bone or tendon at the middle or distal phalanx. Defects with exposed bone or tendon at the distal phalanx that cannot be covered with a V-Y advancement flap.

Extensive dorsal skin loss and the involvement of the adjacent fingers.

Volar skin avulsion with bony or tendon exposure of the finger pulp of the index, middle, or ring finger. Reconstruction of a near-total or total distal phalangeal pulp loss.

Extensive volar and dorsal tissue loss of the finger. Risk of flexion contracture is markedly high when performing this flap in patients who has a concomitant PIPJ injury.

Patients with extensive but not complete pulp defects (90% of brachial plexus injuries in regions such as Taiwan, Southeast Asia, and India) generally have a lower energy than high-speed motor vehicle or motorcycle accidents (approximately 84% of cases in Europe and North America). 1,2 Lower-energy mechanisms tend to produce postganglionic nerve ruptures (breakages within the substance of the peripheral nerve, distal to the dorsal root ganglion) as compared with higher-energy mechanisms which tend to produce more preganglionic root avulsions (tearing of the rootlets of the peripheral nerve directly from the spinal cord, proximal to the dorsal root ganglion). Gunshot wounds are typically seen in war zones and also commonly in the United States (17% of brachial plexus injuries), and they can be subdivided into high-velocity (military rifles, hunting rifles, shotguns) versus lower-velocity (handgun) trauma with implications upon prognosis and management. 3–5 Lastly, sharp lacerating injuries of the brachial plexus, such as with knife attacks, account for approximately 10% of presenting cases at a trauma center in the U.S. Despite regional variations in the mechanism of injury, adult brachial plexus trauma mostly affects young males worldwide (>90%). 1

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Anatomy The brachial plexus is a confluence of interconnecting nerves that reside in between where the spinal nerves emanate from the spinal cord and ultimately course into the shoulder girdle and upper extremity muscles. Each spinal nerve is formed from rootlets of the ventral and dorsal roots that arise from the spinal cord and unite as the spinal nerve before exiting the dural sac of the spinal cord and running along a groove within the bony vertebra between the anterior and posterior tubercles of the transverse processes of C5 to T1. The dorsal root, which contributes sensory nerves only, is thicker and more resistant to avulsion forces. To note, anatomical variations exist where a prefixed or postfixed brachial plexus has substantive contribution to the innervation of the upper or lower trunk from a C4 or T2 spinal nerve, respectively. These variants may cause a less severe injury deficit than expected for a given injury. The dorsal root ganglion is generally positioned just posterior and medial to the vertebral artery, and it is thus contained within the vertebral bony structure and not visible upon surgical exposure, unless the spinal nerve has been avulsed distally 6 (Figure 72.1). The spinal nerves then coalesce into the upper (C5 and C6), middle (C7), and lower (C8 and T1) trunks which are contained between the anterior and middle scalene muscles. Each trunk then splits into anterior and posterior divisions within the area deep to the clavicle. To note, the upper trunk’s anterior and posterior divisions are also positioned very close to the branch point of the suprascapular nerve, to give the appearance of a trifurcation of nerves near that point. Also notable, the posterior division of lower trunk is quite small. After the divisions emerge inferior to the clavicle, they become the lateral, posterior, and medial cords in the area deep to the pectoralis minor (that inserts upon the useful bony landmark of the coracoid process). At the cord level, the axillary artery is sandwiched between the three cords. From the cords arise the branches that innervate the shoulder girdle and distal upper extremity. The axillary and radial nerve are separable at the region of the posterior cord deep to the lateral border of the pectoralis minor. The musculocutaneous nerve can be located at the proximal arm in the plane between the coracobrachialis and biceps brachialis. The median and ulnar nerves are most easily found in the mid-distal arm deep to the brachial veins as they wrap around the brachial artery (Figure 72.2).

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FIGURE 72.1 Spinal nerve and associated anatomy.

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FIGURE 72.2 Brachial plexus anatomy.

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Anatomic Classification of Brachial Plexus Injury There are multiple systems of anatomic classification of brachial plexus injury that have been popularized by major contributors to surgical advances in brachial plexus injury treatment. We will highlight three classification systems: Terzis’ three-level system of root, supraclavicular postganglionic, and infraclavicular injuries 7 ; the Alnot classification of preganglionic root, postganglionic root, supraclavicular and retroclavicular, and infraclavicular injuries 8 ; and Chuang’s level 1 to 4 classification separates injuries into preganglionic (root avulsion), postganglionic, pre- and retroclavicular, and infraclavicular injuries. 9 All three classifications consider the important factors of surgical decisionmaking: whether spinal root avulsion has occurred, the location of postganglionic rupture, and the clavicle as an operative landmark and barrier (Table 72.1). TABLE 72.1 Brachial Plexus Injury Classification Systems Alnot Preganglionic root Postganglionic root Supra-/retroclavicular Infraclavicular

Terzis Preganglionic supraclavicular Postganglionic supraclavicular – Infraclavicular

Chuang Preganglionic root (level 1) Postganglionic spinal nerve (level 2) Pre-/retroclavicular (level 3) Infraclavicular (level 4)

Although any combination of spinal nerve rupture or avulsion is theoretically possible with adult trauma, some common injury patterns for closed brachial plexus injury are consistent worldwide with some variability in frequency 3 : C5-C6: 15% C5-C7: 20%–35% C8-T1: 10% C5-T1: 50%–70% The higher frequency of upper trunk pathology with closed injuries may be related to the reflexive terminal position established by a person when encountering impending collision to the head and neck region. The blunt force at the shoulder region in combination with neck flexion to the contralateral side results in sudden caudal force trajectory upon the arm with the greatest energy directed upon the upper and middle trunks (Figure 72.2). Cephalic traction upon the arm with consequent lower trunk injury is much more rarely encountered, and this occurrence can often be attributed to a loss of consciousness prior to the time point of impact.

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Nerve Injury Classification Classification systems of nerve injury delineate the range of injury from axonotmesis to neurotmesis with progressive involvement of endoneurium, perineurium, and epineurium as injury severity increases 10 (Figure 72.3). Most closed injuries of the brachial plexus are actually mixed in nature (Mackinnon’s sixth degree injury). Thus, during the initial period of time (typically at least 3–6 months post trauma), the demyelinated and defunctionalized nerve is in a period where some of the injured elements that meet criteria for Mackinnon’s first through third degrees of nerve injury severity will recover spontaneously. Allowing time for the nerve to recover spontaneously is akin to waiting for tissue demarcation as is done after thermal injury to the skin. However, with nerve trauma, it is unclear whether the final severity of the injury is determined by the damage of the initial trauma or if favorable and harmful factors during the initial period of time after trauma can affect the evolution of the final severity of the injury (such as with burn injury).

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FIGURE 72.3 Classification of nerve injuries. A. Uninjured nerve consists of myelinated axons, surrounded by endoneurium, grouped into fascicles surrounded by perineum. The outer layer of the nerve is 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. 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.

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Surgical Management Timing Because of the spontaneous recovery that may occur during the initial period after closed brachial plexus trauma, most peripheral nerve surgeons advocate waiting for a period of 3 to 5 months before surgical intervention. Open injuries (e.g., stabbing) where laceration of the nerve is likely warrant exploration within 1 week for direct repair without nerve grafting. Exploration after 2 weeks should be accompanied by preparation for nerve grafting, as the nerve ends will have retracted. Regarding gunshot wounds, most low-velocity gunshot injuries inflicted by handguns only have a small shock wave and zone of temporary cavitation. They contuse, bruise, and stretch the nerve more often than transecting it. Thus, most civilian gunshot wounds (handguns) are managed conservatively for the first 3 to 5 months in a manner similar to closed injuries. High-velocity gunshot injuries (military style rifles, hunting rifles, and shotguns) cause a large shock wave and permanent cavitation, usually inflicting greater than Mackinnon’s fourth degree nerve injury. The prognosis for spontaneous recovery after a high-velocity gunshot wound is poor. Therefore, exploration of these injuries is advisable at 2 to 3 months post injury if clinical and electrodiagnostic evidence of recovery are still absent 4,5,11 (Figure 72.4).

FIGURE 72.4 Approach to brachial plexus injury. CXR, chest X-ray; EMG, electromyography; MRI, magnetic resonance imaging.

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History and Examination The first visit to the peripheral nerve surgeon is frequently several weeks after the time of trauma, as care for multitrauma or life-threatening conditions will be prioritized. The decision to proceed with surgery is guided by clinical evaluation (history, physical examination, electrodiagnosis, and radiographic imaging [chest X-ray, CT myelography, and magnetic resonance imaging (MRI)]). Elements of the patient’s history can give clues to the type and location of injury to expect. The energy of the injuring mechanism (e.g., high-speed motor vehicle, motorcycle, train, moped at high or low speed, fall from height) is a relevant detail for estimating the severity of nerve injury. Concomitant injuries caused by the injuring mechanism are important to consider. Anterior shoulder dislocation and scapular fracture are associated with posterior cord damage. 12 Spine fractures indicate a more proximal focus of energy from the injury mechanism; thus, the site of nerve rupture or avulsion is likely nearby as well. 13 The position of the patient’s head, neck, and arm at the time of impact (if they were conscious) can direct the surgeon to suspect an upper trunk versus lower trunk foci of damage. 14 The first goal of the physical examination is to determine where upon the brachial plexus the nerve ruptures or avulsions have occurred. To localize the deficit in axonal circuitry, it is helpful to use a chart to systematically examine the dermatomes of sensation and motor function of the shoulder girdle and upper extremity (Figure 72.5). Examination should proceed in a distal to proximal fashion. Deficits in the motor and sensory examination delinate approximately where the zone of injury is. The Hoffmann-Tinel sign is an indicator of regeneration of neurons and is also an indirect indicator of the site of nerve rupture during the early period of time after trauma. 15 Horner syndrome (pupillary miosis, upper eyelid ptosis, and anhidrosis upon the face of the ipsilateral side) indicates disruption of the sympathetic pathways (and a likely presence of a root avulsion involving the lower plexus which is situated just adjacent to the sympathetic plexus). 16 Deafferentation pain (a.k.a. phantom limb pain and sensation) is a sign that root avulsion has occurred. Deafferentation pain is sometimes described as causalgia (pain that is severe, burning in nature, and lancinating). 17 Examination at 1 month intervals from the time of trauma until 3 to 5 months after trauma is an acceptable schedule.

FIGURE 72.5 Worksheet for systematic physical examination of the brachial plexus patient.

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Radiographic imaging is used in conjunction with physical examination. On chest X-ray, diaphragmatic muscle paralysis (hemidiaphragmatic elevation on the injured side) suggests a likely involvement of the upper plexus as the diaphragmatic innervation (C3, C4, and C5) that is involved in the zone of injury is located near the upper trunk. Diaphragmatic function also provides information to the surgeon for consideration about whether the phrenic and intercostal nerves may be used as donor nerves. Some will argue that the phrenic nerve should never be used as a donor nerve because of respiratory morbidity, whereas others believe that using the phrenic donor nerve is safe in lower-BMI patients. 18 Also, some surgeons argue against use of the intercostal nerves for donor innervation if the phrenic nerve on that side is not functional, for fear of respiratory morbidity. 19 MRI and CT myelography can both detect the presence of pseudomeningoceles adjacent to the vertebrae, which develop when the dura tears in conjunction with avulsion spinal nerve roots. MRI can also show various signal changes that suggest nerve injury. However, at the current time, MRI has not yet been proven as a reliable modality for delineating nerve rupture or injury within the plexus. 20 Electrodiagnosis consists of both nerve conduction studies and needle electromyography (EMG). Nerve conduction studies use stimulating and recording electrodes to measure various parameters from both motor and sensory nerves. Needle EMG involves insertion of a needle (intramuscular recording electrode) into a muscle to record insertional, spontaneous, and voluntary electrical activity (useful tips in Table 72.2). The baseline nerve conduction study and EMG should be performed no earlier than 3 to 4 weeks after trauma, as certain acute phase injury changes take that amount of time to become detectable. A follow-up electrodiagnostic study should be repeated at approximately 2-month intervals to monitor for spontaneous recovery versus stable denervation. 21 TABLE 72.2 Tips for Interpreting Electrodiagnostic Studies (EDSs) Basics Nerve Conduction Studies (NCSs) NCSs evaluate larger myelinated nerves. SNAP = sensory nerve action potential (sensory nerve)—begins to decrease at day 6 after injury and reach nadir at day 10–11. Beware that sensory NCS tends to overestimate severity of injury. CMAP = compound muscle action potential (motor nerve)—begin to decrease at day 2 or 3 after injury and reach nadir at day 7. CMAP amplitudes are the most useful for quantifying the amount of axon loss (at an early time point before collateral reinnervation occurs-collateral reinnervation occurs from the remaining nerve fibers when there is an incomplete nerve transection). Once collateral reinnervation starts to occur, the CMAP amplitude will appear to improve even though the number of degenerated motor nerve fibers is unchanged. Amplitude reflects the total number of conducting axons. Needle Electromyography (EMG) MUAP = (voluntary) motor unit action potential. (A needle electrode is stuck into the muscle, and the patient voluntarily contracts the muscle; then action potentials are measured). MUAP dropout is proportional to the number of motor axons disrupted; however, MUAP dropout is challenging to quantify and thus less useful for estimating severity. At the late time point (after collateral reinnervation has occurred), MUAP changes (duration and recruitment patterns) are better indicators for motor fiber loss than CMAP changes. However, at least 50% of the motor nerve must be disrupted before these MUAP changes can be discernible. The distal stump of a transected nerve can conduct action potentials for ∼6 d (motor) and ∼10 d (sensory). Diagnostic Tips If muscle is innervated, there are no spontaneous discharges (fibrillations and positive sharp waves). If EDS shows decreased amplitude (not normal but also not severely decreased), then it suggests that the lesion is not a preganglionic avulsion; it is probably a postganglionic rupture and partial rupture of the sensory fibers too. PSW (positive sharp waves)—acute phase injury sign (should subside by 1 y post injury). Fibrillations—acute phase injury sign (does not appear until 2–3 wk after injury; they should subside by 1 y post injury). Fibrillation potentials tend to overestimate the severity of injury—fibrillations may be quite prominent even when the lesion is minimal.

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Complete denervation (chronically fibrotic muscle will show no spontaneous discharge)—completely reinnervated muscle will also return to the state of no spontaneous discharge. Polyphasic waves: if more than five phases occur, the presence of motor unit is likely. Polyphasic waves are a pathologic finding, but the nerve is still alive. Fasciculations = irregular, normal, or complex MUAP. These can be exercise induced, or they can be indicative of lower motor neuron disorders or peripheral/metabolic neuropathy. (We do not really look at this parameter with acute nerve injury.) Voluntary motor units = reflect any presence of motor units (e.g., if empty, then no meaningful recovery; a poor prognostic indicator). Recruitment = reflects how many motor unit potentials have survived (e.g., Rare = only a few motor units are surviving; a poor prognostic indicator). Velocity will indicate demyelination (large fibers [radial nerve] should normally conduct 50–60 m/s; smaller fibers conduct 25– 40 m/s). Degeneration of motor fibers is faster than sensory. If the EMG suggests no recording at all, then it is probably more accurate than physical examination (in cases where one thinks there may be a faint M1 strength on physical examination). If motor nerve conduction (amplitude) is absent at 4 months after injury, this as a bad prognostic indicator, and surgical exploration is warranted.

A lack of improvement in motor function with progressive examinations combined with electrodiagnostic data consistent with stable denervation points to a state of irrecoverable nerve injury that can only be improved upon by surgical intervention. Contraindications to surgery include traumatic brain or spinal cord injuries that may prevent productive participation in a rehabilitative protocol. Also, medical comorbidities prohibitive of a prolonged general anesthetic session (>6–8 hours) must be considered before committing the patient to a surgical course. Joint contractures also need to be addressed concomitantly if they exist. The surgeon should also take careful consideration of the patient’s willingness and ability to comply with postoperative rehabilitation for any patient who has already developed substantial joint contractures during the initial posttrauma time period.

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Categories of Surgical Treatment There are three general categories of surgical management of adult brachial plexus injury: Proximal exploration and reconstruction Distal (close target) nerve transfers Biomechanical restorations (tendon transfers and functioning free muscle transplantations [FFMTs]) Before nerve exploration and repair was possible, there was the biomechanical restorative approach (tendon transfers) that was being done as early as the 1930s with applications to brachial plexus injuries by the 1960s. 22 We have also included the functioning FFMTs that developed in the 1970s in this group. 23 The next approach to surgical intervention for brachial plexus injury was by proximal exploration and visualization of the site of injury directly with concomitant nerve reconstruction (nerve grafting or nerve transfers). Although surgery for the brachial plexus was first attempted in 1900, the field did not see significant advances until the advent of microsurgical techniques in the 1960s. 14 The most recent addition to the toolbox for brachial plexus reconstruction is the distal nerve transfers that utilize intact nerves remote to the zone of injury. With this category of technique developed in the 1990s, a portion of the intact innervation is used to replace the innervation that has been injured. 24 Certain factors affect the selection among these four strategies: time since trauma, surgeon comfort with technique, extent of zone of injury, and availability of donor nerves or musculotendinous units. To note, two or more of these therapeutic categories may be used on the same patient. Furthermore, these surgical categories may be used sequentially in time. Proximal exploration is performed via a neck incision to gain access to the supraclavicular brachial plexus. The incision can be carried infraclavicularly onto the chest for access to the cords and terminal branches of the brachial plexus. This approach allows for both diagnostic and therapeutic objectives. Typically, nerve ruptures will require cable-grafting between the proximal and distal nerve stumps by using sural, saphenous, median antebrachial cutaneous, or lateral antebrachial cutaneous nerves harvested as nerve grafts. Allografts should not be used in this setting. Occasionally, osteotomy of the clavicle is necessary if the zone of injury terminates retroclavicularly, necessitating coaptation directly behind the clavicle. Root avulsions or spinal nerve ruptures with proximal stumps that are too short to support coaptation can be managed by nerve transfers using intraplexus transfer from proximal stumps of neighboring spinal nerves or from extraplexus donors (e.g., CN XI, contralateral C7, intercostal nerves, phrenic, or cervical motor branches of C3/C4). Proximal exploration is often thought of as the most technically daunting approach to brachial plexus injury because of the need for surgical dissection through the fibrotic scar tissue within the zone of injury. Exploration of the lower trunk can be risky in this regard, as adhesions to the pleural cavity and the proximity to great vessels in this case can sometimes also lead to pneumothorax or vessel injury. Postoperative neck immobilization is crucial, as head-turning can potentially disrupt the delicate nerve coaptations. Proximal exploration with the intent of nerve reconstruction should be done within the posttrauma 3- to 5-month timeframe, to ensure opportunity for reinnervation before the time of motor endplate fibrosis at the neuromuscular 
 junction 9 (Table 72.3). TABLE 72.3 Reconstructive Options With Proximal Exploration Donor Nerve

Recipient Nerve

Technical Aspects

CN (cranial nerve) XI (spinal

Suprascapular/posterior division of C5/C6

Use with phrenic (+/-cervical motor branches [CMBs])

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Functional Objective Shoulder abduction

accessory) CMBs, (C3, C4) Phrenic C5-ruptured proximal stump C6-ruptured proximal stump C7-ruptured proximal stump Contralateral C7 Intercostal (T3, T4, T5)

Suprascapular/posterior division of C5/C6 Suprascapular/posterior division of C5/C6 Suprascapular/posterior division of C5/C6 versus anterior division upper trunk, median nerve Median nerve, C8

Use with phrenic and CN XI. (CMBs are too weak to use alone) (+/-) CN XI and CMB. Phrenic is strong enough to use alone Will require cable grafting by sural nerve. Pick one target to avoid cross-innervation

Shoulder abduction

Will require cable grafting by sural nerve

Shoulder abduction, elbow flexion, or finger flexion Finger flexion

Median nerve

Will require cable grafting by sural nerve

Finger flexion

Suprascapular/posterior division of C5/C6, anterior division upper trunk, median nerve Musculocutaneous nerve

For five root injuries without other suitable donors. Needs a vascularized nerve graft (ulnar nerve). Pick one target to avoid cross-innervation Minimum of two intercostals needed. No nerve grafting

Shoulder abduction, elbow flexion, or finger flexion Elbow flexion

Shoulder abduction

Distal (close target) nerve transfers are viable options in cases that are within the 3 to 9 month posttrauma timeframe and also with viable donor nerves available that can be used for reinnervating the deficit. The great benefit of this approach is that the operative site is outside of the zone of injury, and thus the surgeon can avoid the difficulty of operating through fibrotic tissue. Furthermore, the time period in which surgical intervention must be performed can be extended by 2 to 3 months (surgery at 6–9 month post trauma is reasonable) because of the much shorter distance that the innervating axons must travel to the target muscle. However, this category of surgical technique is also limited by the severity of injury. For instance, for total root (C5-T1) injuries, only intercostal nerves will be available for use. The disadvantage of distal motor nerve transfer is that it weakens the intact functional portions of the upper extremity in order to restore an incomplete amount of the original function to the injured portion of the upper extremity. Cortical adaptation with postoperative motor reeducation is also required for regaining the use of the reconstructed innervation 24 (Table 72.4). A number of accompanying sensory nerve transfers also have been described for restoring sensation (Table 72.5). TABLE 72.4 Distal (Close-Target) Motor Nerve Transfer Options Deficit Radial

Median

Distal median Ulnar Musculocutaneous Axillary/suprascapular

Donor Nerve FDS or FCR/PL fascicles of median nerve PT branch of median FCR branch of median Supinator or ECRB branches of radial nerve FCU branch ulnar nerve ECRB branch radial nerve/FCU branch ulnar nerve ECRB radial ECRB/supinator radial Brachialis branch of musculocutaneous Terminal branch of AIN Third lumbrical branch ulnar Terminal branch of AIN EDQ/ECU branches of radial nerve Median and ulnar branches Triceps branch of radial CN XI

Recipient Nerve ECRB branch of radial; PIN ECRL branch of radial; PIN AIN AIN AIN/PT branch median

Functional Objective Wrist extension, thumb/finger extension Wrist extension, thumb/finger extension Finger flexion, thumb flexion

PT AIN AIN

Finger flexion, thumb flexion Finger flexion, thumb flexion; pronation forearm Pronation forearm Finger flexion, thumb flexion Finger flexion, thumb flexion

Recurrent motor branch median nerve Thenar branch median Ulnar motor branch Ulnar motor branch Musculocutaneous Anterior branch of axillary nerve; suprascapular nerve

Thumb opposition Thumb opposition Ulnar intrinsic muscles Ulnar intrinsic muscles Elbow flexion Shoulder abduction, external rotation

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AIN, anterior interosseous nerve; CN, cranial nerve; ECU, extensor carpi ulnaris; EDQ, extensor digiti quinti; ECRB, extensor carpi radialis brevis; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDS, flexor digitorum superficialis; PIN, posterior interosseous nerve; PL, palmaris longus; PT, pronator teres. TABLE 72.5 Distal Sensory Nerve Transfer Options Deficit Median

Ulnar

Donor Nerve Dorsal cutaneous branch or fourth web space branch ulnar Superficial radial Ulnar digital nerve ring finger Dorsal sensory branch radial Lateral antebrachial cutaneous Third web space median

Recipient Nerve First web space branch of median Median nerve Radial digital nerve index finger Radial digital nerve index finger Median sensory Ulnar sensory branch

Third common digital nerve

Ulnar sensory branch

Palmar branch median

Ulnar sensory branch

Posterior interosseous nerve (PIN)

Ulnar sensory branch

Sensory Objective First web space Thumb, index, first web space Radial aspect index finger Radial aspect index finger Thumb, index, middle fingers Little finger and ulnar aspect of ring Little finger and ulnar aspect of ring Little finger and ulnar aspect of ring Little finger and ulnar aspect of ring

Biomechanical restoration (tendon transfers and functioning free 
 muscle transplantation) are the third category of reconstruction. This is usually the chosen reconstructive strategy for cases of late presentation (>9 months after the time of injury) that have no opportunity for axonal regrowth within the timeframe before fibrosis of the motor endplates will occur at the neuromuscular junction. The option of tendon transfer or functioning free muscle transplantation is often used as the lifeboat for the aforementioned two categories or for augmentation of function after previous reconstruction. To note, conventional tendon transfers are only viable options for incomplete brachial plexus injury, when there are available donor musculotendinous units innervated by uninjured portions of the brachial plexus. Tendon transfers are often paired with arthrodeses (shoulder or wrist) for an enhanced functional result. 25 The gracilis myocutaneous flap is the most popular option for the FFMT for the upper extremity 26 (Tables 72.6 and 72.7). TABLE 72.6 Biomechanical Restoration: Tendon Transfer and Functioning Free Muscle Transplantation—Shoulder and Elbow Anatomic Region Shoulder

Elbow

Surgical Intervention

Functional Objective

Alternate Intervention

Upper trapezius transfer Lower trapezius transfer Contralateral lower trapezius transfer Latissimus dorsi transfer Biceps to triceps transfer Brachialis to triceps transfer Triceps to biceps transfer Latissimus dorsi transfer Pectoralis major transfer Steindler flexorplasty Gracilis FFMT (functioning free muscle transplantation)

Shoulder abduction External rotation External rotation Shoulder abduction, external rotation Elbow extension Elbow extension Elbow flexion Elbow flexion Elbow flexion Elbow flexion Elbow flexion

Shoulder arthrodesis Shoulder arthrodesis Shoulder arthrodesis Shoulder arthrodesis

TABLE 72.7 Biomechanical Restoration: Tendon Transfer and Functioning Free Muscle Transplantation—Wrist and Hand Deficit Radial nerve

Anatomic Region Wrist

Surgical Intervention PT ECRL/ECRB

Functional Objective Wrist extension

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Alternate Intervention Wrist arthrodesis

Hand

Median nerve

Ulnar nerve

Hand

FDS III/IV → EDC FCU → EDC FCR → EDC PL → EPL FDS → EPL Gracilis FFMT ECRL → FDP (index/long) FDP side/side (index/long → ring/small) BR → FPL PL (Camitz) EIP → APB FDS via FCU loop → APB ECRL → APB ADM → APB EDM → APB ECU → EPB Fowler wrist tenodesis Zancolli (MCPJ) palmar capsulodesis) EIP/EDM → extensor apparatus FDS III/IV → lateral bands ECRB or ECRL → lateral bands PL → lateral bands ECRB → ADP FDS → ADP EIP → ADP

Finger extension Finger extension Finger extension Thumb extension Thumb extension Finger flexion Finger flexion Finger flexion Thumb flexion Thumb opposition Thumb opposition Thumb opposition Thumb opposition Thumb opposition Thumb opposition Thumb opposition Claw correction Claw correction Claw correction Claw correction Claw correction Claw correction Thumb pinch Thumb pinch Thumb pinch

Thumb arthrodesis Thumb arthrodesis

Thumb arthrodesis Thumb arthrodesis Thumb arthrodesis Thumb arthrodesis Thumb arthrodesis Thumb arthrodesis Thumb arthrodesis

Thumb arthrodesis Thumb arthrodesis Thumb arthrodesis

ADM, abductor digiti minimi; ADP, adductor pollicis; APB, abductor pollicis brevis; BR, brachioradialis; ECRB, extensor carpi radialis brevis; ECRL, extensor carpi radialis longus; ECU, extensor carpi ulnaris; EDC, extensor digitorum communis; EDM, extensor digiti minimi; EIP, extensor indicis proprius; EPB, extensor pollicis brevis; EPL, extensor pollicis longus; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; FDS, flexor digitorum superficialis; FFMT, functioning free muscle transplantation; FPL, flexor pollicis longus; MCPJ, metacarpophalangeal joint; PL, palmaris longus; PT, pronator teres.

Complications across these three categories can range from serious to more localized and minor. Proximal exploration can incur lymphatic leak, large vessel injury, or pneumothorax. Distal transfers are typically much safer with a less morbid complication profile with limited exceptions (pneumothorax for intercostal nerve transfer). Tendon transfers have similarly more localized failure consequences (tendon bowstringing, joint posture deviation, etc.). Functioning free muscle transplantations have the complication profile associated with microvascular free flap transfer—vascular pedicle thromboses with partial or total flap loss. Furthermore, the flap donor site can have local complications such as seroma, hematoma, or infection. FFMTs also require a donor nerve for neurotization, which can incur serious complications such as pneumothorax in cases where the intercostal nerves are used.

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Multidisciplinary Approach Brachial plexus injuries demand a multidisciplinary approach with the involvement of physical medicine and rehabilitation, pain management, and psychiatry teams. From the time of the initial trauma, there is a need for physical therapy and occupational therapy involvement to maintain supple joints— reconstructive intervention is contraindicated if joints are ankylotic. The rehabilitative protocol must be diligently followed for several years after the surgical intervention in order to reap the full benefits of the surgery. Rehabilitative regimens include temperature therapy to aid with dysesthesia and pain, electrical stimulation to minimize atrophy of muscles, and range of motion exercises to maintain supple joints. Orthotic devices may help with shoulder stability and for providing a more natural posture so that the impairment of the injured extremity is less apparent. Involvement of a pain management team is frequently beneficial as the extreme causalgia associated with root avulsion injuries can be debilitating. Pain management therapy will involve pharmacologic agents such as opioid medications, anticonvulsants (e.g., gabapentin, pregabalin), or cannabinoids. A high percentage of the brachial plexus– injured population develops chronic pain problems, and there are data suggesting the benefit of pursuing nonopioid therapy instead of narcotic medication. Gabapentin (Neurontin), pregabalin (Lyrica), and cannabinoids have been shown in rat studies to have trophic effects for regenerating neurons after sciatic nerve injury in rats. 27–29 Furthermore, opioids have been shown to have a neurotoxic effect with spinal neuron apoptosis in rats. 30 Psychiatric consultation has been shown to have a beneficial effect in the brachial plexus population (39% of peripheral nerve patients are depressed). 31

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Obstetric Brachial Plexus Palsy Obstetric brachial plexus palsy (OBPP), neonatal brachial plexus palsy, brachial plexus birth palsy, and pediatric brachial plexus injury all refer to the brachial plexus injury incurred during childbirth, most commonly vaginal delivery. Fortunately, owing to better prenatal monitoring with more stringent criteria for conversion to cesarean section delivery, the incidence of birth-related brachial plexus injury in developed countries has continued to decrease in recent years. 32,33 There are numerous risk factors for OBPP (Table 72.8). The strongest risk factor is undoubtedly shoulder dystocia (approximately 8.3% chance of sustaining brachial plexus palsy with an occurrence of shoulder dystocia). However, 55% of cases of OBPP had no identifiable risk factor. 33 The most commonly encountered OBPP injury overall (46% of all OBPP) is a classic Erb palsy (C5 and C6 palsy). 34 Fortunately, OBPP has a high frequency of spontaneous resolution (77% to 90%). 32 The most common pattern of injury that necessitates operative exploration is a combination of root avulsions and extraforaminal ruptures of C5, C6, and C7 34,35 . Table 72.9 describes the other common patterns of OBPP injury presentation. With the greater potential for spontaneous recovery from obstetric-related brachial plexus trauma, it is not surprising that there is much disagreement upon the optimal management of these cases. There are still some practitioners who rarely choose surgical intervention. TABLE 72.8 Risk Factors and Protective Factors Associated With Obstetric Brachial Plexus Palsy (OBPP)33 Risk Factors (Odds Ratio) Shoulder dystocia (113.2) Birth weight >4.5 kg (26.8) Excessive fetal weight per gestational week (8.22) Breech delivery (3.56) Birth hypoxia (3.08) Instrumented delivery (3.05) Protective Factors (Odds Ratio) Multiple gestation (0.45) Cesarean delivery (0.16) TABLE 72.9 Injury Patterns for Obstetric Brachial Plexus Palsy (OBPP) Cases (n) Ruptures UT rupture UT and MT ruptures UT, MT, and LT ruptures Ruptures and Avulsions Single-root avulsion Two-root avulsion Three-root avulsion Four-root avulsion

47 17 24 6 72 18 28 17 9

Percentage 
 of Cases (n) 39% 14% 20% 5% 61% 15% 24% 14% 8%

MT, middle trunk; LT, lower trunk; UT, upper trunk.

Data compiled from David C.C. Chuang’s operations from 1994 to 2004. Deciphering the clues of the brachial plexus–injured infant is challenging. Rather than a systematic catalog of the presence or absence of each sensory and motor function, the practitioner must use various clever investigative aids to identify deficits and monitor for signs of return of function because the infant

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is unable to willingly cooperate with a directed examination. The tickle test can elicit upper extremity movement. The towel test is a similar ruse to trigger the baby to move the upper extremity by placing a towel over his or her eyes. There are differing opinions upon the threshold for surgical intervention. Terzis advocated surgical exploration if total palsy with Horner syndrome was present at 2 months of age. 36 Gilbert’s threshold was 3 months of age without elbow flexion. 37 Clarke and Curtis described 9 months as the limit for recovery of motor function in response to the “cookie test”. 37 Chuang found no difference in the recovery of elbow and shoulder function when surgical intervention was carried out at 2 versus 11 months, but Chuang’s threshold for surgical intervention was at 3 months if there was little to no wrist extension and finger flexion. He also determined that a persistent lack or stagnation of improvement in elbow or shoulder function warranted intervention at 6 to 12 months. 35 Electrodiagnosis in infants is notoriously unreliable because of its tendency to overestimate the axonal function that is present. 35,38 Surgical intervention within the first year of life involves either proximal exploration with nerve reconstruction or distal nerve transfers in similar fashion as detailed for adult palsy. The notable differences are that the phrenic nerve is generally not used for OBPP, and conventional nerve grafting will frequently involve saphenous, median antebrachial cutaneous , or lateral antebrachial cutaneous nerves in addition to the sural nerves, given the short length of the sural nerve in an infant. The hallmark stigmata and primary challenge of OBPP patients later in childhood is aberrant reinnervation manifesting in cocontraction of the muscles of the shoulder girdle and elbow. Several forms exist: Axons of the shoulder abductors may aberrantly reinnervate the shoulder adductors, leading to a limitation of shoulder abduction and eventually causing an adduction contracture of the 
 shoulder girdle. There also is cross-innervation of the elbow flexors (brachialis, biceps) and elbow extensors (triceps) which weakens both elbow flexion and extension movements. There can be cross-innervation between elbow flexors and shoulder abductors (which causes the trumpet sign). There can also be cross-
 innervation of the shoulder abductors and the elbow flexors/finger 
 flexors, leading to involuntary elbow and finger flexion with attempted shoulder abduction. The development of aberrant reinnervation ultimately leads to muscle imbalance that often causes joint deformities. 39 Interventions for these sequelae of OBPP include biomechanical reconstructions for the shoulder, elbow, and hand and forearm. Shoulder reconstruction involves release of adduction contractures at the shoulder girdle (by releasing both of the hypertrophic pectoralis major and teres major muscles) and performing tendon transfers to augment arm abductors (teres major transferred to infraspinatus). 40–42 Elbow reconstruction should prioritize restoration of elbow extension first, as extension can only be augmented effectively by biceps or brachialis tendon. Biceps to triceps tendon transfer or brachialis to triceps tendon transfers has the two-fold effect of restoring extension at the elbow while concomitantly releasing some of the contracture from the unopposed hypertrophy of the biceps and brachialis. If the preexisting elbow flexion is strong, sacrifice of either the biceps or brachialis can often be tolerated without excessively weakening elbow flexion. However, if necessary, elbow flexion can be augmented by either Steindler flexorplasty or FFMTs. 43–46 To note, prior to undergoing tendon transfer or FFMT reconstruction, the articular integrity of the elbow joint must be excellent. Both shoulder and elbow reconstructions are typically done in the range of 4 to 6 years of age. Hand and forearm function often accommodates surprisingly well. Therefore, waiting until age 6 to 13 years before undertaking hand reconstructive procedures is advisable. Tendon transfers in this regard are highly individualized. Flexors such as PL or FCR may be transferred to the EDC to augment finger extension. A Zancolli procedure might be used for supination contracture. Functioning free muscle transplantation may be required for restoration of finger flexion. 47 Excellent family participation and investment in the child’s postoperative therapy is critical. Surgery without rigorous rehabilitation can render the intervention fruitless, as joint contractures will recur without diligent therapy and continuous lifelong maintenance exercises.

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Outcomes Reporting of outcomes in the field of brachial plexus reconstruction currently lacks standardization. This may be attributed to the highly variable combinations of injury circumstances and severity. Most brachial plexus outcomes investigations focus upon motor recovery with little emphasis upon sensory return or quality of life. 48 OBPP outcome evaluation is also confounded by the use of multiple different evaluation systems (e.g., Mallet score, 49 Gilbert and Tassin Muscle Grading System, Clarke and Curtis Active Movement Scale, Narakas’ Grading System). 50 Even the MRC grading system may vary substantially among practitioners as it is ultimately a clinical description that is subject to each individual examiner’s interpretation. There is currently a focus upon incorporating patient-reported outcome measures (e.g., quality of life, function, pain, satisfaction) into investigations so that we can better understand the effect of brachial plexus injury and reconstruction.

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Conclusion Brachial plexus injuries are permanently physically disabling events. Even the best possible therapeutic interventions are only partially restorative, and the therapeutic course often involves multiple surgeries. Future investigations in the field will focus upon comparing the categories of surgical therapy (proximal exploration and reconstruction, distal nerve transfers, and biomechanical restorations by tendon transfers, or FFMTs) by using standardized outcome measures that involve patient-reported outcome measures. Technological advancements in the area of minimally invasive diagnostic techniques are currently poised to transform the field of brachial plexus reconstruction. Da Vinci robot surgery and MRI are both being actively explored for better application to allow early and more accurate diagnosis of brachial plexus injuries. Developing these modalities into reliable tools for early diagnosis can potentially allow earlier surgical intervention to give more time for nerve regeneration before fibrosis of the motor endplates of the neuromuscular junction occurs. Also, emerging technologies in the area of targeted muscle reinnervation and prosthetic replacement that had initially been applied to upper extremity amputees are now being directed to restoration of limb function for the brachial plexus-injury population. Perhaps, we will now begin to see advancements in the field of brachial plexus treatment brought about by technological advances that outpace our efforts to find new surgical techniques to maximize the notoriously limited healing potential of nerves.

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Acknowledgments The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Questions 1. A 20-year-old male was hit by a train traveling approximately 80 mile per hour. His injuries include subdural hematoma, open pelvic fracture, bilateral hemopneumothoraces, and a suspected brachial plexus injury of his left upper extremity. Three months after the injury, he still has no sensation to the left upper extremity on a C5-T1 dermatomal sensory examination, and there is also no detectable motor function of muscles in the left upper extremity. His electrodiagnostic studies are notable for the results shown in Tables 72.10 and 72.11. His EMG and nerve conduction studies are most consistent with which of the following? TABLE 72.10 Needle Electromyography (EMG) Results Muscle 
 (Left Side) FDP APB FCR Biceps Triceps Deltoid Cervical paraspinal 
 muscles

Insertional Activity Absent Absent Absent Absent Absent Absent Decreased

Fibrillations 2+ 2+ 2+ 2+ 2+ 2+ 2+

Positive Sharp Waves 2+ 2+ 2+ 2+ 2+ 2+ 2+

Amplitude (mV) Absent Absent Absent Absent Absent Absent Decreased

Duration (ms) No MUPs No MUPs No MUPs No MUPs No MUPs No MUPs

Polyphasic Waves

APB, abductor pollicis brevis; FCR, flexor carpi radialis; FCU, flexor carpi ulnaris; FDP, flexor digitorum profundus; MUPs, motor unit potentials. TABLE 72.11 Nerve Conduction Study Results

Sensory Median (index finger) Ulnar (small finger) Superficial radial LABC Median (thumb) MABC Motor Median—APB Ulnar—ADM Radial—ED Axillary—deltoid Musculocutaneous—biceps

Left Latency 3.1 2.7 2.4 2.4 3.2 2.5

Amplitude 18.1 16.5 22.8 7.7 9.7 14.0 Not recorded Not recorded Not recorded Not recorded Not recorded

Right Latency 3.0

Amplitude 26.3

2.5 2.5 3.2

20.7 16.3 24.8

14.9 12.4 8.7

ADM, abductor digiti minimi; APB, abductor pollicis brevis; ED, extensor digitorum; LABC, lateral antebrachial cutaneous; MABC, median antebrachial cutaneous.

a. Five root neuropraxia b. Ruptures of C5 and C6; avulsions of C7, C8, and T1 c. Avulsions of C5 and C6; ruptures of C7, C8, and T1 d. Postganglionic ruptures of C5-T1 e. Root avulsions of C5-T1 2. A 25-year-old gang member presents to the trauma center with severe bleeding after a stab wound to the right shoulder region by a knife. The initial exploration by vascular surgery accomplished repair of the axillary artery laceration. Three days after presentation, the patient is hemodynamically

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stable and without any further transfusion requirement. The trauma team is preparing to discharge the patient to home. The physical examination shows M0 elbow flexion, M3 finger flexion, and anesthesia to the thumb and index fingers. What is the most appropriate next course of action? a. Immediate reexploration of the site of nerve injury for primary repair b. Transfer of intercostal nerves (T3-T5) to musculocutaneous nerve for restoration of elbow flexion c. Double fascicular transfer of expendable flexor carpi ulnaris (FCU) fascicle of ulnar nerve and expendable motor fascicle of median directly to biceps and brachialis branches of the musculocutaneous nerve, for restoration of elbow flexion d. Functioning free muscle transplantation of gracilis muscle to arm for restoration of elbow flexion e. Aggressive physical therapy, occupational therapy, electrostimulation, and follow-up in 1 month to monitor for motor and sensory recovery 3. A 6-month-old girl whose birth weight was 5060 g (11.1 lbs) is being followed at your clinic for obstetric brachial plexus palsy. Her birth was notable for vaginal delivery with shoulder dystocia, and forceps were required to facilitate delivery. Initially at birth, she had no abduction of the arm at the shoulder and very weak flexion at the elbow. Currently, she has some evidence of arm abduction and elbow flexion is improving. There has always been good hand function. Of the following factors, which is the strongest risk factor for OBPP? a. Birth weight >4.5 kg b. Shoulder dystocia c. Instrumented delivery (forceps or vacuum) d. Breech presentation e. Hypoxia/fetal distress 4. A 38-year-old man was involved in a roll-over motor vehicle accident as an unrestrained driver with loss of consciousness and lower extremity fracture as well. One month after the trauma, he has M0 strength of abduction of the arm at the shoulder and M0 strength of flexion at the elbow. Sensation is severely diminished in the distribution of C5 and C6. What is most appropriate next course of action? a. Physical therapy and return visit in 1 month b. Double fascicular transfer of expendable FCU fascicle of ulnar nerve and expendable motor fascicle of median directly to biceps and brachialis branches of the musculocutaneous nerve, for restoration of elbow flexion c. Surgical exploration with resection of neuroma and nerve grafting d. Functioning free muscle transplantation of gracilis muscle to arm for restoration of elbow flexion e. Steindler flexorplasty 5. A 24-year-old man presents to your clinic with M0 strength of elbow flexion and M0 strength of shoulder abduction. It is now 14 months after he developed these deficits after he had landed upon his shoulder when he fell off a roof. What is the most reasonable management strategy for improving his upper extremity function? a. Aggressive physical therapy and electrostimulation therapy b. Double fascicular transfer of expendable FCU fascicle of ulnar nerve and expendable motor fascicle of median directly to biceps and brachialis branches of the musculocutaneous nerve, for restoration of elbow flexion c. Surgical exploration with resection of neuroma and nerve grafting d. Upper trapezius tendon transfer to restore abduction at the shoulder with functioning free muscle transplantation of gracilis for elbow flexion

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e. Shoulder arthrodesis 1. Answer: e. The complete absence of motor unit action potentials on the needle EMG and undetectable motor nerve conduction in combination with the normal amplitude on the sensory nerve conduction studies reflect that the ventral rootlets of the motor innervation and dorsal rootlets of the sensory innervation have all been disrupted. The dorsal root ganglion is still viable, leading to the detectable sensory nerve conduction and amplitudes. However, there is no connection between the peripheral nerve and the spinal cord, so there is no sensation and no motor function detectable in the patient. These EMG and nerve conduction findings are pathognomonic for the occurrence of a preganglionic root avulsion injury. 2. Answer: a. Sharp lacerations of the brachial plexus should be explored within the first week for direct repair if at all possible. Beyond 2 or 3 weeks after injury in the infraclavicular region, the nerve ends will retract, and nerve grafting will likely be necessary to achieve a tension-free coaptation. Repairing within the first week allows for a direct repair (with only a single coaptation site) which will theoretically minimize the loss of regenerating axons (straying away through the discontinuity of the epineurium at the coaptation sites) and maximize the potential for functional recovery. 3. Answer: b. Shoulder dystocia is the factor with the highest odds ratio (OR = 113.2) for occurrence of OBPP. Birth weight >4.5 kg (OR = 26.8), breech presentation (OR = 3.56), instrumented delivery (OR = 3.05), and hypoxia/fetal distress (OR = 3.08) all have substantially lower correlation with OBPP. Much disagreement exists over the criteria and timing by which surgical exploration and intervention should be performed. 4. Answer: a. Closed injuries of the brachial plexus are monitored for the first 3 months. During this time, it is essential to have excellent physical therapy and occupational therapy to keep joints in the hand and upper extremity supple. A baseline electrodiagnostic study may be obtained at approximately posttrauma week 4 and repeated at approximately posttrauma week 12 to monitor for any nerve regeneration. Until month 3, monitoring for motor and sensory recovery at a monthly interval in the clinic is appropriate. 5. Answer: d. At 14 months after injury, nerve surgeries to restore innervation to the native muscles of the shoulder and arm are not an option due to that fibrosis of the motor endplates of the neuromuscular junction will have occurred by the time that axons have the time to regenerate. Salvage procedures such as upper trapezius tendon transfer and FFMT are the only options for improving motor function. Physical therapy and electrostimulation alone without surgical intervention would not be expected to have any significant positive effect upon function. Shoulder arthrodesis may be considered for less-motivated patients or older patients. Arthrodesis leaves the shoulder with a very limited arc of motion with the remaining scapulothoracic muscles driving movement.

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References Thatte, MR, Babhulkar, S, Hiremath, A. Brachial plexus injury in adults: diagnosis and surgical treatment strategies. Ann Indian Acad Neurol. 2013;16:26-33. Soldado, F, Ghizoni, MF, Bertelli, J. Injury mechanisms in supraclavicular stretch injuries of the brachial plexus. Hand Surg Rehabil. 2016;35:51-54. Kim, DH, Cho, YJ, Tiel, RL, Kline, DG. Outcomes of surgery in 1019 brachial plexus lesions treated at Louisiana state University Health Sciences Center. J Neurosurg. 2003;98:1005-1016.Provides a good survey of the range and prevalence of different brachial plexus pathologies that occur at a trauma center in the United States. Kim, DH, Murovic, JA, Tiel, RL, Kline, DG. Penetrating injuries due to gunshot wounds involving the brachial plexus. Neurosurg Focus. 2004;16:1-6. Secer, HI, Solmaz, I, Anik, I, et al. Surgical outcomes of the brachial plexus lesions caused by gunshot wounds in adults. J Brachial Plex Peripher Nerve Inj. 2009;4:11. Groen, GJ, Baljet, B, Drukker, J. Nerves and nerve plexuses of the human vertebral column. Am J Anat. 1990;188:282-296. Terzis, JK, Vekris, MD, Soucacos, PN. Outcomes of brachial plexus reconstruction in 204 patients with devastating paralysis. Plast Reconstr Surg. 1999;104:1221-1240. Alnot, J. Traumatic brachial plexus palsy in the adult: retro-and infraclavicular lesions. Clin Orthop Relat Res. 1988;(237):9-16. Chuang, DC. Adult brachial plexus reconstruction with the level of injury: review and personal experience. Plast Reconstr Surg. 2009;124:E359-E69.Excellent overview with tips and insight from the most prolific brachial plexus surgeon currently in practice. Mackinnon, SE. New directions in peripheral nerve surgery. Ann Plast Surg. 1989;22:257-273. Samardzic, MM, Rasulic, LG, Grujicic, DM. Gunshot injuries to the brachial plexus. J Trauma. 1997;43:645-649. Travlos, J, Goldberg, I, Boome, RS. Brachial plexus lesions associated with dislocated shoulders. J Bone Joint Surg Br. 1990;72B:68-71. Narakas, A. Injuries of the brachial plexus and neighboring peripheral nerves in vertebral fractures and other trauma of the cervical spine. Orthopade. 1987;16:81-86. Tung, TH, Mackinnon, SE. Brachial plexus injuries. Clin Plast Surg. 2003;30:269-287. Buck-Gramcko, D, Lubahn, J. The Hoffmann-Tinel sign. J Hand Surg Eur Vol. 1993;18:800-805. Al-Qattan, M, Clarke, H, Curtis, C. The prognostic value of concurrent Horner’s syndrome in total obstetric brachial plexus injury. J Hand Surg. 2000;25:166-167. Teixeira, MJ, Da Paz, MG, Bina, MT, et al. Neuropathic pain after brachial plexus avulsion–central and peripheral mechanisms. BMC Neurol. 2015;15:73. Socolovsky, M, Di Masi, G, Bonilla, G, et al. The phrenic nerve as a donor for brachial plexus injuries: is it safe and effective? Case series and literature analysis. Acta Neurochir. 2015;157:1077-1086. Terzis, JK, Kostas, I, Soucacos, PN. Restoration of shoulder function with nerve transfers in traumatic brachial plexus palsy patients. Microsurgery. 2006;26:316–324. Fuzari, HKB, Dornelas De Andrade, A, Vilar, CF, et al. Diagnostic accuracy of magnetic resonance imaging in post-traumatic brachial plexus injuries: a systematic review. Clin Neurol Neurosurg. 2018;164:5-10. Ferrante, MA. Electrodiagnostic assessment of the brachial plexus. Neurol Clin. 2012;30:551-580. Granberry, WM, Lipscomb, PR. Tendon transfers to the hand in brachial palsy. Am J Surg. 1964;108:840-844. Ikuta, Y, Kubo, T, Tsuge, K. Free muscle transplantation by microsurgical technique to treat severe Volkmann’s contracture. Plast Reconstr Surg. 1976;58:407-411. Tung, TH, Mackinnon, SE. Nerve transfers: indications, techniques, and outcomes. J Hand Surg Am. 2010;35:332-341.Overview of the “distal nerve transfer” techniques from one of the primary groups that pioneered and popularized this technique. Berger, A, Brenner, P. Secondary surgery following brachial plexus injuries. Microsurgery. 1995;16:43-47. Chuang, DC. Nerve transfer with functioning free muscle transplantation. Hand Clin. 2008;24:377-388.Description of the application of FFMTs to brachial plexus pathology with a comprehensive description of options for neurotization. Camara, CC, Araujo, CV, De Sousa, KKO, et al. Gabapentin attenuates neuropathic pain and improves nerve myelination after chronic sciatic constriction in rats. Neurosci Lett. 2015;607:52-58. Celik, M, Kose, A, Kose, D, et al. The double-edged sword: effects of pregabalin on experimentally induced sciatic nerve transection and crush injury in rats. Int J Neurosci. 2015;125:845-854. Perez, M, Benitez, SU, Cartarozzi, LP, et al. Neuroprotection and reduction of glial reaction by cannabidiol treatment after sciatic nerve transection in neonatal rats. Eur J Neurosci. 2013;38:3424-3434. Mao, J, Sung, B, Ji, RR, Lim, G. Neuronal apoptosis associated with morphine tolerance: evidence for an opioid-induced neurotoxic mechanism. J Neurosci. 2002;22:7650-7661. Bailey, R, Kaskutas, V, Fox, I, et al. Effect of upper extremity nerve damage on activity participation, pain, depression, and quality of life. J Hand Surg Am. 2009;34:1682-1688. Chauhan, SP, Blackwell, SB, Ananth, CV. Neonatal brachial plexus palsy: incidence, prevalence, and temporal trends. Semin Perinatol. 2014;38:210-218.

