Plastic Surgery
Essentials for Students

Tenth Edition

Editors

Catherine L. Ly, MD

Assistant Professor of Surgery
Columbia University Medical Center
New York, NY

Katelyn G. Makar, MS, MD

Assistant Professor of Surgery
Indiana University School of Medicine
Indianapolis, IN

Young Plastic Surgeons Steering Committee

Deana Shenaq, MD (Chair)
Kavitha Ranganathan, MD (Vice Chair)

Undergraduate Education Committee of thePlastic Surgery Educational Foundation

First Edition 1979

Ruedi P. Gingrass, MD (Chair)
Martin C. Robson, MD
Lewis W. Thompson, MD
John E. Woods, MD
Elvin G. Zook, MD

Copyright © 2025

American Society of Plastic Surgeons

444 East Algonquin Road

Arlington Heights, IL 60005

All rights reserved.

Printed in the United States of America

Contributors

Rosevine A. Azap, MD

Resident, University of Texas Medical Branch | Galveston, TX

Annabel E. Baek, MD

Chief Resident, Virginia Commonwealth University | Richmond, VA

Omar E. Beidas, MD

The Aesthetics Clinic | Orlando, FL

Sophia Chryssofos, BS

Medical Student, Cooper Medical School, Rowan University | Camden, NJ

Yasmeen M. Byrnes, MD

Resident, Geisinger Medical Center | Danville, PA

Christina Shree Chopra, MD

Resident, Stony Brook University Hospital | Stony Brook, NY

Robert G. DeVito, MD

Resident, University of Virginia | Charlottesville, VA

Emily Geisler, MD

Resident, University of Texas Medical Branch | Galveston, TX

Yifan Guo, MD

Assistant Professor of Surgery, Children's Hospital of the King's Daughters, Eastern Virginia Medical School | Norfolk, VA

David A. Hill, MD

The Graivier Center | Alpharetta, GA

Amy Kite, MD

Assistant Professor of Surgery, Warren Alpert Medical School of Brown University | Providence, RI

Jessie Koljonen, MD

Chief Resident, Southern Illinois University | Springfield, IL

Kate B. Krucoff, MD

Assistant Professor, Medical College of Wisconsin | Milwaukee, WI

Efstathios Karamanos, MD

Assistant Professor of Surgery, California University of Science and Medicine | Colton, CA

David Kurlander, MD

Assistant Professor of Surgery, Rush University Medical Center | Chicago, IL

Z-Hye Lee, MD

Assistant Professor of Surgery, University of Texas MD Anderson Cancer Center | Houston, TX

Courtney Leonard, MD

Chief Resident, Baylor Scott & White Medical Center | Dallas, TX

Katelyn Lewis, MD

Resident, Yale New Haven Hospital | New Haven, CT

Samantha Lund, MD

Resident, Southern Illinois University | Springfield, IL

Evan B. Lynch, MD, PhD

Chief Resident, University of Kentucky | Lexington, KY

Andrew McGregor, MD

HCA Cosmetic and Reconstructive Surgery | Port St. Lucie, FL

Olivier F. Noel, MD, PhD

Resident, Yale New Haven Hospital | New Haven, CT

Adam O’Toole, MD

Pasadena Cosmetic Surgery | Pasadena, CA

Jaime Pardo Palau, MD, MPH

Resident, Rush University Medical Center | Chicago, IL

Rajiv Parikh, MD

Assistant Professor of Surgery, MedStar Health Washington Hospital Center, Georgetown University School of Medicine | Washington, DC

Michael A. Plastini, MD

Boca Raton, FL

Rajendra Sawh-Martinez, MHS, MD

Chief, Pediatric Plastic Surgery, AdventHealth | Orlando, FL

Prabhu Senthil-Kumar, MD

Assistant Professor of Surgery, Virginia Commonwealth University | Richmond, VA

Deana Shenaq, MD

Assistant Professor of Surgery, Rush University Medical Center | Chicago, IL

Kelly Spiller, MD

Resident, University of Cincinnati | Cincinnati, OH

John T. Stranix, MD

Assistant Professor of Surgery, University of Virginia | Charlottesville, VA

John Tycher, MD

Resident, Washington University in Saint Louis | St. Louis, MO

Amelia C. Van Handel, MD

Valleywise Health Medical Center | Phoenix, AZ

Marc E. Walker, MD, MBA

Songcharoen Endowed Chair of Plastic and Reconstructive Hand Surgery, Associate Professor of Surgery, University of Mississippi Medical Center | Jackson, MS

Sabrina M. Wang, MD, MPH

Resident, Rush University Medical Center | Chicago, IL

Margaret West, BA

Medical Student, Eastern Virginia Medical School, Old Dominion University | Norfolk, VA

Rachel Williams, MD

Resident, Rush University Medical Center | Chicago, IL

Cynthia Yusuf, MD

Resident, Rush University Medical Center | Chicago, IL

Chapter 1
Introduction

Catherine L. Ly, MD
Katelyn G. Makar, MD

Plastic surgery had its beginning nearly 3,000 years ago, when Sushruta, an Indian surgeon, reconstructed the nose by transferring a flap of cheek and then forehead skin. It is a modern field, stimulated by the challenging reconstructive problems of the unfortunate victims of the World Wars. The advent of the operating microscope has thrust the plastic surgeon of today into the forefront of advances in small vessel and nerve repair, culminating in the successful replantation of amputated parts as small as distal fingers and bypassing of lymphatic vessels, only a few millimeters in diameter. These techniques have even been utilized to perform the first composite tissue transplantations of both hands and partial faces. Plastic surgery is ultimately a specialty of innovation in which surgeons are continually pushing the limits of what is possible. The breadth and constant change, however, can also make it daunting to students who may not have had previous exposure to the field. Our goal for Plastic Surgery Essentials for Students is to make it more approachable, so that more students can fall in love with the specialty, just as we did.

Seven years ago, this book was thoughtfully revised and updated by our predecessors, for the benefit of students seeking to better understand the incredible field of plastic surgery. Some of the students who studied its pages are now chief residents in plastic surgery, or maybe even in practice. A person’s first experience of plastic surgery is pivotal, often profoundly affected by the residents on service, their willingness to teach, and even the provided texts. What students encounter on the wards, in the operating room, and in the textbooks they read in preparation for cases, can tip the scale in terms of specialty choice. In this updated edition of Plastic Surgery Essentials for Students, we seek to provide the best possible resource for students to experience, and perhaps choose, plastic surgery.

This book represents the hard work and collaboration of the American Society of Plastic Surgeons (ASPS) Young Plastic Surgeons Steering Committee and Residents Council, representing plastic surgery residents, fellows, and attendings from across the country. All prior chapters have been updated. The book was written primarily for medical students and other students of plastic surgery to obtain a brief introduction into the specialty and provide references for further reading. It is not designed to be a comprehensive text, but rather an outline that can be read in the limited time available in a burgeoning curriculum. It is designed to be read from beginning to end. ASPS is proud to provide complimentary online copies of the Plastic Surgery Essentials for Students handbook to all medical students in the United States and Canada.

Continually updated information that relates to plastic and reconstructive surgery and other information of use to students and other physicians can be found at both the main ASPS website at www.PlasticSurgery.org and the ASPS Education Network website at EdNet.PlasticSurgery.org.

Chapter 2
Careers in Plastic Surgery

Jessie Kolkonen, MD
Kate Krucoff, MD

Plastic and reconstructive surgery is one of the most diverse specialties within the field of medicine. Unlike many other fields, plastic surgery is not confined to a single organ system, region of the body, or patient population. The Greek term “plastikos” means to mold or to shape. By reshaping, remolding, and manipulating both soft and hard tissues, plastic and reconstructive surgeons help patients with a myriad of issues. The goal of our specialty is to restore form and function while adhering to aesthetic principles.

The first known plastic surgery procedures on living patients date back to 600 BCE, when the Indian surgeon, Sushruta, offered reconstruction to patients whose noses had been surgically removed as a form of punishment. As early as 100 BCE, the Romans began performing procedures to improve self-image and cosmetic appearance. Since then, plastic surgery has become integral to the treatment of patients requiring reconstruction due to trauma, burns, scarring, cancer, infection, and more. Rather than treating specific conditions with a limited set of procedures, plastic surgeons use skills and principles based on anatomy, physiology, and tissue transfer when managing patients, from head to toe.

The plastic surgeon must use his or her foundational knowledge of plastic surgical principles, judgment, problem-solving abilities, and surgical technique in order to approach the reconstructive needs of the patient. Because of this, the plastic surgeon often acts as a “last resort” surgical consultant to other physicians in the treatment of many wound problems and is often called “the surgeon’s surgeon.”

Consistent with these far-reaching goals, the scope of the operations performed by plastic surgeons is broad. As outlined by The American Board of Plastic Surgery (ABPS), the specialty of plastic surgery “deals with the repair, reconstruction, or replacement of physical defects of form or function involving the skin, musculoskeletal system, craniomaxillofacial structures, hand, extremities, breast and trunk, external genitalia, or cosmetic enhancement of these areas of the body.” Plastic surgeons use aesthetic surgical principles not only to improve undesirable qualities of normal structures, but also to reinstate “normal” in reconstructive cases. One of the most common procedures in reconstructive plastic surgery is reconstruction of the breast following mastectomy. Breasts may be reduced in size, increased in size, or changed in shape to improve the final aesthetic appearance. Operations of this type are sometimes cosmetic in purpose, but in cases where the patient has a significant asymmetry or surgical defect, the procedure serves important therapeutic purposes.

Microvascular surgery is an important subspecialty within plastic surgery. This involves performing delicate procedures connecting small blood vessels – often several millimeters or less in diameter – to provide a blood supply to tissue used to reconstruct a defect. Using microsurgical techniques, tissue can be moved from one part of the body to another. This is an important option for patients suffering from defects secondary to trauma or cancer resection.

Another area of expertise for the plastic surgeon is hand surgery, including the management of acute hand injuries, the correction of hand deformities, and reconstruction of the hand. This includes injuries or congenital anomalies to the skin, soft tissues, muscles, tendons, bones, nerves, and blood vessels of the hand and fingers. Microsurgery is also a necessary skill in hand surgery, often used while replanting amputated fingers or even entire limbs.

The subspecialty of craniofacial surgery involves correcting both congenital and acquired deformities of the head, neck, face, and skull. Clefts of the lip and palate are the most common, but many other head and neck congenital deformities exist. In addition, the plastic surgeon treats injuries to the face, including fractures of the craniofacial skeleton. Craniofacial surgery can help to reposition and reshape the bones of the face and skull through inconspicuous incisions. Severe deformities of the cranium and face, which previously were uncorrectable or corrected with great difficulty, can now be reconstructed. Such deformities may result from a tumor resection, congenital defect, previous surgery, or previous injury.

The most highly visible area of plastic surgery is aesthetic or cosmetic surgery. Aesthetic surgery includes facelifts, breast augmentations, nasal surgery, body sculpting, and other similar operations to enhance one’s appearance. The plastic surgeon takes pride in utilizing his or her precise technical and artistic skills to enhance patient quality of life through aesthetic procedures. Notably, the results of the plastic surgeon’s expertise and ability are highly visible, leading to a high degree of professional and personal satisfaction.

Plastic surgery is an innovative specialty. Advances such as transplantation, microvascular surgery, fat grafting, and various medical devices have been spearheaded and advanced by plastic surgeons. Ultimately, the discipline requires meticulous attention to detail, sound judgment, and technical expertise in performing the intricate and complex procedures associated with plastic surgery. In addition, plastic surgeons must possess a flexible and adaptable approach that will enable them to work daily with a wide variety of surgical problems. Most importantly, the plastic surgeon must have creativity, curiosity, insight, and a deep understanding of human psychology.

Students interested in a career in plastic and reconstructive surgery would benefit from rotating on their institution’s plastic surgery service to gain experience in, and exposure to, the field. In addition, finding a mentor within the field to help guide one’s development, decision-making, and to answer questions is advised.

The pathway to a career in plastic surgery can follow in one of two ways. The first is through an integrated plastic surgery residency program which starts after medical school. Programs are six years in duration; however, several programs also dedicate one or more years to research. The other route, known as the independent route, is to complete a residency in general surgery, otolaryngology, urology, orthopedic surgery, or neurosurgery followed by an additional three-year independent plastic surgery residency. After the completion of either the integrated or independent pathway, one is eligible to sit for the plastic surgery board examination. In addition, one can attain further training in a plastic surgery fellowship program. Fellowships are typically one year in duration and are offered for specialty training in hand surgery, craniofacial surgery, microsurgery, aesthetic surgery, body contouring surgery, and burn surgery. Newer fellowships in peripheral nerve surgery and gender-affirming surgery have also emerged in recent years.

Traditionally, plastic surgeons have established their practices in large urban settings. However, there is an increasing need for plastic surgeons in smaller communities and rural areas of the country—many metropolitan areas with populations of 65,000 to 268,000 have no plastic surgeons. There are approximately 7,750 board certified plastic surgeons in the United States; many of those currently certified by the ABPS received certification in the past 10 years. There are opportunities for plastic surgeons in private, hospital-based, and academic practices.

Plastic surgeons also have numerous opportunities to use their skills to improve global health. Plastic surgeons can perform direct patient care through short-term missions where they can help treat a wide variety of conditions including congenital birth defects, burns, and traumatic deformities. Plastic surgeons can also contribute to global health through long-term commitments involving the education and training of local surgeons in addition to performing research on issues affecting countries with limited resources.

Plastic surgery is a specialty that dates back thousands of years. It has survived and flourished because it is a changing specialty built by imaginative, creative and innovative surgeons with a broad background and education. The future of this specialty is bright and will continue to progress because of students like you who choose to enter this special field.

Students interested in plastic surgery can find more information from the following:

Nagarkar P, Pulikkottil B, Patel A, Rohrich R. So, you want to be a plastic surgeon? What you need to do and know to get into a plastic surgery residency. Plast Reconstr Surg. 2013;131(2):19-22.

The American Council of Educators in Plastic Surgery (ACEPS)
aceplasticsurgeons.org

American Society of Plastic Surgeons
plasticsurgery.org
facebook.com/PlasticSurgeryASPS

Plastic Surgery Education Network
plasticsurgery.org/for-medical-professionals/education/asps-education-network

Plastic Surgery Research Council
ps-rc.org

Chapter 3
History of Plastic Surgery

Yasmeen Byrnes, MD
Rajendra Sawh-Martinez, MHS, MD

“We restore, rebuild, and make whole those parts which nature hath given, but which fortune has taken away. Not so much that it may delight the eye, but that it might buoy up the spirit, and help the mind of the afflicted.”

Gaspare Tagliacozzi (1545–1597)

The origins of plastic surgery as a distinct field follows the history of scientific advancements, influenced by the scourge of need from social influences and wartime atrocities. Key historical figures and milestones are described in the long and illustrious history of the development of the modern innovative field of plastic surgery.

PLASTIC SURGERY ORIGINS IN ANTIQUITY

The term “plastic” in plastic surgery comes from the Greek “plastikos” which translates to “moldable”

Ancient plastic surgery has its origins in the management of wounds, with historical reference to sewing wound edges with fibers or wound edges approximated with insect mandibles

References in the Edwin Smyth Papyrus (~3000 to 2500 BC) to plastic surgery cases include descriptions of treating fractures, wounds, dislocations, sores and tumors

Early wound healing remedies included use of grease, honey, linen and swabs.

The first semblance to modern reconstruction is found in India with nasal reconstruction

Ancient cultures often punished adulterers, thieves and prisoners of war by mutilating their noses as a way of public shaming

Famed Indian surgeon Sushruta wrote in the Ayurvedam (Indian sacred book of medical knowledge) descriptions of transposed flaps for nasal reconstruction (~600 BC)

He is often credited with descriptions of the first forehead flap for nasal reconstruction, but this is controversial and unknown as the first published report of the forehead flap appears to be in 1794 (Fig. 1)

Greek medical influence is grounded in the writings of Hippocrates in the Corpus Hippocraticum (~460 BC) where descriptions of cauterization of raw surfaces, reduction of displaced fractures and trephination for hematoma evacuation are described

Roman influence in plastic surgery can be found in the famous volumes De Medicina (~30AD) by Aulus Cornelius Celsus with descriptions of vessel ligature, lip flap reconstruction and wound closure by an advancement flap

Writings by Claudius Galen (~129-201 AD) are famed for their intricate anatomical descriptions of muscles and cranial nerves

Figure 1. Depiction of the first reports of the forehead flap for nasal reconstruction. From BL. Letter to the editor. Gentleman’s Magazine 1794;64:891–892.

PLASTIC SURGERY IN THE MIDDLE AGES

Series of medical texts written by Oribasius (325-403 AD) titled Synagogae Medicae describe reconstructive procedures aimed at rebuilding the cheek, nose, ears and eyebrows

The middle ages brought about the first independent surgical treatise in the form of Al Tasrif – On Surgery, written by Abu-l-Qasim or Albucasis (~936-1013 AD) in which surgical instruments, cautery, and the first description of a syringe with a piston was given

This time period also brought about the advent of Western universities, which introduced anatomical classes and cadaver dissections, and anatomists as surgeons

The advent of the printing press (1440 AD) also allowed for the widespread dissemination of medical texts and exchange of ideas

PLASTIC SURGERY AND THE RENAISSANCE

Andreas Vesalius published his anatomical treatise De Humani Corporis Fabrica (1543)

French surgeon Ambrose Pare (1510-1590) compiled his works in Les Oeuvers, in which cleft lip and cleft palate repairs are described, in addition to disputing the practice of “wound cleansing” by hot cautery and pouring boiling oil into wounds

Gaspare Tagliacozzi (1544-1599) is widely considered the founder of plastic surgery as a distinct discipline

He is credited with systematizing surgical approaches to nasal reconstruction

His book De Curtorum Chirurgia per Insitionem (On the Surgery of Injuries by Grafting) in 1597 provided step-by-step guidance and illustration to perform nasal repairs (Fig. 2)

After these landmark achievements, there were limited new advances until the 19th century

Figure 2. Nasal reconstruction with the arm flap. From Tagliacozzi G. De Curtorum Chirurgia per Insitionem. Venice: Bindoni, 1597.

GOLDEN AGE OF PLASTIC SURGERY

English surgeon Joseph Carpue composed a letter to the editor in 1794 that first described the forehead flap

His successful use of this procedure in 1814 marked the rebirth of plastic surgery

Multiple surgeons throughout Europe compared and advanced techniques in rhinoplasty, facial reconstruction, cleft lip and cleft palate repairs including key surgeons such as Carl von Grafe (1787-1840), Johann Dieffenbach (1794-1847) in Germany, and Jacque Delpech (1777-1832) in France

The advent of anesthesia in 1846 introduced new capabilities for all surgical fields and allowed for the blossoming of the golden age of plastic surgery

Key achievements in the golden age of plastic surgery:

Giuseppe Baronio (1758-1811) from Italy first described the use of autologous skin grafting in 1804

First attempts at closing cleft palate defects were performed by Roux and Von Grafe in France in 1819 and 1820, respectively

Pietro Sabattini described lip reconstruction with the “lip switch” technique in 1838 (Fig. 3)

Bernhard Von Langenbeck (1810-1887) outlined two mucoperichondrial flaps for cleft palate closure in 1862

Figure 3. Lip Switch technique described by Sabattini (1838)

KEY FIGURES AND ACHIEVEMENTS IN MODERN PLASTIC SURGERY

World War I created a tremendous amount of disfigured casualties with devastating reconstructive challenges, which catalyzed the formation of our modern conceptualization of plastic surgeons as specialists focused on restoring bodies ravaged by war

Hippolyte Morestin (1868-1919) and Charles Valadier (1873-1931) worked together, pioneering facial reconstructive surgery

Sir Harold Gilles (1882-1960): father of the modern era of plastic surgery, developed a referral center in Europe for casualties of facial disfigurement

Developed and systematically applied flap reconstructions of facial injuries

Employed the tubed flap and skin flaps; bone, cartilage and skin grafts

Published landmark text Plastic Surgery of the Face (1920)

Between 1916 and 1918, Johannes Esser (1877-1946) reported on local flaps commonly used today: cheek rotation, bilobed, island, and “arterialized” flaps

Training programs and organizations dedicated to plastic surgery began developing after World War I, and spread throughout Europe and North America

1931: the American Society of Plastic Surgeons was founded by Jacques Maliniac

1937: the American Board of Plastic Surgery was created

1946: the Plastic and Reconstructive Surgery Journal was founded

1948: the Plastic Surgery Foundation was established

Since the 1960s, new discoveries have brought about a new wave of reconstructive options including modern craniofacial approaches, microsurgical techniques, and more

In the era of modern plastic surgery, subfields began to develop; landmark achievements occurred within multiple areas

Breast and aesthetic surgery:

The field of aesthetic surgery was initiated with the description of the correction of prominent ears in 1881 by Edward Ely

John Roe (1848-1915), Robert Weir (1838-1927), Jacques Joseph (1865-1934) were early pioneers in rhinoplasty

Czerny is credited with performing the first breast augmentation using a lipoma in 1895

In the following decades, various substances were used unsuccessfully for breast augmentation including rudimentary injectables and plastic sponges, until the invention of silicone breast implants in the early 1960s by Cronin and Gerow

Craniofacial surgery:

Paul Tessier (1917-2008) is hailed as the father of modern craniofacial surgery, and developed a revolutionary combination of intra- and extra-cranial approaches for complex cranial deformities

René Le Fort (1869-1951) was a French military surgeon whose cadaver studies led to crucial discoveries in facial bony anatomy and trauma

Flaps and microsurgery:

Jacobson and Suarez performed the first microvascular anastomosis with an operating microscope in 1960 (Fig. 4)

Harry Buncke is recognized as the “father of microsurgery” for his critical role in developing the field, including device innovation and multiple successful animal studies

Angiosome concept by Taylor and Palmer in 1987 led to the development of perforator flaps (Fig. 5)

Figure 4. (Left) Arterial anastomosis with 7-0 silk by Jacobson. (Right) Early version of a microvascular double clamp. From Tamai S. History of microsurgery. Plast Reconstr Surg. 2009 Dec;124(6 Suppl):e282-e294.

Hand and extremity:

Malt and McKhann are credited with the first human extremity replantation (arm) in 1962, followed soon after by Kleinert and Kasdan (incompletely amputated thumb), and Chen (hand)

The first modern peripheral nerve surgeries were developed alongside microsurgery by pioneers including Smith, Bora, Haksitan, and Ito

Gender affirmation:

The earliest reports of “sex reassignment surgery” (as it was called at the time) were from Europe in the early 1900s

In 1952, American veteran Christine Jorgenson, formerly known as George Jorgenson,underwent gender affirmation surgery in Denmark; her case drew international attention

Intestinal vaginoplasty was invented in 1974 and free radial forearm flap phalloplasty in 1982

Figure 5. History of flap development.

REFERENCES

Tagliacozzi G. De curtorum Chirurgia per insitionem. Venice: Bindoni; 1597:43.

BL. Letter to the editor. Gentleman’s Magazine. 1794;64 891-892.

Langenbeck B. Die Uranoplastik mittelst Ablösung des mucös-periostalen Gaumenüberzuges. Arch kl Chir. 1862;2:205–287.

Ollier L. Greffes Cutanées ou Autoplastiques. Bull Acad Méd. 1872;1:243–250.

Breasted J. The Edwin Smith Surgical papyrus. Published in facsimile and hieroglyphic transliteration with translation and commentary. Chicago: University of Chicago Press; 1930.

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;7:39- 58.

Tessier P. Experiences in the treatment of orbital hypertelorism. Plast Reconstr Surg. 1974;53:1-18.

McDowell F. The Source Book of Plastic Surgery. Baltimore: Williams & Wilkins; 1977.

McDowell F. History of Rhinoplasty. Aesth Plast Surg.1978;1:321-348.

Klasen H. History of Free Skin Grafting. Berlin: Springer;1981.

Tamai S. History of microsurgery. Plast Reconstr Surg. 2009 Dec;124(6 Suppl):e282-e294.

Mumford K. Ethically Navigating the Evolution of Gender Affirmation Surgery. AMA J Ethics. 2023;25(6):383-385.

Beekman WH, et al. Augmentation mammaplasty: The story before the silicone bag prosthesis.Ann Plast Surg. 1999;43(4):446-451.

Patterson R. The Le Fort fractures: René Le Fort and his work in anatomical pathology. Can J Surg. 1991 Apr;34(2):183-4.

Chapter 4
Techniques and Principles

Sabrina M Wang, MD
Prabhu Senthil-Kumar, MD

Plastic surgery is a specialty defined by principles and techniques, rather than by organ system or disease process. Plastic surgeries are generally divided into two types of surgical procedures — reconstructive and cosmetic. While the dividing line between the two is sometimes very clear, there is often a significant amount of overlap. The goal of reconstructive surgery highlights this overlap: “the restoration of form and function.” Both reconstructive and aesthetic surgery rely on a detailed knowledge of anatomy and the foundational principles and techniques outlined below.

EVALUATION AND PLANNING

Define the defect

What is missing or abnormal?

Tissue layers

Critical exposed structures or hardware?

Disruption of vascular or neural network

What is left behind and what can be used?

Is the surrounding tissue healthy, or has it been compromised (i.e., radiation therapy, burns, traumatic injury)?

What is the best way to restore form and function?

What works for the patient and their lifestyle?

Replace like with like: the best reconstruction will utilize tissues similar to the missing tissues (i.e.,glabrous skin for reconstruction of the weight-bearing sole or fingertips)

“Don’t throw anything away”

Spare parts surgery

Composite grafts

Biological dressings

Designing incisions: Incision design is critical, as the location of scars impacts both their visibility as well as their ability to heal.

Ideal incision placement

Langer’s lines: Langer, a 19th-century anatomy professor in Vienna, first studied and described the relationship between resting skin tension and wounds. However, his studies were carried out on cadavers and were never intended to serve as a guide for surgical technique.

Borges described relaxed skin tension lines in 1962

Lines follow the furrows formed when skin is relaxed and are revealed by pinching the skin (Fig. 1)

Relaxed skin tension lines are perpendicular to lines of maximum extensibility and reduces tension on the closure

Best incision designs usually involve a combination of factors

Allowing for appropriate access

Taking advantage of pre-existent scars or wrinkles

Placement with respect to aesthetic subunits

Reducing tension on closure

Aesthetic units and subunits (Fig. 2)

Have been described for multiple anatomic regions, including breast, face, and lower extremity

Defined by naturally-occurring concave and convex surfaces

Figure 1. Relaxed skin tension lines (RSTL) versus other skin lines. From Borges A. Plast Reconstr Surg 1984;73(1):144-50.

Figure 2. Aesthetic units and subunits of the face. 1, forehead unit (1A, central subunit; 1B, lateral subunit; 1C, eyebrow subunit); 2, nasal unit; 3, eyelid units (3A, lower lid unit; 3B, upper lid unit; 3C, lateral canthal subunit; 3D, medical canthal subunit); 4, cheek unit (4A, medial subunit; 4B, zygomatic subunit; 4C, buccal subunit; 4D, lateral subunit); 5, upper lip unit (5A, philtrum subunit; 5B, lateral subunit; 5C, mucosal subunit); 6, lower lip unit (6A, central subunit; 6B, mucosal subunit); 7, mental unit; 8, auricular unit; 9, neck unit. From Sabapathy R, et al. Postburn Reconstruction of the Face and Neck. Plast Reconstr Surg, 2022;150(6). From Borges A. Plast Reconstr Surg 1984;73(1):144-50.

Scars that cross aesthetic subunits are more noticeable than those that are hidden in the boundaries between subunits

Methods of excision

Elliptical

Most common method

Usually designed with length: width ratio of 3:1

Wedge

Used for lesions located at or near a free tissue margin

Circular

May be utilized when shorter scar is desired

Serial

For large lesions which cannot be excised in one stage (i.e. congenital nevi)

Frequently used in conjunction with tissue expansion

THE RECONSTRUCTIVE LADDER

Conceptual framework for understanding reconstructive options (Fig. 3)

Starts with most simple option (i.e., healing by secondary intention)

Progresses to more complex options in a step-wise fashion

Figure 3. An early version of the reconstructive ladder. From Janis J, et al. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011 Jan;127 Suppl:205S-212S.

Figure 4. The reconstructive elevator, as proposed by Gottlieb and Krieger. This formulation emphasizes the importance of selecting the most appropriate level of reconstruction as opposed to defaulting to the least complex. From Gottlieb L, et al. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93:1503-1504.

The “reconstructive elevator” (Fig. 4)

Proposed by Gottlieb and Krieger in 1994

Best reconstructive option is not always the least complex

Consider other factors: radiated tissue, possible cancer recurrence, hardware or implants present, complex or high-risk areas, need to plan for back-up options

PRINCIPLES OF SUTURING

Layered closure: any wound deeper than skin should be closed in layers

Eliminate dead space

Prevent dehiscence while wound healing is occurring

Precisely approximate skin edges without tension

Wound edge eversion

Takes advantage of scar contraction

Allows for optimal wound healing

Choosing suture

Permanent versus absorbable

Monofilament versus multifilament

Suture size

Needle type

Cutting

Taper

Surgical glue

Staples

Timing of suture removal

Sutures should be removed from face within 5-7 days

Sutures in other anatomic areas should be removed within 7-14 days

Exceptions include wounds that cross joints, wounds that are under significant tension, wounds in irradiated or otherwise damaged surgical fields

SUTURING TECHNIQUE

Simple interrupted sutures: most commonly used suture technique (Fig. 5a)

Needle enters epidermis at 90-degree angle

Needle turned to exit immediately below deep dermis

Care must be taken to enter and exit at same levels on opposite side

Running simple sutures

Rely on well-approximated wound edges

Not as precise as interrupted sutures, but faster

Subcuticular sutures

Needle passed horizontally through the superficial dermis, parallel to skin surface

Can be running or interrupted

Allows close approximation of skin edges without need for external skin sutures

Horizontal mattress sutures (Fig. 5b)

Everting sutures that spread tension across a wound edge

Needle passed across the wound and then back the other way

Useful in fragile tissue

Also useful in suturing glabrous skin of hands/feet

Can be performed as a running suture

Vertical mattress sutures (Fig. 5c)

Used for increased wound eversion

Far-far near-near suture placement

Figure 5. a) Simple interrupted. b) Horizontal mattress. c) Vertical mattress.

REFERENCES

Thorne CH. Techniques and Principles in Plastic Surgery. In: Thorne CH, ed. Grabb and Smith’s Plastic Surgery, 6th ed. LWW, 2006.

Neligan P. Plastic surgery and innovation in medicine. In: Neligan PC, Gurtner GC, eds. Plastic Surgery, Vol 1: Principles. 3rd ed. Elsevier, 2012.

Wilhemi BJ, Blackwell SJ, Phillips LG. Langer’s lines: to use or not to use. Plast Reconstr Surg. 1999 Jul;104(1):208-14.

Borges AF. Relaxed skin tension lines (RSTL) versus other skin lines. Plast Reconstr Surg. 1984 Jan;73(1):144-50.

Hollenbeck ST, et al. Longitudinal outcomes and application of the subunit principle to 165 foot and ankle free tissue transfers. Plast Reconstr Surg. 2010 Mar;125(3):924- 34.

Spear SL, Davison SP. Aesthetic subunits of the breast. Plast Reconstr Surg. 2003 Aug;112(2):440-7.

Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985 Aug;76(2):239-47.

Gottlieb LJ, Krieger LM. From the reconstructive ladder to the reconstructive elevator. Plast Reconstr Surg. 1994;93:1503-1504.

Janis JE, Kwon RK, Attinger CE. The new reconstructive ladder: modifications to the traditional model. Plast Reconstr Surg. 2011 Jan;127 Suppl:205S-212S.

Chapter 5
Wounds

Courtney Leonard, MD
Prabhu Senthil-Kumar, MD

A wound can be defined as any disruption of the integrity of living tissues. A wound can occur due to various causes such as trauma, thermal injury, ischemia, infection, and other miscellaneous etiologies.

WOUND CLASSIFICATION

Wounds can be broadly classified in multiple ways

Etiology: traumatic, infectious, ischemic, thermal, pressure, neuropathic and surgical wounds

Time to heal:

Acute wound (<4-6 weeks)

Chronic wounds (>4-6 weeks)

Further classified into three major categories: vascular (arterial or venous) ulcers, diabetic ulcers, and pressure ulcers

Skin integrity:

Open wounds: skin integrity was broken

Closed wounds: skin remains intact, but the underlying tissue is damaged

Depth of wound:

Superficial: only involves the epidermis

Partial thickness: involves epidermis and part of the dermis

Full thickness wound: entire thickness of skin and deeper structures

Surgical wounds are classified based on contamination:

Clean wound: uninfected surgical wounds with no inflammation or involvement of the respiratory, gastrointestinal, or genitourinary tracts

Clean contaminated: clean wounds with a slightly increased risk of infection, such as those involving the respiratory, gastrointestinal, or genitourinary tracts

Contaminated wounds: visible contamination, such as spillage from the gastrointestinal tract or a break in sterile technique.

Dirty/infected wound: infection, abscess

STAGES OF WOUND HEALING

Wound healing is a complex, highly regulated, dynamic process involving three phases: inflammation, fibroblast proliferation, and remodeling. Wounds may progress or even regress through these stages based on local and systemic factors. It is imperative to have a proper understanding of the wound type, etiology, chronicity, and patient health status to provide appropriate treatment.

Inflammatory phase (immediately to 2-5 days)

The functional priorities during this phase of wound healing are attainment of hemostasis, removal of devitalized tissues, and prevention of colonization and invasive infection by microbial pathogens, principally bacteria

Following injury, vasoconstriction and coagulation occur by activation of the clotting cascade and platelets; this creates a provisional matrix to provide a scaffold

Cytokines (TGF-β, IL-1β) are released, causing vasodilation and increased permeability, to promote chemotaxis and cell migration into the wound bed

Neutrophils respond first in 24-48 hours to the site to remove dead tissue by phagocytosis and clear infection

Macrophages (most critical for wound healing) follow neutrophils in 48-72 hours, then by lymphocytes in 5-7 days post-injury, all playing a vital role in wound healing

Proliferative phase (days 4-21)

Mainly encompasses epithelialization, angiogenesis, granulation tissue formation, and collagen deposition

If basement membrane is intact in the wound, epithelial progenitor cells in skin appendages and deeper layers restore epidermis in 2 to 3 days

If the basement membrane has been destroyed:

Epithelial proliferation and migration: epithelial cells located on the skin edge begin proliferating and sending out projections to re-establish a protective barrier

Neoangiogenesis: angiogenic factors activate endothelial cells, causing sprouting of capillaries and new vasculature formation in the scaffold

Granular tissue formation and collagen deposition

Fibroblasts migrate into the wound bed and proliferate

Fibroblast synthesis of immature type III collagen tissue, which rapidly gains tensile strength in the wound

Remodeling phase (3 weeks-1 year)

Immature type III collagen is replaced by mature, organized, type I collagen and wound contraction occurs through the actions of myofibroblasts

Extracellular matrix and subsequent scar is organized largely in response to mechanical tension, inflammation, and genetic phenotype

Scar strength gradually increases over time

Strength is 3% of final strength at 1 week, 30% at 3 weeks, 80% at 3 months

Scar maturation requires approximately 9-12 months in an adult, longer in children

Scar revisions may be delayed a year or longer after injury to ensure remodeling is complete

FACTORS INFLUENCING WOUND HEALING

Local factors

Fluid collection: hematoma or seroma

Premature wound closure

Blood supply

Temperature

Infection

Technique (gentle handling of tissues, orienting incisions or closures along optimal vectors to disperse mechanical tension) and ideal suture materials

Timing between injury to closure

Mechanical tension

Location on body

Presence of foreign body

History of radiation

Systemic factors

Age

Nutrition

Nicotine use

Chronic illness (diabetes, hypothyroidism, vascular disease, neuropathy)

Genetic conditions predisposing to poor wound healing (e.g., collagen, vascular disorders)

Medications that interfere with wound healing (chemotherapy, steroids, etc.)

WOUND CLOSURE

Several surgical principles are important to keep in mind to expedite wound healing and reduce the incidence of hypertrophic or pathologic scarring. Approaches to wounds should always include adequate debridement (removal of any nonviable tissue and foreign bodies), bacteriologic control, and optimization of systemic factors governing wound healing.