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Defrancesco, CJ, Shah, DK, Rogers, BH, Shah, AS. The epidemiology of brachial plexus birth palsy in the United States: declining incidence and evolving risk factors. J Pediatr Orthop. 2019;39(2):e134-e140. Al-Qattan, MM, El-Sayed, AA, Al-Zahrani, AY, et al. Narakas classification of obstetric brachial plexus palsy revisited. J Hand Surg Eur Vol. 2009;34:788-791. Chuang, DC, Mardini, S, Ma, HS. Surgical strategy for infant obstetrical brachial plexus palsy: experiences at Chang Gung Memorial Hospital. Plast Reconstr Surg. 2005;116:132-142; discussion 43-44. Terzis, JK, Papakonstantinou, K. Surgical treatment of obstetrical brachial plexus paralysis: the Norfolk experience. Semin Plast Surg. 2004;18:359.Comprehensive overview of obstetric brachial plexus palsy from one of the pioneers of the field. Gilbert, A. Brachial Plexus Injuries. Philadelphia, PA: Taylor & Francis; 2001. Slooff, AC. Obstetric brachial plexus lesions and their neurosurgical treatment. Microsurgery. 1995;16:30-34. Chuang, DC, Ma, HS, Wei, FC. A new evaluation system to predict the sequelae of late obstetric brachial plexus palsy. Plast Reconstr Surg. 1998;101:673-685. Chuang, DC, Ma, HS, Wei, FC. A new strategy of muscle transposition for treatment of shoulder deformity caused by obstetric brachial plexus palsy. Plast Reconstr Surg. 1998;101:686-694. Narakas, AO. Muscle transpositions in the shoulder and upper arm for sequelae of brachial plexus palsy. Clin Neurol Neurosurg. 1993;95(suppl):S89-S91. Price, AE, Grossman, JA. A management approach for secondary shoulder and forearm deformities following obstetrical brachial plexus injury. Hand Clin. 1995;11:607-617. Chuang, DC, Epstein, MD, Yeh, MC, Wei, FC. Functional restoration of elbow flexion in brachial plexus injuries: results in 167 patients (excluding obstetric brachial plexus injury). J Hand Surg Am. 1993;18:285-291. Chuang, DC, Hattori, Y, Ma, HS, Chen, HC. The reconstructive strategy for improving elbow function in late obstetric brachial plexus palsy. Plast Reconstr Surg. 2002;109:116-126. Haerle, M, Gilbert, A. Management of complete obstetric brachial plexus lesions. J Pediatr Orthop. 2004;24:194-200. Al-Qattan, MM. Elbow flexion reconstruction by Steindler flexorplasty in obstetric brachial plexus palsy. J Hand Surg Br. 2005;30:424-427. Chuang, DC, Ma, HS, Borud, LJ, Chen, HC. Surgical strategy for improving forearm and hand function in late obstetric brachial plexus palsy. Plast Reconstr Surg. 2002;109:1934-1946. Dy, CJ, Garg, R, Lee, SK, et al. A systematic review of outcomes reporting for brachial plexus reconstruction. J Hand Surg Am. 2015;40:308313. Tse, R, Kozin, SH, Malessy, MJ, Clarke, HM. International Federation of Societies for Surgery of the Hand Committee Report: the role of nerve transfers in the treatment of neonatal brachial plexus palsy. J Hand Surg Am. 2015;40:1246-1259. Pondaag, W, Malessy, MJ. The evidence for nerve repair in obstetric brachial plexus palsy revisited. Biomed Res Int. 2014;2014:434619.

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CHAPTER 73

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Tetraplegia Jennifer F. Waljee and Kevin C. Chung

Key Points Over half of spinal cord injuries (SCIs) involve the cervical spine, and restoration of upper extremity function is consistently rated a top priority by patients. Surgical reconstruction of upper extremity function provides an important opportunity to restore independence with transfers and activities of daily living. Reconstruction is considered among patients with pain-free, supple joints and who are able to meet the demands of postoperative rehabilitation once the SCI has plateaued, which typically occurs within 1 year. The International Classification for Surgery of the Hand in Tetraplegia (ICSHT) level describes the number of muscles present below the elbow available for tendon transfer and provides the framework for surgical planning. Critical functions to restore among patients with SCIs include elbow extension, forearm pronation, wrist extension, key pinch, digit flexion and extension, and intrinsic balance. Approximately 17,000 new spinal cord injuries (SCIs) occur in the United States each year and are particularly concentrated among young individuals. 1 Most injuries occur among males from trauma, including motorcycle and motor vehicle collisions. Roughly 2,800,000 individuals in the United States live with SCI, and the rates of injury among the elderly due to falls and underlying spinal degenerative disease is increasing. 2 Patients commonly present with concomitant injuries, and over half will develop complications during their initial hospitalization, such as shock, respiratory compromise, and pneumonia. 3 Fortunately, mortality related to SCI has declined considerably in recent decades. Nonetheless, late complications, such as pressure ulceration, sepsis, and venous thromboembolism, remain important causes of death. 4–6 Of all SCIs, 56% affect the cervical spine. 1 SCI resulting in tetraplegia is a devastating injury, and optimal upper extremity function is consistently rated as a top priority to achieve independence with activities of daily living. 7–12 Upper extremity reconstruction, which can include both nerve and tendon transfers, offers a viable way to restore some elements of upper extremity motion and strength. 13–15 Multiple studies indicate that upper extremity reconstruction can effectively improve hand pinch and grasp, enabling recipients to better perform activities of daily living. 7,16–19 Yet despite these established benefits, rates of procedures are often lagging. 19–21 In this chapter, we will review the principles of upper extremity reconstruction for SCI and common techniques.

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Pathophysiology of Injury Tetraplegia results from traumatic injuries to the cervical spine causing the loss of upper motor and sensory neurons. SCI results from 2 phases of injury: primary and secondary injury. The peripheral and central nervous systems are discontinuous because of blunt, sharp, crushing, or avulsion forces. 22 Secondary injury includes the physiologic events that occur due to disruption of the vasculature, edema, ischemia, and hemorrhage, which further compounds the injury. 23 Above the level of the injured spinal cord, nerve function is normal. However, nerve function below the level of injury is absent. Hyperreflexia is common and characteristic of the upper motor nerve injury; nerve function can be elicited at levels below the injury if the lower motor neuron unit is intact. Level of injury is determined by physical examination of motor and sensory function. Symmetry or skip pa erns can occur with certain injury types (central cord syndrome, Brown-Séquard syndrome, anterior cord syndrome). Notably, the manifestations of injury may vary between individuals with the same level of injury, and it is important to perform a full examination of the upper extremity muscle units when planning reconstruction. 24 Within the zone of injury, stabilization of recovery occurs as the edema, ischemia, and hemorrhage resolves. In general, the greatest gains of motor and sensory function occur within 6 to 9 months following SCI, after which neurologic stability typically occurs. 25,26

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Clinical Evaluation Following SCI, loss of function occurs according to the injured segment, and the pattern of function follows the order of innervation by anterior horn cells from cephalad to caudad (Figure 73.1). The American Spinal Injury Association (ASIA) Impairment Scale classification further describes the spinal cord elements related to upper extremity function, and the most common levels of cervical spine injury are at C5 and C6, marked by a loss of elbow extension, wrist flexion, and finger flexion and extension. In general, patients with upper cervical spine injuries have shoulder motion, but absent wrist and hand function. Individuals with midcervical injury typically have elbow flexion, but may have varying degrees of wrist extension, forearm pronation, and hand motion. Patients with lower cervical spine injuries typically have nearly full function of their shoulder, elbow, and wrist, but without intrinsic muscle function. However, there is often variation in the manifestations of each injury, and a full upper extremity examination is necessary to determine reconstructive options.

FIGURE 73.1 Spinal cord innervation of upper extremity motor elements and the American Spinal Injury Association (ASIA) Impairment Scale classification.

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Management of Tetraplegia The management of patients with tetraplegia is multidisciplinary, including surgical care, neurologists, and physical medicine and rehabilitation specialists. Immediately following injury, prevention of contractures ensures options for later reconstruction. Contractures are common, with over half of SCI patients developing a contracture within 1 year of injury, most commonly of the shoulder 43%, elbow and forearm 33%, and wrist and hand 41%. 27 Contractures arise due to spasticity or pathologically increased muscle tone caused by a loss of upper motor neuron innervation and inhibitory control. 28 Stiffness of the soft tissues is caused by shortening and loss of elasticity occurs and can include the skin, subcutaneous tissue, joint capsule, supporting ligaments, tendon, muscle, and neurovascular structures. Mobilization can prevent contractures by providing tensile stress that incites collagen reorganization. Splinting between mobilization exercises is critical, although compliance is variable. 29 The hand should be splinted in a functional position to maximize the potential for tenodesis, with the digits extended and the metacarpophalangeal (MCP) joints in gentle flexion. In addition, the forearm should be positioned in pronation to avoid supination contractures. Medical therapy can also help with prevention of contractures, including the use of spasmolytics (intrathecal, oral, and injected), motor blocks, and targeted electrical stimulation. For patients with severe, refractory spasticity in a nonfunctional limb without expected recovery, motor neurectomy may be considered. 30 Reconstructive procedures including tendon transfers, tenodesis procedures, nerve transfers, joint release, and selective arthrodesis can significantly enhance the upper extremity function of patients with tetraplegia. The primary goal of reconstruction is to provide greater independence for SCI patients with activities of daily living. Prior to surgical reconstruction, it is important to ensure that neurologic recovery has plateaued, typically at 1 year after injury, and that the patient has sufficient social support for recovery. In addition, patients should have reasonable expectations for the potential gains provided from reconstructive procedures, demonstrate emotional adjustment to their injury, and have motivation and support to participate in postoperative therapy. 31 Finally, patients should have minimal pain in the upper extremity that may preclude participation in rehabilitation or use of the hand. Traumatic brain injuries commonly occur among patients with SCI, as well as concomitant mood disorders. It is important to ensure that cognition, depression, anxiety, and other mental health conditions are optimized preoperatively. 32 Prior to any reconstructive procedure, it is essential to ensure that the upper limb is free of contractures, with full passive motion, and in particular the shoulder, elbow, forearm, wrist, MCP, and proximal interphalangeal (PIP) joints. In general, surgical procedures for tendon transfers are delayed for at least 6 to 9 months following injury to establish a baseline for function and identify the motor units that will recover. 26 However, there is no upper limit with respect to timing of tendon transfers from injury for patients who are good candidates. Donor muscles should be strong (M4 or M5 strength) and beyond the zone of injury. Like other tendon transfers, the ideal donor provides synergistic function with a straight line of pull and adequate excursion, and glide through a healthy bed of tissue free of scar.

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Reconstructive Options for Tetraplegia Surgical planning is informed by the patient’s International Classification for Surgery of the Hand in Tetraplegia (ICSHT) level, which describes the number of muscles present below the elbow with at least grade 4 strength that are available for tendon transfer (Table 73.1). Muscles are listed in the order in which recovery is expected in complete tetraplegia. A muscle is considered functional if the strength is grade 4 or higher based on manual testing (Table 73.2). For sensory function, two-point discrimination of 10 mm or less is needed for cutaneous control. Ocular control is needed for patients with wider two-point discrimination. Without adequate sensory input, even the best reconstruction is ineffective because the patient cannot feel or detect how much force is impacted on an object. TABLE 73.1 International Classification for Surgery of the Hand in Tetraplegia Sensibility

Motor Group 0

Muscles Available for Functional Ability Transfer No muscle below elbow suitable for transfer

O or Cu

Level of Injury C4 and higher C5

1

Brachioradialis (BR)

Flexion and supination of the elbow

O or Cu

C6

2

Extension of the wrist

O or Cu

C6

3

Extensor carpi radialis longus (ECRL) ECRB

O or Cu O or Cu O or Cu

C6 C7 C7

4 5 6

Pronator teres (PT) Flexor carpi radialis Finger extensors

O or Cu

C7

7

Thumb extensor

O or Cu

C8

8

Partial finger flexors

O or Cu

C8

9

Lacks intrinsics

x

Exceptions

O or Cu

O or Cu

Extension of the wrist

Reconstructive Priorities

Elbow extension: deltoid to triceps; biceps to triceps Wrist extension: BR to extensor carpi radialis brevis (ECRB) Key pinch: flexor pollicis longus (FPL) tenodesis; Split distal FPL tenodesis Elbow extension: deltoid to triceps; biceps to triceps Key pinch: BR to FPL or FPL tenodesis; Split distal FPL tenodesis Thumb extension: extensor pollicis longus tenodesis Grasp: BR to flexor digitorum profundus (FDP) or ECRL to FDP Release: extensor digitorum communis (EDC) tenodesis

Pronation of the wrist Flexion of the wrist Extrinsic extension of the fingers Extrinsic extension of the thumb

Key pinch: BR to FPL; PT to FPL Split distal FPL tenodesis Grasp: ECRL to FDP; PT to FDP Release: PT to EDC Intrinsic balancing

Extrinsic flexion of the fingers Extrinsic flexion of the fingers

Thumb opposition: ECU to FCU to FPL using flexor digitorum superficialis Intrinsic balancing

TABLE 73.2 Muscle Grading System: British Medical Research Council Grade a 0 1 2 3

Description No contraction Trace contraction Active motion without gravity Active motion against gravity

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4 5

Active motion against gravity and resistance Normal

a

 Only muscles of grade 4 or greater are available for transfer. Tendon transfer results in decline of 1 point due to loss of efficiency.

The decision for and type of reconstruction planned is then informed by three questions: what muscles are missing, what critical functions are needed, and what donor muscles are available. Critical functions include restoration of elbow extension to facilitate transfer and expand the space around an individual for manipulation of the hand. Other needs are key/lateral pinch, forearm pronation, wrist extension, digit flexion and extension for grasp and release, and hand posture for patients with loss of intrinsic function. 33

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ICSHT Levels Group 0 Patients with injury levels of C4 and higher are able to elevate their shoulders as the spinal accessory nerve innervating the trapezius muscle is uninjured. However, these individuals are often ventilator dependent, given the potential injury to the phrenic nerve, and without upper extremity function. Unfortunately, for group 0 patients, there are no muscles below the elbow with sufficient strength for transfer and no options for tendon transfer for upper extremity reconstruction.

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Group 1 Patients with C5 injuries (group 1) typically have preservation of elbow flexion and shoulder abduction through the biceps and deltoid. Brachioradialis (BR) is the only muscle below the elbow available to transfer, and critical functions to restore for this group of patients include wrist extension and key pinch. Voluntary active wrist extension and flexion are essential functions for tetraplegia patients as it provides tenodesis that can impart gross grip and lateral pinch with wrist extension, and release with wrist flexion. To accomplish wrist extension, BR is transferred to extensor carpi radialis brevis (ECRB). 34 ECRB is chosen as the recipient because it inserts on the base of the long finger metacarpal and provides centralized wrist extension. BR function is tested by selectively testing the strength of this muscle in a neutral position to avoid the action of biceps and brachialis. The muscle belly is palpated lateral to the biceps tendon at the elbow. The transfer should not be set with excess tension, but should allow the wrist to flex when the elbow is in extension for release with tenodesis. Transfers should also be tensioned to position the wrist in neutral when the elbow is in flexion. For group 1 patients, flexor pollicis longus (FPL) tenodesis may be performed following BR transfer to restore wrist extension. Key pinch is then accomplished with active wrist extension, with release by passive wrist flexion. To accomplish this, the IP joint of the thumb is stabilized, the A1 pulley around the FPL is released, and the FPL is fixed to the radius. The IP joint of the thumb can either be pinned or fused or a split FPL transfer can be performed (Figure 73.2). In addition, tenodesis of extensor pollicis longus (EPL) and extensor pollicis brevis may be performed to further stabilize the metacarpophalangeal joint. 35 Stabilizing the interphalangeal joint can be accomplished by splitting the FPL tendon and transferring the radial half of the tendon to the EPL. This allows the IP joint to remain straight and stable during attempted key pinch. Alternatively, the EPL tendon may be sutured onto itself in a loop configuration to provide IP joint stability. 36

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FIGURE 73.2 A. Split FPL to EPL tendon transfer to stabilize the thumb interphalangeal joint. B,C. Split FPL to EPL tendon transfer to stabilize the thumb interphalangeal joint. FPL, flexor pollicis longus; EPL, extensor pollicis longus.

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Groups 2 and 3 Group 2 patients have preservation of extensor carpi radialis longus (ECRL) and group 3 patients preservation of ECRB. Patients with C6 injuries are able to perform wrist extension which affords the benefits of tenodesis for rudimentary grasp and release. Therefore, key pinch is a critical function to restore. Key pinch has three components 37 : Allowing FPL to provide active pinch through tenodesis or tendon transfer Stabilizing the interphalangeal joint Position in the thumb in an effective posture of abduction Approximately 2.2 kg of strength are needed for effective key pinch, grasp, and release for common activities of daily living such as manipulating adaptive transportation devices and catheter management. For patients in groups 2 and 3, a one-stage key pinch and release procedure is typically performed, and BR is transferred to FPL (Figure 73.3). Similarly, EPL tenodesis can be performed by creating a loop around the third extensor compartment. The EPL tendon is divided at its musculotendinous junction and sutured to itself distal to the extensor retinaculum and Lister tubercle. 13 Carpometacarpal (CMC) arthrodesis in a position for key pinch is performed to provide stability. To position the thumb, CMC arthrodesis is commonly performed, which may provide greater strength with tendon transfers to actively achieve key pinch, but care is taken not to limit passive and active opening of the hand. 38

FIGURE 73.3 Brachioradialis to flexor pollicis longus transfer to restore thumb flexion.

In addition, for groups 1 to 3, pronosupination imbalance can occur due to innervation of the biceps and supinator among patients without function of the pronator teres (PT) or pronator quadratus (groups 1–3). 39–41 Supination deformities impair the ability to position the hand in space for grasp and release and can exacerbate wrist extension contractures due to gravity in the setting of weakened flexors. 37 Reconstruction of pronation provides for more effective tenodesis, grip, and key pinch. Supination contractures often occur in conjunction with elbow flexion contractures, and mild to moderate contractures can be improved with serial casting and splinting. For patients with contracture, correction of a supination deformity can be accomplished by biceps rerouting transfer to the opposite side of the radius with interosseous membrane release as described by Zancolli, which converts the biceps from an active supinator to a pronator. 42,43 Alternatively, derotation osteotomy of the radius can be performed to place the forearm into pronation, and combined with anterior elbow capsule release and fractional lengthening of the biceps and brachialis for patients with elbow flexion contractures. 39

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Groups 4 and 5 Patients in group 4 have preservation of PT and patients in group 5 have preservation of flexor carpi radialis (FCR). Although tenodesis is critical for grasp and release, tenodesis only provides a force around 1 to 2N, and 2N or greater is required to accomplish most activities of daily living. 12 Therefore, in groups 4 and 5, the presence of these additional muscles provides more reconstructive options that can be used to restore the critical functions of finger flexion for grasp and thumb flexion for pinch to hold objects. For these patients, grasp, pinch, and release are accomplished in two phases, an extensor phase (release) and a flexor phase (grasp), and require thumb stability. Reconstruction can be performed in multiple stages in either order (flexion or extension reconstruction) or a single stage depending on surgeon preference and level of injury. 44 Flexion is restored by transferring ECRL to the flexor digitorum profundus (FDP) tendons, and either BR or PT to the FPL 45 (Figure 73.4). The action of PT is tested by examining the patient’s forearm in pronation with resisted supination while palpating the lateral aspect of the forearm distal to the antecubital fossa. ECRL is chosen to restore function to FDP given its greater excursion and strength compared with BR and PT (Figure 73.5). These tendon transfers predictably restore grasp for activities of daily living (Figure 73.6). Extension is accomplished by an extensor digitorum communis (EDC) tenodesis, in which the digit extensors are anchored to the radius. In the forearm, the fourth compartment is exposed, and the periosteum is elevated as a flap. The extensor tendons are sutured together and then anchored to the shaft of the radius. The tension is set in a reverse cascade, to allow the index finger in the most flexed position for finer pinch, with the MCP joints in extension with the wrist in neutral. 13 The reverse cascade is critical when posturing tendon transfers for patients with SCI as the ulnar digits are less likely to reach the thumb for key pinch. Similar to patients in groups 2 and 3, EPL tenodesis may be performed by constructing a loop around the extensor retinaculum of the third compartment.

FIGURE 73.4 Brachioradialis and extensor carpi radialis longus tendons for transfer.

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FIGURE 73.5 Extensor carpi radialis longus to flexor digitorum profundus of the index, middle, ring, and small fingers.

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FIGURE 73.6 Grasp following reconstruction of flexion by extensor carpi radialis longus to flexor digitorum profundus transfer.

The thumb can be stabilized using either an opponensplasty or by performing CMC arthrodesis. 46 Given the limited number of donor tendons, this is performed by transferring PT or BR to the flexor digitorum superficialis (FDS) of the ring finger. The distal aspect of the FDS is then transected at the decussation, routed through a loop of fascia, and transferred to the abductor pollicis brevis insertion at the MCP joint of the thumb. 45 If thumb CMC arthrodesis is performed, the thumb is positioned for lateral pinch in approximately 20° of extension, 45° abduction, and slight pronation. 13 For patients in whom bilateral reconstruction is planned, opponensplasty may be selected for one side and CMC arthroplasty may be selected for the contralateral side, pending on the patient’s needs for fine pinch or stronger grip. 46

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Group 6 and 7 For patients in group 6, EDC function is preserved, and patients in group 7 EPL function is preserved. Similar to groups 4 and 5, BR, ECRL, and PT remain available for transfer, and critical functions to restore include restoration of strength for pinch and grasp with finger and thumb flexion. In general, FCR is not used as a donor tendon as its power improves the capacity of the tenodesis effect with the release phase and enhances the ability to power a wheelchair. Grasp and pinch can be reconstructed in one stage to restore the flexor phase, given that the extensors are intact. To do this, ECRL is transferred to FDP to restore finger flexion and BR is transferred to FPL to restore thumb flexion. ECRB is not used as a donor as it provides centralized wrist extension. With respect to the thumb, EPL tenodesis is performed as described above with CMC fusion for patients in group 6. For patients in group 7, EPL is intact, and opponensplasty alone is performed by transferring PT to FDS to the ring finger for power. The FDS tendon to the ring finger is then transferred to the abductor pollicis brevis to provide adduction and opposition.

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Group 8 Patients in group 8 have function of digit flexors of the index and middle fingers but lack function of the ring and small fingers. Restoration of full finger flexion is an important reconstructive priority. To do this, side-to-side FDP transfer is performed. In this procedure, the flexor tendons of FDP are anchored together as a single unit to provide finger flexion using either sutures or a free tendon graft.

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Restoration of Elbow Reconstruction Reconstruction of elbow extension is a top priority to restore the ability to reach, provide stability of hand function, and will augment tendon transfers performed for wrist extension, pinch, and grip. For patients with poor triceps function and injuries at levels of C5 and C6 (typically Groups 1–4), common tendon transfers to achieve elbow extension are the posterior deltoid to triceps transfer, which is achieved with supplemental tendon grafting, and biceps to triceps transfer. 47 It is critical that patients have functional brachialis and supinator muscles to ensure elbow flexion and supination following biceps transfer. The brachialis muscle is palpated during elbow flexion in supination for patients without wrist extension. For patients with strong wrist extension, biceps may be used as the level of injury is below the innervation of the brachialis and supinator. Biceps to triceps transfer is performed through a medial approach and routing, rather than posterolaterally, to avoid injury or compression to the radial nerve. The tendon is tunneled in a subcutaneous plane and anchored to the olecranon and/or woven to the triceps tendon. 48 The transfer should accommodate 60° to 90° of elbow flexion passively with tensioning. Alternatively, the posterior third to half of the deltoid can be transferred to the triceps muscle to provide elbow extension among patients. 49 Typically, an interposition graft of fascia is required (e.g., tensor fascia lata; Figure 73.7). The deltoid is raised distally to proximally, protecting the axillary nerve, and a subcutaneous tunnel or open incision can be used for the interpositional graft. The graft is woven from the distal aspect of the deltoid into the distal aspect of the triceps (Figure 73.8). Overall, biceps to triceps transfers are favored, given the earlier mobilization possible in the rehabilitation period and the potential for stretch of the interposition graft for deltoid to triceps transfer with resultant loss of strength.

FIGURE 73.7 Harvest of tensor fascia lata graft for posterior deltoid to triceps transfer.

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FIGURE 73.8 Posterior deltoid to triceps transfer.

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Intrinsic Reconstruction For patients in groups 6 through 9, intrinsic reconstruction can augment hand function by balancing the digit posture in a better position for grasp and release. Patients with intrinsic weakness will have a clawed posture of their hand. The PIP joints are often flexed due to FDS spasticity and hyperextension of the MCP joints due to loss of intrinsic function which provides MCP joint flexion. In addition, an uncoordinated rolling phenomena can occur when grasp is initiated, in which the distal interphalangeal and PIP joints will flex prior to the MCP joint. For the thumb, patients will present with a Froment’s sign, in which FPL is flexed with thumb adduction to overcome weakness of the adductor pollicis. To address intrinsic weakness of the thumb that interferes with key pinch, a portion of the radial aspect of FPL may be transferred to EPL to balance the force across the interphalangeal joint. 50 To create intrinsic balance in the fingers, Zancolli described the creation of a lasso to flex the MCP joints first, followed by the interphalangeal joints, to provide more coordinated movement. To create the lasso, the FDS is released distally and looped onto itself at the A1 pulley to create flexion force at the MCP joint with wrist extension.Alternatively, for patients with central slip deficiencies, free tendon grafts may be used for tenodesis. The integrity of the central slip is identified by the extent to which the digits extend with wrist flexion, and patients with central slip deficiencies will not have digit extension with wrist flexion. Free tendon grafts can be passed around the metacarpal neck volar to the intermetacarpal ligaments and attached to the lateral bands or central slip at the same time EDC tenodesis is performed to provide extension of the PIP joints with flexion of the MCP joints. Overall, intrinsic reconstruction has been shown to greatly enhance hand function and quality of life among patients with SCI and should be considered among patients with clawing or MCP joint hyperextension after flexor reconstruction due to intrinsic weakness. 51

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Future Directions More recently, nerve transfer procedures have been applied to SCI reconstruction. 52 Nerves that innervate muscles from spinal cord segments above the level of the injury and do not provide essential function can be used as donor nerves for transfer among SCI patients. Nerve transfer procedures may be time dependent, in which the recipient muscle is within the zone of injury, and time independent, in which the recipient muscle is lower than the zone of injury. 52 Nerve conduction studies and electromyography can confirm appropriate recipient and donor nerves. Nerve transfer procedures have been described to restore elbow extension, wrist extension, finger extension, and finger flexion. Donor nerves to restore elbow extension include branches of the axillary nerve to the teres minor or posterior deltoid transferred to the triceps branches of the radial nerve. 15,52–57 Nerve transfers have also been described to restore finger flexion using branches of the musculocutaneous nerve to the brachialis that are transferred to the anterior interosseous nerve. Additionally, transfer of the branches innervating either BR or ECRB have also been described for transfer to the anterior interosseous nerve to restore finger flexion, achieving up to M4 strength in most patients. 52,58 Although long-term comparative studies of outcomes between nerve transfers and traditional transfers are not yet available, these procedures provide an innovative approach to include in the armamentarium of reconstructive options for SCI.

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Summary Although surgical reconstruction remains underutilized 
 among individuals who suffer cervical SCIs, tendon and nerve transfer procedures can offer substantial gains in upper extremity function and quality of life in properly selected patients 
 (Table 73.3). Restoration of upper extremity function is consistently described as a top priority for SCI patients, and integrating surgical care into the multidisciplinary management of these 
 injuries is important to ensure that patients have access to all potential treatment options. TABLE 73.3 Summary of Reconstruction of Upper Extremity Function for Tetraplegia Available Donors

Reconstructive Priorities Wrist extension Pinch

Group 1

Brachioradialis (BR)

Group 2&3

BR, extensor carpi radialis longus (ECRL), ECRB

Group 4&5

BR, ECRL, ECRB, Pronator teres (PT), Flexor carpi radialis

Group 6&7

BR, ECRL, ECRB, PT, flexor carpi radialis, extensor digitorum communis, EPL

One-stage key pinch and release Two-stage grasp, pinch, release

One-stage grasp and pinch

Procedures BR to extensor carpi radialis brevis (ECRB) Extensor pollicis longus (EPL) and flexor pollicis longus (FPL) transfer into ECRB, FPL tenodesis, and interphalangeal fusion BR to FPL EPL tenodesis Carpometacarpal (CMC) fusion Flexor phase: BR/PT to FPL ECRL to flexor digitorum profundus Extensor: EPL, extensor digitorum communis tenodesis Thumb: BR or PT to flexor digitorum superficialis (FDS) ring CMC fusion Intrinsic: FDS lasso ECRL to flexor digitorum profundus BR/PT to FPL CMC fusion + EPL tenodesis or transfer PT/BR opponensplasty Intrinsics: FDS lasso

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Acknowledgments The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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Questions 1. A 27-year-old man with a history of SCI from a motor vehicle collision 3 years ago presents for consultation to improve his ability to power his wheelchair. On physical examination, he is able to flex his elbow and extend his wrist. He has M5 strength of biceps, brachialis, BR, extensor carpi radialis longus and brevis, and PT. He is unable to extend his elbow. Which of the following procedures would best enhance his upper extremity function? a. Wrist arthrodesis b. Abductor digiti minimi to abductor pollicis brevis transfer c. Biceps to triceps transfer d. Extensor indicis proprius to EPL transfer e. Side-to-side FDP transfer 2. A 22-year-old woman who suffered a SCI 1 year ago presents for reconstruction to optimize her hand function. She would like to have better hand control to pick up objects. On examination, she has intact elbow flexion and centralized wrist function but is unable to pronate her forearm. She has stiffness with passive motion of her digits and a pressure ulcer across her olecranon. Which of the following options is indicated to optimize her hand function? a. Directed physiotherapy for donor muscle strengthening b. Biceps to triceps transfer c. BR to FPL transfer d. Extensor carpi radialis brevis tenodesis e. Directed physiotherapy for range of motion 3. A 38-year-old man presents for consultation to improve grip approximately 2 years following SCI. On examination, he has intact elbow flexion, wrist extension and flexion, and digit extension. He has weakness with thumb extension and digit flexion. Which of the following procedures would best improve his grasp ability? a. ECRB to FDP transfer b. ECRL to FDP transfer c. FCR to FDP transfer d. BR to FDP transfer e. FDS lasso procedure 4. Which of the following physical examination maneuvers will best assess strength of BR? a. Palpation over the lateral aspect of the mobile wad with the patient abducting the arm in extension b. Palpation over the lateral aspect of the mobile wad with the patient flexing the elbow in neutral c. Palpation over the lateral aspect of the mobile wad with the patient flexing the elbow in supination d. Palpation over the lateral aspect of the mobile wad with the patient flexing the wrist in neutral e. Palpation over the lateral aspect of the mobile wad with the patient flexing the wrist in pronation 5. A 32-year-old patient who suffered a SCI 3 years earlier presents for upper extremity reconstruction. Biceps to triceps transfer to restore elbow extension is planned. The preferred technique for this tendon transfer includes the following: a. Routing the biceps tendon laterally with a supplemental tendon graft (e.g., tensor fasciae latae)

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b. Routing the biceps tendon medially c. Routing the biceps tendon medially with a supplemental tendon graft (e.g., tensor fasciae latae) d. Routing the biceps tendon laterally e. Routing the biceps tendon posteriorly through the triceps muscle 1. Answer: c. This individual has intact strength of his PT and is classified in the ICSHT group 4. Critical functions to restore in this group include elbow extension, key pinch, grasp and release, and intrinsic balancing. For this patient, biceps to triceps transfer or posterior deltoid to triceps transfer would provide strength of elbow extension to position the upper extremity in space and facilitate transfer and mobility. Wrist arthrodesis is not performed in SCI patients as it would result in the loss of tenodesis, which is critical for rudimentary key pinch, grasp, and release. Abductor digiti minimi to abductor pollicis brevis insertion at the thumb MCP joint transfer is a commonly used opponensplasty technique for patients with congenital thumb hypoplasia but would not be appropriate or possible for this patient given the level of injury. Extensor indicis proprius transfer is performed for attritional rupture of EPL but is not performed for patients with tetraplegia. Side-toside FDP transfer is performed among patients with partial innervation of FDP among group 8 patients in whom flexion of the index and long finger is preserved but not of the ring and small finger. However, this option would not be suitable given this patient’s level of injury. 2. Answer: e. This individual has intact strength of his PT and is classified in the ICSHT group 3, as she is noted to have function of her BR and wrist extensors but does not have recovery of her PT following injury. For this patient, critical functions to restore include elbow extension, forearm pronation, key pinch, and intrinsic balancing. Reconstruction of key pinch could offer this patient a greater ability to pick up objects, including a one-stage key pinch and release procedure including BR transfer to FPL, EPL tenodesis, and CMC arthrodesis. However, this patient has notable stiffness of her hand and a pressure wound across her elbow. Reconstructive options are most appropriate for patients with a pain-free upper extremity without evidence of contracture or neglect. Therefore, physiotherapy to overcome contractures, ensure appropriate pressure offloading, and support and compliance with therapy is indicated first prior to undertaking surgical reconstruction. Biceps to triceps transfer is appropriate for suitable patients to restore elbow extension which can allow patients improved reach for objects. Directed therapy for donor muscle strengthening is an important component of rehabilitation following injury but would not specifically address the wrist contractures or pressure offloading in this patient. ECRB tenodesis would not be recommended as it would reduce the ability of wrist flexion and impair tenodesis, which is critical for release of objects. 3. Answer: b. This individual has intact strength of his digital extensors, but not his thumb extensor, and is classified in the ICSHT group 6. For this patient, critical functions to restore include digit flexion and thumb flexion for grasp. BR, ECRL, and PT are available for transfer. Common transfers to restore digit flexion include ERCL to FDP or PT to FDP, and BR to FPL to FPL to restore thumb flexion with EPL tenodesis to provide balance. ECRB is not used as a donor as it provides centralized wrist extension. FCR is not commonly used as a donor tendon as its power facilitates the tenodesis effect and release. The FDS lasso procedure creates a static sling around the A1 pulley to provide improved posture among patients with intrinsic weakness and place the MCP joints in flexion. Although this procedure can facilitate grip by providing better coordination of interphalangeal joint flexion, it would not specifically address restoration of strength to the digital flexors. 4. Answer: b. BR is innervated by roots C5 and C6 via the radial nerve. It originates along the proximal aspect of the lateral supracondylar ridge of the humerus and the lateral intermuscular septum and inserts on the radial styloid. BR serves to flex the elbow with the forearm in neutral or pronation. It can be palpated lateral to the biceps tendon along the mobile wad. It is best assessed by

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placing the patient’s elbow in 90° and the forearm in neutral and asking the patient to flex the elbow. Maintaining the forearm in pronation or supination is critical to isolate the action of BR from other elbow flexors and supinators including biceps and brachialis. 5. Answer: b. Reconstruction of elbow extension is a top priority following SCI among patients without triceps strength to restore the ability to reach, power assistive devices, and facilitate independence with activities of daily living. Biceps to triceps tendon transfer is commonly performed to accomplish this after action of the brachialis is confirmed to maintain elbow flexion. The biceps tendon is routed medially and anchored to the olecranon and woven to the triceps tendon. Routing the tendon laterally is avoided to prevent injury and compression of the radial nerve. Biceps to triceps tendon transfer typically does not require supplemental tendon grafting but is needed for posterior deltoid to triceps transfer, an alternative procedure to restore elbow extension among SCI patients.

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Wangdell, J, Friden, J. Activity gains after reconstructions of elbow extension in patients with tetraplegia. J Hand Surg Am. 2012;37:1003-1010. Johnson, DL, Gellman, H, Waters, RL, Tognella, M. Brachioradialis transfer for wrist extension in tetraplegic patients who have fifth-cervicallevel neurological function. J Bone Joint Surg Am. 1996;78A:1063-1067. Mohindra, M, Sangwan, SS, Kundu, ZS, et al. Surgical rehabilitation of a tetraplegic hand: comparison of various methods of reconstructing an absent pinch and hook. Hand (NY). 2014;9:179-186. Friden, J, Reinholdt, C, Gohritz, A. The extensor pollicis longus-loop-knot (ELK) procedure for dynamic balance of the paralyzed thumb interphalangeal joint. Tech Hand Up Extrem Surg. 2013;17:184-186. Friden, J, Gohritz, A. Tetraplegia management update. J Hand Surg Am. 2015;40:2489-2500. Coulet, B, Waitzenegger, T, Teissier, J, et al. Arthrodesis versus carpometacarpal preservation in key-grip procedures in tetraplegic patients: a comparative study of 40 cases. J Hand Surg Am. 2018;43:483. Coulet, B, Boretto, JG, Allieu, Y, et al. Pronating osteotomy of the radius for forearm supination contracture in high-level tetraplegic patients: technique and results. J Bone Joint Surg Br. 2010;92B:828-834. Friden, J, Reinholdt, C, Gohritz, A, et al. Simultaneous powering of forearm pronation and key pinch in tetraplegia using a single muscletendon unit. J Hand Surg Eur Vol. 2012;37:323-328. Ward, SR, Peace, WJ, Friden, J, Lieber, RL. Dorsal transfer of the brachioradialis to the flexor pollicis longus enables simultaneous powering of key pinch and forearm pronation. J Hand Surg Am. 2006;31:993-997. Zancolli, EA. Paralytic supination contracture of the forearm. J Bone Joint Surg Am. 1967;49A:1275-1284. Gellman, H, Kan, D, Waters, RL, Nicosa, A. Rerouting of the biceps brachii for paralytic supination contracture of the forearm in tetraplegia due to trauma. J Bone Joint Surg Am. 1994;76A:398-402. Friden, J, Reinholdt, C, Turcsanyii, I, Gohritz, A. A single-stage operation for reconstruction of hand flexion, extension, and intrinsic function in tetraplegia: the alphabet procedure. Tech Hand Up Extrem Surg. 2011;15:230-235. House, JH, Gwathmey, FW, Lundsgaard, DK. Restoration of strong grasp and lateral pinch in tetraplegia due to cervical spinal cord injury. J Hand Surg Am. 1976;1:152-159.This study describes the reconstruction of grasp and pinch in 7 patients with C6 and C7 level injuries including surgical techniques for the extensor and flexor phase. All patients at follow-up reported gains in activities of daily living, social self-image, and wheelchair use and achieved an average grasp and pinch force of 5.5 and 3.0 kg. House, JH, Shannon, MA. Restoration of strong grasp and lateral pinch in tetraplegia: a comparison of two methods of thumb control in each patient. J Hand Surg Am. 1985;10:22-29. Kozin, SH, D’Addesi, L, Chafetz, RS, et al. Biceps-to-triceps transfer for elbow extension in persons with tetraplegia. J Hand Surg Am. 2010;35:968-975.This retrospective study examined the outcomes of 45 patients who underwent medial biceps to triceps transfer to restore elbow extension. The majority of patients were able to achieve elbow extension against gravity with functional overhead elbow extension. Kuz, JE, Van Heest, AE, House, JH. Biceps-to-triceps transfer in tetraplegic patients: report of the medial routing technique and follow-up of three cases. J Hand Surg Am. 1999;24:161-172. Bonds, CW, James, MA. Posterior deltoid-to-triceps tendon transfer to restore active elbow extension in patients with tetraplegia. Tech Hand Up Extrem Surg. 2009;13:94-97. Mohammed, KD, Rothwell, AG, Sinclair, SW, et al. Upper-limb surgery for tetraplegia. J Bone Joint Surg Br. 1992;74B:873-879.The authors review the outcomes of 57 patients undergoing reconstruction for elbow extension, hook grip, and key pinch. This retrospective study highlights the effectiveness of split FPL tenodesis to balance the thumb interphalangeal joint. McCarthy, CK, House, JH, Van Heest, A, et al. Intrinsic balancing in reconstruction of the tetraplegic hand. J Hand Surg Am. 1997;22:596-604. Fox, IK, Davidge, KM, Novak, CB, et al. Use of peripheral nerve transfers in tetraplegia: evaluation of feasibility and morbidity. Hand (NY). 2015;10:60-67. Fox, IK, Davidge, KM, Novak, CB, et al. Nerve transfers to restore upper extremity function in cervical spinal cord injury: update and preliminary outcomes. Plast Reconstr Surg. 2015;136:780-792. Bertelli, JA, Ghizoni, MF, Tacca, CP. Transfer of the teres minor motor branch for triceps reinnervation in tetraplegia. J Neurosurg. 2011;114:1457-1460. Bertelli, JA, Tacca, CP, Winkelmann Duarte, EC, et al. Transfer of axillary nerve branches to reconstruct elbow extension in tetraplegics: a laboratory investigation of surgical feasibility. Microsurgery. 2011;31:376-381. Bertelli, JA, Ghizoni, MF. Nerve transfers for elbow and finger extension reconstruction in midcervical spinal cord injuries. J Neurosurg. 2015;122:121-127. Bertelli, JA, Soldado, F, Ghizoni, MF, Rodriguez-Baeza, A. Transfer of the musculocutaneous nerve branch to the brachialis muscle to the triceps for elbow extension: anatomical study and report of five cases. J Hand Surg Eur Vol. 2017;42:710-714. Bertelli, JA, Ghizoni, MF. Nerve transfers for restoration of finger flexion in patients with tetraplegia. J Neurosurg Spine. 2017;26:55-61.

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CHAPTER 74

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Management of Hand Fractures Joshua M. Adkinson and Kevin C. Chung

Key Points All patients evaluated for a hand fracture should also undergo examination of the skin, tendons, and neurovascular structures. Metacarpal fractures typically assume an apex dorsal deformity, whereas proximal phalangeal fractures result in an apex volar deformity. Middle phalanx fracture deformity depends upon the location relative to the flexor digitorum superficialis insertion. Operative intervention is indicated for intra-articular incongruity, rotational malalignment, angular deformity, substantial shortening, multiple fractures, and fractures with soft tissue injury or bone loss. Select the least invasive method that will achieve satisfactory fracture reduction and stability. Prolonged immobilization will invariably lead to stiffness that may be worse than a malunion resulting from no treatment. Fractures of the hand are common, accounting for 10% of all fractures 1 and 41% of upper extremity fractures. 2 Phalanx fractures occur approximately twice as often as metacarpal fractures 2 and most commonly affect the distal phalanx. 3 The economic impact of hand fractures is substantial, and estimated lost productivity alone exceeds $2 billion per year. 4 Given the individual and societal burden of hand fractures, the ideal treatment is timely, minimizes recovery time, and expedites return to work and other activities. This chapter outlines the most common hand fracture patterns and recommended treatment options.

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Principles of Management A thorough initial history and examination are mandatory. The type of trauma will offer insight into the likelihood of associated injuries as well as any social barriers to effective treatment and an optimal outcome. The time since injury should be determined, as this may influence the timing of surgery. Patient age, hand dominance, occupation, hobbies, comorbidities, and previous hand injuries or surgical procedures should be elicited. Furthermore, the treating physician should discuss patient goals of care and, when possible, ascertain the ability to comply with postoperative instructions and therapy. The hand is then thoroughly and systematically examined for deformity, tenderness, swelling, open wounds, digital malalignment, tendon integrity, and neurovascular status. Rotational deformity may be subtle, yet clinically significant, and is evaluated through active range of motion or wrist tenodesis; all digits should point to the scaphoid without overlap or rotation (Figure 74.1). Seemingly small amounts of fracture malrotation can result in digital overlap (e.g., 5° of metacarpal rotation leads to 1.5 cm of digital overlap). 5 Range of motion assessment may be facilitated by digital or wrist neuroblockade after sensory evaluation. Three-view (posteroanterior, lateral, oblique) plain radiographs of the hand are mandatory to assess fracture anatomy and any concomitant degenerative, oncological, or rheumatological pathology. 3

FIGURE 74.1 A. Black lines indicate normal alignment of the digits, with the fingertips pointing to scaphoid (S). White line indicates malrotation and digital overlap resulting from a fracture. B. Malrotation of ring finger after proximal phalanx fracture.

Open fractures of the hand are relatively common and are at an increased risk for infection. Management consists of tetanus administration, antibiotics, irrigation, debridement, and sterile temporary or definitive (e.g., flap) coverage. 6 Definitive fracture treatment is performed when the wound is clean and stable soft tissue coverage can be ensured. Nearly all closed hand fractures can be initially managed with closed reduction and splinting. Stable, nondisplaced fractures may be definitively treated in this manner. The patient is seen within 7 to 10 days for reexamination and new plain radiographs to confirm stability and to rule out fracture displacement.

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In general, metacarpal and phalangeal fractures are adequately treated by 3 to 4 weeks of continuous immobilization and judicious use of immobilization beyond this period only for specific activities. There always exists a balance between adequate immobilization to optimize fracture healing and mobilization to counteract the inevitable onset of stiffness. Prolonged immobilization may be worse than no treatment; the duration of immobilization should be as short as possible to allow fracture healing.

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Fracture Deformity Isolated fractures of the hand lead to a relatively predictable deformity resulting from the muscles and tendons crossing the fracture site. Metacarpal fractures usually lead to an apex dorsal deformity because of intrinsic muscle pull on the metacarpal head. Proximal phalanx fractures typically result in an apex volar deformity because the intrinsic muscles flex the base and the extensor mechanism extends the distal shaft (Figure 74.2). Middle phalanx fracture deformity varies depending on location. Base fractures assume an apex dorsal deformity resulting from the pull of the central slip and the flexion moment imparted by the flexor digitorum superficialis (FDS) insertion. Middle phalanx fractures distal to the FDS insertion assume an apex volar posture because the FDS flexes the shaft and the extensor mechanism extends the distal fragment.

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FIGURE 74.2 Fracture site deformity is based on location of the fracture relative to the flexor and extensor tendons. A. Metacarpal shaft fracture. B. Proximal phalanx fracture. C. Middle phalanx fracture proximal to flexor digitorum superficialis insertion. D. Middle phalanx fracture distal to flexor digitorum superficialis insertion.

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Indications for Repair The primary goals of hand fracture management are to restore anatomic relationships, provide fracture stability with minimal soft tissue injury, and institute early motion. Whereas, most fractures can be managed nonoperatively, surgery may be warranted in the following cases 7 : Articular incongruity Digital malrotation, shortening, or angulation Multiple fractures Open fractures Fractures with soft tissue injury or bone loss The amount of tolerable deformity varies by fracture location and pattern of injury.

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Fracture Repair Techniques Fracture fixation options are dependent on fracture anatomy, associated injuries, and surgeon preference and experience. In general, fixation options include Kirschner wires (K-wires), interosseous wiring, compression screws, plating, and external fixation 8 (Table 74.1). TABLE 74.1 Comparison of Hand Fracture Fixation Techniques Technique K-wires

Advantages Easily removed, low cost, limited soft tissue damage

Compression screws Interosseous wiring Plate and screws External fixation

Rigid fixation, limited periosteal stripping needed Low profile, provides fracture site compression Rigid fixation Rapid and easy application, avoids fracture site, allows for soft tissue reconstruction

Disadvantages Need for additional immobilization, pin tract migration/infection, lack of compression at fracture site Technically demanding Technically demanding, potential wire breakage, requires soft tissue exposure Technically demanding, requires soft tissue exposure, potentially bulky and/or symptomatic hardware May not achieve anatomic reduction, pin site infection, requires removal, rarely definitive solution

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K-Wires K-wires are a commonly used and versatile fixation method for fractures of the hand. They are inexpensive and relatively easy to apply percutaneously. K-wires alone, however, do not provide rigid fixation or compression across the fracture site. 9 As such, additional immobilization may be necessary to prevent fracture fragment displacement in the postoperative period. Multiple K-wire configurations may be used depending on fracture characteristics. Importantly, a single K-wire does not impart rotational stability, and at least two K-wires should be employed to prevent fracture rotation (Figure 74.3). The crossed K-wire technique is commonly used for treatment of hand fractures. With this technique, two wires cross obliquely in an X configuration. Importantly, the K-wires should never cross at the fracture site, as this will lead to distraction of the fracture fragments and limited fracture stability. Instead, one must ensure that the wires cross proximal or distal to the fracture. Although conceptually simple, optimal application of K-wires can be technically difficult. The wire should be advanced to an appropriate bone entry site under fluoroscopic guidance. Slow, precise entry into the bone allows for trajectory modifications and the wire to gain purchase to prevent malposition during advancement.

FIGURE 74.3 Right small finger proximal phalanx transverse fracture (Seymour fracture). A. X-ray findings. B. K-wire fixation.

Tension band wiring is a modification of K-wire fracture fixation that increases construct strength. The tension band concept converts a distraction force (from the flexor tendons) into a compression force at the fracture site. In general, two 0.035- or 0.045-inch K-wires are placed across the fracture site. A 24 gauge (G) or 26G steel wire is then wrapped around the K-wires in a figure-of-eight fashion and secured away from the tendons to prevent attritional injury. This technique can enable immediate motion but requires greater soft tissue exposure than K-wires alone.

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Compression Screws Compression screws may be used for oblique or spiral fractures using the lag principle. This technique is ideal when the fracture length is at least twice the diameter of the bone. Lag screw fixation requires drilling a hole in the near cortex that is the same diameter as the outer diameter of the screw. 10 For example, when applying lag screw fixation for a metacarpal shaft fracture, a 2.0 mm drill bit is used for the near cortex. The far cortex is drilled with a 1.5 mm drill bit. The near cortex acts as a glide hole, whereas the far cortex is captured by the screw threads and leads to compression between the fracture fragments when a 2 mm screw is advanced into the drill hole (Figure 74.4). Prior to screw application, a countersink should be used to prevent screw head prominence. The procedure requires exacting technique and precise fracture reduction. Additional care should be taken when applying lag screws in the softer metaphyseal bone of the metacarpal or phalanges, where aggressive countersinking can lead to the screw head sinking into the medullary canal during tightening. Multiple screws are required to achieve anatomic reduction and impart axial stability of the construct.

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FIGURE 74.4 Technique of lag screw fixation. A. Near cortex (gliding hole) is drilled with the larger drill bit. B. The smaller drill bit is passed into the same tract and drilled in the same trajectory. C. A countersink is used to prevent screw head prominence. D. Screw length is determined. E. Multiple screws are placed to ensure fracture stability. F. A right index finger metacarpal long oblique fracture. G. Multiple screws placed using the lag technique.

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Interosseous Wiring Interosseous wiring is a technically demanding procedure that provides rigid fixation and fracture site compression. It is mainly used for transverse fractures of the phalanges or metacarpals, in joint arthrodesis, or in digital replantation. Typically, a 0.045-inch K-wire is used to create a parallel drill hole in both fracture fragments, dorsal to palmar and radial to ulnar. Alternatively, both wires can be oriented in the dorsal to palmar plane. Through this drill hole, an 18G needle is placed and used a guide for insertion of a 24G or 26G steel wire. The wire is then carefully tightened to prevent breakage.

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Plate and Screws Plate fixation provides a highly stable construct for hand fracture treatment. This technique is most commonly used for metacarpal shaft fractures and for the treatment of nonunion and malunion, where restoring length and stability are essential. Plate fixation is rarely used for phalangeal fractures because of the close relationship of the extensor mechanism to the periosteum of the underlying bone; plate fixation in the phalanges frequently leads to tendon scarring and stiffness. Conversely, the extensor tendons overlying the metacarpals do not sit directly on bone and, as such, are at low risk for adhesions after plate fixation. Dynamic compression style or standard straight plates are available for use in the hand. Compression plate holes are oblong and allow eccentric application of screws. After fixation of one fracture fragment to the plate, the first screw in the adjacent fracture fragment is placed eccentrically away from the fracture; this pulls the fragments into compression as the screw head engages the plate. Subsequent screws are placed in neutral alignment, as no further compression can be achieved with additional screws (Figure 74.5). Compared with other techniques for fracture fixation, plate and screw application requires a relatively large amount of soft tissue dissection and periosteal stripping. Scarring and plate prominence may lead to extensor tendon adhesions and impaired gliding or pain. As a result, tenolysis and/or plate removal may be needed after fracture healing.

FIGURE 74.5 Technique of compression plate application. A. Initial screw is placed in neutral position. B. The second screw is placed eccentrically away from the fracture site. C. The remaining screws are placed in neutral position as no further compression can occur through the plate. D. Right small finger metacarpal shaft fracture. E. Compression plate fixation.

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External Fixation External fixation is a relatively simple technique that is useful for fractures with substantial soft tissue injury, marked comminution, bone loss, and/or contamination. It can be rapidly applied, avoids the fracture site, and allows early mobilization. Most commonly, two percutaneous pins are placed proximal and two pins distal to the fracture site. Commercially available external fixator systems connect these pins using a bridging carbon fiber bar. Rarely is external fixation the definitive solution for hand fracture management.

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Phalanx Fractures Distal Phalanx Distal phalangeal fractures are the most common fractures in the hand. They are classified by location as tuft, shaft, and base fractures. Tuft fractures most frequently occur in combination with nail bed injuries and warrant an evaluation of the integrity of the nail plate and nail bed. A concomitant nail bed injury should be washed out and closed with fine absorbable suture. The nail plate may act as a splint for the fracture, although these injuries should be protected with an external splint for approximately 3 to 4 weeks. Tuft fractures often heal with a malunion, but these are rarely symptomatic. Nondisplaced shaft fractures may be managed with immobilization only. Displaced shaft fractures are treated by closed reduction and application of a single longitudinal K-wire. Articular fractures of the dorsal base of the distal phalanx often involve the extensor tendon insertion (i.e., mallet fracture). Most of these injuries may be managed with distal interphalangeal (DIP) joint splinting in full extension for 6 weeks. Dorsal block K-wire fixation is recommended for fractures involving more than one-third of the articular surface or in the setting of volar subluxation of the distal fragment (Figure 74.6). In children, fractures may occur through the physis and entrap a portion of the nail bed (i.e., Seymour fracture) (Figure 74.7). These fractures should be treated with extraction of the nail bed, irrigation, and K-wire fixation in a timely fashion to prevent infection and subsequent osteomyelitis.

FIGURE 74.6 Dorsal block pinning of a distal phalanx intra-articular fracture.

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FIGURE 74.7 Seymour fracture. A. Clinical findings. B. X-ray findings. C. Nail bed extracted from fracture site and repaired.