Healing by primary intention: wound closure by direct approximation, pedicled/ free flap, or skin graft

Debride necrotic or nonviable tissue and irrigate copiously to expedite inflammatory phase

Dermis should be accurately approximated; wound edges should be aligned at the same depth to prevent overlapping or gapping

Skin glue may be used if the wound is limited to partial thickness depth

Scar may be red, raised, or pruritic at peak of collagen synthesis (approximately 6 weeks after closure)

Healing by secondary intention: wound is left open to heal

Myofibroblasts promote contraction of wound edges

Epithelialization proceeds from wound margins towards center at 1 mm/day under ideal circumstances

Secondary healing is beneficial in heavily contaminated or “dirty” wounds (e.g., abscess drainage site), or wounds in areas that have excellent vascular supply (e.g., scalp)

Can often provide a more aesthetic or less obvious scar in the right setting

Healing by tertiary intention: delayed wound closure after several days

Intentional interruption of healing started as secondary intention

May proceed any time after granulation tissue has formed in the wound

Delayed closure should be performed when the wound is not infected

In previously infected wounds, quantitative culture should demonstrate < 100 CFU bacteria/gram of tissue

Skin grafting may be considered in larger wounds for definitive closure after adequate debridement with a well-vascularized wound bed

MANAGEMENT OF THE CLEAN WOUND

Aim to obtain a closed wound as soon as possible to prevent infection, fibrosis, secondary deformity

General principles:

Updated tetanus vaccine: administer if not within 10 years of booster for clean minor wounds or within 5 years for contaminated wounds

Local anesthesia:

Lidocaine with epinephrine preferred due to fast onset, longer anesthetic time, and improved hemostasis

Literature shows epinephrine is safe to use in digits, nose, penis, etc., unless area is already vascularly compromised

Tourniquets may help provide bloodless fields in digits/extremities

Surgical prep:

Aqueous-based:

Povidone-iodine: one of the few products that is widely effective and safe on nearly all skin and mucosal surfaces; must be diluted 1:1 with normal saline when used around the eyes; must be allowed to dry for full bactericidal effect

Chlorhexidine gluconate (CHG): more sustained antimicrobial activity and more resistant to neutralization by blood products than iodine

Contraindicated on genitalia, mucosal surfaces, and open wounds

Alcohol-based:

Ethyl and isopropyl alcohol: quick, sustained, durable, with broader spectrum antimicrobial activity

When used alone, fast and short acting, has broad-spectrum antimicrobial activity, and is inexpensive; can also be combined with iodine or CHG

Highly flammable

Contraindicated on genitalia, mucosal surfaces, and open wounds

Debridement and irrigation: remove clot, debris, foreign bodies, and necrotic tissue; copious irrigation to remove debris and decrease bacterial inoculum

Closure: approximate dermis as atraumatically as possible, consider undermining of wound edges to relieve tension

Dressing: must provide absorption, protection, immobilization, even compression, ideally without interfering with function

Types of wounds and their treatment

Superficial abrasions: cleanse to remove foreign material and apply moist dressings or ointments to provide moist environment for re-establishment of epidermis

Remove gross debris buried in dermis within 24 hours of injury to prevent infection, prolonged inflammation, and traumatic tattoos

Contusion: evacuate soft tissue hematoma if a fluctuant, organized collection is present or if pressure of hematoma is compromising surrounding tissue (ears, nailbed, nasal septum, etc.)

Early: minimize by cooling with ice (24-48 hours)

Later: warm compresses helpful to speed reabsorption of blood

Laceration: revise and trim wound edges as necessary, debride, and reapproximate wound edges with sutures or surgical glue; may require multiple layers of closure depending on depth of wound and structures involved

Avulsion:

Partial: revise and suture the soft tissue flap if viable

Total: avulsed tissue may be irrigated, cleansed, defatted, and applied as a full thickness skin graft

Puncture wound: evaluate underlying damage, possibly explore wound for foreign body, and obtain X-ray if appropriate

If small, consider leaving open or partially open to promote egress of drainage

Bullet wounds: considered clean wounds that require local wound care and healing by secondary intention

Animal bites: debride, irrigate, and close primarily or leave open, depending upon anatomic location, time since bite, etc.

Augmentin is typically a mainstay of antibiotic prophylaxis

Consider rabies vaccine, if necessary

Wounds of face:

Largely develop as result of trauma

Important to first obtain a thorough trauma workup and rule out any intracranial injury, airway issues, or other intra-thoracic or abdominal injury

The face has reliable and excellent vascular supply, allowing for greater window of opportunity for delayed wound closure

Consider serial examination and delayed closure to evaluate extent of necrotic tissue burden before definitive debridement, particularly if “questionably viable” tissue is in the wound bed

Re-establishment of symmetry: carefully align anatomic landmarks such as vermilion border, ala, eyelid, eyebrow, helical rim

Special wounds:

Amputation of parts

Place amputated part in saline-soaked gauze in a plastic bag and place the bag on ice; avoid direct contact with ice to prevent thermal injury

Ischemia times for replantation are dictated by the amount of muscle in the amputated part

Digits: 12 hours of warm and 24 hours of cold ischemia

Upper/lower extremities: 6 hours of warm and 12 hours of cold ischemia

Cheek injury: may require exploration for parotid duct or facial nerve injury

Intraoral injuries: tongue, cheek, palate, and lip wounds require approximation with absorbable suture

Eyelids: align grey line and close in layers, keeping suture tails away from cornea and conjunctiva; consider temporary tarsorrhaphy

Ear injuries:

Auricular hematoma requires incision and drainage and well-molded dressing or sutured bolster to prevent cauliflower ear deformity

Through-and-through laceration requires 3-layer closure including cartilage

Tapered, non-cutting needles are indicated for cartilage repair to prevent fracturing or cheese-wiring of cartilage

Large composite defects must be approached in staged fashion

MANAGEMENT OF THE CONTAMINATED WOUND

Guidelines for management of contaminated acute wounds:

Majority of traumatic wounds may be closed primarily after adequate sharp debridement and copious irrigation

Consider healing by secondary intention if:

Heavy bacterial inoculum

Long time lapse since initial injury

Crushed or ischemic tissue (i.e., severely contused or avulsion injury)

Prolonged steroid use

Antibiotics: systemic antibiotics are only useful if a therapeutic tissue level can be reached within four hours of injury or debridement

Wound closure

Buried deep dermal sutures should be used to keep wound edge tension to a minimum; limit the amount of foreign material in the wound as much as possible

Monofilament sutures are less prone to infection and are recommended in traumatic wounds

With regard to deep open abdominal wounds, loss of domain can occur when muscle, fascia, or skin necrose or retract, allowing extrusion of viscera

The goal of closure is to recreate lost domain and reestablish function of abdominal wall; may require multiple stages and coordination with general surgery team

Guidelines for management of contaminated chronic wounds:

Debridement and irrigation, may require serial debridement to establish wound stability

Other forms of debridement:

Wet-to-dry dressings: involves applying moistened gauze to a wound bed, allowing the gauze to dry, and changing the dressings usually twice a day

Provides mechanical debridement as the gauze dries and is removed

Chemical debridement agents include collagenase, bromelain

Systemic antibiotics are of little use, unless patient demonstrates systemic signs of infection

Topical antimicrobials

Silver sulfadiazine and mafenide acetate ointments

Antimicrobial cleansers: acetic acid, hypochlorous acid

Biological dressings (allograft, xenograft, etc.)

Integra™ (Integra LifeSciences Corporation):

Bilayer wound matrix: superficial layer is a semi-permeable silicone membrane that mimics epidermis, deep layer is a collagen-GAG matrix that mimics dermis

The silicone layer is peeled off after incorporation of the deep layer

Useful for wound coverage over devascularized wound bed with limited immediate reconstructive options (e.g., exposed bone without periosteum)

Final closure

Often require a flap, skin graft, or delayed flap

Debridement helps convert a chronically contaminated wound to an acute clean wound by reducing biofilm

WOUND DRESSINGS

Dressings serve to protect the wound from trauma and to provide an ideal environment for healing. Some dressings provide protection as well as mechanical or chemical debridement.

Antibacterial ointments

Bacitracin, Bacitracin/Neomycin/Polymyxin B, Mupirocin, and mafenide acetate

Provide a moist environment conducive to epithelialization

Beware of secondary inflammatory reactions that may mimic infection

Mupirocin effective against MRSA

Mafenide has better penetration of cartilage

Prolonged use of mafenide may promote fungal overgrowth

Silver-based dressing

Silver ions disrupt bacterial cell walls and DNA synthesis, inactivate bacterial enzymes

Useful in burns

Antibacterial activity penetrates the eschar

Medical grade honey

Low pH debrides necrotic tissue and high osmolarity help to reduce edema through osmosis

Splinting and casting

Immobilization decreases shear forces on wounds and may help to promote wound healing

Splinting for extended periods of time can lead to stiffness

Pressure dressings

May be useful to obliterate “dead space” or to prevent seroma/hematoma

Do not compress flaps too tightly, may compromise vascular supply

NEGATIVE PRESSURE WOUND THERAPY (NPWT)

Beneficial tool for wounds not amenable to primary closure (large or contaminated wounds) and for allowing increased time between injury and time to closure (such as in wounds requiring coordination of two surgical teams, etc.)

Technique includes application of foam sponge or gauze to the wound bed, covered with adhesive dressing, applied to a vacuum device that provides constant sub atmospheric pressure (-50 to -175 mmHg)

Sponge should not be applied directly onto blood vessels or other fragile structures, grossly purulent or necrotic wounds, or on denuded bone

NPWT may be placed over bilayer matrices (e.g., Integr™a , Integra LifeSciences Corporation) to promote ingrowth of granulation tissue and development of a vascularized wound bed

NPWT applied over a split thickness skin graft has been proven to increase take of the graft

Dressing should be changed every 48-72 hours to assess wound progress and viability of tissue

Veraflo™ (3M™ , Solventum): NPWT that allows for instillation of solution into wound to help with irrigation and debridement

Mechanism of action:

Maintains moist wound environment and reduces edema

Promotes local wound blood flow and angiogenesis, reduces presence of inflammatory mediators, and speeds overall collagen synthesis and rate of wound closure by offloading mechanical tension on wound

Advantages: can be used as adjunct to serve as bolster for skin grafts, provides exudative management for draining wounds, and shortens time needed to create favorable wound bed

Wound care regimen is less frequent, making NPWT ideal for more cumbersome or extensive wounds that would otherwise require multiple daily dressing changes

Disadvantages: cost of device, pain or discomfort with dressing changes and peri -wound irritation secondary to adhesive tape

REFERENCES

Roseborough IE, Grevious MA, Lee RC. Prevention and treatment of excessive dermal scarring. J Natl Med Assoc. 2004 January; 96(1): 108–116.

Alster TS, West TB. Treatment of scars: a review. Ann Plast Surg. 1997;39:418-32.

Eppley BL. Alloplastic Implantation. Plast Reconstr Surg. 1999; 104:1761-83.

Broughton G, Janis JE, Attinger CE. Wound Healing: An Overview. Plast Reconstr Surg. 2006 Jun;117(7 Suppl):1e-S-32e-S.

Buchanan PJ, Kung TA, Cederna PS. Evidence-Based Medicine: Wound Closure. Plast Reconstr Surg. 2014 Dec;134(6):1391-1404.

Fonseca RJ. Oral and Maxillofacial Surgery. St. Louis, MO: Elsevier, 2018.

Hunt TK, et al. Physiology of wound healing. Adv Skin Wound Care. 2000;13 (suppl 6-11).

Purdue GF, Hunt JL. Chondritis of the burned ear: a preventable complication. Am J Surg. 1986;152:257–259.

Klein AW. Collagen substitutes: bovine collagen. Clin Plast Surg. 2001;28:53-62.

Lawrence WT. Physiology of the acute wound. Clin Plast Surg. 1998;25: 321-40.

Mast BA, et al. Scarless wound healing in the mammalian fetus. Surg. Gynecol. Obstet. 1992; 174:441.

Nwomeh BC, Yager DR, Cohen, K. Physiology of the chronic wound. Clin Plast Surg. 1998; 25:3.

Saltz R, Zamora S. Tissue adhesives and applications in plastic and reconstructive surgery. Aesthetic Plast Surg. 1998;22:439-43.

Stadleman WK, Digenis AG, Tobin GR. Physiology and healing dynamics of chronic cutaneous wounds. Am J Surg. 1998;176:26S-38S.

Terino EO. Alloderm acellular dermal graft: applications in aesthetic soft tissue augmentation. Clin Plast Surg. 2001;28:8399.

Witte MB, Barbul A. General principles of wound healing. Surg Clin North Am. 1997; 77:509-28.

Venturi ML, et al. Mechanisms and clinical applications of the vacuum assisted closure (VAC) device: a review. Am J Clin Dermatol. 2005;6:185.

Ubbick DT, et al. A systematic review of topical negative pressure therapy for acute and chronic wounds. Br J Surg. 2008;95(6):685-92.

Chapter 6
Grafts and Flaps

Jessie Koljonen, MD
Efstathios Karamanos, MD

When a deformity cannot be closed primarily, and secondary healing would be unlikely, too slow, or suboptimal, grafts and flaps are employed to restore normal function and/or anatomy.

GRAFTS

Grafts are harvested from a donor site and transferred to the recipient site without carrying its own blood supply. It relies on new blood vessels from the recipient site bed to be generated (angiogenesis). A graft must have a wound bed of healthy tissue (granulation tissue, muscle, fascia, bone with intact periosteum, tendon with intact paratenon, or cartilage with intact perichondrium) because the graft is dependent on blood supply from the wound.

Skin grafts

Thickness (Fig. 1)

Full-thickness skin grafts (FTSGs): consist of entire epidermis and dermis

Split-thickness skin grafts (STSGs): consist of epidermis and varying degrees of dermis; can be described as thin, intermediate, or thick (typical intermediate depth STSG is 12/1000 inch in depth)

Figure 1. Components of FTSG versus STSG.

Donor site

FTSG leaves behind no epidermal elements in the donor site from which resurfacing can take place

Donor site usually closed primarily

Must be taken from an area that has skin redundancy

Usually harvested with a scalpel between the dermis and the subcutaneous fat

After harvest, it can be defatted to thin it out prior to placing on a wound

STSG leaves behind adnexal remnants such as hair follicles and sweat glands, foci from which epidermal cells can repopulate and resurface the donor site

Typically harvested with a pneumatic or electric dermatome

The donor site is usually covered with an occlusive dressing and left to heal secondarily

Recipient site

FTSGs usually used to resurface smaller defects because they are more limited in size

Commonly used to resurface defects of the face or hand

Provide better color consistency, texture, and undergo less secondary contraction

STSGs usually used to resurface larger defects

Undergo more secondary contraction as they heal compared to an FTSG

Typically darken in color compared to the area from which they were harvested

Survival

FTSGs and STSGs survive by the same mechanism

Plasmatic imbibition (first 24-48 hours): initially, the skin graft passively absorbs nutrients from the wound bed by diffusion

Inosculation: by day 3, the cut ends of the vessels on the underside of the dermis line up with and begin to form connections to those of the wound bed

Angiogenesis: by day 5, new blood vessels grow into the graft and the graft becomes vascularized

Skin grafts fail by four main mechanisms:

Poor wound bed: because skin grafts rely on the underlying vascularity of the bed, wounds that are poorly vascularized with bare tendon, cartilage, or bone, or are damaged due to radiation or ischemia, will not support a skin graft

Synthetic materials cannot be covered by grafts for this reason

Shear: shear forces separate the graft from the bed and prevent the contact necessary for revascularization and subsequent “take,” which refers to the process of attachment and revascularization of a skin graft in the donor site

Hematoma/seroma: prevent contact of the graft to bed, inhibit revascularization

Must be drained by day 3 to ensure “take”

Infection: bacteria have proteolytic enzymes that lyse protein bonds needed for revascularization

Bacterial levels greater than 10⁵ cells/gram of tissue in the wound will cause graft failure

Skin substitutes: are used for temporary wound coverage, or as a bridge to another form of reconstruction, typically a skin graft

Allograft or acellular dermal matrices: cadaveric skin or dermis

Xenograft: skin from a different species, such as pigs; provides only temporary coverage

Synthetic: products like Integra™ (Integra LifeSciences Corporation), which is collagen/silicone bilayer designed to provide an occlusive environment as granulation forms through the tissue matrix; granulation will then support a skin graft after the silicone is removed

Other grafts

Nerve: most common donor site is the sural nerve

Fat: can be harvested as a structured graft or as lipoaspirate

Tendon: common donor sites are the palmaris longus, plantaris, extensor digitorum longus

Cartilage: common donor sites are the nasal septum, ear conchal bowl, rib

Bone: common donor sites are the calvarium, iliac crest, tibial tuberosity, rib

Muscle: typically small, can be harvested from any muscle

Composite: a graft that has more than one component, i.e., cartilage and skin graft, or a dermal-fat graft

FLAPS

Flaps are tissues transferred with an intact vascular supply to the recipient site. They survive through this blood supply and are not dependent on the wound bed. Flaps can be used when the wound bed is unable to support a skin graft (such as to cover exposed hardware), or when a more complex, larger, or more aesthetic reconstruction is needed. They are the most versatile type of reconstruction used by plastic surgeons. Flap harvest always leaves a donor site that will need to be closed either primarily, with a graft, or with another flap.

Classification

By composition (type of tissue transferred)

Single component

Skin flap: e.g., parascapular flap

Muscle flap: e.g., rectus abdominis muscle flap or latissimus dorsi muscle flap

Bone flap: e.g., fibula flap

Fascia flap: e.g., temporoparietal fascia

Multiple components:

Fasciocutaneous: e.g., radial forearm flap or anterolateral thigh flap

Myocutaneous: e.g., transverse rectus abdominis myocutaneous flap or latissimus myocutaneous flap

Osteocutaneous: e.g., fibula flap with a skin paddle or medial femoral condyle flap with skin paddle

Composite flap: comprised of multiple flap components that are directly attached to each other and harvested on single pedicle (e.g., latissimus osteomyocutaneous flap with muscle, skin, and bone)

Chimeric flap: multiple flap components that are harvested on their own vessel and freely mobile, with a single feeding vessel (Fig. 2)

Figure 2. Multi-segment fibula flap with fibula bone osteotomies, harvest of soleus muscle cuff based on muscle perforators, and independent skin paddle based on cutaneous perforators. From Saint-Cyr M, et al. Free Tissue Transfers and Replantation. Plast Reconstr Surg 2012;130(6):858e-878e.

By location (proximity to the primary defect that needs to be reconstructed)

Local flaps

Raised from the tissue adjacent to the primary defect

Movement into the defect can be described as advancement, rotation, or transposition

Includes V-Y, rhomboid, and bilobed flaps

Regional

Raised from tissue in the vicinity but not directly adjacent to the primary defect

Movement is described as transposition or interpolation

Such as the pedicled latissimus flap for breast reconstruction

Distant

Raised from tissue at a distance from the primary defect

Usually requires re-anastomosis of the blood vessels to recipient blood vessels in the primary defect (see “free flaps” below)

There are a few examples of distant pedicled flaps, such as using a groin flap for hand reconstruction

By vascular pattern

Random vs. axial

Random pattern flaps

Do not have a specific or named blood vessel as their blood supply

Designed based on the size of the flap base

Because of the random nature of the vascular pattern, these flaps are limited in dimensions, specifically in a length:base width ratio of 3:1

If designed longer than 3:1, a random blood supply often cannot support the flap (Fig. 3, 4).

Figure 3. (Top) Advancement flap design. (Below) V-Y flap. Both are often designed as random flaps. From Buchanan P, et al. Evidence-Based Medicine: Wound Closure. Plast Reconstr Surg 2016;138(3S):257S-270S.

Axial pattern flaps

Designed with a specific named vascular system that enters the base and runs along its axis (Fig. 5)

Allows the flap to be designed as long and as wide as the territory the axial artery supplies (angiosome)

Blood supply requires artery and its accompanying vein

Greater length possible than with random flap

All free flaps are axial (see “free flaps” below)

Peninsular: skin and vessel intact in pedicle

Island: vessels intact, but no skin over pedicle

Pedicled vs. free

Pedicled flaps

Flap blood supply remains attached to its source

Transferred to the defect with its vascular pedicle acting as a leash

Figure 4. (Top) Bilobed flap. (Below) Rhomboid flap. Both may be designed as random flaps. From Buchanan P, et al. Evidence-Based Medicine: Wound Closure. Plast Reconstr Surg 2016;138(3S):257S-270S.

Figure 5. Axial/arterial pattern skin flaps.

Free flaps

Detached at the vascular pedicle and transferred from the donor site to a recipient site

At the recipient site, the flap artery and vein are anastomosed to recipient vessels using microsurgical techniques

Allows more flexibility as tissues can be transferred nearly anywhere but requires microsurgical skill and increased operative time

Perforator flaps

Supplied by smaller vessels that pass through or in between deep tissues

Typically harvested without the deep tissues in order to minimize donor site morbidity and to yield only the necessary amount of tissue for transfer

Figure 6. Mathes and Nahai classified fascial and fasciocutaneous flaps based on their vascular anatomy. Type A (left) are those flaps with a direct cutaneous pedicle to the fascia. Type B (center) are those flaps with a pedicle that has a septocutaneous perforator. Type C (right) are those with a musculocutaneous perforator. From Buchanan PJ, Kung TA, Cederna PS. Evidence-Based Medicine: Wound Closure. Plast Reconstr Surg. 138(3S):257S-270S, September 2016.

Can be transferred either as a pedicled or free flap

Perforators are described by their path from the main vessel to the skin (Fig. 6)

Common perforator flaps:

Deep inferior epigastric perforator flap (DIEP): skin and fat of the lower abdomen supplied by the deep inferior epigastric artery and vein perforators without the rectus abdominis muscle

Anterolateral thigh perforator flap (ALT): skin and fat of the anterolateral thigh supplied by the descending branch of the lateral circumflex femoral vessel perforator(s)

Thoracodorsal artery perforator flap (TAP/TDAP flap): skin and fat of the lateral back supplied by the thoracodorsal artery and vein perforator without the latissimus dorsi muscle

Choosing the right flap

The primary defect (recipient site considerations): “replace like with like”

Size

Location

Tissue type to be replaced: Muscle can eliminate more dead space, skin is better for resurfacing

Functional and aesthetic considerations

The secondary defect (donor site considerations)

Location

Adhere to an angiosome, the territory that is supplied by a given vessel

What type of tissues are needed

Functional and aesthetic morbidity

Flap survival

Success depends not only on survival, but also ability to achieve the goals of reconstruction

Flap failure results ultimately from vascular compromise or the inability to achieve the goals of reconstruction.

Tension

Kinking of pedicle

Compression

Vascular thrombosis (typically more often a consideration in free flaps)

Infection

REFERENCES

Mathes SJ. Reconstructive Surgery: Principles, Anatomy and Techniques. New York, Elsevier Science, 1997.

McCarthy JG. Plastic Surgery, vol. 1. New York: Elsevier Science, 1990.

Russell RC, Zamboni WA. Manual of Free Flaps. New York: Elsevier Science, 2001.

Serafin D. Atlas of Microsurgical Composite Tissue Transplantation. New York: Elsevier Science, 1996.

Buchanan PJ, Kung TA, Cederna PS. Evidence based medicine: wound closure. Plast Reconstr Surg. 2014 Dec;134(6):1391-1404.

Saint-Cyr M, Wong C, Buchel EW, Colohan S, Pederson WC. Free tissue transfers and replantation. Plast Reconstr Surg. 2012 Dec;130(6):858e-878e.

Chapter 7
Microsurgery

Olivier F. Noel, MD, PhD
Rajiv Parikh, MD

INTRODUCTION

Microsurgery: type of surgery which uses precision instruments and a microscope to perform intricate surgery on small structures (arteries, veins, nerves, lymph vessels)

Examples:

Free tissue transfer (aka "free flap" surgery), wherein living tissue is transplanted from one part of the body to another (Fig. 1)

Appendage replantation or reconstruction (Fig. 2)

Vascularized composite allotransplantation (VCA), wherein living tissue is transplanted from one individual to another (face and hand transplants)

Potential tissues transferred: skin, muscle, tendons, bone, nerve, lymph nodes

Transferred tissue is selected so it can survive based on a vascular pedicle

Tissue is transferred to another region of the body

Artery and vein are re-connected (“anastomosed”) to blood vessels in the recipient site

Microvascular anastomosis restores blood supply to the transferred tissue

Figure 1. Free tissue transfer (“free flap”) for breast reconstruction following mastectomy. Abdominal tissue is transferred to the former breast site, including the Deep and/or Superficial Inferior Epigastric Artery/Vein (DIEA/V, SIEA/V). From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconst Surg 2017;139(1):204e-29e.

Figure 2. Right hand reconstruction following blast injury. Free tissue transfer of 3 toes, including bone, tendon, artery, vein, and nerve reconstruction. Lower image and x-ray are 15 years post-op. Patient has function and sensation. From Upton J et al. Free-tissue transfer. Plast Reconstr Surg 2009;124(6):e313-26.

FREE FLAP TYPES

Isolated tissue (pedicle)

Skin/subcutaneous Tissue

Deep inferior epigastric artery perforator (DIEP)

Superficial circumflex iliac artery perforator (SCIP)

Muscle

Latissimus dorsi (thoracodorsal artery)

Rectus abdominis (deep inferior epigastric artery)

Fasciocutaneous

Radial forearm free flap (RFFF; radial artery)

Anterolateral thigh (ALT; descending branch of lateral femoral circumflex artery)

Bone

Fibula (peroneal artery)

Iliac crest (deep circumflex iliac artery)

Nerve

Combined with other tissues as “innervated” flap

Innervated/free functional gracilis (+ obturator nerve)

Free toe transfer (+ digital nerves) (Figure 2)

Lymph nodes (vascularized lymph node transplant, VLNT)

Groin (SCIP) and omentum are examples

Transferred with surrounding fat and supplying blood vessels

Composite: combination of tissues taken as a single flap

Myocutaneous

Fasciocutaneous

Osteocutaneous

Innervated myocutaneous

Appendage: finger, toe, penis (replant or reconstruction)

Allogeneic composite tissue: face or hand transplant

For details, see Grafts & Flaps (Chapter 6), Gender Affirmation Surgery (Chapter 25), Composite Tissue Allotransplantation (Chapter 26), and Lymphedema (Chapter 27)

SUPERMICROSURGERY

Microneurovascular anastomosis for vessels of 0.3 to 0.8 mm and single nerve fascicles

Requires high magnification operating room microscope and ultrafine microsurgical instruments as well as needles (11-0 to 13-0 microsutures)

Applications in lymphedema surgery, digital replantation, pediatric microsurgery, neuroplastic surgery, and perforator to perforator reconstruction

SURGICAL INDICATIONS

Adequate/acceptable result cannot be achieved by simpler method

Severe tissue loss with exposed vital structures such as joint surfaces, bone without periosteum, vessels/nerves

Large “dead space” requiring obliteration (filling)

Restore form and/or function (i.e., breast reconstruction after mastectomy; Fig. 1)

Loss of digits after blast injury to hand

Congenital deformity: facial paralysis, severe thumb hypoplasia

Gender affirmation surgery: female-to-male bottom surgery

Lymphedema: cancer patients with lymph nodes removed for staging

Lymphovenous bypass: vessels anastomosed to local vein to redirect drainage around obstruction; lymph vessel diameter <0.8 mm

Peripheral nerve reconstruction: nerve fascicle diameter ranges 0.1-1 mm

In situ nerve repair/coaptation/dissection needed

CONTRAINDICATIONS

No absolute contraindications

Age (young or old) less important than overall health

Systemic disease: microsurgery contraindicated if patient cannot tolerate prolonged anesthesia, (e.g., surgery duration of 8-12 hours)

Cardiovascular and respiratory health

Renal insufficiency (high complication rate)

Hepatic function

Bleeding/clotting disorders (hypercoagulable state increases flap failure rate)

Smoking:

Digital replantation contraindicated, ~80-90% failure

No increased failure risk for free flaps

Smokers have more wound healing complications; encourage quitting

Previous radiation: not a contraindication

BASIC OPERATIVE TECHNIQUE

Details may be finalized intraoperatively, based on:

Defect size/missing tissue after debridement or tumor resection

Caliber and appearance of available vessels

Begin with dissection of tissue for transfer (+ vessels) and exposure of recipient vessels

Team communication is critical (surgeons, anesthesia, nursing)

Key portions of the surgery are beyond the limits of human eyesight

Tiny blood or lymphatic vessels: ~0.5-4 mm

Magnification is used during dissection, anastomosis (of artery, vein, and/or lymph vessels), and nerve coaptation

Magnification tools:

Magnifying loupes (custom glasses with attached magnifying lenses, 2.5-6.5x)

Surgical microscope (4-40x)

Anastomosis:

Blood flow temporarily obstructed with specialized atraumatic “Acland” clamps

Artery or lymph vessel: sewn together by hand (Fig. 3)

Interrupted suture technique common

End-to-end or end-to-side anastomoses are most common

Small caliber suture: 8-0 nylon (0.4 mm) to 12-0 nylon (0.01 mm)

Veins: vessel sizer used to estimate size of vein

Vessel coupler often used: vessel ends pulled through rings and edges everted onto sharp pins then opposing pins inter-digitate, sealing the vessels together (Fig. 4)

Clamps released to evaluate flow across anastomosis (Fig. 5)

Final steps are inset of transferred tissue and closure of donor site

Figure 3. Arterial anastomosis of synthetic vessel under the microscope. A pair of green “Acland” clamps obstructs blood flow to enable visualization. From van Mulken T et al. Preclinical Experience Using a New Robotic System Created for Microsurgery. Plast Reconstr Surg. 2018;142(5):1367-1376.

Figure 4. Vein anastomosis using a vessel coupler. The end of each vein has been pulled through the rings and everted onto the sharp pins. As the coupler is closed, opposing pins will interdigitate to seal the veins together. From Jandali S, et al. 1000 Consecutive Venous Anastomoses Using the Microvascular Anastomotic Coupler in Breast Reconstruction. Plast Reconstr Surg 2010;125(3):792-8.

Figure 5. Clinical photograph of an end-to-end arterial anastomosis and venous anastomosis with a coupler device. From Kagaya Y et al. A Quantitative Evaluation of the Flow-Increasing Effect of Flow-Through Arterial Anastomosis in the Vascular Pedicle of Free Flaps: A Prospective Clinical Before-and-After Study. Plast Reconstr Surg. 2021; 148(4):871-881.

POST-OPERATIVE MONITORING AND COMPLICATIONS

Gold standard: physical exam

Color

Temperature

Turgor

Capillary refill

Handheld doppler: signal checked at marked site on flap skin/surface

Pinprick to assess bleeding (slow, bright red blood is normal)

Arterial compromise: pale, cool, flaccid, slow cap refill

Venous congestion: purple/blue, tense, brisk cap refill (Fig. 6)

Most vascular complications occur in the first 48 hours

Figure 6. Breast reconstruction complicated by venous congestion of the left breast DIEP flap (upper right), while the right flap continued to have a good color (lower right). Congestion was addressed by anastomosis of an additional vein. Preoperative image (upper left) and postoperative image at 28 months (lower left). From Tran NV, et al. Microvascular Complications of DIEP Flaps. Plast and Reconst Surg 2007;119(5):1397-405.

ADJUNCT MONITORING DEVICES

Implantable doppler

Probe placed around artery or vein during surgery, connects to external flow monitor (Fig. 7)

Laser Doppler

Flow coupler: similar to implantable Doppler

Transcutaneous tissue oximetry

Placed on flap skin paddle

Measures tissue oxygen saturation (StO2) (Fig. 8)

Early detection of vascular compromise

Prompt return to operating room is critical

Evacuate any hematoma

Inspect vessels

Remove thrombus, revise anastomosis, and/or alleviate kinking, vein grafts

Consider leech therapy if vein patent but flap remains congested

Need antibiotics coverage while on leech therapy for coverage against Aeromonas hydrophila (can consider ciprofloxacin, Bactrim or ceftriaxone)

Figure 7. Implantable Doppler used to monitor a left cheek free flap reconstruction. A small silastic cuff probe (left lower) is placed around the vessel (right) and connected to an external flow monitor (upper left). From Paydar K, et al. Implantable Venous Doppler Monitoring in Head and Neck Free Flap Reconstruction Increases the Salvage Rate. Plast Reconst Surg 2010.

Figure 8. Transcutaneous tissue oxygen saturation value is projected on the device screen for each flap, which can also be monitored remotely. Typically, a drop of 20% or more in oxygen saturation is concerning for an ischemic event and warrants further flap perfusion investigation. From Lin SJ, et al. Tissue Oximetry Monitoring in Microsurgical Breast Reconstruction Decreases Flap Loss and Improves Rate of Flap Salvage. Plast Reconstr Surg. 2011;127(3):1080-1085.

MICROSURGERY TRAINING

Specialized technical skills necessary

Use of magnifying loupes and/or microscope (Fig. 9)

Tissue and vessel handling

Anastomosis techniques

Suturing at microscopic scales

Often taught in a hands-on lab setting

Animal-derived or synthetic vessel models

May be incorporated into residency training or offered as a stand-alone course

Figure 9. Microsurgical working space with instruments and microscope. A digital camera enables optimal teaching. (Inset) Magnification of the visual field with a scale bar is shown. From Pion E et al. New, Innovative, Three-Dimensional In Vivo Model for High-Level Microsurgical and Supermicrosurgical Training: A Replacement for Animal Models. Plastic and Reconstructive Surgery, Plast Reconstr Surg. 2022;150(2):432-436.

REFERENCES

Jandali S, et al. 1000 Consecutive Venous Anastomoses Using the Microvascular Anastomotic Coupler in Breast Reconstruction. Plast Reconstr Surg. 2010;125(3):792-8.

Macadam SA, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg. 2017;139(1):204e-29e.

Pu LLQ. A Comprehensive Approach to Lower Extremity Free-tissue Transfer. Plast Reconstr Surg Glob Open. 2017;5(2):e1228.

Galanis C, et al. Microvascular Lifeboats: A Stepwise Approach to Intraoperative Venous Congestion in DIEP Flap Breast Reconstruction. Plast Reconstr Surg. 2014;134(1):20-7.

Tran NV, Buchel EW, Convery PA. Microvascular Complications of DIEP Flaps. Plast Reconstr Surg. 2007;119(5):1397-405.

Noel OF, et al. Surgical simulation education in plastic surgery: current state of the art and need for improvement. Art of Surgery. 2023;7:1.

Paydar KZ, et al. Implantable Venous Doppler Monitoring in Head and Neck Free Flap Reconstruction Increases the Salvage Rate. Plast Reconstr Surg. 2010;125(4):1129-34.

Upton J, Guo L, Labow BI. Pediatric free-tissue transfer. Plast Reconstr Surg. 2009;124(6 Suppl):e313-26.

Butler CE, Adelman DM. Principles of Microsurgery. In: Thorne CH, editor. Grabb and Smith's Plastic Surgery, 7th Edition. Philadelphia: Lipincott Williams & Wilkins; 2014.

Chang DS, Janis JE, Garvey PB. Basics of Microsurgery. In: Janis JE, editor. Essentials of Plastic Surgery, 2nd Edition. St. Louis: Quality Medical Publishing, Inc. / CRC Press; 2014.

Chapter 8
Skin and Subcutaneous Lesions

Kelly Spiller, MD
Deana Shenaq, MD

ANATOMY

Layers of the skins

Epidermis: “Come, Let’s Get Sun Burned”

Stratum corneum: keratinocytes compact, surrounded by lipid layer making skin waterproof

Stratum lucidum: only found in glabrous skin

Stratum granulosum: keratinocytes contain keratohyalin granules

Stratum spinosum: keratinocytes form intercellular connections via desmosomes

Stratum basale:

Basal cells: stem cells that differentiate into keratinocytes; origin of basal cell carcinoma

Melanocytes: origin of melanoma

Merkel cells

Dermis

Papillary

Reticular

Sweat glands

Apocrine:

Areola, axilla, labia majora/scrotum, periumbilical, perianal

Deposit sweat into hair follicles

Cause body odor + pheromones, start functioning at puberty

Hidradenitis suppurativa: malfunction of apocrine glands

Hurley classification:

Stage 1: abscess formation without sinus tracts

Stage 2: recurrent abscesses with sinus tracts, scarring

Stage 3: diffuse involvement with multiple interconnected sinus tracts and abscesses

Treatment: medical therapy first line

Mild: topical clindamycin

Moderate: oral antibiotics

Refractory: adalimumab (Humira): anti-TNF monoclonal antibody

Surgical excision is last resort

Radical resection of all hair-bearing skin with 1-2 cm of normal skin

Heal by secondary intention, primary closure, skin grafting, local flaps

Eccrine:

Everywhere except vermillion border, nail plate, external auditory canal, nipple- areolar complex, labia, glans, clitoris

Highest amount in palms, soles

Functions:

Deposit sweat onto skin surface

Sweat is clear, colorless, odorless: contains water + electrolytes

Temperature homeostasis, secrete IgG, stem cells

Hyperhidrosis: overactive eccrine glands

Apoeccrine

Axilla, perianal areas

Secrete watery sweat in response to psychological/emotional stress

BENIGN SKIN LESIONS

Acrochordon (skin tag):

Single or multiple small, skin-colored, pedunculated papules

Treatment (symptomatic lesions): cryotherapy, snip excision, or shave excision

Epidermal inclusion cyst (sebaceous cyst, epidermoid cyst):

Caused by proliferation of epidermal cells in dermis, often arising after trauma

Skin-colored to yellow, firm, mobile nodules, often with an overlying central punctum

Well-circumscribed by cyst wall composed of stratified squamous epithelium

Communicate with surface via small opening, which may contain keratinaceous plug or blackhead

Typically asymptomatic, may become inflamed/infected

Treatment:

Acute infection: incision and drainage (avoid definitive excision as the tissue will be extremely inflamed)

Definitive treatment: surgical excision including cyst wall

Pilar cyst (trichilemmal cyst):

Originates from outer root sheath of hair shaft

Lined by stratified squamous epithelium which undergoes keratinization

Firm, slow-growing subcutaneous nodules typically on the scalp

No overlying central punctum

Most common cutaneous cyst of the scalp

Definitive treatment: surgical excision including cyst wall

Pilomatrixoma:

Caused by overgrowth of hair follicle matrix cells

Slow-growing, “rock-hard” subcutaneous masses with blue hue or ulcerative appearance

Bimodal distribution (first and sixth decades); more common in children

Mutation: CTNNB1 (dysregulates beta-catenin/LEF)

Treatment: surgical excision

Dermoid cyst:

Congenital cysts located along lines of embryonic fusion in the head and neck region

Most commonly along the superolateral orbital ridge, midline of nose, and scalp

Skin-colored, non-tender, non-compressible, slow growing masses

Can arise in the dermis or subcutaneous tissue

May be fixed to underlying periosteum

Can cause underlying bone erosion

Midline dermoids require pre-operative US or MRI to rule out intracranial excision

Most common over anterior fontanelle, midline nose (40%)

Treatment: surgical excision (with neurosurgery assistance if intracranial)

Seborrheic keratosis (verruca senilis, pigmented papilloma):

Hyperpigmented, waxy, verrucous papules with a characteristic “stuck-on” appearance

Appear in the fifth to seventh decades of life, usually on the head, neck, or trunk

Arise from the basal layer of the epidermis, are composed of well -differentiated basal cells

Treatment (cosmetic): cryotherapy, shave biopsy, dermabrasion

Trichoepitheliomas:

Neoplasms of follicular origin

Multiple, yellowish-pink, translucent papules distributed symmetrically on the cheeks, eyelids, and nasolabial area

More common in women

Can be confused with basal cell carcinoma

Treatment: excision to rule out basal cell carcinoma

Eccrine poroma:

Solitary lesion (firm papule less than 2 cm in size) usually on the sole of the foot or the palm of the hand in persons older than 40 years

May also occur on the chest, the neck, or other locations

Can degenerate into malignant eccrine poroma or porocarcinoma

Treatment: surgical excision

Verrucous nevus:

Closely set skin colored, brown, or gray-brown verrucous papules. May coalesce to form well-demarcated linear plaques along skin tension lines

Hyperkeratosis, acanthosis, and papillomatosis

Treatment: excision to deep dermis; consider laser, cryotherapy, or dermabrasion for more extensive lesions not amenable to excision

Desmoid tumor:

Caused by overgrowth of musculoaponeurotic layer of the abdominal wall with unpredictable progression

Treatment: excision with 1 cm margins

Cylindroma:

Adult-onset firm nodules of the face or scalp with smooth, flesh-colored, possibly telangiectatic surfaces

More common in women

Associated with Brooke-Spiegler syndrome (autosomal dominant, AD)

Treatment:

Solitary lesions: surgical excision, electrodessication

Grouped lesions: may need staged excision

Figure 1. Pyogenic granuloma. These lesions occur most commonly on the face (above). (Below) This lesion on the left supraclavicular fossa shows evidence of recent bleeding (arrowhead). From Li W, et al. Cysts, pits, and tumors. Plast Reconstr Surg 2009;124(1 Suppl):106e-16e.

Pyogenic granuloma (Fig. 1):

Appears in early childhood, usually following minor trauma, as a rapidly growing, small (<1cm) red lesion

Friable and prone to bleeding

Treatment: silver nitrate vs. surgical excision

Rhinophyma:

End-stage acne rosacea

Overgrowth of sebaceous glands of skin

Treatment:

Initial: isotretinoin, antibiotics

Refractory: tangential excision with healing by secondary intent

Mucocele:

Cysts formed from mucin leakage of minor salivary glands

Located on lower lip

Treatment: surgical excision

Pyoderma gangrenosum:

Dramatic deterioration of surgical wounds after 4 days to 6 weeks

Predominantly affects breasts, abdomen

Fever, chills, cellulitis, wound breakdown

Rapidly enlarging area of central skin ulceration plus violaceous skin with irregular borders

Risk factors: inflammatory bowel disease

Treatment: high-dose steroids, topical tacrolimus; avoid debridement

Xanthelasma palpebrarum:

Asymptomatic yellow-orange papules and plaques, commonly on the medial eyelids

Associated with hyperlipidemia (lesions do not resolve with correction of hyperlipidemia)

Treatment (cosmetic): surgical excision

Syringoma:

Asymptomatic, skin-colored or yellow papules and plaques of the eyelids or upper cheeks

Treatment (cosmetic): laser, cryotherapy, electrodessication, excision

Nevus of Ota (nevus fuscoceruleus ophthalmomaxillaris or oculodermal melanocytosis):

Dermal melanocytic hamartoma with bluish hyperpigmentation

Occurs along ophthalmic and maxillary divisions of trigeminal nerve

Caused by failure of complete embryonic migration of melanocytes from the neural crest to the epidermis

Results in dermal nesting, resultant dermal melanin causes Tyndall effect

More prevalent in females, darker-pigmented individuals

Bimodal age incidence, peaks at 1 year of age and puberty

10% associated with ipsilateral glaucoma

Recommend ophthalmologic referral

Malignant degeneration to melanoma occurs in approximately 4% of reported cases

Treatment: laser therapy – either Q-switched laser with ruby (694 nm), alexandrite (755 nm), or neodymium: yttrium-aluminum-garnet (1064 nm)

Nevus of Ito:

Large blue-grey lesion that arising over areas innervated by the posterior supraclavicular and lateral cutaneous brachial nerves (shoulder)

Treatment: Q-switched laser

Spitz nevus:

Well-circumscribed pink papule that rapidly increases in size

Pigmented variant (spindled cell nevus of Reed) is dark brown to black in color with pseudopods at the periphery, giving it a “starburst” appearance

May mimic melanoma

Most common in children (head and neck region)

Treatment: surgical excision

Dermatofibroma (benign fibrous histiocytoma):

Solitary, firm, hyperpigmented macule or thin papule on the lower extremity

4 times more common in women than in men

Treatment: surgical excision for painful or pruritic lesions

Lipoma:

Soft, rubbery, non-tender, mobile subcutaneous nodules that are slow-growing

Mature adipocytes surrounded by thin fibrous capsule

Treatment: surgical excision

Neurofibromas:

Associated with NF1; derived from Schwann cells

Types:

Plexiform: develop deep inside the body (involving nerves, blood vessels); presents with pain, numbness, weakness, disfigurement

Small risk of malignant degeneration

Dermal: small, nodule-like; no malignant potential

Treatment: excision, must sacrifice underlying nerve

Schwannomas:

Peripheral nerve sheath tumors

Treatment: resection, can spare underlying nerve

Glomus tumor:

Benign hamartomas originating from glomus body (vascular, neural elements responsible for thermoregulation)

Presents with pain, point tenderness, sensitivity to cold

Diagnosis: MRI (bright, discrete mass on T2-FLAIR)

Treatment: excision

Nevus sebaceous (Jadassohn nevus):

Hairless, solitary, linear, well-demarcated patch or thin plaque on the scalp

Pink, yellow, orange or tan in color

Hormonal changes cause the lesion to thicken and become more verrucous and nodular in appearance during adolescence

RAS mutation

Associated with maternal HPV

<1% risk of degeneration into basal cell carcinoma

Treatment: serial monitoring vs. selective excision (less risk of carcinoma than previously thought)

Squamous cell carcinoma (SCC)

Layers of the skins

SCC precursors:

Actinic keratoses:

Erythematous, rough, scaly lesions in sun-exposed areas

5-10% risk of progression to squamous cell carcinoma

Risk factors: age, male, fair skin

Treatment:

<15 lesions: cryotherapy

>15 lesions: topical imiquimod (Aldara), topical 5-fluorouracil (pyrimidine synthetase inhibitor), retinoids, diclofenac gel, surgical excision

Cutaneous horn:

Hard, cone-shaped cutaneous projections typically caused by excessive epidermal growth and retention of keratin

20% associated with premalignant lesions, 15% associated with SCC

Treatment: shave biopsy to exclude malignancy or definitive surgical excision

Keratoacanthoma (Fig. 2):

Solitary papule that grows rapidly in size with a crateriform center

Treatment: surgical excision recommended, cannot be reliably distinguished from SCC

Figure 2. Keratoacanthoma demonstrating rapid growth over a 3-month period. From Lee EH, et al. Benign and premalignant skin lesions. Plast Reconstr Surg 2010;125(5):188e-98e.

Leukoplakia:

If on floor of mouth: 60% association with SCC in situ (SCCis) or invasive SCC

If on buccal mucosa: typically benign

Bowen’s disease:

Squamous cell carcinoma in situ (SCCis)

Full thickness epidermal atypia

Presents as a thin eczematous, erythematous plaque

Erythroplasia of Queyrat: SCCis of the glans penis

Arises from keratinocytes in stratum basale

Erythematous, scaly or verrucous papule or plaque

Risk factors: age, sun exposure, lighter skin

High-risk lesions: poorly defined borders, recurrent lesion, immunosuppressed patient, rapid growth, neurologic symptoms, invasion to fat, size >2 cm, or size >6 mm in the central face, ears, scalp, genitalia, hands/feet

High risk subtypes: adenoid (acantholytic, adenosquamous, desmoplastic, metaplastic (carcinosarcomatous)

Marjolin’s ulcer: SCC arising in chronic wound, area of previous radiation or chronic inflammation

Margins:

Low-risk: 4 mm

High-risk: 6 mm or Mohs micrographic surgery

May metastasize (most often with lesions on the ear or lip, lesions >2 cm in size, and in the immunosuppressed population)

Basal cell carcinoma

Most common skin cancer

Arises from keratinocytes in stratum basale

Pink, pearly papule with overlying telangiectasia and rolled borders; ulceration may be present, giving a characteristic “rodent bite” ulcer (Fig. 3)

Risk factors: age, sun exposure, lighter skin

High risk: poorly defined borders, recurrent lesion, immunosuppressed patient, site of previous radiation, peri-neural involvement, aggressive histology (morpheaform, sclerosing, mixed infiltrative, basosquamous, or micronodular), >2 cm in the trunk/extremities, or >1 cm in the head and neck

Figure 3. (Above, left) Superficial basal cell carcinoma. (Above, right) Nodular basal cell carcinoma. (Below, left) Infiltrative basal cell carcinoma. (Below, right) Pigmented basal cell carcinoma. From Lee E, et al. Benign and premalignant skin lesions. Plast Reconstr Surg 2010;125(5):188e-98e.

Types:

Nodular (least aggressive with lowest risk of recurrence)

Infiltrating

Micronodular

Morpheaform

Sclerosing

Metatypical (basosquamous)

Gorlin syndrome: autosomal dominant mutation in PTCH1

Multiple basal cell carcinomas, odontogenic cysts of mandible, facial dysmorphism, skeletal abnormalities of the vertebrae, skull and ribs

Treatment: surgical excision, Mohs, electrodessication, cryosurgery, Imiquimod (TLR7 agonist) for <2 cm BCCs of the trunk, extremities, or neck), photodynamic therapy, 5-FU, and radiation therapy

Margins:

Low-risk: 4 mm

High-risk: 6-10 mm or Mohs

Vismodegib and Sonidegib (a selective inhibitor of hedgehog pathway activation) are approved for the treatment of metastatic basal cell carcinoma and locally advanced basal cell carcinoma that has recurred after surgery, or in patients who are not surgical or radiation therapy candidates

Melanoma

3% of all skin cancers, but 65% of all skin cancer deaths

Risk factors: lighter skin, age, sun exposure, family or personal history

Figure 4. ABCDE signs of melanoma. A 75-year-old man with a left cheek lesion presenting with asymmetry, border irregularity, color variation, and diameter of 2.5 cm evolving over an 8-year period. From Dzwierzynski W. Managing malignant melanoma. Plast Reconstr Surg 2013;132(3):446e-60e.

ABCDE signs of melanoma (Fig. 4):

Asymmetry

Border irregularity

Color variation

Diameter (>6 mm)

Enlarging or evolving

Predisposing conditions:

Dysplastic nevus: atypical melanocytes with potential for transformation

6-10% risk melanoma

Atypical mole syndrome or familial atypical multiple mole melanoma (FAMMMS):

More than 100 melanocytic nevi

1+ measures >8 mm

1+ with clinically atypical features

10% risk of melanoma

Giant congenital melanocytic nevi:

2% risk of melanoma (similar to general population)

>20 cm nevus in adult or lesion with potential to exceed 20 cm in child

Lesions overlying spine have higher risk of occult spina bifida

Satellite lesions have higher risk of malignancy

Treatment: tissue expansion, serial excision

Excision does not reduce risk of melanoma

Types of melanoma:

Superficial spreading: most common

Often arise in pre-existing nevi

Prolonged radial growth phase prior to invading dermis

Initially flat, but can become irregular or raised as the lesions grow

Nodular: second most common

Males more common than females

Arises de novo in normal skin

Dome-shaped, dark: may resemble blood blister

Lentigo maligna (Hutchinson’s freckle): rare (only 4% melanomas)

Present as large, tan lesions with convoluted patterns and multiple amelanotic patches

May arise from pre-existing lentigo maligna lesions

Grow in a slow, radial fashion, before the vertical growth phase develops

Women more common than men

Acral lentiginous:

Rarest type in Caucasians, 30-60% of melanoma in dark-skinned individuals

Arises in palms, soles of feet, and nail beds

Risk factors: age 50 to 70, irregular border, change of lesion size, pigment in surrounding skin (Hutchinson sign), personal history of melanoma, single finger involvement

Amelanotic:

Lack pigment, often mistaken for other lesions

Desmoplastic:

Aggressive local growth, less frequent nodal metastases

Often confused with common nevi, blue nevi, Spitz nevi, pyogenic granulomas, or hemangiomas

Diagnosis:

Gold standard: excisional biopsy

Shave biopsy is often performed by other providers but can under-estimate depth

Has not been shown to affect prognosis/survival

Classification:

Breslow thickness: most important prognostic variable (followed by ulceration)

<1 mm, 1-2 mm, 2-4 mm, >4 mm

Clark level:

Level 1: confined to epidermis

Level 2: extends into upper papillary dermis

Level 3: extends down to reticular dermis

Level 4: extends to subcutaneous tissue

Immunohistochemistry: S100, HNB45, Mort1+

Treatment:

Surgical excision with margins determined by Breslow depth

Melanoma in-situ (MIS): 0.5 cm

< 1 mm: 1 cm

1.01-2mm: 1-2 cm (generally 2 cm where allowable such as the trunk and extremities, and 1 cm in more aesthetically sensitive areas like the head and neck)

>2.01 mm: 2 cm

Sentinel lymph node biopsy (SLNB)

Indicated for intermediate thickness (1-4 mm) melanomas

May also be indicated for high-risk thin melanomas (0.75-1 mm thick with ulceration)

Completion lymph node dissection (CLND) if positive SLN or a clinically palpable node

Medical therapy for advanced (stage 3-4) disease

Immunomodulation + targeted molecular therapy toward mutations found in melanocytic lesions

Vemurafenib and dabrafenib: BRAF inhibitors, improved survival but develops rapid resistance with associated relapse

Interleukin-2: mmunomodulator that activates the host immune system to attack malignant cells, severe side effect profile

Ipilimumab: monoclonal antibody that suppresses CTLA-4, small but durable response, significant immunologic side effects

Nivolimumab: anti-PD-1 monoclonal antibody

Pembrolizumab: targets PDL1 receptor

Merkel cell carcinoma

Firm, painless nodule (up to 2 cm in diameter) or a mass (>2 cm in diameter), usually in the head and neck region

Red in color but may be flesh-colored, blue

Rapidly enlarges, aggressive with frequent nodal involvement

Risk factors: AEIOU

Asymptomatic

Expanding rapidly (>3 mo)

Immunosuppressed

Over 50 years old

UV-exposed site

Histology: CK20+, NSE+ small blue cells

Treatment: surgical excision (1-2 cm margins down to investing fascia), SLNB, adjuvant radiation

Paget's disease

Paget's disease of the breast: eczematous skin changes of the nipple areolar complex

Associated with ipsilateral breast cancer

Extramammary Paget's disease: intraepithelial carcinoma involving the vulvar, perianal, perineal, scrotal, and penile regions

Presents as well-defined, moist, erythematous plaques associated with pruritis

7 to 40% rate of associated malignancy

Treatment: wide local excision

Dermatofibrosarcoma protuberans (DFSP)

Malignant mesenchymal tumor, arises in the dermis and is characterized by latency in its initial detection, slow infiltrative growth, and local recurrence if not adequately treated

Caused by chromosomal translocation t(17;22) fusing COL1A1 with PDGF-B

Most common on the trunk followed by the proximal extremities

Treatment: wide local excision with excision of deep fascia, margins up to 5 cm

Metastatic disease: chemotherapy (imatinib: PDGF receptor tyrosine kinase inhibitor)

Angiosarcoma

Appears as a purple plaque, commonly found in the face and scalp in older Caucasian men

50% in the head and neck

Also commonly found in the breast and extremities, particularly in patients with a history of lymphedema or radiation therapy

Treatment: wide local excision

Frequently multifocal

Local recurrences common

Stewart-Treves syndrome

Lymphangiosarcoma in post-mastectomy patients

Diagnosis: incisional biopsy

Treatment: WLE if possible with margins of at least 1 cm, or isolated limb perfusion with tumor necrosis factor and melphalan

INDICATIONS FOR MOHS EXCISION

Sensitive anatomic locations

Recurrent BCC or SCC

Locations prone to recurrence: “H-zone” of the face- periorbital, periauricular, temple, upper lip, nose/ nasolabial fold

Involvement of critical structures like eyelid, lip, nose

Functionally important areas: genitals, perianal location, hands, feet

Previously irradiated fields

Large tumors >2 cm

Lesions with ill-defined tumor margins

Aggressive histiologic subtype

Immunosuppressed patients

VASCULAR ANOMALIES

Congenital hemangiomas

Present at birth

No post-natal growth

Red-violaceous discoloration with coarse telangiectasias, central pallor, and a peripheral pale halo

More common in the extremities, equal sex distribution, and are solitary with an average diameter of 5 cm

Two types:

Rapidly involuting congenital hemangioma (RICH):

Involutes rapidly after birth

50% of lesions have completed regression by 7 months of age

Rthe remaining tumors are fully involuted by 14 months

Affects the head or neck (42%), limbs (52%) or trunk (6%)

Rarely requires treatment but may leave behind atrophic skin

Non-involuting congenital hemangioma (NICH):

Does not regress (remains unchanged with persistent fast -flow)

Involves the head or neck (43%), limbs (38%), or trunk (19%)

Staged excision can be considered if the scar will be less noticeable than lesion

Infantile hemangiomas

Usually appear in the first two weeks of life, with 80% appearing in the first month of life

Proliferating phase: 0-9 months

Most of the growth achieved by 3 months

Involuting phase: 9 months to 12 years

Usually completed by age 4

Involution leaves some scar or discoloration in 50% of patients

Biopsy is rarely indicated, but are GLUT-1 positive on immunostaining

Treatment:

Small (<2-3 cm) well-localized lesions: can use intralesional corticosteroid

Larger problematic lesions can be treated with oral prednisolone or propanolol

Propanolol: side effects of hypoglycemia

Surgery is indicated in the case of:

Failure or contraindication to pharmacotherapy

A well-localized tumor in an anatomically favorable area

If resection will be necessary in the future and the scar would be the same

Lesions (of any stage) that are compromising function (vision) or destroying vital structures

Kaposiform hemangioendothelioma

Presents as a large (>5 cm), superficial, and diffuse lesion, with the overlying skin deep red-purple, tense, painful, and shiny

Typically involves the trunk and extremities

50% present at birth (but can appear in childhood)

Kasabach-Merritt phenomenon is common (thrombocytopenia <25,000, bruising, bleeding)

Regression often seen after age 2, although long-term chronic pain and stiffness can persist

Diagnosis: MRI

First-line treatment is vincristine

Capillary malformations

Slow-flowing vascular malformation characterized by ectatic vessels located at various levels within the dermis

Treatment: pulsed dye laser

Venous malformations

Most common type of vascular malformation

Present at birth, slowly increase in size as the child grows, change size with position, and are prone to thrombosis (phlebolith formation)

Treatment: first line is sclerotherapy [sodium tetradecyl sulfate (STS), ethanol]

Aspirin helpful to prevent painful phleboliths

Lymphatic malformations (cystic hygromas)

Characterized as microcystic, macrocystic, or combined

Most commonly occur in the cervicofacial region, axilla/chest, mediastinum, retroperitoneum, buttock, and perineum

Diagnosis: MRI

Treatment: reserved for symptomatic lesions that cause pain, significant deformity, or threaten vital structures

First line: sclerotherapy (doxycycline, STS, ethanol)

Can also use erbium laser or surgical excision

Arteriovenous malformations

High-flow vascular malformations characterized by warmth, pain, bony destruction, discoloration and sometimes ulceration of the overlying skin

Treatment: embolization followed by excision 24-72 hrs later

REFERENCES

Bichakjian CK, et al. Basal Cell Skin Cancer, Version 1.2016, NCCN Clinical Practice Guidelines in Oncology. J Natl Compr Canc Netw. 2016;14(5):574-97.

Miller SJ, et al. Basal cell and squamous cell skin cancers. J Natl Compr Canc Netw. 2010;8(8):836-64.

Dzwierzynski WW. Managing malignant melanoma. Plast Reconstr Surg. 2013;132(3):446e-60e.

Pavri SN, et al. Malignant Melanoma: Beyond the Basics. Plast Reconstr Surg. 2016;138(2):330e-40e.

Trost JG, Applebaum DS, Orengo I. Common Adult Skin and Soft Tissue Lesions. Semin Plast Surg. 2016;30(3):98-107.

Jalalabadi F, et al. Common Pediatric Skin Lesions: A Comprehensive Review of the Current Literature. Semin Plast Surg. 2016;30(3):91-7.

Greene AK. Current concepts of vascular anomalies. J Craniofac Surg. 2012;23(1):220-4.

Lee EH, Nehal KS, Disa JJ. Benign and premalignant skin lesions. Plast Reconstr Surg. 2010;125(5):188e-98e.

Li WY, Reinisch JF. Cysts, pits, and tumors. Plast Reconstr Surg. 2009;124(1 Suppl):106e-116e.

Chapter 9
Thermal, Electrical, and Chemical Injuries

Samantha Lund, MD
Amelia C. Van Handel, MD

Thermal injuries are caused by exposure to extreme temperatures, chemicals, or electricity, and can result in destruction of the skin and underlying tissue causing local and systemic effects. The management of a major thermal injury requires an understanding of the pathophysiology, diagnosis, and treatment not only of the local skin injury, but also of the derangements that occur in hemodynamic, metabolic, nutritional, immunologic, and psychologic homeostatic mechanisms.

BURNS

Pathophysiology: amount of tissue destruction is based on temperature (> 40° C) and time of exposure

Diagnosis and prognosis:

Burn size: % of total body surface area (TBSA) burned

Rough estimates can be based on the rule of 9’s (Fig. 1) or by the patient’s palm size (the palm is approximately 1% TBSA)

The Lund-Browder chart is used to determine %TBSA

Note that different charts are required for adults and children due to head:chest size discrepancy and limb differentials for ages birth to seven years (Fig. 2, 3)

Figure 1. TBSA burn based on rule of 9's

Figure 2. Lund-Browder chart for pediatric burns

Figure 3. Lund-Browder chart for adult burns

Age: burns at the extremes of age (very young or very old) carry a greater morbidity and mortality

Depth: may be difficult to assess initially as injuries evolve and deepen over 24-72 hours

Varies based on type and temperature of etiologic agent, and time of exposure

Classification (Fig. 4 and Table 1)

First degree: superficial; erythema but no skin breaks; similar to a sunburn

Second degree: blisters present, red and painful, skin blanches

Superficial partial-thickness: involves epidermis and upper dermis

Deep partial-thickness: involves deeper dermis

Third degree: full-thickness; insensate, charred, or leathery in appearance; can appear bright cherry red but does not blanche

Fourth degree: deeper tissue such as muscle or bone affected

Figure 4. Classification of burns by depth

Zones of injury:

Coagulation (central): tissues undergo necrosis and are irreparably damaged

Stasis (intermediate): vasoconstriction and ischemia (can improve or worsen, depending on treatment)

Hyperemia (peripheral): heals without scarring

Location: face and neck, hands, feet, and perineum may cause specific functional issues and warrant careful attention; often necessitate hospitalization and/or transfer to a burn center (Table 2)

Inhalation injury: beware of burns occurring in enclosed spaces

Signs include singed nasal/facial hair, carbon particles in pharynx, hoarseness, and conjunctivitis

Patients may not initially have any signs of airway compromise, so must have high index of suspicion

Inhalation injuries decrease the chance of survival and therefore require specific attention and treatment (Fig. 5)

Consider associated injuries like fractures; depending on circumstances surrounding burn, patients may require full trauma workup

Co-morbid factors (pre-existing cardiovascular, respiratory, renal and metabolic diseases; seizure disorders; alcoholism or drug abuse) should be considered and optimized during the acute and subacute treatment period to improve outcomes

Prognosis: best determined by burn size (TBSA), age of patient, presence of inhalation

Circumferential burns: can restrict blood flow to extremity or respiratory excursion of chest and may require emergent escharotomies

Certain criteria are used to make the determination regarding whether transfer to a burn is necessary (Table 2)

Treatment plan

History and physical exam

In pediatric burns, where the history does not correlate with the burn injury, consider the possibility of child abuse – contact social work and/or follow hospital -specific protocols

Relieve respiratory distress: escharotomies and/or intubation (see below)

Prevent and/or treat burn shock – fluid resuscitation with large bore IV x 2

Figure 5. Survival from burns with and without inhalational injury

Monitor resuscitation with foley catheter and hourly urine output

Treat ileus and nausea: NG tube if > 20% TBSA burn or intubated

Tetanus prophylaxis

Thromboembolic prophylaxis

Baseline laboratory studies (i.e., CBC, CMP, UA, chest x-ray, EKG, cross-match, arterial blood gases, and carboxyhemoglobin)

Cleanse, debride, and treat the burn wounds

Respiratory involvement:

Three major causes of respiratory distress in the burned patient

Unyielding burn eschar encircling chest

Distress may be apparent immediately

Requires escharotomies (cutting into the eschar to relieve constriction)

Carbon monoxide poisoning

May be present immediately or have a delayed presentation; high level of suspicion if patient exposed to smoke in an enclosed space

Diagnosed by carboxyhemoglobin levels measured in arterial blood gas

Important to remember that patients with a history of smoking may have baseline elevated carboxyhemoglobin

Initial treatment is displacement of CO by 100% O2 by facemask

Hyperbaric oxygen treatment may be of value, but is often not practical in many locations

Smoke inhalation leading to pulmonary injury

Insidious in onset (18-36 hours)

Due to incomplete products of combustion, not heat (direct thermal injury to lungs occurs only secondary to steam burns)

Causes chemical injury to alveolar basement membrane and subsequent pulmonary edema

Initial treatment is humidified O2, but intubation and respiratory support may be required

Secondary bacterial infection of the initial chemical injury leads to progressive pulmonary insufficiency and infection – mucosal barrier of respiratory tract is damaged

Severe inhalation injury alone or in combination with thermal injury carries a grave prognosis

Three stages of presentation have been described:

Acute pulmonary insufficiency (immediately postburn to 48 hours)

Pulmonary edema (48-72 hours)

Bronchopneumonia (25 days)

Monitor respiratory and mental status — be aware of hoarseness, wheezing, stridor. If any concerns about current or future airway involvement, best to intubate patient prior to excessive airway edema

Burn shock

Massive amounts of fluid, electrolytes, and protein are lost from circulation almost immediately after burning (Table 3)

Systemic inflammatory response occurs if > 20% TBSA burn in adults, >30% TBSA in children, and >15% TBSA in elderly — results in a hypermetabolic state and increased capillary permeability

Resuscitation requires replacement of sodium ions and water to restore plasma volume and cardiac output – initiate if adult burns >15-20% TBSA and pediatric burns >10% TBSA

Many formulas have been reported to achieve resuscitation, but these serve only as a guide for initial IVF; must also monitor UOP and hemodynamics to appropriately titrate rate

Parkland formula: 4 cc Ringer’s lactate/kg/%TBSA burn over the first 24 hours

1/2 of the 24-hour fluid requirement should be given in the first 8 hours postburn and the remaining 1/2 over the next 16 hours

Remember to factor in any fluid boluses patient may have received either in ED or at OSH when performing calculations

Administration of colloid during or after resuscitation can vary from burn center to burn center

Children should receive maintenance fluids (weight-based 5% dextrose in half-normal saline), as well as resuscitative fluids

Monitoring resuscitation

Urine output 0.5-1cc/kg/hr in adults and 1cc/kg/hr in children <12 yo

A clear sensorium, pulse <140/min, BP >90/60 mmHg, HCO₃ >18meq/L, cardiac output >3.5 L/min/M² in adults

CVP in acute major burns is unreliable – use if myocardial disease, age >65 yo, inhalation injury, fluid requirements >150% of expected

Metabolic considerations

Increased metabolic demands in patients with burn injury (hypermetabolic state)

High carbohydrate/high protein diet – dietician and tube feeds as needed

Early feeding (start at 12 hours) – prevents mucosal atrophy, ulceration, bacterial translocation in gut

Measure prealbumin to determine nutritional status (goal >20)

Treatment of the burn wound

Primary treatment is early excision of full thickness burns as soon as possible

As soon as patient in stable, plan for multiple trips to the operating room

Surgeries performed in a warm room

Begin with largest areas first

Hand burns should be excised by 14 days post-injury

Face burns typically excised last

Necrotic tissues or any burned tissue not expected to heal within 2-3 weeks may be removed by any of several techniques

Formal excision

Tangential (layered) debridement

Enzymatic debridement

Hydrotherapy — a useful adjunct

Specific burn wound dressings differ from one burn center to another

The most common topical antibacterials are silver sulfadiazine (Silvadene®) and mafenide acetate (Sulfamylon®)

Dressing changes at least 1x/day with soap and water

Status of burn wound bacterial colonization and effectiveness of topical antibacterial treatment can be monitored by physical exam or biopsies of wound for quantitative and qualitative bacteriology

Systemic antibiotic therapy only used for sepsis, not prophylactically (breeds resistant organisms)

Wound closure by the patient’s own skin (autograft) is the ultimate goal of treatment

Other options include:

Secondary intention healing

Allograft: will need to be replaced with autograft in a delayed fashion

Xenograft: will need to be replaced with autograft in a delayed fashion

Artificial skin: various dermal replacement products exist (Integra®, Restrata®, Matriderm®, Keresis®, BTM®, etc.)

Cultured epithelial cells: available only at certain centers, require time to grow them and $$$

Autografts should be applied to priority areas first, such as the hands, face and important joints, as well as the neck for possible tracheostomy placement

Once healed, pressure with elastic support/compression garments is usually necessary to reduce hypertrophic scarring

Physical therapy/occupational therapy - important adjunct in burn care, helps prevent contractures, especially for burns that cross joint surfaces

Complications: can occur in every physiologic system or secondary to burn injury

Renal failure

From hypovolemia

Beware of nephrotoxic medications in the burn patient

Myoglobinuria associated with compartment syndrome

Gastrointestinal bleeding

Curling’s ulcer: gastric ulcer that results from large TBSA burn due to decreased plasma volume that causes ischemia of gastric mucosa

More likely in burns over 40% TBSA

Usually remains subclinical

Antacids and H2 blockers

Increased risk with burn wound sepsis

Burn wound sepsis (Table 4)

Monitored by physical exam, vitals, and tissue biopsy (qualitative and quantitative)

Must keep bacterial count <10⁵ bacteria/gm of tissue

Clinically suspect global sepsis with:

Sudden onset of hyper- or hypothermia

Unexpected congestive heart failure or pulmonary edema

Development of the acute respiratory distress syndrome

Ileus occurring after 48 hours post-burn

Mental status change

Azotemia

Thrombocytopenia

Hypofibrinogenemia

Hyper- or hypoglycemia is especially suspect if burn > 40% TBSA

Blood cultures may be positive but in many cases are not

Progressive pulmonary insufficiency

Can occur after:

Smoke inhalation

Pneumonia

Cardiac decompensation

Sepsis from any cause

Produces:

Hypoxemia

Hypocarbia

Pulmonary shunting

Acidosis

Over-resuscitation

If IVF rate remains elevated despite adequate UOP, increased risk for:

Abdominal compartment syndrome

Extremity compartment syndrome

Acute respiratory distress syndrome (ARDS)

Wound contracture and hypertrophic scarring:

Largely preventable

Active range of motion of involved and adjacent joints is encouraged to prevent joint contractures from the outset

Splints and passive range of motion are used if active range of motion is unable to be performed, e.g., elbow and knee are kept in extension, fingers are kept in a position opposite to the burn injury to prevent contracture of reconstructed surfaces

Limb elevation and range of motion are useful for reducing edema and maintaining movement

Timely wound closure with adequate amounts of skin should largely eliminate these problems

Continued postoperative splinting and silicone-lined compression garments are of value in the remodeling of collagen with prevention of hypertrophic scars

Contractures may require future revision and reconstructive procedures months to years after original burn injury

Laser and steroid/5-FU injections can be helpful adjuncts to surgical procedures in tertiary burn reconstruction

CHEMICAL BURNS

Pathophysiology

Tissue damage secondary to a chemical depends on:

Nature of agent

Concentration of the agent

Quantity of the agent

Length of time the agent is in contact with tissue

Degree of tissue penetration

Mechanism of action

Diagnosis

Chemical burns are deeper than initially appear and may progress with time

Alkali burns may be more severe due to ability to deeply penetrate tissues

Fluid resuscitation needs often underestimated

Watch for renal/liver/pulmonary damage

Treatment

Initial treatment is dilution of the chemical with tap water

Copious irrigation for 30 minutes

Exception: brush cement/concrete/powdered lye/other powders off dry

Special attention to eyes: after copious irrigation with saline, consult ophthalmologist

After 12 hours initial dilution, local care of the wound with debridement, topical antibacterials, and eventual wound closure is same as for thermal burn

Of particular note are:

Gasoline

Excretion by lung

May cause large skin burn, if immersed

Watch for atelectasis, pulmonary infiltrates; surfactant is inhibited

Phenol

Dull, gray color to skin, may turn black

Urine may appear smoky in color

Spray water on burn surface

Wipe with polyethylene glycol

Direct renal toxicity

Hydrofluoric acid

Irrigate copiously with water

Subcutaneous injections of 10% calcium gluconate or intra-arterial infusion in affected extremities

Serial EKG and BMP monitoring of patients — may become hypocalcemic

Pulmonary edema may occur if subjected to fumes

Monitor effectiveness of treatment by frequent pain assessment — if treatment is working, pain should decrease

White phosphorous burn

Do not allow to desiccate — may ignite

Each particle must be removed mechanically

Copper sulfate (2%) may counteract to make phosphorous more visible (turns black in color)

Watch for EKG changes (Q-T interval and S-T and T wave changes)

May cause hemoglobinemia and renal failure

ELECTRICAL BURNS

Pathophysiology

Effects of passage of electric current through the body depend on:

Type of circuit

Voltage of circuit

Resistance offered by body

Amperage of current flowing through tissue

Pathway of current through the body

Duration of contact

Tissue resistance to electrical current increases from nerve (least resistant) to vessel to muscle to skin to tendon to fat to bone

Diagnosis

Types of injury

Arc injury: localized injury caused by intense heat, current does not run through patient’s body

Injury due to current

Due to heat generated as current flows through tissue

Injury more severe in tissue with high resistance (i.e., bones)

Vessels thrombose as current passes rapidly along them

Deeper structures are usually more profoundly affected (e.g., muscles of the deep volar forearm compartment more affected than superficial volar forearm compartment)

Effect of current may not be immediately seen

Special effects of electrical injury

Cardiopulmonary

Anoxia and ventricular fibrillation may cause immediate death

Early and delayed rhythm abnormalities can occur

EKG changes may occur after burn in a delayed fashion; need serial EKG monitoring

Renal

High risk of renal failure due to hemoglobin and myoglobin deposits in renal tubules – important to see if myoglobinuria is present

Requires higher IVF/urine flow (75 cc/h in adults)

Must alkalinize urine to keep hemoglobin and myoglobin in more soluble state

Mannitol may be useful to clear heavy protein load

Musculoskeletal

Tetanic muscle contractions may be strong enough to fracture bones, especially spine

Although there may be minimal external damage, have a high suspicion for compartment syndrome in extremities — requires emergent fasciotomy

Spinal cord damage

Can occur secondary to fracture or demyelinating effecting of current

Abdominal effects

Intraperitoneal damage can occur to GI tract secondary to current

Vascular effects

Vessel thrombosis progresses with time

Delayed rupture of major vessels can occur

Cataract formation — late complication

Seizures

Treatment

CPR if necessary

Fluids usually higher amounts than Parkland formula calculation

No formula is accurate because injury is more extensive than can be predicted by skin damage

Alkalinize with NaHCO₃, if myoglobinuria or hemoglobinuria present

Monitoring

CVP or pulmonary wedge pressure helpful since total capillary leak does not occur as it does in a in thermal burn

Maintain urine output at 75-100 cc/h until all myoglobin and/or hemoglobin disappears from urine

Wound management

Topical agent with good penetrating ability is needed [i.e., silver sulfadiazine (Silvadene®) or mafenide acetate (Sulfamylon®)]

Debride non-viable tissue early and repeat as necessary (every 48 h) to prevent sepsis

Major amputations frequently required

Technicium-99 stannous pyrophosphate scintigraphy may be useful to evaluate muscle damage

Treat associated injuries (e.g., fractures or compartment syndrome)

COLD INJURIES

The two conditions of thermal injury due to cold are local injury (frostbite) and systemic injury (hypothermia).