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Proximal/Middle Phalanx Condylar fractures of the proximal and middle phalanges are by definition intra-articular and are associated with development of arthritis. Phalangeal condylar fractures are classified as type I (unicondylar and nondisplaced), type II (unicondylar and displaced), and type III (bicondylar). Nonoperative management may be considered for nondisplaced fractures, but close radiographic followup is mandatory to rule out subsequent displacement. Displaced fractures are treated with closed reduction and at least two K-wires or open reduction and screw fixation. 11 Bicondylar fractures may be challenging to manage and are treated by open reduction through the interval between the central slip and lateral band with subsequent screw or K-wire fixation. Extreme care must be exercised when performing open repair of condylar fractures to avoid injury to the vascular supply arising from the attached collateral ligaments. Early motion, when possible, will limit postoperative stiffness and pain. Phalangeal neck fractures are inherently unstable. As such, the majority of these injuries are treated with K-wire fixation. Nondisplaced shaft fractures may be managed with splinting or buddy tape to an adjacent uninjured digit for 3 to 4 weeks. If malrotated or displaced greater than 10° to 25° in the sagittal plane or 10° to 15° in the coronal plane, reduction and fixation are required. Transverse or short oblique fractures are treated with K-wires or, rarely, plate fixation. Long oblique and spiral fractures are treated with interfragmentary screw fixation (Figure 74.8). The screw diameter should be less than one-third of the length of the fracture. At least two screws are recommended to impart stability to the construct. Nondisplaced phalangeal base fractures are treated with splint immobilization for 3 to 4 weeks. If displaced or associated with malrotation, open reduction and K-wire or screw fixation are warranted. Proximal interphalangeal (PIP) joint fracture-dislocations require special consideration and are discussed elsewhere in more detail. Given the articular incongruity that results from these injuries, patients frequently develop a stiff and painful PIP joint. Treatment options range from dynamic external fixation, K-wire or screw fixation, and dorsal block pinning to more complex volar plate arthroplasty and hemihamate reconstruction of the volar base of the middle phalanx.

FIGURE 74.8 Left middle finger middle phalanx oblique fracture. A. X-ray findings. B. After lag screw fixation.

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Metacarpal Fractures Head Metacarpal head fractures are rare and typically result from an axial load or dorsal fracture-dislocation of the metacarpophalangeal (MCP) joint. Computed tomography scan may better visualize the fracture pattern and assist in surgical planning. Nonoperative management is recommended for fractures with less than 25% articular involvement. For fractures with greater articular involvement, >1 mm articular incongruity, or collateral ligament instability, surgery is warranted. Fracture fragments may be small and comminuted, and extreme care must be taken to avoid stripping the vascular supply arising from the collateral ligaments. Avascular necrosis of the metacarpal head is rare but has been reported. 12 Although headless screw fixation is an optimal choice of fixation for metacarpal head fractures, most injuries are comminuted or associated with joint disruption; these injuries may be best treated by dynamic external fixation or acute arthroplasty. 13

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Neck Metacarpal neck (i.e., boxer’s) fractures are common and typically involve the fifth metacarpal. This injury often results from a punching mechanism in the amateur fighter or someone who strikes a hard object. A relatively large amount of angular deformity is acceptable in the ring and small fingers because of a mobile carpometacarpal (CMC) joint that can accommodate for palmar angulation. As a result, the majority of these injuries are managed nonoperatively. Unreduced metacarpal neck fractures with significant apex dorsal deformity may result in a prominence (metacarpal head) in the palm that is particularly bothersome to athletes and manual laborers. Nonoperatively managed patients 
 should also be counseled about the loss of the dorsal knuckle prominence. Closed reduction of a metacarpal neck fracture is accomplished using the Jahss maneuver 14 (Figure 74.9). This is most frequently carried out in the emergency department using a nerve block at the wrist. The MCP and PIP joints are fully flexed, whereas a volar force is directed against the metacarpal shaft, and a dorsal force is applied to the proximal phalanx. This combination of forces is used to lever the metacarpal head into anatomic alignment. The hand is then immobilized in an ulnar gutter splint or cast with the MCP joint in 70° of flexion for 3 weeks, followed by an active range of motion therapy program.

FIGURE 74.9 Jahss maneuver for reducing a metacarpal neck fracture.

Surgery is recommended in the setting of pseudoclawing (hyperextension of the MCP joint and concomitant PIP joint flexion with attempted digital extension), excessive shortening, and malrotation after attempted closed reduction. Surgical indications for apex dorsal deformity depend upon the involved digit (Table 74.2). The amount of tolerated angular deformity is controversial, however, and multiple studies have shown excellent outcomes with substantial angulation (up to 70° in the fifth

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metacarpal neck). Most commonly, metacarpal neck fractures are managed with percutaneous K-wire fixation and many configurations can be utilized—transverse, retrograde, and antegrade. Buried antegrade intramedullary pin application may be superior because it avoids the extensor mechanism and obviates the risk for pin tract infection (Figure 74.10). Open repair of acute metacarpal neck fractures is reserved for failed percutaneous treatment or an unacceptable closed reduction. TABLE 74.2 Acceptable Angulation for Metacarpal Fractures Digit Neck Index Middle Ring Small Shaft Index Middle Ring Small

Angulation (degrees) 10 20 30–40 50–60 10 20 30 40

FIGURE 74.10 Left small finger metacarpal neck fracture. A. X-ray findings. B. After intramedullary pinning with antegrade wires.

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Shaft Metacarpal shaft fractures may occur from an axial load, torsion, or crush. Indications for surgical management are similar to metacarpal neck fractures; however, less angular deformity is tolerated in the metacarpal shaft (see Table 74.2). Nondisplaced fractures may be treated with splinting or casting for 4 weeks with the interphalangeal joints free. Unstable or displaced fractures can be treated with percutaneous pins or open reduction and plate or lag screw fixation. The operative approach is through a dorsal longitudinal incision between the metacarpals. The juncturae may be divided to improve exposure of the fracture. External fixation is reserved for fractures with segmental loss, unstable soft tissue coverage, or contamination. Nondisplaced oblique and spiral fractures are usually unstable and are often best treated with surgery. If nonoperative management is selected, weekly radiographs should be obtained to rule out late displacement. If the fracture is obliquely oriented and the fracture length is at least twice the bone diameter, lag screws may be the best choice, although placement requires exacting technique. Percutaneous pinning may also be used for metacarpal shaft fractures, although this requires longer periods of immobilization and delayed initiation of therapy.

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Base Extra-articular metacarpal base fractures are managed similarly to shaft fractures. Most are nondisplaced and managed with immobilization for 3 to 4 weeks. If displaced or obliquely oriented, closed or open reduction and fixation is recommended. Given the substantial mobility of the thumb CMC joint, a relatively large amount of displacement is well tolerated. Reduction is indicated if the distal fragment is flexed greater than 30°, as this amount of deformity leads to compensatory thumb MCP joint hyperextension.

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Thumb (Bennett/Rolando) A Bennett fracture represents an oblique intra-articular fracture-dislocation of the thumb metacarpal base. The anterior oblique (beak) ligament is the main stabilizer of the thumb CMC joint and is responsible for maintaining the small volar ulnar fragment in anatomic alignment. The metacarpal subluxates proximally, radially, and dorsally secondary to the pull of the abductor pollicis longus, extensor pollicis brevis, and adductor pollicis, respectively (Figure 74.11). Closed reduction is achieved with a combination of thumb axial traction, abduction, and pronation (Figure 74.12). Because the fracture is inherently unstable, percutaneous pinning with K-wires is advocated. A common configuration is to place a K-wire across the articular surface perpendicular to the long access of the metacarpal into the second metacarpal base. An additional wire is placed retrograde across the trapeziometacarpal joint. If an acceptable reduction cannot be achieved with closed reduction, open reduction is performed through an incision overlying the dorsal CMC joint with plate, interfragmentary screw, or pin fixation. A Rolando fracture is similar to a Bennett fracture, except that the fracture is comminuted and characterized by a Y- or Tshaped fracture pattern.

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FIGURE 74.11 Deforming forces acting a Bennett fracture.

FIGURE 74.12 Reduction maneuver for a Bennett fracture.

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Segmental Loss Segmental bone loss is common with gunshot wounds to the hand. Self-inflicted injuries typically involve the nondominant hand. Segmental loss is often associated with open and contaminated wounds and is managed with external fixation until the wound is clean and definitive soft tissue coverage can be ensured. On occasion, the distal bone fragment collapses into the void left behind by the bone loss, given the perception of minimal soft tissue loss. However, when the distal fragment is distracted to anatomic length, the soft tissue loss becomes apparent. Bone grafting and rigid fixation is recommended during or after soft tissue reconstruction. Tendon reconstruction is typically delayed because the requisite immobilization needed to ensure bone union will lead to poor tendon glide and an unsatisfactory outcome.

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Outcomes The wide variety of hand fracture types and options for management present challenges for outcomes reporting. There is no reference standard objective or subjective outcomes measure for hand fracture management. Although radiographic assessments and functional measurements are the classic means by which management options are compared, patient-reported outcome measures have been increasingly used as they provide a greater potential understanding of the patient perception of disability and quality of life. In general, a combination of these measurements provides the clearest picture of function, pain, and disability after treatment. Radiographic outcomes typically include fracture union, residual deformity, hardware complications, or development of arthrosis, whereas functional outcomes include total active motion (Table 74.3) and grip/pinch strength. The Jebsen-Taylor Hand Function test is one of the most common functional tests performed to assess outcomes after hand fracture management. The most commonly used patient-reported outcome measures include the Disabilities of the Arm, Shoulder, and Hand, Short Form-36, and Michigan Hand Questionnaire. 15-18 TABLE 74.3 Total Active Range of Motion Result Excellent Good Fair Poor

Motion (degrees) >220 180–219 130–179 35°) and humpback deformity on the lateral projection.

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Vascularity The scaphoid is almost entirely covered by articular cartilage; it has a delicate vascular supply with greater than 70% of the scaphoid’s intraosseous vascularity from the dorsal scaphoid branches of the radial artery. These vessels enter the dorsal ridge in a retrograde direction, providing the single dominant intraosseous vessel to the proximal pole of the scaphoid. A minor volar contribution comes from the radial artery or its superficial palmar branch. 32 Because of this unique vascular anatomy, the proximal pole of a fractured scaphoid is particularly prone to avascular necrosis and nonunion, especially when the fragment is small.

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Classification At least 13 distinct schemes for classification of acute scaphoid fractures have been proposed based upon assessment by plain radiography. Schemes generally divide fractures by anatomical location, fracture plane orientation, and/or stability and displacement. 33 The most commonly cited classification scheme is the modified Herbert 34 system followed by the Russe 35 system. A summary of the modified Herbert and Russe classifications can be found in Tables 75.2 and 75.3. TABLE 75.2 Modified Herbert Classification of Scaphoid Fractures Type A1

Description Tubercle

A2

Incomplete waist

B1

Distal oblique

B2

Complete waist

Depiction

Stability Stable

Unstable

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B3

Proximal pole

B4 D1

Fracture dislocation Fibrous union

D2

Pseudoarthrosis

D3

Sclerotic pseudoarthrosis

Varies, usually waist fracture Nonacute

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TABLE 75.3 Russe Classification of Scaphoid Fractures Type D4

Description Avascular necrosis

Depiction

Stability

HO

Horizontal oblique

Most stable

T

Transverse

Intermediate stability

VO

Vertical oblique

Least stable

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Radiographic Evaluation Physical examination has a high sensitivity and low specificity for detecting acute scaphoid fractures, so radiographs including PA, lateral, pronated and supinated oblique, and scaphoid views are utilized. Approximately 20% of patients with negative radiographs have an occult acute fracture. Clinical suspicion with negative radiographs has historically been followed by immobilization in a thumb spica cast and follow-up radiographic examination at 2 weeks. This strategy still fails to detect 9% of scaphoid fractures, results in delayed fracture diagnosis, and unnecessarily immobilizes many patients. For these reasons, early advanced imaging in patients with negative plain films and suspicion for a fracture based upon history or examination findings has become increasingly popular. MRI is the most sensitive and specific imaging modality for diagnosing scaphoid fractures and also allows assessment of osseous blood supply and soft tissue injuries. Computed tomography (CT) scan reformatted in the long axis of the scaphoid is slightly less sensitive and specific for identification of scaphoid fracture, but has the advantage of superior bony detail. 36

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Operative Indications Operative indications are dependent upon fracture alignment and stability. Nondisplaced fractures may be treated with immobilization. Indications for operative management of the fractured scaphoid include 37

Greater than 1 mm of displacement at the waist Lateral intrascaphoid angle >35° Bone loss or comminution Dorsal intercalated segment instability Malalignment Any proximal pole fracture Delayed presentation is also a relative indication for surgery, as this population has an increased risk of nonunion with nonoperative treatment. Because of the scaphoid’s retrograde vascular supply, distal pole and tubercle fractures have a low incidence of nonunion and can generally be treated nonoperatively. Less invasive surgical techniques have resulted in an increased operative treatment of nondisplaced scaphoid waist fractures. Proponents cite improvements in union rate and earlier mobilization, but outcomes studies examining operative versus nonoperative management of nondisplaced scaphoid waist are inconclusive. 38

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Nonoperative Treatment Nonoperative treatment is reserved for nondisplaced scaphoid waist and distal pole fractures. Repeat images at 2 weeks are obtained to verify if alignment has been maintained. Above elbow thumb spica, short arm thumb spica and simple short arm casting have all been advocated, without conclusive evidence one method is superior. Recently, a randomized trial demonstrated better healing when the thumb is not included. 39 The duration of immobilization depends upon the patient and the location of the fracture. Distal pole and tubercle fractures generally require only 6 to 8 weeks to heal, whereas scaphoid waist fractures usually require 12 weeks. Immobilization can be discontinued when bony union has been demonstrated. We advocate CT scan to confirm healing between 10 and 12 weeks, when the fracture is no longer visible on plain radiographs.

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Open Reduction and Internal Fixation Until the mid-1980s, most scaphoid fixation was performed using Kirschner wires. In 1984, Herbert and Fisher popularized the use of headless compression screws, revolutionizing the treatment of scaphoid fractures. 40 The initial screw was not cannulated and required a jig for insertion. Subsequently, a cannulated modification (Herbert-Whipple screw) was developed, allowing insertion over a fluoroscopically targeted guidewire. 41 When there is bone loss or comminution, cancellous or corticocancellous autogenous bone graft from the distal radius can be used to fill the void and aid in healing. Fracture location often dictates the surgical approach. Because of the volar obliquity of the scaphoid axis, proximal pole fractures are more easily visualized using a dorsal approach, whereas distal pole fractures are amenable to a volar approach. Waist fractures can be addressed from either side, with advantages and drawbacks to each. A volar approach provides wide bony exposure, and facilitates correction of a humpback deformity using structural bone graft to support the collapsed volar cortex. However, the volar margin of the trapezium hinders retrograde screw placement. The dorsal approach to a scaphoid waist fracture provides an unobstructed path for screw placement, but exposure is more limited, and bone grafting for correction of a humpback deformity is more difficult from the dorsal approach. Furthermore, the dorsal location of the dominant blood supply is at risk with distal exposure. Percutaneous and mini-open techniques can be performed from dorsal or volar with minimal soft tissue and vascular disruption. 42 These approaches are best suited for nondisplaced fractures, though displaced fractures can still be treated percutaneously with the aid of joystick manipulation using Kirschner wires and arthroscopic visualization.

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Postoperative Management and Rehabilitation After surgical treatment of a scaphoid fracture, the patient is immobilized in a short arm splint with or without a thumb spica component. Finger motion is initiated immediately and the surgical dressing is changed at 2 weeks to a cast or removable brace. Some surgeons allow intermittent splint removal for light active range of motion exercises at the wrist even before bony union. Assessment of bony union is variable among surgeons, with some relying on CT scans to determine healing. Progressive wrist range of motion and strengthening is initiated following bony union.

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Outcomes Distal pole scaphoid fractures are quite vascular and in the absence of substantial displacement can be treated nonoperatively. Displaced scaphoid waist fractures are treated operatively, and the rate of union is generally thought to be approximately 90%, though this depends upon surgical technique and patient factors. Proximal pole fractures are managed with surgery, with some reports of union at 95%. 43

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Complications Nonunion is the most important adverse outcome for scaphoid fracture. The overall incidence is approximately 10%, but this rate may be elevated by delayed presentation, fracture comminution, smoking, incomplete immobilization, or errors in surgical technique. 44 Because of the retrograde nature of scaphoid vascularity, proximal pole fractures have an increased incidence of nonunion and avascular necrosis. The shortening and collapse of the scaphoid is manifested with flexion of the distal fragment and proximal scaphoid extension. When not corrected, a predictable pattern of degenerative changes known as scaphoid nonunion advanced collapse arthritis occurs. A detailed classification system and complex treatment algorithms have been developed for treatment of scaphoid nonunion. 45 Treatment principles for scaphoid waist nonunion include debridement and reduction of the fracture if necessary, rigid fixation, and bone grafting to restore the native shape and length of the scaphoid and induce osteogenesis. When nonunion is present in the absence of scaphoid flexion, screw fixation and autogenous distal radius cancellous bone grafting can be performed via a dorsal or volar approach (Figure 75.12). When a humpback deformity is present, a volar approach is recommended such that the scaphoid can be extended and then held in alignment with corticocancellous autogenous bone graft. 45

FIGURE 75.12 A. This patient presented with subacute wrist pain and radiographs demonstrated a scaphoid waist nonunion. B, C. This was treated with debridement of the nonunion, cancellous bone grafting from the distal radius, and stabilization with a headless compression screw via a volar approach.

An alternative to nonvascularized bone grafting is the use of pedicled or free vascularized bone flaps. A variety of these flaps have been applied to nonunions when decreased vascularity of the proximal fragment is suspected, and to those that have been recalcitrant to treatment with nonvascularized autograft. In theory, by bringing new blood supply to the fracture site these flaps can aid in the healing of a hypovascular fracture site. The 1,2 intercompartmental supraretinacular artery (1,2 ICSRA) flap was the first to be described, and several additional pedicled flaps from the dorsal and volar distal radius are available. 46 These are limited by their small size and diminutive vascular pedicles. As an alternative, the medial femoral condyle free flap has been popularized as a robust and reliable source of vascularized bone for treatment of scaphoid waist nonunion. 47 In cases of proximal pole nonunion with avascular necrosis, the fragment may be too small or sclerotic to allow intercalary bone grafting and fixation of the scaphoid. When this proximal fragment is unsalvageable in a young patient, replacement of the entire proximal pole including the proximal articular surface may be indicated. Options include nonvascularized osteochondral rib graft and a vascularized free medial femoral trochlea osteochondral free flap 48 (Figure 75.13). In patients who are

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older and have low functional demand and in those who have developed arthritis of the radioscaphoid joint or irreducible flexion of the distal scaphoid fragment, salvage options such as proximal row carpectomy or limited intercarpal fusion are recommended.

FIGURE 75.13 In cases of proximal pole nonunion with avascular necrosis, the fragment may be too small or sclerotic to allow intercalary bone grafting and fixation of the scaphoid. In this case, the proximal pole can be entirely resected (A), and the scaphoid reconstructed with a medial femoral trochlea osteocartilaginous free flap harvested from the knee (C). Fixation of the osteocartilaginous flap is achieved using a cannulated headless compression screw (B).

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Other Carpal Fractures Triquetral Fractures The triquetrum is the second most common carpal fracture. Dorsal rim fractures result from hyperflexion and radial deviation resulting in avulsion of the dorsal radiocarpal and dorsal intercarpal ligaments with a cortical fragment of the triquetrum. Most injuries can be treated with 3 to 6 weeks of immobilization; however, large fragments may require surgical fixation. In dorsal rim fractures with associated lunotriquetral ligament avulsion and resultant instability, the fragment can be ignored and the joint simply pinned. 49 Triquetral body fractures reflect a high-energy mechanism and are often associated with other pathology such as a greater arc perilunate dislocation. Displaced body fractures and those associated with carpal instability patterns require surgical treatment.

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Hamate Fractures Hook of Hamate Two patterns of hamate fracture present with relative frequency: fractures of the hook and hamatometacarpal fracture-dislocations. The hook of the hamate may be injured by compressive trauma during stick-and-ball sports or by avulsion at its attachment to the transverse carpal ligament. This injury may be associated with weak or painful grip due to the hook’s role as a pulley for the ring and small flexor digitorum profundus tendons, or with ulnar nerve symptoms due to irritation of the adjacent motor branch. Advanced imaging with CT scan or MRI may be required for diagnosis. Treatment of acute hook fractures is 6 to 12 weeks of immobilization. 49 Established symptomatic nonunions are treated with excision of the hook fragment.

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Hamatometacarpal Fracture-Dislocation An axial load applied to the fourth and fifth metacarpals may result in fracture of metacarpal base, extending through the carpometacarpal joint to include the dorsal hamate. The presence of a hamatometacarpal fracture-dislocation can easily be missed on a standard radiographic series, and clinical suspicion should prompt a pronated oblique film or CT scan. Treatment for these injuries may include closed immobilization, percutaneous pinning of the carpometacarpal joints, or open reduction and internal fixation. 50

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Questions 1. A 45-year-old woman presents to the emergency department with snuffbox and distal tubercle tenderness 2 hours after a bicycle accident. She is insistent upon avoiding surgery. A favorable outcome utilizing immobilization without operative intervention is most likely if her X-ray reveals scaphoid fracture of which type? a. Incomplete waist fracture b. Nondisplaced proximal pole fracture c. Nondisplaced proximal pole fracture with sclerosis d. Displaced distal tubercle fracture 2. Verification that a VLP has been placed upon the distal radius in a position that is unlikely to cause flexor tendon irritation or rupture can be best obtained using which plain radiographic view? a. PA b. Lateral c. Oblique d. Carpal tunnel view 3. Which clinical factor has not been implicated as a risk factor for radius fracture displacement after initial closed reduction and plaster immobilization? a. Dorsal comminution b. Age over 60 c. Associated fracture of the ulna d. Volar tilt of 10° 4. Dorsal bridge plating of a distal radius fracture should be strongly considered for initial management of which patient? a. 35-year-old woman with left closed intraarticular, comminuted distal radius fracture and bilateral operative femur fractures b. 95-year-old male with a right intraarticular distal radius fracture characterized by 5° of dorsal angulation, ulnar neutral variance, and 1 mm of articular step-off c. 25-year-old male pitcher with depressed fracture of the volar lunate facet d. 45-year-old woman with a heavily comminuted metadiaphyseal fracture of the left distal radius and ipsilateral segmental fractures of the second through fifth metacarpals 5. To what is the high risk of nonunion after treatment of a proximal pole scaphoid fracture attributable? a. The anterograde nature of the primary blood supply to the scaphoid, which enters volarly b. The retrograde nature of the scaphoid’s blood supply, which enters volarly c. The anterograde nature of the scaphoid’s blood supply, which enters dorsally d. The retrograde nature of the scaphoid’s blood supply, which enters dorsally 6. A 23-year-old woman comes in to the emergency department after falling off her snowboard onto an outstretched left hand. Physical examination demonstrates tenderness in the anatomic snuffbox. Initial PA, lateral, and oblique plain radiographs of the wrist demonstrate no fracture. What additional imaging is most sensitive and specific for detection of an acute scaphoid fracture? a. Immediate MRI b. Immediate CT scan c. Immobilization and follow-up plain radiography in 2 weeks d. Immobilization and follow-up plan radiography in 2 days 1. Answer: a. The modified Herbert classification scheme divides scaphoid fractures into three major

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groups: stable, unstable, and nonacute. Of the types listed above, only incomplete waist is a stable type of fracture. As such, immobilization in a thumb spica cast for up to 12 weeks will likely result in fracture union. Proximal pole fractures are at high risk for nonunion and avascular necrosis, and generally fracture of the proximal pole is considered an indication for operative fixation in order to reduce this risk. Avascular necrosis of the proximal pole occurs with a fracture that is subacute or chronic condition and may be identified following a new acute injury. However, given that acute scaphoid fractures can be easily missed, delayed detection at the time of reinjury symptom exacerbation, or radiographic examination for an unrelated complaint is not uncommon. Nonoperative treatment of a proximal pole nonunion is not recommended. Displaced scaphoid fractures, regardless of the anatomical location, are not amenable to nonoperative treatment. 2. Answer: b. A VLP should be placed distal enough that all articular fragments are stabilized by locking screws/pegs supporting the subchondral bone. However, placing the plate too distal leads to volar prominence of the distal edge of the plate putting the flexor tendons at risk for irritation or attritional rupture. As such, when possible, a VLP should be placed be positioned proximal enough that it lies entirely volar to the volar rim of the distal radius. The proximodistal position of the plate and the volar/dorsal relationship between plate and volar rim are best visualized on the lateral projection. Although proximodistal placement of the plate can be assessed to some degree on the PA, oblique views, the volar rim is easily distinguishable only on the lateral. The carpal tunnel view is not applicable to distal radius fractures, but can be used to visualize hook of hamate, pisiform, and trapezium fractures. 3. Answer: d. In a landmark 1989 study, Lafontaine et al demonstrated five clinical/radiographic predictors of distal radius fracture displacement after initial closed reduction and immobilization. These were initial dorsal angulation greater than 20°, dorsal comminution, radiocarpal intraarticular involvement, associated fracture of the ulna, and age greater than 60 years. In a larger 2006 study, Mackenney et al found that the most important predictors of fracture instability were advanced age, dorsal comminution, and the position of the fracture at presentation. Volar tilt of 10° is well within the range of normal and would not be considered a marker of fracture instability. 4. Answer: a. A dorsal bridge plate is a long, straight implant which spans the distal radius and is anchored into the radial shaft and second or third metacarpal. By unloading the radiocarpal joint and maintaining distraction across the fracture, dorsal bridge plating can provide rigid stability and maintain some degree of articular reduction via ligamentotaxis. Notably, this technique does not call for direct open manipulation of fracture fragments. For this reason, it is useful for heavily comminuted fractures wherein surgical exposure would result in unacceptable devascularization of the fragments. Additionally, because this bridging technique protects the distal radius from any axial loading, it is relatively indicated in polytraumatized patients who require early upper extremity weight bearing to facilitate lower extremity rehabilitation or transfers. 5. Answer: d. Gelberman et al demonstrated that 70% to 80% of the intraosseous vascularity (and the entire proximal pole) comes from the dorsal scaphoid branches of the radial artery, entering through the dorsal ridge. These dorsal vessels enter the scaphoid distally and course in a retrograde direction to supply the proximal pole of the scaphoid. A minor volar contribution comes from radial artery or its superficial palmar branch, which gives off several volar scaphoid branches at the level of the radioscaphoid joint, entering the bone at its distal tubercle. 6. Answer: a. Approximately 20% of patients with clinical suspicion for a scaphoid fracture and negative initial plain radiographs have an occult fracture. For this reason, patients with negative radiographs have traditionally been immobilized for 2 weeks and then sent for repeat plain radiography seeking interval displacement or resorption. Disadvantages of this strategy include the fact that is unnecessarily immobilizes many of patients and still fails to detect 9% of scaphoid fractures. In an effort to avoid these disadvantages, immediate advanced imaging has gained

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popularity. MRI is the most sensitive commonly employed modality (97.2%), followed by CT (90.7%).

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References Karl, JW, Olson, PR, Rosenwasser, MP. The epidemiology of upper extremity fractures in the United States, 2009. J Orthop Trauma. 2015;29(8):e242-e244. Swart, E, Tulipan, J, Rosenwasser, MP. How should the treatment costs of distal radius fractures be measured? Am J Orthop. 2017;46(1):E54E59. Kleinman, WB. Stability of the distal radioulna joint: biomechanics, pathophysiology, physical diagnosis, and restoration of function what we have learned in 25 years. J Hand Surg Am. 2007;32(7):1086-1106. Pechlaner, S, Kathrein, A, Gabl, M, et al. Distal radius fractures and concomitant lesions. Experimental studies concerning the pathomechanism. Handchir Mikrochir Plast Chir. 2002;34(3):150-157. Shehovych, A, Salar, O, Meyer, C, Ford, DJ. Adult distal radius fractures classification systems: essential clinical knowledge or abstract memory testing? Ann R Coll Surg Engl. 2016;98(8):525-531. Ng, CY, McQueen, MM. What are the radiological predictors of functional outcome following fractures of the distal radius? J Bone Joint Surg Br. 2011;93(2):145-150. Goldfarb, CA, Yin, Y, Gilula, LA, et al. Wrist fractures: what the clinician wants to know. Radiology. 2001;219(1):11-28. Medoff, RJ. Essential radiographic evaluation for distal radius fractures. Hand Clin. 2005;21(3):279-288. Graham, T. Surgical correction of malunited fractures of the distal radius. J Am Acad Orthop Surg. 1997;5(5):270-281. Lafontaine, M, Hardy, D, Delince, P. Stability assessment of distal radius fractures. Injury. 1989;20(4):208-210.This study examined 112 distal radius fractures treated with closed reduction and plaster immobilization. Five criteria including dorsal angulation >20, dorsal comminution, intraarticular radiocarpal fracture, associated ulnar fracture, and age exceeding 60 years were found to predict loss of reduction despite immobilization. As a result, the authors recommended close radiological surveillance and possible early fixation of fractures with three or more of these risk factors. Mackenney, PJ, McQueen, MM, Elton, R. Prediction of instability in distal radial fractures. J Bone Joint Surg Am. 2006;88A:1944-1951.Over 4000 distal radial fractures were prospectively assessed for early and late instability. Patient age, metaphyseal comminution of the fracture, and ulnar variance, but not dorsal angluation were identified as the most consistent independent predictors of radiographic outcome. Formulas to predict the radiographic outcome were constructed using these independent predictors, and can be used to inform surgical decision-making. Agee, JM. Application of multiplanar ligamentotaxis to external fixation of distal radius fractures. Iowa Orthop J. 1994;14:31-37. Fernandez, DL. Closed manipulation and casting of distal radius fractures. Hand Clin. 2005;21(3):307-316. Trumble, TE, Wagner, W, Hanel, DP, et al. Intrafocal (Kapandji) pinning of distal radius fractures with and without external fixation. J Hand Surg Am. 1998;23(3):381-394. Chia, B, Catalano, LW, Glickel, SZ, et al. Percutaneous pinning of distal radius fractures: an anatomic study demonstrating the proximity of K-wires to structures at risk. J Hand Surg Am. 2009;34(6):1014-1020. Chaudhry, H, Kleinlugtenbelt, YV, Mundi, R, et al. Are volar locking plates superior to percutaneous k-wires for distal radius fractures? A meta-analysis. Clin Orthop Relat Res. 2015;473(9):3017-3027.This is a metaanalysis of seven randomized controlled trials to determine whether patients treated with volar locking plates achieved better function, wrist motion, radiographic outcomes, or fewer complications patients treated with Kwires for dorsally displaced distal radius fractures. Patients treated with volar locking plates had slightly better early function, fewer superficial wound infections, and similar radiographic outcomes as patient treated with K-wires. The clinical significance of these differences is questionable, and both methods of fixation are still in use. Orbay, JL, Fernandez, DL. Volar fixation for dorsally displaced fractures of the distal radius: a preliminary report. J Hand Surg Am. 2002;27(2):205-215.This clinical series marks the introduction of volar locking fixation for the treatment of distal radius fractures and is the first documentation of outcomes using this technique. The authors conclude that this is a versatile technique with a favorable complication profile and is applicable to many patterns of distal radius fracture. Soong, M, Earp, BE, Bishop, G, et al. Volar locking plate implant prominence and flexor tendon rupture. J Bone Joint Surg Am. 2011;93A:328335.This study classified volar locking plates applied to the distal radius according to their degree of volar prominence on the lateral radiograph. The authors conclude that there is an increased risk of flexor tendon rupture when plates are more prominent than the volar rim, corresponding to placement beyond the watershed line. Quadlbauer, S, Pezzei, C, Jurkowitsch, J, et al. Early rehabilitation of distal radius fractures stabilized by volar locking plate: a prospective randomized pilot study. J Wrist Surg. 2017;6(2):102-112. Dy, CJ, Wolfe, SW, Jupiter, JB, et al. Distal radius fractures: strategic alternatives to volar plate fixation. Instr Course Lect. 2014;63:27-37. Azzi, AJ, Aldekhayel, S, Boehm, KS, Zadeh, T. Tendon rupture and tenosynovitis following internal fixation of distal radius fractures. Plast Reconstr Surg. 2017;139(3):717e-724e. Hanel, DP, Lu, TS, Weil, WM. Bridge plating of distal radius fractures. Clin Orthop Relat Res. 2006;445:91-99. Sammer, DM, Chung, KC. Management of the distal radioulnar joint and ulnar styloid fracture. Hand Clin. 2012;28(2):199-206. Hanel, DP, Jones, MD, Trumble, TE. Wrist fractures. Orthop Clin North Am. 2002;33(1):35-57. Desai, MJ, Kamal, RN, Richard, MJ. Management of intercarpal ligament injuries associated with distal radius fractures. Hand Clin. 2015;31(3):409-416. Placzek, JD, Boyer, MI, Gelberman, RH, et al. Nerve decompression for complex regional pain syndrome type II following upper extremity surgery. J Hand Surg Am. 2005;30(1):69-74. Mathews, AL, Chunk, KC. Management of complications of distal radius fractures. Hand Clin. 2015;31(2):205-215.

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Wall, LB, Brodt, MD, Silva, MJ, et al. The effects of screw length on stability of simulated osteoporotic distal radius fractures fixed with volar locking plates. J Hand Surg Am. 2012;37(3):446-453.This biomechanical study investigated the effect of screw length upon the stability of distal radius fractures fixed with volar locking fixation. The authors found that locked unicortical distal screws of at least 75% the AP length of the distal radius produce construct stiffness similar to bicortical fixation. They concluded unicortical distal fixation using screws of adequate length does not compromise construct integrity and should be entertained in cases of extraarticular distal radius fracture to avoid extensor tendon injury. Slutsky, DJ, Herman, M. Rehabilitation of distal radius fractures: a biomechanical guide. Hand Clin. 2005;21(3):455-468. Waljee, JF, Ladd, A, MacDermid, JC, et al. A unified approach to outcomes assessment for distal radius fractures. J Hand Surg Am. 2016;41(4):565-573. Garala, K, Taub, NA, Dias, JJ. The epidemiology of fractures of the scaphoid: impact of age, gender, deprivation and seasonality. Bone Joint J. 2016;98B(5):654-659. Freedman, DM, Botte, MJ, Gelberman, RH. Vascularity of the carpus. Clin Orthop Relat Res. 2001;(383):47-59. Berg Ten, P, Drijkoningen, T, Strackee, S, Buijze, G. Classifications of acute scaphoid fractures: a systematic literature review. J Wrist Surg. 2016;05(02):152-159. Filan, SL, Herbert, TJ. Herbert screw fixation of scaphoid fractures. J Bone Joint Surg Br. 1996;78(4):519-529. Russe, O. Fracture of the carpal navicular: diagnosis, nonoperative treatment, and operative treatment. J Bone Joint Surg Am. 1960;42A:759768. Yin, ZG, Zhang, JB, Gong, KT. Cost-effectiveness of diagnostic strategies for suspected scaphoid fractures. J Orthop Trauma. 2015;29(8):e245e252. Cooney, WP, Dobyns, JH, Linscheid, RL. Fractures of the scaphoid: a rational approach to management. Clin Orthop Relat Res. 1980;(149):9097. Ram, AN, Chung, KC. Evidence-based management of acute nondisplaced scaphoid waist fractures. J Hand Surg Am. 2009;34(4):735-738. Buijze, GA, Goslings, JC, Rhemrev, SJ, et al. Cast immobilization with and without immobilization of the thumb for nondisplaced and minimally displaced scaphoid waist fractures: a multicenter, randomized, controlled trial. J Hand Surg Am. 2014;39(4):621-627. Herbert, TJ, Fisher, WE. Management of the fractured scaphoid using a new bone screw. J Bone Joint Surg Br. 1984;66B:114-123.This clinical series marks the introduction of the headless compression screw for the treatment of scaphoid fractures and is the first documentation of outcomes using this technique. The authors document high rates of fracture union in primary and secondary cases and conclude that this device has wide applicability in the treatment of scaphoid fractures. Modern scaphoid (and other) fixation is based upon a cannulated modification of this original headless compression screw. Whipple, TL. Stabilization of the fractured scaphoid under arthroscopic control. Orthop Clin North Am. 1995;26(4):749-754. Merrell, G, Slade, J. Technique for percutaneous fixation of displaced and nondisplaced acute scaphoid fractures and select nonunions. J Hand Surg Am. 2008;33(6):966-973. Suh, N, Grewal, R. Controversies and best practices for acute scaphoid fracture management. J Hand Surg Eur Vol. 2018;43:4-12.This review article represents a current and complete collation of the evidence surrounding the diagnosis, management, and outcomes of acute scaphoid fractures. Evidence-based recommendations are included with citation of the supporting literature. Pinder, RM, Brkljac, M, Rix, L, et al. Treatment of scaphoid nonunion: a systematic review of the existing evidence. J Hand Surg Am. 2015;40(9):1797-1805. Janowski, J, Coady, C, Catalano, LW III. Scaphoid fractures: nonunion and malunion. J Hand Surg Am. 2016;41:1087-1092. Rizzo, M, Moran, S. Vascularized bone grafts and their applications in the treatment of carpal pathology. Semin Plast Surg. 2008;22(3):213-227. Jones, DB Jr, Moran, SL, Bishop, AT, Shin, AY. Free-vascularized medial femoral condyle bone transfer in the treatment of scaphoid nonunions. Plast Reconstr Surg. 2010;125(4):1176-1184. Higgins, J, Burger, H. Proximal scaphoid arthroplasty using the medial femoral trochlea flap. J Wrist Surg. 2013;2(3):228-233. Pan, T, Lögters, TT, Windolf, J, Kaufmann, R. Uncommon carpal fractures. Eur J Trauma Emerg Surg. 2016;42(1):15-27. Kim, JK. A novel hamatometacarpal fracture-dislocation classification system based on CT scan. Injury. 2012;43(7):1112-1117.

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CHAPTER 76

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Flexor Tendon Repair and Reconstruction Xuan Qiu and Kevin C. Chung

Key Points Complete flexor tendon lacerations should be repaired early (preferably within 7 days of injury). Flexor tendon undergoes both intrinsic and extrinsic healing after repair. At least four-strand core sutures placed 1 cm from the tendon ends should be used to repair flexor tendon lacerations. Epitendinous sutures augment flexor tendon repair strength. Early protective motion improves the functional outcome of flexor tendon repair. Shortening of a single digit flexor digitorum profundus tendon more than 1 cm should be avoided to prevent the quadriga effect. Finger flexion is powered by the actions of extrinsic and intrinsic muscles of the hand across multiple joints. Flexor tendon injuries result in loss of finger flexion and impair power grip. These injuries are often a result of penetrating trauma to the volar aspect of the fingers, palm, wrist, or forearm. Avulsion of flexor digitorum profundus insertion at the base of the distal phalanx, or degenerative flexor tendon tears in systemic inflammatory conditions such as rheumatoid arthritis, can also result in loss of finger flexion. Management of flexor tendon injuries can be challenging, especially those within the fibrous digital sheath, because of the tendency for peritendinous adhesion formation after surgery, which discourages smooth gliding and prevents normal range of motion of the fingers. The evolution of treatment for flexor tendon injuries has exemplified how clinical practice has been driven by our understanding of the molecular biology and biomechanics of tendon healing from basic science and clinical research to ultimately overcome the challenges in managing these conditions. Recent advances in surgical techniques, suture design, and postsurgical rehabilitation protocols have made flexor tendon repair and reconstruction more satisfactory to both the patient and surgeon.

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Anatomy There are nine flexor tendons in the hand. The flexor pollicis longus (FPL) controls thumb flexion; the flexor digitorum profundus (four FDP) and flexor digitorum superficialis (four FDS) control finger flexions. The flexor tendon muscles originate from the volar proximal to mid forearm, and distally their tendons enter the carpal tunnel before continuing to insert on the palmar aspect of the fingers. The contraction of the flexor tendon muscles leads to flexion of the fingers to make a composite fist; the distal tendon insertions determine the level of flexion (Table 76.1). TABLE 76.1 Flexor Tendon Muscles Muscles Flexor pollicis longus (FPL)

Flexor digitorum profundus (FDP)

Flexor digitorum superficialis (FDS)

Description Origin: radial shaft and interosseous membrane Insertion: base of the distal phalanx of the thumb Innervation: anterior interosseous branch of the median nerve (AIN) Action: flexion of the interphalangeal (IP) joint of the thumb Origin: proximal ulna and the interosseous membrane Insertion: base of the distal phalanx of index, middle, ring, and small fingers Innervation: AIN for the index and middle fingers; ulnar nerve for the ring and small fingers Action: flexion of the distal interphalangeal (DIP) joint Origin: ulnar head from medial humeral epicondyle, the ulnar collateral ligament, and the coronoid process; radial head from proximal radius Insertion: palmar aspect of the middle phalanx Innervation: median nerve Action: flexion of the proximal interphalangeal (PIP) joints

Unlike the FDP tendons that spread to the fingers in the same coronal plane at the wrist and forearm, the FDS tendons are stacked in two layers, with the more superficial tendons inserting onto the middle and ring fingers, and the deeper tendons inserting onto the index and small fingers, respectively. Additionally, each FDS tendon divides into two slips, radial and ulnar, to wrap around the FDP tendon to continue distally on the dorsal aspect of the FDP tendon. They reunite at the Camper chiasm before dividing again into two slips to insert onto the palmar aspect of the middle phalanx (Figure 76.1).

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FIGURE 76.1 Anatomy of flexor tendons. (Reproduced with permission from Machol, JA IV, Chen, NC, Eberlin, KR. Acute repair of flexor tendon injuries. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 6, Figure 37-1a.)

The FDS and FDP tendons within the flexor tendon sheath receive nutritional supply and eliminate wastes by two ways: vascular perfusion and synovial diffusion. The direct arterial supply to the flexor tendons comes from the well-developed vincular system, which takes off the common digital arteries and continues to the dorsal aspect of the tendon (Figure 76.2). The palmar aspect of the tendon is relatively avascular, and the paratenon promotes material exchange by means of diffusion. 1

FIGURE 76.2 Vascularity of flexor tendons.

The flexor tendons are covered by a thin layer of fibroblasts known as the epitenon, which is surrounded

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by a synovial sheath. The membranous inner component of the sheath provides a smooth gliding surface in addition to secreting synovial fluid rich in hyaluronic acid, 2 which provides both lubrication and nutrition. The outer component of the sheath is the retinaculum, which condenses into fibrous bands of tissue that forms a fibro-osseous tunnel on the palmar surface of the fingers to restrain the flexor tendons close to the adjacent bone or joint. These fibrous bands are known as the pulleys (Figure 76.3A). They are named based on the orientation of their fibers, including annular (A) and cruciate (C) pulleys. The thumb has its own pulley system, which includes two annular pulleys, A1 and A2, separated by an oblique pulley which is the most important one in the thumb (Figure 76.3B). 3

FIGURE 76.3 Pulley systems of the fingers (A) and thumb (B). (A. Reproduced with permission from Machol, JA IV, Chen, NC, Eberlin, KR. Acute repair of flexor tendon injuries. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 6, Figure 37-1B.)

In the fingers, the A pulleys are numbered A1 through A5, and the C pulleys are numbered C1 through C3. The A2 and A4 pulleys originate from the periosteum of the proximal and middle phalanx, respectively. They are the most important pulleys in maintaining grip power and preventing bowstringing of the flexor tendons during active finger flexion. The A1, A3, and A5 pulleys arise from the volar plate of the metacarpophalangeal (MCP), proximal interphalangeal (PIP), and distal interphalangeal (DIP) joints, respectively. They prevent bowstringing of the flexor tendons across these joints during active finger flexion. The A1 pulley is the most commonly affected pulley in trigger fingers and usually divided during trigger finger release. The more flexible cruciate (C1–C3) pulleys are located inbetween the annular pulleys and in close proximity with the joints. They function to accommodate full flexion and

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extension of the joints without significant collapse or expansion of the adjacent annular pulleys during finger motion.

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Clinical Evaluation Evaluation of patients with possible flexor tendon injuries should begin with a detailed history to determine the mechanism and timing of the injury. The position of the hand and fingers at the time of injury, and the presence of a soft tissue mass on physical examination, can often provide a clue on where the proximal end of the lacerated tendon is located. The location and extent of skin injuries should be carefully assessed. Any notable deformity suggests underlying bone or ligamentous injury, which may require manipulation or reduction. Plain radiographs can help confirm bone or joint abnormalities as well as the presence of a foreign body. Local anesthetics or sedation should be held until after a careful neurovascular examination. Loss of sensation to light touch and two-point discrimination in a digital nerve distribution suggest nerve transection. Delayed capillary refill or an abnormal digital Allen test suggests a digital artery laceration, which can also be confirmed with a Doppler. Flexor tendon injury can lead to loss of the active finger flexion, normal finger cascade, resting flexor tone resulting in extension posturing, and tenodesis effect. The tenodesis effect is the phenomenon of finger flexion when the wrist is passively extended. Individual fingers should be examined to determine the integrity of the FDS and the FDP tendons. Active finger flexion at the PIP joint while adjacent digits are held down in full extension at the MCP, PIP, and DIP joints indicates that the FDS tendon is intact. Active finger flexion at the DIP joint while the finger is held in full extension at the middle phalanx indicates that the FDP tendon is intact (Figure 76.4). Similarly in the thumb, active flexion at the IP joint indicates that the FPL tendon is intact. Partial tendon injury can manifest as pain with active finger flexion. These injuries are either repaired if the laceration involves more than 50% of the cross-sectional area or debrided if the involvement is less than 50% of the cross-sectional area to minimize catching during finger range of motion. 4

FIGURE 76.4 Physical examination of flexor tendons. A. FDS. B. FDP.

Flexor tendon injuries are classified into five anatomic zones (zone 1 through zone 5) based on location (Figure 76.5). 5 Zone 1 is the area distal to the insertion of the FDS tendon, i.e., only involving the FDP tendon. Zone 2 describes the area within the flexor tendon sheath distal to the A1 pulley but proximal to the FDS insertion; therefore, injuries within this zone can potentially compromise both the FDS and the FDP tendons. Historically Zone 2 injuries were challenging to manage because of the complex anatomy and the high likelihood of complications after repair, earning Zone 2 the name of no man’s land. 6 Zone 3 describes the area in the palm distal to the carpal tunnel. Zone 4 is the area within the carpal tunnel. Zone 4 tendon injury is rather uncommon because the overlying trapezium and hamate prominence shield the tendons in this zone from laceration. Zone 5 is the area from the proximal muscle-tendon junction to the

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carpal tunnel.

FIGURE 76.5 Flexor tendon zones of injury. (Reproduced with permission from Wiesel, SM. Operative Techniques in Orthopaedic Surgery. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2010. Figure 56-1a.)

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Management The treatment goal of a flexor tendon injury is to restore a strong and smooth construct such that a rehabilitation protocol can promote tendon gliding and minimize peritendinous adhesion, and ultimately restore normal motion of the finger. Sometimes this requires partial excision of the FDS tendon to decrease the repair bulk, 7,8 or partial release of the adjacent pulleys. 9 Any fresh open wounds in the hand noted during initial examination should be thoroughly irrigated with sterile saline. A dose of firstgeneration cephalosporin should be administered if there is no contraindication. Tetanus prophylaxis should also be provided to the patient if not up-to-date. In the setting of vascular compromise to the digit with concomitant flexor tendon injury, emergency wound exploration and microvascular repair or reconstruction to restore digital perfusion are indicated, and the lacerated flexor tendons can be repaired at the same time. Otherwise definitive repair of flexor tendon laceration can be scheduled within 7 days of the injury. The injured finger and the wrist should be splinted in slight flexion to prevent further proximal migration of the proximal end of the lacerated tendon. Beyond 6 weeks, the primary repair of flexor tendon is unlikely to succeed because of myostatic contracture of the lacerated tendon and swelling of the tendon ends that do not permit tendons to be retrieved through the pulleys. In the cases of delayed presentation, the surgeon should be prepared for conducting two-stage tendon reconstruction or primarily tendon grafting if the wound bed is not too scarred. Early animal studies suggested that tendon healing required adhesion formation, characterized by infiltration of fibroblasts and capillary buds, which came from the surrounding synovial sheath. 10-12 However, later experiments demonstrated the alternative intrinsic tendon healing without adhesion formation. This was illustrated in an elegant study in which repaired tendon bathed in the synovial fluid of a rabbit knee healed without extrinsic blood supply. 13 This intrinsic tendon healing undergoes three phases of wound healing: inflammation, neovascularization, and remodeling. The earliest stage is characterized by an increase in the inflammatory cells including macrophages 14 and their mediators such as interleukins and matrix metalloproteinases. 15 During tendon healing, neovascularization occurs to bring necessary nutrients for tendon repair and healing, 16 with concomitant early rise of vascular endothelial growth factor 17 and integrin family of cell adhesion receptors. 18 Eventually new collagen formation and reorientation of the collagen fibers restore the tendon morphology and synovial sheath anatomy. 19 Several factors affect the quality of the flexor tendon repair. Core sutures are those that traverse the main substance of the tendon for coaptation of the repair site. There are different techniques of core suturing, from the classic two-stranded Tajima to the simple four-stranded Strickland and cruciate, and to the more complex multi-stranded Modified Becker/Massachusetts General Hospital (MGH) suture repair (Figure 76.6A–C). Biomechanical studies have shown that increasing the suture caliber can increase the tensile strength at the repair site. 20 Similarly, an increased number of core strands also increases repair strength 21 (Table 76.2). 22 Of the two parameters, the core strand number is more important than suture caliber in terms of increasing repair site strength. 23 Based on these data, a nonabsorbable suture, 3-0 to 4-0 depending on the size of the tendon to be repaired, should be placed at 1 cm from the cut edges to provide at least 4-strand core sutures across the repair site to ensure the approximation of the tendon ends for optimal healing. 24 Moreover, locking core suture loops are stronger than grasping loops, 25 and the location of the core suture knot, inside or outside of the repair site, has not been shown to affect the repair site strength. 26

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FIGURE 76.6 Flexor tendon repair. Core sutures: Tajima (A), cruciate (B), and modified Becker/MGH (C). D. Epitendinous suture. (Reproduced with permission from Machol, JA IV, Chen, NC, Eberlin, KR. Acute repair of flexor tendon injuries. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. A. Part 6, Figure 37-Tech Fig 3. B. Part 6, Figure 37-Tech Fig 5. C. Part 6, Figure 37-Tech Fig 6. D. Part 6, Figure 37-Tech Fig 7a.)

TABLE 76.2 Estimated Repair Strength Without an Epitendinous Suture Type of Repair Two-strand Four-strand Six-strand

0 weeks 1800 g 3600 g 5400 g

1 week 900 g 1800 g 2700 g

3 weeks 1200 g 2400 g 3600 g

6 weeks 2200 g 4200 g 6500 g

Reproduced with permission from Strickland, JW. Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg. 1995;3:44-54. Epitendinous sutures are those that are placed on the superficial aspect of the repair site circumferentially to smoothen the edges for improved gliding and repair site strength (Figure 76.6D). Deeply placed epitendinous sutures provide better repair strength compared to those placed superficially. 27 Epitendinous sutures placed further from the cut edges also improve the tensile strength at the repair site. 28 Therefore, epitendinous sutures for Zone 2 are recommended in addition to the core sutures to augment the repair with a 6-0 nonabsorbable material placed at 2 mm from the cut edges and 2 mm deep. This combination of the core and epitendinous sutures is placed to minimize the gap formation at the repair site, as studies have shown that a gap less than 3 mm is the critical gap to facilitate adequate healing of the tendon and increased repair strength with time. 29 Shortening of the FDP tendon by more than 1 cm is undesirable because of the quadriga effect, when increased tension in the repaired tendon leads to flexion lag and weakened grip in the adjacent fingers, because the FDP tendons share a common muscle belly whose excursion is defined by the shortest tendon. Specific considerations are required for injuries in the different zones. Zone 1 flexor tendon avulsions are further classified into type I through type III by Leddy and Packer (Figure 76.7). 30 In type I

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avulsion, the FDP tendon retracts into the palm with disruption of the vincular system, and thus needs urgent repair within 2 weeks from the time of injury. In type II avulsion, the FDP tendon retracts to the level of the PIP joint, and can be repaired within 6 weeks from the time of injury, because of preservation of some of the vincular blood supply. Type III injuries usually do not retract proximal to the A4 pulley because of a large bony fragment; these may be repaired with a Kirschner wire or a screw. Pure tendon lacerations in Zone 1, on the other hand, may require tendon-to-bone repair with or without a button if the distal stump is less than 1 cm in length, otherwise it can be repaired primarily. In delayed presentation of Zone 1 injuries outside of the time window for repair, DIP arthrodesis can be considered in the setting of intact FDS function, understanding that the overall grip strength will be decreased.

FIGURE 76.7 Leddy classification of Zone 1 flexor tendon injuries.

Zone 2 flexor tendon injuries are more challenging because of the complex anatomy in this area. Care

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should be taken to preserve the A2 and the A4 pulleys when the lacerated tendons are passed through them during the repair. The FDP tendon should be carefully pulled through the FDS tendons if it retracts proximal to the chiasm. The proximal end of the FPL laceration in Zone 2 may retract to the thenar musculature or even more proximally, which requires extension of the incision to the thenar eminence, or a separate incision in the carpal tunnel or distal forearm, respectively. Milking the digit from proximal to distal and wrist and MCP flexion can help to deliver the proximal tendon end near the laceration. If the proximal FPL tendon cannot be retrieved readily, we prefer to make an incision at the wrist, radial to the FCR tendon to find the proximal tendon end. A small feeding catheter is threaded into the sheath, taking great care not to create a false path. The proximal tendon is then sutured to the catheter, which is used to guide the tendon through the sheath. After tendon repair, gentle range of motion of the finger can detect repair site gapping or catching at the edge of a pulley. Flexor tendon injuries in Zones 3, 4, and 5 are repaired with similar techniques as those used in Zone 2 injuries, although epitendinous sutures may not be necessary because there is more room in these zones for tendon excursion, which decreases the intensity of the adhesions. Furthermore, multiple structures are cut in these zones, which require expedient repairs to keep the tourniquet time within 2 hours. Repairs in Zones 3, 4, and 5 have less adhesion formation and better prognosis. Microsurgery may be needed for concomitant nerve or arterial injuries at the time of tendon repair.

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Rehabilitation and Outcomes After successful flexor tendon repair, a dorsal blocking splint is applied to maintain the wrist flexion at 20° to 30°, the MCP joint flexion at 50° to 70°, and PIP and DIP joints in full extension. Animal studies have demonstrated that early protective motion promotes tendon healing. 31 The strength of the repair determines the type of postoperative motion therapy. Studies have concluded that at least four core strands are needed to create a strong enough repair to withstand the strain across the repair site from light active motion (Figure 76.8). 22 Therapy should begin within a week of the surgery under the guidance of an experienced hand therapist. Early motion rehabilitation protocol in the appropriate patients helps to decrease intrasynovial adhesion formation and prevent digital stiffness.

FIGURE 76.8 Estimated strength to failure (in grams) for flexor tendon repairs with epitendinous sutures. (Reproduced with permission from Strickland, JW. Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg. 1995;3:44-54.)

It has been well accepted that 3 to 5 mm of tendon excursion sufficiently prevents adhesion formation in Zone 2 repairs. 32 Within this range, increased tendon excursion does not affect the tensile properties of the repair site. 33 Similarly, increasing the level of applied force during rehabilitation does not affect the ultimate strength of the repaired tendon. 34 A prospective randomized clinical trial demonstrated that the active place-and-hold therapy improved finger active range of motion, compared to passive motion therapy, although functional outcome scores were similar in both groups. 35 More rigorous active finger range of motion starts at 3 to 4 weeks postoperatively. The protective dorsal splint is eventually discontinued around 6 to 8 weeks postoperatively. Individual digit strengthening is gradually introduced at 10 weeks after surgery, and the patient may return to normal activities at 4 to 6 months after surgery. In pediatric patients and those who are unable to safely participate in an early motion rehabilitation program, cast immobilization for 4 to 6 weeks is used to protect the repair. The cast is applied to maintain the wrist in neutral, MCP joints at 70° of flexion, and IP joints in extension. Careful initiation and progression of range-of-motion exercises with frequent monitoring are critical to achieve a

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good outcome. Outcomes of flexor tendon repair surgery depends on multiple factors, including severity of initial injury, timing and quality of the repair, patient’s underlying medical conditions that may affect tendon healing, and the quality of postoperative rehabilitation. Majority of Zone 1 and Zone 2 repairs have good to excellent outcomes, almost all Zone 3, 4, and 5 repairs have good to excellent outcomes.

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Complications The most common complication after flexor tendon repairs is finger stiffness, which can be a result of either tendon adhesion or IP joint contractures. Other complications, such as infection, skin flap necrosis, and tendon rupture after repair, can also occur. These complications adversely affect the outcome and should be addressed promptly. Peritendinous adhesion can happen with crush injuries, inflammatory conditions, fractures, excessive surgical manipulation during primary repair, tendon grafting, poor postoperative rehabilitation, and wound complications. Based on the American Society for Surgery of the Hand guidelines, 36 the postoperative total active motion (TAM) of the digit can be determined using the following formula:

A grading system categorizes the functional outcome based on the postsurgical TAM as a percentage of the normal TAM of 260°. An excellent outcome is the recovery of 100% of the normal TAM; a good outcome is the recovery of more than 75% of the normal TAM but less than 100%. A recovery of less than 75% but more than 50% is considered fair, and anything less than 50% is considered poor. At 4 to 6 months after the flexor tendon repair surgery, if a patient’s digit function is no longer improving with occupational therapy and there is still substantial limitation in the active motion but passive motion has been restored, tenolysis followed by immediate mobilization may release the adhesion and help to gain full or near full active range of motion. However, tenolysis is a complicated procedure that can result in neurovascular injury, worsening stiffness, and even tendon rupture; therefore, it should be recommended only for patients with fair or poor outcomes. These risks should be thoroughly discussed with the patient preoperatively. Similarly, IP joint contractures are initially managed with passive stretching exercises and static progressive splinting. Beyond 4 to 6 months after the index procedure, joint releases to correct the contractures can be considered. Rupture within the first 3 weeks of the initial tendon repair warrants an attempt for repeat repair, which has reasonable success. If the rupture occurs more than 3 weeks after the primary repair, tendon reconstruction should be considered.

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Tendon Reconstruction Single-stage flexor tendon grafting can be used to reconstruct flexor tendon injuries that have significant segmental tendon loss or damage, or those that present late and outside of the time window for primary repair, or ruptures that occur after primary repair but are not amenable to repeat repair. Graft donor sites include the palmaris, plantaris, long toe extensors, extensor indicis proprius and extensor digiti minimi, and toe flexors. Alternatively, the proximal FDS or FDP tendon can be used as a graft depending on which motor source the surgeon chooses to keep to power the tendon graft. Patients with extensive scarring, joint contractures not responsive to aggressive hand therapy, and incompetent pulleys need two-stage reconstruction. The first stage in the two-stage reconstruction includes the placement of a silicone tendon implant in the flexor tendon sheath, repair and/or reconstruction of the pulley system over the implant, and scar and joint contracture release. This process promotes the formation of a pseudosheath over the silicone implant in the next 3 months. During the second stage of the procedure, a tendon graft is passed through the pseudosheath to replace the implant. For either single-stage or two-stage flexor tendon grafting, the tendon graft is first repaired to the distal phalanx either directly to the FDP tendon stump, or with a pull-through suture to secure the distal stump in a drill hole in the distal phalanx and the suture tied over a button on top of the nail. After appropriate tensioning, the proximal end of the tendon graft is repaired to the motor unit proximally to the remnant FDS or FDP tendon stump. Early motion rehabilitation under close supervision of an experienced hand therapist can be initiated in a similar fashion as that for primary repair, provided that the graft junctures are strong. In summary, flexor tendon injuries require early intervention. Understanding the biology of tendon healing and the mechanics of the repair methods can direct treatment to improve functional outcomes. A strong repair of the tendon ends with at least four-strand core sutures and an epitendinous suture minimizes gap formation and creates a coaptation that tolerates early protective motion therapy to promote healing and decrease adhesion formation. Chronic injuries are treated with tendon reconstruction. Appropriately setting tension of the repair or reconstruction prevents the quadriga effect. Modern surgical techniques, suture design, and postsurgical rehabilitation protocols have led to satisfactory outcomes in these otherwise challenging injuries.

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Questions 1. A 20-year-old male presents at about 3 weeks after accidentally cutting his right index finger at the distal interphalangeal joint. His clinical photo at presentation and initial radiographs are shown in Figure 76.9. Upon finger exploration the distal tendon stump appeared to be 0.5 cm, and the proximal tendon stump was found within the A4 pulley. Which of the following best describes his injury and the treatment? a. Zone 1 Leddy type 1 injury, primary repair with four-strand core sutures and an epitendinous suture b. Zone 1 Leddy type 2 injury, tendon-to-bone repair with nonabsorbable sutures tied over a button c. Zone 1 Leddy type 3 injury, tendon-to-bone repair with a suture anchor d. Zone 2 injury, primary repair with four-strand core sutures and an epitendinous suture e. Zone 2 injury, two-stage reconstruction 2. A 7-year-old girl presents with a laceration to the left index finger that occurred about 5 days previously. Resting hand posture, initial radiographs, and photos from surgical exploration of the finger are shown in Figure 76.10. What is the best treatment for her? a. Tendon debridement b. Tendon-to-bone repair with nonabsorbable sutures tied over a button c. Primary repair with at least four-strand core sutures and an epitendinous suture d. Single-stage reconstruction with a tendon graft e. Two-stage reconstruction with a silicone rod followed by a tendon graft 3. A 32-year-old man presents with a nonfunctioning right small finger from an injury at the proximal interphalangeal joint about 5 months ago. The clinical photo at presentation is shown in Figure 76.11A, and Figure 76.11B–D are pictures from the surgical exploration of the finger, showing the intact and competent tendon sheath. What is the best treatment for him? a. Tendon excision b. Tendon-to-bone repair of the injured tendon using a suture anchor c. Primary repair with at least four-strand core sutures and an epitendinous suture d. Single-stage reconstruction with a tendon graft e. Two-stage reconstruction with a silicone rod followed by a tendon graft 4. A year after the surgery, the patient in question 3 developed loss of grip in his right small finger. He is able to fully extend the small finger. However, when he attempted to make a fist, the proximal and distal interphalangeal joints of the small finger extend instead. What is the likely cause of this condition and what is the best treatment for him? a. Adhesion causing stiffness; hand therapy and progressive static splinting to gain flexion b. Rupture of the central slip; extension splinting at the proximal interphalangeal joint c. Attritional rupture of the small finger FDP in the palm; end-to-side repair to the adjacent ring finger FDP tendon d. Quadriga effect; tendon lengthening e. Progressive laxity in the tendon graft; lumbrical release

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FIGURE 76.9 Clinical photo and radiographs.

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FIGURE 76.10 Clinical and intraoperative photos, and radiographs.

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FIGURE 76.11 Clinical and intraoperative photos.

1. Answer: b. The clinical history, location of the laceration and proximal tendon stump, and the lack of bony fragment on the radiographs suggest that this was a Zone 1 Leddy type 2 injury of the FDP. The distal tendon stump was too short for primary repair, and therefore the best treatment was a tendon-to-bone repair, which could be achieved with nonabsorbable sutures tied over a button or

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using a suture anchor. 2. Answer: c. The intraoperative photos suggest that this was an acute Zone 2 flexor tendon injury with complete laceration of the FDP tendon, possibly also the FDS tendon. Tendon debridement is only indicated for lacerations less than 50% of the tendon. Tendon-to-bone repair with nonabsorbable sutures tied over a button is usually used to repair a Zone 1 injury. Tendon reconstructions are used for more chronic injuries. This acute flexor tendon injury is best treated by primary repair using at least four-strand core sutures and an epitendinous suture. 3. Answer: d. The clinical history and initial clinical photo suggest that this was a Zone 2 flexor tendon injury involving both the FDP and FDS. Tendon excision will not restore finger flexion. Tendon-to-bone repair with a suture anchor is usually used to repair a Zone 1 injury. The chronicity of the injury makes the primary repair not appropriate because of degeneration of the tendon ends, retraction of the proximal tendon stump, and scarring of the soft tissue. The intraoperative photos demonstrate a competent pulley system, so the best treatment option among the choices is a singlestage reconstruction with a tendon graft. Two-stage reconstruction is used when the tendon sheath is so severely scarred that passing of a tendon graft is impossible. 4. Answer: e. The clinical scenario describes a lumbrical-plus finger, characterized by paradoxical extension of the interphalangeal (IP) joints with active finger flexion, likely from progressive lengthening of the tendon graft over time in this case. The lumbricals originate from the profundus tendons and extend the IP joints while flex the metacarpophalangeal joints through pulling the lateral bands. When there is laxity in the FDP tendon, the power of the proximal flexor muscle cannot effectively pull the finger into flexion, and the lumbrical is pulled instead, causing extension of the IP joints. The best treatment therefore is lumbrical release. Adhesions will not result in paradoxical IP joint extension. Central slip rupture causes a Boutonniere deformity characterized by PIP flexion and DIP extension. Attritional rupture of the small finger FDP can lead to a loss of finger flexor; however, it will not result in paradoxical IP joint extension. The quadriga effect is a result of over shortening of the FDP tendon during repair, limiting the ability of the adjacent fingers to fully flex, because the FDP tendons to the long, middle, ring, and small fingers share a common muscle belly and the shortest tendon determines the overall excursion.

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Acknowledgments The work was supported by a Midcareer Investigator Award in Patient-Oriented Research (2 K24AR053120-06) to Kevin C. Chung. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.

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References Lundborg, G, Myrhage, R, Rydevik, B. The vascularization of human flexor tendons within the digital synovial sheath region – structural and functional aspects. 
 J Hand Surg. 1977;2(6):417-427. Hagberg, L, Tengblad, A, Gerdin, B. Hyaluronic acid in flexor tendon sheath fluid after sheath reconstructions in rabbits: a comparison between tendon sheath transplantation and conventional two stage procedures. Scand J Plast Reconst Surg Hand Surg. 1991;25(2):103-107. Doyle, JR, Blythe, WF. Anatomy of the flexor tendon sheath and pulleys of the thumb. J Hand Surg. 1977;2(2):149-151. Chow, SP, Yu, OD. An experimental study on incompletely cut chicken tendons – a comparison of two methods of management. J Hand Surg. 1984;9(2):121-125. Verdan, CE. Half a century of flexor-tendon surgery: current status and changing philosophies. Bone Joint Surg Am. 1972;54(3):472-491. Bunnell, S. Surgery of the Hand. 2nd ed. Philadelphia, PA: JB Lippincott; 1948. Tang, JB. Flexor tendon repair in zone 2C. J Hand Surg. 1994;19(1):72-75. Zhao, C, Amadio, PC, Zobitz, ME, An, KN. Resection of the flexor digitorum superficialis reduces gliding resistance after zone II flexor digitorum profundus repair in vitro. J Hand Surg. 2002;27(2):316-321. Kwai Ben, I, Elliot, D. “Venting” or partial lateral release of the A2 and A4 pulleys after repair of zone 2 flexor tendon injuries. J Hand Surg. 1998;23(5):649-654. Mason, ML, Allen, HS. The rate of healing of tendons: an experimental study of tensile strength. Ann Surg. 1941;113(3):424-459. Potenza, AD. Tendon healing within the flexor digital sheath in the dog. Bone Joint Surg Am. 1962;44-A:49-64. Potenza, AD. Critical evaluation of flexor-tendon healing and adhesion formation within artificial digital sheaths. Bone Joint Surg Am. 1963;45:1217-1233. Lundborg, G. Experimental flexor tendon healing without adhesion formation – a new concept of tendon nutrition and intrinsic healing mechanisms: a preliminary report. Hand. 1976;8(3):235-238.Elegant animal study to demonstrate intrinsic healing of tendons. Gelberman, RH, Vandeberg, JS, Manske, PR, Akeson, WH. The early stages of flexor tendon healing: a morphologic study of the first fourteen days. J Hand Surg. 1985;10(6 Pt 1):776-784. Berglund, M, Hart, DA, Wiig, M. The inflammatory response and hyaluronan synthases in the rabbit flexor tendon and tendon sheath following injury. J Hand Surg Eur Vol. 2007;32(5):581-587. Gelberman, RH, Khabie, V, Cahill, CJ. The revascularization of healing flexor tendons in the digital sheath: a vascular injection study in dogs. Bone Joint Surg Am. 1991;73(6):868-881. Boyer, MI, Watson, JT, Lou, J, et al. Quantitative variation in vascular endothelial growth factor mRNA expression during early flexor tendon healing: an investigation in a canine model. J Orthop Res. 2001;19(5):869-872. Harwood, FL, Monosov, AZ, Goomer, RS, et al. Integrin expression is upregulated during early healing in a canine intrasynovial flexor tendon repair and controlled passive motion model. Connect Tissue Res. 1998;39(4):309-316. Manske, PR, Gelberman, RH, Lesker, PA. Flexor tendon healing. Hand Clin. 1985;1(1):25-34. Taras, JS, Raphael, JS, Marczyk, SC, Bauerle, WB. Evaluation of suture caliber in flexor tendon repair. J Hand Surg. 2001;26(6):1100-1104. Thurman, RT, Trumble, TE, Hanel, DP, et al. Two-, four-, and six-strand zone II flexor tendon repairs: an in situ biomechanical comparison using a cadaver model. J Hand Surg. 1998;23(2):261-265.Biomechanical study in cadavers to demonstrate increased repair strength with increased number of core sutures. Strickland, JW. Flexor tendon injuries: I. Foundations of treatment. J Am Acad Orthop Surg. 1995;3(1):44-54.Classic review on flexor tendon anatomy, biology, biomechanics, and treatment after injuries. Osei, DA, Stepan, JG, Calfee, RP, et al. The effect of suture caliber and number of core suture strands on zone II flexor tendon repair: a study in human cadavers. J Hand Surg. 2014;39(2):262-268. Chung, KC. Operative Techniques: Hand and Wrist Surgery. 3rd ed. Philadelphia, PA: Elsevier; 2018. Hotokezaka, S, Manske, PR. Differences between locking loops and grasping loops: effects on 2-strand core suture. J Hand Surg. 1997;22(6):995-1003. Pruitt, DL, Aoki, M, Manske, PR. Effect of suture knot location on tensile strength after flexor tendon repair. J Hand Surg. 1996;21(6):969-973. Lotz, JC, Hariharan, JS, Diao, E. Analytic model to predict the strength of tendon repairs. J Orthop Res. 1998;16(4):399-405.Biomechanical study to establish the added repair strength with an epitendinous suture. Merrell, GA, Wolfe, SW, Kacena, WJ, et al. The effect of increased peripheral suture purchase on the strength of flexor tendon repairs. J Hand Surg. 2003;28(3):464-468. Gelberman, RH, Boyer, MI, Brodt, MD, et al. The effect of gap formation at the repair site on the strength and excursion of intrasynovial flexor tendons: an experimental study on the early stages of tendon-healing in dogs. Bone Joint Surg Am. 1999;81(7):975-982.Animal study that established acceptable gap formation for tendon repair. Leddy, JP, Packer, JW. Avulsion of the profundus tendon insertion in athletes. 
 J Hand Surg. 1977;2(1):66-69.Classification system of Zone 1 flexor tendon injury. Gelberman, RH, Manske, PR, Akeson, WH, et al. Flexor tendon repair. J Orthop Res. 1986;4(1):119-128. Duran, RJ, Houser, RG, Coleman, CR, Postlethwait, DS. A preliminary report in the use of controlled passive motion following flexor tendon repair in zones II and III. J Hand Surg. 1976;1(1):75-83.Principles for the Duran Protocol after flexor tendon repair.

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Silva, MJ, Brodt, MD, Boyer, MI, et al. Effects of increased in vivo excursion on digital range of motion and tendon strength following flexor tendon repair. J Orthop Res. 1999;17(5):777-783. Boyer, MI, Gelberman, RH, Burns, ME, et al. Intrasynovial flexor tendon repair: an experimental study comparing low and high levels of in vivo force during rehabilitation in canines. Bone Joint Surg Am. 2001;83-A(6):891-899. Trumble, TE, Vedder, NB, Seiler, JG III, et al. Zone-II flexor tendon repair: a randomized prospective trial of active place-and-hold therapy compared with passive motion therapy. Bone Joint Surg Am. 2010;92(6):1381-1389.Level I evidence comparing active place-and-hold with passive motion therapy. Kleinert, HE, Verdan, C. Report of the committee on tendon injuries (International Federation of Societies for Surgery of the Hand). J Hand Surg. 1983;8(5 Pt 2):794-798.American Society for Surgery of the Hand determination of total active motion of the digit.

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CHAPTER 77

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Extensor Tendon Repair and Reconstruction Amir H. Taghinia and A. Samandar Dowlatshahi

Key Points The extrinsic extensors of the digits are innervated by branches of the radial nerve and primarily mediate metacarpophalangeal (MP) joint extension. The intrinsic extensors of the digits are innervated by the ulnar and median nerves and primarily mediate MP joint flexion and interphalangeal (IP) joint extension. At the digit level, minimal tendon excursion translates into substantial change in joint position. Redundancies in the extensor system, such as the juncturae tendinae, can initially mask injury. Extensor injuries are classified by zones starting at the distal interphalangeal (DIP) joint (zone 1) and sequentially progressing proximally. Acute closed injuries of the digital extensor system are best treated with splinting; however, open injuries usually require exploration and repair if the injury is substantial. The mainstay of rehabilitation at the digital level (zones 1–4) remains static splinting; however, early motion protocols have shown promising results in more proximal injuries (zones 5–8). The extensor apparatus is a well-balanced system of interlinking tendons and fibroligamentous bands that orchestrate the fine positional movements of each digit. As opposed to flexor tendons, extensors exhibit minimal excursion, especially in the digits. Seemingly negligible position changes in the extensor mechanism can translate into large degrees of motion in the digits. Thus, even minor disruptions of the delicate balance of these tendons can cause significant functional deficits. Due to the superficial position of extensor tendons, they are vulnerable to injury and exposure. Nevertheless, the phylogenetic evolution of the extensor apparatus has led to interconnections and duplications that allow functional redundancy. This 
 redundancy can compensate for acute injury to one of the parts and lead to misdiagnosis. Once edema has subsided, and secondary support structures have fatigued, clinically significant deformity and functional loss become evident. This combination of factors—redundancy and late manifestation—along with significant anatomic variation in the extensor system makes accurate diagnosis difficult, but crucially important. After repair, the proximity of the tendons to bone, the high incidence of associated periosteal stripping and capsular injuries, and the limited excursion of the extensors makes repair prone to adherence. Furthermore, the mechanical strength of the repair and status of local soft and hard tissues may not allow early mobilization. The stronger opposing action of the flexor system makes early rehabilitation even more problematic. Although not always preventable, stiffness and adhesions can be minimized with meticulous surgical technique and rational rehabilitation protocols. Associated injuries to the thin soft tissue cover of the dorsum of the hand need to be treated concomitantly because they have a direct impact on functional outcomes. This chapter will discuss the anatomy and physiology of the extensor mechanism of the hand as well as injury patterns, repair strategies, and rehabilitation protocols. The importance of an in-depth anatomical understanding of this complex system cannot be overstated. Anatomy helps the reader to diagnose injury patterns understand the logic behind repair and rehabilitation.

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Clinical Anatomy and Function An appreciation of the fine mechanics and physiology of the extensor apparatus goes well beyond descriptive anatomy. The system is composed of unsheathed extrinsic and intrinsic tendons aided by retinacular structures and stabilized by periarticular constituents. Extension of the fingers follows a slightly different mechanism than the thumb. Full finger extension occurs because of a coordinated proximal to distal contraction of extrinsic and intrinsic muscles that set up an integrated series of tenodesis actions via fibroligamentous interconnections. There is no better way to demonstrate the tenodesis action of these interconnections than to passively flex the wrist. This action relaxes the long digital flexors and stretches the extensors. Performing this passive tenodesis examination in an injured hand is one of the best ways to diagnose an extensor tendon injury, especially proximal to the metacarpophalangeal (MP) joint (Figure 77.1).

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FIGURE 77.1 Wrist tenodesis. This 2-year-old girl sustained a laceration on the dorsum of the small finger MP joint. In this age group, assessing active motion is difficult. Relying on the tenodesis effect, maximal flexion of the wrist demonstrates lack of extensor tone in the small finger (A), and exploration confirms a tendon laceration at zone 5 (B). C. Figure-of-eight braided absorbable sutures were used to repair the tendon and the hand was immobilized in a cast for 3 weeks. D, E. Full active range of motion is demonstrated 6 months after the repair with minimal hand therapy. Similar injuries in adults can be treated with core and cross-stitch sutures with early mobilization.

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Extrinsic System The extrinsic extensor muscles are so called because they are located outside the anatomic boundaries of the hand. They are innervated by branches of the radial nerve or posterior interosseous nerve (PIN). The radial nerve proper innervates (in order) the brachioradialis (BR), extensor carpi radialis longus (ECRL), and (sometimes) extensor carpi radialis brevis (ECRB) muscles. BR is not a wrist or digital extensor—it flexes the elbow. ECRL and ECRB are both wrist extensors (Table 77.1). BR and ECRL are innervated above the elbow, whereas ECRB is innervated below the elbow. Thus, a radial nerve laceration at or below the elbow is likely to maintain wrist extensor function. TABLE 77.1 Extrinsic Extensors of the Hand and Wrist Muscle

Origin

Insertion

Innervation

Function

Extensor carpi radialis longus (ECRL) Extensor carpi radialis brevis (ECRB) Extensor carpi ulnaris (ECU) Extensor digitorum communis (EDC) Extensor indicis proprius (EIP) Extensor digiti minimi (EDM) Abductor pollicis longus (APL)

Lateral supracondylar ridge of humerus

Dorsal base of second metacarpal

Radial nerve

Wrist extension and radial deviation

Lateral epicondyle of humerus

Dorsal base of third metacarpal

Radial nerve

Wrist extension

2

Lateral epicondyle of humerus and posterior border of ulna Lateral epicondyle of humerus

PIN

Extensor pollicis brevis (EPB) Extensor pollicis longus (EPL)

Posterior surfaces of radius and interosseous membrane Posterior surfaces and ulna and interosseous membrane

Thumb extensor shroud Thumb dorsal base of distal phalanx

PIN

Wrist extension and ulnar deviation Finger MP joint extension Index finger MP joint extension Small finger MP joint extension Thumb abduction, extension at CMC joint Thumb MP joint extension Thumb IP joint extension, retropulsion

6

Posterior surfaces of ulna, radius, and interosseous membrane

Dorsal base of fifth metacarpal Finger extensor shroud Index finger extensor shroud Small finger extensor shroud Base of thumb metacarpal

Posterior surfaces and ulna and interosseous membrane Lateral epicondyle of humerus

PIN PIN PIN PIN

PIN

Extensor Compartment 2

4 4 5 1

1 3

CMC, carpometacarpal; IP, interphalangeal; MP, metacarpophalangeal; PIN, posterior interosseous nerve.

All other extrinsic extensor muscles are innervated by the PIN, a branch of the radial nerve. The musculotendinous junctures of these tendons start at the mid to distal forearm. The most distal muscle belly, which occasionally extends beyond the carpus, is the extensor indicis proprius (EIP). This is the last muscle to receive innervation from the PIN, and thus the last to recover after a nerve injury. At the level of the wrist, the tendons are stabilized by a synovial-lined sheath termed the extensor retinaculum. This retinaculum is composed of horizontal fibers that form an overarching system of tunnels spanning the dorsal wrist and acting as a pulley to prevent bowstringing. Vertical, fibrous septae separate the tunnel into six individually numbered compartments (Figure 77.2).

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FIGURE 77.2 Illustration of the dorsal extensor system shows the extensor retinaculum covering the extensor tendons at the wrist. Under the retinaculum, the extensors traverse six compartments numbered sequentially: (1) APL and EPB, (2) ECRL and ECRB, (3) EPL, (4) EIP and EDC, (5) EDM, and (6) ECU. The juncturae tendinae connect the finger extensor tendons on the dorsum of the hand; there are no juncturae that link to the thumb extensors. In most cases, the ring finger sends connections to the middle and small fingers; but the connection between the index and middle fingers can be variable. (Reproduced with permission from Shoshana, W. Ambani, SW, Chung, KC. Rheumatoid arthritis of the hand and wrist. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 6, Figure 24-4.)

The extensor digitorum communis (EDC) is the shared extensor (with a common muscle belly) for all four fingers. It travels through the fourth extensor compartment along with the EIP, the independent extensor of the index finger. The EIP extends the index finger independently of the other digits, hence inviting its moniker pointer finger. The only other independent finger extensor is the extensor digiti minimi (EDM) (also named extensor digiti quinti) that is the sole tendon in the fifth extensor compartment. These two independent tendons provide redundancy of finger extension, thus making them suitable for tendon transfers. They typically lie ulnar to the EDC at the level of the MP joints. At the distal metacarpal level, the extensors of the fingers are often connected by oblique tendinous connections termed juncturae tendineae (see Figure 77.2). At the MP joint, the extrinsic tendons attach to the sagittal bands, specialized retinacular fibers that encircle the MP joints and insert onto the volar plates (Figure 77.3). These transverse laminar fibers provide radioulnar stability, effectively centralizing the tendon over the convexity of the metacarpal head. The attachments of the extrinsic finger extensors onto these structures make them effective extensors of the MP joints, which are not intuitive, because they do

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not directly insert onto the proximal phalanges. 1

FIGURE 77.3 Finger extensor apparatus. Dorsal (A) and lateral (B) anatomic illustrations of the finger extensor apparatus. (Reproduced with permission from Smith, MD, Machol, JA IV, Chen, NC. Acute repair of extensor tendon injuries in zones I to VI. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 6, Figure 41-1B and Figure 41-1C.)

Thumb extension is primarily mediated by the extensor pollicis longus (EPL). As it travels through the third extensor compartment, it makes a sharp radial turn around Lister tubercle (a dorsal bony prominence of the radius) and heads towards the thumb. This tendon forms the dorsal boundary of the anatomic snuffbox. It facilitates thumb interphalangeal (IP) joint extension but its most direct action is retropulsion (the act of lifting one’s thumb off a table while keeping the palm resting flat) (Figure 77.4). The extensor pollicis brevis (EPB) and abductor pollicis longus (APL) travel through the first dorsal compartment; their action is to extend the thumb MP and carpometacarpal (CMC) joints, respectively.

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FIGURE 77.4 Retropulsion. The ideal way to test the EPL is by asking the patient to rest the hand, palm down, on a flat surface and lift the thumb.

There is significant variation in extrinsic extensor tendon anatomy. The more common variants and their clinical relevance are outlined in Table 77.2. TABLE 77.2 Surgically Relevant Anatomical Pearls Anatomical Variant The first extensor compartment is partially divided by a fibrous septum in 29% of the population, and by a bony septum in 5%. Complete separation has been observed in 8.5% of cases. An extensor carpi radialis intermedius (ECRI) is present in 12% of limbs, located either radial to ECRL or in between ECRL and ECRB

Surgical Relevance During release of the first extensor compartment for de Quervain’s syndrome, all subcompartments must be identified and released The ECRI can be used as a tendon graft or in tendon transfers involving the radial wrist extensors

The EIP is absent in 4% of individuals. Its muscle belly extends further distal than other extensor tendons. It is located ulnar and volar to EDC of the index finger. An extensor medii proprius (EMP) is the middle finger equivalent of the EIP and is present in 10% of individuals. The extensor indicis et medii communis is a variant of EIP that inserts onto the index and middle fingers.

The EIP is often used for tendon transfers, either after EPL spontaneous rupture or for opponensplasty. Anatomic differences can help more easily localize the tendon. The EMP, if present, can be used for tendon transfers.

The extensor digitorum brevis manus muscle is an anomalous dorsal muscle, present in 3% of hands, which arises distally on the wrist between the index and middle finger metacarpals. The EDM is doubled in 72% of cases.

The muscle belly can be hypertrophic to the point where it is mistaken for a ganglion cyst. It can complicate a planned EIP tendon transfer. This muscle can be mistaken for a ganglion cyst.

This redundancy allows the tendon to be used for tendon grafts or additional tendon transfers.

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Intrinsic System The intrinsic muscles originate and insert within the anatomic boundaries of the hand. For the extensor apparatus, these muscles are the interossei and the lumbricals. There are seven interosseous muscles, four dorsal, and three volar. They are all innervated by the deep branch of the ulnar nerve. In addition to abducting (dorsal interossei) and adducting (volar interossei) the fingers, the interossei are the primary flexors of the finger MP joints. They course dorsal to the deep transverse metacarpal ligament and insert into the digital lateral bands (see Figure 77.3). The lumbrical muscles are unique in that they originate from the finger profundus flexor tendons. There are four lumbrical muscles in the hand, one for each finger, and they lie on the radial side of the respective flexor tendon. They course volar to the deep transverse metacarpal ligament before attaching to the radial lateral band of the respective finger. The median nerve innervates the lumbrical muscles of the index and middle fingers, and the ulnar nerve innervates those of the ring and small fingers. The intrinsic extensor tendons lie volar to the axis of rotation of the MP joint and dorsal to the axis of rotation of the IP joints. Thus, they cause the MP joints to flex and the IP joints to extend. These musculotendinous units are maximally stretched (taut) when the MP joint is passively extended and the PIP joint is simultaneously flexed. They are maximally lax when the MP joint is passively flexed and the PIP joint is extended (Figure 77.5). Intrinsic muscle action is also responsible for volumetric grip that starts with coordinated MP joint flexion and simultaneous IP joint extension. 2 Patients with combined lower median and ulnar nerve palsy are unable to perform volumetric grip, and instead initiate finger flexion at the IP joints, curling the fingers towards the palm utilizing the extrinsic flexors.

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FIGURE 77.5 Intrinsic tightness. The intrinsic muscles flex the MP joints and extend the PIP joints of the fingers. In the passive posture of maximal MP joint flexion and PIP extension, these muscles are fully lax. In contrast, the opposite passive posture of maximal MP joint extension and PIP flexion puts them at peak stretch. When the intrinsic muscles are contracted or tight, achieving this second posture is difficult. A. Intrinsic tightness can be demonstrated if the PIP joint cannot be easily flexed when

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the MP joint is held in extension. B. Flexing the MP joint and confirming normal PIP joint flexion rules out a problem with the PIP joint.

The intrinsic muscles of the thumb are mainly involved in rotational motion. However, both the adductor pollicis (ulnar) and the abductor pollicis brevis (radial) insert onto the EPL tendon at the MP joint level, which along with the EPB, gives them the ability to extend the IP joint of the thumb at least to neutral, thus potentially obscuring an EPL injury.

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Digital Extensor System Just distal to the sagittal bands, the extrinsic extensor system splits into a central slip and two lateral slips (see Figure 77.3). 3 Distal to this trifurcation, there is a crossing of fibers from the lateral bands to the central slip and vice versa. The myriad of crisscrossing fibers create a contiguous coalescence of fibers termed the extensor hood. The central slip then terminates as it inserts onto the dorsal base of the middle phalanx. The lateral slips pass on either side of the PIP joint and merge with the lateral bands forming the conjoined lateral bands. These bands then course dorsally and join the triangular ligament on either side, ultimately uniting to form the terminal tendon that inserts onto the dorsal base of the distal phalanx. At the PIP joint level, the transverse retinacular ligament tethers and stabilizes the extensor mechanism, not dissimilar to the sagittal bands at the MP level. The oblique retinacular ligament (ORL, of Landsmeer) arises from the lateral aspect of the flexor tendon sheath at the neck of the proximal phalanx (A2 pulley) and passes volar to the axis of rotation of the PIP joint, inserting onto the extensor mechanism along the middle phalanx. Although previously thought to link PIP and distal interphalangeal (DIP) motion, the ORL has been found to be variably present and often attenuated—its role remains controversial. 3-5

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Extension Function MP joint extension is primarily mediated by the extrinsic extensor tendons. Historically, it was thought to be mediated by the sagittal bands as they lasso around the base of the proximal phalanx. However, more recent evidence suggests that the extensor continuation to the extensor hood and middle phalanx is the major mediator of MP extension. 6 Interphalangeal joint extension is more complex and requires the interplay of both intrinsic and extrinsic systems (Figure 77.6).

FIGURE 77.6 Coordinating IP joint motion. A. When the MP joint is flexed, the extrinsic extensors are rendered tighter while

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the intrinsic interosseous-lumbrical system is lax and redundant. The lax structures are not able to generate significant force in this situation. Thus, IP joint extension is mediated by the extrinsic system when the MP joint is flexed. In contrast, when the MP joint is extended, the extrinsic system becomes lax and less effective. B. Meanwhile, MP joint extension tightens the intrinsic tendons, thus making them better IP joint extensors. In summary, extensor action on the IP joints is mediated by the extrinsic system when the MP joint is flexed and by the intrinsic system when the MP joint is extended.

Digital extensor tendon excursion is much wider at the forearm and wrist level than the digit. The excursion of a common extensor proximal to the wrist is approximately 5 cm. The excursion of the extensor mechanism at the PIP joint level is only a few millimeters, despite a PIP joint arc of motion of 100°. 7 Every millimeter of extensor tendon lengthening over the proximal phalanx leads to 12° of extension deficit at the PIP joint. 8 Any small disturbance of this delicate balance causes deformity that can be progressive and difficult to correct. Similar issues plague the DIP joint where each millimeter of relative terminal tendon lengthening results in 25° of extension lag. 9 The interlinkages of the extensor mechanism have further pathophysiologic implications. Normal function relies on individual tendons acting about the axis of rotation of multiple joints, and on stabilization of joints between where the axial force is generated and where it is intended to act. If one interlinkage is disrupted, this derangement causes (progressive) reciprocal deformity of adjacent joints. This phenomenon is seen in boutonnière, swan-neck, and so-called zig-zag deformities, where injury/deformity in one joint pathologically alters the position of an adjacent joint.

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Clinical Assessment The clinical assessment of a patient with suspected extensor deficit or derangement requires thorough knowledge of the anatomical and mechanical features of extensor function. Cross-functionality of the extensor mechanism can mask serious injury that may manifest later as recalcitrant chronic deformity. The best way to diagnose injury is to assess function distal to the level of the injury. This is especially relevant in the hand, wrist, and forearm where retraction of the proximal tendon ends may obscure visualization. In the fingers, accurate diagnosis can be made by exploring an acute wound in the emergency room (ER). Extensors in this area are superficial and will not retract much. However, one needs adequate lighting, retraction, and hemostasis because small wounds with venous bleeding can obscure injury. When in doubt, one should close the wound, apply a splint, and reexamine in a few days.

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Injury Patterns, Repair, and Rehabilitation Extensor tendon injuries are classified based on location. Kleinert and Verdan 10 initially delineated these zones from 1 to 8, and Doyle 11 later added a ninth zone for the muscular area of the mid to proximal forearm. The zones start at the DIP joint and progress proximally. Odd numbers are over joints and even numbers in between. There are separately numbered zones for the thumb (Figure 77.7).

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FIGURE 77.7 Zones of extensor muscle and tendon injury. These are numbered from I to IX starting at the DIP joint and progressing proximally. Zone I is over the DIP joint, zone II is over the middle phalanx and so on. Zone IX is located in the forearm proximal to zone VIII (not shown).

These zones are significant because they require different approaches for repair and rehabilitation. A detailed outline of injury patterns and repair paradigms will follow. However, certain generalizations

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about rehabilitation are worth mentioning first. Rehabilitation of zone 1 and 2 injuries requires static splinting for 6 weeks followed by night splinting and range of motion exercises. More proximal injuries were traditionally treated by 3 to 4 weeks of static splinting followed by controlled motion. This approach may increase adhesions particularly in those with multiple concomitant injuries that involve bone and other soft tissue, as the tendon forms scars to adjacent structures during healing. Early controlled motion using dynamic splinting has shown promising results for zone 4 to 7 injuries, and may be especially suited for patients who are compliant and have associated bony and soft tissue injuries. 12-14 The idea is that early controlled gliding of the tendon will break up impending adhesions while minimizing risk of rupture. Dynamic splinting protocols are just as effective as early active motion protocols with less risk of tendon rupture. 15,16 More proximal injuries in zones 8 and 9 carry the least risk of adhesions and can be treated with static splinting for 3 to 4 weeks.

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Zone 1 Disruption of the terminal extensor tendon from the base of the distal phalanx results in a mallet finger injury. The mechanism is either an open injury, or more commonly by closed rupture with or without associated fracture of the distal phalanx. Sudden, resisted flexion of the DIP joint is the leading cause. The terminal tendon usually inserts onto a thin area on the dorsal/proximal aspect of the distal phalanx. This area corresponds to the dorsal ledge of the epiphysis prior to skeletal maturity. The DIP joint is held in a flexed posture with decreased or absent active extension (Figure 77.8). Compensatory hyperextension at the PIP joint (swan-neck deformity) can occur acutely in patients with congenital or traumatic PIP volar plate laxity. Elderly patients with osteoarthritis can present with a mallet deformity that is atraumatic.

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FIGURE 77.8 Type I (closed) bony mallet finger. A. Clinical posture of the digit after injury shows extension lag at the DIP joint. B. A small bony fragment, still attached to the terminal tendon, has been separated from the distal phalanx. Most mallet injuries present in this way with or without a small avulsion fracture.

Radiographs are necessary to rule out a fracture of the distal phalanx, and need to be appropriately centered on the involved digit. The lateral view is critical, to assess joint congruity and subluxation. Fractures are often missed on the anteroposterior view alone. Injuries presenting within 4 weeks of trauma are considered acute; after 4 weeks, they are chronic. If left untreated, hyperextension of the PIP joint can develop because of proximal and dorsal migration of the lateral bands, 17 creating the swan-neck

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deformity. Doyle and others classified mallet finger injuries into four types. 11 Table 77.3 outlines this classification and the treatment algorithm for each type of injury. Closed injuries without subluxation encompass the great majority of mallet injuries (types I and IVb). These injuries are best treated with continuous splinting of the DIP joint in extension for 6 weeks, followed by 2 weeks of night splinting. Splinting must be continuous. If at any time the patient is to remove the splint (e.g., for hygiene), it must be rested against a flat surface to ensure continuous extension of the DIP joint. Splinting in extreme hyperextension or placing the splint too tightly can cause dorsal skin necrosis. Different types of splints (aluminum foam, premade plastic, or custom-made thermoplastic) placed volar or dorsal have been used in the literature, with comparable outcomes. 18,19 The main predictor of long-term extension lag appears to be compliance with splinting. The authors recommend a dorsal aluminum foam splint with the DIP joint in slight hyperextension. Active PIP joint motion is encouraged. TABLE 77.3 Doyle Classification of Mallet Injury Type I

After 8 wk, initiate splint weaning and controlled active motion under therapist guidance. II

Description Closed injury, with or without small dorsal avulsion fracture

Treatment 8 wk continuous splinting with DIP in full extension, PIP free. Look for skin maceration and breakdown.

Open injury with laceration to the terminal extensor

Surgical tendon repair with running suture incorporating skin and tendon, and transfixation of DIP joint with axial or oblique 0.045 in K wire for 6 wk followed by night time splinting for 4 wk.

III

Open injury with loss of skin and/or tendon substance

IV A

Transepiphyseal plate fracture in children (Seymour’s fracture)

Primary repair if possible. Positioning of DIP joint in hyperextension is permissible if allows for apposition of tendon ends. May require homodigital or cross-finger flap for coverage with or without tendon graft. Requires operative washout, reduction and antibiotic coverage. Longitudinal K wire often necessary.

IV B

Hyperflexion injury with 20%–50% fracture of articular surface Hyperextension injury with >50% fracture of articular surface with early or late volar subluxation of distal phalanx

IV C

Pearls and Pitfalls If extensor lag is evident at 8 wk, then resume splinting until extensor lag is resolved.

Operative and conservative methods of treatment are acceptable based on current literature, even in the presence of volar subluxation of the distal phalanx. Operative treatment consists of extension block pinning.

Beware of bulky suture material that can become symptomatic and extrude. The DIP joint is invariably open and needs to be washed out. Consider staged reconstruction: soft tissue, then tendon reconstruction.

Dislocated nailplate often present. Untreated Seymour fracture can lead to osteomyelitis. Patients are always advised that they may have a permanent dorsal bump with either surgical or nonsurgical treatment.

Residual extensor lag of 5° to 10° is common, despite adequate treatment and patient compliance (Figure 77.9). Erythema and swelling over the dorsal aspect of the DIP joint can last several months.

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FIGURE 77.9 Type II (open) mallet finger. A. Clinical posture of the digit shows a more significant extension lag than typically seen in a closed mallet injury. B. Dorsal view demonstrates a healing laceration over the DIP joint. C. Repair was performed with a running stitch and protected with a longitudinal pin. D. Three months postoperatively, the finger demonstrates mild extension lag as can be seen often in these cases despite timely and adequate repair. Even a miniscule amount of tendon lengthening in this area translates to significant extension lag.

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Chronic Mallet Injuries There is no formal time cut off for closed treatment with splinting. Tenderness and inflammation over the DIP extensor surface are considered to be relative indications for closed treatment, even several months after injury. Surgical options include direct tendon repair with or without skin imbrication (tenodermodesis), tendon rebalancing with a central slip tenotomy (Fowler tenotomy), ORL reconstruction, or DIP joint arthrodesis. Technique of skin imbrication/tenodermodesis: An elliptical wedge of skin and scarred tendon is excised. 20 The closure incorporates both skin and tendon as a single unit. A Kirschner wire maintains the joint in full extension for 6 weeks. Fowler tenotomy/central slip tenotomy: At least 6 to 12 months are required since injury to allow the terminal tendon to mature. The principle underlying this procedure is a release of the central slip, allowing the now centrally untethered lateral bands to move proximally and reduce the slack within the extensor system distal to the PIP joint, correcting the extensor lag at the DIP joint. A boutonnière deformity is prevented by keeping the triangular ligament intact. The release is performed from underneath the extensor system via a midaxial incision. Passing a freer elevator underneath the lateral bands ensures that any adhesions are released so that they can glide freely. Spiral ORL reconstruction: This procedure links the position of the PIP joint to that of the DIP joint. Performed with a tendon graft 21,22 or a lateral band, 23 it links the terminal tendon or distal phalanx to the flexor tendon sheath or proximal phalanx, leading to a dynamic tenodesis (Figure 77.10).

FIGURE 77.10 Spiral oblique retinacular ligament reconstruction. A. The swan-neck posture of a mallet deformity is shown

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with lax lateral bands and PIP volar plate. B, C. The tendon graft is secured to the distal phalanx with a pull out suture that is brought volarly and stabilized with a button. It is routed adjacent to the flexor sheath volar to the PIP joint, and then anchored to the side of the proximal phalanx (Thompson) or the flexor sheath (Kleinman and Peterson). Extension of the PIP puts tension on the graft, resulting in extension of the DIP. Flexion of the PIP relaxes the graft and allows flexion of the DIP.

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Posttraumatic Swan-Neck Deformity A swan-neck deformity is flexion of the DIP joint with hyperextension of the PIP joint. It occurs after a traumatic (untreated) mallet finger when the PIP volar plate is lax. It is important to ascertain whether the deformity is primarily due to PIP joint laxity or DIP extension lag; this is done by blocking PIP hyperextension and assessing active DIP extension. With PIP hyperextension blocked, if the DIP can be actively extended fully, then the main problem is PIP laxity. Otherwise, the main problem is DIP extension deficit. For PIP joint laxity, one should attempt conservative treatment with figure-of-eight splinting. If that is not effective, then volar plate imbrication or FDS tenodesis may work. If the primary issue is DIP extension deficit, then ORL reconstruction or Fowler tenotomy are advocated. Joints should be supple before operative correction is attempted.

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Zone 2 These injuries are located over the middle phalanx and are usually sharp. They can involve the two conjoined lateral bands and the triangular ligament that restrains them in the dorsal midline. Only one lateral band is sufficient to achieve full extension of the DIP joint. If the injury involves less than 50% of the extensor mechanism, then routine wound care and splinting for 7 to 10 days is sufficient treatment, followed by active motion. If greater than 50% of the tendon is cut, then primary repair and a longer period of immobilization is indicated. The extensor system at this level is thin and cannot carry a core suture. A simple running nonabsorbable 5-0 suture can be augmented with a running cross-stitch (e.g., Silfverskiöld; Figure 77.11). PIP motion is permitted postoperatively. The DIP joint is held in extension for 6 weeks after which active motion can commence. Chronic zone 2 injuries can be treated with spiral ORL reconstruction, as in chronic mallet injuries.

FIGURE 77.11 Extensor tendon repair techniques. A. The Silfverskiöld cross-stitch technique is demonstrated for a zone 2 injury. More proximal injuries can be repaired with 2 to 4 core sutures and augmented with the cross-stitch using a finer monofilament suture (B). Repair of a T-2 thumb extensor injury is demonstrated with core Ethibond suture (green) and Silfverskiöld cross-stitch (C).

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Zone 3 As in mallet injuries, zone 3 injuries can be open lacerations or closed ruptures, the latter with or without avulsion fracture of the middle phalanx. The injury may result in PIP joint extension deficit and DIP joint hyperextension, the so-called boutonnière deformity. In the setting of an isolated (closed) central slip injury, PIP joint extensor lag is usually not present at first. The intact lateral bands and triangular ligament maintain an extension moment on the PIP joint due to their position dorsal to the PIP joint rotation axis. However, the extension torque gets shifted completely to the lateral bands, and over several weeks the restraining triangular ligament stretches out, thereby allowing volar translation and shortening of the lateral bands. This in turn increases direct pull at the terminal extensor tendon, leading to hyperextension of the DIP joint (Figure 77.12), and the boutonnière posture. 24,25 Concomitant injury to adjacent structures may also be necessary to cause a boutonnière deformity. 26

FIGURE 77.12 Development of boutonnière deformity. A. The central slip is disrupted from the base of the middle phalanx leading to all extensor forces being concentrated into the lateral bands. B. The lateral bands slip volarly and become flexors of the PIP joint and hyperextensors of the DIP joint. (Reproduced with permission from Shoshana, W. Ambani, SW, Chung, KC. Rheumatoid arthritis of the hand and wrist. In: Chung, KC , ed. Operative Techniques in Plastic Surgery. Philadelphia, PA: Wolters Kluwer; 2019. Part 6, Figure 24-7A.)

A more reliable test for central slip disruption was suggested by Elson (Figure 77.13). 27 This test is found to be the most sensitive test for diagnosing acute central slip disruption. 28 In clinical practice, the aforementioned tests are difficult to perform in the acute setting because of pain and swelling. A digital block may be helpful to do a proper Elson test. In suspected cases where the examination is inconsistent or unreliable, the clinician should splint the PIP in extension and reexamine after a week once swelling and pain have subsided.

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FIGURE 77.13 Elson test. With the finger held at 90° of PIP joint flexion against a right-angled surface (such as the end of a table), active extension is tested. If the central slip is intact, the DIP joint should have very little active extension ability (flail). A. This is because an intact central slip will draw the origin of the lateral bands distally. B. However, if the central slip is disrupted, the proximal migration of the lateral bands stretches them and allows active DIP joint extension.

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Closed Central Slip Injury Treatment of a closed central slip rupture with or without boutonnière deformity consists of splinting or pinning the PIP joint in full extension for 6 weeks, followed by an additional 4 to 6 weeks of protective splinting. The patient performs active DIP flexion and extension exercises to keep the lateral bands gliding. In patients with a boutonnière deformity, active DIP flexion helps to pull the lateral bands back into a more dorsal and central position thus correcting the deformity. When treated early in a compliant patient, the injury will usually respond to this conservative approach.

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Closed Central Slip Injury with Associated Avulsion Fracture Depending on the size of the fracture, these can also be treated closed. Larger fragments can be repaired by Kirschner wire or screw fixation. In the presence of comminution, the fragment(s) can be excised and a tendon-to-bone juncture performed.

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Open Zone 3 Injury A traumatic PIP arthrotomy is usually present and requires joint irrigation. In cases where there is minimal to no distal tendon, a suture anchor is employed or a trough can be created in the middle phalanx for passing a suture. If there is sufficient tendon for repair, a cross-stitch suture with or without a single-core suture is sufficient. A pin protects the repair for 6 weeks. Range of motion exercises can commence after pin removal but night splinting should continue for another 3 weeks.

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Posttraumatic Boutonnière Deformity This deformity refers to DIP joint hyperextension and PIP joint flexion. In addition to trauma discussed earlier, arthritis, burns, and synovitis can also cause this condition via attenuation and rupture of the central slip. The changes occur in three stages: dynamic imbalance (early), established tendon contracture with supple joints (delayed), and fixed contracture (late/chronic). Passively correctable deformities should initially be treated with splinting as even late treatment can allow realignment of the lateral bands. 29 Surgical treatment of chronic boutonnière deformity is extremely challenging. Supple joints are a necessity before any surgical interventions; thus, fixed chronic cases should be treated with serial splinting and stretching to maximize joint mobility. The distal Fowler tenotomy transversely divides the extensor mechanism at the junction of the middle and proximal thirds of the middle phalanx while preserving the ORL. This effectively creates a surgical mallet finger, decreasing tone at the DIP joint and increasing tension at the PIP by allowing the extensor to slide proximally. A modification of this procedure shifts the lateral bands dorsally and suturing them together over the PIP joint. 29 Lastly, Curtis proposed a four-stage process to correct this deformity with reasonable outcomes. 30 The reconstruction involves tenolysis, sectioning of the transverse retinacular ligament, distal Fowler tenotomy, and advancement and reinsertion of the central tendon.

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Zone 4 The extensor mechanism in this zone is broad and the convexity of the proximal phalanx shields the lateral bands, thus most injuries are partial. Surgical exploration is often necessary to diagnose the degree of injury. Injuries that involve less than 50% of the extensor mechanism and/or those in which PIP active extension is spared can be managed conservatively with range of motion exercises after the skin laceration has healed. The choice of repair is variable and includes either figure-of-eight absorbable sutures, or core sutures (2 or 4 of 4-0 or 5-0 nonabsorbable suture) augmented with a cross-stitch on the dorsal surface. Similar to zone 3 injuries, the PIP joint should be splinted in extension for 4 to 6 weeks while the DIP joint is exercised. Dynamic splinting can be considered in this zone. 31,32

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Zone 5 These injuries occur over the MP joint, are almost always open, and should be considered human bite injuries unless proven otherwise. The classic fight bite occurs when the fully flexed MP joint forcefully strikes human maxillary incisors. The teeth lacerate the skin, extensor tendon, and joint capsule before inoculating the joint with oral flora. The finger then returns to its natural extended posture, sealing the joint and catalyzing an impending septic arthritis. The clinician should be suspicious for those with innocuous appearing injuries. Primary tendon repair will be required after thorough joint irrigation. The lacerated tendon is proximal to the area of skin injury. Flexing the joint recreates the multilevel injury tract and wash out all of the inoculated tissues. Once identified, the tendon ends can be repaired with a two- or four-core (e.g., modified Kessler) suture followed by an epitendinous suture. If the sagittal bands are lacerated, they should also be repaired to keep the tendon centralized. Radial sagittal band injuries are particularly prone to subsequent subluxation. 33 The surgeon should obtain wound cultures and commence broad-spectrum antibiotics. If there is frank septic arthritis, the wound and joint need to be opened widely, debrided, irrigated, and left open to allow egress of purulence; and the tendon repaired secondarily once the infection has resolved. Postoperative therapy should be tailored to the patient, mechanism, and extent of injury. In cases where the injury is not caused by human bite, the layers must be carefully identified and repaired separately. Postoperative rehabilitation with intermittent-controlled active motion and relative motion splinting is particularly useful in reliable, motivated patients (Figure 77.14).