Frostbite

Pathophysiology: formation of ice crystals in tissue fluid usually in areas that lose heat rapidly (e.g., extremities)

Anything which increases heat loss from the body (such as wind velocity) or decreases tissue perfusion (such as tight clothing) predisposes the patient to frostbite

Ability of various tissues to withstand cold injury is inversely proportional to their water content

Treatment: key to successful treatment is rapid rewarming in a 40°C water bath

Admission to hospital usually required

Tetanus prophylaxis

Thrombolysis

If < 24 h since injury, consider systemic thrombolysis

NSAIDs, heparin, and aspirin therapy

Wound management: blister removal not required

Physical therapy: important to maintain range of motion; daily whirlpool and exercise

Sympathectomy, anti-coagulants, and early amputation were of questionable value in controlled studies

Usually wait until complete demarcation before proceeding with amputations. Nonviable portions of extremities will often autoamputate with good cosmetic and functional results, but takes a long time

Hypothermia

Diagnosis

Core temperature < 34°C

Symptoms and signs mimic many other diseases

High level of suspicion necessary during cold injury season

Treatment

Must be rapid to prevent death

Monitor EKG, CVP, and arterial blood gases and pH during warming and resuscitation, maintain urine output of 50 cc/h

Begin Ringer’s lactate with 1 ampule NaHCO₃

Oral airway or endotracheal tube if necessary

Rapidly rewarm in 40°C hydrotherapy tank (requires 1-2 hours to maintain body temperature at 37°C)

Treat arrhythmias with IV lidocaine or amiodarone drip if necessary

Evaluate and treat any accompanying disease states

LIGHTNING INJURIES

Cutaneous effects: lightning strikes may cause cutaneous burn wounds

Contact burns from clothing on fire or contact with hot metal (i.e., zippers, etc)

Entry and exit burns are usually small, may be partial or full -thickness

Lightning burns are not the same as electrical burns; don’t cause deep tissue injury

May have temporary ischemic effects on extremity, such as pallor or neurologic deficits

Spontaneous recovery after a few hours is the expectation; probably due to local vasoconstriction

Systemic effects can occur such as arrhythmias, cataracts, CNS symptoms (similar to electrical injuries)

REFERENCES

Gallagher JJ, Wolf SE, Herndon DN. Burns. In: Townsend CM, et al, eds. Sabiston’s Textbook of Surgery, 18th ed. Philadelphia: Saunders, 2007.

Gibran N. Burns. In: Mulholland MW, et al., eds. Greenfield’s Surgery Scientific Principles and Practice. 5th ed. Philadelphia: Lippincott Williams and Wilkins, 2010.

Gibran NS, Heimbach DM. Current status of burn wound pathophysiology. Clin Plast Surg. 2000; 27:11-22.

Grunwald TB, Garner WL. Acute Burns. Plast Reconstr Surg. 2008;121: 311-319e.

Klein MB, et al. An analysis of the long-distance transport of burn patients to a regional burn center. J Burn Care Res. 2007;28:49- 55.

Klein MB. Thermal, Chemical, and Electrical Injuries. In: Grabb and Smith’s Plastic Surgery, 7th edition, eds. Thorne CH, et al. Philadelphia: Lippincott Williams & Wilkins, 2014.

Matthews MS, Fahey AL. Plastic surgical considerations in lightning injuries. Ann Plast Surg. 1997;39:561-5.

van Zuijlen PP, et al. Dermal substitution in acute burns and reconstructive surgery: a subjective and objective long-term follow-up. Plast Reconstr Surg. 2001; 108: 1938- 46.

Zuo KJ, Medina A, Tredget EE. Important Developments in Burn care. Plast Reconstr Surg. 2017; 139(1):120e-138e.

Chapter 10
Facial Fractures

Rachel Williams, MD
Yifan Guo, MD

Facial fractures are a common consequence of trauma and can significantly impact both function and aesthetic appearance. An understanding of the basic anatomy of the face, common fracture patterns, and principles of evaluation and management is essential for accurate diagnosis and effective treatment. This chapter introduces the foundational concepts of facial fractures, including their classification, clinical signs, indications for intervention, and surgical approaches.

INITIAL EVALUATION

Obtain history: mechanism of injury, prior history of facial trauma, time of injury and subjective complaints, medical comorbidities, and past surgeries

Physical exam

ABCs

Evaluate C-spine in patients with facial trauma

Inspect and palpate

Cranial nerve exam: sensation (CN V1, V2, V3) and motor (CN VII)

Eyes

Test pupillary light response

Test extraocular movements (EOM) to rule out entrapment

Assess for enophthalmos or proptosis

Ears

Assess for battle sign (bruising of mastoid), which can indicate skull base fracture

Assess for hemotympanum

Nose

Palpate nasal bones

Rule out septal hematoma

Midface

Assess for malar flattening

Assess for any increased mobility

Mandible

Assess occlusion (ask patient if their bite feels normal)

If patient unresponsive, examine wear of teeth

Any damaged or missing teeth

Palpate TMJ

Evaluate for dental injury, missing teeth

Diagnostics

Maxillofacial CT is gold standard to evaluate facial fractures

Evaluate sagittal, coronal and axial views

3D Reconstruction can be helpful for surgical planning

MANDIBLE FRACTURES

Often more than one fracture site

Teeth within line of fracture should be kept if root is not fractured

Classified based on location of mandible (Fig. 1), simple vs. comminuted, open vs. closed, and intracapsular vs. extracapsular (condylar)

Subtypes:

Symphyseal/parasymphyseal

Body

Angle

Coronoid

Condylar and subcondylar

Ramus

Indications for open reduction and internal fixation (ORIF): displaced fracture with abnormal occlusion

Maxillomandibular fixation used to restore occlusion

Figure 1. Anatomical regions of mandible. From Morrow BT, et al. Evidence-based medicine: Mandible fractures. Plast Reconstr Surg . 2014 Dec;134(6):1381-1390.

ZYGOMATICOMAXILLARY FRACTURES

Zygoma articulates with maxilla, sphenoid, temporal and frontal bones

Signs:

Flattened malar eminence

Trismus

Infraorbital nerve paresthesia

Diplopia, enopthalmos

Zygomaticosphenoid articulation most important for reduction of fracture

ORIF to restore facial width and malar projection

Approaches: eyelid (transconjunctival or subtarsal), intraoral, lateral brow or coronal (for arch)

ORBITAL FRACTURES

Orbital floor and medial wall fractures most common

Obtain ophthalmology consult to rule out ophthalmic emergencies: retrobulbar hematoma, hyphema, globe rupture, optic nerve injury, entrapment of extraocular muscles

Signs:

Enophthalmos: fractures cause increase in intraorbital volume

Diplopia (especially with upward gaze)

Hypoglobus

Proptosis/exophthalmos: due to periorbital swelling

Emergent intervention needed with entrapment of extraocular muscles

Indications for ORIF: persistent diplopia, fracture >50% orbital floor, clinically significant enophthalmos

ORIF through subtarsal and transconjunctival incisions

Figure 2. Coronal CT showing right orbital trapdoor fracture with displacement of inferior rectus muscle through fracture. Note the rounded shape of the muscle belly compared with the unaffected eye. From Morrow BT, et al. Evidence-based medicine: Mandible fractures. Plast Reconstr Surg . 2014 Dec;134(6):1381-1390.

NASAL FRACTURES

Most common facial fracture

Septal hematoma must be drained urgently

Paired nasal bones compose upper one-third of nose

Lower two-thirds is paired cartilage

Fractures typically treated within 2 weeks of injury

Closed reduction performed for simple nasal fractures

Open reduction if severe displacement or failed closed reduction

NASO-ORBITO-ETHMOID (NOE) FRACTURES

Fracture of nasal bone, frontal maxilla, lacrimal bone and ethmoid bone

Can involve medial canthal tendon

Markowitz classification (Fig. 3):

1: single non-comminuted fragment

2: comminution, tendon attached to fragment

3: comminution with tendon avulsion

Signs:

Telecanthus

Shortened depressed nasal bone

Mobility of medial canthus on exam

Rule out concurrent brain injury

Early intervention to repair with canthal reattachment

FRONTAL BONE FRACTURES

High force injury

Anterior table fracture:

Signs: forehead depression, step-off

Treatment: observation or ORIF

Figure 3. Markowitz classification of NOE fractures. From Chaudry O, et al. Facial Fractures: Pearls and Perspectives. Plast Reconstr Surg.2018 May;141(5):742e-758e.

Posterior table fracture:

Risks: CSF leak, meningitis

Treatment (Fig. 4):

CSF leak present: Neurosurgical consultation, sinus obliteration or cranialization

No leak: observation or delayed repair

Frontal outflow tract injury:

Requires sinus obliteration

Figure 4. Decision tree for management of frontal sinus fractures. From Chaudry O, et al. Facial Fractures: Pearls and Perspectives. Plast Reconstr Surg. 2018 May;141(5):742e- 758e.

MAXILLARY FRACTURES

Frontal, zygomatic, palatine and alveolar processes

Strength from three buttresses

Nasomaxillary

Zygomatic

Pterygomaxillary

Le Fort classification (Fig. 5):

I: transverse fracture through maxilla above apices of teeth

Mobility of hard palate and teeth only

II: pyramidal fracture involves nasal bridge, maxilla, orbital floor and infraorbital rim

III: craniofacial disjunction involves zygomatic arch, orbital walls and nasal bridge

Fracture through pterygoid plates

Entire midface is mobile

Treatment:

Alveolar fracture: arch bars and place segment in occlusion with IMF wires

Le Fort fractures: observation for minimally displaced fractures without occlusal changes; IMF with open reduction and internal fixation of nasomaxillary and zygomaxillary buttresses for displaced fractures

Figure 5. Le Fort classic description of midfacial fracture lines. Biomechanically these function as crumple zones and protect the neurocranium from frontal trauma. From Chaudry O, et al. Facial Fractures: Pearls and Perspectives. Plast Reconstr Surg . 2018 May;141(5):742e-758e.

REFERENCES

Thorne CH, Chung KC, Gosain AK, et al. Grabb and Smith’s Plastic Surgery. 8th ed. Wolters Kluwer; 2019.

Neligan PC, Chung KC. Operative Techniques in Plastic Surgery. Wolters Kluwer; 2021.

Vercler CJ, Chung KC. Michigan Manual of Plastic Surgery. 2nd ed. Wolters Kluwer; 2014.

Sharabi SE, et al. Facial fractures. Plast Reconstr Surg. 2011 Feb;127(2):25e-34e.

Chapter 11
Head and Neck

Evan B. Lynch, MD, PhD
Z-Hye Lee, MD

The head and neck region presents one of the most complex and functionally significant areas of reconstructive plastic surgery. Plastic surgeons frequently manage defects related to congenital anomalies, trauma, and oncologic resections in the head and neck area. The content of this chapter will focus on neoplasms of the head and neck, and their subsequent reconstruction. Essential functions including speech, swallowing, vision, and facial expression underpin the reconstructive efforts and a multi-disciplinary approach is critical for success. Strategies are guided by defect size and location, pathology, and regional priorities. This chapter will provide a comprehensive guide to tackle these challenging problems from the perspective of a plastic surgeon.

INFECTIONS

The head and neck are relatively resistant to infection due to their robust vascularity.

Routes of spread

Upper aerodigestive infections may track into the mediastinum

Scalp and orbital infections may spread intracranially via the dural sinuses and ophthalmic veins

Types

Facial cellulitis: mostly due to staphylococcus or streptococcus

May use a cephalosporin

Oral cavity infections: mostly due to anaerobic Streptococcus and Bacteroides

Use extended spectrum penicillin or other anaerobic coverage (Augmentin/Unasyn)

Acute sialadenitis: fever, pain, swelling over the involved parotid gland

Seen with dehydration, debilitation, diabetics, poor oral hygiene

Treat with antibiotics, fluids

Atypical mycobacteria: seen in enlarged lymph nodes

Drainage rarely required

Special cultures may be necessary

NEOPLASTIC (exclusive of skin, see Chapter 8)

Neoplastic processes are primarily managed by otolaryngologists, but provide major reconstructive challenges for plastic surgeons.

TNM staging

The AJCC 8th edition introduced major changes to the TNM, or tumor-node- metastasis staging of head and neck neoplasms, most notably with the creation of a separate algorithm for HPV-associated oropharyngeal squamous cell carcinoma.

HPV status is determined by p16 immunohistochemistry as a surrogate

HPV DNA testing is recommended for prognostic accuracy

HPV-associated diseases have a better overall prognosis than other SCCs

T: Tumor – denoted by the specific size of the major tumor mass

N: Nodes – denoted by the number of affected nodes, and considers nodal chains on both the ipsilateral and contralateral neck as modifiers

M: Metastasis – denotes the distant spread of this disease

Most common site is lungs, regardless of primary subsite or tissue type

HPV+ SCC has lower metastasis risk to non-HPV associated disease

American College of Radiology recommends comprehensive imaging (CT, MRI and FDG-PET/CT for accurate staging

Salivary gland tumors

Classification of tumors by location

Parotid: most common (80%), most are benign (80%)

Submandibular: 55% incidence of malignancy

Minor salivary glands: least common, with highest incidence of malignancy (about 75%)

Diagnosis

Primarily by physical examination

Any mass in the pre-auricular region or at the angle of the jaw is a parotid tumor until proven otherwise

Bimanual palpation: simultaneous intraoral and external palpation

Signs more commonly seen with malignancy:

Fixed or hard mass

Pain

Loss or disturbance of facial nerve function

Cervical lymphadenopathy (metastases)

Treatment

For benign tumors:

Surgical removal of gland with sparing of adjacent nerves, e.g., facial nerve with parotid; lingual and hypoglossal nerves with submandibular

For malignant tumors:

Surgical removal of entire gland with sparing of nerve branches that are clearly not involved

Radiation therapy if tumor not completely removed

Cervical lymph node dissection with tumors prone to metastasize to nodes

Pathology

Benign

Pleomorphic adenoma: (benign mixed) high recurrence rate with local excision

Papillary cystadenoma lymphomatosum (Warthin's tumor): may be bilateral, (10%) male, age 40-70

Malignant

Mucoepidermoid

Malignant mixed

Adenocarcinoma

Oral cavity tumors

Classification

Anatomical: malignancies behave differently according to anatomic site and prognosis worsens from anterior to posterior

Histopathologic

Benign: fibroma, osteoma, lipoma, cyst, etc.

Malignant

Most are squamous cell carcinoma or variants (may be related to HPV, see above)

Palate carcinomas are often of minor salivary gland origin

Sarcomas in mandible, tongue, other sites are rare

Diagnosis

Examination: including indirect laryngoscopy and nasopharyngeal endoscopy when indicated

“If tumor is the rumor, tissue is the issue” — biopsy of any lesion is essential for diagnosis

X-rays and scans as indicated

Treatment

Surgical

Benign: simple excision

Malignant

Wide local excision with tumor-free margins with/without lymph node dissection

Palliative resection may be indicated for comfort and hygiene

Immediate reconstruction with vascularized flaps when indicated by size and location of defect (see next section)

Radiation therapy

Pre-operative

To increase chance for cure, especially with large lesions

May make an inoperable lesion operable by shrinking it and reducing involvement with unresectable structures

Post-operative

If tumor-free margin is questionable

For recurrence

Prophylactic — controversial

Chemotherapy: usually for advanced disease

Immunotherapy: increasing indications to downsize tumors or as primary treatment

RECONSTRUCTION

General principles

Goals

Tension free closure of skin and soft tissue

Maintenance of motor and sensory function

Recreation of aesthetic contours

Restore speech and swallowing function

Reconstructive ladder

Primary closure (often best option if possible)

Skin graft (full thickness for best color and quality match)

Local flaps (often require two stages)

Tissue expansion

Free tissue transfer

Reconstructive elevator

More modern approach to head and neck reconstruction

Advocates for selecting the optimal technique based on defect complexity and patient needs, often bypassing intermediate steps for large, composite defects

Scalp

Anatomy:

S (skin), C (Subcutaneous tissue), A (Aponeurosis/Galea), L (Loose areolar tissue), P (Pericranium)

Goals:

Function: protection of intracranial structures from dessication, injury or infection

Aesthetic: maintaining appropriate hairline, limiting alopecia, scar patterns

Replace “like with like”

Primary closure often possible, can be assisted with galeal relaxation incisions (scoring), where an additional 3 cm can be gained

Rotation and/or advancement flap options

Should be roughly 4-to-6 times the size of the defect

O-to-Z flap

3- or 4-flap Orticochea technique

Tissue expansion is an excellent option (can allow up to 50% reconstruction without obvious alopecia)

Free tissue transfer: typically reserved for large defects, defects previously radiated or planned to undergo radiation, or failed previous reconstructions

Latissimus dorsi flap ± posterior ribs and skin graft for composite defects

ALT free flap for vascularized fascia coverage

Eyelid

Anatomy:

Eyelid is composed of 3 lamellae

Anterior lamella: skin and orbicularis oculi muscle

Middle lamella: orbital septum

Posterior lamella: tarsus and conjunctiva

Eyelid loss can be partial thickness (anterior ± septum) or full thickness (all 3 lamellae), which drives reconstructive options

Main goal: tension-free coverage of the globe to prevent exposure keratopathy and ectropion (chronic eyelid irritation)

Defect size and thickness determines reconstruction options

<30% can be closed primarily; performing lateral canthotomy and cantholysis can allow closure of defects up to 50%

>50% requires local flap rearrangements, which often requiring two or more stages

Upper eyelid

Cutler-Beard flap: staged pedicled flap from lower eyelid

Lower eyelid

Hughes flap: staged pedicled flap from upper eyelid

Tenzel semicircular flap

Mustarde cheek advancement flap

Unipedicled (Fricke) flap

Bipedicled (Tripier) lid switch flap

Skin grafting is an option for anterior lamellar defects that cannot be closed primarily

Nose

Anatomy:

Nine subunits: single dorsum, tip, columella, and paired sidewalls, soft triangles, and alar lobules (Fig. 1)

Main goal: create aesthetic piriform aperture coverage and maintain airway patency and nasal lining

Often complicated by need for cartilaginous support

Numerous local flap options:

Bilobed flap: for defects up to 1.5 cm; Y-shaped tissue pivoted to fill defect and one donor site, with the other donor closed primarily

Nasolabial flap: tissue from along the cheek-nose junction swung into defect on the nasal ala or sidewall

Forehead flap: workhorse two- or three-staged technique where tissue from the central forehead is swung down to reconstruct part or all of the nose

Free tissue transfer is often reserved for subtotal/total reconstruction, or when local tissue isn’t available or sufficient

Radial forearm flaps: thin, pliable coverage that can also be used for lining or composite defects where palatal reconstruction is also desired

Auricular helical rim flap can be used to reconstruct alar defects due to its contour and cartilage support

Figure 1. Nasal subunits

Ear

Anatomy:

The ear is made up of distinct subunits that have characteristic contour, cartilage support and skin characteristics

Optimal functional and aesthetic outcomes depend on defect size, cartilage loss and remnant structures available for reconstruction

Ear subunits include the helix, antihelix, scaphoid fossa, concha, tragus, antitragus and lobule

Main goals: primarily aesthetic reconstruction (symmetry important)

Options by size:

<15-20 mm or ¼ of auricular height: wedge excision and primary closure

>20mm but less than 40 mm (¼ to ¾ of auricular height):

Antia-Buch chondrocutaneous advancement flap: advancement of the helical rim and adjacent tissue to reconstruct marginal auricular defects in a single stage

Staged postauricular chondrocutaneous advancement flaps

Total reconstruction: fabrication of an autologous cartilage construct (typically rib cartilage) or alloplastic (Medpor) implant covered local tissue

Temporoparietal fascia flap provides excellent vascularized coverage of construct

Tissue expansion of parietal scalp and postauricular tissue is an acceptable option

Free tissue transfer is rarely used in this population

Congenital microtia

Autologous rib cartilage should not be harvested before age 8-10, when sufficient rib cartilage exists for reconstruction and sufficient adult ear growth has occurred

Alloplastic reconstruction can be used with no donor site morbidity, but there are high rates of infection, reoperation and implant extrusion

One of the few facial structures where a prosthesis is a good option

Lip

Anatomy:

Anatomic subunits of the lip include the cutaneous (white) lip, the vermillion (red) lip, the vermillion border, oral mucosa and commissures

Critical associations include the philtral columns, cupid’s bow and the continuity of the orbicularis oris muscle, and the modiolus

Main goal: recreate oral competence and speech with a sensate aesthetic construct

Perfect alignment of incisions key, or otherwise can be very noticeable

Defects are characterized by location (central, lateral), depth (partial vs. full - thickness), and size (measured as a percentage of the lip)

Rule of thirds for defects

<1/3: primary closure

<2/3: local flaps

Abbé lip switch flap: two-stage, section of lip swung to fill defect in opposite lip

Estlander flap: lateral end of lip swung up to end of opposite lip

>2/3:

Karapandzic flap: circumoral incision to mobilize lip and cheek, may narrow oral opening (microstomia) (Fig. 2)

Complex defects may require total lip reconstruction, where the radial forearm, ALT and gracilis are workhorse free flaps

Figure 2. Karapandzic flap illustrating circumoral incision to mobilize lip and cheek

Cheek

Oncologic resection of skin cancers, oropharyngeal cancers or parotid tumors can leave defects on the face and cheek

Anatomy: skin, subcutaneous tissue, mimetic facial muscles, buccal fat pad, and oral cavity

Options for reconstruction:

Primary closure

Indications: small cheek defects where there is sufficient surrounding tissue laxity to allow tension-free closure without distortion of adjacent anatomic landmarks such as the eyelid, oral commissure, or alar base

Local rotational or advancement flaps

Indications: moderate-sized defects that cannot be closed primarily without causing distortion, but where local tissue is available and a good color and texture match is desired

Nasolabial flap:

Indications: small to moderate defects of the medial cheek, perinasal, and perioral regions; especially useful for defects near the nasolabial fold, alar base, and upper lip

Flap design: along the nasolabial fold, with the superior border at the alar base and the inferior border at the oral commissure; typically raised in the subcutaneous plane, preserving the underlying facial artery when possible

Cervicofacial flap (Fig. 3):

Indications: large cheek defects, especially those involving the lower and lateral cheek, infraorbital, and preauricular regions; preferred when a large area of skin and subcutaneous tissue is required, and when a good color and texture match is critical

Flap design: superior border of the flap raised at the zygomatic arch, lateral border at the preauricular crease, and inferior border extending into the cervical region; can be raised in either the subcutaneous plane or the deep plane (superficial musculoaponeurotic system, SMAS), with both approaches showing low complication rates

Figure 3. Cervicofacial flap

Submental island flap:

Indications: moderate to large defects of the lower and midface, particularly in the lower cheek, submandibular, and perioral regions; especially useful when free tissue transfer is not feasible or when a hairbearing flap is desired in male patients

Flap design: based on the submental artery and vein, with the skin paddle designed in the submental region, typically between the mandibular border and the hyoid bone; dissection is performed in the subplatysmal plane, taking care to preserve the vascular pedicle

Free tissue transfer

Indicated for large defects with a paucity of local tissue for coverage

Workhorse flaps include fasciocutaneous flaps, including the radial forearm free flap (RFFF), medial sural artery perforator (MSAP) flap, and the anterolateral thigh flap (ALT)

Can obtain composite flaps (osteocutaneous, or neurotized ALT/RFFF) depending on defects after resection

Mandible

Main goal: restore speech and mastication

Most common pathologies:

Squamous cell carcinoma (SCC)

Histology: invasive nests/cords of atypical squamous cells, keratin pearls, intercellular bridges

Imaging: ill-defined lytic lesion, cortical destruction, soft tissue mass

Physical: ulcerated mucosal lesion, induration, possible trismus

Treatment: marginal resection if no medullary invasion; segmental mandibulectomy if medullary or extensive cortical invasion; the American Head & Neck Society recommends segmental resection for medullary invasion

Success: 5-year survival ~60% for both marginal and segmental resection; segmental resection may improve local control in medullary invasion

Ameloblastoma

Histology: islands of odontogenic epithelium with peripheral palisading and reverse polarization; follicular and plexiform patterns

Imaging: multilocular “soap-bubble” or “honeycomb” radiolucency, often in posterior mandible

Physical: painless jaw swelling, facial asymmetry

Treatment: segmental resection is standard for solid/multicystic types; marsupialization plus curettage for unicystic types

Success: ~4.5% recurrence for marsupialization plus curettage for cystic types; <5% recurrence for segmental resection with free flap reconstruction

Odontogenic keratocyst (keratocystic odontogenic tumor)

Histology: parakeratinized stratified squamous epithelium, palisaded basal layer, corrugated surface

Imaging: well-defined unilocular or multilocular radiolucency, often in posterior body/ramus

Physical: asymptomatic swelling, sometimes incidental

Treatment: enucleation with peripheral ostectomy or marsupialization for large lesions

Success: recurrence rates 10-30% with enucleation, lower with adjunctive therapy

Ossifying fibroma

Histology: well-circumscribed fibro-osseous lesion with fibrous stroma and mineralized material (bone/cementum)

Imaging: well-demarcated, mixed radiolucent-radiopaque lesion, often in premolar-molar region

Physical: slow-growing, painless swelling

Treatment: enucleation or curettage for small lesions; resection for large/recurrent lesions

Success: recurrence is rare after complete excision

Gold standard is bony reconstruction, but soft tissue reconstruction may be indicated for posterior defects

Non-vascularized bone grafts: only for small lateral defects (<6 cm) and if no radiation is planned, per the American Head & Neck Society

Vascularized bone graft (free flap)

Fibula osteocutaneous flap: workhorse, can be shaped into an entire mandible and can also provide skin and soft tissue for floor of mouth or tongue reconstruction

Can also use scapular flap, iliac crest flap

Vascularized soft tissue-only free flap

Mandibular defects posterior to angle involving non-tooth bearing mandible can be reconstructed with soft tissue free flap only

Titanium reconstruction plates are an option for patients who cannot tolerate a free flap operation but extrusion through the tissue is a common problem

Maxillary reconstruction

Main goal is to restore three-dimensional anatomy of the midface

Separate the oral and nasal cavities

Provide bony support for midface structures

Enable functional outcomes such as intelligible speech, effective swallowing, mastication, with acceptable facial aesthetics

Classified by the Brown classification system for maxillary defects (Fig. 4)

Stratifies defects vertically and horizontally

Vertical

Class I: Limited maxillectomy not involving oroantral fistula

Class II: Maxillectomy with oroantral or oronasal fistula, orbit spared

Class III: Maxillectomy with orbital involvement, globe spared

Class IV: Maxillectomy with orbital exenteration

Horizontal

Class 1: Defect in central palate

Class a: Defect in hemipalate (one side only)

Class b: Defect extends to contralateral palate

Class c: Total hard palate defect

Figure 4. Brown classification for maxillary defects

Gold standard for treatment is vascularized osteocutaneous free flaps

Fibula free flap provides bony support and the opportunity for dental rehabilitation, specifically in cases where the alveolus and dental arch require reconstruction

Preferred for Brown class II through IV defects

Long segment of bone (up to 25 cm)

Capacity for multiple osteotomies to recreate the facial buttresses

Accepts dental implants

Adaptations:

Two- or three-piece depending on need for midface projection

Double-barreled (stacked, biaxial) to improve bony height

Prelaminated osteomucosal flap for central maxillary defects with need for buccal mucosa

Deep circumflex iliac artery osteocutaneous flap (DCIA)

Preferred for Brown class IIB/C defects

Robust bone stock (iliac crest), but limited length

Scapular free flaps

An option for patients with contraindications to fibula flaps

Preferred for Brown class II defects, and select III and IV defects

Useful for reconstructions with extensive soft tissue defects but limited bony involvement

Lowest donor site morbidity

Allows for chimeric designs – incorporating tissue based off the subscapular system (latissimus dorsi, parascapular skin) and has long pedicle

Can be more technically challenging, difficult to work with a 2-team approach in head and neck reconstruction

RFFF: option for resurfacing of palatal defects that need palatal or alveolar reconstruction and desire dental rehabilitation

Oral cavity reconstruction

Main goals: restore swallowing and speech, prevent fistula formation

Can use skin grafts for small posterior pharyngeal defects

Partial tongue resection can be closed primarily

Free flaps:

Free radial forearm utilized for thin, pliable reconstruction (i.e., partial tongue, buccal mucosa, pharyngeal defects)

Anterolateral thigh (ALT) provides more significant bulk (i.e., for subtotal/total glossectomies)

Hypopharyngeal/esophageal reconstruction

Main goals: Restore alimentary continuity, facilitate speech rehabilitation (usually through tracheoesophageal puncture)

Free tissue transfer remains the gold standard for reconstruction

Tubed ALT flap

Provides excellent speech and swallow rates, with low rates of stricture formation

Minimal donor site complications and low fistula formation rates

Free jejunal flap

Provides excellent swallow rates and the lowest rates of stricture formation

Higher rates of fistula formation, and the poorest speech outcomes

RFFF

Less commonly used due to higher fistula and stricture rates, and worse speech and swallow outcomes

Most ideal for high BMI patients in whom ALT flap is too thick

MISCELLANEOUS

Orthognathic surgery

Deformities of the mandible

Classification:

Retrognathia: mandibular retrusion with respect to maxilla

Prognathia: mandibular protrusion with respect to maxilla

Micrognathia: underdeveloped, retruded mandible

Open bite: teeth cannot be brought into opposition

Crossbite: lower teeth lateral to upper teeth

Micro- and microgenia: under or overdevelopment of chin

Teeth numbers

Pediatric teeth are lettered A through T (A-J for maxilla; K-T for mandible)

Adult teeth are numbered 1-32 (1-16 for maxilla; 17-32 for mandible)

1, 16, 17, 32 are considered “thirds,” which are your third molars, or “wisdom teeth”

Dental position and surfaces of the teeth

Mesial: moving toward the midline

Distal: moving away from the midline

Lingual: surface facing toward the tongue

Facial (labial or buccal): surface facing the cheek or lips

Incisal: biting surface of anterior tooth

Occlusal: biting surface of posterior tooth

Overjet: position of maxillary teeth relative to the mandibular teeth in sagittal plane; can be positive or negative

Overbite: position of maxillary teeth relative to mandibular teeth in the coronal plane

Angle class of occlusion

Class I: normal occlusion; mesiobuccal cusp of maxillary first molar fits into the buccal groove of the mandibular first molar

Class II: retrognathia; mesiobuccal cusp of maxillary first molar is mesial to the buccal groove of the mandibular first molar

Class III: prognathia or pseudoprognathia (cleft pathology, maxillary deficiency); mesiobuccal cusp of maxillary first molar is distal to the buccal groove of the mandibular first molar

Treatment

Establishment of normal or near normal occlusion of primary importance

Use of osteotomies with repositioning of bone segments, bone grafts as needed, with or without orthodontic corrective measures as needed

Mandibular distraction for severe discrepancies often seen in Pierre Robin Sequence (microretrognathia, glossoptosis, and upper airway obstruction)

Deformities of the maxilla

Most commonly, retrusions or underdevelopment, “dish-face”

Must also examine the vertical height of the midface (vertical maxillary excess, VME versus vertical maxillary deficiency, VMD)

Temporomandibular joint disorder

Etiology: previous trauma, arthritis, bone overgrowth, bruxism, tumors

Symptoms: pain, crepitus, joint noises, limited opening, occlusion change

Diagnosis

Consider patient history

Examination: auscultation, opening, occlusion

Imaging: tomograms, arthrogram/arthroscopy is gold standard, MRI

Treatment

Conservative: joint rest, analgesics, bite plate, etc.

Surgery: seldom indicated

Virtual Surgical Planning (VSP)

Standard adjunct to head and neck reconstruction and has growing applications in trauma

Leverages high resolution CT imaging to create a 3D model of the patient’s anatomy prior to surgery, allowing for pre-operative simulation of osteotomies, pre-bending of plates and planned hardware placement (Fig. 5)

Figure 5. VSP with resection noted in red, with two-piece fibula free flap reconstruction (yellow, green) and custom plate

Advantages:

Improved operative efficiency by reducing operative times

Improved precision, improving aesthetic and functional outcomes

Immediate dental restoration in certain reconstructions

Limitations:

High upfront cost and potential delays due to manufacturing; this has delayed its widespread adoption in the trauma setting

Limited flexibility intraoperatively if complications encountered

REFERENCES

Cordeiro PG, Santamaria E. A classification system and algorithm for reconstruction of maxillectomy and midface defects. Plast Reconstr Surg. 2000;105(7): 2331-2346.

Brown JS, Rogers SN. Classification of maxillectomy defects. Head Neck. 2002;24(5):L 423-431.

Hanasono MM, et al. Reconstructive plastic surgery of the head and neck: Current techniques and flap atlas. Thieme Medical Publishers, 2016.

Wei FC, Mardini S. Flaps and Reconstructive Surgery. 1st ed. Elsevier Saunders, 2009.

Hidalgo DA. Fibula free flap: A new method of mandible reconstruction. Plast Reconstr Surg. 1989; 84(1): 71-79.

Larrabee WF, Sherris DA, Teixeira J. Principles of facial reconstruction: A subunit approach to cutaneous repair. 3rd ed. Thieme Medical Publishers, 2021.

Wong CH, Wei FC. Microsurgical free flap in head and neck reconstruction. Head Neck. 2010; 32(9): 1236-1245.

Genden EM. Head and neck cancer: Management and reconstruction. Thieme Medical Publishers, 2019.

Chapter 12
Pediatric Plastic Surgery

Kelly Spiller, MD
Yifan Guo, MD

The field of pediatric plastic surgery encompasses unique conditions, treatment principles, and complication profiles. The most common pediatric plastic surgery problems include congenital craniofacial anomalies, acquired craniofacial problems (such as facial fractures), brachial plexus injuries, hand anomalies, congenital nevi, and vascular malformations. Cleft lip and palate are discussed in a separate chapter.

CONGENITAL CRANIOFACIAL ANOMALIES

Craniofacial embryology and development

Facial embryology:

Facial development occurs between 3-8 weeks of gestation

Face originates from 5 prominences that appear during 4th week (Fig. 1)

Central frontonasal prominence, arising from mesenchyme ventral to forebrain

Paired maxillary prominences

Paired mandibular prominences

Paired maxillary and mandibular prominences both arise from neural crest cells migrating from 1st branchial arch

These prominences surround the primitive mouth (stomodeum)

Prominences give rise to:

Frontonasal prominence, which divides into:

Medial nasal process: nasal tip, columella, philtrum and premaxilla

Lateral nasal process: nasal alae

Maxillary prominences: upper jaw, upper lip (lateral to philtrum), orbital floor, inferior portion of lateral nasal wall

Mandibular prominence: lower jaw

Between 5-6 weeks nasal processes enlarge, migrate and coalesce in the midline to unite with maxillary processes and form upper lip

Figure 1. Craniofacial embryology. The five facial prominences. From Losee, JE, Kirschner, RE, Whitaker, LA, Bartlett, SP. Congenital nasal anomalies: a classification scheme. Plast Reconstr Surg 2004;113:676-689.

Cranial development:

Cranium divided into:

Neurocranium: structures that surround the brain

Viscerocranium: structures that surround oral cavity, pharynx, upper respiratory system and face

Ossification

Cranial base (occipital, sphenoid and temporal bones): endochondral ossification

Cranial vault: intramembranous ossification

Cranial growth responds to increased brain volume

Brain size triples by 1 year

Brain size quadruples by 2 years

Cranial vault is 90% of adult size by age 5

Brain has reached 95% of adult size by age 8-10

Normal cranial growth occurs through

Suture growth: perpendicular to suture

Appositional growth: bone resorption of the inner surface and bone deposition on the outer surface

Craniosynostosis (CS)

Definition: premature fusion of one or more cranial vault sutures

Calvarium grows parallel to fused suture

Incidence: 1:2,500 live births

Normal suture and fontanelle closure

Suture fusion:

Metopic: 6-8 months

Sagittal: 22 years

Coronal: 24 years

Lambdoid: 26 years

Squamosal: 35 years

Fontanelle closure:

Posterior: 3-6 months

Anterior: 9-12 months

Characteristic head shape according to suture affected (Fig. 2)

Sagittal: scaphocephaly (Greek, scapho, meaning boat-shaped) or dolichocephaly

Metopic: trigonocephaly (Greek, trigono, meaning triangular or keel-shaped)

Metopic ridge: can be normal variant that develops as suture is closing during first year of life, observe asymptomatic ridge in child <1 year

Coronal, bilateral: brachycephaly (Greek, brachy, meaning short in AP direction)

Coronal, unilateral: plagiocephaly (Greek, plagios, meaning oblique or slanted)

Associated with Harlequin deformity

Must distinguish from positional plagiocephaly, where suture is normal

Head deformity is similar, but there is a parallelogram configuration of the head (if seen from above) with anterior displacement of the ipsilateral ear, frontal bossing, and occipital flattening

Unicoronal craniosynostosis looks like a trapezoid from above

Categorized into non-syndromic and syndromic types

Non-syndromic CS (most common, 67-80%)

Order of frequency according to suture type:

Sagittal (40-50%)

Metopic (25%)

Coronal (5-10% bilateral; 15-20% unilateral)

Lambdoid (<3%)

Figure 2. Skull deformities related to nonsyndromic craniosynostoses. From Tahiri Y, Bartlett SP, Gilardino MS. Evidence-based medicine: Nonsyndromic craniosynostosis. Plast Reconstr Surg. 2017 Jul;140(1):177e-191e.