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FIGURE 77.14 Zone 5 extensor tendon laceration. This 35-year-old carpenter sustained penetrating trauma to the dorsum of his hand by a screwdriver. Extension deficit was evident preoperatively, but subtle. A. Intraoperative exploration revealed a transected EDC tendon as well as injury to the shroud mechanism and traumatic MP joint arthrotomy. (B) Repair of the joint capsule with 6-0 absorbable suture. Repair of extensor tendon with 4-0 nonabsorbable core suture (modified Kessler; C), augmented with a 6-0 epitendinous suture (locking running; D). After repair, the patient is placed in an extension wrist splint and a yoke splint with the affected digit in hyperextension relative to the neighboring digits. E, F. Controlled active motion begins immediately with both splints in place. The wrist splint is discontinued at 3 weeks and the yoke splint at 6 weeks, followed by strengthening and passive range of motion. This carpenter returned to work 3 days postoperatively.

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Sagittal Band Injuries Isolated sagittal band injuries are most often closed injuries resulting from resisted extension of the finger or direct trauma to the dorsum of the MP joint. These are often mistaken for a trigger finger because of the snapping that occurs when the extensor tendon shifts back and forth between its natural position and the intermetacarpal groove. The radial sagittal band is more often affected. Usually, the affected finger cannot be actively extended from a flexed starting position but can be held in the fully extended position. Closed injuries are treated conservatively by relative motion splinting or casting. In late presentations or cases of failed conservative treatment, surgical reconstruction is warranted.

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Zone 6 Extensor tendon injuries over the metacarpals may not be readily apparent because the juncturae tendinae can transmit extensor force from adjacent, intact tendons. Although exploration for a suspected tendon laceration may confirm its presence, it should be performed in a controlled setting where visualization is excellent. Venous bleeding in the ER setting can impair visibility and result in misdiagnosis. The ability to hyperextend the MP joint and/or extend against resistance are often better indicators of extensor integrity than direct visualization in the ER. Local anesthesia can be administered before attempting these maneuvers to eliminate the influence of pain. The tendons in zone 6 are oval-shaped and thick, making them amenable to core suture repair techniques. Injuries that involve greater than 50% of the tendon cross-sectional area may be repaired with 3-0 or 4-0 nonabsorbable core sutures. Various core suture techniques have been proposed; the authors prefer the modified Kessler method. A subsequent circumferential epitendinous suture lends additional strength and smooths the edges of the repair. In injuries not suitable for early mobilization, figure-of-eight absorbable sutures may also be utilized (Figure 77.1). Even if a single slip of the EDC is involved, all fingers should be splinted.

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Zone 7 Extensor tendon injuries over the wrist usually damage the extensor retinaculum. Partial release of the retinaculum is often necessary to gain access to the injured tendons. Controversy exists about whether a part of the retinaculum should be excised to minimize adhesions. 34 The surgeon can usually maintain or repair part (about 50% of its length) of the retinaculum to prevent subsequent bowstringing while excising the portion over the repair site to minimize adhesions. The only exception is the EPL tendon (see section on Special Considerations for the Thumb). The tendons are in close proximity in this zone, thus multiple tendons are usually involved in sharp injuries. Furthermore, retraction is common because there are fewer locally tethering structures. The surgeon must carefully identify all injured structures and make sure that the injured ends match correctly. A four- to six-strand core suture repair is ideal. The close proximity of tendons makes problematic adhesions more likely in this zone. Dynamic splinting or early motion protocols should be considered postoperatively.

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Zone 8 Distal forearm extensor tendon injuries are treated similar to zone 7 injuries. Because multiple tendons are often involved, it may be difficult to identify and match ends correctly. A systematic radial to ulnar (or vice versa) survey can be helpful. Independent wrist and thumb motion should be prioritized. Similar to zone 7, core sutures should be used to repair the stout tendons in this area. The extrinsic extensor tendons that have their muscle bellies end most distally in the forearm are the EIP (most distal), EPL, EPB, and APB. The remainder of the extensor musculotendinous junctions is approximately 4 cm proximal to the wrist. Thus, injuries in this zone may present with a mixed picture of lacerations through the tendon substance, at the musculotendinous junction, or the muscle belly. The proximal tendon end may retract into the belly of the muscle. The surgeon should carefully identify as much proximal tendon as possible because tendon-to-tendon repair is much stronger than tendon to muscle. In the forearm, there is no 
 need for Bruner-type zigzag incisions. Linear or curvilinear 
 access incisions look nicer and are less likely to create ischemic skin flaps.

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Zone 9 In the most proximal zone, penetrating trauma usually causes direct laceration of the muscle bellies. Each can be isolated, identified, and its severed ends carefully matched. The overlying fascia can be repaired either with figure-of-eight absorbable sutures or with barbed sutures. The advantage of barbed sutures is timesavings and knotless repairs that decrease likelihood of muscle strangulation. Given abundant soft tissue, adhesions are unlikely to cause substantial tethering in this zone. Furthermore, repairs are inherently weaker due to closure of the muscle fascia alone without tendon substance. Therefore, these repairs should be protected and immobilized for 3 to 4 weeks before commencing range of motion exercises.

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Special Considerations for the Thumb The treatment of thumb extensor injuries is similar to the 
 finger analog for each of the respective zones of injury T1–T5 (see Figure 77.6) with a few caveats and pearls as outlined herein: For zone T5 injuries of the EPL (wrist), the tendon should be displaced out of the third compartment and repaired over 
 the extensor retinaculum. This maneuver should not be replicated with finger extensors that tend to bowstring. The change in EPL tendon routing does not alter its mechanics significantly, but does provide a better soft tissue bed to decrease adhesions. Extensor lacerations just proximal to the MP joint (zones T4 and T5) result in significant recoil of the EPL. It is best to check thumb retropulsion (see Figure 77.3) than to hopelessly explore the wound in the ER. Additional proximal incisions are sometimes needed if the tendon retracts significantly and/or repair is delayed (Figure 77.15). An uncommon and unusual tendon injury that occurs in zone T5 is spontaneous rupture of the EPL tendon after distal radius fracture. The rupture usually occurs in closed nondisplaced fractures treated nonoperatively, and it can present weeks to months after the initial fracture. The mechanism is unclear but watershed blood supply and/or extravasation of blood into a tight compartment with subsequent pressure ischemia have been proposed. The best treatment is transfer of the EIP tendon to the EPL tendon. 35 Dividing the EIP proximal to the extensor hood minimizes likelihood of extension lag in the index finger. Patients adjust well to this transfer and start using it naturally soon after rehabilitation. Paradoxically, the majority of patients can still independently extend the index finger. 36 A rarely discussed alternative is EPL reconstruction with a tendon graft that is a closer reconstitution of normal anatomy but requires appropriate tensioning, compensating for a shortened EPL muscle.

FIGURE 77.15 Proximal EPL laceration. EPL lacerations proximal to the MP joint can retract significantly because there are no tethering linkages such as juncturae tendinae to prevent proximal migration. A. This patient sustained such an EPL laceration. Proximal extension of the wound was not enough to uncover the proximal end of the tendon. B. Instead, a separate transverse wrist incision exposed the proximal EPL that was then routed to the distal wound. The injury was repaired with nonabsorbable four-core sutures (3-0, modified Kessler) and augmented by an epitendinous cross-stitch. C. Three months postoperatively, the patient demonstrates normal thumb retropulsion and IP hyperextension.

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Questions 1. A 32-year-old woman with fibromyalgia comes to the office after being seen in the emergency department 3 days prior with a laceration to the dorsal aspect of the right hand caused by broken glass. The laceration was repaired in a single layer in the emergency department. On physical examination, the patient can extend all fingers but cannot hyperextend her long finger beyond the neutral position. The interphalangeal joints can be fully extended actively. What explains the findings? a. There is no tendon injury. b. The patient has an accessory extensor tendon to the long finger. c. The patient has a partial tendon laceration of less than 50%. d. Junctura tendinum and intact intrinsic muscles are extending the finger. e. Her inability to fully extend is related to pain and swelling following the laceration. 2. A 23-year-old right-hand–dominant man presents to clinic after a sprain of the left ring finger sustained while playing flag football. The finger is swollen and bruised. His PIP joint is held in flexion, and is slightly lax to valgus stress. The DIP joint is hyperextended. Which is the most likely diagnosis? a. Avulsion of the superficial flexor tendon b. Central slip disruption c. Sagittal band rupture d. Avulsion of the deep flexor tendon e. Swan-neck deformity 3. A 34-year-old man presents to the office with a mallet deformity of the nondominant index finger sustained 13 years ago. He did not seek treatment at the time. On examination, which of the following deformities is likely to be present? a. Clinodactyly b. Hook-nail deformity c. Boutonnière d. Swan-neck e. Camptodactyly 4. A 37-year-old nurse presents to the emergency department with sudden weakness in his thumb. He fractured his distal radius 3 months previously. This was a nondisplaced fracture. He also has CMC joint laxity, symmetric to the unaffected hand. On exam, thumb retropulsion is absent. Which is the most appropriate treatment? a. Fusion of the CMC joint of the thumb b. Fusion of the IP joint of the thumb c. Transfer of the anterior interosseous nerve to the recurrent branch of the median nerve d. Transfer of the EIP tendon to the abductor pollicis brevis tendon e. Transfer of the EIP tendon to the EPL tendon 5. A 45-year-old man comes to the office because of sudden inability to extend the distal phalanx of the long finger after playing basketball. Physical examination shows that the distal phalanx of the long finger is held in 45° of flexion. The patient has no active extension of the joint. There is only minimal swelling over the DIP joint. X-rays are normal. Which of the following is the most appropriate management? a. Arthrodesis of the DIP joint in 15° of flexion b. Exploration and repair of the extensor tendon

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c. Percutaneous pin fixation of the DIP and proximal interphalangeal (PIP) joints d. Splinting of the DIP joint at 0° e. Observation only 6. A 17-year-old girl undergoes extensor tendon repair in zone 4 and open treatment of a proximal phalangeal fracture affecting the nondominant fifth finger. At the 6-week postoperative visit, she is unable to actively extend the finger at the DIP and PIP joints. She has been very compliant with splinting. What is the most likely diagnosis? a. An unidentified terminal extensor injury b. Rupture of the repaired extensor tendon c. Unidentified sagittal band injury d. Malingering e. Tendon adhesions 1. Answer: d. There is redundancy built into the extensor mechanism. Despite complete EDC injury, the neighboring extensor tendons can bypass the site of laceration and exert pull on the distal stump of the extensor via the juncturae tendinae, hereby allowing full digit extension. Suspicion of injury should prompt surgical exploration and repair. Furthermore, the intrinsic system (interossei and lumbricals) inserts onto the extensor hood via the lateral bands and can extend the digit at the IP joints. 2. Answer: b. The central slip is ruptured, leading to extension lag at the PIP joint and an acute boutonnière deformity. Although a simple sprain may also cause PIP extension lag, it will not cause simultaneous DIP hyperextension. An abnormal Elson test can confirm the diagnosis. A ruptured superficial flexor tendon is rare and would lead to an inability to flex at the PIP joint with the neighboring digits held in extension. A ruptured deep flexor tendon makes DIP flexion impossible. Sagittal band rupture leads to subluxation of the extensor tendon and weakened extension at the MP joint. Swan-neck deformity results from terminal extensor tendon disruption and inability to actively extend the DIP joint independent of PIP position. 3. Answer: d. Flexion deformity of the distal joint seen in mallet finger will lead to secondary hyperextension of the proximal joint. This occurs in a zigzag fashion because of the imbalance of forces. If the terminal tendon is displaced proximally, the conjoined bands will slide proximally and become extensors to the proximal joint. A boutonnière deformity is a flexion deformity of the PIP joint from disruption of the central slip. The lateral slips migrate volarly becoming hyperextensors of the DIP joint clinodactyly is a congenital condition in which there is radial deviation of the fifth finger, usually at the middle phalangeal level. A hook nail results from loss of bone to support the nail, usually after amputation, causing curvature of the nail. Camptodactyly is also a congenital condition in which there is a fixed flexion deformity of the PIP joint of the fifth finger. 4. Answer: e. The scenario depicts a classic case of EPL tendon rupture following distal radius fracture. The reported incidence of EPL tendon rupture ranges from 0.2% to 3%. Ruptures can occur after internal or external fixation due to impingement of hardware on the tendon or due to ischemic changes in the tendon within the third dorsal compartment. Reconstruction of the EPL tendon can be accomplished either by tendon grafting, typically palmaris longus interposition between the proximal and distal healthy segments of the EPL tendon, or by transfer of the EIP to the distal segment of EPL tendon. Thumb IP joint fusion may be useful in flexor pollicis longus ruptures that cannot be repaired, but this would not restore thumb retropulsion and is rarely performed in this circumstance. Fusion of the CMC joint can alleviate pain from basal joint arthritis, but would result in further loss of motion of the thumb. Transfer of the EIP to the abductor pollicis brevis and transfer of the anterior interosseous nerve to the recurrent branch of the median nerve are techniques for restoring thumb palmar abduction/opposition and would not restore retropulsion/extension.

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5. Answer: d. The physical exam is consistent with an avulsion of the terminal extensor tendon, a mallet injury. In the absence of joint subluxation, conservative nonoperative management with splinting is recommended. This requires splinting the DIP joint in extension or slight hyperextension. One can employ prefabricated stack splints, malleable aluminum splints, or custom-made thermoplastic splints. Outcomes of each of these treatments are similar, but the type of splinting is generally more limited by skin irritation. Pin fixation for the DIP joint is recommended for patients who cannot tolerate splinting or those with special circumstances, such as a surgeon who requires unencumbered use of the hand. Pin fixation should cross the DIP joint only. Arthrodesis is an option for patients with degenerative arthritis of the DIP joint. Surgical mallet treatment is not recommended, unless it is an open injury. Observation is not advised due to the possibility of secondary effects such as a swan-neck deformity. 6. Answer: e. Her exam is consistent with adhesions of the repaired extensor tendon at the site of the fracture. This is a common issue, especially when multiple tissues are injured in close proximity. Because the extensor system is stuck at the level of the hood, both the central slip as well as lateral bands are lacking excursion, hence the lack of extension at the PIP and DIP joints. Early motion protocols can be used to minimize adhesions; however, the osteosynthesis and tendon repair should be of sufficient strength to allow early motion. A terminal extensor injury, as in a mallet, would not lead to extension lag at the PIP joint. A rupture of the repaired tendon is a possibility but unlikely in the setting of compliance with postoperative immobilization. A sagittal band injury would influence extension at the MP joint, not the PIP of DIP joints. To rule out malingering, the wrist can be passively flexed and extended (tenodesis) to verify excursion of the extensor system.

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References Van Sint Jan, S, Rooze, M, Van Audekerke, J, Vico, L. The insertion of the 
 extensor digitorum tendon on the proximal phalanx. J Hand Surg. 1996;
 21(1):69-76. Arnet, U, Muzykewicz, DA, Fridén, J, Lieber, RL. Intrinsic hand muscle function, part 1: creating a functional grasp. J Hand Surg. 2013;38(11):2093-2099. Harris, C, Rutledge, GL. The functional anatomy of the extensor mechanism of the finger. J Bone Joint Surg Am. 1972;54A:713-726.In this oftcited classic article, the authors carefully dissect the extension function of the human finger using fresh cadaver specimens. A methodical and precise rendition of the anatomy is provided along with the proposed role of each structure alone and in unison with others. el-Gammal, TA, Steyers, CM, Blair, WF, Maynard, JA. Anatomy of the oblique 
 retinacular ligament of the index finger. J Hand Surg. 1993;18(4):717-721. Adkinson, JM, Johnson, SP, Chung, KC. The clinical implications of the oblique retinacular ligament. J Hand Surg. 2014;39(3):535-541.The authors review the oblique retinacular ligament, its discovery, functional role, and clinical significance. Although the role of the ligament is now thought to be insignificant, the concept of linking interphalangeal joint motion led to the development of effective surgical interventions for mallet injuries and swan-neck deformities. Marshall, TG, Sivakumar, B, Smith, BJ, Hile, MS. Mechanics of metacarpophalangeal joint extension. J Hand Surg. 2018;43(7):681e1-681e5. Minamikawa, Y, Peimer, CA, Yamaguchi, T, et al. Wrist position and extensor tendon amplitude following repair. J Hand Surg. 1992;17(2):268-271. Vahey, JW, Wegner, DA, Hastings, H. Effect of proximal phalangeal fracture deformity on extensor tendon function. J Hand Surg. 1998;23(4):673-681. Schweitzer, TP, Rayan, GM. The terminal tendon of the digital extensor mechanism. Part II: kinematic study. J Hand Surg. 2004;29(5):903-908. Kleinert, HE, Verdan, C. Report of the committee on tendon injuries (International Federation of Societies for Surgery of the Hand). J Hand Surg. 1983;8(5 Pt 2):
 794-798. Doyle, J. Extensor tendons: acute injuries. In: Green, D , ed. Operative Hand Surgery. 3rd ed. New York, NY: Churchill Livingstone; 1993. Browne, EZ, Ribik, CA. Early dynamic splinting for extensor tendon injuries. J Hand Surg. 1989;14(1):72-76. Mowlavi, A, Burns, M, Brown, RE. Dynamic versus static splinting of simple zone V and zone VI extensor tendon repairs: a prospective, randomized, controlled study. Plast Reconstr Surg. 2005;115(2):482-487. Kitis, A, Ozcan, RH, Bagdatli, D, et al. Comparison of static and dynamic splinting regimens for extensor tendon repairs in zones V to VII. J Plast Surg Hand Surg. 2012;46(3-4):267-271. Collocott, SJ, Kelly, E, Ellis, RF. Optimal early active mobilisation protocol after extensor tendon repairs in zones V and VI: a systematic review of literature. Hand Ther. 2018;23(1):3-18. Neuhaus, V, Wong, G, Russo, KE, Mudgal, CS. Dynamic splinting with early motion following zone IV/V and TI to TIII extensor tendon repairs. J Hand Surg. 2012;37(5):933-937. Evans, D, Weightman, B. The Pipflex splint for treatment of mallet finger. J Hand Surg Edinb Scotl. 1988;13(2):156-158. Pike, J, Mulpuri, K, Metzger, M, et al. Blinded, prospective, randomized clinical trial comparing volar, dorsal, and custom thermoplastic splinting in treatment of acute mallet finger. J Hand Surg. 2010;35(4):580-588. Handoll, HHG, Vaghela, MV. Interventions for treating mallet finger injuries. Cochrane Database Syst Rev. 2004;(3):CD004574.This Cochrane review assessed four randomized controlled trials for the treatment of acute mallet finger to ascertain effective treatment methods. There was methodological flaws in all of the trials, and there was no comparative advantage seen in different splinting methods or pin fixation. The importance of patient compliance was stressed. Iselin, F, Levame, J, Godoy, J. A simplified technique for treating mallet fingers: tenodermodesis. J Hand Surg. 1977;2(2):118-121. Thompson, JS, Littler, JW, Upton, J. The spiral oblique retinacular ligament (SORL). J Hand Surg. 1978;3(5):482-487. Kleinman, WB, Petersen, DP. Oblique retinacular ligament reconstruction for chronic mallet finger deformity. J Hand Surg. 1984;9(3):399-404. Oh, JY, Kim, JS, Lee, DC, et al. Comparative study of spiral oblique retinacular ligament reconstruction techniques using either a lateral band or a tendon graft. Arch Plast Surg. 2013;40(6):773-778. Hart, RG, Uehara, DT, Kutz, JE. Extensor tendon injuries of the hand. Emerg Med Clin North Am. 1993;11(3):637-649. Rockwell, WB, Butler, PN, Byrne, BA. Extensor tendon: anatomy, injury, and reconstruction. Plast Reconstr Surg. 2000;106(7):1592-1603, 1673. Grau, L, Baydoun, H, Chen, K, et al. Biomechanics of the acute boutonniere deformity. J Hand Surg. 2018;43(1):80e1-80e6. Elson, RA. Rupture of the central slip of the extensor hood of the finger. A test for early diagnosis. J Bone Joint Surg Br. 1986;68B:229231.Recognizing that closed rupture of the central slip is easily missed until the late appearance of a boutonniere deformity, Elson proposed a new test to assess integrity of the central slip. Absence of extension force at the PIP joint and fixed extension at the DIP joint, when the finger is held in PIP flexion, are signs of complete rupture. Rubin, J, Bozentka, DJ, Bora, FW. Diagnosis of closed central slip injuries: a cadaveric analysis of non-invasive tests. J Hand Surg Edinb Scotl. 1996;21(5):614-616. Littler, JW, Eaton, RG. Redistribution of forces in the correction of boutonniere deformity. J Bone Joint Surg Am. 1967;49A:1267-1274.The authors describe the pathophysiology of the boutonniere deformity and a method of repair that involves using the lateral bands, where they are detached from the terminal tendon and repaired to the central slip insertion. In this reconstruction for chronic deformity, the new insertion of the bands functions to extend the PIP joint.

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Curtis, RM, Reid, RL, Provost, JM. A staged technique for the repair of the traumatic boutonniere deformity. J Hand Surg. 1983;8(2):167-171. Hung, LK, Chan, A, Chang, J, et al. Early controlled active mobilization with dynamic splintage for treatment of extensor tendon injuries. J Hand Surg. 1990;15(2):251-257. Chester, DL, Beale, S, Beveridge, L, et al. A prospective, controlled, randomized trial comparing early active extension with passive extension using a dynamic splint in the rehabilitation of repaired extensor tendons. J Hand Surg Edinb Scotl. 2002;27(3):283-288. Koniuch, MP, Peimer, CA, VanGorder, T, Moncada, A. Closed crush injury of the metacarpophalangeal joint. J Hand Surg. 1987;12(5 Pt 1):750-757. Newport, ML, Blair, WF, Steyers, CM. Long-term results of extensor tendon repair. J Hand Surg. 1990;15(6):961-966. De Smet, L, Van Loon, J, Fabry, G. Extensor indicis proprius to extensor pollicis longus transfer: results and complications. Acta Orthop Belg. 1997;63(3):178-181. Moore, JR, Weiland, AJ, Valdata, L. Independent index extension after extensor indicis proprius transfer. J Hand Surg. 1987;12(2):232-236.

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CHAPTER 78

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Tenosynovitis Disorders of the Upper Extremity Lydia A. Helliwell and Kyle R. Eberlin

Key Points Lateral epicondylitis results from microtears at the origin of the common extensor tendon mass, specifically the extensor carpi radialis brevis tendon, causing mucoid degeneration. It is often a selflimited condition that may take 1 to 2 years to resolve. Medial epicondylitis affects the common flexor tendon mass, most often the pronator teres and flexor carpi radialis. Conservative management is the mainstay of medial epicondylitis treatment, and all patients should be assessed for possible ulnar neuropathy. De Quervain disease is a stenosing tendiopathy involving the tendons of the first dorsal compartment (abductor pollicis longus and extensor pollicis brevis), resulting in painful wrist and thumb motion. Treatment options include splinting, corticosteroid injections, and operative decompression. Intersection syndrome results in pain, swelling and often crepitus over the junction on the first and second extensor compartments, approximately 4 cm proximal to the radiocarpal joint. It often resolves with nonoperative treatment such as therapy and splinting. Trigger fingers occur by a combination of thickening of the A1 pulley and nodule formation within the flexor tendon, resulting in pain and locking of the finger. Corticosteroid injections are effective in many patients, but if unsuccessful, surgery may be considered. Diabetics are less likely to respond to nonoperative treatment. Painful tendinopathy of the elbow, wrist, and hand includes some of the most common issues presenting to upper extremity surgeons. Collectively, these conditions are often described as tenosynovitis disorders; however, this nomenclature can be misleading as the term tenosynovitis implies the existence of an inflammatory process. In contrast, many common disorders involving the tendons of the upper extremity are the result of degenerative or mechanical stresses, rather than an inflammatory process. These conditions include lateral and medial epicondylitis of the elbow, de Quervain disease, intersection syndrome, and trigger finger. In addition to these common pathologies, there are several less common disorders involving the tendons of the wrist and hand. Almost every tendon in the hand and wrist can cause pain if irritated through mechanical stresses or stenosing forces. Atypical conditions include tendinopathy of the extensor carpi ulnaris (ECU), flexor carpi radialis (FCR), and extensor pollicis longus (EPL) tendons. In addition, there are also inflammatory tendon disorders of the wrist and hand, including rheumatoid arthritis, calcific tendinitis, as well as myriad infections that can affect these areas. The purpose of this chapter is to discuss the common tendinopathies affecting the upper extremity. Despite the ubiquitous nature of tendon disorders in the upper extremity, treatment controversies remain. Both nonoperative and operative treatments exist and a definitive treatment algorithm remains elusive despite a plethora of studies.

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Lateral Epicondylitis Lateral epicondylitis is a common cause of lateral elbow pain. First described by Runge in 1873 in a patient unable to write because of pain and tenderness over the lateral epicondyle, it became commonly known as tennis elbow after Morris described a similar condition as lawn tennis arm in 1882. 1 Despite its common name and association, lateral epicondylitis may be precipitated by any activity that results in forceful repetitive motion of the forearm extensors. 2 It may also develop insidiously without antecedent trauma. The pain can be acute 
 or chronic in nature and typically begins near the lateral epicondyle and radiates distally along the dorsal forearm. Manual activities, 
 particularly lifting loads greater than 20 kg, have been associated with the development of lateral epicondylitis. It has been estimated that approximately 1% to 3% of the population will develop lateral epicondylitis during their lifetime. It is equally common in men and women, and prevalence peaks between the ages of 45 and 54 years. 2 The lateral epicondyle is the origin for the common extensor tendons that include the tendons of the extensor carpi radialis brevis (ECRB), the extensor digitorum communis (EDC), and the ECU. Although each of these tendons may be involved in the process, the classic finding of lateral epicondylitis includes ECRB tendon pathology. The ECRB is located deep to the extensor carpi radialis longus (ECRL) and EDC and acts as a wrist extensor, inserting distally on the base of the third metacarpal. Changes within the ECRB tendon substance represent the sine qua non for lateral epicondylitis. Although initially believed to be an inflammatory process involving the common origin of the wrist extensors, histopathologic analysis has shown an absence of inflammatory cells and instead has revealed markers of a degenerative process consistent with tendinosis rather than tenosynovitis. The tendons frequently demonstrate repetitive microtrauma, and the body’s attempt to repair these microtears results in a number of pathologic findings including hyaline and mucoid degeneration, fibrosis, calcifications, and fibrovascular proliferation. Inflammatory cells, such as macrophages and neutrophils, are lacking. 3 Despite these findings, the true pathogenesis of lateral epicondylitis remains a matter of debate. Many theories have been postulated, with some hypothesizing that repetitive contact between the capitellum and the ECRB tendon may be the causative problem. 4 Patients often present with pain over the lateral epicondyle and the common extensor tendon origin, immediately distal and anterior to the lateral epicondyle. On exam, resisted wrist extension with the elbow extended and the wrist pronated is a provocative maneuver that may elicit increased pain. A complete elbow examination should be performed to ensure that there is no other source of elbow pain. Other causes of elbow pain, including osteoarthritis, osteochondritis dissecans, occult fracture, lateral ulnar collateral ligament injury, plica, radial tunnel syndrome, and synovitis of the radiohumeral joint should be considered and exonerated. Imaging studies add limited information in the diagnosis of lateral epicondylitis. Radiographic images of the elbow may be obtained to rule out arthritic changes as a source of pain but have not been found to aid significantly in the diagnosis of lateral epicondylitis. Ultrasound (US) and magnetic resonance imaging (MRI) have both been utilized for diagnosis, to assess disease severity and for purposes of preoperative planning. Ultrasound has been found to have a lower sensitivity for detection of both lateral and medial epicondylitis (64%–82%) and therefore, MRI is often the modality of choice, with a higher sensitivity of 90% to 100%. 5 However, the severity of disease present on MRI does not necessarily correlate with symptoms, and patients with resolved pain may continue to have pathologic findings present on MRI. MRI is often reserved for recalcitrant cases in which the patient fails to improve with 6 months of conservative treatment or when the diagnosis in unclear. 6 The treatment of lateral epicondylitis remains one of the most controversial subjects in hand and upper extremity surgery. In his paper on tennis elbow published in 1936, Cyriax wrote “the condition usually clears up in eight to twelve months without any treatment except perhaps avoidance of the painful

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movements.” 7 For many surgeons, activity modification continues to be the mainstay of treatment for lateral epicondylitis, with up to 90% of patients improving without intervention in some studies. 8 Other studies, however, suggest that up to 40% of people continue to have discomfort after 1 to 5 years of nonoperative treatment. 9 Modalities for nonoperative management include counterforce bracing, wrist and elbow splinting, physical therapy, iontophoresis, shockwave therapy, laser therapy, nonsteroidal antiinflammatory medications, and a number of different injection therapies (corticosteroids, botulinum toxin, platelet-rich plasma, and autologous blood). Despite numerous randomized controlled studies, none of these interventions has been definitively proven to work better than rest and therapy alone. 8 Physical and occupational therapy for lateral epicondylitis often includes gentle stretching with progression to more aggressive strengthening. Studies comparing physical therapy to no intervention found patients improved in the short term, but differences in the long term were not significant. 10 Counterforce bracing and wrist splinting are also employed; counterforce bracing appears to work by offloading the common extensor origin by applying pressure to a more distal site on the muscle, which then acts as the new muscle origin. Cock-up wrist splints maintain the wrist in extension, thereby offloading the extensors. Several studies have compared bracing or splinting to physical therapy and to each other with conflicting results. 11 Injections into and around the lateral epicondyle remain highly controversial. Corticosteroid injection into the site of maximal tenderness is a common intervention performed when pain is not relieved with therapy or splinting alone. Various combinations of dexamethasone, betamethasone, and triamcinolone with or without local anesthesia have been given. Some studies have shown an improvement in pain at 4 to 6 weeks, but this advantage usually is not present at 12 months. 12 The exact mechanism by which steroid injection might improve pain is not well understood as corticosteroids usually counteract inflammation, which as mentioned earlier, is not present in lateral epicondylitis. There is no prospective, randomized trial demonstrating a long-term benefit of steroid injection for lateral epicondylitis. Additionally, complications such as fat atrophy and/or hypopigmentation may occur (Figure 78.1).

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FIGURE 78.1 Atrophy and discoloration after multiple steroid injections for lateral epicondylitis.

Botulinum toxin A has also been used in the treatment of lateral epicondylitis to temporarily paralyze the extensor muscles to reduce further microtrauma and pain. Studies have been variable in their results, with no clear long-term benefit conferred. Transient loss of finger extension is a potential side effect. Platelet-rich plasma and autologous blood are two other injection therapies that have been attempted without demonstrable benefit at long-term follow-up. 12 Surgical intervention for lateral epicondylitis is usually reserved for the small percentage of patients who fail 6 to 12 months of conservative management and who remain significantly affected by pain. In general, the main surgical tenet includes debridement of the common origin of the wrist extensors at the site of tendinopathy. A number of surgical techniques have been described, including open, percutaneous, and arthroscopic approaches. Many patients will improve with or without surgery, and therefore the decision to proceed with surgical intervention is complicated; the choice of approach is determined by surgeon experience and patient preference. All surgical procedures for lateral epicondylitis aim to address the pathology associated with the ECRB. Open, percutaneous, or arthroscopic release of the ECRB from the lateral epicondyle, open, or arthroscopic debridement of the ECRB tendinosis, denervation of the lateral epicondyle, and anconeus rotation have all been described with fair to good results. The open approach is performed via a small incision over the common extensor tendon distal to the lateral epicondyle. The interval between the ECRL and EDC is identified and incised. The ECRB is found directly deep to these muscles, and can be divided and the tendonosis debrided. The diseased tissue is usually white-gray in color with a friable, disorganized appearance. The joint can be inspected for plica. Care is taken not to debride the lateral ulnar collateral ligament, as this will lead to elbow instability. A volar wrist splint is usually applied to

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maintain the wrist in extension and take stress off the common extensor origin until the incision has healed and elbow motion has returned to normal. Outcomes after open treatment have been good to excellent in several studies. Nirschl and Pettrone reported that after 88 open ECRB debridements, 98% of patients improved and 85% were able to return to work. 13 The arthroscopic approach utilizes the same principles, approaching the diseased ECRB from its medial aspect. This approach has the advantage of visualizing the joint directly and for identifying other pathology, including loose bodies and plicae. Disadvantages include decreased visualization of the ECRB tendon, resulting in potential incomplete debridement of diseased tissues, and greater possibility of radial nerve injury. Studies have shown that the arthroscopic approach has similar results to the open approach at long-term follow-up of 130 months. 14 However, when open, arthroscopic, and percutaneous approaches were compared, no difference in functional outcome, pain intensity, or patient satisfaction was found at 1-year follow-up. 15 Complications from either approach are wound breakdown, infection, injury to the lateral ulnar collateral ligament, neurovascular injury, and incomplete relief of pain with ongoing disability. Overall, lateral epicondylitis remains a conundrum for upper extremity surgeons, with many available treatment options but no conclusively disease-modifying interventions.

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Medial Epicondylitis Medial epicondylitis, also known as golfer’s elbow, is a common cause of medial elbow pain. Although less prevalent than lateral epicondylitis (35° of angulation, complete ligament tear is likely. If this occurs with joint flexed, it is a proper collateral tear. If this occurs with joint fully extended, it is an accessory collateral tear. If the joint can be stressed >15° more than contralateral, a complete tear is likely. If a mass is palpable proximal to the tMCPJ, this may indicate a Stener lesion. However, the absence of this finding does not rule it out. Evaluate X-rays because avulsion fractures are common. Is the avulsion displaced? More than 2 mm of displacement? Is it proximal to the level of the adductor hood? If so, this is likely a bony Stener lesion (Figure 80.8). Is 20% or more of the joint surface involved? Is the UCL unstable? Is advanced imaging necessary? 35 Ultrasound MRI

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FIGURE 80.7 Thumb MCP anatomy. Note that the proper collateral ligament (P) is tight in 30° of flexion, while the accessory collateral (A) is tight in full extension. This is why when testing for a collateral ligament injury one must check the joint fully extended and flexed to 30°. This relationship is the same for finger PIP collateral ligaments.

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FIGURE 80.8 Stener lesion. A. X-ray of a thumb with instability and pain on testing of the ulnar collateral ligament. Note the small fracture fragment proximal to the joint line (red arrow). B. MRI of the same thumb with avulsed ulnar collateral ligament (yellow arrow) retracted proximal to the adductor aponeurosis (blue arrow).

If a complete UCL tear is diagnosed (aka Skier’s thumb), open repair of the ligament is warranted. 36 These injuries usually involve detachment off of the distal site, but proximal tears and midsubstance tears do occur as well. Small minimally displaced (4 mm with static instability) can be observed with standard radiographs. Reducibility of the scaphoid, or correction of DISI deformity, may signify whether a reconstruction can be performed. If the deformity is not reducible, a salvage operation should be considered, e.g., scaphoidectomy and partial fusion versus PRC. Long-standing carpal malalignment owing to SL ligament disruption leads to a predictable pattern of wrist arthritis or SLAC. Standard PA X-rays may reveal radial styloid arthritis (stage I), radioscaphoid arthritis (stage II), scaphocapitate arthritis (stage III), or pancarpal arthritis (stage IV). The degree of arthritis and which articular surfaces have been affected or spared become important when deciding which pain-relieving operation to perform. If the radiolunate or capitolunate joints have been affected, the patient is not a candidate for PRC (Figure 81.3).

FIGURE 81.3 Scapholunate advanced collapse (SLAC arthritis). (From Michelotti, BF, Chung, KC. Scaphoid excision and four-corner fusion. In: Chung, KC , ed. Operative Techniques: Hand and Wrist Surgery. 3rd ed. Philadelphia; PA: Elsevier Saunders; 2017:244; with permission.)

Diagnosis of SL injury begins with a focused history and physical examination. History of fall onto an outstretched hand, dorsal wrist pain, and pain that is exacerbated with axial loading should prompt careful examination of the SL interval. Palpation over the SL ligament, just distal to the Lister tubercle and between the EPL and EDC tendons, may elicit pain. The scaphoid shift test is performed by dorsally directing pressure through the distal scaphoid tubercle while passively moving the wrist from ulnar to radial. With laxity or disruption of the SL ligament, the proximal scaphoid will dislocate dorsally. A clunk is appreciated when the bone is reduced into the scaphoid fossa of the radius. Dislocation in association with pain should prompt further evaluation with adjunctive tests such as noncontrast MRI or

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wrist arthroscopy. Standard three-view wrist X-rays may identify widening of the SL interval. More than 4 mm of gapping (Terry Thomas sign) may be static SL instability but it may also be nonpathologic widening of the interval as seen in elderly; therefore, this must be considered in the context of history and physical examination and may be compared with the unaffected side. A true PA X-ray may reveal the signet ring sign, where the distal pole of the scaphoid projects through the proximal pole and appears as a ring. With tearing or attrition of the secondary stabilizing ligaments (STT, DIC, RSC), the scaphoid assumes a flexed position and the lunate extends (DISI deformity). The SL angle is normally between 30° and 60° (mean 47°) but with DISI deformity, the angle exceeds 60° (Figure 81.4).

FIGURE 81.4 A. Scaphoid ring sign and Terry Thomas sign. B. Lateral radiograph demonstrating an increased SL angle. (From Michelotti, BF, Chung, KC. Scapholunate ligament reconstruction. In: Chung, KC , ed. Operative Techniques: Hand and Wrist Surgery. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2017:185; with permission.)

In the patient with pain but normal X-ray findings (possible predynamic instability) or with evidence of dynamic instability (gapping of the SL interval with wrist loading), arthroscopy may be performed to further characterize the injury pattern. Geissler described an arthroscopic grading system to classify interosseous ligament injury 7 : Grade I: Attenuation and hemorrhage of interosseous ligament seen from radiocarpal joint, with no step-off present as seen from midcarpal joint

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Grade II: Attenuation and hemorrhage of interosseous ligament seen from radiocarpal joint, with step-off seen through midcarpal joint; the probe can be placed between the scaphoid and lunate Grade III: Incongruence or step-off is seen between the scaphoid and the lunate from both the radiocarpal and midcarpal portals; the probe can be placed and freely rotated between the scaphoid and lunate Grade IV: Incongruence or step-off is seen between the scaphoid and lunate from both the radiocarpal and midcarpal portals; gross instability is noted, and the 2.7 mm arthroscope may be passed through the gap between the scaphoid and lunate Grades I to III of the Geissler classification system represent partial injury to the SLIL or predynamic instability. Grade IV represents complete disruption of the SLIL and dynamic instability.

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Treatment Treatment of SL pathology is dictated by the degree of ligamentous disruption and the chronicity of the injury.

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Predynamic Instability Arthroscopic debridement and percutaneous pinning of SL interval Proprioceptive rehabilitation

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Dynamic Instability, Direct Repair Possible Dorsal SLIL repair with or without capsulodesis

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Dynamic Instability, Direct Repair Not Possible Ligamentous reconstruction from DIC and palmaris graft Bone-tissue-bone graft Three-ligament tenodesis

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Static, Reducible Instability Three-ligament tenodesis

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SLAC Scaphoidectomy and partial fusion PRC

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Predynamic Instability Initial treatment of suspected predynamic SL should consist of a trial of bracing and nonsteroidal antiinflammatories. If this fails to reduce pain localizing to the SL interval, Geissler and others suggest that predynamic instability (Geissler grade I to III) can be treated by arthroscopic debridement and/or percutaneous pinning of the SL interval. 7,9,10 Chronic predynamic instability has also been treated with selective proprioceptive rehabilitation, arthroscopic debridement, or capsular shrinkage. Whipple determined that in patients who were treated within 3 months of injury, 83% remained symptom-free and maintained their reduction in up to 7-year follow-up. 9

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Dynamic Instability Treatment of dynamic instability depends on whether the ligament is repairable. Assuming it has been only 6 weeks from the time of injury (acute), the ligament can either be repaired (midsubstance tear) or anchored to the bone with bone tunnels or suture anchors. Repair of the dorsal portion of the SL ligament is all that is required to restore normal relationships between the carpus. 2,11,12 When direct repair of the ligament is not possible, a three-ligament tenodesis, or bone-tissue-bone ligament reconstruction may be considered 13–15 (Figure 81.5). Proponents of the bone-tissue-bone construct suggest that bone-to-bone contact may heal more predictably than a bone-tendon interface. However, studies have shown that the tissue portion of the graft may stretch and fail, the bone graft may not unite, and, with static instability, rotatory subluxation of the scaphoid cannot be addressed.

FIGURE 81.5 Tendon reconstruction of the scapholunate interosseous ligament (Brunelli and modifications). FCR, flexor carpi

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radialis. (From Michelotti, BF, Chung, KC. Scapholunate ligament reconstruction. In: Chung, KC , ed. Operative Techniques: Hand and Wrist Surgery. 3rd ed. Philadelphia, PA: Elsevier Saunders; 2017:199; with permission.)

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Static, Reducible Instability When the secondary stabilizing ligaments of the scaphoid fail because of an acute, high-energy injury, or over time with attrition (STT, DIC, RSC), the scaphoid assumes a flexed, pronated posture. It is important to carefully examine the patient for the ability to reduce or correct the DISI deformity and for the absence of articular wear, as both are a contraindication for reconstruction. The initial three-ligament tenodesis uses a portion of the flexor carpi radialis (FCR) tendon to pass through a bone tunnel in the scaphoid, from palmar to dorsal, to improve the abnormally flexed posture in addition to reconstructing the dorsal portion of the SL ligament. The distal tendon graft is anchored to the radius. This was well tolerated but resulted in average loss in wrist flexion of 45% as compared with the unaffected side. 16 A modified tenodesis addressed the decrease in wrist flexion by anchoring the FCR tendon to the dorsal lunate instead of crossing the radius. 17 In the patient with dynamic or staticreducible instability, long-term data suggest that the modified Brunelli tenodesis is effective at reducing pain, may permit near-normal wrist motion, and will likely improve patient-reported outcome measures. Some patients still develop SLAC arthritis and will need wrist fusion procedures. 18,19

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Static, Irreducible Instability When the DISI deformity is fixed and cannot be reduced, or there are signs of articular wear, the patient is no longer a candidate for ligamentous reconstruction but should be counseled on salvage procedures for pain relief. Rotatory subluxation of the scaphoid, around the RSC ligament, results in abnormal contact of the scaphoid with the radial styloid and scaphoid fossa of the radius. Over time, this leads to articular wear and a predictable progression of arthritis beginning with the radial styloid, progressing to the radioscaphoid articulation, scaphocapitate and lunocapitate joints, and finally to the lunate fossa. The most common salvage procedures aimed at relieving wrist pain caused by SL or SLAC are scaphoidectomy and intercarpal fusion, and PRC. Recent data suggest that the PRC is more cost-effective. 20

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Rehabilitation and Recovery Painless motion is the goal of an SL repair or reconstruction. Patients are immobilized in a wrist brace for 8 weeks or until K-wires are removed. Gentle range of motion exercises is initiated and gradually advanced over 3 months. Protecting the reconstruction assures its durability and long-term effectiveness, therefore, a subtle loss in motion is accepted. Patients are counseled to expect loss of motion after any type of wrist surgery.

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Lunotriquetral Ligament Injury Diagnosis Injury to the LT in isolation is a rare but commonly overlooked diagnosis. This injury may be encountered in a patient with concomitant ulnar-sided wrist pathology and is often seen in athletes who participate in high-energy or impact sports. 21 Lunotriquetral injury can occur after a fall onto an outstretched wrist with a dorsally directed force through a volar-flexed wrist, or as part of the perilunate instability spectrum with pressure directed through the thenar region as the wrist is extended and ulnarly deviated. The LT is similar to the SL in that it is a U-shaped, interosseous ligament, connecting the lunate to the triquetrum, stabilizing the LT joint. The LT ligament also consists of a dorsal, membranous, and volar portion but differs from the SL ligament in that its volar portion is the strongest. Secondary stabilizers of the LT interval include radiolunotriquetral ligament and the DRC. The triquetrum is tightly articulated with the hamate, and it is through this interaction that the proximal and distal carpal rows are linked. With radial deviation, the hamate forces the triquetrum to flex, which translates through the LT and SL ligaments resulting in scaphoid flexion. With ulnar deviation, the hamate drives the triquetrum into extension, carrying the lunate and scaphoid into extension as well. With disruption of the LT ligament, and the secondary stabilizing ligaments, in the absence of a concomitant SL tear, the lunate remains tightly articulated with the scaphoid and assumes a flexed position (Figure 81.6). LT injury also exists along an injury spectrum with both dynamic and static instability. With static instability, the SL angle becomes more acute (12 mm s2PD) and normal ( scapula > lateral arm > radial forearm b Gracilis with STSG, latissimus dorsi, ALT, rectus abdominus, lateral arm, radial forearm, scapular

a

Flap choices for each option are listed more to less optimal.

b

Nerve coaptation may be considered.

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ATL, anterolateral thigh flap; STSG, split-thickness skin graft.

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Other Reconstructive Options Tissue Expansion Tissue expansion is another modality available, although infrequently used, to aid with lower extremity reconstruction. It is typically used for skin resurfacing, coverage of wounds, removal of benign defects, and repair of contour abnormalities as it provides local tissue with appropriate skin match and similar quality. It is difficult to use in the acute setting and is more suitable for chronic conditions. The expanded tissue has a good blood supply from essentially being delayed, which can contribute to successful reconstruction. It is best to expand tissue transversely from the defect, as the tissue moves better in that plane. Large, crescent-shaped expanders work best. They can be placed near the edge of a wound or with an endoscope to limit incisions. Expanders do have high infection rates (up to 30%). The more distal they are placed, the more common the complications and are infrequently successful below the knee, making the lower leg a relative contraindication to their use. 1,8,31

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Negative-Pressure Wound Therapy The first commercially available negative pressure wound therapy device, or the wound vacuum-assisted closure (VAC), was available in 1996 (KCI, San Antonio, TX) and has transformed the practice of wound care. 30 The VAC uses an open-cell polymer foam in the wound bed, which is sealed and placed under negative pressure. In doing so, it promotes granulation tissue formation on a cellular level and increases blood flow, while grossly contracting the wound and decreasing bacterial contamination. 1,8,30 The wound VAC is most useful as a temporizing measure before definitive closure and is not meant to be used as a definitive reconstruction. 8 It can safely be placed on soft tissue, bone, and tendon and produce adequate granulation tissue to take a skin graft or even achieve secondary healing in some cases 30 and will increase the survival of random pattern flaps. 8

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Dermal Regeneration Templates A dermal regeneration template is a form of artificial skin (Integra, Life Sciences, Plainsboro, NJ) that can be used for the treatment of wounds. Integra is a layered product that is made up of bovine type I collagen with glycosaminoglycans that is covered with a silicone layer. The collagen matrix allows dermal regeneration, whereas the silicone is a temporary protective barrier. It is an immediate off-theshelf product that can be used to close wounds and is particularly useful in patients who do not have adequate local donor tissue. Currently, Integra is most commonly used for burn wounds, but it can also be used for vascular ulcers, for wounds from lesion excision, and for tendon and bone exposure. It is placed on the wound bed and left in place for three or more weeks. Then, the silicone barrier is removed and a thin skin graft is placed over the Integra. 32,33

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Other Problems Chronic Osteomyelitis Chronic osteomyelitis is most commonly caused by retained necrotic bone, infected bone, ischemic tissue, dead space, and inadequate soft-tissue coverage. Treatment of chronic wounds and osteomyelitis require conversion to an acute wound again. This is best approached by thinking of the infected or necrotic area as a tumor and removing it in entirety, until healthy, viable tissue with punctate bleeding has been reached. Bacteria require eradication with antibiotics, typically those that cover Staphylococcus species, as those are most common. If present, hardware can harbor bacteria and should be removed. If the fracture is still not repaired and requires fixation, an external fixator is appropriate. 1,9

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Persistent Nonunion Bony nonunions are more common in the foot because of the tenuous vascular supply of the talus and navicular bones. Some avascular necrosis is caused by trauma, whereas others are from damage from open approaches during fixation. Typically, this problem can be treated with arthrodesis. In patients who have had multiple revisions, infection, or significant osteonecrosis, vascularized bone flap is used. Large bone gaps require free fibula or free iliac crest. Smaller defects benefit from medial femoral condyle free flaps. 18 This flap is ideal because it contains a vascularized periosteum and cancellous bone and can be utilized to fix many different persistent nonunions. The donor site at the distal femur is well tolerated and does not cause any instability; the patient can be weight-bearing on the donor site immediately. 34

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Salvage of Below-Knee Amputation Stumps Another important aspect of lower extremity reconstruction is salvage of amputation stumps. Patients are much more likely to use a prosthesis if they have a below-knee amputation versus an above-knee amputation. However, sometimes the trauma that cause the amputation creates a wound that is not amenable to primary closure without either shortening the stump, revising the amputation, or doing a free flap for coverage. About 14 cm of length is necessary to support a prosthesis for a below-knee amputation. If done during the inciting event, free flap with spare parts can be performed to preserve length, otherwise, traditional free flaps can be performed to make the amputation remnant amenable for a prosthesis 1,4,9

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Avascular Necrosis of the Femoral Head Avascular necrosis of the femoral head is a progressive condition that initially affects patients between the ages of 20 and 50 years and is caused by alcohol consumption, steroids, trauma, and Perthes disease. It starts with osteonecrosis, which leads to cartilage destruction and secondary degenerative changes. Typically, this condition would be managed with total arthroplasty, but in this age group, it is fraught with a high rate of complications and a high rate of revisions. It can also be treated with core decompression, but this does not provide structural support. A good solution in this patient population is to use a vascularized free fibula graft. It requires core decompression of the dead sequestrum to create space for the fibula. The fibula is placed in this cored-out tunnel in the femoral head and brings both support and revascularization. Younger patients have a better outcome with free fibula grafting, although 20% of this patient population will still require a total joint replacement later in life. 1,35,36

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Reconstruction of Peroneal Nerve Injuries The common peroneal nerve is the most frequent nerve injury of the lower extremity, as it can be injured with penetrating trauma, fractures, knee dislocations, ankle sprains, or iatrogenically during a knee surgery. Traction injuries recover spontaneously, but patients who suffer irreversible damage benefit from surgical treatment, otherwise these patients are committed to wearing a foot drop brace. Treatment options include nerve grafting and tendon transfer. Nerve grafting has shown favorable results, particularly in small nerve gaps. Tendon transfer should be reserved for those who failed nerve recovery or repair. A posterior tibialis tendon to anterior tibial tendon transfer is the standard tendon transfer to treat foot drop. Garozzo et al had favorable results when combining nerve repair with grafting in a onestage procedure, discussing that they felt tendon imbalance was part of the reason for poor recovery after nerve grafting alone. 37-39

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Oncologic Reconstruction In cases of oncologic extirpation, extremity reconstruction can prevent an amputation. Most cases are caused by bony sarcomas, and removal of a large segment of bone requires a vascularized reconstruction, particularly in instances where the patient has been radiated. Most bony defects are amenable to reconstruction with a free fibula. However, the femur and tibia require strength, which can be accomplished with a double-barreled fibula or a fibula placed in an allograft (Capanna technique). 1,9

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Aesthetics of the Lower Extremity Although the ultimate goal of lower extremity reconstruction is to create a functional result, appearance should not be ignored. The most important aspect of attaining an aesthetic result is proper flap choice. Muscle flaps covered by skin grafts tend to have a less aesthetic result. Over time, they remain bulky and frequently require revision for contouring. If a muscle flap is required, attention to inset and postoperative management can improve results. First, choosing a flap of appropriate dimensions for the defect can make the initial aesthetic result better. Then, insetting the flap with horizontal mattress sutures promotes a smoother junction between the flap and the native skin. Postoperative care with compression with an ACE wrap or compression sock can aid in shrinking the flap to fit the defect. If fasciocutaneous flaps are used, thinner flaps are better. This can be achieved by choosing a flap that is thinner to begin with (depending on the patient’s body habitus), thinning the flap around the perforator intraoperatively, or performing revisions to thin the flap secondarily. Bulky flaps are not just an anesthetic problem in the lower extremity, those located distally can prevent proper footwear fit. If the cosmetic result after the initial reconstruction is poor, a revised reconstruction with a fasciocutaneous free flap may provide a better result. 40-42

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Postoperative Management Postoperative patient management is dictated by the reconstruction performed. For all free flaps, standard clinical free flap monitoring, including internal and/or external Doppler signal, color, capillary refill, and temperature are performed hourly by the nursing staff for the first 48 hours, then every 2 hours for the next 48 hours, and then every 4 hours for the remaining hospitalization. If the patient has a buried flap, an internal Doppler device is used. All patients are initially on bed rest with the affected extremity elevated for 2 to 3 weeks. It is important to off-load pressure on the reconstruction, usually this can be achieved with positioning and splinting, but sometimes it requires an external fixator. Most acute reconstructions are prone to venous and lymphatic insufficiency early on. It is important to keep the extremity elevated and not dependent. After 2 to 3 weeks, a dangle protocol is started to give the reconstruction a gradual accommodation period. The patient is non-weight-bearing on that extremity until cleared by the orthopedic service.

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Conclusion Lower extremity reconstruction is a challenging area of surgery that requires consideration of a patient’s occupation, other injuries, and comorbidities before a reconstructive plan is initiated. The best results are attributed to proper flap choice and timing, although the ability to incorporate microsurgery has significantly advanced orthoplastic extremity reconstruction.

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Questions 1. A 27-year-old man had a previous fracture of the foot. He has been repaired operatively with open reduction internal fixation and bone grafting and has a nonunion of the talonavicular joint. What is the best option for treatment of this foot wound? a. Repeat bone grafting b. Vascularized fibular graft c. Medial geniculate artery flap d. Iliac crest osteocutaneous flap 2. An 88-year-old man with advanced heart failure has a chronic wound on his posterior heel with exposed tendon lacking paratenon. Which of the following is the best option for this patient? a. Split-thickness skin graft b. Reverse sural artery flap c. ALT flap d. Tissue expansion 3. Which is not true of the rule of thirds for lower extremity reconstruction? a. Gastrocnemius is a good option for proximal third defects b. Reverse soleus is a good option for middle third defects c. Soleus is a good option for middle third defects d. Free flaps are good options for distal third defects 4. A 65-year-old man just underwent an aortobifemoral bypass procedure. It was complicated by a ruptured pseudoaneurysm at the femoral anastomosis, and the patient now has an open wound with exposed graft. Which of the following is true? a. The wound should be treated with a wound VAC until it granulates. b. A sartorius flap should be placed over the exposed vessels. c. Treatment for this patient’s condition will require repeated laparotomy. d. A skin graft should be adequate to obtain coverage. 5. Which half of the gastrocnemius flap is a better option for most knee wounds and why? a. Medial because its blood supply is more robust. b. Lateral because the flap is larger with better reach. c. Medial because there is no risk of peroneal nerve injury. d. Lateral because the pedicle location is more consistent. 1. Answer: c. Having failed primary reconstructive options with hardware and bone grafting, likely from poor vascular supply, this patient needs a vascularized reconstruction, preferably a vascularized corticocancellous bone flap. Bone grafting did not correct his problem in the past. Although plausible, a vascularized fibular graft is essentially a cortical bone graft and is larger than necessary and more difficult to inset into the desired location. An iliac crest osteocutaneous flap creates a significant donor defect to the lateral abdominal wall. 2. Answer: b. This elderly patient with significant comorbidities is not a candidate for a free flap or any other prolonged operation, so an ALT flap is not an option for him. Exposed tendon lacking paratenon will not have good graft take, so a split-thickness skin graft is not an option. Tissue expansion in the distal lower extremity has a very high complication and failure rate and is therefore not advisable. Reverse sural artery flap is a good option in this patient as it can be harvested quickly and will provide stable coverage. If flap viability is a concern, a delay procedure could be performed. Although not an answer choice, Integra and then skin grafting later would also be a possibility in this scenario.

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3. Answer: b. Reconstructing the leg can be thought of as a rule of thirds, with gastrocnemius being the classic option for the proximal third. Soleus for the middle third, and free flap for the distal third. Reverse soleus is indicated for distal third but is less ideal than a free flap since it is more prone to necrosis. 4. Answer: b. Exposed vascular structures should be covered with vascularized tissue, and a sartorius flap would fulfill this purpose. A wound VAC should not be placed directly onto vasculature. The wound is located at the distal part of the groin and should not require laparotomy for management. A skin graft would be inadequate to cover exposed vessels and would not take over a vascular prosthesis. 5. Answer: c. The peroneal nerve is at risk for injury if the lateral head of the gastrocnemius is used, and therefore the medial head is preferable.

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References Griffin, JR, Thornton, JF. Lower extremity reconstruction. Sel Read Plast Surg. 2009;11(R1):1-59. Olson, SA, Glasgow, RR. Acute compartment syndrome in lower extremity musculoskeletal trauma. J Am Acad Orthop Surg. 2005;13(7):436444. Gustilo, RB, Mendoza, RM, Williams, DN. Problems in the management of type III (severe) open fractures: a new classification of type III open fractures. J Trauma. 1984;24(8):742-746.This is the article that introduced the most widely used classification system for open extremity fractures. This is important for plastic surgeons, as it is needed to help salvage and reconstruct the extremities on patients who have type IIIB and IIIC injuries. Soltanian, H, Garcia, R, Hollenbeck, ST. Current concepts in lower extremity reconstruction. Plast Reconstr Surg. 2015;136(6):815e-829e. Byrd, HS, Spicer, TE, Cierney, G 3rd. Management of open tibial fracture. Plast Reconstr Surg. 1985;76(5):719-730.Classic article regarding classifying and treating open tibial fractures. Of particular note, this was written by plastic surgeons, so it more clearly defines which types of injuries can be treated with local flaps, versus those that require distant tissue transfer. Hollenbeck, ST, Toranto, TJ, Taylor, BJ, et al. Perineal and lower extremity reconstruction. Plast Reconstr Surg. 2011;128(5):551e-563e. Pasquale, MD, Frykberg, ER, Tinkoff, GH; ACS Committee on Trauma ; Ad Hoc Committee on Outcomes . Management of complex extremity trauma. Bull Am Coll Surg. 2006;91(6):36-38. Ong, YS, Levin, LS. Lower limb salvage in trauma. Plast Reconstr Surg. 2010;125(2):582-588. Levin, LS, Heitmann, C. Lower extremity reconstruction. Semin Plast Surg. 2003;17(1):069-082. Lachica, RD. Evidence-based medicine: management of acute lower extremity trauma. Plast Reconstr Surg. 2017;139(1):287e-301e. Godina, M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78(3):285-292.Landmark article discussing the timing of treating lower extremity fractures with free flaps. The author broke patients into three groups—early, delayed, and late—and then assessed infections, flap failure rates, number of anesthetics, hospitalization time, and time to healing. This article is what led to more common treatment of open fracture with free flaps in the acute period. Ducic, I, Attinger, CE. Foot and ankle reconstruction: pedicled muscle flaps versus free flaps and the role of diabetes. Plast Reconstr Surg. 2011;128(1):173-180. Suh, HS, Oh, TS, Lee, HS, et al. A new approach for reconstruction of diabetic foot wounds using the angiosome and supermicrosurgery concept. Plast Reconstr Surg. 2016;138(4):702e-709e. Higgins, TF, Klatt, JB, Beals, TC. Lower extremity assessment project (LEAP) – the best available evidence on limb-threatening lower extremity trauma. Orthop Clin North Am. 2010;41(2):233-239.The LEAP project is a landmark randomized, prospective trial performed at 8 trauma centers, developed to determine who would benefit from salvage versus who would benefit from primary amputation. While they were unable to make this determination, they did find that patient’s ability to function afterward was more because of their functional ability before trauma, regarding their social, economic, and personality disadvantages. Whether treated with salvage or amputation, this patient population had equivalent 2-year outcomes. Bosse, MJ, MacKenzie, EJ, Kellam, JF, et al. An analysis of outcomes of reconstruction or amputation after leg-threatening injuries. N Engl J Med. 2002;347(24):1924-1931. Steiert, AE, Gohritz, A, Schreiber, TC, et al. Delayed flap coverage of open extremity fractures after previous vacuum-assisted closure (VAC) therapy – worse or worth it? J Plast Reconstr Aesthet Surg. 2009;62(5):675-683. Wong, TM, Lau, TW, Li, X, Fang, C, Yeung, K, Leung, F. Masquelet technique for treatment of posttraumatic bone defects. Sci World J. 2014;2014:1-6. Haddock, NT, Wapner, K, Levin, LS. Vascular bone transfer options in the foot and ankle: a retrospective review and update on strategies. Plast Reconstr Surg. 2013;132(3):685-693. Ronga, M, Ferraro, S, Fagetti, A, Cherubino, M, Valdatta, L, Cherubino, P. Masquelet technique for the treatment of a severe acute tibial bone loss. Injury. 2014;45(suppl 6):S111-S1115. Wagels, M, Rowe, D, Senewiratne, S, Theile, DR. History of lower limb reconstruction after trauma. AZN J Surg. 2013;83(5):348-353. Hollenbeck, ST, Woo, S, Ong, S, Fitch, RD, Erdmann, D, Levin, LS. The combined use of the Ilizarov method and microsurgical techniques for limb salvage. Ann Plast Surg. 2009;62(5):486-491. Rozbruch, SR, Weitzman, A, Watson, JT, Freudigman, O, Katz, HV, Ilizarov, S. Simultaneous treatment of tibial bone and soft-tissue defects with the Ilizarov method. J Orthop Trauma. 2006;20(3):197-205. Weiland, AJ, Moore, JR, Daniel, RK. Vascularized bone autografts. Experience with 41 cases. Clin Orthop Relat Res. 1983;174:87-95. Gottlieb, LJ, Krieger, LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93(7):1503-1504. Parrett, BM, Talbot, SG, Pribaz, JJ, Lee, BT. A review of local and regional flaps for distal leg reconstruction. J Reconstr Microsurg. 2009;25(7):445-455.Good review article about options for reconstruction of the lower extremity. Behan, FC. The Keystone Design Perforator Island Flap in reconstructive surgery. ANZ J Surg. 2003;73(3):112-120. D’Arpa, S, Toia, F, Pirrello, R, et al. Propeller flaps: a review of indications and results. Biomed Res Int. 2014;2014:1-7. Morrison, WA, Crabb, DM, O’Brien, MB, Jenkins, A. The instep of the foot as a fasciocutaneous island and as a free flap for heel defects. Plast Reconstr Surg. 1983;72(1):56-63. Agarwal, P, Raza, H. Cross-leg flap: its role in limb salvage. Indian J Orthop. 2008;42(4):439-443. Colen, DL, Colen, LB, Levin, LS, Kovach, SJ. Godina’s principles in the twenty-first century and the evolution of lower extremity trauma

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reconstruction. J Reconstr Microsurg. 2018;34(8):563-571. Manders, EK, Oaks, TE, Au, VK, et al. Soft tissue expansion in the lower extremities. Plast Reconstr Surg. 1988;81(2):208-219. Prystowsky, JH, Nowygrod, R, Marboe, CC, et al. Artificial skin (Integra Dermal regeneration template) for closure of lower extremity wounds. Vasc Surg. 2000;34(6):557-567. Lee, LF, Porch, JV, Spenler, W, Garner, WL. Integra in lower extremity reconstruction after burn injury. Plast Reconstr Surg. 2008;121(4):12561262. Rodriguez-Vegas, JM, Delgado-Serrano, PJ. Corticoperiosteal flap in the treatment of nonunions and small bone gaps: technical details and expanding possibilities. J Plast Reconstr Aesthet Surg. 2011;64(4):515-527. Urbaniak, JR, Coogan, PG, Gunneson, EB, Nunley, JA. Treatment of osteonecrosis of the femoral head with free vascularized fibular grafting: a long-term follow-up study of one hundred and three hips. J Bone Joint Surg Am. 1995;77(5):681-694. Kawate, KYH, Sugimoto, K, Ono, H, et al. Indications for free vascularized fibular grafting for the treatment of osteonecrosis of the femoral head. BMC Musculoskelet Disord. 2007;78:1-8. Garozzo, D, Ferraresi, S, Buffatti, P. Surgical treatment of common peroneal nerve injuries: indications and results: a series of 62 cases. J Neurosurg Sci. 2004;48(3):105-112. Vigasio, A, Marcoccio, I, Patelli, A, et al. New tendon transfer for correction of drop-foot in common peroneal nerve palsy. Clin Orthop Relat Res. 2008;466(6):1454-1466. Sedel, L, Nizard, RS. Nerve grafting for traction injuries of the common peroneal nerve: a report of 17 cases. J Bone Joint Surg Br. 1993;75B:772-774. Marek, CA, Pu, LQ. Refinements of free tissue transfer for optimal outcome in lower extremity reconstruction. Ann Plast Surg. 2004;52(3):270275. Ohjimi, H, Taniguchi, Y, Kawano, K, et al. A comparison of thinning and conventional free-flap transfers to the lower extremity. Plast Reconstr Surg. 2000;105(2):558-566. Jeon, BJ, Lim, SY, Pyon, JK, et al. Secondary extremity reconstruction with free perforator flaps for aesthetic purposes. J Plast Reconstr Aesthet Surg. 2011;64(11):1483-1489.

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CHAPTER 97

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Perineal Reconstruction Julie E. Park

Key Points Perineal reconstruction may be required because of burns, infection, trauma, hidradenitis suppurative, or cancer. Reconstructive options can vary according to location of acquired defect. Reconstructive options include local, regional, and free flap reconstruction. Indications for specific reconstructive choice varies according to location and depth of acquired defect. Support of pelvic contents and obliteration of any dead space is essential in perineal reconstruction.

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Anatomy The perineal region spans the pubic symphysis and the coccyx in the anteroposterior dimension and the ischial tuberosities in the transverse dimension. It is divided into anterior and posterior triangles by a hypothetical transverse line between the ischial tuberosities. The anterior triangle contains the urogenital structures, which include the vulva and vagina in females and the scrotum and penis in males. The posterior triangle includes the anorectal structures. The superior border of the perineum is the pelvic floor, which consists of the levator ani and coccygeus muscles (Figure 97.1). The pelvic floor, also referred to as the pelvic diaphragm, supports and separates the pelvic cavity from the perineum. The perineum refers to the area between the anus and vagina or scrotum. It has a superficial and deep fascial layer. The deep fascia is contiguous to Colles fascia. 1 The specifics of the anatomy of perineal structures are delineated in Table 97.1.

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FIGURE 97.1 Structure of the female (A) and male (B) perineum. C. Cross section of penis.

TABLE 97.1

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Anatomy and Neurovascular Pedicles of Structures of the Perineum 1,49 Vulva Anatomy

Vasculature

Innervation

Vagina

Penis

Scrotum

External aspect of female genitalia Labia majora Bilateral, hairbearing skin folds that fuse to form anterior/posterior commissures Labia minora Bilateral folds within labia majora, superiorly forms clitoral frenulum and hood Flanks vestibule, which houses urethra and introitus

Muscular tube that connects vestibule to the uterus Inferior to urethra Introitus—opening Approximate dimensions: Diameter 2.6– 3.25 cm Length Anterior wall 6 cm Posterior wall 7.5 cm

Radix—root Corpus—body Dorsal: two corpora cavernosa Ventral: corpus spongiosum Glans penis—tip Urethra passes through corpus spongiosum, meatus at tip of glans penis

Sack with two separate pockets that contain the testes, epididymis, ductus deferens Protect testes, help maintain temperature of 35°C Thin skin over dartos and cremaster muscles

Internal pudendal artery Internal pudendal vein and vaginal venous plexus

Uterine and vaginal arteries, branches of internal iliac Vaginal venous plexus

Dorsal penile artery Deep artery of the penis Both branches of internal pudendal artery Dorsal veins of penis

Anterior scrotal artery, branch of deep external pudendal artery Posterior scrotal artery, branch of internal pudendal artery Testicular veins

Anterior—branches of ilioinguinal (T12-L1) and genitofemoral (L1-2) nerves Posterior—internal pudendal nerve (S2-4)

Pudendal nerve Sympathetic and parasympathetic nerves of pelvic plexus

Dorsal penis

Posterior scrotal nerves Anterior scrotal nerves Genital branch of genitofemoral nerve Perineal branch of posterior femoral cutaneous nerve

nerve

of

The perineum plays important roles in micturition, defecation, sexual activity, and body image, all of which need to be considered when planning reconstructive goals. Functional requirements include obliteration of any dead space, prevention of pelvic prolapse, and possible reconstruction of genitalia. The challenges of reconstructing the perineum consider dependent pressure during postoperative recovery, bacterial contamination from urogenital and perianal areas, and the propensity for radiation therapy to be used when oncologic resection is necessary.

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Considerations by Etiology There are multiple scenarios in which the perineum requires reconstruction. Benign disease processes include burns, infection (such as Fournier’s gangrene), trauma, and hidradenitis suppurativa. Oncologic resections include Paget disease; carcinomas of the vulva/vagina, penis, and/or scrotum; and anorectal cancer. Reconstruction of congenital defects is beyond the scope of this chapter while gender affirmation procedures are discussed in detail in Chapter 100.

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Burns The American Burn Association considers any perineal burn as a major injury and criteria for burn center referral. 2-4 Isolated perineal burns are unusual as the area is relatively protected by the thighs and abdomen. Perineal burns are typically part more extensive burns of trunk and lower extremity. 4 Adult etiology is typically due to flame, whereas pediatric etiology is usually due to scald burns from spills or immersion. 2,4 A third reason for perineal burns is the military cause. 3 The incidence of perineal burns ranges anywhere from 1.7% to 13% in adults and 1% in children. 4,5 Across adult, pediatric, and military cohorts, there is an increased male to female ratio. 3-5 The presence of a perineal burn is an independent risk factor for an increase in morbidity and mortality, although this is not from injuries to the urogenital structures, but is thought to be related to increased bacteremia and/or relationship to more extensive injuries. 2,3,5 The presence of perineal burns is associated with increased hospital acquired infections and urinary tract infections. 2,5 Increased infection risks can convert partial-thickness burns to deeper tissue injury and can interfere with skin graft take. 4 There is consensus that urinary catherization should be limited to resuscitation as much as possible, with some advocating its use to help hygiene and comfort. 2,4,5 Longterm catheterization risks infection and urethral stenosis. There is debate regarding the superiority of suprapubic versus urethral catheters. 2,4,5 As with any other burn, the depth of the burn will determine need for excision and grafting. Unlike burns on other areas of the body, genitalia burns are typically not treated with early excision. The exception to this is the presence of extensive, deep necrotic tissue. Conservative treatment with topical antimicrobials and wound care is recommended. Most partial-thickness wounds heal by epithelialization. Perineal wounds heal well with secondary intention after eschar excision. If the perineal burn is part of more extensive burns, the other areas of burns have priority for skin grafts from available donor sites. Larger wounds may require excision and grafting to prevent deformities. Full-thickness injuries to genitalia may require full-thickness skin graft to prevent contracture and care must be taken with bolster dressings to secure the grafts. Internal vaginal burns can benefit from vaginal stents to help prevent stenosis. 2,4,5 Contracture of perineum can restrict the range of motion of hip and adversely affect micturition, defecation, and sexual activity. There are additional psychosocial complications of burns to genitalia that span loss of self-esteem and libido. 4

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Infections Necrotizing soft tissues of the perineum is often referred to as Fournier gangrene. It can involve the skin, subcutaneous tissue, fascia, and muscle. Mortality rates range between 10% and 40%. There is a male predominance. The most common comorbidity is diabetes mellitus, 6 and other risk factors include the following 7 : Recent surgery to perineal structures Malignancy Alcoholism Morbid obesity Immunocompromise The mainstay of treatment is prompt surgical debridement, broad spectrum IV antibiotics, and resuscitation. Surgical debridement should aggressively target any infected, ischemic, and/or necrotic tissues. Second look operations are often necessary. Antibiotic therapy should cover gram positive, gram negative, and anaerobic bacteria and then be adjusted to the antibiotic sensitivities as speciation of cultures return. Ideally, blood cultures should be drawn prior to antibiotic initiation. Common microorganisms involved in Fournier gangrene include the following 7-9 : Polymicrobial Escherichia coli Staphylococcus aureus Streptococcus species Enterobacter Pseudomonas aeruginosa Bacteroides Proteus species Clostridia species Klebsiella Corynebacteria Acinetobacter baumannii There are conflicting reports on the benefits and cost-effectiveness of hyperbaric oxygen therapy. 7,8 Some patients may require urinary and/or fecal diversion. 7,8 Negative pressure wound dressings are helpful in controlling the wound once the infection is adequately debrided and treated. 7 Orchiectomy should be performed only if the testicle itself is not viable. 8,9 In the event of total scrotal involvement and debridement, protection of the testicles from desiccation can be performed by placement in subcutaneous thigh pockets. However, as a long-term reconstruction, this is not well tolerated in younger patients and may decrease fertility owing to the increased temperature of the thigh pockets. 9 Testicular dressings should be designed to keep the testicle from desiccation and allow for granulation tissue to form. After granulation tissue is present, scrotal reconstruction can be performed with split-thickness skin grafts or thigh flaps.

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Trauma Perineal injuries from military trauma are typically involved in other traumas of the lower extremity and/or abdomen and pelvis and can be caused by blast injuries such as given by improvised explosive devices 10,11 or combat-related burns. 3 Military improvised explosive device injuries are further complicated by bacteria and soil particles that can be driven deep into the involved tissues. 10,11 In the civilian population, perineal trauma can be from straddle injuries, motor vehicle accidents, and anogenital penetration due to either accidental falls or sexual assault. 12,13

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Hidradenitis Suppurativa Hidradenitis suppurativa presents as painful, recurrent nodules that progress to abscesses and malodorous, draining sinus tracts, which eventually lead to considerable fibrosis. Typically located in the axilla and/or groin, it can present in any area of the body with apocrine glands, such as the neck, breast, pannus, genito-anal region, and thighs. French surgeon Alfred Velpeau first described the clinical presentation of hidradenitis in 1839. However, it was another French surgeon, Aristide Verneuil, who linked the process to skin-bearing apocrine glands in 1857. 14,15 This gave rise to the term Hidradenitis Suppurativa, meaning suppurative sweat gland, and engendered its eponym Verneuil disease. Hidradenitis suppurativa was once believed to be a disease arising from inflammation of apocrine glands with subsequent bacterial superinfection. 14,16,17 However, it is now understood to be a disease process of the terminal hair follicle, or the infundibulum. 18-20 A perifollicular lymphocytic infiltration results in inflammation, which prompts hyperkeratosis of the epithelium of the infundibulum. The resulting occlusion causes dilation of the follicle bulb and cyst formation. Eventually, the cyst ruptures, releasing keratin debris and other follicular contents, such as bacteria, into the dermis, resulting in an acute neutrophilic inflammatory response that progresses to a granulomatous stage with the presence of foreign body giant cells. If the inflammatory response is extensive, abscess formation occurs, creating further destruction of other follicles as well as apocrine and eccrine glands. Sinus tracts and fistulas form between ruptured follicles and the surface of the skin. 18,20,21 In reality, hidradenitis suppurativa is a misnomer based on historic clinical observations. Advances in understanding the pathophysiology of hidradenitis suppurativa has given rise to the term acne inversa. 14,15,22 The incidence of hidradenitis is around 1%. There is a 3:1 female to male predominance and tends to manifest in the second or third decade. There may be a hormonal component associated with it, noting a decrease in severity after menopause. It is also associated with obesity, diabetes mellitus, metabolic syndrome, and nicotine use as well as other inflammatory disease processes, such as inflammatory bowel disease, pyoderma gangrenosum, arthritis, and poly cystic ovarian disease. 19,23 There are two commonly accepted scales describing the level of severity of hidradenitis, the Hurley Scale and the modified Sartorius Scale. These grade according to severity, location, and degree of scaring. The process can result in considerable physical and psychosocial disability. A Cochran review of literature published up to 2015 found a paucity of high level evidence regarding the efficacy of definitive therapies for hidradenitis. 23 However, treatment modalities and algorithms have been suggested based on clinical practice, often graded to levels of classification or severity of disease. Patient-focused life style modulations include smoking secession, weight loss, and avoidance of compression and friction in intertriginous areas. Intralesional triamcinolone has been described to decrease erythema, induration, pain, and lesion size in flare-ups, but long-term efficacy has not been established. Antibiotic therapies include topical treatments such as clindamycin gel and oral therapies such as tetracycline, ampicillin, ciprofloxacin, and rifampicin. Most advocate treatments ranging from 2 to 6 weeks. Chronic suppressive therapy may result in resistance. Though staphyloccocus species are predominant in many of the acute abscess, chronic lesions often are polymicrobial, in which anaerobic bacteria predominate. 20 Antibiotic therapies do not treat the underlying problem, which is an abnormal inflammatory response. Several monoclonal antibody antiinflammatory therapies have been studied. Adalimumab, which targets and blocks TNF-α, is approved by the US Food and Drug Administration for treatment of hidradenitis. 21 There have been several studies on laser therapy using either carbon dioxide (CO2), 1064-nm neodymium-doped yttrium aluminum garnet (Nd:YAG), or Intense Pulse Light. Though improvement was noted, recurrence can still occur. 19 Surgical excision is the only method at present to definitively treat the scars and sinus tracts of chronic

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hidradenitis. However, new areas of hidradenitis may still occur adjacent to the treated areas. Incision and drainage can relieve pain from fluctuant abscesses but should be avoided in firm, solid nodules that are not purulent. Repeated incision and drainage procedures can also add to the scar burden. Local excision procedure such as unroofing sinus tract or tangential excision may spare skin but are subject to higher recurrence rates compared to wide excision. These wounds are left to heal by secondary intention. Wide excision has a lower recurrence rate, but to resect the entire affected areas, large wounds can result. The smaller wounds can be closed primarily. Larger wounds can be covered with split-thickness skin grafting. Rotational flaps have been described to cover larger wounds. Care should be taken in designing flaps to minimize moving affected tissue into the wound. Another option for treating these large wounds is healing by secondary intention. Unlike many other patients requiring perineal reconstruction, hidradenitis patients are uniquely accustomed to painful, malodorous drainage that requires assiduous dressing changes. Therefore, they are often willing to accept open, clean wounds that require dressing changes and, while still painful, are not malodorous and draining. 24 If hidradenitis is left to fester as chronic wound, over time, squamous cell carcinoma can arise in it, also known as a Marjolin ulcer. 25-28

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Oncologic Causes Perineal reconstruction for oncologic defects has challenges specific to the nature of the cancer patient. Fibrosis from neoadjuvant radiation therapy can compromise local tissues available for reconstruction. The need to start adjuvant radiation therapy can limit the available time for postoperative healing as well as create the need for more durable coverage. Adjuvant radiation therapy can also cause stenosis of the perineal structures, such as the vagina. The need for creating stomas must be taken into consideration when planning flaps and possible rectus muscle harvest. Cancer patients may also present with baseline nutritional deficits from either cancer cachexia and/or neoadjuvant chemotherapy. 1 Preoperative anemia may present via chronic blood loss from, for example, colon cancer, or from neoadjuvant chemotherapy. Optimization of nutrition and anemia may be limited owing to need for resecting the cancer. All of these things can adversely affect postoperative healing. Given the challenges of perineal reconstruction in oncologic patients, combination of closure with flaps decreases major wound complications compared to primary closure. 29,30

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Vulva and Labia Malignancies of the vulva constitute 1% of female malignancies and 5% genital cancers. 1,31 Ninety-five percent of the cancers are squamous cell carcinoma (Bowen and Paget disease 32 ), with melanoma, sarcoma, and basalioma comprising the remainder. 1 In younger patients, human papilloma virus is the leading cause of cancer, whereas in older patients, lichen sclerosus is often the culprit. Surgical excision is the first line of therapy and bilateral lymph node dissection is often warranted. Oncologic defects tend to be limited to skin and subcutaneous tissue. The reconstructive goals are tailored reestablishment of genitalia, body image, sexual health, and micturition. 1

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Vagina Vaginal defects can result from primary vaginal malignancy, such as sarcoma. More often, acquired defects are due to colorectal, gynecologic, or urologic malignancies as part of abdominal perineal resections or pelvic exenterations. The anterior wall of the vagina is close to the urethra and bladder; the lateral wall is close to the pelvic muscles; whereas the posterior wall abuts the rectum. Defects involving the posterior wall need to maintain the separation of the rectum from the vagina. Oncologic resections of various areas of the vagina can include nearby structures and add to the complexities of reconstruction. 33,34 The resections can be partial or complete and have been classified according to location and extent. 33 Cordeiro et al. described a classification of full-thickness vaginal defects from oncologic resection that is based on extent of resection and location after simplifying the vagina to a model of a cylinder that is closed superiorly (Table 97.2). Type I defects are partial, noncircumferential vaginal defects. This is further subdivided into type IA for anterior and lateral wall defects and type IB for posterior wall defects. Type II defects are circumferential defects and are subclassified as type IIA for the upper one-to twothirds and type IIB for total vaginectomies. 33 TABLE 97.2 Classification of Vaginal Defects From Oncologic Resection 33,34

Type I IA

Defect Partial, noncircumferential Anterior or lateral wall defects

IB Type II IIA IIB

Posterior wall defect Circumferential Upper one-third to two-thirds Total vaginectomies

Associated Oncologic Resection Bladder cancer Primary vaginal malignancies Advanced colorectal cancer—abdominal perineal resection Uterine or cervical cancers Pelvic exenterations

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Scrotum and Penis Most scrotal tumor resections are due to squamous cell carcinoma, Paget disease or human papilloma virus–related processes. Oncologic defects of the penis can be either partial or complete and are typically related to lichen sclerosus, carcinoma in situ, carcinoma of the penis, and neuroendocrine tumors. 1

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Reconstruction According to Anatomy The major goals of perineal reconstruction include a tension-free closure with well-vascularized tissue to restore or preserve sexual function, body image, micturition, and defecation. The pelvic cavity must be supported and any dead space must be obliterated in this noncompressible space. Tissue that matches the thickness of the reconstructed region and minimal donor site morbidity are other considerations. 1,34,35 Multiple algorithms exist regarding the choices in perineal reconstruction, depending on the size and location of the defect. 31-37 Other factors that affect reconstruction choice include the presence or need for radiation therapy, need for pelvic support, and presence of a dead space. 35 Because the pelvis is generally noncompressible, inadequate obliteration of dead space with well-vascularized tissue can lead to collections, infection, and dehiscence. If the flap chosen for reconstruction lacks adequate volume, an omental flap can be added to obliterate pelvic dead space. Patient-specific factors include amount of skin laxity, obesity, and other medical comorbidities that may restrict the extent of surgery the patient can tolerate. In obese patients, myocutaneous flaps such as the gracilis or rectus abdominus myocutaneous flaps may be converted to muscle flaps with skin grafting. In cancer patients, the potential for ostomy creation needs to be considered when planning abdominal-based flaps. Furthermore, pedicles such as the deep inferior epigastric artery may have been ligated in the cancer extirpation. The perineum is rich in anastomosing vessels and perforators perfusing the region. There are multiple local, fasciocutaneous, island, perforator, and myocutaneous flaps that can be considered. Small defects can be closed primarily or with local undermining. However, it is important that this can be achieved without distortion of the perineum, especially the urethra. Defects in which primary closure would cause perineal distortion or dehiscence require closure going up the reconstructive ladder. Perforator and muscle-sparing techniques have been applied to traditional myocutaneous flaps and advancement flaps to minimize donor site morbidity, improve arc of rotation, and provide thinner, better matching tissues. 37-42 The next section will discuss perineal reconstruction based on anatomic region. The flaps available for reconstruction by anatomy are summarized in Table 97.3. Because of the numerous flaps available to reconstruct the perineal region, the details of each flap are noted in Table 97.4, which also includes a citation in which specific, technical methods for harvesting the flap can be found. TABLE 97.3 Flaps for Reconstruction by Anatomy Vulva

Vagina IB

Vagina IIA

Vagina IIB

Perineum

Scrotum

Penis

VRAM

Tubed VRAM

Rolled TRAM

RAM

SCIP

Lotus petal

ORAM

Tubed V-DIEP

Rolled DIEP

ALT

Gluteal fold rotational

V-DIEP

Tubed ORAM

Gracilis- rotational or VY advancement ALT Perineal artery perforator Internal pudendal perforator

ms ORAM/VRAM

Tubed ms ORAM/VRAM

Rolled ORAM/ms ORAM Bilateral gracilis

VY advancement of gracilis, gluteal, or perineal perforator +/− omental flap Bilateral gluteal fold rotational

Radial forearm free flap Pedicled ALT

Pudendal thigh (Singapore)

Vagina IA Pudendal thigh

Internal pudendal perforator

Perineal artery perforator

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Internal pudendal perforator

ALT, anterior lateral thigh; DIEP, deep inferior epigastric perforator; ms, muscle-sparing; ORAM, oblique rectus abdominus myocutaneous; SCIP, superficial circumflex iliac perforator; TRAM, transverse rectus abdominus myocutaneous; V-DIEP, vertical deep inferior epigastric perforator; VRAM, vertical rectus abdominus myocutaneous. TABLE 97.4 Flaps Used to Reconstruct the Perineum Flap

Type

Vasculature

Defect

Pudendal thigh flap (Singapore flap)

Rotational island flap

Posterior labial artery

Vulva Vagina

Lotus petal flap

Rotational perforator flap

Perineal and internal pudendal artery

Vulva Partial vagina

Gluteal fold flap

Rotational flap Lowest petal of the lotus petal flap

Internal pudendal artery

Vulva Vagina Perineum

Gluteal VY advancement flap

Advancement flap

Internal pudendal artery perforators

Vulva Partial vagina

Anterior lateral thigh flap

Rotational perforator flap

Descending branch of LCA

Vulva Scrotum Penis

Superficial circumflex iliac perforator flap Gracilis flap

Rotational perforator flap

SCIA

Scrotum

Rotational myocutaneous flap

Medial femoral circumflex artery

Vagina Perineum

Rotational myocutaneous flap

DIEA

Vagina Perineum

Rotational myocutaneous

DIEA

Vagina Perineum

Rectus abdominus myocutaneous (RAM) flaps VRAM

Benefits

Limitations

Thin skin Erogenous sensation

Details on Harvest Monstrey Pedicle could be et al. 50 resected in defect or in field of radiation Needs additional flap if significant pelvic dead space

Thin skin Similar skin quality Donor site well concealed

Yii & Perforators to Inner and Niranjan 51 intermediate petals may be resected in defect or in field of neoadjuvant radiation

Donor site well concealed Usually not in field of radiation therapy for vulvar cancers Thin skin Similar skin quality Well-concealed donor site Avoids potential kinking of pedicle because not rotated Out of field of radiation therapy May include muscle if needed Can be sensate

Thin, tissue

durable

Out of field of radiation therapy

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Hashimoto Potential kinking of 
 et al. 52 pedicle when rotated for inset Donor site sensitive when sitting

Donor site when sitting

sensitive

Lee et al. 53

Lin et al. 45 Depending on patient Xu & Watt BMI, tissue may be 47 bulky Sensation innervated by lateral femoral cutaneous nerve and not erogenous Requires knowledge of perforator dissection

Han et al. 44

Pusic & Skin paddle can be Mehrara 34 unreliable in obese patients

Pusic & Mehrara 34

TRAM

flap Rotational myocutaneous flap

DIEA

Vagina Perineum

ORAM

Rotational myocutaneous flap Perforator/musclesparing rotational flap

DIEA

Vagina Perineum

Vertical DIEP/musclesparing

Perforator/musclesparing rotational flap

DIEA

Vagina Perineum

Internal pudendal perforator flaps

Rotational, propeller, or VY advancement flaps

Perforators of the internal pudendal artery

Vulva Scrotum Perineum

Perineal artery Perforator Flaps

Rotational, propeller, or VY advancement flaps

Perforators of the perineal artery branch of pudendal artery

Vulva Perineum

Radial Forearm flap

Free flap

Radial artery

Penis

Rolled for total vaginal reconstruction Thinner subcutaneous tissue More rectus and fascia preserved

Pusic & Can have thick Mehrara 34 subcutaneous layer

Lee & Pedicle of pure Dumanian perforator dissection 43 delicate and can be inadvertently avulsed; medial muscle-sparing strip of rectus is protective

More rectus and fascia preserved

Pedicle of pure perforator dissection delicate and can be inadvertently avulsed; medial muscle-sparing strip of rectus is protective

Free style–based perforator flap design based on defect and near by perforators found by Doppler.

Requires understanding of perforator flap dissection

Free style–based perforator flap design based on defect and near by perforators found by Doppler.

Flaps could be affected by neoadjuvant radiation therapy Requires understanding of perforator flap dissection

Thin Sensate Urethra reconstruction

Donor site visible Requires microsurgery

Wang et al. 54

Hong et al. 37

Kim et al. 39

Gottlieb 46

DIEA, deep inferior epigastric artery; DIEP, deep inferior epigastric perforator; LCA, lateral circumflex artery; ORAM, oblique rectus abdominus myocutaneous; SCIA, superficial circumflex iliac artery; TRAM, transverse rectus abdominus myocutaneous; VRAM, vertical rectus abdominus myocutaneous.

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Vulvar Reconstruction Applying the subunit principle, the vulva can be divided into three zones. The upper-third spans the mons to the labia, the middle third consists of the labia minora and majora, and the lower third involves the vaginal introitus and perineum. 1 Upper-third defects that are small (25), skin infections, axillary or pelvic node dissection, radiation, and genetic predisposition are known risk factors for secondary lymphedema. Patients should be counseled that there is no cure for primary and secondary lymphedema. Hence, nonsurgical and surgical treatments focus on symptom improvement and arresting disease progression. Prevention is the most effective intervention for lymphedema. Hence, at-risk patients should be closely monitored for any changes in limb volume to identify subclinical edema and implement early interventions. The first-line treatment for lymphedema is compressive decongestive therapy, which consists of skin care, manual lymphatic drainage, and compression therapy. Lymphovenous anastomosis is indicated in the early stages of lymphedema with patent lymphatic vessels identified on indocyanine green lymphography. In this procedure, lymphatic fluid is bypassed into peripheral subdermal venules. Vascularized lymph node transfer is thought to restore physiologic lymphatic drainage either by reconstituting lymphatic channels or by soaking up excess lymphatic fluid and facilitating egress into the peripheral venous circulation. The lymphatic system has three vital functions: support of the immune system, gastrointestinal lipid absorption, and fluid balance. Functionally, to accomplish fluid balance, the lymphatic system is structurally composed of a unidirectional circulatory network responsible for reabsorption and return of approximately 90% of interstitial capillary ultrafiltrate to the circulatory system. 1 Lymphedema is the result of derangements in fluid balance. Lymphedema is a chronic, progressive, and debilitating disease characterized by abnormal accumulation of protein-rich interstitial fluid resulting in swelling, inflammation, and irreversible tissue changes typically affecting the limbs 1,2 (Figure 98.1). The underlying mechanism is a drainage dysfunction due to a malformed or disrupted lymphatic system causing an insufficiency in reabsorption of ultrafiltrate and transport back to the circulatory system. 1

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FIGURE 98.1 A patient with lymphedema of the left lower extremity.

Lymphedema profoundly impacts patient physical function, psychosocial well-being, and quality of life. 3-6 Lymphedema patients perform worse on objective tests of limb function and demonstrate greater functional impairment in recreational activities and tasks of daily living. 4-6 Psychosocial morbidity includes depressive symptoms such as helpless and hopelessness, poor body image, and social isolation to avoid scrutiny. 5,6 Finally, the economic burden of care is profound both to the patient and healthcare

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system as patients are typically afflicted with recurrent infections, open wounds, chronic pain and often require long-term intensive treatment for this chronic, progressive condition. 7,8 Current treatment options are largely palliative with the primary goals of providing symptom relief and preventing disease progression.

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Primary Lymphedema Primary lymphedema is a result of intrinsic defects in lymphatic system development. Although genetic derangements underlie the disease mechanisms in primary lymphedema, the most commonly used classification of primary lymphedema is based on the time of onset of clinically apparent swelling. The types of primary lymphedema in this classification are congenital lymphedema, lymphedema praecox, and lymphedema tarda. 9,10 Congenital lymphedema presents at birth, and it accounts for 6% to 12% of primary cases. Women are affected twice as often as men, and the lower limb is involved three times as commonly as the upper limb. Lymphedema praecox presents most commonly as unilateral lower limb edema after birth up to age 35. It accounts for majority (77%–94%) of cases. Lymphedema praecox affects women four times as often as men. Finally, lymphedema tarda, also more common in women, presents after age 35. It accounts for 11% of primary cases. 10 Although primary lymphedema is most commonly classified by time of onset, this classification is insufficient to account for phenotypic variations within categories. Additionally, time of onset alone as a feature of the disease provides no clear basis for clinical management. Recently, advances in molecular techniques have contributed to identifying causal mutations linked to specific phenotypes of primary lymphedema. 11,12 There are currently nine causal genetic mutations known for primary lymphedema and as more genes and causal mechanisms are identified, the classification of primary lymphedema based on phenotype will provide a better clinical structure for diagnosis and treatment. 11,12

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Secondary Lymphedema Secondary lymphedema is an acquired dysfunction of the lymphatic system from disruption by extrinsic factors. Disruption of the lymphatic system may be secondary to infection, malignancy, or as a consequence of tissue trauma most commonly from proximal lymph node dissection. The most common form of secondary lymphedema worldwide is caused by infection with Wuchereria bancrofti, a filarial nematode parasite that invades and obstructs lymphatic channels. The global burden of lymphatic filariasis is between 120 and 250 million people, largely affecting populations in low-income countries. 13 In middle and high-income countries, the most common cause of secondary lymphedema is tissue trauma from surgical procedures. 2 In the United States, the greatest burden of noninfectious secondary lymphedema is among the breast cancer patient population (breast cancer-related lymphedema (BCRL)) due to the relatively higher incidence of the disease compared to other solid malignancies. However, patients with other malignancies who undergo dissection of lymph node basins, including gynecological and genitourinary tumors, sarcomas, and melanoma, are also at risk for secondary lymphedema. 2,6,14 Among breast cancer patients, the risk of BCRL is strongly associated with axillary procedures. 15,16 The incidence of lymphedema following sentinel lymph node biopsy is between 5% and 7%. 16,17 The incidence for patients who undergo axillary lymphadenectomy is approximately 20% and that for patients who undergo a combination of axillary lymphadenectomy and radiation therapy reaches 25% to 40%. 16-19 Clearly, it appears that a higher degree of axillary intervention results in a higher risk of secondary lymphedema. Lymphedema incidence and prevalence data are not as robust for other solid malignancies. However, several large series in the gynecological patient population report up to 10% to 15% prevalence of clinically diagnosed secondary lymphedema. 2,9,14,20 Similar to the breast cancer population, pelvic lymphadenectomy and radiation treatments put patients at higher risk of lower limb lymphedema. 14,20 Finally, there is a long list of widely debated risk-reducing behaviors proposed for patients at risk of developing secondary lymphedema. The most commonly cited of these risk-reducing behaviors include avoidance of venipuncture, blood-pressure monitoring, and resistance exercise involving at-risk limbs. The plurality of evidence has thus far not shown these risk-reducing behaviors as credible. 21 Moreover, there is evidence that both aerobic and resistance exercise, in addition to not increasing the risk of lymphedema, provide strength and physical function benefits. 21-23 The best evidence supported and widely acknowledged risk factors for secondary lymphedema include obesity, infections, radiation, and genetic predisposition. 24 Of these factors, obesity is perhaps the best recognized with robust evidence of its association with secondary lymphedema and equally good evidence that weight loss interventions can ameliorate symptoms of secondary lymphedema. 25 Thus, obesity and infections are potentially controllable risk factors that should be acted upon by clinicians who encounter high-risk patients.

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Natural History and Pathophysiology The natural history of primary lymphedema is widely variable within each of the currently defined categories (congenital, praecox, and tarda). The reason for this is that natural history perhaps depends more on underlying causal mutations and their penetrance rather than time of onset. Moreover, classification by underlying mechanism necessitates consideration of other associated features such as vascular anomalies and limb growth disturbances that manifest in several primary lymphedema phenotypes and can influence natural history. 11,12 Patients who develop BCRL typically present an average of 8 to 12 months after surgery. 26 Up to 77% of patients who will develop BCRL do so by the third year after surgery and then the risk is approximately 1% per year. 27 Hence, some patients develop BCRL even decades after surgery. Most patients with lower limb secondary lymphedema have been treated for gynecological and genitourinary tumors. 2 Data from several large series showed that up to 75% of these patients who developed secondary lymphedema did so within the first year of surgery. 2,14,20 In the absence of interventions, secondary lymphedema is generally a progressive disease. However, the rate of disease progression is widely variable with some patients rapidly developing debilitating disease and others having an indolent course for several years. With sustained disruption of lymphatic function by intrinsic defect or secondary influence, there is accumulation of protein-rich fluid within the affected tissues. The accumulated protein-rich ultrafiltrate triggers a pathological cytokine activation cascade that incites a profound inflammatory response. 1 Inflammatory cells, fibroblasts, keratinocytes, and adipocytes taxi to the involved tissues in response to proinflammatory messaging. The incoming cells induce a chronic inflammatory state, increased collagen deposition, fibrosis of skin and subcutaneous tissues, and excess adipose deposition. 1 The clinically overt manifestation of lymphedema begins with pitting edema that correlates with interstitial accumulation of protein-rich ultrafiltrate. Eventually, with fibrosis of lymphatic vessels, skin, and subcutaneous tissues, the edema is wooden and does not resolve with elevation. With these tissue changes, skin breakdowns and bouts of erysipelas are common and underlie a significant aspect of the morbidity of the disease. Lastly, severe limb hypertrophy and dysmorphia with a hyperkeratotic verrucous appearance otherwise known as elephantiasis ensues with further extracellular fibrosis and adipogenesis 10 (Figure 98.2).

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FIGURE 98.2 A patient with bilateral lower extremity elephantiasis characterized by severe limb hypertrophy and verrucous hyperkeratosis

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Diagnosis Lymphedema is a clinical diagnosis that depends mostly on thorough history gathering and physical examination. Secondary lymphedema patients will have a history of antecedent trauma to the lymphatic system and report common symptoms such as limb swelling and heaviness, aching, fatigue, numbness, stiffness, and impaired mobility. Primary lymphedema patients in contrast, generally will not have an antecedent injury to the lymphatic system, will most likely be female, and may allude to a family history of idiopathic limb swelling. Clinicians must also consider that patients can present with a mixed picture of primary and secondary lymphedema. Patient-reported outcome (PRO) instruments are increasingly gaining ground as part of the subjective assessment of lymphedema, especially in BCRL as this makes up a large proportion of secondary lymphedema population. 6 Data from PROs, as a complement to clinical symptoms, add information about functional impairment and psychosocial impact to capture a fuller picture of the patient’s experience with lymphedema. The upper limb lymphedema-27 (ULL-27) questionnaire is currently the only validated condition-specific PRO for BCRL; however, most studies to date use generic functional, cancer and symptom-specific PRO instruments . 6,28 Regardless of the PRO instrument used, several studies demonstrate that lymphedema patients have poorer health-related quality of life with decreased physical functioning, psychological, and social well-being. 3-6,28 In conjunction with the information gathered from the subjective history, patient-reported symptoms, and physical examination, objective measurements improve the accuracy and reliability of lymphedema diagnosis. Objective measurements also provide a means of interval assessments to track disease progression or the effects of interventions. There are several contemporary objective measurements used in clinical practice including bioimpedance spectroscopy, perometry, skin tonometry, tissue dielectric constant, water displacement, and circumferential measurement. 29 Ideally, an objective measure is easy to use, noninvasive, hygienic, cost-effective, reliable, reproducible, and quantifiable, and each of the above listed measures have merits and demerits with regards to these criteria. Water displacement (volume of water a limb displaces when immersed) is considered the most accurate measurement because of its high reliability. 29-31 However, significant challenges limit its use in clinical practice. For instance, water displacement cannot be used in patients with open wounds for hygiene reasons, and it cannot be used for severe lower limbs that do not fit in the water tanks. Circumferential measurements are the most commonly used measure in clinical practice and if properly performed meet the desired criteria outlined earlier. 29,31 The measurement is performed with nonelastic tape beginning from a fixed point on the limb and repeated at intervals. Using anatomical landmarks (e.g., radial styloid and elbow) as part of the intervals decreases measurement error. Lastly, having baseline measurements of ipsilateral and contralateral limbs are vital to account for potential differences between dominant and nondominant limbs. A 2 cm or greater increase in circumference is widely accepted as the definition of lymphedema. 29,31

Radiographic tests also play a role in the objective assessment of lymphedema. Lymphoscintigraphy, the most commonly used radiographic test in lymphedema assessment, is a qualitative test based on detection of peripherally injected radiolabeled Technetium-99m colloid uptake by proximal nodal basins 31 Historically, lymphoscintigraphy has been mostly useful as a simple qualitative confirmatory test for lymphatic dysfunction. However, there is no standard protocol for quantifying radiocolloid uptake and transit time, making it difficult to standardize quantification of disease severity across centers and studies. Near-infrared fluorescence lymphography with indocyanine-green (ICG) has gained wider use, also as a qualitative test of lymphatic function. It shows superficial (up to 12 mm depth) lymphatic flow in real time, including the pattern of flow, that is, a linear pattern or various backflow patterns (splash, stardust and diffuse) that can be correlated with the severity of disease. Additionally, the ability to see

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flow in real time with this test is useful for intraoperative navigation in microsurgical lymphatic reconstruction. 32,33 Finally, surveillance on at-risk patients is a new paradigm in the assessment of secondary lymphedema. 29,31,34 This paradigm originates in the knowledge that all modes of lymphedema treatment are palliative and not curative, thus making prevention the most effective intervention. Current surveillance guidelines propose preoperative and standardized interval postoperative subjective (patient-reported outcomes) and objective (e.g., circumferential measurement) assessments of ipsilateral and contralateral limbs for 3 to 5 years after surgery. 29,34 Lymphatic stasis and accumulation of protein-rich fluid trigger the cascade leading to disease progression. Hence, the objective of surveillance is to detect subclinical interstitial fluid accumulation manifested by as little as 3% to 5% limb volume changes. 34 Early detection permits time for implementing interventions to ameliorate fluid accumulation before the cascade of inflammation, fibrosis, and adipocytosis associated with chronic edema ensue.

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Staging Although there is no universally accepted scheme, the most widely used staging classification for lymphedema is the International Society of Lymphology (ISL) staging system, which is based on the progression of clinical features of the disease 24 (Table 98.1). In this classification, early-stage disease is described as latent or subclinical edema. From latency, the disease progresses to clinically overt but reversible edema with or without pitting. Irreversible edema follows and finally, elephantiasis which is characterized by severe limb hypertrophy and dysmorphia with acanthotic hyperkeratosis and a cobblestone appearance of the skin. However, more recently proposed staging schemes are based on the premise that objective results including imaging and limb circumference measurements are useful adjuncts to ISL staging to clarify diagnosis and disease severity. The MD Anderson classification defines stages of lymphedema based on flow patterns observed on ICG lymphography 33 (Figure 98.3). In this scheme, the severity of stages depends on a combination of the extent of patent linear lymphatic channels and extensiveness of dermal backflow seen on ICG lymphangiography. Cheng’s lymphedema grading system in contrast bases its five-grade scheme on differential circumference at distinct anatomic landmarks (e.g., 10 cm above and below the elbow joint in upper limbs) between the affected limb and uninvolved contralateral limb 35 (Table 98.2). TABLE 98.1 International Society of Lymphology Lymphedema Staging Classification Stage 0 I II

III

Description Subclinical Spontaneously reversible Not spontaneously reversible

Pathophysiology Impaired lymph 
 transport Early lymph accumulation

Lymphostatic elephantiasis

Chronic lymphatic 
 stasis and inflammation, 
 further fibrosis and fatty deposition

Fat hypertrophy and 
 deposition with tissue 
 fibrosis

Clinical Features Swelling not evident Swelling relieved by limb elevation Pitting may be present Swelling not improved by limb elevation Pitting edema present with fibrosis Swelling not improved by limb elevation Edema nonpitting and wooden Hyperkeratotic and verrucous skin changes

From International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016;49(4):170-184.

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FIGURE 98.3 Lymphedema classification based on extent of patent lymphatics and lymphatic obstruction seen on indocyanine lymphography. A. Stage 1: many patent lymphatic vessels, with minimal, patchy dermal backflow. B. Stage 2: moderate number of patent lymphatic vessels, with segmental dermal backflow. C. Stage 3: few patent lymphatic vessels, with extensive dermal backflow. D. Stage 4: no patent lymphatic vessels seen, with severe dermal backflow involving the entire arm and extending to the dorsum of the hand. (Reproduced with permission from Chang, DW, Suami, H, Skoracki, R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013;132(5):1305-1314.)

TABLE 98.2 Cheng’s Lymphedema Grading System Grade 0 I II III IV

Symptoms Reversible Mild Moderate Severe Very 
 severe

Circumferential Differentiation 40

Lympho-
 scintigraphy Partial occlusion Partial occlusion Total occlusion Total occlusion Total occlusion

Reprinted by permission from Springer: Patel, KM, Lin, CY, Cheng, MH. A prospective evaluation of lymphedema-specific quality-of-life outcomes following vascularized lymph node transfer. Ann Surg Oncol. 2015;22(7):2424-2430. Copyright © 2014 Society of Surgical Oncology. Circumference differentiation: circumference of the lesioned limb subtracted from the circumference of the healthy limb and divided by the circumference of the healthy limb, which is measured at 10 cm above and below the elbow, 15 cm above and below the knee, and 10 cm

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above the ankle.