Longstanding debate as to whether non-syndromic patients have increased incidence of developmental delay. New evidence shows some degree of executive dysfunction in up to 50% of these children

Treatment indications:

Prevent increased intracranial pressure (ICP)

Correct the cranial deformity and normalize appearance

Treatment:

Varies depending on suture affected and severity

Usually performed within first year of life to take advantage of molding capacity of skull

Minimally invasive procedures: extended strip suturectomy/craniectomy (<4-6 months, age limit varies by institution and surgeon) ± springs ± postoperative helmet therapy

Anterior vault reshaping [fronto-orbital advancement (FOA)/reshaping], for bicoronal, unicoronal, and metopic

Total vault reshaping for sagittal

Posterior vault reshaping for sagittal – proponents of this operation believe that frontal dysmorphology normalizes over time after addressing the posterior vault

Syndromic CS:

Higher incidence of elevated ICP than non-syndromic

Major associated syndromes:

Apert: bicoronal CS, exorbitism, severe midfacial retrusion, complex syndactyly of digits of the hands/feet, developmental delay; autosomal dominant (AD) mutation in FGFR2

Crouzon: bicoronal CS, shallow orbits (proptosis, exorbitism), midfacial retrusion, conductive hearing loss, parrot-beak nose, high crowded dental arch; normal intelligence; FGFR2 mutation

Pfeiffer: bicoronal CS, exorbitism, midfacial retrusion, broad thumbs and toes, can have developmental delay; FGFR1/2 mutation

Muenke: bicoronal CS, midface hypoplasia, carpal/ tarsal fusions, hearing loss, developmental delay; AD mutation FGFR3

Characteristic head shape involves turribrachycephaly (Greek, turri, tower)

Pfeiffer associated with cloverleaf skull (Kleeblattschadel)

Fusion of coronal, lambdoid, sagittal sutures; squamosal spared

Goals of surgery:

Expand intracranial volume

Normalize head shape and appearance

Correct profound exorbitism to prevent corneal exposure/blindness

Correct malocclusion (operations targeting occlusion are done later in childhood/ adolescence)

General timeline of surgical interventions: may vary

Suturectomy for decompression of elevated ICP, if present (<3 months)

Posterior cranial vault distraction (6-12 months) – this is becoming the first line treatment in many syndromic patients, as it creates more volume per mm of advancement compared with FOA, and its use decreases the number of intracranial procedures required

Anterior/total vault reshaping/fronto-orbital advancement (FOA) (4-12 months)

Midface procedures: Le Fort III or monobloc advancement (4-12 years).

Orthognathic surgery: skeletal maturity

In general, craniofacial distraction leads to greater advancement, less relapse than conventional procedures

Autologous bone preferred in pediatric population

Diploic space is narrow but still available in infants

Can also use cortical bone scrapings

Craniofacial clefts

Lack of fusion of facial processes resulting in abnormal separation of skeletal and soft tissue structures of the face and cranium (alternative theory of lack of mesodermal penetration)

Rare, estimated 1.4-5.1 per 100,000 births

Classified by Paul Tessier, father of modern craniofacial surgery

Tessier classification system relates soft tissue to skeletal landmarks (Fig. 3)

Any combination of clefts is possible

0: midline cleft lip

0-7: lower half of face

8-14: upper half of face

Cleft lip: failure of fusion of maxillary and medial nasal processes

Tessier 2, 3, and 4: failure of fusion of frontonasal/ maxillary prominences

Proboscis lateralis: failure of fusion of lateral and maxillary nasal prominences

Facial dysostoses are associated with certain clefts:

Craniofacial/hemifacial microsomia: #7 cleft (most common facial cleft)

Treacher Collins: clefts # 6, 7, 8

CHARGE syndrome:

Deletion of CHD7

Coloboma, heart defects, atresia of nasal choanae, retardation of growth, GI issues, ear deafness

Orofacial clefts

Figure 3. Tessier classification of orofacial clefts. (A) soft tissue clefts and (B) bony clefts.

Facial dysostoses

Treacher Collins syndrome (mandibulofacial dysostosis):

Rare, autosomal dominant, variable penetrance disorder

Associated with TCOF1 mutations on chromosome 5q

1st branchial arch, groove and pouch affected

Defined by the bilateral presence of three Tessier Clefts #6, 7, 8, which result in all the phenotypic manifestations

Clinical manifestations:

Hypoplasia/aplasia of the zygomatic arch

Lateral orbit deficiency

Midface retrusion

Micrognathia

Lateral canthus hypoplasia/downward slanting palpebral fissures

Hypoplasia of temporalis muscle

Coloboma and retraction of lower lid

Variable ear malformations (microtia/anotia) and deafness

Mandibular hypoplasia with microretrognathia

Airway compromise due to narrow pharyngeal diameter

May require tracheostomy and/or mandibular distraction

Parrot-beak nose ± choanal atresia

Normal intelligence

Treatment:

Maxillary or mandibular hypoplasia: airway management including mandibular distraction, counterclockwise craniofacial distraction

Absent mandibular condyles: autologous bone grafts (calvaria, rib, iliac crest) and autologous fat/tissue transfer

Craniofacial microsomia (hemifacial microsomia):

Spectrum of morphogenetic abnormalities affecting the craniofacial skeleton, soft tissues and neuromuscular structures derived from the 1st and 2nd branchial arches

Proposed cause: thrombosis of stapedial artery

Second most common craniofacial malformation (following cleft lip and palate)

3:2 male:female

1:3,500-5,600 live births affected

Usually unilateral (therefore the more common name hemifacial microsomia)

Manifestations:

Hypoplasia of mandibular ramus (uni or bilateral)

± hypoplasia of the maxilla, zygoma and temporal bone

Deviated chin

Tilted occlusal plane (cant) → malocclusion

Microtia ± hearing loss

Paresis of CN V or CN VII common

Associated with Tessier #7 facial cleft

Pruzansky classification:

Small ramus with identifiable anatomy

A functioning TMJ but with abnormal shape and glenoid fossa

Glenoid fossa is in acceptable functional position

TMJ is abnormally placed

Absent ramus and non-existent glenoid fossa

Treatment:

Augment deficient areas

Skeletal: autologous bone (calvarium, rib, iliac crest)

Soft tissue: free flap and/or fat grafting

Mandibular correction depends upon severity of hypoplasia

Distraction may be necessary to achieve correction of malocclusion versus conventional orthognathic procedures to correct jaw discrepancies at skeletal maturity

Bone-anchored hearing aids

Goldenhar syndrome (oculo-auriculo-vertebral spectrum):

Variant of craniofacial/hemifacial microsomia with additional manifestations

Cause: faulty neural crest cell migration, associated with intrauterine occlusion of stapedial artery

Only 5% of hemifacial microsomia cases have these features

Sporadic occurrence

Manifestations:

Prominent frontal bossing, low hairline

Low-set ears

Anterior accessory auricular appendages

Colobomas of upper eyelid

Epibulbar dermoids

Hemifacial microsomia

Vertebral spine abnormalities

Abnormalities of heart, kidneys, lungs

Pierre Robin sequence:

1:8,500-20,000 live births

Triad of:

Micrognathia

Glossoptosis (tongue retruded back into the pharynx)

Upper airway obstruction

Sequence, not a syndrome, but can co-occur with a syndrome

Intrinsic/extrinsic disturbance of mandible development (leads to micrognathia)

Arrest of rotation/descent of tongue from between palatal shelves

Lack of palatal fusion or high, U-shaped palate

Tongue remains pressed against posterior pharynx = airway obstruction and feeding issues

May or may not have cleft palate

May be isolated or associated with certain craniofacial syndromes

Stickler syndrome (hereditary arthro-ophthalmopathy): AD or AR mutations in COL2A1, COL11A1, COL11A2

Cleft palate, midface hypoplasia, retinal detachment, sensorineural hearing loss, joint abnormalities

Nager syndrome: AR mutation chromosome 9

Radial hand deformities, mandibular/ maxillary hypoplasia, high nasal bridge, long philtrum, cleft palate with VPI, class II malocclusion, short stature

Treacher Collins (see above)

Treatment:

Immediate treatment goals in the neonate are establishing a patent airway and improving feeding; four treatment modalities available

Conservative treatment: if newborn demonstrates adequate feeding and weight gain; mild airway obstruction relieved by change in positioning

Tongue-lip adhesion: temporary suturing of tongue to lower lip to address glossoptosis, higher risk of needing gastrostomy tube

Tracheostomy: immediate airway control in emergent scenario, but significant morbidity; currently used as last resort

Mandibular distraction: preferred by most centers where available for significant upper airway obstruction; addresses mandibular hypoplasia

Tongue moves anteriorly and relieves airway obstruction

Lower risk of requiring gastrostomy for feeding compared with tongue-lip adhesion.

Requirements:

Continuous pulse oximetry and airway monitoring

Multidisciplinary evaluation by genetics, ophthalmology, PRS, feeding specialist

Laryngoscopy/bronchoscopy: other airway anomalies are relative contraindication to distraction

Polysomnogram (sleep apnea)

Van der Woude:

AD mutation IRF6

Cleft lip and palate, lower lip pits, facial clefting, syndactyly

Most common cause of inherited cleft palate

Popliteal pterygium:

AD mutation IRF6

Cleft lip and palate, popliteal webbing, toe webs, lip pits, webbing of mouth and eyelids

DiGeorge (velocardiofacial syndrome):

AD, 22q11 deletion

Diagnosis: FISH

Hypocalcemia, coloboma, heart defects (aberrant medialized carotid arteries), choanal atresia, growth retardation, GU anomalies, ear anomalies, deafness

Consult immunology, cardiology

Moebius syndrome:

Defect in 1st and 2nd branchial arches

Bilateral congenital abducens and facial nerve palsy, club feet/ syndactyly, rudimentary fingers + toes, cardiac defects, clefts, microgenia

Parry-Romberg (coup de sabre, linear scleroderma):

Slow progressive hemifacial atrophy following ipsilateral branches of trigeminal (V) nerve

Starts age 5-15 years, lasts 2-10 years

Involves skin, eyes, soft, tissue, muscle, and bone in trigeminal nerve distribution; does not affect sensation

Associated with epilepsy, presents with cutaneous vertical furrow

Treatment:

Mild-moderate: fat transfer

Moderate-severe: free flap surgery once disease process is stable

Methotrexate, steroids

Ophthalmology consult for eye involvement

Beckwith-Wiedemann:

Mutation on chromosome 11

Macrosomia, macroglossia, omphalocele, ear folds

Other embryologic defects:

Branchial cyst, sinus, or fistula

Epithelial-lined tract frequently in the lateral neck presenting along the anterior border of the sternocleidomastoid muscle.

May present as a cyst or as a sinus connected with either the skin or oropharynx, or as a fistula between both skin and oropharynx openings

Treatment: excision

Thyroglossal duct cyst or sinus:

Cyst in the mid-anterior neck over or just below the hyoid bone, with or without a sinus tract to the base of the tongue (foramen cecum); moves with swallowing

Treatment: Sistrunk procedure (removal of cyst, sinus tract, and portion of hyoid)

Ear deformities

Embryology: 4-10 weeks gestation

6 mesenchymal hillocks form from 1st pharyngeal cleft + 1st-2nd pharyngeal arch

Hillocks 1-3: tragus, root of helix, and superior helix

Hillocks 4-6: posterior helix, antihelix, antitragus, lobule

Antihelix: 2nd branchial arch

Meckel’s cartilage: 1st branchial arch

Middle ear: 1st pharyngeal pouch

Congenital:

Anotia: complete absence; very rare

Microtia: vestigial remnants or absence of part of ear

May present with other mandibular deformities, such as hemifacial microsomia, Goldenhar or Treacher Collins

Treatment:

Nagata (2-stage) vs. Brent (4-stage) techniques (several modifications exist): construction of sculpted ear framework from autologous rib cartilage graft that is buried under scalp skin

Usually requires 2-4 operations starting at age 6-8, when rib cartilage is big enough

Nagata method usually requires child to be age 10 or older

Synthetic implant (Medpor) covered by vascularized temporoparietal fascial flap

Risk of extrusion from minor trauma, loss 2/2 infection

Bone anchored hearing aids: place behind mastoid after ear reconstructi

Prominent ears: creation of an antihelical fold and/or re-positioning/reduction of concha

Mustarde sutures: horizontal mattress sutures from scapha to concha, recreating antihelical fold

Furnas sutures: concho-mastoid sutures

Stenstrom’s technique: scoring of anterior surface of antihelical cartilage

Gibson principle: cartilage will warp away from scored surfaced

Luckett’s technique: excision of crescent-shaped portion of skin away from posterior antihelix

Stahl ear: normal ear with third crus, can be accompanied by prominence

Third crus “unfurls” the helical rim and makes ear appear pointed

Cryptotia (“pocket ear” or “hidden ear”)

Superior helical rim buried behind skin of scalp

Caused by anomaly of intrinsic transverse + oblique auricular muscles

On exam: able to recreate normal ear appearance with digital manipulation

Treatment: ear molding in infancy vs. superior incision to release cartilage, resurface posterior defect with skin graft or local flap (V-Y, Z-plasty)

Constricted ear:

Hooding of scapha, helix + flattening of antihelix, hypoplasia of superior third of auricle, Tanzer classification is useful for describing severity

Mild “lop ear” vs. severe “cup ear”

Treatment:

Infancy: ear molding (start by 2 weeks of age d/t presence of maternal estrogen making ear pliable)

Adult: redundant cartilage excision, flag flap transfer (Banner flap)

More severe constricted ear requires autologous reconstruction (treated similarly to microtia)

Darwin’s tubercle: pointed thickening at junction of upper- and middle-third of helix

Trauma:

Loss of part or all of ear: treated similarly to microtia/anotia

Can attempt microvascular reimplantation in acute setting

Auricular hematoma: requires evacuation with bolster dressing

Failure to drain → cauliflower ear

Use of a prosthetic ear may be indicated in some patients

PEDIATRIC FACIAL FRACTURES

Epidemiology: uncommon; less than 15% of all facial fractures

Frequency increases with age

Unique characteristics in children:

At birth, ratio of cranial:facial volume is 8:1; by completion of growth, it becomes 2.5:1; This changing ratio produces variation in fracture site frequency with age

Protective anatomical factors

Larger fat pads

Decreased pneumatization of sinuses

Skeletal flexibility

Compliant sutures

Fractures that entrap orbital contents (trap-door fractures) are more common secondary to greater bony elasticity

Up to 75% can have associated serious trauma (especially cervical spine, neurological, ophthalmologic and abdominal)

Causes:

Most common overall (per National Trauma Databank): motor vehicle crashes (MVC), violence, and falls

Some variation by age:

0-5 years: falls

6-11: MVC, sports

12-18 years: sports, assault

Fracture sites:

Vary with age

Most common overall are orbital and mandible

Skull fractures more common in younger children

Facial fractures more common as children grow, following midface growth (maxilla, zygomaticomaxillary complex, nasal, mandible)

General treatment principles (see Chapter 10):

Growing skeleton possesses inherent plasticity that may render operative intervention unnecessary for a given injury

Usually more conservative treatment preferred in this patient population due to fear of altering growing facial skeleton and developing dentition

BRACHIAL PLEXUS BIRTH PALSY

Anatomy:

Spinal roots: C5-T1

Trunks: upper, middle and lower

Divisions: anterior and posterior from each trunk

Cords: lateral, posterior and medial

Terminal branches: major peripheral nerves of upper extremity: musculocutaneous, axillary, radial, ulnar, median

Incidence: 1.5 per 100 full-term births

Risk factors:

Shoulder dystocia

Forceps delivery

Gestational diabetes (macrosomia)

Breech delivery

Upper-root cervical injury in 73% or Erb-Duchenne palsy

Caused by injury in Erb’s point (convergence of C5-C6 roots as they form upper trunk)

“Waiter’s tip” appearance: lack of deltoid, supraspinatus and biceps functions

Evaluation:

Passive and active ROM

Evaluate with reflexes, such as Moro

Imaging usually not helpful

Treatment:

Physical therapy to preserve ROM

Indications for surgical exploration:

Absent biceps or deltoid function by 3-6 months

Absent elbow flexion, wrist, thumb or finger extension by 9 months

Flail limb with Horner’s syndrome

Follow patients longitudinally

Partial recoveries or no recoveries may need tendon transfers or nerve grafting

90% will have spontaneous resolution within 2 months

If biceps function recovered by 6 months, near -normal function can be expected

CONGENITAL HAND ANOMALIES

Limb grows by proliferation of mesenchyme

Limb bud appears at 4 weeks, finger buds at 6 weeks, finger apoptosis 6-8 weeks, ossification at 8-12 weeks

HOX genes:

Proximal-distal limb growth: epical ectodermal ridge (AER)

Regulated by fibroblast growth factor (FGF)

Loss of AER → arrested limb development

Anterior-posterior limb growth (radial-ulnar axis): zone of polarizing activity (ZPA)

Responsible for AP axis differentiation

Involves sonic hedgehog (SHH), Hoxb8

Duplication of ZPA → mirror hand/foot

Dorsal/ventral:

Dorsal: Wnt7a induces transcription factor LMx-1b

Ventral: engrailed-1

Swanson types of embryonic failure:

Failure of formation

Failure of differentiation (separation)

Duplication

Overgrowth

Undergrowth

Generalized skeletal deformities:

Dystrophic dwarfism

Congenital trigger finger:

More common in ulnar digits

Associated with malformations of superficial and deep flexors

Treatment: A1 pulley release, tenoplasty of chiasm with partial A2 pulley release

Congenital trigger thumb:

Flexion of IP joint of thumb, sporadic locking

Treatment:

Observe at 1 year

Treat after 3 years

Associated with Notta’s node (enlargement of flexor tendon proximal to A1 pulley)

Do not excise this

Salter-Harris fractures: pediatric fractures across growth plate

SALTER

Straight across growth plate

Above (most common)

Below

Through everything

“Erasing” of growth plate or crush

VASCULAR ANOMALIES

Tumors: endothelial cell proliferation, malignant or benign (e.g., hemangiomas)

Infantile hemangioma: most common benign tumor of infancy; incidence 4-10% by 1 year

3:1 female > male; 60% in head and neck, 25% in trunk

Appears in first weeks of life as a telangiectasia or clustered pinhead red lesions

Associated with GLUT1 mutations

Phases:

Proliferative: rapid evolution until 0-12 months, 80% of tumor size by 5 months

Involuting phase: lasts 1 to 10 years; tumor shrinks, color fades, lesion flattens

Involuted phase: involution complete at age >10 years, but can occur earlier; half of cases will have residual atrophy and contour deformity

Treatment:

Conservative: total involution occurs in 50% by 5 years, 70% by 7, and 90% by 9

Propranolol: induction of apoptosis and fat development, serves to limit proliferative phase; side effect of hypoglycemia

Intralesional steroids: in growth phase, they can arrest growth but will not regress; oral steroids are option when lesion too large

Laser: pulsed light and Nd:YAG lasers, mainly for ulcerated hemangiomas and for residual color

Surgery: typically delayed until school age otherwise to give time for involution

Urgent if hemangioma threatens important structures or function (i.e., visual, nasolaryngeal or auditory obstruction)

Complications:

Bleeding

Ulceration (often painful)

Infection

Kasabach-Merrit: profound thrombocytopenia with kaposiform hemangioendothelioma

High output heart failure if large visceral hemangiomas

Emotional distress

Congenital hemangioma:

Present at birth

Two forms:

Rapidly involuting congenital hemangioma (RICH): disappears by first year

Non-involuting congenital hemangioma (NICH): does not respond to pharmacotherapy

Vascular malformations: congenital malformation of vessels (venous, capillary, lymphatic, arteriovenous)

Structural and morphologic anomalies resulting from faulty embryologic development

Present at birth, grow proportionately, and do not regress, unlike hemangiomas

Capillary malformations or port-wine stains:

0.3% newborns; 3:1 female > male

Face in 80%, usually affect distribution of V1-V2

Treatment: photocoagulation with laser ± imiquimod (anti-angiogenesis)

Associated with:

Sturge-Weber syndrome: may be associated with ocular and CNS anomalies

Klippel-Trenauney: in extremity, overlying deeper venous malformation and skeletal hypertrophy

Parkes-Weber syndrome: similar to previous, but with associated AV fistula

Venous malformations: bluish/purple lesions with spongy texture that swell with dependency and deflate with elevation

Incidence 1-4%

Treatment: sclerotherapy, compression garments for symptoms, Nd:YAG or argon lasers, surgical resection (if morbidity of resection is reasonably low)

Lymphatic malformations (previously called cystic hygroma); macrocystic or microcystic

Soft and compressible, can cause bony overgrowth

Combined venous-lymphatic are common

Frequently infected; aggressive antibiotics crucial

Treatment: sclerosing agents, laser ablation, surgery, compression; antibiotics for infectious episodes

Arteriovenous malformations: pulsatile high-flow lesions

Anatomy and hemodynamics defined by angiography

Varying clinical states

Quiescent: appearing as only a pink stain

Expansive: with thrill and dilated venous network

Destructive: with cutaneous ulcers, necrosis, bleeding

Decompensated: causing cardiac compromise

Treatment: embolization prior to surgical resection within very short time frame; wide local excision (high recurrence), ischemic suture techniques

Complications:

Consumptive coagulopathy

Heart failure

Local destruction of anatomy

Bleeding

REFERENCES

Beckett JS, et al. Altered brain connectivity in sagittal craniosynostosis. J Neurosurg Pediatr. 2014 Jun;13(6):690-8.

Buchanan EP, Xue AS, Hollier LH, Jr. Craniofacial syndromes. Plast Reconstr Surg. 2014;134:128e-153e.

Losee JE, et al. Congenital nasal anomalies: a classification scheme. Plast Reconstr Surg. 2004;113:676-689.

Janis JE. Essentials of Plastic Surgery. 2nd ed. Boca Raton, FL: Taylor and Francis, 2014.

Weinzweig J. Plastic Surgery Secrets. 2nd ed. Philadelphia, PA. Mosby, 2010.

Losee JE. Pediatric Plastic Surgery. In: Neligan PC, Plastic Surgery. 3rd ed. New York, NY: Elsevier Saunders, 2013.

Grunwaldt L, et al. Pediatric facial fractures: demographics, injury patterns, and associated injuries in 772 consecutive patients. Plast Reconstr Surg. 2011;128:1263-1271.

Chapter 13
Cleft Lip and Palate

Evan B. Lynch MD, PhD
Rajendra Sawh-Martinez, MHS, MD

Cleft lip and palate deformities are common congenital craniofacial defects with significant implications for function, appearance, and psychosocial well-being. These anomalies arise from disruptions in embryologic fusion of facial processes, leading to a spectrum of defects involving the lip, alveolus, and palate, that may occur in isolation in combination. Cleft lip (CL) and/or cleft palate (CP, CL/P) requires a lifelong, staged, multidisciplinary approach — from surgical repair and speech therapy to psychosocial support and dental/orthodontic rehabilitation. Modern cleft care remains a global health priority, with over 75% of cases occurring in low- and middle-income countries.

EMBRYOLOGY

Upper face is assembled through the coordinated fusion of five key prominences (Fig. 1) between 6 and 8 weeks of gestation; fusion is essential for the development of a normal anatomic lip and palate (Fig. 2)

Unpaired, midline frontonasal prominence: forehead, nasal midline and septum, as well as primary palate and midline lip (philtrum)

Paired lateral nasal prominences: nasal alae

Paired maxillary prominences: maxilla and zygoma, alveolus, secondary palate and lateral portion of upper lip

Failure of fusion leads to a wide spectrum of orofacial clefting

Bilateral failure of maxillary and frontonasal prominence fusion leads to a protrusive primary palate often referred to as the “premaxilla”

Unilateral failure leads to a spectrum of clefts ranging from mini-microform cleft (notching) to complete cleft lip and palatal defects

Anterior fusion failure leads to cleft lip

Failure of the lateral nasal prominence and the maxillary prominences lead to oblique facial clefts

Failure of fusion between the mandibular and maxillary prominences leads to transverse facial clefts, as commonly seen in Treacher Collins Syndrome

Figure 1. Facial prominences (A, coronal; B, axial). The frontonasal prominence (blue) gives rise to the forehead, midline of nose, septum, philtrum, middle portion of upper lip and primary palate. The lateral nasal prominences (green) form the nasal alae. The maxillary prominence (red) contains the palatal shelves which fuse with the frontonasal prominence in the midline. Failure of this fusion leads to orofacial clefting. Reprinted with permission, Comprehensive Cleft Care, 2nd Ed. Losee and Kirschner, ed.

Figure 2. Basic anatomy of the lip and palate

DIAGNOSIS

Second-trimester ultrasound (anatomy scan) can reliably detect cleft lip using coronal and axial facial views; detection with three-dimensional ultrasound, and when indicated, fetal MRI shows high rates of success and can identify associated abnormalities

Isolated cleft palate is challenging to diagnose prenatally

Initial priorities after postnatal diagnosis include:

Prompt referral to multidisciplinary team (see below)

Airway and feeding assessment to ascertain the need for intervention by otolaryngologists and speech language pathologists while inpatient

Early referral associated with improved outcomes and timely surgical intervention

EPIDEMIOLOGY

Terminology

Orofacial clefting typically considers cleft lip with or without palate (CL, CL/P) and cleft palate (CP) as similar entities, but these are distinct pathologies

Prevalence

Globally

CL/P: 1.0 to 1.7 per 1,000 births

CP: 0.3 to 0.8 per 1,000 birthers

By ethnicity

Native American ~ Asian > Hispanic > Caucasian > Black

By sex

CL/P more common in males (2:1 ratio)

CP more common in females (2:1 ratio)

By family history (Table 1)

Strongest risk factor for both CL/P and CP

Environmental risks

Lack of maternal folic acid supplementation

Advanced maternal age (>35 years)

Maternal smoking

Anticonvulsant or retinoic acid exposure (highest risk)

High maternal fever during early pregnancy (>39°C)

Consanguinity

Table 1. CL/P or CP risk stratified by family history

High maternal fever during early pregnancy (>39°C)

Consanguinity

Syndromic associations

CL/P: trisomy 21, Pierre Robin Sequence, Van der Woude (lower lip pits with IRF6 genetic association)

CP: DiGeorge Syndrome (most common) or Stickler syndrome

CLASSIFICATION

Cleft lip

CL divided into unilateral/bilateral and incomplete/complete (Fig. 3)

Figure 3. Cleft lip classification

Anatomic associations with unilateral cleft lip

Competence of the orbicularis oris muscle is disrupted by the cleft; normally these fibers will dessicate at the midline and insert into the dermis of opposing philtral columns

Caudal (anterior) nasal septum deviates away from cleft side

Cranial (posterior) nasal septum deviates toward the cleft side

Nasal ala

Cleft nasal ala (lower lateral cartilage, LLC) is collapsed, retruded and inferiorly displaced

Non-cleft nasal ala is laterally and superiorly displaced

Orbicularis oris on cleft side inserts on the alar base or piriform rim, contributing to vertical deficiency of the lateral lip element

Lateral lip element (cleft side) is shortened and vertically deficient

Medial lip element (non cleft side) is often hypoplastic

Columella is shortened on and deviates away from the cleft side

Functional deficits

Cleft lip

Cannot form fluid/air seal in eating/speech

Malocclusion of teeth

Cleft palate

Cannot separate nose from mouth so air escapes during speech (velopharyngeal insufficiency)

Cannot suck on breast/bottle well due to poor seal for intraoral negative pressure

Middle ear disease/infections, often chronic

Cleft palate

Veau classification (Fig. 4)

Type 1: clefts of the soft palate posterior to the hard palate

Type 2: complete cleft of the secondary palate up to the incisive foramen

Type 3: complete unilateral cleft lip, alveolus and palate

Type 4: bilateral complete cleft lip, alveolus and palate

LAHSHAL classification (Fig. 5)

Derivation of the Kernahan and Stark “Striped Y” classification which assigns a letter (L for Lip, A for alveolus, H for hard palate and S for soft palate) to each part of the orofacial \ anatomy to delineate location of cleft

Figure 4. Veau Classification. A) Type 1; B) Type 2; C) Type 3; and D) Type 4. Reprinted with permission, Comprehensive Cleft Care, 2nd Ed. Losee and Kirschner, ed.

Figure 5. LAHSHAL Classification. Each element (Lip, Alveolus, Hard Palate and Soft Palate) is given a letter to denote area of clefting. Reprinted with permission, Comprehensive Cleft Care, 2nd Ed. Losee and Kirschner, ed.

Submucous cleft

Submucous cleft palate is a distinct entity with an abnormal attachment of the palatal muscles with an intact oral and nasal mucosa

Cardinal signs

Bifid uvula

V-shaped notch at hard palate

“Zona pellucida” or translucent area in the midline of the soft palate

MANAGEMENT

Multidisciplinary Care

American Cleft Palate-Craniofacial Association (ACPA) has updated guidelines to emphasize standardized, interdisciplinary and longitudinal care

ACPA-approved teams must include core specialists who meet patients annually to review care

Plastic surgeon: provides primary surgical repair, revisions and care planning

Otolaryngologist (ENT): ear tube placement and hearing plan

Audiologist: hearing assessment

Speech-language pathologist (SLP): early feeding counseling, speech development patterns, velopharyngeal function

Pediatric dentist: early dentition assessment, regular cleaning as patients have high risk of carious disease

Orthodontist: arch/palatal expansion, assessment and preparation for alveolar bone grafting

Geneticist or genetic counselor: assess syndromic/recurrence risk for family

Psychologist or social worker: coping, family support, school support

Nurse/team coordinator: central point of communication

Presurgical orthopedics and early management strategies for wide clefts

Goals:

Reduce the alveolar gap between cleft

Improve nasolabial symmetry, alar base collapse and lip malposition

Facilitate more successful surgical repair

Techniques:

Lip taping: easy to perform, cheap, less time-intensive way to narrow arch dimensions

Can be initiated in the first week of life and has been shown to improve pre-operative lip symmetry

Can be done with commercial products (DynaCleft tape) or Steri-Strips

Nasoalveolar molding (NAM): passive molding device that has been shown to narrow arch width, improve nasal form and create a more favorable configuration for surgical repair

Can be costly and require frequent dental visits for revision of the device over the first several weeks of life

Lip adhesion surgery: first stage surgery indicated in children with wide unilateral or bilateral clefts, where presurgical orthopedics were unsuccessful

Similarly, in patients with severe tissue deficiency, this will reduce tension until the time of definitive cheiloplasty and palatal repair

Longitudinal cleft care: key interventions

0-2 weeks: initial team referral, feeding support, genetic evaluation

1-3 months: presurgical orthopedics, CL planning and repair

3-6 months: lip adhesion or CL repair

6-12 months: CP repair, SL/P assessment begins

2-5 years: speech therapy, nasal/lip revisions as needed

6-9 years: orthodontic care, alveolar bone grafting timed with canine eruption

10-14 years: orthodontic care, psychosocial monitoring, VPI surgery if indicated

14-18 years: orthognathic surgery planning, definitive cleft rhinoplasty

Surgical intervention

Simultaneous nasal correction (primary cleft rhinoplasty) at the time of lip surgery has been shown to improve nasal aesthetics, obviate the need for future nasal surgery in 44-83% of patients and increase patient-reported outcome metrics after repair

Drawbacks include increasing scar burden and thereby enhancing maxillary restriction, leading to potential need for orthognathic surgery in some patients

Unilateral cleft lip repair

Goals:

Establishment of normal oral competence

Removal of anatomic deformity with minimal scar burden

Correction of nasal deformity

Key anatomic landmarks for markings:

Nordhoff’s point: intended Cupid’s bow peak, cleft side

Position is on the lateral lip element where the vermillion height is greatest

Determine height by isolating the Cupid’s bow peak on the non-cleft side (reference height)

Use calipers to transpose to the cleft side for symmetry

Philtral height (non-cleft side) is compared to the cleft philtral height; the difference of these two lengths determines need for interposition flaps/triangles

Alar base

Columellar base

Fisher’s anatomic subunit repair: emphasizes aligning the incision along the natural borders of the lip’s aesthetic units

Markings recreate the philtral ridge/column and white roll

Repair is “hidden” within the junction of anatomic subunits

Utilizes “Fisher’s triangles” to address height discrepancy between cleft and non-cleft sides

This approach is less dependent on cleft severity for achieving symmetry

Rotation-advancement repair (Millard and its modifications): uses a curvilinear incision on the medial lip element (rotation) and an advancement flap from the lateral lip element

A flap: primary rotation flap from medial lip element rotated downward to bring the cleft-side Cupid’s bow peak into alignment with the noncleft side

B flap: primary advancement flap from the lateral lip element advanced medially to fill the defect created by the rotation of the A flap

C flap: small triangular back cut from the superior aspect of the medial lip element to provide additional length to the medial lip

M flap: small triangular mucosal flap created at the vermilion border of the lateral lip element

Primary role is to augment the central vermilion, thereby improving the fullness and continuity of the red lip and minimizing notching at the vermilion border

L flap: lateral mucosal flap, typically designed from the lateral lip element, and is used to reconstruct the nasal floor and the oral vestibule

Inset into the defect created after rotation and advancement of the main lip elements, helping to restore the continuity of the nasal sill and the mucosal lining of the upper lip

Bilateral cleft lip repair

Key anatomic landmarks for markings:

Peaks of Cupid’s bow (crista philtra right and left)

Midline of Cupid’s bow (labiale superius)

Oral commissures (cheilion)

Alar base

Vermillion-mucosal junction

Mulliken bilateral lip repair: prolabial skin and mucosa are preserved to form the philtrum and the central vermillion, while the muscle is discarded

Lateral lip elements (muscle, mucosa and vermillion) are advanced medially to reconstruct the oral sling and augment the central tubercle

Cleft palate repair

Goals:

Address the aberrant insertion of the levator veli palatini (LVP) on the hard palate to restore posterior, coronal continuity

Reduce nasal efflux of fluid with feeding, improve suck

Competent velum to allow for normal speech development

Minimize adverse effects on craniofacial growth

Early repair (before 9 months): improved speech outcomes at the cost of increased maxillary hypoplasia

Late repair (after 1 year): worse speech outcomes with reduced risk of maxillary hypoplasia

Hard palate repair

Von Langenbeck: straight line closure with lateral relaxing incisions

V-Y pushback: adds length with V-Y pushback sending flaps posteriorly

Two flap palatoplasty (Bardach): hard palate mucoperiosteal flaps based on the greater palatine artery; does not lengthen palate so must be paired with a soft palate repair to achieve length

Soft palate repair

Furlow double-opposing z-plasty: three-layer tension-free closure with opposing myonasal and myomucosal flaps that bring the sagittally positioned LVP posterior

Poor success in wide clefts

Palatal length at the expense of width

Lower rates of velopharyngel insufficiency compared to IVVP

Intravelar veloplasty (IVVP) (Sommerlad technique): meticulous dissection of the levator muscle and straight-line repositioning; leaves a large soft-tissue defect between the hard palate and the newly-posteriorly positioned soft palate

Lower rates of middle ear pathology (otitis media)

Similar speech outcomes

Less effect on maxillary growth compared to Furlow

Adjuncts to address oronasal fistula

Buccal myomucosal flap: myomucosal flap (buccinator muscle) inferior to the Stenson’s duct and rotated into the hard-soft palate junction; decreases rates of VPI with decreased risk of maxillary restriction for wide clefts (Veau III/IV)

Buccal fat pad flap: placed within lateral relaxing incisions for wide clefts (will mucosalize); isolate with a mucosal incision superior to Stenson’s and obtain fat deep to buccinator, anterior to masseter and inferior to the zygomatic arch

Alveolar cleft bone grafting (ACBG)

Autologous bone grafting (typically from iliac crest) within the cleft alveolus to restore bony continuity and provide periodontal support to teeth adjacent to and erupting into the cleft margin

Typically performed at ages 6-8 (when the canine root is 1/2 to 2/3 formed)

Early grafting is associated with improved success, as erupted canines bring bone into the graft during eruption, providing stability

Pre-operative maxillary expansion and alignment of the alveolar segments is critical to success, reducing tension and improving bony fill

Adjuncts

Recombinant Human Bone Morphogenic Protein-2 (rhBMP-2): osteoinductive protein that stimulates bone formation and can be used as an alternative or an adjunct

Major complication with rhBMP-2 is increased risk of facial swelling, which can be significant

Collagen membranes have been utilized to provide barrier function to grafts to protect the nasal layer and improve infectious complication rates

Orthognathic surgery

Risk of maxillary hypoplasia with cleft lip and palate repair is common, with conservative estimates saying 1 in 4 will require orthognathic surgery to address malocclusion

Typically, cleft patients have angle class III malocclusion, and can present with anterior crossbite, negative overjet, midface retrusion or pseudoprognathism

Comprehensive presurgical orthodontic care prior to treatment is essential for preventing relapse. If velopharyngeal insufficiency or fistulae exist in the palatal, these will worsen with orthognathic surgery

Treatment options:

Le Fort I maxillary advancement: standard treatment for class III

Distraction osteogenesis, with Le Fort I osteotomy: reserved for large advancements (typically >1 cm) or when soft-tissue tension and relapse risk is high)

REFERENCES

Fisher DM, Sommerlad BC. Cleft lip, cleft palate, and velopharyngeal insufficiency. Plast Reconstr Surg. 2011 Oct;128(4):342e-360e.

Fisher DM. Unilateral cleft lip repair: an anatomical subunit approximation technique. Plast Reconstr Surg. 2005 Jul;116(1):61-71.

Millard DR. Complete unilateral clefts of the lip. Plast Reconstr Surg. 1960; 26(5): 595-605.

Mossey PA, et al. Cleft lip and palate. Lancet. 2009 Nov 21;374(9703):1773-85.