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Treatment and Outcomes Nonsurgical Treatment Generally, lymphedema treatment is palliative and not curative; therefore, the main objectives are preventing disease progression and ameliorating symptoms. Nonsurgical treatments are first line, including in situations when subclinical limb swelling is identified on lymphedema surveillance. Nonsurgical treatments also play an adjunctive role to preserve outcomes from surgical treatment of lymphedema. Finally, patient education is a crucial element of lymphedema care. Patients at risk of secondary lymphedema should be made aware of their lifetime risk, and they should be educated on early signs and symptoms to recognize. Additionally, clinicians should educate patients on practical and evidence-based risk-reducing strategies such as skin care, exercise, and weight loss. 24,29,31,34

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Complete Decongestive Therapy Complete decongestive therapy (CDT) is considered the first line in lymphedema management. It is a multimodal approach that incorporates manual lymphatic drainage (MLD), compression bandaging, exercise, and skin care. This treatment involves a reductive phase (phase I) and a maintenance phase (phase II). In phase I, patients see a lymphedema specialist five times a week for up to 8 weeks and undergo MLD, compression therapy, and physiotherapy to achieve limb volume reduction. Phase II is largely patient-directed and includes meticulous skin and nail care, wearing compression garments or sleeves, self-lymph drainage massage and exercise to preserve gains in limb volume reduction. The drawbacks of CDT are that it is labor intensive, expensive, and time-consuming, making patient noncompliance an issue. Hence, a number of randomized trials have examined the effectiveness of lessintensive treatments such as compression bandaging alone and physiotherapy alone compared to CDT with mixed results. In 2015, the Cochrane Library published a systematic review of MLD for lymphedema treatment. 36 In that review, two similarly conducted trials comparing MLD with compression bandaging to compression bandaging alone reported equivalent additional volume reduction in favor of MLD and compression bandaging, especially for patients with mild to moderate disease. 37,38 However, other trials comparing MLD with compression to compression alone or compression with physiotherapy have shown no significant differences in volume reduction and subjective quality-
 of-life metrics. 36 Thus, in the absence of incontrovertible evidence that less-intensive therapy is superior or noninferior, CDT remains the first-line treatment for lymphedema.

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Surgical Treatment Surgical treatments are indicated when first-line conservative measures fail and when patients present with late-stage disease. There are two main categories of surgical treatment: excisional and physiologic procedures. Excisional procedures are essentially a surgical reduction of excess fibroadipose tissue in the affected limb whereas physiologic procedures reconstruct the lymphatic system to improve physiologic drainage. The goals of surgical treatment are to decrease the load of lymph production by excisional procedures or liposuction: to increase the drainage of the lymph by bypassing the lymph into subdermal venule or transfer of robust vascularized lymph node flap to restore the lymphatic drainage function.

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Excisional Procedures

Liposuction Chronic lymphedema induces excess adipose deposition in the subcutaneous tissues with subsequent limb hypertrophy and associated morbidities including limb heaviness, limited mobility, functional impairments, and cosmetically unappealing appearance. In patients with later stage disease who have failed conservative treatment and present with limb hypertrophy and nonpitting edema, liposuction combined with controlled compression therapy has been shown to be a safe and effective technique for significantly reducing limb volume. 39 Studies have also shown sustained limb volume reduction with this technique up to 15 years after surgery. 40 Albeit, postoperative care involves permanent use of compression garments and mandatory close follow-up to refit the garments periodically to maintain volume reduction gains from the procedure. 39,40 Liposuction should be performed with tumescent technique and under tourniquet control to minimize blood loss and the need for transfusions. Moreover, fluid monitoring is imperative for patients who undergo large volume liposuction (>5 L), and these patients should be admitted for postoperative monitoring. Contraindications to liposuction include metastatic disease, open wounds, medical history of coagulopathy, patients unfit for surgery, or patients deemed unreliable to adhere to postoperative compressive therapy. 40 Complications of liposuction are generally minor and include small woundhealing problems, paresthesia, and contour irregularities. Rapid recurrence occurs if the patient is noncompliant with postoperative compressive therapy. 40

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Direct Excision Direct excision techniques are not widely used and are generally reserved for patients with severe refractory lymphedema suffering significant morbidity with no other surgical options. For these patients, direct excision techniques offer limb debulking to improve function; however, outcomes are generally not ideal. The Charles procedure is one such technique for severe lower limb lymphedema. The Charles procedure resects skin and subcutaneous tissue to the level of the deep fascia 41 (Figure 98.4A). Split or full thickness skin grafts harvested from the resected specimen are then used as coverage for the open wounds. The procedure is fraught with risks including blood loss requiring transfusion, substantial skin graft failure necessitating reoperations or prolonged wound care, acute infections, recurrence of lymphedema, contour irregularities, and unaesthetic appearance of the limb in the long term. Another direct excision technique applies staged elliptical excisions of skin and subcutaneous tissues 42 (Figure 98.4B). Excisions may be targeted to specific sites to limit the morbidity of the operation; however, patients remain at significant risk of infections, delayed wound healing, contour irregularities, unaesthetic appearance, loss of limb function, and recurrence of lymphedema.

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FIGURE 98.4 Excisional procedures for lymphedema. A. The Charles procedure: excision with skin grafting. B. Elliptical excision and primary closure.

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Physiological Procedures Over the past century, surgeons have devised several techniques to treat lymphedema aimed at restoring the physiologic drainage function of the lymphatic system. The general basis of these techniques are bypassing lymph into venous system or using transferred tissue containing normal lymph nodes to reestablish functional drainage. Contemporarily, lymphovenous anastomosis (LVA) and vascularized lymph node transfer (VLNT) are the most commonly used physiological procedures in clinical practice. Advances in imaging and surgical techniques have contributed immensely to the popularization of LVA and VLNT. Near-infrared fluorescence lymphography with ICG converted identifying patent lymphatic channels, for bypass techniques, from a somewhat speculative to a more precise process. Additionally, ICG lymphography has enhanced instructional studies on the function of the lymphatic system, patterns of obstruction underlying different stages of the disease, and lymphatic system response to surgical techniques. 32,33 The introduction of supermicrosurgery techniques that made it possible to perform anastomoses between submillimeter diameter lymphatic vessels and subdermal venules has also contributed immensely to the contemporary popularization of LVA. 43

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Lymphovenous Anastomosis Peripheral collectors return lymphatic fluid to the venous circulation centrally via the thoracic duct. In lymphedema patients, the function of peripheral collectors is progressively impaired due to stasisinduced lymphatic channel fibrosis. LVA restores lymphatic fluid return to the venous circulation but does so peripherally with anastomosis of patent lymphatic channels to adjacent subdermal venules, to bypass lymph to the venous system (Figure 98.5). Although there are no clear evidence-based guidelines on indications for LVA, there is effectively wide agreement on conditions favorable to LVA. LVA is considered by most authors to be appropriate for patients with early-stage lymphedema. These patients generally exhibit partial lymphatic obstruction with residual patent lymphatic vessels on lymphoscintigraphy and ICG lymphography; moreover, they have not developed extensive fibrosis and adipose hypertrophy. 33,44

FIGURE 98.5 A patent lymphovenous anastomosis. Isosulfan blue dye passes through the anastomosis from the lymphatic

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vessel into the venule. (Reproduced with permission from Chang, DW, Suami, H, Skoracki, R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013;132(5):1305-1314.)

ICG lymphography obviates the need for extensive dissection to find patent lymphatic channels. It enables intraoperative lymphatic mapping to identify target lymphatic collectors suitable for anastomoses. The ICG dye is injected intradermally in the webspaces of the hand or foot and binds to proteins transported in lymphatic fluid. Near-infrared light from an imaging source detects the ICG thus enabling real-time visualization of lymphatic fluid clearance. 32,33 Identifying patent collectors that demonstrate distal to proximal dynamic directional flow without dermal stasis is key to success of the anastomosis. 33,44 A tourniquet is not necessary for a bloodless field if the surgical site is infiltrated locally with dilute epinephrine for vasoconstriction. A small transverse incision (2–3 cm) just through the dermis is all that is required, and dissection is performed in the superficial subcutaneous plane to isolate the lymphatic vessels identified on fluorescence lymphography. Injecting patent blue dye distal to the incisions helps with identifying otherwise clear lymphatic channels in situ. After identifying a suitable subdermal vein and collecting lymphatic vessel, end-to-end or side-to-end anastomosis is made and the passage of patent blue dye across the anastomosis serves an immediate patency test. Additionally, the passage of indocyanine green fluorescence across the anastomosis confirms anastomotic patency. Most authors advocate several anastomoses to increase the likelihood of success with LVA. However, the basis of this practice is largely theoretical, as there is no evidence associating a threshold number of anastomoses with likelihood of success. 44 Most LVA outcomes studies are small retrospective case series with significant flaws in design. Study populations are often heterogeneous due to notable differences in criteria for patient selection for surgery, and because patients with distinctly different conditions (e.g., primary and secondary lymphedema) are often mixed. This heterogeneity does undoubtedly confound findings. Moreover, variations in surgical technique(s) and adjunctive treatments, duration and adequacy of follow-up, and both objective and subjective outcome measurements used make high-level evidence difficult to obtain. 45 With these shortcomings in mind, several reviews to date report objective limb volume reduction and subjective patient-reported symptom improvement after LVA. 45 In one of the larger and oft-cited case series consisting of 100 patients, Chang et al. demonstrated that 96% of patients who underwent upper limb LVA procedure reported symptom improvement. 33 Quantitatively, mean volume reduction varied depending on lymphedema stage. International Society of Lymphology classification stage I and stage II lymphedema patients had an average of 61% reduction in volume at 12 months, and stage III patients had only 17% volume reduction at 12 months. In another large series, Campisi et al. followed 843 LVA patients postoperatively (5–15 y) and reported that 73% had over 75% volume reduction and 24% had over 50% volume reduction. 46 In summary, LVA is a minimally invasive procedure that involves a low risk of morbidity to patients. 43,46 Although more rigorously conducted studies are necessary to establish LVA outcomes and better delineate patients who would most benefit from the procedure, a considerable plurality of current evidence demonstrates objective and subjective benefit for patients with early-stage lymphedema potentially eliminating the need for continued use of compression garments. 43,45,46

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Vascularized Lymph Node Transfer VLNT is a transfer of lymphatic tissue including lymph nodes from one of several possible donor sites to proximal or distal recipient beds in the affected limb. There are two prevailing theories posited for the mechanism by which VLNT works. The first theory proposes that the transferred physiologically normal lymph nodes, through the action of growth factors and cytokines, induce reconstitution of lymphatic flow within the recipient bed. 47 The other theory is that vascularized lymph nodes behave like the motor of a pump, taking up interstitial fluid and subsequently diverting the fluid into the peripheral venous circulation. There is an accompanying catchment effect whereby the decrease in subcutaneous interstitial pressure in the lymphedematous limb due to the pump-like action further directs lymph from surrounding tissues into the transferred lymph nodes. 48 Vascularized lymph node flaps can be transferred to proximal or distal recipient sites in the affected limb. However, by the pump theory, the gravity effect resulting in interstitial fluid accumulating distally in lymphedematous limbs would maximize the drainage efficiency of flaps transferred to distal recipient sites. Other benefits of using a distal recipient site include an unscarred and nonoperated area with available recipient vessels. Lastly, the number of vascularized lymph nodes in the transferred flap is positively correlated with the degree of limb volume reduction. Therefore, choosing a flap with a high number of viable lymph nodes within it increases the chance of a successful outcome. 49 There are a few donor sites described for VLNT, each with potential merits and risks. 44,50 The groin is the most commonly used donor site for lymph node harvest. Groin lymph node flaps offer the benefit of a concealed scar and the option to combine as a chimeric flap with abdominally based flaps for breast reconstruction. Groin lymph node flaps may be based on the superficial circumflex iliac, superficial inferior epigastric, or the deep inferior epigastric artery if combined with autologous breast reconstruction. Reverse lymphatic mapping and avoiding dissection below the inguinal crease improves the chances of including lymph nodes that drain the abdominal wall while leaving behind those that drain the lower limb to avoid iatrogenic lower limb lymphedema. The submental lymph node flap, based on the submental artery, includes lymph nodes from level Ia and Ib in the neck (Figure 98.6). Drawbacks of this flap include the potential for injury to the marginal mandibular branch of the facial nerve that can be avoided with dissection under microscope for better visualization. The merits of the submental lymph node flap are that it has a substantial number of lymph nodes that have been correlated with better outcomes with VLNT. Additionally, there is no risk of iatrogenic lymphedema. The supraclavicular flap is based on the transverse cervical artery and branches of the external jugular vein. This flap is commonly reported to have a variable blood supply and an inconsistent skin paddle (if required) and also leaves a visible scar. In the lateral thoracic lymph node flap, axillary level I lymph nodes (inferior to lateral border of pectoralis minor) are harvested based on the lateral thoracic or thoracodorsal vessels. Harvesting these nodes carries the risk of iatrogenic upper limb lymphedema. Lastly, the omentum is a rich source of lymphatic tissue and can be harvested in open or laparoscopic fashion. The risks of omentum harvest include intra-abdominal solid and hollow viscus injuries and adhesions. 44

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FIGURE 98.6 A. Design of the vascularized submental lymph node flap with a 2.5-cm elliptical skin paddle. B. The donor site was primarily closed and located below the mandibular edge, which allows the scar to be hidden. C. Sizable lymph nodes are evident at the base of the flap (yellow arrows) along the course of the submental artery (red arrow). A facial vein (blue arrows) was separated from the facial artery. D. Minimal donor site morbidity with an inconspicuous scar after the vascularized submental lymph node flap transfer at the 24-month follow-up. (Courtesy of Ming-Huei Cheng, MD.)

VLNT is the most recent of surgical treatments for extremity lymphedema (Figure 98.7). Although studies are accumulating, there are yet no consistent objective and quality-of-life outcomes data from which to draw definitive conclusions on efficacy. 50 However, the principal theories underlying the mechanism by which VLNT works are backed by clinical and laboratory evidence that offer a foundation with which to establish appropriate indications and produce higher level objective and subjective outcomes evidence of efficacy.

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FIGURE 98.7 A. A 60-year-old woman with breast cancer-related lymphedema of the right upper extremity. B. She underwent left vascularized groin lymph node flap transfer to the right wrist. C. The skin paddle in the wrist was de-epithelialized, and the left upper medial arm was subjected to liposuction at 14 and 27 months. At the 36-month follow-up, the reduction rates of the affected limb circumference were 40% and 38% above the elbow and below the elbow, respectively, without the use of a compression garment. The improvements in circumferential difference were 25% and 18% above the elbow and below the elbow, respectively. (Courtesy of Ming-Huei Cheng, MD.)

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Questions 1. In using circumferential measurement as an objective diagnostic test, what is the minimum increase in limb circumference used to define lymphedema? a. 1 cm b. 2 cm c. 3 cm d. 5 cm e. 10 cm 2. Which of the following is not a risk factor for secondary lymphedema? a. Cellulitis b. Resistance exercise c. Radiation d. Overweight 3. A 45-year-old woman is suspected to have developed lymphedema of the right lower extremity 7 months after pelvic node dissection and radiation for uterine cancer treatment. Which of the following is the most appropriate diagnostic imaging test? a. Magnetic resonance imaging b. Lymphoscintigraphy c. Fluorescence lymphography d. Lymphangiography 4. A 52-year-old woman presents with swelling, heaviness, and soreness of the left upper extremity that began 12 months ago. Two years ago, she underwent bilateral mastectomies with right axillary lymph node sampling. You suspect secondary lymphedema. Which of the following is the most appropriate treatment? a. Compression therapy b. LVA c. Diuretics d. CDT 5. A 39-year-old woman describes a 20-year history of unilateral lower extremity swelling. She thinks her grandmother had a similar problem. On exam, her left lower extremity is severely enlarged with nonpitting wooden edema and verrucous hyperkeratosis. Which of the following is not an appropriate surgical option? a. Excision b. Vascularized lymph node transplant c. Amputation d. LVA 1. Answer: b. Circumferential limb measurement is one of the most commonly used objective tools in lymphedema diagnosis generally, because it is inexpensive and convenient to use in clinical settings. The reliability of the test is high if it is administered properly: obtaining multiple circumference points along the limb using nonelastic tape measure. A 2 cm increase in limb circumference is most commonly used to define lymphedema. 2. Answer: b. Venipuncture, blood-pressure monitoring, and resistance exercise involving at-risk limbs are a few of several factors that have been largely discredited as risk factors for lymphedema. There also is robust evidence that both aerobic and resistance exercise, in addition to not increasing the risk of lymphedema, provide strength and physical function benefits. All of the other options are

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recognized risk factors for lymphedema. Radiation impairs lymphatic transport with fibrosis of lymphatic channels. Although the mechanism is not well understood, patients with overweight/obesity (BMI >25) have a higher incidence of lymphedema after exposure to risk (e.g., lymph node dissection). Moreover, excess adipose deposition is a key element of lymphedema pathophysiology. Cellulitis and other soft tissue infections also increase the risk of developing lymphedema. Overweight/obesity and soft tissue infections are potentially controllable risk factors. 3. Answer: b. Lymphoscintigraphy is the standard diagnostic test for lymphedema. The test requires injecting radiolabeled colloid into the dermis at the distal limb and observing the transit and proximal uptake of colloid in the nodal basin. Magnetic resonance imaging may show changes in the skin and subcutaneous tissues secondary to lymphedema; however, it is not a standard imaging technique used in diagnosis of lymphedema. In fluorescence lymphangiography, indocyanine green is injected in the dermis at the distal limb and a near-infrared light source is used to observe lymphatic drainage. It is a useful adjunct to lymphoscintigraphy for diagnosis and surgical planning for physiologic procedures but it is not the recognized gold standard diagnostic test. Lymphangiography involves injection of contrast dye directly into a lymphatic vessel to visualize the lymphatic system under fluoroscopy. Lymphangiography is not widely used because of concerns that the inflammatory reaction to intraluminal injection of contrast can damage lymphatic vessels. 4. Answer: d. CDT is the first-line treatment for lymphedema. It comprises several elements including MLD, compression therapy, and skin care, which in combination are effective in decreasing limb swelling and bouts of skin infections. Compression therapy is one of the elements of CDT, and several studies have compared its effectiveness as a lone measure, to CDT so far with mixed results. Hence, CDT remains the standard treatment for lymphedema. LVA is a surgical option for treating lymphedema in patients who have failed conservative treatments. Diuretics are not effective as primary treatment for lymphedema. 5. Answer: c. Staged elliptical excisions or excision of diseased tissue followed by wound coverage with skin grafts are surgical options for patients who present with late-stage lymphedema and elephantiasis causing functional limitations. Amputation is not a primary treatment for lymphedema and unnecessarily subjects the patient to significant loss of limb function. Vascularized lymph node transplant and LVA are surgical options to reconstruct the lymphatic system. These options are most appropriate in patients with earlier stage lymphedema (International Society of Lymphology stage I or II) with partial lymphatic obstruction and no severe hypertrophic limb changes.

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References Jiang, X, Nicolls, MR, Tian, W, et al. Lymphatic dysfunction, leukotrienes, and lymphedema. Annu Rev Physiol. 2018;80:49-70. Cormier, JN, Askew, RL, Mungovan, KS, et al. Lymphedema beyond breast cancer: a systematic review and meta-analysis of cancer-related secondary lymphedema. Cancer. 2010;116(22):5138-5149. Gärtner, R, Jensen, MB, Kronborg, L, et al. Self-reported arm-lymphedema and functional impairment after breast cancer treatment – a nationwide study of prevalence and associated factors. Breast. 2010;19(6):506-515. Fu, MR, Ridner, SH, Hu, SH, et al. Psychosocial impact of lymphedema: a systematic review of literature from 2004 – 2011. Psychooncology. 2013;22(7):1466-1484. Heiney, SP, McWayne, J, Cunningham, JE, et al. Quality of life and lymphedema following breast cancer. Lymphology. 2007;40(4):177-184. Pusic, AL, Cemal, Y, Albornoz, C, et al. Quality of life among breast cancer patients with lymphedema: a systematic review of patientreported outcome instruments and outcomes. J Cancer Surviv. 2013;7(1):83-92. Basta, MN, Fox, JP, Kanchwala, SK, et al. Complicated breast cancer-related lymphedema: evaluating health care resource utilization and associated costs of management. Am J Surg. 2016;211(1):133-141. Boyages, J, Xu, Y, Kalfa, S. Financial cost of lymphedema borne by women with breast cancer. Psychoocology. 2017;26(6):849-855. Rockson, SG, Rivera, KK. Estimating the population burden of lymphedema. Ann N Y Acad Sci. 2008;1131:147-154. Szuba, A, Rockson, SG. Lymphedema: classification, diagnosis and therapy. Vasc Med. 1998;3(2):145-156. Mortimer, PS, Rockson, SG. New developments in clinical aspects of lymphatic disease. J Clin Invest. 2014;124(3):915-921. Connell, F, Gordon, K, Brice, G, et al. The classification and diagnostic algorithm for primary lymphatic dysplasia: an update from 2010 to include molecular findings. Clin Genet. 2013;84(4):303-314. Lymphatic filariasis. World Health Organization. Available at http://www.who.int/news-room/fact-sheets/detail/lymphatic-filariasis. Accessed April 1, 2018. Beesley, V, Janda, M, Eakin, E, et al. Lymphedema after gynecological cancer treatment. prevalence, correlates, and supportive care needs. Cancer. 2007;109(12):2607-2614. McLaughlin, SA, Wright, MJ, Morris, KT, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: patient perceptions and precautionary behaviors. J Clin Oncol. 2008;26(32):5220-5226. DiSipio, T, Rye, S, Newman, B, Hayes, S. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and metaanalysis. Lancet Oncol. 2013;14(6):500-515. Yen, TW, Fan, X, Sparapani, R, et al. A contemporary, population-based study of lymphedema risk factors in older women with breast cancer. Ann Surg Oncol. 2009;16(4):979-988. Ashikaga, T, Krag, DN, Land, SR, et al. Morbidity results from the NSABP B-32 trial comparing sentinel lymph node dissection versus axillary dissection. J Surg Oncol. 2010;102(2):111-118. Ververs, JM, Roumen, RM, Vingerhoets, AJ, et al. Risk, severity, and predictors of physical and psychological morbidity after axillary lymph node dissection for breast cancer. Eur J Cancer. 2001;37(8):991-999. Ki, EY, Park, JS, Lee, KH, et al. Incidence and risk factors of lower extremity lymphedema after gynecologic surgery in ovarian cancer. Int J Gynecol Cancer. 2016;26(7):1327-1332. McLaughlin, SA, DeSnyder, SM, Klimberg, S, et al. Considerations for clinicians in diagnosis, prevention and treatment of breast cancerrelated lymphedema, recommendations from an expert panel: part 2: preventive and therapeutic options. Ann Surg Oncol. 2017;24(10):2827-2835. Schmitz, KH, Ahmed, RL, Troxel, AB, et al. Weight lifting for women at risk for breast-cancer-related lymphedema. JAMA. 2010;304(24):26992705. Kolden, GG, Strauman, TJ, Ward, A, et al. A pilot study of group exercise training (GET) for women with primary breast cancer: feasibility and health benefits. Psychooncology. 2002;11(5):447-456. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2013 consensus document of the International Society of Lymphology. Lymphology. 2013;46(1):1-11. Shaw, C, Mortimer, P, Judd, PA. A randomized controlled trial of weight reduction as a treatment for breast cancer-related lymphedema. Cancer. 2007;110(8):1868-1874. Norman, SA, Localio, AR, Potashnik, SL, et al. Lymphedema in breast cancer survivors: incidence, degree, time course, treatment and symptoms. J Clin Oncol. 2009;27(3):390-397. Petrak, JA, Senie, RT, Peters, M, et al. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer. 2001;92(6):1368-1377. Launois, R, Alliot, F. Quality of life scale in upper limb lymphoedema – a validation study. Lymphology. 2000;33(suppl):266-274.The study describes the construction and validation of the Upper Limb Lymphedema—27 Questionnaire, currently the only condition-specific, quality-
 of-life, patient-reported outcome measure for upper extremity lymphedema. It improves the opportunity to design outcomes studies that provide informative conclusions about the effectiveness of lymphedema treatments. McLaughlin, SA, Staley, AC, Vicini, F, et al. Considerations for clinicians in the diagnosis, prevention, and treatment of breast cancer-related lymphedema: recommendations from a multidisciplinary expert ASBrS panel part 1: definitions, assessments, education, and future directions. Ann Surg Oncol. 2017;24(10):2818-2826.

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Chen, YW, Tsai, HJ, Hung, HC, et al. Reliability study of measurements for lymphedema in breast cancer patients. Am J Phys Med Rehabil. 2008;87(1):33-38. Armer, JM, Hulett, JM, Bernas, M, et al. Best practice guidelines in assessment, risk reduction, management, and surveillance for post-breast cancer lymphedema. Curr Breast Cancer Rep. 2013;5(2):134-144. Ogata, F, Narushima, M, Mihara, M, et al. Intraoperative lymphography using indocyanine green dye for near-infrared fluorescence labeling in lymphedema. Ann Plast Surg. 2007;59(2):180-184.This study introduced near-infrared lymphography with indocyanine green (ICG) for intraoperative lymphatic mapping during microsurgical lymphatic reconstruction. The practice obviates the need for extensive dissection to find patent lymphatics, essentially making LVA an easier minimally invasive procedure. Chang, DW, Suami, H, Skoracki, R. A prospective analysis of 100 consecutive lymphovenous bypass cases for treatment of extremity lymphedema. Plast Reconstr Surg. 2013;132(5):1305-1314. International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: 2016 consensus document of the International Society of Lymphology. Lymphology. 2016;49(4):170-184. Patel, KM, Lin, CY, Cheng, MH. A prospective evaluation of lymphedema-specific quality-of-life outcomes following vascularized lymph node transfer. Ann Surg Oncol. 2015;22(7):2424-2430. Ezzo, J, Manheimer, E, McNeely, ML, et al. Manual lymphatic drainage for lymphedema following breast cancer treatment. Cochrane Database Syst Rev. 2015;21(5):CD003475. Johansson, K, Albertsson, M, Ingvar, C, et al. Effects of compression bandaging with or without manual lymph drainage treatment in patients with postoperative arm lymphedema. Lymphology. 1999;32(3):103-110. McNeely, ML, Magee, DJ, Lees, AW, et al. The addition of manual lymph drainage to compression therapy for breast cancer related lymphedema: a randomized controlled trail. Breast Cancer Res Treat. 2004;86(2):95-106. Brorson, H, Svensson, H. Liposuction compared with controlled compression therapy reduces arm lymphedema more effectively than controlled compression therapy alone. Plast Reconstr Surg. 1998:102(4);1058-1067. Brorson, H. Liposuction in lymphedema treatment. J Reconstr Microsurg. 2016;32(1):56-65. Dumanian, GA, Futrell, JW. The Charles procedure: misquoted and misunderstood since 1950. Plast Reconstr Surg. 1996;98(7):1258-1263. Salgado, CJ, Mardini, S, Spanio, S, et al. Radical reduction of lymphedema with preservation of perforators. Ann Plast Surg. 2007;59(2):173179. Koshima, I, Inagawa, K, Urushibara, K, et al. Supermicrosurgical lymphaticovenular anastomosis for treatment of lymphedema in the upper extremities. J Reconstr Microsurg. 2000;16(6):437-442.In the evolution of LVA using larger caliber cutaneous veins, patency was a concern primarily because of backflow from the higher pressure cutaneous venous system. This study described supermicrosurgical LVA using subdermal venules with more favorable pressures, potentially improving patency rates. Allen, RJ, Cheng, MH. Lymphedema surgery: patient selection and an overview of surgical techniques. J Surg Oncol. 2016;113(8):923-931. Scaglioni, FM, Fontein, BYD, Arvanitakis, M, et al. Systematic review of lymphovenous anastomosis (LVA) for the treatment of lymphedema. Microsurgery. 2017;37(8):947-953 Campisi, C, Davini, D, Bellini, C, et al. Lymphatic microsurgery for the treatment of lymphedema. Microsurgery. 2006;26(1):65-69. Shesol, BF, Nakashima, R, Alvavi, A, et al. Successful lymph node transplantation in rats, with restoration of lymphatic function. Plast Reconstr Surg. 1979;63(6):817-823.The authors demonstrated, in laboratory experiments, that vascularized transplanted nodes established connections with local, open lymphatic channels after lymphadenectomy. This four-decade old finding forms a basis of contemporary VLNT techniques. Cheng, MH, Huang, JJ, Wu, CW, et al. The mechanism of vascularized lymph node transfer for lymphedema: natural lymphaticovenous drainage. Plast Reconstr Surg. 2014;133(2):192e-198e. Lin, CH, Ali, R, Chen, SC et al. Vascularized groin lymph node transfer using the wrist as a recipient site for management of postmastectomy upper extremity lymphedema. Plast Reconstr Surg. 2009;123(4):1265-1275. Pappalardo, M, Patel, KM, Cheng, MH. Vascularized lymph node transfer for treatment of extremity lymphedema: an overview of current controversies regarding donor sites, recipient sites and outcomes. J Surg Oncol. 2018;117(7):1420-1431.

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CHAPTER 99

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Pressure Injuries Christi M. Cavaliere and Rachel E. Aliotta

Key Points When external pressure exceeds capillary bed pressure (32 mm Hg), perfusion is impaired and results in ischemic tissue and pressure-related injuries. Relieving pressure over a bony prominence for 5 minutes every 2 hours will allow adequate perfusion and reduce the risk of soft tissue breakdown. Pressure injury resolution can only occur if infection is treated, pressure is relieved, and exacerbating spasms or contractures are controlled. Medical and nutrition optimizations are critical before reconstruction should be attempted. Because of the high risk of recurrence, the choice of soft tissue closure should always anticipate the need for future reoperations. Successful pressure injury treatment depends on multidisciplinary team efforts employing both medical and surgical management in a team-based approach. Unrelieved prolonged pressure, commonly over a bony prominence such as the sacrum, can result in localized soft tissue injury. Although historically referred to as bed sores, or decubitus ulcers, these wounds can occur anywhere on the body when there is increased pressure or friction, shearing forces, or limb spasticity. 1 Constant and attentive repositioning is essential for prevention and healing of pressureinduced wounds. Wound management begins with identifying and aggressively managing the modifiable factors that contribute to pressure injury development such as positioning, incontinence, spasticity, nutrition, equipment, and medical comorbidities. Early interventions include dressing care and cleaning of the wound as well as appropriate support surfaces. Bedside debridement of nonviable or infected tissue may be appropriate in some cases; however, surgical management may be necessary in more severe cases or to promote patient comfort. Preoperative medical optimization, thorough debridement, and tension-free soft tissue coverage for closure of these defects remain the fundamental pillars of pressure injury management. 2 With increasingly complex patient populations suffering from these often-debilitating wounds, multidisciplinary specialty team care is essential for long-term success.

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Epidemiology An estimated 2.5 million pressure injuries are treated annually in the United States. 3 These patients are more likely to have increased hospital admissions and longer length of stay, and they are more likely to be discharged to a skilled nursing facility on discharge. 4 With costs over $11 billion, pressure injuries pose a significant burden to the health-care system. 5 The cost to treat one hospital-acquired pressure injury is estimated to be over $100,000. 6,7 Moreover, pressure-related injuries are now considered among the eight preventable conditions identified by the Centers for Medicare and Medicaid Services in 2008 as, never events. By this designation, the cost of treatment is no longer reimbursable for hospitals, no matter the inevitability or attempts made to prevent their occurrence. 8,9 Certain populations have been identified as high risk for developing pressure-related injuries 2 : Patients with hip fracture or spinal cord injury (SCI) Patients with lower extremity trauma resulting in bone or soft tissue injury with fixation and casting Elderly patients with immobility and/or cachexia Intensive care unit (ICU) patients The risk is even more pronounced in the SCI population, in which there is an estimated incidence of 20% to 30% in paraplegic and quadriplegic patients. 10 Patients may also present with more complicated risk factors, such as long-term use of pain medications, suicidal behavior, history of incarceration, smoking, and substance abuse. 2,11 Multiple pressure injury risk assessment tools have been developed to stratify patient risk and may be used to guide prevention interventions, such as the Braden, Waterlow, and Norton scales. Patient characteristics are included in the scales, such as mobility, nutrition, incontinence, and mental status. 12–14 Predictive value of these scales is fair, but there is no significant effect of implementation of the scales on reducing the incidence of pressure injuries. 15 The National Pressure Injury Advisory Panel is the authoritative voice for pressure injury prevention, treatment, and outcomes in the United States. In 2016 the National Pressure Injury Advisory Panel updated the pressure injury staging system. Although there are some clinical exceptions, in general stage 1 and 2 pressure injuries are treated nonoperatively. Stage 3 and 4 may require operative intervention to ameliorate. Proper staging may require initial debridement of any overlying nonviable tissue if the extent of injury is indeterminate on initial clinical examination (Table 99.1). TABLE 99.1 National Pressure Ulcer Advisory Panel Staging System for Pressure Injuries16

Stage 1 Stage 2 Stage 3

Description Nonblanching erythema Partial-thickness loss of dermis Full-thickness loss; subcutaneous tissue visible (but no muscle or bone)

Stage 4

Full-thickness loss with exposed bone, tendon, or muscle

Unstageable

Full-thickness loss, unknown depth due to eschar or slough

Deep tissue pressure injury Mucosal membrane

Purple/maroon colored intact skin with unknown true depth, or epidermal separation revealing dark wound bed or blood filled blister

Treatment Pressure relief Pressure relief, wound care Pressure relief, wound care, possible surgical debridement Pressure relief, wound care, possible surgical debridement Wound care, removal of devitalized tissue for proper staging, possible surgical debridement Pressure relief, monitor wound over time, may go on to need surgical debridement

Found on mucous membranes with a history of a medical device used at the location. These are not staged.

The economics of pressure injuries and prevention are astounding. Pressure-related injuries account for

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the second-most common hospital billing claim, and are estimated to cost $70,000 to $150,000 per patient for stage 3 or 4 injuries, at times resulting in over $250,000 in legal settlements. 6,17,18 Therefore, understanding common clinical situations and appropriate documentation and coding is essential in clinical practice management.

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Pathophysiology Pressure Pressure injures are caused by unrelieved mechanical pressure to soft tissue, most commonly over a weight-bearing bony prominence such as the sacrum, ischium, heel, or trochanter (Figure 99.1). When external pressure exceeds capillary bed pressure (32 mm Hg), perfusion is impaired resulting in both ischemic tissue injury and pressure-related injury. Relieving pressure over a bony prominence for 5 minutes every 2 hours will generally allow adequate perfusion and reduce the risk of soft tissue breakdown 19 (Figure 99.2). When the pressure exerted on the soft tissue becomes higher than that of the supplying blood vessels, edema and ischemia occur, metabolic waste products and free radicals accumulate, and with time permanent tissue destruction leads to significant defects 20 . Perhaps counterintuitively, the clear relationship between pressure and time is seen pathologically first in the muscle overlying the bone, followed by the superficial soft tissues and lastly the skin. 21 This distribution with less visible injury at the surface and the more extensive tissue injury deep, adjacent to the bone, is referred to as the tip of the 
 iceberg (Figure 99.3).

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FIGURE 99.1 Common sites of pressure on the human body when seated, prone, and supine. (Reprinted with permission of Cleveland Clinic Center for Medical Art & Photography ©2018. All rights reserved.)

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FIGURE 99.2 The inverse relationship between time and pressure in the formation of pressure injuries.

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FIGURE 99.3 Tip of the iceberg cone-shape pattern of pressure-related injury from unrelieved pressure affecting the deepest structures adjacent to the bone with the greatest injury.

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Inflammation Inflammation plays a key role in tissue injury, repair, and regeneration. Dynamic reciprocity, or the ongoing bidirectional interaction between cells and their surrounding environment, is an integral process in wound healing. 22 The lack of objective quantifiable biochemical and physiologic markers that can be used to assess wound status is still a major hurdle in the progress of improved treatment regimens.

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Edema Increased applied pressure leads to plasma extravasation and edema. Inflammatory mediators (e.g., prostaglandin E2) are released in response to compression and cause leakage through cell membranes, which increases the amount of interstitial fluid. With local denervation there is a loss of sympathetic tone to area vasculature, leading to vasodilation and vessel engorgement. This is exacerbated by circulatory disease (i.e., heart or renal failure, venous insufficiency) and further increases edema in dependent areas.

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Other Factors Additional factors contributing to or exacerbating soft tissue loss include friction, shearing forces, malnutrition, moisture, and neurologic injury. Perspiration, wound drainage, and incontinence can lead to an increased coefficient of friction between the wound and dressing or bed linens. This further potentiates contact damage and tissue breakdown. 23 Despite this, there is no known direct evidence linking urinary or fecal incontinence with the direct formation of pressure-related injuries themselves.

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Clinical Prevention and Management Control Extrinsic Factors Behavioral modification: The mainstay of pressure injury prevention is the even distribution of pressure across the body in contact with any surface. Mobilize and/or reposition Avoid prolonged sitting Encourage smoking cessation Manage excess perspiration in and around wound and skin folds with appropriate dressings and clothing Establish effective toileting routine to reduce/prevent soilage and maceration Pressure relief: No single specific device has been proven superior for prevention relative to others. 24 Minimize head-of-bed elevation to reduce sacral shear forces (20%, headache, flushing, sweating, chills, nasal congestion, piloerection, and pallor. Patients with lesions above T6 are particularly susceptible.

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Postoperative Complications Complication rates are high, with recurrence and wound dehiscence as the most common complications. Recurrence rates as high as 80% are reported in some studies. 43,47 However, the literature examining complications and outcomes remains varied and is often limited to single-center retrospective analyses. Unfortunately, postoperative complications further raise the already substantial cost of surgery and care for these pressure-related injuries 51 (Table 99.2). TABLE 99.2 Risk Factors for Postoperative Complications Recurrence/Reoperation Young age (150 blood pressure control c. Add antiemetic d. Administer intravenous dantrolene e. Check urine output and place Foley catheter 3. A 54-year-old woman with paraplegia since age 24 comes to your clinic with a stage IV pressure injury of unknown time period; you suspect at least 6 months in duration based on your history and physical examination, in which you see denuded bone at the base of the wound and pinkgranulating tissue on the periphery. She has been diligent with pressure offloading and wound care with moisture dressings, but it does not seem to be improving. Which of the following is the most appropriate next step? a. Order MRI of the pelvis b. Schedule for elective flap closure c. Order CT of the pelvis d. Schedule for debridement and bone biopsy e. Discuss long-term palliative care for this wound 4. A 38-year-old woman who works in accounting and spends most of her time in a wheelchair presents to your clinic with a trochanteric pressure-related sore. After appropriate medical workup and optimization of nutrition, you decide to cover her wound with a posterior thigh musculocutaneous flap. What is the chief disadvantage of this flap? a. Unreliable blood supply b. Limited amount of skin, fat and, muscle provided c. Limited upward mobility of the flap d. Inability to be readvanced if wound recurrence later

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e. High rate of donor site morbidity 5. You receive a consult for a 19-year-old boy who underwent a 13-hour liver transplant; following the case in the ICU, he was noted to have redness and skin breakdown on the left scapula and sacrum. When you roll him to assess the wounds, you note two well-demarcated areas of redness and blanching skin with minor skin breakdown involving the epidermis only overlying the tip of the scapula and the sacrum. There is no drainage or exposed structures. What is the most appropriate management of this pressure-related injury? a. Local wound care with placement of soft foam dressing and rigorous pressure offloading b. Excision of blanching area with placement of wet to dry gauze to be changed daily c. Excision of blanching area with placement of split thickness skin graft d. Excision of blanching area with local advancement flaps to close e. No intervention, encourage discharge from the hospital as soon as possible 1. Answer: c. This patient has a clean wound, which is not infected, and she does not have any systemic illnesses to preclude her from closure at this time. For wounds of this size and in this location a skin graft would not be a durable option. She is now ambulatory and the wound has soft tissue at the base indicating that a total ischiectomy is not required to get this wound healed. She has poor nutrition indicated by her recent laboratory test results, which will place her at increased risk for wound-healing complications, and she should have a nutrition consult to improve her nutrition prior to reconstruction first. Preoperative goals of albumin >3 g/dL and prealbumin >20 mg/dL 
 should ideally be attained before performing elective flap closure for ischemic injuries, as studies have shown low serum prealbumin predicts a poor prognosis for wound healing. Although reasonable, there is no indication for MRI at this time given the duration and cause of her injury and that she does not have exposed bone on examination. 2. Answer: e. AD is a medical emergency characterized by severe hypertension. It can be brought on by wide array of stimuli below the level of the lesion. It can occur intraoperative or postoperatively. Commonly in a resting patient on the nursing floor, bladder or bowel distension can be the source of triggering an acute AD event. Therefore, bladder and bowel output should be monitored and considered when patients with SCI become acutely clinically unstable. 3. Answer: d. Patients with chronic nonhealing wounds in the face of adequate wound care and medical optimization must be examined and investigated for underlying condition. Any wound presenting with exposed bone, particularly in a chronic or nonhealing wound should be biopsied to rule out pathologic involvement and infection. 4. Answer: c. The posterior thigh flap has a very reliable blood supply (first perforating branch from the profunda femoris artery); it provides generous skin, fat, and muscle and retains the ability to readvance the flap if needed later. Additionally, medial and lateral donor sites and the gluteal muscles remain intact for additional flaps if needed later on. Depending on the size of the flap, the donor site can often be closed primarily, or with a skin graft if too large. The primary disadvantage is the limited upward mobility of the flap with only 10 to 12 cm of movement, which may necessitate additional flaps to be utilized if not adequate for larger wounds. 5. Answer: a. This early-stage pressure-related injury is acutely related to his recent surgery and will likely recover when he is no longer in a confined position for many hours. Iatrogenic pressurerelated injuries such as these are considered never events, and hospitals are no longer reimbursed for treatments provided for their care when acquired in the hospital setting. The operating room and ICUs should follow strict guidelines for pressure-offloading surfaces during long operative cases or in patients who have high risk in critical care settings to avoid these from occurring.

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References Tchanque-Fossuo, CN, Kuzon, WM Jr. An evidence-based approach to pressure sores. Plast Reconstr Surg. 2011;127(2):932-939. Ricci, JA, Bayer, LR, Orgill, DP. Evidence-based medicine: the evaluation and treatment of pressure injuries. Plast Reconstr Surg. 2017;139(1):275e-286e. Reddy, M, Gill, SS, Rochon, PA. Preventing pressure ulcers: a systematic review. JAMA. 2006;296(8):974-984. Russo, CA, Steiner, C, Spector, W. Hospitalizations related to pressure ulcers among adults 18 years and older, 2006: statistical brief #64. Healthcare Cost and Utilization Project (HCUP) Statistical Briefs. Rockville, MD; 2006. Cushing, CA, Phillips, LG. Evidence-based medicine: pressure sores. Plast Reconstr Surg. 2013;132(6):1720-1732. Padula, WV, Mishra, MK, Makic, MB, Sullivan, PW. Improving the quality of pressure ulcer care with prevention: a cost-effectiveness analysis. Med Care. 2011;49(4):385-392. Description of NPUAP. National pressure ulcer advisory panel. Adv Wound Care. 1995;8(4 suppl):93-95. Zaratkiewicz, S, Whitney, JD, Lowe, JR, et al. Development and implementation of a hospital-acquired pressure ulcer incidence tracking system and algorithm. J Healthc Qual. 2010;32(6):44-51. Centers for Medicare and Medicaid Services. Medicare program: changes to the hospital inpatient prospective payment systems and fiscal year 2009 rates; payments for graduate medical education in certain emergency situations; changes to disclosure of physician ownership in hospitals and physician self-referral rules; updates to the long-term care prospective payment system; updates to certain IPPS-excluded hospitals; and collection of information regarding financial relationships between hospitals. Final rules. Fed Regist. 2008;73(161):4843349084.The publication of these guidelines and changes in Medicare reimbursement for hospital acquired pressure related injuries changed the paradigm for pressure sore treatment and resulted in a drastically increased emphasis on the prevention and treatment of these wounds in all patients and facilities across the United States moving forward. McKinley, WO, Jackson, AB, Cardenas, DD, DeVivo, MJ. Long-term medical complications after traumatic spinal cord injury: a regional model systems analysis. Arch Phys Med Rehabil. 1999;80(11):1402-1410. Stal, S, Serure, A, Donovan, W, Spira, M. The perioperative management of the patient with pressure sores. Ann Plast Surg. 1983;11(4):347356. Waterlow, JC. Requirements for specialist training. Lancet. 1985;1(8428):576. Wang, LH, Chen, HL, Yan, HY, et al. Inter-rater reliability of three most commonly used pressure ulcer risk assessment scales in clinical practice. Int Wound J. 2015;12(5):590-594. Braden, BJ, Bergstrom, N. Predictive validity of the Braden scale for pressure sore risk in a nursing home population. Res Nurs Health. 1994;17(6):459-470. Moore, ZE, Cowman, S. Risk assessment tools for the prevention of pressure ulcers. Cochrane Database Syst Rev. 2014;(2):CD006471. National Pressure Ulcer Advisory Panel. NPUAP Pressure Injury Stages. Available athttp://www.npuap.org/resources/educational-andclinical-resources/npuap-pressure-injury-stages/ . Accessed November 8, 2018. Lyder, CH, Wang, Y, Metersky, M, et al. Hospital-acquired pressure ulcers: results from the national Medicare patient safety monitoring system study. J Am Geriatr Soc. 2012;60(9):1603-1608. Bennett, RG, O’Sullivan, J, DeVito, EM, Remsburg, R. The increasing medical malpractice risk related to pressure ulcers in the United States. J Am Geriatr Soc. 2000;48(1):73-81. Dinsdale, SM. Decubitus ulcers: role of pressure and friction in causation. Arch Phys Med Rehabil. 1974;55(4):147-152. Landis, EM. The capillary pressure in frog mesentery as determined by micro-
 injection methods. Am J Physiol. 1926;75(3):548-570.In a series of landmark studies, the concept of the pressure-time relationship and soft tissue destruction was explored. As the pressure exerted on the soft tissue becomes higher than that of the supplying blood vessels, edema and ischemia occurs, metabolic waste products and free radicals accumulate, and with time permanent tissue destruction leads to significant defects. Daniel, RK, Wheatley, D, Priest, D. Pressure sores and paraplegia: an experimental model. Ann Plast Surg. 1985;15(1):41-49. Schultz, GS, Davidson, JM, Kirsner, RS, et al. Dynamic reciprocity in the wound microenvironment. Wound Repair Regen. 2011;19(2):134-148. Gerhardt, LC, Strassle, V, Lenz, A, Spencer, ND, Derler, S. Influence of epidermal hydration on the friction of human skin against textiles. J R Soc Interface. 2008;5(28):1317-1328. McInnes, E, Jammali-Blasi, A, Bell-Syer, SE, et al. Support surfaces for pressure ulcer prevention. Cochrane Database Syst Rev. 2011; (4):CD001735. Kwok, AC, Simpson, AM, Willcockson, J, et al. Complications and their associations following the surgical repair of pressure ulcers. Am J Surg. 2018;216(6):1177-1181.This 10-year examinated of the NSQIP database examined complications following repair of ulcers in 1243 cases, and showed mortality rates on par with hepatobiliary cancer and cardiac surgery risk for death. Elderly age, diabetes and dependency were associated with increased mortality following pressure ulcer surgery. Flap repair of these ulcers was found to be associated with decreased complications. The overall 30day mortality for patients undergoing pressure ulcer surgery was found to be 3%. Tedeschi, S, Negosanti, L, Sgarzani, R, et al. Superficial swab versus deep-tissue biopsy for the microbiological diagnosis of local infection in advanced-stage pressure ulcers of spinal-cord-injured patients: a prospective study. Clin Microbiol Infect. 2017;23(12):943-947.This article examined the concordance rate between taking a superficial swab versus a deep tissue culture in the pressure sores of 116 spinal cord injury patients (a homogenous population not actively receiving antibiotics at the time of culture); they found a concordance rate of only 22%, with 27% false negative and 16% false-positives. Thus, concluding superficial swabs are not to be relied on for clinical diagnosis and treatment in advanced ulcers.

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Heym, B, Rimareix, F, Lortat-Jacob, A, Nicolas-Chanoine, MH. Bacteriological investigation of infected pressure ulcers in spinal cord-injured patients and impact on antibiotic therapy. Spinal Cord. 2004;42(4):230-234. Huang, AB, Schweitzer, ME, Hume, E, Batte, WG. Osteomyelitis of the pelvis/hips in paralyzed patients: accuracy and clinical utility of MRI. J Comput Assist Tomogr. 1998;22(3):437-443. Ovington, LG. Advances in wound dressings. Clin Dermatol. 2007;25(1):33-38. Black, J, Clark, M, Dealey, C, et al. Dressings as an adjunct to pressure ulcer prevention: consensus panel recommendations. Int Wound J. 2015;12(4):484-488. Singh, A, Halder, S, Menon, GR, et al. Meta-analysis of randomized controlled trials on hydrocolloid occlusive dressing versus conventional gauze dressing in the healing of chronic wounds. Asian J Surg. 2004;27(4):326-332. Graumlich, JF, Blough, LS, McLaughlin, RG, et al. Healing pressure ulcers with collagen or hydrocolloid: a randomized, controlled trial. J Am Geriatr Soc. 2003;51(2):147-154. Molan, P, Rhodes, T. Honey: a biologic wound dressing. Wounds. 2015;27(6):141-151. Health Quality Ontario. Management of chronic pressure ulcers: an evidence-based analysis. Ont Health Technol Assess Ser. 2009;9(3):1-203. Belmin, J, Meaume, S, Rabus, MT, Bohbot, S; Investigators of the Sequential Treatment of the Elderly with Pressure Sores . Sequential treatment with calcium alginate dressings and hydrocolloid dressings accelerates pressure ulcer healing in older subjects: a multicenter randomized trial of sequential versus nonsequential treatment with hydrocolloid dressings alone. J Am Geriatr Soc. 2002;50(2):269-274. Yang, C, Goss, SG, Alcantara, S, et al. Effect of negative pressure wound therapy with instillation on bioburden in chronically infected wounds. Wounds. 2017;29(8):240-246. McKanna, M, Geraci, J, Hall, K, et al. Clinician panel recommendations for use of negative pressure wound therapy with instillation. Ostomy Wound Manage. 2016;62(4):S1-S14. Orgill, DP, Bayer, LR. Negative pressure wound therapy: past, present and future. Int Wound J. 2013;10(suppl 1):15-19. Fischer, BH. Topical hyperbaric oxygen treatment of pressure sores and skin ulcers. Lancet. 1969;2(7617):405-409. Worth, ER, Tettelbach, WH, Hopf, HW. Arterial insufficiencies: enhancement of healing in selected problem wounds. In: Weaver, LK , ed. Hyperbaric Oxygen Therapy Indications. 13th ed. North Palm Beach, FL: Best Publishing; 2014:25-46. Adunsky, A, Ohry, A, Group, D. Decubitus direct current treatment (DDCT) of pressure ulcers: results of a randomized double-blinded placebo controlled study. Arch Gerontol Geriatr. 2005;41(3):261-269. Burke, DT, Ho, CH, Saucier, MA, Stewart, G. Effects of hydrotherapy on pressure ulcer healing. Am J Phys Med Rehabil. 1998;77(5):394-398. Kenneweg, KA, Welch, MC, Welch, PJ. A 9-year retrospective evaluation of 102 pressure ulcer reconstructions. J Wound Care. 2015;24(suppl 4a):S12-S21. Thiessen, FE, Andrades, P, Blondeel, PN, et al. Flap surgery for pressure sores: should the underlying muscle be transferred or not? J Plast Reconstr Aesthet Surg. 2011;64(1):84-90. Bamba, R, Madden, JJ, Hoffman, AN, et al. Flap reconstruction for pressure ulcers: an outcomes analysis. Plast Reconstr Surg Glob Open. 2017;5(1):e1187. Sameem, M, Au, M, Wood, T, et al. A systematic review of complication and recurrence rates of musculocutaneous, fasciocutaneous, and perforator-based flaps for treatment of pressure sores. Plast Reconstr Surg. 2012;130(1):67e-77e. Keys, KA, Daniali, LN, Warner, KJ, Mathes, DW. Multivariate predictors of failure after flap coverage of pressure ulcers. Plast Reconstr Surg. 2010;125(6):1725-1734. Schryvers, OI, Stranc, MF, Nance, PW. Surgical treatment of pressure ulcers: 20-year experience. Arch Phys Med Rehabil. 2000;81(12):15561562. Yamamoto, Y, Tsutsumida, A, Murazumi, M, Sugihara, T. Long-term outcome of pressure sores treated with flap coverage. Plast Reconstr Surg. 1997;100(5):1212-1217.Examining 45 ischial and 24 sacral sores in 53 paraplegic patients between 1990 and 1995, the types of flaps were categorized into fasciocutaneous or myocutaneous/muscle flaps. These investigators found that overall, the ischial sores had a higher recurrence rate than sacral sores; however, there was no significant difference in the percent pressure sore free survival (%PSFS) between the sites of sores. The group of the sores reconstructed with the fasciocutaneous flap demonstrated significant or marginally significant better results in the %PSFS compared with those reconstructed with myocutaneous or muscle flaps. These observations suggested the use of fasciocutaneous flaps provides just as durable, if not better longterm results in the surgical reconstruction of pressure sores compared to the myocutaneous or muscle flap. Dakson, A BD, Thibault-Halman, G, Christie, S. Venous thromboembolism and pressure ulcers in acute spinal cord injury: a retrospective review. JSM Spine. 2016;1(1):1001. Brem, H, Maggi, J, Nierman, D, et al. High cost of stage IV pressure ulcers. Am J Surg. 2010;200(4):473-477. Khor, HM, Tan, J, Saedon, NI, et al. Determinants of mortality among older adults with pressure ulcers. Arch Gerontol Geriatr. 2014;59(3):536541. Manzano, F, Perez-Perez, AM, Martinez-Ruiz, S, et al. Hospital-acquired pressure ulcers and risk of hospital mortality in intensive care patients on mechanical ventilation. J Eval Clin Pract. 2014;20(4):362-368. Bazalinski, D, Przybek-Mita, J, Baranska, B, Wiech, P. Marjolin’s ulcer in chronic wounds: review of available literature. Contemp Oncol (Pozn). 2017;21(3):197-202.