Chapter 14
Facial Paralysis

Margaret West, BA
Yifan Guo, MD

The facial nerve innervates a total of 23 paired muscles and the orbicularis oris muscle. The majority of muscles innervated by the facial nerve act in facial expression, and, thus, are critical structures for communication. As a result, facial paralysis can pose both social and physical consequences for the patient. While numerous procedures for facial reanimation exist, it is important to acknowledge that no reconstructive technique is able to reproduce the delicate balance between all mimetic muscles.

FACIAL NERVE ANATOMY (CN VII)

Embryology:

Second branchial (pharyngeal) arch

Course:

Exits skull base from the stylomastoid foramen

Travels within the parotid gland and divides into five motor branches

Landmarks for identification:

Tympanomastoid suture: medial to the suture line

Tragal pointer: 1 cm inferior and deep

Posterior belly of the digastric muscle: found midway between muscle and styloid process

Functional components:

Motor: innervates muscles of facial expression (17 pairs + 1 unpaired orbicularis oris muscle)

Sensory:

External auditory canal

Auricular concha

Tympanic membrane (minor contribution)

Special sensory (taste): anterior 2/3rds of the tongue

Parasympathetic innervation

Lacrimal glands

Submandibular glands

Sublingual glands

Five motor branches that control facial mimetic muscles (Table 1; Fig. 1, 2)

MIMETIC MUSCLES

The mimetic muscles are responsible for facial expression and can be broadly grouped based on their functional roles in controlling facial apertures, such as the eyes and mouth. The muscles act by either constricting (sphincter-like function) or expanding (opening and elevating) facial features. This balance allows for the expressions for nonverbal communication and facial function.

Functional groupings:

Constriction of facial apertures (sphincter function):

Orbicularis oculi: closes the eyelids

Orbicularis oris: closes the lips

Buccinator: compresses the cheek against the teeth; assists with oral competence

Expansion of facial apertures (antagonists to sphincters): widen the eyes or mouth by elevating or depressing the surrounding soft tissues

Figure 1. Major branches (frontal/temporal, zygomatic, buccal, marginal mandibular, cervical) of the facial nerve. From Roostaeian J, et al. Anatomical considerations to prevent facial nerve injury. Plast Reconstr Surg 2015;1318-27.

Figure 2. Lower branches of the facial nerve lie within the deep fascia of the head and neck. Above is before removal of a layer of deep fascia, while below is after removal. Note that the deep fascia still underlies the nerves after removal. From Minelli L, et al. The Deep Fascia of the Head and Neck Revisited: Relationship with the Facial Nerve and Implications for Rhytidectomy. Plast Reconstr Surg 2024;1273-1288.

Upper lip retractors

Levator labii superioris, levator anguli oris, zygomaticus major, zygomaticus minor

Lower lip depressors

Depressor anguli oris, depressor labii inferioris

Functional groupings

Forehead and eyelid animation

Frontalis, corrugator, orbicularis oculi

Perioral movement: antagonistic groups acting on the lips

Lip retractors (see above)

Orbicularis oris (acts as a sphincter to close the lips)

Anatomic layers of mimetic muscles: the mimetic muscles are organized in distinct layers

Most superficial: depressor anguli oris, part of zygomaticus minor, orbicularis oculi

Deepest: buccinator, mentalis, levator anguli oris

Motor innervation pattern:

Most mimetic muscles receive motor innervation from the deep surface of the muscle

Exception: buccinator, mentalis, levator anguli oris (deepest layer anatomically) are innervated from their superficial surface

CAUSES OF FACIAL PARALYSIS

Facial paralysis can be classified based on anatomic location, etiology, or clinical characteristics, such as time course and severity. The following section outlines key causes, organized by etiology.

Congenital

Idiopathic

Nerve compression injury during delivery or in utero

Absence of facial motor units or nerve

Syndromic

Moebius syndrome

Bilateral CN VI and VII paralysis; characterized by inability to abduct one or both eyes, absence of facial movement (spares cervical and marginal mandibular branches)

Imperative to put children in speech therapy (speech development, facial movement, saliva control)

Hemifacial microsomia: unilateral underdevelopment of facial structures

Non-syndromic

Absence or maldevelopment of facial musculature

Osteopetrosis: can cause nerve compression

Birth trauma (especially in neonates, where the facial nerve is more superficial)

Acquired

Idiopathic

Bell’s Palsy: most common cause of unilateral facial palsy in adults; affects all portions of the facial nerve

Not addressed surgically; managed with corticosteroids and antivirals, stretching/ exercises, and Botox for hyperactive muscles

Typically resolves within 6 months

Melkersson-Rosenthal syndrome: recurrent facial paralysis, orofacial swelling, fissured tongue

Autosomal dominant, treatment is nonsurgical, definitive diagnosis by lip biopsy

Traumatic

Central: penetrating injury, iatrogenic (i.e., intracranial surgery)

Intratemporal: petrous temporal bone fracture, penetrating injury, iatrogenic (i.e., middle ear surgery)

Facial: facial lacerations, blunt or penetrating trauma, mandibular fractures, iatrogenic (i.e. parotidectomy)

Tumor

Central: brainstem tumors

Intratemporal: glomus tumors, cholesteatoma, facial nerve schwannomas, SCC, rhabdomyosarcoma, arachnoid cysts or metastases

Facial: parotid tumors, tumors of the external auditory canal or middle ear, facial nerve schwannomas, metastatic lesions

Inflammatory

Herpes zoster oticus (Ramsay Hunt Syndrome), acute otitis media, malignant otitis externa, Lyme disease (often bilateral)

Neuromuscular

Myasthenia gravis

Additional considerations:

Timing matters with traumatic injury: Wallerian degeneration begins within 72 hours; allows intraoperative nerve stimulation up until 72 hours have passed

Medial to the lateral canthus: arborization complicates repair; exception exists for temporal and marginal mandibular branches, which lack cross-innervation

Frey syndrome: “gustatory sweating” from aberrant regeneration of the auriculotemporal nerve (CN V3)

Intratemporal injury presents with facial muscle paralysis, hyperacusis, partial loss of ipsilateral taste, decreased salivation, decreased nasal/lacrimal secretion

Extratemporal injury presents with facial muscle paralysis only

HISTORY AND PHYSICAL EXAM

A comprehensive evaluation of patients with facial paralysis should include a detailed history and structured physical exam. Both rest and dynamic facial movements must be addressed.

History

Etiology

Inciting factors: trauma, surgery, hereditary conditions

Time since onset: important for determining eligibility for nerve repair

Patient-reported triggers: recent infection, delivery history, known tumors

Functional impairments (“top-down” approach)

Ophthalmic symptoms: ocular dryness, incomplete eyelid closure, visual changes

Nasal complaints: nasal airway obstruction, nasal valve collapse

Oral symptoms: drooling, difficulty speaking or eating

Psychosocial impact: depression, social withdrawal, appearance-related distress

¼ of patients have anxiety/depression (impaired smile is a predictor for anxiety/ depression)

General medical history

Comorbid conditions (i.e., diabetes, autoimmune disease)

Prior surgeries, radiation, infections

Physical exam

Forehead/ frontalis

Eyebrow elevation ability, degree of brow ptosis

Symmetry of forehead rhytids

Unilateral vs. bilateral involvement

Eyes and eyelids/ orbicularis oculi

Function

Assess eye closure: orbicularis oculi

Check Bell’s phenomenon (upward globe rotation with attempted eye closure)

Upper eyelid

Levator palpebrae superioris (CN II) and Mueller muscle (sympathetic)

Assess for dermatochalasis, lid retraction

Globe integrity

Visual acuity, dry eye signs, conjunctival injection, lagophthalmos

Lower eyelid

Ectropion, snap test (pull and release lower lid), position of inferior canalicular punctum

Ears, nasal airway, and midface

Changes in hearing (i.e., stapedius dysfunction)

Nasal asymmetry or collapse on forced inspiration

Cottle’s test for nasal valve patency (pull on cheek to see if airflow improves)

Asymmetry of nasolabial folds

Philtral deviation

Mouth and perioral region

Commissure depression or deviation

Upper lip droop

Vermillion inversion

Tooth show and smile shape

Speech quality

Intraoral exam: dental hygiene, cheek biting, food pocketing

Lower face

Asymmetric smile

Inability to keep cheeks puffed

Chin dimpling loss

Drooling/oral incompetence

Synkinesis: involuntary contraction of muscles not normally activated together due to aberrant reinnervation

Common patterns: eyelid closure with smiling, brow wrinkling with mouth movement, lip twitching with eyelid closure

Assessment: evaluate each branch of CN VII

More proximal injuries often show greater synkinesis

Treatment: physical therapy/biofeedback, Botox, selective myectomy

Other cranial nerves and vessels

Evaluate CN V, XI, XII for additional deficits and donor potential

Palpate facial and superficial temporal arteries for vessel access in free muscle transfer procedures

Clinical grading scales

Provide a semi-quantitative assessment of facial paralysis for baseline and follow-up documentation

Sunnybrook facial grading system

House-Brackmann Facial Nerve Grading System (FNGS 2.0)

The use of machine learning and digital facial grading tools is emerging and may be used as an adjunct to traditional grading scales

MANAGEMENT

Management of facial paralysis aims to restore facial symmetry and function, particularly eyelid closure, oral competence, and dynamic expression, while minimizing psychosocial distress. Treatment is highly individualized, depending on cause, duration of paralysis, and patient-specific goals (Fig. 3).

Figure 3. Approach to dynamic reconstruction in facial palsy. From Fattah A., et al. Facial Palsy and Reconstruction. Plast Reconstr Surg 2011;340e-352e.

Treatment goals and principles

Restore facial movement (dynamic procedures) or improve resting tone/symmetry (static procedures)

Prevent complications such as corneal exposure and oral incompetence

Improve quality of life, psychosocial function, and nonverbal communication

Timing is critical: viable mimetic muscles may be reinnervated with in 12-18 months after onset of paralysis

Pre-operative evaluation

History (see above)

Physical exam (see above)

Diagnostics

Clinical grading scales (see above)

Electromyography (EMG): needle insertion into muscle groups

Fibrillations indicate denervation

Does not become positive until 2-3 weeks after onset of paralysis (should be considered after 3 weeks)

Electroneurography: evaluates the nerve/muscle unit

Compound muscle action potentials (CMAPs): summation of the action potentials from muscle fibers innervated by queried nerve; compare normal side to the injured side

Non-surgical

Non-operative care may be definitive in mild or early cases or serve as adjunctive therapy in more advanced stages

Eye protection: ocular surface health should be maintained to prevent vision loss

Daytime use of artificial tears and nighttime lubricating ointments

Protective eye taping or moisture chambers during sleep, eye patches

Referral to ophthalmology for ongoing monitoring

Temporary tarsorrhaphy in refractory cases; permanent tarsorrhaphy is rare due to cosmetic concerns

Forced blinking exercises to strengthen eye closure

Botulinum toxin injections: prevent acetylcholine release across the neuromuscular junction

Reduce hypertonicity and synkinesis

Weaken the contralateral non-paralyzed side to improve dynamic balance

Injections repeated every 3-4 months and remain mainstay for treating asymmetric movement and aberrant reinnervation

Physical and speech therapy

Mirror biofeedback and EMG-assisted rehab can aid in motor retraining

The routine use of neuromuscular stimulation is controversial and not universally recommended

The routine use of neuromuscular stimulation is controversial and not universally recommended

Massage therapy, thermal application, and neuromuscular stimulation can aid recovery

Speech therapy is essential for pediatric patients or those with oromotor dysfunction

Psychosocial support: the significant burden of facial paralysis is increasingly recognized, and psychological interventions are core components of comprehensive care

Surgical

Options are broadly categorized by their functional goals (dynamic vs. static), anatomical site, and timing after onset (Fig. 4)

Figure 4. Timing of reanimation following facial nerve Injury. From Aronson, S, et al. Evidence-Based Practices in Facial Reanimation Surgery. Plast Reconstr Surg 2023;520e-533e.

Neurotization procedures: ideal for patients within 12-18 months of paralysis onset and with viable mimetic musculature

Masseteric nerve transfer (CN V to VII): offers strong motor unit input with rapid reinnervation

Hypoglossal nerve transfer (CN XII to VII): effective but may cause tongue weakness and partial tongue atrophy

Cross-facial nerve graft (CFNG): sural nerve graft connects contralateral facial nerve to the affected side

Used alone or as part of a two-staged procedure

Sural nerve from contralateral facial nerve tunneled across the upper lip and the ipsilateral side

Allow 9-12 months for nerve to grow across

Observe Tinel sign to confirm nerve growth (tapping over nerve elicits “pins and needles” in its distribution)

Can incorporate a “babysitter” procedure in which a temporary nerve donor (hypoglossal or masseteric) is connected to the paralyzed nerve while a CFNG is simultaneously placed to provide definitive reinnervation later

Free functional muscle transfer (FFMT): for long-standing paralysis where mimetic muscles are no longer viable

Two-stage technique: first, a CFNG is placed; after 9-12 months, a free muscle (usually gracilis) is transferred and coapted to the graft (Fig. 5)

Dual-innervated FFMT: coapting both the CFNG and masseteric nerve to the transferred muscle

Single-stage technique: use ipsilateral masseteric nerve as donor for gracilis muscle

Can reduce recovery time and financial burden on patient

Figure 5. Two-stage approach to CFNG and free functional gracilis muscle transfer, showing the first stage (above, left), coaptation of nerve cable autograft from sural donor (above, right), second stage (below, left) showing CFNG traveling across the midline, and free functional muscle transfer from gracilis performed at subsequent surgery (below, right). From Aronson, S, et al. Evidence-Based Practices in Facial Reanimation Surgery. Plast Reconstr Surg 2023;520e-533e.

Gracilis is favored for its consistent anatomy, adequate excursion, and reliable neurovascular pedicle (other options: pectoralis minor, latissimus dorsi)

Innervated by the anterior branch of the obturator nerve

Blood supply from the medial circumflex femoral artery

Set tension based on resting tension at the donor site

Contiguous regional muscle transfers: for long-standing facial paralysis when native mimetic muscles are no longer viable and a simpler alternative to free muscle transfer is preferred; useful for adults or as salvage options and have the advantage of shorter recovery

Temporalis transfer (McLaughlin or Rubin techniques): temporalis muscle is re-routed to the oral commissure for smile restoration

Blood supply: deep temporal artery

Innervation: deep temporal nerves (CN V3)

Masseteric muscle transfer: less common but can be used in specific reconstructions

Provide motion to the lower half of the face

Static procedures: restore resting symmetry without voluntary movement, especially important for those who are not candidates for dynamic reanimation (i.e., elderly, massive facial defects after trauma or cancer, failed reanimation)

Facial slings: fascia lata, acellular dermal matrix (ADM), or synthetic grafts can support the oral commissure; multivector suture technique

Unilateral facelifts: can improve symmetry in the midface

Nasal valve collapse can be addressed with alar or spreader grafts

Brow lifting for brow ptosis (ipsilateral) and contralateral compensatory hypertonicity

Region-specific interventions:

Brow and forehead

Eyelids

Gold or platinum eyelid weights to assist closure (eyelid loading), placed anterior to tarsal plate

Eyelid (palpebral) springs

Lower lid tightening procedures such as lateral canthoplasty, lateral canthopexy, or midface lift for ectropion

Corneal neurotization via nerve grafts can restore corneal sensation and protect ocular surface

Midface and nose

Use of spreaders and alar grafts to treat nasal valve insufficiency

Spreaders for internal valve collapse, alar for external valve collapse

Volume restoration with fat grafting or fillers to improve nasolabial fold symmetry

Unilateral facelift to address nasolabial fold asymmetry

Mouth and lower face: aim to restore oral competence and improve speech, eating, and social interaction

Unilateral face lift and static suspension of the oral commissure

Dynamic reanimation with muscle transfer (temporalis, masseter) and FFMT

Masseteric or hypoglossal to distal facial branches nerve transfers for smile

REFERENCES

Aronson S, et al. Evidence-based practices in facial reanimation surgery. Plast Reconstr Surg. 2023. 152:520e–31e.

Daeschler SC, Zuker RM, Borschel GH. Facial paralysis. In: Neligan PC, ed. Plastic Surgery. 5th ed. Elsevier; 2025. Fattah A, et al. Facial palsy and reconstruction. Plast Reconstr Surg. 2012. 129:340e–52.

Garcia RM, et al. Contemporary solutions for the treatment of facial nerve paralysis. Plast Reconstr Surg. 2015;135:1025e–36e.

Minelli L, van der Lei B, Mendelson BC. The deep fascia of the head and neck revisited: Relationship with the facial nerve and implications for rhytidectomy. Plast Reconstr Surg. 2024; 153:1273–85.

Chapter 15
Breast Reconstruction

John Tycher
Rosevine A. Azap
David E. Kurlander

BREAST ANATOMY

Mastering breast anatomy is essential for understanding how the breast changes with aging and principles of reconstruction, reduction, and mastopexy (Fig. 1)

Figure 1. Anatomy of the breast. From van Deventer P, et al. The Blood Supply of the Breast Revisited. Plast Reconstr Surg 2016;137(5):1388-1397.

Breast tissue

Glandular and adipose tissue are enclosed by superficial fascia and deep fascia overlying chest wall muscles

Cooper’s ligaments: suspensory attachment of the breast to the overlying fascia anteriorly; attenuation results in breast ptosis

Boundaries for mastectomy:

Superior border is the clavicle

Inferior border is the rectus abdominis fascia/ inframammary fold (IMF)

Medial border is the sternum

Lateral border is the anterior border of latissimus dorsi muscle

Important elements in planning breast surgery:

Breast footprint: superior margin of the breast is lower than the clavicle

Conus: three-dimensional shape, projection, and volume of the breast tissue

Skin envelope: adequate quantity and quality to drape the conus

Nipple areola complex (NAC)

Diameter 30-45mm

Aesthetic pleasing breast shape has NAC position:proportion 45:55 (Fig. 2)

Figure 2. Ideal nipple position. UPL, upper pole line; NM, nipple meridian; LPL, lower pole line; UPS, upper pole slope; LPC, lower pole convexity. From Mallucci P, et al. Population analysis of the perfect breast: a morphometric analysis. Plast Reconst Surg 2014;134(3):436-447.

Vasculature

Arterial supply (Fig. 3):

Internal mammary artery perforators (60%)

Lateral thoracic artery (30%)

Thoracoacromial artery: pectoral branchessupply pectoralis major muscle and overlying breast tissue

Intercostal arteries 3, 4, 5

NAC receives blood supply through subdermal plexus and parenchymal vessels, dominant supply from 2nd and 3rd branches of IMA

After nipple sparing mastectomy,blood supply is the subdermal plexus

After breast reduction or mastopexy, the blood supply is the breast pedicle or parenchyma, as you must divide the skin and subdermal plexus to reposition the NAC

Venous drainage (Fig. 4)

Mainly to axillary vein but some to internal mammary and intercostal veins

Veins are more superficial on the medial breast and deeper on the lateral aspect of the breast

NAC: superomedial/medial and inferior pedicles contain the most extensive and more reliable venous drainage patterns for NAC

Lymphatics

Dominant drainage to axilla (97%)

To internal mammary nodes (3%)

Level I: nodes lateral to lateral border of pectoralis minor

Level II: nodes lying beneath pectoralis minor

Figure 3. Arterial blood supply to the breast

Figure 4. Resultant venogram of the right breast using plain radiography showing the venous drainage of the breast, including the inferolateral veins (green), superolateral veins (orange), medial veins (pink and purple), and inferior veins (blue). Note the anastomoses between the dominant veins around the nipple-areola complex. From Le Roux C, et al. Preventing venous congestion of the nipple-areola complex: an anatomical guide to preserving essential venous drainage networks. Plast Reconst Surg 2011;127(3):1073-1079.

Level III: nodes medial to medial border of pectoralis minor and extending to apex of the axilla

Nerve supply (Fig. 1)

Cervical plexus: sensory branches of C3-4 from supraclavicular nerve

Lateral branches of intercostal nerves: provide sensation to lateral side of breast

Lateral cutaneous branch of the 4th intercostal nerve provides major sensory innervation to nipple (T4 dermatome)

Medial branches of intercostal nerves 2-7 provide sensation to medial breast

RECONSTRUCTION

Breast cancer now affects one in eight women over the course of their lifetime and is the leading cause of cancer-related death in women

All patients that have undergone or will undergo mastectomy are entitled to breast reconstructive surgery covered by insurance (Women’s Health and Cancer Rights Act, 1998)

Symmetry procedure for the contralateral breast is also covered

Patients undergoing mastectomy should be offered a pre-operative referral to a plastic surgeon

In relation to the timing of the mastectomy, breast reconstruction can be:

Immediate: during the same anesthetic as the mastectomy

Delayed-immediate: tissue expander placed during time of mastectomy and then definitive reconstruction delayed until a later time

Delayed: during surgery separate from the mastectomy

Possible preferences of patients:

No reconstruction or flat closure

Women may choose to wear an external prosthetic

Reconstruction of breast mound to attain close to natural breast shape, feel, contour

Breast mound reconstruction may or may not be followed with NAC reconstruction, depending on patient preference

Mastectomy defects frequently include loss of the NAC (such as in skin-sparing mastectomy)

Mastectomy skin necrosis is the unplanned loss of skin due to inadequate blood supply following surgery

Previous irradiation, such as in BCT, may cause difficulties with wound healing, skin contraction and discoloration, capsular contracture, and fat necrosis

If desired, following unilateral breast reconstruction, the opposite breast can be contoured to obtain symmetry, using mastopexy, reduction or augmentation mammoplasty

Options based on type of oncologic surgery

Breast conservative therapy (BCT) or partial mastectomy or lumpectomy: 50-70% of breast cancer patients; removal of the tumor only; requires post-operative radiation

Reconstructive options:

Oncoplastic surgery

Volume replacement: chest wall perforator flaps (LICAP, AICAP, MICAP, LTAP, TDAP), small implant

Volume displacement: mastopexy, breast reduction

Contralateral surgery for symmetry

Mastectomy options:

Nipple-sparing mastectomy (NSM) or total skin-sparing mastectomy (TSSM): removal of all breast tissue with preservation of all skin, including NAC (Fig. 5)

Reconstruction can be with autologous tissue or implant- based

Simple (total) mastectomy: removal of all breast tissue, including NAC

Reconstruction in delayed fashion will require tissue expansion or autologous tissue

Modified radical mastectomy: removal of all breast tissue, NAC, pectoralis fascia, as well as level I-II lymph nodes

Same principles of reconstruction as for simple mastectomy

Halsted radical mastectomy: removal of all breast tissue, NAC, pectoralis major and minor muscles, muscular fascia, Level I-III lymph nodes

Does not improve disease control compared to modified radical mastectomy and is largely of historical interest now

Goldilocks mastectomy: performed through a Wise skin pattern; the inferior de-epithelized mastectomy flap is folded under the Wise pattern in order to obtain a breast mound

Can be fat grafted for further volume

Figure 5. Examples of mastectomy incisions. From Cordeiro P, et al. Two-Stage Implant-Based Breast Reconstruction: An Evolution of the Conceptual and Technical Approach over a Two-Decade Period. Plast Reconstr Surg 2016;138(1):1-11.

Techniques

Choose based on:

Patient preference

Need for adjuvant radiation before or after the breast reconstruction (Fig. 6, 7)

Uni- or bilateral mastectomy

Defect of the breast envelope: NSM, total simple mastectomy, mastectomy skin necrosis

Immediate or delayed reconstruction (increased skin requirements)

Habitus of the patient: BMI, size of the breast or desired size of the reconstructed breasts, possible donor sites for autologous reconstruction

Figure 6. Decision algorithm for breast reconstruction in patient faced with mastectomy and post-mastectomy radiotherapy. MSKCC, Memorial Sloan-Kettering Cancer Center; LD, latissimus dorsi; TE, tissue expander. DIEP, deep inferior epigastric perforator. From Zhong T, et al. Evidence-based medicine: breast reconstruction. Plast Reconstr Surg 2013;132(6):1658-1669.

Figure 7. Options for timing of radiation in relation to autologous reconstruction. A) Mastectomy with radiation therapy of the chest wall and subsequent delayed autologous reconstruction. B) Pre-operative radiation therapy followed by mastectomy with immediate autologous reconstruction. C) Mastectomy, immediate autologous reconstruction followed by radiation therapy. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconst Surg 2017;139(1):204e-229e.

Implant-based reconstruction

One- or two-stage options:

Direct-to-implant reconstruction: place implant at time of mastectomy

Use of tissue expanders (TE) with staged breast implant insertion once adequate skin expansion has occurred

Acellular dermal matrix (ADM) may be used for partial or total coverage of the device

Breast implants may be saline or silicone

Placement in relation to pectoralis muscle:

Total submuscular coverage

Placed under the pectoralis major without releasing its inferior origin and full coverage is achieved by recruiting serratus anterior and less commonly rectus sheath flaps

Excellent vascularized soft-tissue coverage

Greater risk of animation deformity and loss of strength

Inferior restriction limits ptosis, projection and definition

Partial muscle coverage (dual plane):

Implant covered superiorly by pectoralis major and inferiorly by the mastectomy flap ± ADM

Allows for lower pole expansion without flap recruitment, improving projection and shape

Loss of inferior muscle attachment can cause superior migration (“window-shading”) and subcutaneous coverage at the lower pole reintroduces risks of visibility and palpability

Pre-pectoral

Several improvements since the 1960s have made this approach more feasible

Mastectomies have become less aggressive

Use of constructs with ADMs ± mesh

Devices that assess tissue perfusion

Techniques in fat grafting

Implant designs with less rippling

No animation deformity and preservation of muscle function

Less post-operative pain and shorter recovery

Breast-implant associated anaplastic large-cell lymphoma (BIA-ALCL): T-cell non-Hodgkin lymphoma, almost exclusively associated with textured breast implants

Patient presentation: late-onset, peri-implant effusion, or a discrete capsular mass approximately 8-10 years after implantation

Diagnosis: pathologic and cytologic evaluation (CD30 positive, ALK negative) of the implant capsule and seroma fluid

Treatment: en-bloc capsulectomy with implant removal (excellent prognosis)

Breast-implant associated squamous cell carcinoma (BIA- SCC): arises from metaplastic epithelium within implant capsule

Rarer than BIA-ALCL

Patient presentation: swelling, pain, and sometimes erythema years after implantation

Unlike BIA-ALCL, BIA-SCC behaves aggressively and has a higher mortality rate

Autologous reconstruction

Pedicled flaps

Latissimus dorsi myocutaneous flap (Fig. 8)

For adequate volume of the reconstructed breast, usually combined with:

TE with or without ADM; after completion of the tissue expansion, the TE is eventually exchanged for a breast implant

Fat grafting

Figure 8. Three different skin paddles for the latissimus dorsi flap. (above, left) Oblique skin island design in two different orientations. (above, right) Vertical skin island design. (below, left) Horizontal skin island design at the bra line. From Zhong T, et al. Evidence-based medicine: breast reconstruction. Plast Reconstr Surg 2013;132(6):1658-1669.

Figure 9. Pedicled TRAM flap. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg 2017;139(1):204e-229e.

Figure 10. Hartrampf’s classification of TRAM flap zonal blood supply. Hartrampf names zone I directly over the muscle pedicle and zone II lying across the midline. (Right) Ninkovic’s classification of TRAM flap and deep inferior epigastric perforator flap zonal blood supply. Holm et al. performed an in vivo study of deep inferior epigastric perforator flaps with indocyanine green and concluded that although zone I remains the most reliably perfused zone, any flow across the midline is less than ipsilateral flow and proposed that Hartrampf’s zone II should be renamed zone III. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg 2017;139(1):204e-229e.

Figure 11. Exposure of the thoracodorsal recipient vessels (left) and internal mammary recipient vessels (right). From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg 2017;139(1):204e-229e.

Pedicled TRAM flap (Fig. 9, 10) using superior epigastric vessels for blood supply (rectus abdominus muscle is used as a “carrier” for the blood vessel)

Free flaps

Technically more demanding, requiring microvascular techniques; flap is entirely disconnected and sewn to vessels in the chest

Recipient vessels may anastomosed to internal mammary vessels (or their perforators) or the thoracodorsal vessels (Fig. 11)

As compared to pedicled TRAM, lower risk of partial flap loss and fat necrosis, but potential total flap loss

Transverse rectus abdominis myocutaneous (TRAM) flap: rectus abdominus muscle, fat and skin on a transverse paddle, based on inferior deep epigastric artery (DIEA)

Requires abdominal wall reconstruction/anterior rectus sheath with mesh

Muscle-sparing TRAM flap (MS-TRAM):

Only a portion of the rectus muscle is harvested (Fig. 12)

In unilateral reconstruction, can harvest zones 1-3 (TRAM or MS- TRAM)

Deep inferior epigastric perforator (DIEP) flap: only skin and fat are harvested on perforating vessels from DIEA

Technically more demanding

Clinical relevance of not taking any muscle compared with muscle-sparing techniques is still under debate

CT angiography may help with perforator harvest planning (Fig. 13)

Uni-pedicled (Fig. 14) or double-pedicled (stacked)

Superficial inferior epigastric artery (SIEA) flap: SIEA has to be of adequate caliber (artery with a palpable pulse, vein >1 mm) to be used for anastomosis

Not all patients have an adequate SIEA, may be affected by the position of the lower abdominal incision

SIEV may be the dominant venous drainage and is commonly preserved in case it is needed for venous outflow

Gluteal artery perforator (GAP) flap on superior (SGAP) or inferior (IGAP) gluteal artery perforators (Fig. 15): typically reserved for patients without sufficient abdominal wall tissue or for those who are not candidates for abdominal based reconstruction

Transverse upper (TUG) gracilis flap (Fig.16) and vertical upper gracilis (VUG) flap

Profunda artery perforator flap (PAP) (Fig. 17): introduced in 2012 and has quickly become the preferred option from the thigh

Can be harvested in supine position with no need for position changes

Lumbar artery perforator flap (LAP) (Fig. 18): improved donor site versus SGAP

Requires position change

Requires harvest of DIEA and DIEV composite grafts to increase pedicle length and improve caliber match

Turbocharging:

Vascular augmentation using vascular sources within flap territory

Example: performing a DIEP flap to the recipient internal mammary vessels then anastomosing an additional vessel from this system

Supercharging:

Vascular augmentation using a distant source of vessels such as axillary or thoracodorsal vessels

Example: performing a pedicled TRAM flap, then augmenting the flow by anastomosing the deep inferior epigastric vessels to the thoracodorsal vessels

Figure 12. Classification of muscle-sparing free TRAM procedures. MS0 refers to sacrifice of the full width of the rectus muscle, MS1 preserves the lateral segment, MS2 preserves the lateral or medial segments, and MS3 preserves the entire muscle (equivalent to a DIEP flap). MS1 can be further subdivided into MS1-M and MS1-L, depending on whether it is the medial or lateral segment that is spared. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg 2017;139(1):204e-229e.

Figure 13. Computed tomographic angiography of abdominal perforators. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg 2017;139(1):204e-229e.

Figure 14. DIEP flap. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg 2017;139(1):204e-229e.

Figure 15. Superior gluteal artery perforator (SGAP) flap and inferior gluteal artery perforator (IGAP) flap. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg 2017;139(1):204e-229e.

Figure 16. Transverse upper gracilis (TUG) flap. From Macadam S, et al. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg. 2017;139(1):204e-229e.

Figure 17. Profunda artery perforator (PAP)flap. From Teotia S, et al. Categorizing Patient Selection, Outcomes, and Indications in a Decade of 405 Profunda Artery Perforator Flaps. Plast Reconstr Surg. 2024;154(4):632e-640e.

Figure 18. Lumbar artery perforator (LAP) flap. From Teotia S, et al. Bilateral Lumbar Artery Perforator Flaps for Breast Reconstruction: A Perforator Classification System. Plast Reconstr Surg. 2024; 154(3):413e-420e.

Minimally invasive techniques:

Laparoscopic assist and harvest

Using CTA, an ideal DIEP perforator is selected based on location (low, central) and short intramuscular course

Dissection occurs in the extraperitoneal space and all other collateral muscle branches are dissected from the undersurface of the rectus

Pedicle is delivered through minimal fascial incision

Preserves the lateral intramuscular and retrorectus course of the abdominal wall innervation

Robotic-assisted harvest:

Flaps are elevated in standard fashion and the perforator is dissected down to posterior sheath

Robot is used to intra-abdominally dissect the entire pedicle length while minimizing disruption of fascia or muscle except where the perforator exits the fascia

Fat grafting

Does not increase the risk of breast cancer recurrence

Volume augmentation of a reconstructed breast

Improve shape of the breast, corrects contour deformities, commonly in the upper pole for fullness

Ipsilateral corrections include:

Nipple reconstruction

Scar revisions

Volume adjustments either by reduction (i.e., direct resection or liposuction) or by augmentation (i.e., implants, additional flaps, or lipofilling)

Shape corrections: can be accomplished by repositioning and/or rotating the flap or implant, skin resections, and adjustments of the inframammary fold or other borders of the flap

Symmetry is the goal of the reconstruction; the contralateral side may be adjusted by the common techniques of:

Augmentation

Reduction

Mastopexy

Breast neurotization: involves nerve coaptation during breast reconstruction with the goal of restoring meaningful sensation to the breast

During a mastectomy, sensory nerves to the skin and nipples are often transected

Can pose significant quality of life implications for patients afterwards, including safety concerns (i.e., injuries acquired due to lack of sensation)

Nipple-areola complex (NAC) reconstruction:

NAC is one of the aesthetic units of the breast; for the completeness of the aesthetic of the breast some women chose to have the NAC reconstructed

Nipple sharing (graft from the contralateral nipple) if available and dimensions adequate (Fig. 19)

Local skin flaps (C-V, C-Y, star flap, skate flap) with or without use of cartilage, ADM graft, revision with fat grafting to improve projection (Fig. 20)

Intra-dermal color tattoo to match opposite NAC:

May follow nipple reconstruction procedure

3-D tattoo to simulate also the nipple projection from frontal view (no surgical nipple reconstruction)

In-situ or remote-donor skin graft (groin or labia majora/ minora) may also be used for areola

Figure 19. Drawings demonstrating the two commonly accepted techniques for nipple sharing. Both harvest 50 percent of the nipple. (Above) Drawings show sagittal harvest for nontubular nipples. The lower half of the nipple is taken and the donor site closed with simple interrupted sutures, leaving an imperceptible scar under the nipple. (Below) Drawings show coronal harvest for tubular, large nipples. Note that the donor site is closed with a purse-string suture, leaving a natural appearing nipple. From Zenn M, et al. Unilateral nipple reconstruction with nipple sharing: time for a second look. Plast Reconstr Surg 2009;123(6):1648-1653.

Figure 20. Different techniques for nipple reconstruction. (Above) CV flap. (Center) Star flap. (Below) Skate flap. From Zhong T, et al. Evidence-based medicine: breast reconstruction. Plast Reconstr Surg 2013;132(6):1658-1669.

REFERENCES

Van Deventer PV, Graewe FR. The Blood Supply of the Breast Revisited. Plast Reconstr Surg. 2016 May;137(5):1388-1397.

Mallucci P, Branford OA. Population analysis of the perfect breast: a morphometric analysis. Plast Reconstr Surg. 2014 Sep;134(3):436-447.

Hall-Findlay EJ, Shestak KC. Breast Reduction. Plast Reconstr Surg. 2015 Oct;136(4):531e-544e.

Le Roux CM, et al. Preventing venous congestion of the nipple-areola complex: an anatomical guide to preserving essential venous drainage networks. Plast Reconstr Surg. 2011 Mar;127(3):1073-1079.

Cordeiro PG, Jazayeri L. Two-Stage Implant-Based Breast Reconstruction: An Evolution of the Conceptual and Technical Approach over a Two-Decade Period. Plast Reconstr Surg. 2016 Jul;138(1):1-11.

Zhong T, McCarthy CM, Price AN, Pusic AL. Evidence-based medicine: breast reconstruction. Plast Reconstr Surg. 2013 Dec;132(6):1658-1669.

Macadam SA, Bovill ES, Buchel EW, Lennox PA. Evidence-Based Medicine: Autologous Breast Reconstruction. Plast Reconstr Surg. 2017 Jan;139(1):204e-229e

Zenn MR, Garofalo JA. Unilateral nipple reconstruction with nipple sharing: time for a second look. Plast Reconstr Surg. 2009 Jun;123(6):1648-1653.

Butz DR, Kim EK, Song DH. C-Y Trilobed Flap for Improved Nipple-Areola Complex Reconstruction. Plast Reconstr Surg. 2015 Aug;136(2):234-237.

Hidalgo DA, Spector JA. Mastopexy. Plast Reconstr Surg. 2013 Oct;132(4):642e- 656e.

Greco R, Noone B. Evidence-Based Medicine: Reduction Mammoplasty. Plast Reconstr Surg. 2017 Jan;139(1):230e-239e.

Blondeel PN, et al. Shaping the breast in aesthetic and reconstructive breast surgery: an easy three-step principle. Part IV-- aesthetic breast surgery. Plast Reconstr Surg. 2009 Aug;124(2):372-382.

Richardson H, Ma G. The Goldilocks mastectomy. Int J Surg. 2012;10(9):522-526.

Sbitany H. Important Considerations for Performing Prepectoral Breast Reconstruction. Plast Reconstr Surg. 2017 Dec;140(6S Prepectoral Breast Reconstruction):7S-13S.

Sigalove S, et al. Prepectoral Implant-Based Breast Reconstruction: Rationale, Indications, and Preliminary Results. Plast Reconstr Surg. 2017 Feb;139(2):287-294.