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CHAPTER 100

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Gender-Affirming Surgery William M. Kuzon, Jr and Katherine M. Gast

Key Points Gender dysphoria, the incongruence between anatomic sex and gender identity, affects 0.6% of the population, 1.4 million people in the United States. Treatment of gender dysphoria including mental health, hormonal therapy, puberty suppression, and gender-affirming surgery is deemed medically necessary by nearly all expert led medical societies including the American Medical Association and the American Society of Plastic Surgeons. Chest and genital surgery is often covered by insurance, including Medicare. WPATH, the World Professional Association for Transgender Health, is an international society with universally adopted standards of care (SOC) for gender-expansive patients, including prerequisites prior to hormonal therapy and gender-affirming surgery. Transfeminine surgery for patients assigned male at birth but identified as women, includes facial feminization, thyrochondroplasty, breast augmentation, and vaginoplasty. Transmasculine surgery for patients assigned female at birth but identified as men, includes mastectomy, metoidioplasty, and phalloplasty. Multidisciplinary care inclusive of mental health for gender-expansive patients, much like a bariatric or transplant surgery model, is paramount for good patient outcomes. Gender dysphoria is the incongruence between one’s experienced and assigned gender, 1 estimated to affect 0.6% of the population. 2 It is now recognized that gender identity may be nonbinary and patients may identify as transmasculine, transfeminine, trans (without gender specification), gender queer, nonbinary, gender expansive, or agender. 3 Table 100.1 provides helpful definitions of gender, sex, and other terms used throughout this chapter. TABLE 100.1 Definitions of Gender, Sex, and Other Terms Used in the Care and Treatment of Transgender and Gender Nonconforming Patients Gender Cisgender Sex Gender dysphoria

Internal sense of being a man or woman as defined by culture norms and customs. Patient with gender identity that matches anatomic sex. Nontransgender patients. Physical anatomy, assigned at birth. Incongruence between gender identity and physical sex resulting in functional impairment: Separate from sexual orientation ICD 10 diagnosis code F64 Included in the DSM V

Disorders of sexual development Sexual orientation Gender-affirming surgery Transfeminine patient Transmasculine patient

Reproductive organs and genitals do not develop as expected. DSD patients may or may not experience gender dysphoria. The emotional, sexual, romantic attractions one has with other people. Procedures to align a patient’s body and features with their gender identity. Assigned male at birth, identifies as female or on the feminine end of gender spectrum. Assigned female at birth, identifies as male or on the masculine end of gender spectrum.

DSD, disorders of sexual development

Patients with gender dysphoria have normal anatomy and hormonal physiology, distinguishing this patient population from those with disorders of sexual development. Notably, there is now substantial and accumulating evidence that an individual’s gender identity is determined largely by biological

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factors, and sexual orientation is an independent characteristic not directly related to gender identity. 4-6 For gender dysphoric patients, management must be individualized for each patient. The timeline of care typically follows this order: mental health counseling, hormonal therapy, and lastly, surgery for patients who desire it. 7 Gender-affirming surgery is recognized as medically necessary and associated with quality of life and functional improvements by every professional-led medical association, including the American Society of Plastic Surgeons. 8 Transgender and gender-expansive patients are an underserved and at-risk patient population within plastic surgery. 9 Patients have impaired access to care and experience discrimination in housing, employment, and social services. 10-12 Transgender patients have elevated rates of homelessness, joblessness, estrangement from their families and social support systems, interpersonal violence, suicide, HIV, and mental health comorbidities. Rates of comorbid mental illness and of suicidal ideation and suicide attempts greatly exceed those of the general population. 13-15

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Official Standards of Care The WPATH, is an international society of patients, health-care providers, and advocates that issues a SOC document (current Version 7 is from 2011) to define best practices and to prevent patient harm and regret. 7 The WPATH SOC define recommended prerequisites prior to hormonal therapy and genderaffirming surgery procedures (Table 100.2). The SOC have been criticized as authoritative and paternalistic, and alternative “informed consent” models of care have been advocated. 16-20 Although we acknowledge that the SOC are a source of controversy, we also strongly support adherence to the WPATH SOC when providing surgical care to gender-dysphoric patients. This cannot be overemphasized; Plastic Surgeons cannot independently diagnose gender dysphoria, so the determination of surgical candidacy for any gender confirming procedure should be made in the setting of a multidisciplinary team and in accordance with WPATH SOC. TABLE 100.2 The World Professional Association for Transgender Health Standards of Care Guidelines 7 , a Procedure Transfeminine Breast augmentation (implants/lipofilling)

Specifications

Referral(s) b

Hormones

Persistent, well-documented gender dysphoria

Not an explicit criterion, but recommended that patients receive 12 mo postfeminizing hormone therapy.

Orchiectomy d

Persistent, well-documented gender dysphoria

One referral (letter) by a qualified mental health professional Two referrals (letters) by qualified mental health professionals.

Vaginoplasty d

Persistent, well-documented gender dysphoria Must be living 12 continuous months in gender role that is congruent with gender identity

Two referrals (letters) by qualified mental health professionals

Persistent, well-documented gender dysphoria

One referral (letter) by a qualified mental health professional Two referrals (letters) by qualified mental health professionals If one letter is from therapist, the other should be from evaluator Two referrals (letters) by qualified mental health professionals. If one letter is from therapist, the other should be from evaluator.

Transmasculine Mastectomy and creation of male chest Hysterectomy and ovariectomy d

Metoidioplasty or phalloplasty d

Persistent, well-documented gender dysphoria

Persistent, well-documented gender dysphoria Must be living 12 continuous months in gender role that is congruent with gender identity

12 continuous months of hormone therapy as appropriate to patient’s gender goals. Exception if the patient has medical or personal reasons to not take hormones. c 12 continuous months of hormone therapy as appropriate to patient’s gender goals. Exception if the patient has medical or personal reasons to not take hormones. c

Not a prerequisite

12 continuous months of hormone therapy as appropriate to patient’s gender goals. Exception if the patient has medical or personal reasons to not take hormones. c

12 continuous months of hormone therapy as appropriate to patient’s gender goals. Exception if the patient has medical or personal reasons to not take hormones. c

Reprinted by permission from World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version. Elgin, IL: The World Professional Association for Transgender Health; 2011. WPATH SOC Guidelines can be accessed at https://www.wpath.org/media/cms/Documents/Web%20Transfer/SOC/Standards%20of%20Care%20V7%20%202011%20WPATH.pdf.

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a Standards of care guidelines for the surgical treatment of gender dysphoria in transgender and gender-nonconforming adults, suggested by the World Professional Association for Transgender Health. Note that patients should be 18 years of age, able to legally give consent, and any comorbid psychiatric conditions must be “reasonably well controlled.” b

Referral letters should include:

1. 2. 3. 4. 5. 6. 7.

Patient’s identifying characteristics Diagnosis and other psychological evaluation results Details of relationship to patient: duration of care, type of evaluation, type of counseling or treatment Endorsing patient’s application and explaining how they fulfill criteria for surgery Confirmation of informed consent Confirmation of availability for coordination of care Confirmation of adequately controlled mental health concerns

c

To introduce a period of reversible estrogen or testosterone suppression, before the patient undergoes irreversible surgical intervention.

d

Though it is not an explicit criterion, it is recommended that these patients also have regular visits with a mental health or other medical professional.

Note that for all procedures, except when specific variance from the Standards of Care are justified, the patient should be 18 years of age and legally able to consent to the surgery on their own.

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Comprehensive Gender Care Ideal care for transgender patients requires close communication and collaboration among a diverse multidisciplinary team; centers for cleft lip and palate, bariatric, or transplant surgery are analogous models. This is a critical point: close collaboration between team members is vital to good patient outcomes. 21 Depending on where patients are in their transition, they may need mental health, social work, pediatric or adult endocrinology, fertility services, and/or surgery if they choose. Patients also need access to “gender-friendly” providers who can provide permanent hair removal, speech therapy, and pelvic floor physiotherapy. Organized peer support is also valuable for patients and families. Centers performing gender-affirming surgery should have resources in all these areas available. In addition, it is important to provide a supportive environment of care. This population is very sensitive to misgendering, so it is important to educate all staff who interact with patients to use preferred pronouns, and, especially if the patient has not yet made a legal name change, preferred first names. For patients undergoing surgical procedures and who are admitted to hospital, they should be identified and housed in their expressed gender.

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Care of Children and Adolescents The care of children and adolescents with gender dysphoria requires specialized training and is also evolving rapidly. Preadolescent children may express gender dysphoria consistent with gender identity disorder of childhood. 1,22-24 In some studies, 60% or more of these children will “desist” and return to the gender consistent with their anatomy, 24 although there is not a clear consensus in the literature. 1 For this reason, surgery is never indicated in children nor advised in the WPATH SOC (see Table 100.2). 7 If gender dysphoria persists into or appears in adolescence and is consistent with a diagnosis of gender dysphoria of adolescence and adulthood, patients may be candidates for puberty suppression therapy. 25 This typically consists of GnRH agonists that suppress the pulsatile stimulation of the gonads, which is safe and reversible; cross-hormone therapy at age 15 or 16 may then be initiated later. Hormonal therapy for transfeminine patients (assigned male at birth, identify as female), includes estrogen and spironolactone or finasteride (androgen blockers). Hormonal therapy for transmasculine patients (assigned female at birth, but identify as male) includes testosterone. On a case-by-case basis, with treatment decisions made among the adolescent, the family, and the multidisciplinary treatment team, surgical intervention in adolescents may be appropriate. For chest recontouring in transmasculine adolescents, WPATH SOC recommend a year of testosterone therapy before surgery. 
 The decision to perform genital surgery on an adolescent, in addition to the WPATH SOC criteria for adults, is again a case-by-case decision by the multidisciplinary team. This remains a topic of active discussion by WPATH’s SOC Committee, as poor psychosocial, body image, and mental health outcomes may manifest in late adolescence.

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Gender-Affirming Surgery Gender-affirming surgeries generally fall within the scope of well-trained plastic surgeons. Table 100.3 outlines the main surgical treatments of gender dysphoria. For transfeminine patients, gender-affirming surgery often includes facial feminization, thyroid chondroplasty or “tracheal shave,” orchiectomy, breast augmentation, and vaginoplasty. For transmasculine patients, gender-affirming surgical procedures can include hysterectomy and oophorectomy, mastectomy, and genital reconstruction (i.e., phalloplasty, metoidioplasty). TABLE 100.3 Transfeminine and Transmasculine Gender-Affirming Surgeries That Fall Within the Scope of Plastic Surgery Transfeminine Surgery Facial feminization surgery

Transmasculine Surgery

Lower hairline Shave brow bone +/− posterior reset of the anterior wall of frontal sinus Rhinoplasty Malar augmentation Reduce angle of mandible Tracheal shave Laryngoplasty Voice surgery performed by ENT Breast augmentation

Mastectomy Periareolar Circumareolar Inferior pedicle Double-incision free nipple graft

Orchiectomy

Hysterectomy +/− Salpingo-oophorectomy

Vaginoplasty Penile inversion (most common) Sigmoid

Metoidioplasty Phalloplasty

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Transfeminine Surgery Facial Feminization Human beings are accustomed to determining the gender of an individual simply by looking at them while clothed. This is possible because, in addition to obvious morphologic differences in the breasts and body, there are major differences in both skeletal and soft tissue morphology that distinguish the cisfemale from the cis-male face. 26 An incongruence between their facial morphology and their feminine gender is a source of dysphoria for many transwomen who find it difficult to “pass” in society with a distinctly male face. The goal of facial feminization surgery is to alter the craniofacial bony skeleton and soft tissues of the face to achieve a facial appearance that is easily identified as female rather than male.

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Female Facial Morphology Masculine faces have been described as being square or rectangular, with a tall forehead, high hairline, a pronounced posterior sloping forehead contour, and prominent supraorbital ridges. Masculine faces tend to have wide and prominent mandibular angles, a square chin, a long upper lip, and a relatively acute nasolabial angle. In contrast, feminine faces have been described as oval-shaped, with a shorter, vertically oriented forehead and lower hairline, minimal supraorbital ridges, a shorter upper lip, narrower mandibular angles, a more obtuse nasolabial angle, and a more pointed chin. A masculine-appearing nose is generally larger and “less delicate” than the average feminine nose. There are multiple other differences between the masculine and feminine craniofacial skeleton and soft tissue envelope. To achieve optimal facial feminization, a careful analysis of each patient’s facial features and a comprehensive, individualized surgical plan developed. Because the prominent male supraorbital ridge and robust mandible most often require significant bony resection and recontouring, surgeons performing facial feminization must be skilled in maxillofacial and craniofacial surgical procedures. 27

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Preoperative Evaluation All of the sex-specific characteristics noted above should be carefully assessed on physical examination. Most importantly, a thorough discussion with the patients should define their perception of their facial features and their desired changes. For patients undergoing forehead recontouring, a lateral cephalograph or maxillofacial computed tomography scan should be obtained. This is essential to determine the thickness of the frontal bone over the frontal sinus and to gauge the degree of supraorbital reduction that will be necessary. If the frontal bone is sufficiently thick and the setback required is modest, burring of the supraorbital ridges may be sufficient. If the frontal bone is thin and/or if the setback required is significant, the surgeon must be prepared to do a formal frontal sinus recession, removing the anterior table of the frontal sinus in total, performing osteotomies on the excised segment of bone, and then replacing and rigidly fixing the bone segments in a reshaped, feminine configuration. If rhinoplasty, brow lifting, or blepharoplasty are to be performed (Figure 100.1), the usual analysis of nasal airflow and anatomy, dry eye, negative orbital vector, and so on should be done. If mandibular recontouring or height reduction is planned, an analysis of occlusion and consideration of an X-ray to identify the mental foramen and inferior alveolar nerve position are important.

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FIGURE 100.1 Facial feminization. Preoperative (A, B) and 6-month postoperative (C, D) photos of a patient who underwent feminizing brow lift, forehead and supraorbital ridge recontouring, and septorhinoplasty.

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Forehead Feminization Forehead feminization generally includes both lowering the hairline and reducing the prominence of and reshaping the supraorbital ridges. A pretrichial incision can be used to correct widow’s peak and bring the hairline forward with posterior scalp advancement and forehead skin excision. This incision can serve as the access point for a bony brow reduction with lateral burring of the supraorbital rims, burring or formal recession of the anterior table of the frontal sinus, and brow lift. Hair grafting can help disguise the scar and contour the hairline.

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Midface Feminization Malar implants or fat grafting can help define the cheekbones and feminize the midface. A rhinoplasty should focus on correcting a dorsal hump, osteotomies to narrow the upper vault, cephalic trim to rotate the nasal tip and create a supratip break, and interdomal sutures to create more tip definition.

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Feminization of the Mandibular Contour and Lower Face An upper lip lift, done through a gull-wing excision of skin along the nasal sill, can provide incisal tooth show at rest and increase the fullness of the vermillion. A narrowing genioplasty, most commonly through a transverse and vertical wedge excision osteotomy, reduces the prominence of the chin. The mandible angles can be reduced through osteotomies or burring through intraoral access incisions. If appropriate, reduction of the total mandibular height can be performed via resection of the entire inferior border of the mandible.

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Thyrolaryngoplasty The laryngeal prominence of the thyroid cartilage, or Adam’s apple, is a distinctly masculine feature that is often noticeable on profile of transfeminine patients. The thyroid cartilage is connected to the superior hyoid bone through thyrohyoid membrane and to the inferior cricoid cartilage through the cricothyroid ligaments. The thyroid cartilage consists of paired lamina with a central superior thyroid notch and midline laryngeal prominence. The cartilage is more prominent in men because of a more acute angle (90° versus 120°) between the paired lamina. Reduction of the prominence of the thyroid cartilage, also erroneously referred to as a “trach shave” (Figure 100.2), should be performed through a submental incision to leave a scar that is not visible on frontal view. Dissection should expose the superficial surface of the thyroid cartilage and can be aided by lighted retractors or endoscopic instruments. The location of the anterior commissure of the vocal cords can be determined by passing a flexible laryngoscope, observing the emergence of a needle passed through the thyroid cartilage, and marking that location with methylene blue. The “Adam’s apple” is then reduced by shaving the external surface of the thyroid cartilage down until a reasonable contour is achieved. In adults, the thyroid cartilage is frequently calcified, so the use of a bur or rongeurs may be necessary. The resection should be conservative to avoid vocal cord injury.

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FIGURE 100.2 Thyroid chondroplasty, or “tracheal shave.” Preoperative (A, B) and postoperative (C, D) photos of feminizing thyrochondroplasty to eliminate appearance of the Adam’s apple, a commonly denoted masculinizing feature. E. Intraoperative photo of thyroid cartilage just after cartilage trim. Approach should be made through a submental incision to minimize scarring.

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Voice Pitch Alteration The average pitch of the female voice is higher than that of the male voice, so the field of vocal pitch alteration surgery is rapidly evolving. 
 A number of procedures have been described, 28 but the most commonly performed contemporary procedures involve endoscopic, laser-assisted fusion of the anterior vocal cords. This moves the anterior commissure posteriorly and shortens vocal cord length, effectively raising the pitch of the voice. These specialized procedures require subspecialty training and are best performed by surgeons certified by the American Board of Otolaryngology/Head and Neck Surgery.

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Breast Augmentation Feminizing breast surgery in transfeminine patients most often requires augmentation with an implant. Fat grafting, or lipofilling, has been described and may be an option for modest augmentation, but patient goals and chest wall morphology usually requires an alloplastic device. Breast augmentation, as in cisgender women, involves placement of a silicone- or saline-filled device through an incision in the inframammary fold in either the subpectoral or subglandular position. Preoperatively, patients over 40 years of age on feminizing hormones should have a screening mammogram and assessment of breast cancer risk with complete family history. WPATH SOC requires one letter of readiness from a mental health professional prior to surgery and 1 year of estrogen therapy for breast development is recommended. No duration of “real-life experience” or living full time in the female gender role is required. Holding estrogen prior to surgery is recommended to prevent perioperative venous thromboembolism (VTE) given the elevated risk of VTE in transfeminine patients on hormonal therapy. 29,30 Preoperative physical examination should note the location of the nipples on the chest wall, which is often more lateral than cisgender women. The sternum and chest wall is also wider in transgender women. The implants must be placed with the nipple centered on the implant, so it is difficult to achieve cleavage in the midline in bras and clothing. Patients should be counseled about this at time of consultation. The inframammary fold is higher and more transverse in male chests; the patient’s goals of size and shape should be discussed, and the surgeon should estimate the upper limit of implant size that is achievable with the existing skin envelope. Often, breasts are constricted and tuberous appearing, which may necessitate scoring of the parenchyma at time of augmentation to redrape the parenchyma over the implant. Choice of subpectoral or subglandular position is a choice between the surgeon and patient. The subpectoral plane creates a more natural slope of the breast mount superiorly but limits the medial extent of the implant, especially if the patient has a wide sternum. The subglandular plane, although carrying a higher risk of capsular contracture, provides greater definition of the breast mount and may be preferable in patients with a broad pectoralis major muscle. Our preferred approach is through a 6-cm inframammary fold (IMF) incision at the location of the desired IMF, which may be lower than the existing fold. The new location of the IMF should be determined based on the diameter of the implant to be placed, placing the nipple at the most projecting aspect of the breast mound. Markings in the preoperative area should include sternal notch, midline, current IMF, desired IMF, breast base width, and limits of the pocket dissection. If subpectoral position is selected, complete release of the pectoralis major origin inferiorly should be performed with weakening of the medial sternal attachments. Postoperative care following transfeminine breast augmentation is similar to that of cis-gender women. A superior strap can be considered to keep implants low in the pocket in subpectoral augmentations. If significant IMF work is done, a postoperative underwire bra can help reinforce that position to prevent dropping of the implant. Results of breast augmentation are presented in Figure 100.3.

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FIGURE 100.3 Breast augmentation. Preoperative (A, B) and Postoperative (C, D) photos of transfeminine breast augmentation via an inframammary approach, placing smooth, round implants in the subpectoral position.

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Vaginoplasty Transfeminine gender-affirming bottom surgery creates a neoclitoris from the dorsal glans penis, labia minora from the prepuce or distal penile shaft skin, and labia majora from scrotal skin with removal of the erectile tissue of the penis, bilateral orchiectomy, and creation of a vagina (Figure 100.4). The vagina may be lined with inverted penile shaft skin (the penile inversion vaginoplasty technique, or Amsterdam procedure) or sigmoid colon (most often reserved as a rescue operation in cases of vaginal stenosis). 31

FIGURE 100.4 Penile inversion vaginoplasty. Preoperative (A) and postoperative (B) photos of transfeminine penile inversion vaginoplasty. Patients must continue to dilate or engage in penetrative intercourse to maintain depth and prevent neovaginal contraction.

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Preoperative Considerations The WPATH SOC guidelines dictate that prior to vaginopalsty surgery, patients must have two letters of readiness from independent mental health professionals, be on estrogen therapy for 1 year, and live in their congruent female gender role (formerly known as “real-life experience”) for 1 year (see Table 100.2). Vaginoplasty surgery is sterilizing, so discussion of preserving fertility through banked sperm must take place, especially for young patients. Patients should be 18 years old, with exceptions made when appropriate. Postoperatively, most patients are able to achieve orgasm with stimulation of the neoclitoris. Many also achieve orgasm with stimulation of the prostate with penetration. Patients should perform permanent hair removal with either laser (most effective in patients with fair skin and dark hair) or electrolysis. Hair around the circumference of the base of the penis and the posterior scrotum must be cleared as this tissue will line the introitus and posterior vaginal wall. The duration of hair removal depends on patient’s hair pattern and response to the hair removal sessions. Typically, this takes 3 to 6 months. Estrogen is held 3 weeks prior to surgery while the patient is on modified activity restrictions postoperatively to lower the risk of VTE. And a bowel prep is performed the day before surgery to clear the rectum of stool and lower the risk of rectal perforation (2% incidence) and rectovaginal fistula (around 1%). 32

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Penile Inversion Vaginoplasty Technique The penile inversion vaginoplasty procedure begins with elevation of a posterior perineal flap on skin that has previously been cleared of hair. The scrotal skin is split up the midline through the raphe to the base of the penis. A bilateral orchiectomy is performed with ligation of the spermatic cords at the level of the external inguinal ring; testicles should be sent to pathology for evaluation. A space for the vagina is dissected between the urethra and the rectum with sharp and then blunt dissection along the prerectal fascia. To be sure of not entering the rectum, the surgeon’s left hand can be placed in the rectum while making the tunnel with the right, feeling the anterior wall of the rectum between their two hands. The neovaginal tunnel should be developed up to the peritoneal reflection. One can instill betadine into the rectum with a moist sponge in the neovagina. Any evidence of betadine on the sponge will indicate a water leak and rectal injury in need of repair. A circumferential incision is then made 2 cm proximal to the glans penis and the penis is then degloved superficial to Buck fascia. The penis is then pulled through the skin tube and the mons pubis is undermined for 8 to 10 cm to facilitate pullback of the penile shaft skin to line the neovagina. The neoclitoral flap is then raised from a W-shaped dorsal glans penis flap, incorporating the distal penile shaft skin as associated labia minora flaps. The neoclitoral flap is based on the dorsal penile artery, nerve, and associated veins. The neurovascular bundle is within Buck’s fascia, and it is peeled off the tunica albuginea of the corpora distal to proximal with sharp dissection. The pedicle is dissected to the level of the pubic symphysis. A Foley catheter is placed in the urethra and the corpus spongiosum is separated from the paired corpora cavernosa. The corpora cavernosa are then separated, clamped, divided, and suture ligated in the midline. The neoclitoral flap is inset to the stumps of the corpora and the urethra is shortened and inset just posterior to the clitoris. The labia minora flaps are sutured around the neourethral edge to form a vulva. The central penile skin tube is inverted and pulled back. The scrotal skin is fashioned into labia majora with placement of incision in the groin crease. The penile skin tube is then lengthened with full thickness skin graft from the extra scrotal skin and finally a vaginal pack is placed with drains to remain in place for 5 to 7 days.

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Postoperative Care and Management of Complications Postoperative care includes modified activity of shuffling between chair and bed while the pack is in place and chemoprophylaxis for deep venous thrombosis (DVT). Following removal of the pack, drains, and Foley, the patient is taught to dilate and perform three times daily vaginal rinses. In addition to those seen with any major surgical procedure, complications of vaginoplasty include wound dehiscence and tissue loss (25%–39%), urethral stenosis and/or divergent urinary stream (20%–55%), vaginal or introital stenosis (6%–27%), pelvic floor spasm or dyspareunia (2%, which may require referral to a pelvic floor physiotherapist), and rectovaginal fistula (0.01%–2%). 32-34 Most series report a 20% or higher rate of revisionary surgery, especially for divergent urinary stream and aesthetics. 32 Speculum examinations should be performed in clinic to assess healing of the internal lining of the vagina. If areas of hypertrophic granulation tissue develop, then spot treatment with silver nitrate is helpful. If patients should develop malodorous vaginal secretions in the immediate postoperative period, suspicion must be high for a rectovaginal fistula. Imaging with per rectum contrast can help diagnose a fistula. If a fistula develops, the patient must have a temporary diverting ostomy for several months and keep dilating. If the patient stops dilating, the vaginal vault will completely contract down. A secondary gracilis flap may be considered in refractory cases of rectovaginal fistula. Patients must dilate for life or the vagina will slowly contract and they will lose depth. Patients will need to use lubricant for penetrative intercourse and are at elevated risk for urinary tract infections with a shorter urethra. The prostate is not removed and patients will need prostate cancer screening with a per vagina prostate examination beginning at the age of 50.

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Transmasculine Surgery Mastectomy Top surgery, or gender mastectomy, is a commonly requested operation among transmasculine patients. Patients often wear binders, very tight compressive garments, to flatten their chests and appear masculine in clothing. They report significant dysphoria related to their breasts, with resulting impairment in social and emotional function. 35 One letter of readiness is required per WPATH SOC, but no duration of testosterone therapy is needed prior to surgery in adults. Agender, gender fluid, or gender expansive patients who do not desire hormonal therapy may need top surgery owing to dysphoria related to their breasts.

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Preoperative Considerations Complete patient medical, surgical, social, and family histories should be obtained with emphasis on risk factors for breast cancer. Patients with strong family histories of breast cancer should be referred to a breast center for assessment of risk and potential imaging. If patients truly desire risk-reducing mastectomies for future breast cancer risk, this is a different operation and should be performed by a breast surgeon. Top surgery is a cosmetic mastectomy and breast tissue is left behind. Patients should be screened accordingly for cancer with clinical examinations and mammography after the age of 40 postoperatively. There is no need to discontinue testosterone therapy in the perioperative period as studies have not shown any effect on wound healing, bleeding, or DVT risk in cisgender men. 36

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Surgical Planning Degree of breast tissue, volume of parenchyma to be resected, skin redundancy, and ptosis are all factors that determine optimal technique. 37 Algorithms have been published to help determine optimal surgical technique, 38 but modifications should be made based on surgeon and patient preference.

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Periareolar Mastectomy Patients with small breast volume with limited skin are candidates for a periareolar mastectomy with a small incision along the inferior areola border from 9 o’clock to 3 o’clock. The tissue is directly excised through this incision, first dissecting planes along the breast capsule to the inframammary fold, medial, lateral, and superior borders of the breast. The parenchyma is elevated off the pectoralis major muscle and removed. The inframammary fold is ablated and scored to remove any feminine definition of breast borders. Liposuction can be used to further contour the chest, including lateral chest side wall and preaxillary fat. Drains are placed through separate stab incisions and the patient is placed in a compression vest. This technique limits the ability to reposition the nipples to a more masculine location on the chest wall, but skin recoil slightly reduces the diameter of the nipple areolar complex (NAC). The advantage of this technique is a favorable inferior periareolar scar that may be unnoticeable when shirtless (Figure 100.5).

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FIGURE 100.5 Periareolar mastectomy. Preoperative (A, B) and postoperative (C, D) photos of transmasculine gender mastectomy using the periareolar incision technique. Ideal candidates for this procedure have a small breast size (A cup), grade 0-I ptosis, and good tissue elasticity.

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Circumareolar Mastectomy In patients with modest skin excess who desire a limited scar technique, a concentric-circle, circumareolar approach, with resizing of the NAC, and small donut skin excision may be performed. The new diameter of the NAC should be measured with maximum skin resection width of 2 cm. The parenchyma is excised directly through a full thickness incision on the inferior areola border, and the intervening skin to be removed is deepithelialized. The NAC survives on a deepithelialized dermal pedicle based superiorly. Following completion of the parenchyma resection along the breast capsule, liposuction is used through a separate stab incision along the inframammary fold to contour the chest wall superiorly and laterally. The inframammary fold is undermined and scored through the open incision. Closure of the donut incision is achieved with a spoke wheel pattern of 2-0 polydioxanone suture to help distribute skin excess and relieve tension on the closure. The important thing is to prevent undue tension on this scar, as it tends to spread due to forces in all directions. As in the periareolar approach, the ability to relocate the nipple into a more lateral masculine position is limited.

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Double Incision with Free Nipple Grafting Most patients with significant breast volume and long-term use of a binder require a double-incision free nipple grafting technique to adequately remove excess skin and contour the chest (Figure 100.6). The first incision should be located just inferior to the IMF to prevent superior displacement in closure. The second incision is on top of the breast and generally designed to be straight across. In closure, the incision should be straight or, if the patient prefers, slightly curved downward. A lateral upward extension along the lateral border of the pectoralis may be used to help camouflage the lateral scar. The nipples are taken off as full thickness grafts either as a central piece around the nipple papule or as a two-piece graft of areola and small piece of papule if patient desires reduction of papule diameter. The nipple size should be approximately 2.4 cm × 2.0 cm and oval shaped.

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FIGURE 100.6 Double-incision mastectomy with free nipple grafting. Preoperative (A, B) and postoperative (C, D) photograohs showing transmasculine mastectomy using the double-incision with free nipple grafting technique. Candidacy selection for this method includes patients of various breast sizes, grade II ptosis and above, and moderate to poor tissue elasticity.

The inferior incision is made first and the breast tissue is undermined superficial to the pectoralis major fascia to the superior border of the breast. The superior breast incision is then made and dissection carried down to the breast capsule. All subcutaneous fat should be preserved on the superior mastectomy flap

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and dissection carried up to the superior border of the breast. A small amount of parenchyma is left superiorly to retain some contour, which appears like pectoralis major development, and the remaining parenchyma is then resected. Drains are placed through separate stab incisions inferior and lateral on the chest wall. The IMF is then obliterated and scored to remove the feminine contour of the inferior breast. The incision is then closed in three layers, Scarpa fascia, deep dermal, and subcuticular. The patient is then placed in the seated position, and sterile stickers (labels for medications on the field) are used to estimate nipple position along the lateral inferior border of the pectoralis major muscle. The patient is then placed back in the supine position and the nipple inset area is marked as a transverse ellipse 2.4 × 2.0 cm. This area is deepithelialized and the thinned nipple graft sutured in place. A bolster dressing is then secured.

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Postoperative Care Drains are removed within 1 week and bolsters removed at 1 week. The patient is kept in a compression vest for 3 weeks postoperatively with modified activity restrictions. Aggressive scar management with massage and silicone sheeting at night at 3 weeks postoperatively helps prevent bothersome hypertrophic scars. The breast tissue should all be sent to pathology and results reviewed with the patient, regardless of age. Revisionary surgery is relatively common, with incidence approximately 40% 39 in general, any decision to revise the scar or perform liposuction to improve contour should be delayed until 4 to 6 months postoperatively for postoperative edema to completely resolve.

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Phalloplasty In properly selected transmale patients, phalloplasty may be indicated. Phalloplasty procedures have specific goals including constructing reasonable male anatomy to affirm gender identity, preservation of erogenous and orgasmic sensibility, the ability to stand to urinate, and the potential for penetrative intercourse. In reality, achieving all of these goals is challenging and, although current reconstructive strategies all employ similar principles, there is wide variation among surgeons in the specifics of phalloplasty procedures. The choice of a one- or multiple-staged approach, which specific flaps are used for phallic and urethral reconstruction, the methods for reconstruction of the pars fixa of the urethra, and strategies to restore or preserve erogenous sensibility vary considerably among surgeons and centers; there is no hard evidence supporting one specific approach for phallic construction. This large variation in the specifics of phalloplasty procedures is principally related to the large cutaneous surface of the male phallus, necessitating a large cutaneous donor site and because of the complexity and difficulty of reconstructing the pars fixa and the penile urethra. 40 Complications of urinary stricture and fistula are prevalent. Considerable variation among centers has resulted from attempts to improve on these high urologic, flap-related, and prosthetic complication rates, ranging from 33% to 77% in large case-series. 41,42 Regarding donor-site selection, an individualized discussion with each patient regarding the acceptance of, and the location of, a large cutaneous donor-site scar is essential. Because Plastic Surgeons are not trained in urethral reconstruction or the management of urethral strictures and fistulas, we believe it is mandatory that a qualified reconstructive urologist is involved in each phalloplasty that involves urethral reconstruction. It therefore becomes a shared decision between the Plastic Surgeon and the Urologist regarding urethral reconstruction. That, along with the lack of consensus in the literature, is the basis of the variation in methods for urethral reconstruction. Transmasculine patients desiring a phalloplasty will also generally undergo hysterectomy, oophorectomy, and vaginectomy. This can be done at the time of phalloplasty or done as a separate procedure several months beforehand.

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Surgical Staging Reconstruction of the male external genitalia is always performed in multiple stages. There is, however, no “standard” sequence. Hysterectomy, oophorectomy, and vaginectomy are often performed as standalone procedures several months in advance of the phalloplasty. There is accumulating evidence that this may reduce the incidence of urethral leaks into the cavity left by the vaginectomy, but some centers will still do the vaginectomy at the time of phalloplasty. Many centers will perform a urethral lengthening or even a formal metoidioplasty (see below) to establish the pars fixa urethra in advance of formal phalloplasty, either synchronous with, or as a separate stage from the vaginectomy. The formal phalloplasty, usually a free tissue flap transfer procedure, is then performed. If a pars fixa reconstruction has not been done in a prior stage, it is done at the time of the formal phalloplasty. Reconstruction of the penile urethra can be done using the classic “tube within a tube” single-flap technique, using two separate flaps for urethra and for phallic skin, or by prefabricating a urethra within the penile flap in advance. Many centers perform a coronaplasty and begin scrotal construction at the time of phalloplasty, although this is not universal. Scrotoplasty and insertion of testicular prosthesis are done once the phalloplasty and urethral reconstruction are healed for several months. If penile prosthesis for erectile function are to be placed, this is always done in a delayed stage, typically no sooner than 1 year after the phalloplasty. This myriad of approaches to staging underscores the difficult and the as-yet imperfectly resolved challenge of reconstruction of functional male genitalia. Below, we will describe the general approach for a single-stage, one-flap phalloplasty, followed by a discussion of some specific alternatives. A brief description of historical flap design and utilization is outlined in Table 100.4. TABLE 100.4 Penile Reconstruction: Free-Flap Utilization Methods a Year 1936

Donor Site Abdomen

Described As Classic method

1946

Abdomen

Tube within a tube

1972

Groin (+below waist) Radial artery free flap

1982

2006

Anterolateral thigh flap

Updated tube within a tube design Pedicled to groin

Description Use of pedicled oblique to create tube for neophallus Neophallus with neourethra using a multistage approach. Branches of femoral and saphenous systems are used for recipient free-flap vessels Flaps from radial artery used for tube design. May be used as outer phallus with ulnar or radial artery flap for urethral reconstruction

Downfalls No neourethra Scarring; insensate neophallus Scarring, insensate neophallus, unsatisfactory cosmetic results Scarring, difficult to create sustainable corona ridge and shape neophallus, still relatively high complication rate May not be option in patients with thick thighs

a

Historical account of donor-site location and free-flap reconstruction methods in the creation of the neophallus for transmasculine genderaffirming surgery.

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Single-Stage, One-Flap Phalloplasty This approach, using the radial forearm free flap, is arguably the most commonly employed strategy at the present time. It is also possible to perform phallic construction with an anterior-lateral thigh (ALT) flap, although the thickness of that flap in most patients makes it difficult to produce a tube-within-a tube structure without constructing an unduly large phallus. Below, the radial forearm flap procedure is described; using ALT would be analogous. The patient is prepared for surgery according to the general guidelines discussed above. Specific to this procedure, a suprapubic urinary catheter is required. For the portion of the flap that will become the urethra, permanent hair removal is mandatory preoperatively to prevent future strictures. Preoperative examination focuses on examination of the forearm and an Allen’s test to ensure perfusion of the hand based on the ulnar artery alone. The flap is planned as a “tube-within-a-tube.” The dimensions of the flap account for penile length (average erect length of the male penis is 5.75 inches [about 15 cm]), the inner circumference of the urethra (3–4 cm), and the external phallic skin (at least 15 cm). This therefore requires a very large skin flap, 15 × 18 cm minimum, on the forearm. The flap is based on the radial artery and its venae commitans, with the ulnar forearm becoming the urethral portion. The cephalic vein, and the medial and lateral antebrachial cutaneous nerves are harvested with the flap. A strip of the skin surface is deepithelialized to separate the urethra and phallic skin, and the urethral portion is tubed over a Foley catheter. The remaining flap skin is now sutured around the urethral portion and to the distal urethra. Some centers will also perform a primary glansplasty at this point, although reports of necrosis of the flap distal to the coronal incision argue for delaying the glansplasty for a later stage. After flap transfer, the donor defect is closed with a skin graft. Preparation of the recipient site can occur synchronously with flap elevation. Again, there are multiple variations in the specifics, but the basic elements include the following: 1. Preparing recipient vessels for the free flap, typically in the groin using branches of the femoral and saphenous systems, 2. Lengthening the female urethra to create the pars fixa urethra of the male. Vaginal mucosal turnover flaps, labia minora flaps, and buccal mucosal grafts have all been employed in various combinations for this purpose 3. Deepithelializing the clitoris after release of the chordee and harvesting one of the clitoral nerves for coaptation to a flap nerve 4. Beginning scrotal reconstruction with V-Y and/or transposition flaps of the labia majora The still-innervated clitoris at the base of the neophallus provides for erogenous sensation; tactile sensation on the phallus is provided through the medial and lateral antebrachial cutaneous nerve coaptations to the clitoral and ilioinguinal nerves. This approach preserves erogenous and orgasmic sensibility in nearly 100% of patients. The radial forearm flap is then transferred to the recipient site and positioned so that the clitoris is at the base of the neophallus. The urethral coaptation is performed leaving a Foley catheter in place. The flap is reinnervated by coapting one of the flap nerves (typically the LABC) to the selected clitoral nerve and the other flap nerve to a local cutaneous nerve, generally the ilioinguinal nerve. The flap is revascularized via microvacular anastomoses, and the remaining local incisions are closed. Postoperative care is as for any free-tissue transfer with urinary drainage via the suprapubic catheter. The Foley catheter is left in the reconstructed urethra for 3 to 6 weeks before a cystoscopy and/or urethrogram verify urethral integrity. The advantages of this approach are the reliable anatomy and robust vascularity of the radial forearm flap, the ability to perform a one-stage construction of the phallus and urethra, excellent return of tactile

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sensation in the phallic skin, and acceptable aesthetics of the phallus. The primary disadvantage is the very large cutaneous donor site on the forearm. Efforts to improve the aesthetics of the donor site by sparing the deep fascia over the majority of the forearm or by using Integra to generate a thicker base for skin grafting have been described. 43 As discussed above, the ALT flap can be used in an analogous fashion, as has the latissimus dorsi myocutaneous flap. Figure 100.7 demonstrates the result from a single-stage, radial forearm flap phalloplasty.

FIGURE 100.7 Phalloplasty using radial forearm free flap. A. Preoperative photo of radial forearm donor site. B. Immediate postoperative photo of neophallus. The patient had previously undergone a scrotoplasty with testicular implants.

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Single-Stage Phalloplasty With Two Flaps Because of the very large donor defect on the forearm and concerns about reduced vascularity at the periphery of large free-flap skin paddles, the simultaneous use of two separate flaps, one for the urethra and one for the phallus have been described. Common combinations include a small radial forearm or ulnar forearm free flap for the urethral component and a pedicled ALT flap for phallic skin or a pedicled superficial circumflex iliac artery perforator flap for the urethra and an ALT flap for phallic skin. Multiple other permutations of flaps have been proposed and tried; this heterogeneity underscores the significant challenge of phallic construction.

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Staged Phalloplasty In an attempt to overcome the high urethral stricture and fistula rates observed after single-stage phalloplasty, staged procedures have been proposed. One strategy is to perform a urethral lengthening (a construction of the pars fixa urethra) or even a full metoidioplasty as a first stage, followed by the flapbased phalloplasty as a second stage. In this approach, the pars fixa urethra is constructed in the same way as for single-stage phalloplasty, but it is allowed to heal completely before the phalloplasty flap procedure is performed. Another strategy has been to prefabricate the penile urethra prior to phalloplasty. 44 Several months in advance of the planned phalloplasty, the donor flap is partially raised; and vaginal mucosa, buccal mucosa, or skin grafts are tubed around a catheter within the substance of the flap. This neourethra is allowed to mature for several months before the entire donor flap is raised and transferred as the neophallus.

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Scrotal Construction Scrotal construction is generally begun at the time of phalloplasty using hair-bearing flaps from the labia majora. It is important to place the neoscrotum in its normal anatomic location, anterior to the perineum at the base of the phallus so as not to interfere with the legs while walking. Multiple specific designs for scrotal reconstruction have been described, with the most commonly used strategy likely being a V-Y plasty of the labia majora in combination with labial flaps rotated 90°, thereby recruiting additional skin anteriorly.

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Prostheses for Erectile Function Semirigid or hydraulic prostheses have been used to achieve erection in phalloplasty patients. The insertion of the prosthesis is always delayed, generally for at least a year, after phalloplasty. Multiple strategies to encase the prostheses in synthetic or biologic sheaths and to anchor the prosthesis to the pubis have been proposed to overcome the high complication rate associated with penile prostheses in phalloplasty patients. Because most centers still report a 30% or higher rate of extrusion necessitating removal within 2 or 3 years of prosthesis placement and because reoperation rates approach 100% at 5 years, some centers decline to place penile prostheses. 45,46 As an alternative, patients can be instructed on the use of external stiffening strategies to engage in intercourse. New prostheses, developed specifically for phalloplasty patients, may improve success rates in the future.

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Complications and Outcomes of Phalloplasty Because phalloplasty is a multistage, complex flap-based endeavor, patients should be informed that complications are common. In addition to all the complications attendant with any surgery and with freeflap surgery specifically, the rates of urinary strictures and fistulas and complications with penile implants remain, as noted above, high despite the multiple strategies employed to lessen the frequency of complications. 47,48 There are no high level-of-evidence studies using validated instruments to accurately define patientreported or health status outcomes in phalloplasty patients. However, the less rigorous data in the existing body of literature indicate that despite the high complication rate, the overall patient satisfaction and results of phalloplasty appear to be acceptable and that “regret” following phalloplasty is rare.

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Metoidioplasty For patients who decline the complexity, multiple stages, and donor-site morbidity of a phalloplasty, metoidioplasty may be a reasonable option. Testosterone therapy will result in clitoromegaly, allowing conversion of the clitoris into a small phallus. The basic elements of the procedure include a release of the ventral chordee of the clitoris, a release of the clitoral suspensory ligament, and lengthening of the female urethra to exit the tip of the enlarged clitoris. The same techniques for urethral lengthening for phalloplasties are employed: vaginal mucosal turn-over flaps, labia minora flaps, and buccal grafts, usually in combination. Because the most critical part of this procedure is the urethral lengthening, and because the complications of urethral strictures and fistulas are common, it is again our opinion that a reconstructive urologist should be involved unless the Plastic Surgeon has received additional specialized training. The goal of metoidioplasty is to fashion a phallus to affirm male gender identity and to allow standing micturition, although not all patients achieve this latter goal. Metoidioplasty typically results in a phallus 4 to 8 cm in length so penetrative intercourse is not generally possible (Figure 100.8).

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FIGURE 100.8 Metoidioplasty. A small phallus resulted from metoidioplasty in this patient.

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Summary Gender-affirming surgery is a broad and growing part of Plastic Surgery. For properly selected gender dysphoric individuals, appropriate surgical intervention can have significant, positive health and quality of life benefits. Because the diagnosis of gender dysphoria and the selection of candidates for genderaffirming surgical intervention are outside of the scope of expertise of Plastic Surgeons, it is essential that care is delivered in a multidisciplinary environment and especially in collaboration with the mental health team. The WPATH SOC should be the guiding principles for working with this patient population and for gauging a patient’s readiness for surgery. As reviewed above, a very broad range of surgical procedures can be considered for both transfeminine and transmasculine individuals. Facial feminization surgery and transgender top surgery are within the scope of well-trained Plastic Surgeons. On the other hand, genital sex reassignment procedures, both vaginoplasty and phalloplasty, involve anatomy and may result in complications that are outside the scope of current Plastic Surgery training. Surgeons intending to become involved in these procedures must seek additional training and should work with gynecologic and urologic colleagues to assure appropriate patient outcomes.

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Questions 1. The neoclitoris is constructed from the dorsal aspect of the glans penis in a penile inversion vaginoplasty operation. The nerve supplying this flap that provides erogenous sensation and orgasmic function is the a. Dorsal penile nerve b. Ilioinguinal nerve c. Pudendal nerve d. Clitoral nerve 1. A patient presents requesting penile inversion vaginoplasty surgery. What are the prerequisites for transfeminine bottom surgery according to WPATH criteria? a. Two letters of readiness for surgery from mental health professionals b. One year of living full time in congruent gender (as a woman) c. One year of hormonal therapy including estrogen d. All of the above 3. During the preoperative consultation for radial forearm phalloplasty, a patient asks about postoperative urinary function. It is very important to him to be able to stand and use a urinal after surgery. What is the incidence of postoperative urinary stricture/fistula? a. 5% b. 10% c. 30% d. 80% 4. A patient presents to the office 3 weeks following penile inversion vaginoplasty surgery complaining of malodorous secretions from her neovagina. On examination, there is feculent smelling discharge. What should be ruled out? a. Vaginal candidiasis b. Menstruation c. Inadequate hygiene d. Rectovaginal fistula 5. To prevent perioperative VTE, what medication should be held 3 weeks prior to vaginoplasty surgery in transfeminine patients? a. Spironolactone b. Estradiol c. Testosterone d. Depo-provera 6. A patient desires a radial forearm phalloplasty for gender-affirming bottom surgery. Prior to the operation the operating surgeon must perform what test? a. Retrograde urethrogram b. Allen’s test c. Speculum examination d. Angiogram of upper extremity 1. Answer: a. The dorsal penile nerve is invested between Buck fascia and the tunica of the corpus cavernosa and together with the dorsal penile artery and veins composes the pedicle of the neoclitoral flap. 2. Answer: d. The WPATH SOC are internationally accepted guidelines for transgender care including prerequisites prior to genital gender-affirming surgery.

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3. Answer: c. Urinary strictures and fistula are common at the juncture of the urethral portion of the radial forearm and the pars fixa urethra. 4. Answer: d. Rectovaginal fistula is a rare (1% incidence) but serious complication of penile inversion vaginoplasty surgery. A temporary diverting ostomy is required to let the fistula heal in and the patient must continue to dilate the neovagina during this time. Failure to dilate will result in contraction of the entire neovagina. 5. Answer: b. Transfeminine patients are at elevated risk of VTE on estrogen therapy, over 14 times that of cisgender women after 9 years of therapy. Vaginoplasty is a major 5-hour operation with 1 week of modified activity restrictions. Holding estrogen therapy is socially and emotionally difficult for transgender women, but is necessary to prevent a postoperative pulmonary embolus. 6. Answer: b. An Allen test assesses the superficial and deep arches of the hand. Harvest of a radial forearm flap will potentially threaten the vascular supply of the hand in patients with an incomplete arch.

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References American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 5th ed. Arlington, VA: American Psychiatric Publishing; 2013. Flores, AR, Herman, JL, Gates, GJ, Brown, TNT. How many Adults Identify as Transgender in the United States? 2016. Available at http://williamsinstitute.law.ucla.edu/wp-content/uploads/How-Many-Adults-Identify-as-Transgender-in-the-United-States.pdf. Accessed August 17, 2018. Richards, C, Bouman, WP, Barker, M-J. Genderqueer and Non-binary Genders. London, UK: Palgrave Macmillan; 2017. Gender and Genetics. Genomic Resource Centre: Gender and Genetics. http://www.who.int/genomics/gender/en/. Published December 1, 2010. Accessed August 27, 2018. Swaab, DF, Garcia-Falgueras, A. Sexual differentiation of the human brain in relation to gender identity and sexual orientation. Funct Neurol. 2009;24(1):17-28. Saraswat, A, Weinand, JD, Safer, JD. Evidence supporting the biologic nature of gender identity. Endocr Pract. 2015;21(2):199-204. World Professional Association for Transgender Health. Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People. 7th Version. Elgin, IL: The World Professional Association for Transgender Health; 2011. American Society of Plastic Surgeons. Comment Letter on Proposed Rule on Medicare Program: Hospital Inpatient Prospective Payment System for Acute Care Hospitals and the Long-term Care Hospital Prospective Payment System and Proposed Policy Changes and Fiscal Year 2018 Rates. American Society of Plastic Surgeons; June 2017. https://www.regulations.gov/document?D=CMS-2017-0055-4304. Accessed August 17, 2018. Weissler, JM, Chang, BL, Carney, MJ, et al. Gender-affirming surgery in persons with gender dysphoria. Plast Reconstr Surg. 2018;141(3):388e396e.The authors describe a multidisciplinary approach for the treatment of gender dysphoria treatment, and the specific role of plastic surgeons within its collaborative, integrated care framework. They outline plastic surgery’s advancement in transgender medicine and underscore the breath of positive health outcomes that follow gender-affirmation surgeries. James, SE, Herman, JL, Rankin, S, et al. The Report of the 2015 US Transgender Survey. Washington, DC: National Center for Transgender Equality; 2016. http://www.transequality.org/sites/default/files/docs/usts/USTS%20Full%20Re port%20-%20FINAL%201.6.17.pdf. Accessed August 17, 2018. Bockting, WO, Miner, MH, Swinburne Romine, RE, et al. Stigma, mental health, and resilience in an online sample of the US transgender population. Am J Public Health. 2013;103(5):943-951. Grant, J, Mottet, L, Tanis, J. Injustice at Every Turn: A Report of the National Transgender Discrimination Survey. Washington, DC: National Center for Transgender Equality and National Gay and Lesbian Task Force; 2011. Accessed August 17, 2018. https://www.hivlawandpolicy.org/resources/injustice-every-turn-
 a-report-national-transgender-discrimination-survey-jaime-m-grant. Reisner, SL, Greytak, EA, Parsons, JT, Ybarra, ML. Gender minority social stress in adolescence: disparities in adolescent bullying and substance use by gender identity. ML J Sex Res. 2015;52(3):243-256. Adams, KA, Nagoshi, CT, Filip-Crawford, G, et al. Components of gender-nonconformity prejudice. Int J Transgenderism. 2016:17:185-198. Fredriksen-Goldsen, KI, Simoni, JM, Kim, HJ, et al. The health equity promotion model: reconceptualization of lesbian, gay, bisexual, and transgender (LGBT) health disparities. Am J Orthopsychiatry. 2014;84(6):653-663. Deutsch, MB. Use of the informed consent model in the provision of cross-sex hormone therapy: a survey of the practices of selected clinics. Int J Transgend. 2013(3):140-146. Callen Lorde Community Health Center. Transgender Health Program Protocols. New York, NY: Callen Lorde Community Health Center; 2011. Tom Waddell Health Center. Protocols for Hormonal Reassignment of Gender. http://www.sfdph.org/dph/comupg/oservices/medSvs/hlthCtrs/TransGendprotocols122006.pdf. Revised May 7, 2013. Accessed August 17, 2018. Cavanaugh, T, Hopwood, R, Gonzalez, A, Thompson, J. The Medical Care of Transgender Persons. Boston, MA: Fenway Health; 2015. http://www.lgbthealtheducation.org/wp-content/uploads/COM-2245-The-Medical-Care-of-Transgender-Persons-v31816.pdf. Accessed August 17, 2018. Cavanaugh, T, Hopwood, R, Lambert, C. Informed consent in the medical care of transgender and gender-nonconforming patients. AMA J Ethics. 2016;18(11):1147-1155. Coleman, E, Bockting, W, Botzer, M, et al. Standards of care for the health of transsexual, transgender, and gender-nonconforming people, version 7. Int J Transgenderism. 2012;13(4):165-232. Vance, SR Jr, Ehrensaft, D, Rosenthal, SM. Psychological and medical care of gender nonconforming youth. Pediatrics. 2014;134:1184. Shechner, T. Gender identity disorder: a literature review from a developmental perspective. Isr J Psychiatry Relat Sci. 2010;47:132. Steensma, TD, McGuire, JK, Kreukels, BPC, et al. Factors associated with desistence and persistence of childhood gender dysphoria: a quantitative follow-up study. J Am Acad Child Adolesc Psychiatry. 2013;52:582-590.Thirty-seven percent of adolescents (