Shakir S, et al. Laparoscopically Assisted DIEP Flap Harvest Minimizes Fascial Incision in Autologous Breast Reconstruction. Plast Reconstr Surg. 2020 Sep;146(3):265e-275e.

Selber JC. The Robotic DIEP Flap. Plast Reconstr Surg. 2020 Feb;145(2):340-343.

Kueckelhaus M. Minimally Invasive Robotic-assisted Perforator-to-Perforator DIEP Flap Breast Reconstruction. Plast Reconstr Surg Glob Open. 2024 May 13;12(5):e5800.

Haddock NT, Teotia SS. Lumbar Artery Perforator Flap: Initial Experience with Simultaneous Bilateral Flaps for Breast Reconstruction. Plast Reconstr Surg Glob Open. 2020 May 18;8(5):e2800.

Haddock NT, Teotia SS. Consecutive 265 Profunda Artery Perforator Flaps: Refinements, Satisfaction, and Functional Outcomes. Plast Reconstr Surg Glob Open. 2020 Apr 7;8(4):e2682.

Chapter 16
Trunk Reconstruction

Robert G. DeVito, MD
John T. Stranix, MD

There are three major areas to consider in trunk reconstruction–chest wall reconstruction, abdominal wall reconstruction, and spine reconstruction. This chapter is therefore divided into three sections to cover each of these topics.

CHEST WALL RECONSTRUCTION

Chest wall anatomy

Skin and subcutaneous tissue

Muscle layers (Fig. 1):

Pectoralis major (2 heads):

Sternocostal head: adduction, flexion, and internal rotation of the humerus

Clavicular head: flexion of the humerus

Blood supply: pectoral branch of the thoracoacromial artery, perforating branches from intercostal arteries

Pectoralis minor: stabilization of the scapula

Serratus anterior: protract and stabilization of the scapula

Latissimus dorsi: adduction, extension, and internal rotation of the humerus

Blood supply: thoracodorsal artery

Intercostal muscles: elevate and depress ribs

External: fibers run inferomedially

Internal: fibers run superomedially

Innermost: fibers run transversely

The neurovascular bundle containing the intercostal nerves, arteries, and veins run between the internal and innermost layers on the inferior aspect of respective ribs

Diaphragm: along with the intercostal muscles, serves as the primary muscle of respiration

Figure 1. Chest wall anatomy. From Isaac KV, Elzinga K, Buchel, EW. The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects. Plast Reconstr Surg. 2022 Mar 1;149(3):547e-562e.

Bony structures: provide stable skeletal support to protect vital organs, contribute to both respiratory physiology and upper extremity function (Fig. 1)

Sternum (composed of manubrium, body, and xiphoid)

Ribs (12 total)

True ribs (1-7): articulate directly with the sternum

False ribs (8-12): articulate with costal cartilages instead of sternum

Floating ribs (11-12): do not communicate with either the sternum or the ribs superior to them

Clavicle

Thoracic vertebrae

Pleura

Visceral pleura: covers the lung and hilar structures

Parietal pleura: lines the thoracic cavity

Common pathology requiring chest wall reconstruction

Trauma

Tumor resection (Fig. 2)

Infection (including sternal osteomyelitis after median sternotomy)

Congenital anomalies

Figure 2. (Left) Oncologic specimen. (Right) Irradiated lateral chest wall defect with initial inset of a synthetic mesh. From Isaac KV, Elzinga K, Buchel, EW. The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects. Plast Reconstr Surg. 2022 Mar 1;149(3):547e-562e.

Goals of reconstruction

Rigid airtight thoracic cavity

Protection of the thoracic and abdominal contents

Optimization of respiration

Obliteration of dead space for intrathoracic defects

Stable soft-tissue coverage

Control of infection

Aesthetic reconstruction (when reasonably possible)

Sternal reconstruction

Usually these wounds/defects are related to postoperative infection after cardiac surgery

Complication rate after median sternotomy is 0.5-5.0%

More common when internal mammary artery (IMA) is harvested for coronary artery bypass grafting

Sternal wounds can be classified based on anatomy, as well as presenting signs/symptoms

Starzynski classification of sternal defects:

Loss of upper sternal body and adjacent ribs: minimal physiologic effect

Loss of entire sternal body and adjacent ribs: moderate physiologic deficit

Loss of manubrium and upper sternal body with adjacent ribs: severe physiologic deficit

Pairolero and Arnold in 1984 proposed a classification based on time to infection:

Type 1: within the first three days postoperatively

Treatment: exploration, debridement, primary closure

Type 2 : within first three weeks postoperatively

Treatment: exploration, debridement, serial dressing changes or negative pressure wound therapy (NPWT), flap closure in staged manner

Type 3: draining sinus tract from chronic osteomyelitis that typically presents months to years after surgery

Treatment: exploration, debridement, serial dressing changes/NPWT, flap closure in staged manner

Typical flap selection for sternal wounds include pectoralis major, omentum, and vertical rectus abdominis muscle flaps

Pectoralis major: based on the pectoral branch of the thoracoacromial artery

Most often used as an advancement flap where both pectoralis major muscles are released from skin and undermined then advanced towards midline

Can also be used as turnover flap if IMA is still intact

Omentum: based on right or left gastroepiploic artery

Typical indication is for sternal wounds requiring dead space obliteration, inferior wounds that pectoralis major muscle is suboptimal for, or secondary reconstruction when pectoralis major has already been utilized

Vertical rectus abdominis muscle (VRAM): based on superior/inferior epigastric artery

Typically used in setting of failed initial reconstruction or reconstruction requiring skin island

Important to consider if one or both IMA were harvested for use in bypass grafting, as inferior epigastric arteries are continuations of IMAs

Non-sternal reconstruction

Most frequently indicated in setting of malignancy or locally destructive benign pathology

Malignant pathology:

Lung carcinoma

Locally advanced breast carcinoma

Soft tissue sarcoma

Chondrosarcoma

Ewing sarcoma

Metastatic disease

Benign pathology:

Osteochondroma

Chondroma

Fibrous dysplasia

Desmoid tumor

Osteomyelitis

Osteoradionecrosis

Trauma

Skeletal reconstruction:

Goals:

Minimize paradoxical motion

Aid/palliate respiratory mechanics

Protect thoracic viscera

Maintain chest wall aesthetics

Indication: if defect is > 4 contiguous ribs or is > 5 cm

Defects above this size are prone to result in a flail segment which will produce paradoxical motion of the chest wall and negatively impact respiratory mechanics

Note: previous radiation from oncologic treatment can result in stiffening of chest wall that may decrease the negative effects of these size defects on respiratory mechanics

Reconstructive options:

Alloplastic material

Widely available, however can be expensive and intolerant of bacterial contamination

Mesh: oolypropylene, PTFE (Gore-Tex)

Methylmethacrylate: rigid, forms by exothermic reaction, relatively higher infection and extrusion rates

Titanium: radiopaque and requires underlay of a different mesh

Acellular dermal matrices: semirigid and expensive, but less prone to infection

Autologous material: bone grafts (can be associated with poor wound healing and high donor site morbidity)

Split rib, iliac crest, fibula

Soft-tissue reconstruction: typically locoregional options are explored before utilizing free tissue transfer

Locoregional flaps:

Pectoralis major: anterior wounds and intra-thoracic

Serratus anterior: based on serratus branch off the thoracodorsal artery, commonly used for intra-thoracic applications

Latissimus dorsi: can be utilized for anterior, lateral, and posterior chest wall wounds as well as intra- thoracic space obliteration

Rectus abdominis

External oblique

Thoracodorsal artery perforator flap

Intercostal artery perforator flap

Omentum: used for intra-thoracic space obliteration

Free flaps: commonly used for larger wounds related to oncologic resection, osteoradionecrosis, or results of severe infection

Commonly used in conjunction with alloplastic materials and ADM

Provide significant reconstructive freedom, however patients may have suboptimal recipient vessels or be poor overall candidates for free flaps

Recipient vessels: internal mammary artery/vein, thoracodorsal artery/vein

Commonly utilized flaps: anterolateral thigh (ALT) flap, latissimus dorsi flap (contralateral side if lateral), rectus abdominis

Congenital chest wall reconstruction

Poland syndrome:

Etiology: due to kinking of the subclavian artery around week six of gestation leading to vessel hypoplasia

Characteristics (Fig. 3):

Absence of sternal head of the pectoralis major muscle

Hypoplasia of the breast or nipple

Deficiency of the subcutaneous fat or axillary hair

Bony abnormalities of the anterior chest wall

Syndactyly or hypoplasia of ipsilateral extremity

Shortened ipsilateral forearm

Figure 3. Schematic an anterior view of Poland syndrome in a male patient and a female patient. Notice the asymmetric axillary folds. From Seyfer AE, Fox JP, Hamilton CG. Poland syndrome: evaluation and treatment of the chest wall in 63 patients. Plast Reconstr Surg. 2010 Sep;126(3):902-911.

Treatment:

For adolescent females, can place a tissue expander for breast reconstruction and perform serial expansions during puberty

Once at full development, an ipsilateral innervated latissimus dorsi flap for creation of anterior axillary line, with an implant for breast reconstruction

Pectus excavatum:

Characteristics: depression of the sternum that can lead to cardiovascular/respiratory abnormalities and/or cosmetic deformities

Treatment: performed in multi-disciplinary fashion with pediatric surgery (first three options usually for symptomatic patients with compromised cardiorespiratory function)

Sternal osteotomies for repositioning

Posterior strut for support (if required)

Nuss procedure: utilize steel bars for support

There are also implantable prostheses that can be used for cases without cardiovascular compromise to restore normal chest wall contour

Pectus carinatum:

Excessive protrusion of the sternum

Treatment: performed in multi-disciplinary fashion with pediatric surgery

Repositioning of the sternum and abnormal costal cartilage to restore normal contour

Mild cases in females can often be camouflaged with breast implants

ABDOMINAL WALL RECONSTRUCTION

Abdominal wall anatomy

Layers of the abdominal wall (Fig. 4)

Skin

Subcutaneous tissue

Scarpa’s fascia: superficial fascial system

Usually approximated during abdominal closure for aesthetic purposes as well as for strength properties

Medial musculature

Rectus abdominis: originates from the costal cartilages of ribs 5-7 and inserts onto pubic crest; main function is flexion of the trunk

Figure 4. Abdominal wall anatomy. From Patel NG, Ratanshi I, Buchel EW. The Best of Abdominal Wall Reconstruction. Plast Reconstr Surg. 2018 Jan;141(1):113e-136e.

Above the arcuate line:

Anterior rectus sheath: composed of external oblique and internal oblique fascial confluences

Posterior rectus sheath: composed of internal oblique and transversus abdominis fascial confluences

Note: the internal oblique contributes to both the anterior and posterior rectus sheaths above the arcuate line

Below the arcuate line:

Anterior rectus sheath: composed of external oblique, internal oblique, and transversus abdominis fascia

No posterior sheath (layers posterior to rectus abdominis at this level are transversalis fascia and parietal peritoneum)

Transversalis fascia

Parietal peritoneum

Lateral musculature:

External oblique: functions in trunk flexion and contralateral rotation of the torso

Fibers run inferomedially

Internal oblique: functions in trunk flexion and contralateral rotation of the torso

Fibers run superomedially

Note: the neurovascular bundles lie between the internal oblique and the transversus abdominis muscle

Ventral rami T7-L4 supply motor innervation to the abdominal wall

Transversus abdominis: fibers run transversely

Huger zones: used to delineate anatomic regions of perfusion

Zone 1: region between xiphoid, pubic symphysis, and linea semilunaris

Perfused by the deep inferior epigastric arteries

Zone 2: region between anterior superior iliac spines bilaterally, pubic symphysis, and groin creases

Perfused by superficial circumflex femoral arteries, external pudendal arteries, and superficial inferior epigastric artery

Zone 3: region lateral to rectus muscles

Perfused by intercostal perforators

Goals of reconstruction

Provide protection for intra-abdominal viscera

Repair and prevent recurrence of hernia with strong fascial support

Restore abdominal wall function by maintaining innervation allowing for proper contractility

Common abdominal wall pathology requiring reconstruction

Ventral hernia or recurrent ventral hernia

Relevant hernia terminology:

Reducible: hernia contents are able to be easily manually pushed back into the abdominal cavity

Nonreducible: hernia contents cannot be manually pushed back into the abdominal cavity

Incarcerated: hernia contents are not able to be reduced back into the abdominal cavity and cause pain or bowel dysfunction

Strangulated: hernia contents are devascularized and ischemic inside the hernia sac; surgical emergency

Incisional hernia: hernia through a prior fasciotomy site (usually from prior midline laparotomy procedure); rates of incisional hernia vary between 10-30%

Spigilean hernia: ventral hernia through the linea semilunaris

Lumbar hernia: hernia of the posterior trunk which usually involves retroperitoneal structures

Trauma

Tumor resection

Infection (e.g., mesh infection from prior hernia repair, necrotizing infection)

Congenital abdominal wall defects (gastroschisis, omphalocele)

Reconstructive considerations and algorithm

Primary closure

Can be reasonably utilized when fascial defect is <3 cm in diameter

Defects this small are relatively uncommon if plastic surgery is consulted

Mesh considerations: indicated in cases of defects with tension

Types of mesh:

Synthetic mesh: can be absorbable (Vicryl, Dexon) or non-absorbable (polypropylene, PTFE)

Biologic mesh: human, porcine, and bovine acellular dermal matrices (ADMs)

Utilizes tissue remodeling process to aid in tissue incorporation

More infection-resistant that synthetic meshes, but more costly

Planes of mesh placement:

Intraperitoneal: mesh placed deep to the fascial repair

Mesh adheres to abdominal wall through forces of intraabdominal pressure

Retrorectus: mesh placed between the posterior sheath and the rectus muscle

Considered to be the ideal layer for mesh placement because mesh has protection from outside environment as well as viscera

Overlay: mesh is placed superficial to the fascial repair

Mesh is high risk for exposure in setting of wound healing complications

Interposition bridge: mesh is sutured as a bridge between the fascial edges of the hernia defect; high risk of hernia recurrence

Mesh infections: synthetic is usually less tolerant of contamination than biologic mesh

If mesh becomes infected, it should be explanted

Component separation:

Anterior release (Fig. 5):

Involves division of the external oblique aponeurosis lateral to the semilunar line, separating the external oblique from the internal oblique to allow for medial advancement; can be performed with or without separation of the rectus abdominis muscle from the posterior sheath

Figure 5. Component separation with anterior release. From Althubaiti G, Butler CE. Abdominal wall and chest wall reconstruction. Plast Reconstr Surg. 2014 May;133(5):688e-701e.

Advancement of each hemi-abdominal flap with anterior release

Epigastrium: 5 cm

Umbilicus: 10 cm

Suprapubic: 3 cm

Posterior release (TAR)

Begins with dissection in the retrorectus plane; then the posterior lamella of the internal oblique aponeurosis is incised (medial to intercostal nerve to rectus muscle) allowing access to the transversus abdominis. Transversus abdominis is then divided and the plane between the transversus abdominis and the transversalis fascia is developed from medial to lateral

Can provide 8-12 cm of advancement per side

Utilization with mesh is possible; ideal placement of mesh is in the retrorectus plane

Tissue expansion: utilized for defects involving the skin and subcutaneous tissue

Pedicled flaps: pedicled ALT flap, pedicled rectus femoris flap, and pedicled tensor fascia lata flap have all been described

Free flaps: free ALT and free latissimus dorsi muscle flaps

NPWT: can be utilized for the open abdomen in an acute setting or for chronic soft tissue wounds of the abdominal wall skin and subcutaneous tissue

SPINE RECONSTRUCTION

Back anatomy

Paired paraspinous muscles run parallel to spine, function to stabilize and extend vertebrae

3 distinct muscle bellies: iliocostalis, longissimus, spinalis

Trapezius muscle

Latissimus dorsi

Serratus posterior

Indications

Cervical, thoracic, lumbar level spine surgery requiring watertight hardware coverage

Instrumentation of the spine can be performed due to deformity, malignancy, trauma, or degenerative conditions

Considerations

Is instrumentation being placed? If so, has the patient had prior surgeries or instrumentation?

Infectious history?

Is hardware high-profile or low-profile?

Underlying factors affecting wound healing (nutritional status, prior wounds, history of radiation)?

Concern for CSF leak?

Surgical approach

Debridement: critically important step

Prior wound edges should be excised, unincorporated bone graft should be removed

Goal is to maintain hardware, as it provides stability to spinal cord (and wound); note difference from areas such as extremity reconstruction

Cervical:

Modern spine surgery often utilizes an anterior approach to the cervical spine, but the posterior approach is sometimes still indicated

Due to the constant motion of the neck and shoulder girdle, as well as thin skin and soft tissue coverage, posterior approaches are more likely to develop infection or wound complications

Options: paraspinous flaps, trapezius muscle flaps, or fasciocutaneous advancement perforator flaps

Thoracic:

Wounds, infections, or fluid collections are all possible indications for soft tissue coverage of the thoracic spine

Paraspinous muscle flaps are the workhorse of soft tissue coverage of the thoracic spine

Latissmus dorsi muscle flaps, either as an advancement flap or a turnover flap, can also provide coverage

Omentum: based on gastroepiploic arteries, requires tunneling through the retroperitoneum

Lumbosacral:

Lumbar spine wounds can be associated with instrumentation or less commonly sacrectomy defects

Paraspinous flaps are the workhorse soft coverage flap choice in the lumbar spine

Reverse latissimus dorsi flap

Lumbar artery perforator flap

Omentum

For sacrectomy defects: gluteal fasciocutaneous V-Y flaps are a mainstay for posterior approach sacrectomies

For anterior/posterior approach sacrectomies (less common), a vertical rectus abdominis muscle flap can be tunneled transpelvically

Bony defects:

Large (>4.5 cm) bony spinal column gaps have a relatively high fail rate with when treated with non- vascularized bone graft

Clinical indications:

Sacrectomy, oncologic vertebrectomy, osteoradionecrosis, osteomyelitis

Surgical techniques:

Pedicled rib, pedicled iliac crest, pedicled calvarium, free bone flap (fibula)

REFERENCES

Clemens MW, et al. Introduction to chest wall reconstruction: anatomy and physiology of the chest and indications for chest wall reconstruction. Semin Plast Surg. 2011 Feb;25(1):5-15.

Bakri K, et al. Workhorse flaps in chest wall reconstruction: the pectoralis major, latissimus dorsi, and rectus abdominis flaps. Semin Plast Surg. 2011 Feb;25(1):43-54.

Corkum JP, et al. Reconstruction of massive chest wall defects: A 20-year experience. J Plast Reconstr Aesthet Surg. 2020 Jun;73(6):1091-1098.

Althubaiti G, Butler CE. Abdominal Wall and Chest Wall Reconstruction. Plast Reconstr Surg. 2014 May;133(5):688e-701e.

Isaac KV, Elzinga K, Buchel, EW. The Best of Chest Wall Reconstruction: Principles and Clinical Application for Complex Oncologic and Sternal Defects. Plast Reconstr Surg. 2022 Mar 1;149(3):547e-562e.

Chang BL, et al. Reconstruction of the Chest. In: Plastic Surgery, Vol. 4. 5th ed. Elsevier: 2024.

Seyfer AE, Fox JP, Hamilton CG. Poland syndrome: evaluation and treatment of the chest wall in 63 patients. Plast Reconstr Surg. 2010 Sep;126(3):902-911.

Giordano S, et al. Component Separation Decreases Hernia Recurrence Rates in Abdominal Wall Reconstruction with Biologic Mesh. Plast Reconstr Surg. 2024 Mar 1;153(3):717-726.

Bhardwaj P, et al. Year-Over-Year Ventral Hernia Recurrence Rates and Risk Factors. JAMA Surg. 2024 Jun 1;159(6):651-658.

Ramirez OM, Ruas E, Dellon AL. "Components separation" method for closure of abdominal-wall defects: an anatomic and clinical study. Plast Reconstr Surg. 1990 Sep;86(3):519-26.

Novitsky YW, et al. Outcomes of Posterior Component Separation With Transversus Abdominis Muscle Release and Synthetic Mesh Sublay Reinforcement. Ann Surg. 2016 Aug;264(2):226-32.

Othman S, et al. Comparative Effectiveness Analysis of Resorbable Synthetic Onlay and Biologic Intraperitoneal Mesh for Abdominal Wall Reconstruction: A 2-Year Match-Paired Analysis. Plast Reconstr Surg. 2022 May 1;149(5):1204-1213.

Shubinets V, et al. Management of Infected Mesh After Abdominal Hernia Repair: Systematic Review and Single-Institution Experience. Ann Plast Surg. 2018 Feb;80(2):145-153.

Patel NG, Ratanshi I, Buchel EW. The Best of Abdominal Wall Reconstruction. Plast Reconstr Surg. 2018 Jan;141(1):113e-136e.

Garvey PB, et al. Immediate soft-tissue reconstruction for complex defects of the spine following surgery for spinal neoplasms. Plast Reconstr Surg. 2010 May;125(5):1460-1466.

Mericli AF, et al. Paraspinous muscle flap reconstruction of complex midline back wounds: Risk factors and postreconstruction complications. Ann Plast Surg. 2010 Aug;65(2):219-24.

Mericli AF, et al. Reconstruction of complex posterior cervical spine wounds using the paraspinous muscle flap. Plast Reconstr Surg. 2011 Jul;128(1):148-153.

Mathes DW, Thornton JF, Rohrich RJ. Management of Posterior Trunk Defects. Plast Reconstr Surg. 2006 Sep;118(3):73e-83e.

Chapter 17
Pelvic Reconstruction

Robert G. DeVito, MD
John T. Stranix, MD

There are several major areas to consider in pelvic reconstruction. These include perineal reconstruction, which is commonly indicated in the reconstruction of defects related to colorectal and anal cancer. Second is genitourinary reconstruction, which includes reconstruction of the vulva, vaginal canal, penis, and scrotum. Regardless of the origin of the pathology, the treatment of pelvic wounds requires multidisciplinary care.

ANATOMY

The perineal area is the region between the scrotum/vagina and the anus. It can be divided into an anterior (urogenital) triangle and a posterior (anal) triangle.

Borders

Anterior: pubic arch/arcuate ligament of pubis

Posterior: tip of coccyx

Medial/lateral: inferior pubic rami and ischial tuberosity

Superior: pelvic floor

Inferior: skin/fascia

Male perineum (Fig. 1)

Penis: radix, corpus, and glans

Skin, dartos fascia (superficial), and Buck’s fascia (deep)

Neurovascular bundle - deep dorsal vein, dorsal artery, paired dorsal nerves

Erectile tissue - paired corpus cavernosum, corpus spongiosum

Penile urethra

Scrotum: contains testes, epididymis, and ductus deferens

Female perineum (Fig. 1)

Vulva

Mons pubis

Labia majora: skin, Camper’s fascia and Colle’s fascia (superficial fascia)

Labia minora: folds of skin without fat

Clitoris: derived from the undifferentiated phallus, and has paired corpora, vestibular bulbs, and glans

Vestibule

Vagina

Blood supply

Internal pudendal artery: branches into perineal artery (supplies perineum and scrotum/vulva) and the common penile artery (bulbourethral, dorsal, and deep cavernosal branches)

Superficial and deep external pudendal arteries: branch off common femoral artery and anastomose with branches of the internal pudendal artery

Testicular/ovarian arteries: branch off aorta

Innervation

Pudendal nerve (S2-S4) runs with internal pudendal artery

Multiple branches to perineal and genitalia structures

Ilioinguinal nerve (L1): gives branches to upper scrotum/labia

Figure 1. Male and female perineal anatomy. From Weichman KE, Matros E, Disa JJ. Reconstruction of Peripelvic Oncologic Defects. Plast Reconstr Surg. 2017 Oct;140(4):601e-612e.

ETIOLOGY OF PERINEAL WOUNDS

Benign conditions:

Hidradenitis suppurativa

Necrotizing fasciitis

Fournier’s gangrene

Trauma

Autoimmune conditions

Human papillomavirus (HPV)

Vaginal agenesis: variable, ranging from congenital absence to incomplete development

Range of presentation results in a range of reconstructive options including nonsurgical and surgical options

Hypospadias: incomplete development of the urethra where the urethra exits ventrally and penile shaft has a ventral curvature

Epispadias: urethral opening on the dorsal aspect of the penis

Peyronie’s disease: connective tissue disease resulting in penile curvature during erection

Malignant conditions:

Colorectal cancer

Vulvar cancer

Vaginal cancer

Uterine cancer

Penile cancer

Bladder cancer

PRINCIPLES OF RECONSTRUCTION

Benign conditions: treating underlying conditions and wound debridement and preparation are paramount

Malignant conditions: discuss care with multidisciplinary team, consider radiation needs (neoadjuvant vs. adjuvant), assess likely defect size

RECONSTRUCTIVE OPTIONS

Debridement and wound bed preparation are paramount

Skin grafts: difficult to bolster, but can be ideal for superficial wounds

Local flaps: suboptimal in radiated wound beds due to radiation injury to local tissue

Random pattern flaps

V-Y advancement flaps

Perforator flaps

Regional flaps:

Vertical rectus abdominis muscle (VRAM) (Fig. 2)

Workhorse flap in perineal reconstruction

Based on deep inferior epigastric artery

Commonly used for large defects left after abdominoperineal resection (APR), vaginal reconstruction

Obliterates pelvic dead space

Figure 2. Schematic of use of VRAM flap for partial vaginectomy defect. From Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg. 2002 Sep 15;110(4):1058-65.

Gracilis flap: based on medial circumflex femoral artery

Can be utilized as a muscle only flap or with a skin paddle

Can be utilized bilaterally for larger reconstructive needs

Anterolateral thigh (ALT): based on descending branch of lateral femoral circumflex artery

Must be tunneled deep to rectus femoris and sartorius muscle if being used in perineal reconstruction

Singapore flap (pudendal thigh flap): island neurovascular flap based on the labial artery (branch from pudendal arteries)

Posterior thigh flap: based on inferior gluteal arteries

Ideal when abdomen is not available as an option

Omental flap: based on gastroepiploic arteries

Ideal for eliminating dead space in the pelvis to help prevent pelvic hernia

Free flaps: rarely indicated considering number of local options

ANATOMIC-BASED TREATMENT ALGORITHM

Penis:

Penile loss from oncologic disease or trauma

Goals for reconstruction: cosmetically acceptable, ability for standing micturition, preserved sensation, and sexually functional (most options require prosthetic)

Skin grafting: for partial thickness or skin only defects (as seen in Paget’s disease for example)

Radial forearm free flap

Free or pedicled ALT

Free fibula flap

Abdominal flaps

Urethral reconstruction using skin grafts or vein or mucosal grafts

In setting of amputation, replantation can be attempted

Use superficial dorsal artery for arterial repair, prefer multiple nerve coaptations

Successful replantation can be performed after 6 hours of warm ischemia or 16 hours of cold ischemia

Hypospadias: occurs in 1:150-300 males; most commonly meatus is in distal third

Surgical correction usually between age 6 months - 9 months

Surgical principles are based on anatomic location but are based on releasing chordee, create new urethra, and advancing the urethral meatus to tip of penis

Epispadias: urethral opening on the dorsal aspect of the penis; occurs much less commonly than hypospadias

Surgical options based on urethral opening locations

Peyronie’s disease: affects 3-9% of the population aged 40-60

Surgical considerations:

Indications: inability to engage in sexual activity, failed conservative management

Surgical techniques can involve plication of tunica or dermal grafts depending on severity

Scrotum: defects are most commonly related to Fournier’s gangrene, HPV, squamous lesions, or other cutaneous malignancy

Split thickness skin grafts: temporize with NPWT

Gracilis flap

Pedicled fasciocutaneous flaps (Singapore, perforator flaps, lateral thigh flaps)

Reconstruction needs to be able to provide temperature regulation to preserve testicular function

Vulva:

Defects can arise from oncologic defects, HPV, squamous cell carcinoma

Options can include:

Singapore flaps

Fasciocutaneous thigh perforator flaps

Pedicled gracilis flaps

Groin flaps

Vagina:

Oncologic wounds, HPV, and vaginal, cervical, uterine, colorectal malignancies can result in vaginal canal defects

Defect classification is shown in Fig. 3

Figure 3. Vaginal defect classification system as proposed by Cordeiro et al. From Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg. 2002 Sep 15;110(4):1058-65.

Based on defect location and size, reconstructive options can vary (Fig. 4)

Partial defects:

Anterior/lateral wall: Singapore flaps

Posterior wall: VRAM (Fig. 5)

Circumferential defects:

Upper two-thirds: VRAM

Total: bilateral gracilis flaps

Intestinal flaps have also been utilized (ileum, sigmoid colon)

Mons pubis (Fig. 4):

Local flaps (random pattern or advancement flaps) can give successful reconstruction when wound is not radiated

In setting of radiation, regional fasciocutaneous or myocutaneous flaps are required (commonly ALT)

Perianal (Fig. 4, 5):

Commonly from anal cancer or rectal cancer requiring abdominoperineal resection (APR)

Utilize the VRAM flap if abdomen is available, if not bilateral gluteal advancement flaps can be performed

Bilateral gluteal advancement flaps can be performed in conjunction with an omental flap to eliminate pelvic dead space if abdomen is available but VRAM unavailable

Figure 4. Perineal reconstruction algorithm. From Mericli AF, Martin JP, Campbell CA. An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction. Plast Reconstr Surg. 2016 Mar;137(3):1004-1017.

COMPLICATIONS

Complication rates will depend on the pathology and type of reconstruction

Notably APR performed after neoadjuvant chemotherapy and radiation can have wound complication rates of 40-60% without flap reconstruction

Figure 5. Inset of a VRAM flap into the perineum for a combined vaginal, perineal raphe, and perianal wound. From Mericli AF, Martin JP, Campbell CA. An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction. Plast Reconstr Surg. 2016 Mar;137(3):1004-1017.

Wound/scars

Infection

Chronic pain

Utilization of pelvic therapy after perineal reconstruction can be helpful in treatment

Sexual dysfunction

Urinary dysfunction

Vaginal stenosis

REFERENCES

Asaad M, et al. Surgical Outcomes of Vertical Rectus Abdominis Myocutaneous Flap Pelvic Reconstruction. Plast Reconstr Surg. 2024 Nov 1;154(5):1105-1114.

Campbell CA, Butler CE. Use of adjuvant techniques improves surgical outcomes of complex vertical rectus abdominis myocutaneous flap reconstructions of pelvic cancer defects. Plast Reconstr Surg. 2011 Aug;128(2):447-458.

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 Jan;123(1):175-183.

Mericli AF, Martin JP, Campbell CA. An Algorithmic Anatomical Subunit Approach to Pelvic Wound Reconstruction. Plast Reconstr Surg. 2016 Mar;137(3):1004-1017.

Cordeiro PG, Pusic AL, Disa JJ. A classification system and reconstructive algorithm for acquired vaginal defects. Plast Reconstr Surg. 2002 Sep 15;110(4):1058-65.

Weichman KE, Matros E, Disa JJ. Reconstruction of Peripelvic Oncologic Defects. Plast Reconstr Surg. 2017 Oct;140(4):601e-612e.

Crosby MA, et al. Outcomes of Partial Vaginal Reconstruction with Pedicled Flaps following Oncologic Resection. Plast Reconstr Surg. 2011 Feb;127(2):663-669.

Kim JT, Yew Ming Ho S, Hwang JH, Lee JH. Perineal perforator-based island flaps: the next frontier in perineal reconstruction. Plast Reconstr Surg. 2014 May;133(5):683e-687e.

Chapter 18
Pressure Injuries

Rosevine A. Azap, MD
Adam O’Toole, MD

TERMINOLOGY

“Pressure injury” is the preferred term over “pressure/decubitus ulcer” or “bed sore”

Decubitus was a term to describe lying position; however, any position that causes sustained pressure to an area (e.g., sitting/supine/side position) can cause a pressure injury

Can also occur due to casting or splinting after surgical procedures

Pressure injury, defined: ischemic tissue loss resulting from pressure, usually over a bony prominence

STAGING

National Pressure Injury Advisory Panel (NPIAP) redefined the definition of pressure injuries in 2016 (Fig. 1)

Stage I: non-blanchable erythema of intact skin

Stage II: partial thickness skin loss with exposed dermis

Stage III: full-thickness skin loss

Stage IV: full-thickness skin and tissue loss with exposed fascia, muscle, tendon, ligament, cartilage, or bone

Unstageable: full-thickness skin and tissue loss in which the extent of tissue damage cannot be determined because it is obscured by slough or eschar

Deep tissue injury: persistent non-blanchable deep red, maroon, or purple discoloration

Figure 1. Staging system for pressure injuries. Reference: Emily Geisler, MD

"ICEBERG PHENOMENON"

The skin damage visualized often underestimates the true depth and extent of the underlying tissue injury. This is due to underlying muscle being more susceptible to ischemia than skin.

EPIDEMIOLOGY

Pressure injuries are a common complication with costly implications to the healthcare system. This reflects systemic issues in mobility, nutrition, and access to care.

Acute inpatient care: the prevalence of pressure injuries is 12.7%, with a hospital-acquired incidence of 10%

Quadraplegic (tetraplegic) patients:

Prevalence of pressure injuries is 33.9% in long-term care settings, with some studies reporting that up to 73.4% of tetraplegic spinal cord-injured individuals experience a pressure injury at some point post-injury.

Bedbound hospital patients (general hospitalized patients):

Prevalence of pressure injuries is 12.8% and the incidence of hospital -acquired pressure injuries is 8.4%

Intensive care unit (ICU) patients:

Prevalence of pressure injuries in ICU patients is 16.9– 26.6%, and the incidence ranges from 10% to as high as 25.9%.

Hip fracture patients:

Incidence of pressure injuries during hospitalization is 22.7–27%

In geriatric hip fracture patients, the postoperative pressure injury rate is 5.15%

COST

In the United States, the average incremental cost per hospital acquired pressure injury is approximately $21,767 per patient, with higher costs for more severe injuries. Nationally, hospital-acquired pressure injuries are estimated to cost the US healthcare system up to $26.8 billion annually, with the majority of costs attributable to advanced-stage (stage III and IV) injuries. For surgical patients, hospital acquired pressure injuries add about $8,200 to the cost of a hospital stay, representing a 44% increase over baseline costs.

AFFECTED BODY AREAS

Often form on skin that covers bony areas (Fig. 2)

Most common (order varies in literature): sacrum/coccyx > heels > ischial tuberosities (in spinal cord injury) or hips/trochanters

(general/ICU/hip fracture patients) > other bony prominences

Spinal cord injury patients: ischial tuberosities > sacrum/coccyx, heels, and trochanters

Bedbound hospital patients: sacrum > heels > hips/trochanter

ICU patients: sacrum > heels > hips/trochanter > ears and shoulders

Patients with hip fractures: sacrum > heels

Figure 2. Pressure injury locations. Reference: Emily Geisler, MD

RISK FACTORS

Extrinsic: non-physiologic, environmental factors

Pressure (perpendicular force) leads to deep necrosis; can develop after 2 hours of unrelieved pressure

Shear (parallel force) leads to superficial necrosis due to perforator compromise

Friction

Moisture

Intrinsic: physiologic factors

Altered activity/mobility

Cognitive deficit or altered consciousness

Decreased autonomic control (e.g., incontinence)

Infection → sepsis/ischemia

Increased age

Sensory loss

Chronic illness: vascular disease/anemia

Malnutrition

Medications/immunocompromised (e.g., steroids)

Risk assessment:

Braden risk assessment scale: measures pressure injury risk using 6 domains (sensory perception, moisture, activity, mobility, nutrition, and friction/shear)

Norton risk assessment scale: measures pressure injury risk using 5 domains (physical condition, mental condition, activity, mobility, and incontinence)

TREATMENT

Non-surgical

Prevention is the best treatment

Skin care and moisture control

Repositioning: supine turn every 2 hours (avoid dragging/ shearing skin of the patient while repositioning), seated lift every 10 minutes

Optimizing nutrition and comorbidities

Manage spasticity

Relieving pressure using air mattresses, cushions, heel protectors

Air-fluidized beds (Clinitron®) gold standard for pressure injury prevention

Systemic infection/sepsis unlikely with pressure injury (unless immunocompromised): look for other sources, e.g., urinary tract infection or respiratory tract when patients with pressure injuries presenting with fevers and leukocytosis

If localized infection is present (look for signs of local cellulitis), topical antimicrobial agents (Silvadene®, Sulfamylon®) can be used and, if needed, oral or IV antibiotics

Bone biopsy is the gold standard to assess osteomyelitis

Can direct antibiotic therapy to treat osteomyelitis, but virtually impossible to eradicate infection with antibiotics alone

MRI may be helpful as imaging study, while bone scans are often non-specific due to presence of periostitis associated with open wounds

Long-term antibiotics are not indicated

Pressure0injury closure may be accelerated using topical protein growth factors

Stage III-IV patients require sharp debridement, highly absorptive dressings (alginates, hydrocolloid beads, foams, hydrogels)

Negative pressure wound therapy (NPWT) may be beneficial to assist closure

Surgical

Patient motivation is an important determinant of recurrence risk in the alert patient

Pre-operative planning to consider: social history (smoking history, support system, etc.), spasticity management, bladder habits (urinary diversion/urostomy), bowel regimen (diverting colostomy), nutritional status (assess baseline labs, including ESR, CRP, albumin, and prealbumin), wound cultures, wound care, and postoperative positioning and resources

Due to high recurrence rates, surgery tends to be reserved for patients with reversible pathologies and stage III/IV pressure injuries

Excisional debridement of pressure injury and bursa and any heterotopic calcification is necessary

Closure of the wound should be performed using healthy, durable tissue that can provide adequate padding over the bony prominence (myocutaneous vs. fasciocutaneous flap) and is tension-free, keeping in mind post-operative positioning

Reconstruction of pressure injuries varies by anatomic site:

Sacrum: lumbosacral fasciocutaneous flap, unilateral/bilateral gluteal fasciocutaneous or myocutaneous rotation flap, bilateral gluteal myocutaneous V-Y advancement flap

Ischium: gluteal fasciocutaneous or myocutaneous rotation flap, posterior hamstring myocutaneous V-Y advancement flap, posterior thigh fasciocutaneous flap, gracilis flap, tensor fascia lata (TFL) flap

Trochanter: TFL flap ± vastus lateralis

Girdlestone procedure is utilized for trochanteric pressure injuries for extensive bony involvement

Partial or complete ostectomy to reduce bony prominence – may lead to new pressure injuries elsewhere (be careful when off-loading)

Aftercare including appropriate surfaces and wound management are paramount

Lifestyle and activity modification often required in order to reduce recurrence risk

Complications and recurrence:

Hematoma, infection, wound dehiscence

Recurrence: overall 7-82%

Long-term complications include Marjolin’s ulcer

REFERENCES

Zeller JL, Lynm C, Glass RM. Pressure Ulcers. JAMA. 2006;296(8):1020.

Wassel CL, et al. Risk of Readmissions, Mortality, and Hospital-Acquired Conditions Across Hospital-Acquired Pressure Injury (HAPI) Stages in a US National Hospital Discharge Database. Int Wound J. 2020;17(6):1924-1934.

Padula WV, Delarmente BA. The National Cost of Hospital-Acquired Pressure Injuries in the United States. Int Wound J. 2019;16(3):634-640.

Spector WD, et al. Marginal Hospital Cost of Surgery-Related Hospital-Acquired Pressure Ulcers. Med Care. 2016;54(9):845-51.

Shiferaw WS, et al. The Global Burden of Pressure Ulcers Among Patients With Spinal Cord Injury: A Systematic Review and Meta-Analysis. BMC Musculoskelet Disord. 2020;21(1):334.

Cowan LJ, et al. Pressure Ulcer Prevalence by Level of Paralysis in Patients With Spinal Cord Injury in Long-Term Care. Adv Skin Wound Care. 2019;32(3):122-130.

Le Fort M, et al. Risk Analyses of Pressure Ulcer in Tetraplegic Spinal Cord-Injured Persons: A French Long-Term Survey. Arch Phys Med Rehabil. 2017;98(9):1782-1791.

Li Z, et al. Global Prevalence and Incidence of Pressure Injuries in Hospitalised Adult Patients: A Systematic Review and Meta-Analysis. Int J Nurs Stud. 2020;105:103546.

Tervo-Heikkinen TA, et al. Pressure Injury Prevalence and Incidence in Acute Inpatient Care and Related Risk Factors: A Cross-Sectional National Study. Int Wound J. 2022;19(4):919-931.

Chaboyer WP, et al. Incidence and Prevalence of Pressure Injuries in Adult Intensive Care Patients: A Systematic Review and Meta-Analysis. Crit Care Med. 2018;46(11):e1074-e1081.

Labeau SO, et al. Prevalence, Associated Factors and Outcomes of Pressure Injuries in Adult Intensive Care Unit Patients: The DecubICUs Study. Intensive Care Med. 2021;47(2):160-169.

Fulbrook P, et al. State-Wide Prevalence of Pressure Injury in Intensive Care Versus Acute General Patients: A Five-Year Analysis. J Clin Nurs. 2023;32(15-16):4947-4961.

González-Méndez MI, et al. Incidence and Risk Factors Associated With the Development of Pressure Ulcers in an Intensive Care Unit. J Clin Nurs. 2018;27(5-6):1028-1037.

Jia YJ, et al. Incidence, Prevalence and Risk Factors of Device-Related Pressure Injuries in Adult Intensive Care Unit: A Meta-Analysis of 10,084 Patients From 11 Countries. Wound Repair Regen. 2023 Sep-Oct;31(5):713-722.

Chiari P, et al. Predictive Factors for Pressure Ulcers in an Older Adult Population Hospitalized for Hip Fractures: A Prognostic Cohort Study. PloS One. 2017;12(1):e0169909.

Forni C, et al. Prospective Prognostic Cohort Study of Pressure Injuries in Older Adult Patients With Hip Fractures. Adv Skin Wound Care. 2018;31(5):218-224.

Galivanche AR, et al. Postoperative Pressure Ulcers After Geriatric Hip Fracture Surgery Are Predicted by Defined pre-operative Comorbidities and Postoperative Complications. J Am Acad Orthop Surg. 2020;28(8):342-351.

Rosin NR, et al. A Primary Care Provider's Guide to Prevention and Management of Pressure Injury and Skin Breakdown in People With Spinal Cord Injury. Top Spinal Cord Inj Rehabil. 2020;26(3):177-185.

Visconti AJ, Sola OI, Raghavan PV. Pressure Injuries: Prevention, Evaluation, and Management. Am Fam Physician. 2023;108(2):166-174.

Liu Y, et al. The Prevalence, Incidence, and Associated Factors of Pressure Injuries Among Immobile Inpatients: A Multicentre, Cross-Sectional, Exploratory Descriptive Study in China. Int Wound J. 2019;16(2):459-466.

Edsberg LE, et al. Revised National Pressure Ulcer Advisory Panel Pressure Injury Staging System: Revised Pressure Injury Staging System. J Wound Ostomy Continence Nurs. 2016;43(6), 585-597.

Bauer J, Phillips LG. CME Article: Pressure Sores. Plast Reconstr Surg. 2008; 121 (1 Suppl): 1-10.

Janis JE, O’Reilly EB. Pressure Sores. In: Janis JE, ed. Essentials of Plastic Surgery. ²nd ed. Boca Raton: CRC Press, 2014. 641-650. Print.

ASPS Resident Education Center.

Chapter 19
Hand and Upper Extremity

Evan B. Lynch, MD, PhD
Amy C. Kite, MD

The hand conveys dexterity, sensation, and strength—factors essential to patient function and identity. For the plastic surgeon, mastery of hand surgery reflects the understanding of intricate anatomy, structural problem solving, and patient goals. Hand surgeons have a broad practice including acute trauma, congenital abnormalities, peripheral nerve, microsurgical reconstruction and replantation, elective hand surgery, and dermatological conditions. The hand poses challenges that require both technical skill and an appreciation of form and function. Advances in microsurgery, nerve transfers, tendon repair, and biologic scaffolds continue to transform outcomes for patients. This chapter provides the fundamental knowledge in anatomy, pathophysiology, and surgical decision-making. We provide a comprehensive overview of recent technical advances in hand surgery essential for all practitioners engaged in the care of patients with upper extremity complaints.

HAND ANATOMY

Nerves

Sensory: median, ulnar, radial sensory nerves (Fig. 1)

Motor: intrinsic muscles of hand

Median nerve: thenar muscles, radial lumbricals

Ulnar nerve: interossei, ulnar lumbricals, hypothenar muscles

Figure 1. Hand sensory distribution.

Muscles and tendons (Table 1)

Flexor system (Fig. 2)

Extrinsic flexors

Flexor digitorum profundus (FDP): attaches to distal phalanx and bends the distal interphalangeal joint (DIPJ), proximal interphalangeal joint (PIPJ), and metacarpal phalangeal joints (MCPJ)

Flexor digitorum superficialis (FDS): attaches to middle phalanx and bends PIP and MCPJ

Intrinsic flexors: lumbricals and interossei contribute to MCPJ flexion

Extensor system (Fig. 3)

Extrinsic extensors:

Join the extensor hood at the proximal phalanx and extend the MCPJ

Extrinsic extensor tendon trifurcates and the central slip inserts on the dorsal middle phalanx and the remaining tendon splits to form the lateral slips, which are joined by the lumbricals to form the conjoined lateral band

Intrinsics: interossei and lumbricals; pass volar to the axis of the MCPJ (where they act as flexors) and move dorsal to the axis of the PIPJ to insert on the dorsal distal phalanx

Act as extensors of the PIP and DIP joints

Conjoined lateral band converges distally to form the terminal tendon and inserts onto the dorsal distal phalanx base and extends the DIPJ

At the wrist, the extensors are encased on the extensor retinaculum, which is superficial and prone to injury (Fig. 4)

Table 1. Hand muscle actions and innervations.

Figure 2. Flexor tendon system. From Khor WS, Langer MF, Wong R, Zhou R, Peck F, Wong JKF. Improving Outcomes in Tendon Repair. Plast Reconstr Surg. 2016;138:1045e–1058e.

Figure 3. Extensor tendon system. From Rockwell WB, Butler PN, Byrne BA. Extensor tendon: anatomy, injury, and reconstruction. Plast Reconstr Surg. 2000;106: 1592-603, 1673.

Skeleton (Fig. 5)

Figure 4. Extensor compartments of the hand: (1st) APL, EPB; (2nd) ECRL, ECRB; (3rd) EPL; (4th) EDC, EIP; (5th) EDQ; (6th) ECU. From Rockwell WB, Butler PN, Byrne BA. Extensor tendon: anatomy, injury, and reconstruction. Plast Reconstr Surg 2000;106:1592-603, 1673.

Figure 5. Bones of the hand. From Marks M, Marks C. Fundamentals of Plastic Surgery. Philadelphia:W.B. Saunders Co., 1997.

INITIAL EVALUATION OF THE INJURED HAND

Evaluation of ABC’s

Hand injuries are frequently associated with multisystem trauma

Patient must be stable and cleared from a trauma standpoint before further evaluation

History

Time and place of accident

Mechanism of injury (position of hand while injured)

Right- or left-hand dominance

Occupation

Age

Comorbidities and medications

Examination

Observation

Position of fingers: the resting cascade of the fingers is in slight flexion and pointing towards the scaphoid due to the relative pull of the flexors superseding the extensors

An abnormally straight finger might indicate a flexor tendon injury (the unopposed extensors hold the finger straight)

Great way to evaluate for malrotation in the setting of fractures.

Sweating patterns: lack of perspiration may indicate denervation, or increased vasomotor activity might indicate complex regional pain syndrome (CRPS)

Anatomic structures beneath the injury

Sensory: must test prior to administering anesthesia

Tools

Two-point discriminator (subjective assessment)

Semmes-Weinstein Monofilament testing (objective assessment)

Test all sensory territories (median, ulnar, radial)

Test both sides of each finger to test radial and ulnar digital nerves

Motor:

Profundus: stabilize PIP joint in extension, ask patient to flex fingertip (Fig. 6)

Superficialis: stabilize other DIP joints in extension to neutralize profundus action

Ask patient to flex unstabilized finger (Fig. 7)

Motor branch of median nerve; test palmar abduction of thumb against resistance

Motor branch of ulnar nerve; ask patient to fully extend fingers, then spread fingers or cross fingers

Extensor tendons

Ask patient to extend fingers at MCP joints with hand flat on table (tests long extensors)

Ask patient to extend PIP, DIP joints with MPs flexed (tests intrinsic extensors)

Figure 6. Testing profundus function.

Figure 7. Testing superficialis function.

Vascular

Color: nailbed should be pink, blanch with pressure, and show capillary refill around two seconds

Temperature: finger or hand should be similar in temperature to uninjured parts

Turgor: pulp space should be full without wrinkles

Pulse oximetry/doppler are useful adjuncts to physical exam findings

Management:

Initial:

If there is significant bleeding, apply direct pressure or wrap with a pressure dressing to the affected area

Do not clamp vessels

Lidocaine with epinephrine can aid in exploration but only after neuro examination is completed

Avoid epinephrine in the digits if there is a concern that the vascular supply is compromised

Tourniquet at 250 mmHg may be used as last resort, but must be released intermittently

Do not use a tourniquet longer than two hours

Splint in safe position if possible (Fig. 8)

Intrinsic plus position:

Collateral ligaments are at maximum tension, so motion can be regained with least effort

Wrist extended (30o), MCP joints flexed (60-70o), IP joints straight, thumb abducted and rotated in opposing position

Proper splinting prevents further injury, prevents vessel obstruction, prevents further tendon retraction

All flexor tendon, nerve and vascular injuries, open fractures, and complex injuries are managed in the operating room

Many injuries can be treated in the emergency department or clinic using field blocks, digital blocks or wrist blocks

Tetanus prophylaxis and antibiotic coverage as indicated

Definitive:

Thorough cleaning of entire hand and forearm, with wound protected

Apply sterile drapes

Inspect wound: use tourniquet or BP cuff for hemostasis

Wound irrigation with normal saline

May need to extend wound to inspect all vital structures

Assure hemostasis with fine clamps and cautery

Nerve injuries should be repaired with magnification

Tendons should be repaired primarily if possible

Flexor tendon injuries in Zone II, classically referred to as ”no man’s land” (Fig. 9), should be repaired by a trained hand surgeon

Primary repair depends on laceration thickness (full or partial)

Partial thickness injuries (<50%) may benefit from nonoperative intervention (if no clinical symptoms, like triggering, are present) or epitendinous suture alone

Full thickness injuries require 4-core strand suture technique at a minimum

Epitendinous sutures are used to reduce gapping and improve tendon gliding

If a hand surgeon is not available, clean and suture the skin wound, splint the hand, and refer as soon as possible for delayed primary repair

Repair should be done within 14 days

Reduce all fractures and dislocations, apply internal or external fixation if needed

Irreducible dislocations require operative management

Post-operative dressings

Splinting should be in safe position when possible

Dressings should not be tight to anticipate swelling

Figure 8. Position of safety

Figure 9. Flexor zones of the hand

SPECIAL INJURIES

Fingertip: most common injury

Tip amputations

Basic principles: maintain length, bulk and sensibility

Treatment options include secondary healing, skin graft, local flap

Pediatric amputations: children under 4 years old have enhanced rates of neovascularization, so composite grafting of the amputated tip sometimes leads to repair without microsurgical techniques

Composite amputations should be reserved for young children, with clean amputated tips undergoing sharp (not crush or avulsion) injuries

Nailbed injury:

Nailbed typically repaired with fine resorbable suture

Nail can be cleaned and replaced as a splint, or silastic sheet used as splint to prevent adhesion of the eponychial fold to the nailbed

Amputation:

Indications for replantation: thumb, multiple digits, proximal amputations such as hand or arm, zone 1, and children

Relative contraindications to replantation include segmental defects, single finger (nonthumb) in zone II injuries, severe crush or avulsion injury, significant comorbidities, or life-threatening trauma

Care of amputated part

Remove gross contamination and irrigate with saline

Wrap part in gauze moistened in saline, place in clean plastic bag or specimen cup, seal

Lay plastic bag/container on ice, or float on ice cubes in water; don’t immerse part directly in ice water or pack directly in ice

Include amputated segment in the X-ray

Burned hand:

Initial treatment

Cleanse wound, debride blisters

Determine depth of burn and body percentage

Evaluate blood supply; circumferential full thickness burns may require escharotomy

Layered dressing: apply antimicrobial layer (such as bacitracin or other ointments), non-stick layer (Vaseline- impregnated gauze), absorbent layer, and compressive layer

Elevate burned limb, immobilize in safe position to prevent contractures

Refer to plastic surgeon if burn is extensive or may require grafting

Hand therapy may be needed to maintain motion

Frostbite:

If acute needs rapid rewarming in a water bath at 38-42oC for 15 min intervals

Elevate, debride clear blisters, leave hemorrhagic blisters intact

Referral to burn center for evaluation and further management

INFECTIONS

General principles:

Infection can be localized by finding:

The point of maximum tenderness

Fluctuance is associated with an abscess, and often has a central opening with draining pustular fluid

Area of erythema and edema; erythema or ascending lymphangitis usually denotes lymphatic involvement

Pain with motion

Pressure from edema and purulent fluid in a closed space can produce necrosis of tendons, nerves, blood vessels, and joints in a few hours

Extreme cases can lead to amputation and even death

Infections that need immediate operative drainage or debridement:

Flexor tenosynovitis

Evaluate for Kanavel’s four cardinal signs (semi flexed position of finger, dactylitis (sausage digit), tender over flexor sheath, pain with passive extension)

Treatment is to open and irrigate tendon sheath

Untreated infection can destroy the tendon

Broad-spectrum antibiotics

Deep space infections of the hand

Septic arthritis (beware the fight bite, often tooth penetrates and seeds bacteria into MCPJ)

Necrotizing fasciitis (necrotizing soft tissue infection, NSTI)

Clinical diagnosis, life-threatening

Exam often shows pain out of proportion, bullae, crepitus

Subcutaneous emphysema can be seen on XR

LRINEC score can also be helpful

Do not wait for advanced imaging for operative debridement if there is a suspicion for NSTI

Treatment principles:

Surgical drainage, cultures

Immobilization in safe position, elevation

Antibiotics

Common infections:

Paronychia: infection of the lateral nail fold

Treatment:

If early, incision along the margin left open to drain

If late, with pus under nail, must remove nail

Felon: Infection pulp space of fingertip; closed space without ability to expand so very painful

Treatment is drainage utilizing a midvolar incision

“Fishmouth” or transverse incisions are contraindicated due to potential injury of the neurovascular bundle

Approach on the ulnar side for the index, long and ring fingers

Approach on the radial side for the thumb and small finger

Septate of pulp must be divided to ensure adequate drainage

Subcutaneous abscess: incise and drain with care not to injure digital nerve

Be alert to possibility of foreign body

Bite injuries:

Debride, cleanse thoroughly, culture

Screen patients for rabies prophylaxis based on wound and local exposure risk – intralesional immunoglobulin postexposure prophylaxis can be indicated in addition to the rabies vaccine

Must rule out penetration of joint space – may need to explore in OR

Do not close wound

Special considerations stratified by vehicle

Human bite: concern for Eikenella corredens (Augmentin), evaluate for possible zone V extensor tendon injury

Dog bite: concern for Pasteurella spp (Augmentin)

Cat bite: concern for Pasteurella and Bartonella (Augmentin), increased risk of occult infection due to inoculation depth

FRACTURES

General principles:

Evaluate digits for angulation or malrotation, palpate for tenderness, check range of motion

XR in multiple planes:AP, true lateral, oblique

Anatomic reduction

Restoration of bony alignment, joint congruence and rotational stability

Minimizes abnormal loading to prevent traumatic arthritis, malunion or nonunion

Immobilize for fracture healing

Prevent micromotion at the site of repair

Hand therapy to maintain motion – immobilization leads to stiffness

Specific fractures:

Metacarpal fractures:

Generally unstable fractures, can accept 10-40° angulation depending on metacarpal affected (greater angulation tolerated in ulnar MCs), if no malrotation present

Assess malrotation/scissoring – have patient make a fist slowly, if involved finger overlaps another, there is rotation at the fracture site, which must be reduced

If angulation/malrotation are acceptable – treatment with splinting with buddy taping may be sufficient

If fracture is unstable with malrotation, closed fixation with percutaneous pinning, open reduction with plates and screws, or intramedullary headless compression screws may be performed

Phalangeal fractures:

Unstable fractures require internal or percutaneous fixation

Tuft fractures (distal phalanx):

If crushed, mold to shape

Repair associated nailbed injury if needed (see above)

Splint for comfort (DIP only) for 1-2 wks

Intra-articular fractures:

Definitive management depends on the level of stability (see below, joint injuries)

Stable intra-articular fractures can be managed with immobilization and rehabilitation with joint protection

Unstable fractures, or fractures with > 2mm of step off require operative fixation to improve patient reported and functional outcomes

JOINT INJURIES

Dislocation

If already reduced, test for stability through arc of motion

Test collateral ligament stability with radial and ulnar stressing at affected joint

Test MPJ in flexion and IP joints in extension

Compare laxity to contralateral side to establish baseline

Most can be treated with closed reduction; open reduction is be necessary when closed reduction fails, often soft tissue prevents the reduction

Ligamentous injury: usually lateral force

Skier’s thumb: acute rupture of the ulnar collateral ligament of the MCP joint, requires operative repair

Gamekeeper’s thumb: chronic rupture of ulnar collateral ligament of MCP joint due to repetitive valgus stress and attenuation

Requires operative reconstruction

Wrist injury: multiple ligaments can be involved

Diagnosis may require MRI arthrogram or arthroscopy

Clinical diagnosis by pattern of pain, x-rays, palpation for abnormal movement

Treatment

Immobilize 2-3 weeks for digital joint injury (MP or IP dislocation), then protected motion

Thumb MPJ and wrist sprains require 6 weeks immobilization (some, e.g., thumb ulnar collateral ligament, might need operative repair)

NERVE INJURIES

Traumatic peripheral nerve injuries

Anatomy

Nerve is comprised of neurons, supportive glial cells (including Schwann cells which produce myelin) and connective tissue

Motor nerves originate from the anterior horn of the spinal cord, while sensory nerves carry afferent nerve signals from the periphery to the dorsal root ganglion

Neurons are structured in specific layers linking form and function (Fig. 10)

Specialized connective tissue called the endoneurium surrounds the nerve fibers which are separated into fascicles

Figure 10. Anatomy of a peripheral nerve. Republished with permission from Green’s Operative Hand Surgery, 7th edition.

Timing:

Classically, nerves heal 1 mm a day (metric) or 1 inch a month (imperial)

3-to-6 months: injuries may be neuropraxic or axonometic (see below), which carry excellent recovery rates

Performing electromyography (EMG) helps tease out recovery potential and need for surgical intervention

6-to-12 months: injuries explored at this time may have recovery potential if distal, but recovery distance to distal target may preclude repair for very distal targets from the injury, nerve transfer may be indicated

12 months and beyond: low recovery potential, should consider tendon transfers or free functional muscle transfer (FFMT, typically gracilis)

Initial management of injury:

Perform motor and sensory exam after injury

Thoroughly irrigate and close all wounds if not emergent, or explore emergent or highly contaminated wounds in the operating room

Mechanisms of injury:

Nerve injuries occur through sharp, crush, avulsion and blast mechanisms in the hand and upper extremity

Sharp injuries: treat with primary coaptation of transected distal and proximal segments with 8-0 nylon suture under loupe or microscope visualization

Early management leads to better outcomes

For non-sharp injuries, resect proximal and distal segments until healthy fascicles are appreciated

Perform direct coaptation if possible

If nerve gaps exist

<3 cm: perform interposition reconstruction using nerve autograft or allograft

>3 cm: perform with interposition cable grafting from autologous nerve (sural most common donor nerve)

Nerve pathology:

Classification of nerve injury

Nerve injury is classically defined by the Sunderland classification (Fig. 11)

Figure 11. Sunderland classification of nerve injury. Republished with permission from Green’s Operative Hand Surgery, 7th edition.

A terminal neuroma occurs due to disorganized healing of injured fascicles at site of injury

These clinically lead to both phantom limb pain and residual limb pain

Diagnosis includes a positive Tinel sign (electrical symptoms elicited by tapping at the site of neuroma), improvement of pain with lidocaine injection at the site or neuroma, or ultrasound imaging

Surgical management of neuromas and transected nerves (amputation)

Excision, traction neurectomy, burying nerve in muscle or bone

Regenerative peripheral nerve interface (RPNI): implantation of the terminal nerve end into a free, nonvascularized muscle graft

Targeted muscle reinnervation (TMR): coaptation of the terminal nerve end into a sacrificed motor nerve branch of a local muscle

Centro-central coaptation: Direct coaptation of both digital nerve ends of the same finger centrally within the pulp

TMR and RPNI creates an EMG signal which can control a myoelectric prosthesis

Nerve transfers

Sacrificing nonessential nerve functions to enhance recovery of essential function

Brachial plexus injury

Anatomy

Brachial plexus is derived from the spinal roots C5-T1 and further subdivided by trunks, divisions, cords and branches (Fig. 12)

Injuries are characterized based on their location relative to the dorsal root ganglion

Preganglinotic injuries compromise root avulsions from the spinal cord

Postganglionic injuries compromise traction injuries or lacerations distal to the dorsal root ganglion

Figure 12. Brachial plexus. Republished with permission from Green’s Operative Hand Surgery, 7th edition.

Injuries can be diagnosed with MRI to assess for pseudomeningocele in root avulsions, EMG to assess postganglionic stimulation and intraoperative sensory nerve action potentials (SNAPs)

Recovery potential depends on location of injury and timing

For non-recoverable nerve injuries, nerve transfers are indicated to restore essential functions of the upper extremity, primarily elbow flexion, shoulder stability and hand function

Nerve compressions: compression of nerve by overlying muscle, ligament or fascia

Common examples:

Carpal tunnel: compression of median nerve by transverse carpal ligament at the wrist

Cubital tunnel: compression of ulnar nerve at elbow

Major sites of compression of the ulnar nerve around the elbow include the medial intramuscular septum proximally, Arcade of Struthers, Osborne’s ligament, aponeurosis of the two heads of the FCU (can be contiguous with Osborne’s) and the deep flexor/pronator aponeurosis distally. In 11% of the population, an accessory muscle, the anconeus epitrochlearis, replaces Osborne’s ligament and is an additional site of compression

Diagnosis by symptoms, exam, and EMG

Tinel’s sign: percussion of area leads to radiating pain through nerve distribution

Muscle wasting of hands (intrinsics for ulnar nerve compression, thenar for median nerve)

Treatment options include splinting, NSAIDs, steroid injections, surgical release

CONGENITAL DEFECTS

Common defects:

Polydactyly: most common

Duplication of fingers, usually border digits

Duplication of 5th finger is common autosomal dominant trait in African-Americans

Thumb duplication often requires reconstructive surgery, and is characterized by the Wassel classification system

Syndactyly: 2nd most common

May be simple, involving skin and soft tissue only, complex, involving bone, and complicated, involving additional abnormalities including extra bones, abnormal tendons or ligaments

Treatment: goal to decrease deformity and improve function

Some problems are treated in infancy (e.g., splinting for club hand, thumb reconstruction)

Some treated by 12 months, before handedness develops – e.g. separation of syndactyly

Some require multi-stage procedures

HAND TUMORS

Benign:

Ganglion cysts: most common tumor of upper extremity

Synovial cyst of joint or tendon sheath

Most common location scapholunate ligament

Treatment is observation, aspiration, or excision (aspiration with high recurrence, less so in children)

Giant cell tumor: second most common tumor, arises from proliferation from tendon sheath

Glomus tumors: tumors of thermoregulatory neuromyoarterial apparatus

Presents with pain and temperature sensitivity at base of nail

Located in nail matrix

Bone tumors: enchondroma, osteoid osteoma

Malignant:

Skin cancers (e.g., basal cell, squamous cell, melanoma)

Malignant bone tumors are uncommon in hand

MISCELLANEOUS

Rheumatoid arthritis: synovial hypertrophy leads to severe joint destruction

Less commonly seen now with disease modifying drugs

Hand surgeons can perform synovectomy, joint replacement, carpal tunnel release

Dupuytren’s contracture: fibrous contraction of palmar fascia causes flexion contractures of fingers

Treatment is surgical excision, percutaneous release with a needle (needle aponeurotomy) or Xiaflex (collagenase) for MCPJ contractures

Surgical intervention is often indicated when there is PIPJ contractures

Compartment syndrome: surgical emergency characterized by increased pressure within a closed myofascial space

Leads to compromised tissue perfusion, ischemic complications when capillary perfusion pressures are exceeded by intra-compartmental pressures from trauma and/or infection

Key clinical exam features include pain out of proportion to injury (earliest and most reliable clinical sign), pain with passive range of motion, paresthesias with tense swollen compartments

Late signs include paralysis, pallor and pulselessness.

Late findings often indicate advanced, irreversible damage

Diagnosis is primarily through clinical exam

In the instance of unreliable exams (obtunded, sedated or pediatric patients), direct intracompartmental pressure measurement is performed

Treatment is emergent fasciotomy and release of the compressive forces

Complications of missed diagnosis or late diagnosis are permanent motor or sensory deficits, rhabdomyolysis from muscle breakdown and renal failure, limb loss or Volkmann’s contracture

REFERENCES

Wolfe SW, et al, eds. Green's Operative Hand Surgery. 8th ed. Elsevier: 2021.

Moran SL, et al. Nerve injuries and nerve transfers in the upper extremity. J Hand Surg Am. 2021;46(1):26-38.

Rhee PC, Jones DB, Moran SL. Targeted muscle reinnervation and regenerative peripheral nerve interfaces. Plast Reconstr Surg. 2019;144(2):327-337e.

Chung KC, Shauver MJ. Evidence-based medicine: The role of observational studies and randomized controlled trials. Plast Reconstr Surg. 2009;124(6):e305–e313.

Khor WS, et al. Improving outcomes in tendon repair. Plast Reconstr Surg. 2016;138(5):1045-1058e.

Rockwell WB, Butler PN, Byrne BA. Extensor tendon: Anatomy, injury, and reconstruction. Plast Reconstr Surg. 2000;106(7):1592-1603.

Jones NF, Shin AY, Jupiter JB, eds. Master Techniques in Orthopaedic Surgery: The Hand. Wolters Kluwer Health: 2010.

Diao E. Surgical anatomy and approaches in hand surgery. J Hand Surg Glob Online. 2020;2(2):90-98.

Chim H, Moran SL. Advances in hand surgery: Regenerative techniques and biologics. Clin Plast Surg. 2022;9(2):197-209.

Kozin SH, Zlotolow DA, Richards RR, eds. The Pediatric Upper Extremity. Springer: 2020.

Chapter 20
Lower Extremity

Annabel Baek, MD
Rajiv Parikh, MD

The plastic and reconstructive surgeon is often called upon to treat many defects of the lower extremity. These include chronic wounds of various etiologies, traumatic wounds, and oncologic resections with extensive soft-tissue loss or exposed critical structures such as bone, tendon, or vessels. A multidisciplinary approach that emphasizes patient-centered and defect-centered reconstruction is critical to success.

CHRONIC WOUNDS

Each wound requires accurate diagnosis. Not all lower extremity wounds will require surgical intervention when appropriate management is pursued. The key to healing includes wound hygiene, correction of the underlying problem, treatment of any concurrent infection, optimizing nutrition, and specific surgical intervention when appropriate. The plastic surgeon is an integral member of the multidisciplinary treatment team from the onset of the problem (Fig. 1). Remember that two different predisposing conditions may occur in the same patient. If so, the treatment must address both conditions.

Figure 1. Clinical flow diagram for management of complex lower extremity wounds. From Parikh RP, Sacks JM. Limb Salvage for Chronic Lower Extremity Wounds. Plast Reconstr Surg. 2025 Jun 1;155(6):p 1056e-1070e.

Venous stasis ulcer

Etiology: venous hypertension related to venous valvular incompetence that results in chronic inflammation and eventual skin breakdown

Appearance:

Usually found over medial malleolus

Increased edema

Increased hemosiderin deposition (dark discoloration)

Treatment:

Most heal if venous hypertension controlled

Compression is first-line: bandages (i.e., ACE wraps), bandage-like systems (i.e., Unna boots), stockings (customizable), intermittent pneumatic compression

Unna boots may heal ulcers in patients who are noncompliant with bedrest or must continue to work

Decrease edema with constant bedrest and foot elevation in addition to compression whenever possible

Pressure gradient stocking and a commitment to avoiding standing for long periods of time are necessary for long-term success

Surgery

Debridement:

Removes non-vitalized and/or infected tissue

Jumpstarts healing with fresh tissue edges that have growth factors

Skin substitutes can be utilized with success following debridement

Free tissue transfer may be required if critical structures are exposed (bones, nerves, tendons)

Important considerations pre-operatively include evaluating the superficial and deep venous systems

Anastomoses to both the superficial and deep systems may be necessary

Other surgical treatments include ablative surgery (laser, endovenous, or open) for refluxing veins and valvuloplasty

Ischemic ulcer

Etiology: proximal arterial occlusion resulting in decreased perfusion and resultant tissue ischemia

Appearance:

Usually more distal on the foot than venous stasis ulcers

Most often on lateral aspects of great and fifth toes, and dorsum of foot

No edema

No change in surrounding pigmentation

Painful

Surrounding skin may be shiny and hairless due to lack of nutrients

Diagnosis: doppler ankle/brachial indices (ABI)

0.9 to 1 is normal, 0.75-0.9 is moderate peripheral arterial disease (PAD), 0.5-0.75 is severe atherosclerotic disease, and <0.5 is critical limb ischemia

Diabetes can falsely elevate ABIs (often >1) due to calcification of vessels

Treatment:

Most require revascularization based upon angiographic findings

Following revascularization, wounds should be debrided to healthy bleeding tissue

Provided that the wound is clean and revascularization is successful, reconstruction can be performed

A more proximal amputation may be required if revascularization is not possible

Usually a skin graft will close the wound; free tissue transfer may be required if critical structures or bone are exposed

Diabetic ulcer

Etiology: multifold; decreased sensation (neurotrophic) results in unperceived traumas that then go untreated, calcified vessels can lead to decreased perfusion, and hyperglycemia negatively affects wound healing

Appearance:

Usually on plantar surface of foot over metatarsal heads or heel

Edema ±

No change in surrounding pigmentation

Treatment:

Debride necrotic tissue and use topical and systemic antibiotics to control the infection

Be conservative in care; early amputation is detrimental since patients often have limb-threatening infections in the other leg within a few years

After control of bacterial contamination, small ulcers may be excised and closed primarily; larger ulcers may require flap coverage (local or free tissue transfer)

Treatment should also include resection of underlying bony prominence

Post-operative diabetic foot care at home is paramount to proper management. Patient education in caring for and examining their feet is extremely important

Pyoderma gangrenosum

Etiology: neutrophilic dermatoses, often associated with autoimmune diseases

Appearance:

Violaceous, cutaneous ulcers that rapidly evolve

May be associated with purulence if there is superimposed infection

Treatment: very difficult to treat

May include anti-inflammatory drugs or immunosuppressives, as well as local wound care enzymatic agents

Success in treatment has been reported with hyperbaric oxygen in conjunction with local wound care

Surgical treatment is often contraindicated as excision causes perpetuation and worsening of wounds (pathergy)

ACUTE TRAUMA

Lower extremity trauma is frequently very complex, and often requires a team approach involving the orthopedic, vascular, and plastic surgeons (“orthoplastic” approach). Functional limb restoration, defined as functional, pain-free ambulation is the goal of extremity salvage operations.

Initial management

All patients with lower extremity trauma should be evaluated for associated injuries, and treated according to advanced trauma life support (ATLS) criteria

Surgical debridement and irrigation of the wound in the operating room is the proper initial management

Specific management depends upon 1) the level of injury and 2) presence or absence of vascular, nerve, and/or bony injury

Limb-threatening injuries, vascular interruption, or open fracture are best assessed and treated in the OR

Fasciotomy is often required to maintain tissue perfusion in severe high energy or crush injuries when compartment syndrome exists

Fractures of the lower leg are usually classified by the Gustilo system (Table 1)

Type I and II fractures usually have a good outcome with varied treatment

Gustilo Type III injuries have a worse prognosis and often require plastic surgical intervention

ONCOLOGIC

The primary goal for the oncologic surgeon is to achieve negative margins, which can result in a variety of defects involving heterogeneous tissues with or without exposure of vital structures. Additionally, these patients require neoadjuvant/adjuvant radiation and/or chemotherapy. Much like in traumatic reconstruction, the plastic surgeon is an integral part of a multidisciplinary team to provide durable, functional, and successful reconstruction.

Pre-operative considerations:

Discussion with the surgical oncologist to determine likely defect (size, depth, structures involved)

Pre-operative radiation therapy may render local flap options unusable

Functional status of the patient and patient goals

Final pathology with negative margins should be confirmed

Reconstruction goals:

Durable soft tissue coverage – important for the patient to be able to undergo postoperative radiation (generally initiated within 6 weeks post-operatively)

Functional restoration

TREATMENT

Non-surgical

Wound vac/negative pressure wound therapy

Applies negative pressure to aid in wound healing

Valuable for stabilization of wounds and maintaining wound bed sterility

Can accelerate wound healing in smaller defects without exposed vital structures

Surgical care

Indications for limb salvage versus amputation:

Several assessment tools exist but none have been shown to be useful as a sole guide/predictor in management

Consider co-morbidities, baseline patient mobility and function, social factors, patient goals, concomitant injuries, and whether multi-level injury

Posterior tibial nerve function as the determinate has been challenged

Some patients who initially lack plantar sensation have improvement postoperatively

Plastic surgery may still be involved in amputations to preserve length for prosthesis or optimize functional outcomes

Fillet flaps: use tissue from amputated part to close surgical site and preserve limb length

Concomitant targeted muscle reinnervation (TMR) or regenerative peripheral nerve interface (RPNI) for neuropathic pain prevention

Essentials:

Adequate debridement

Timing

Classic Godina study from 1986 advocated early coverage within 72 hours

Has been challenged, especially for more extensive injuries where patient may not be able to undergo coverage due to other critical injuries

Wound vac has probably helped increase the safe period between time of injury and time of reconstruction

Cover all vital structures (nerves, vessels, tendons, joints, hardware) within 7 to 10 days

Zone of injury

Need to debride all damaged, non-vitalized tissue

If performing flap coverage, be aware of potential microscopic vessel injury in surrounding tissue (i.e., from atherosclerosis, trauma, radiation)

This zone of injury may affect flap or recipient vessel choice

Need for vascularized tissue coverage (i.e., flap coverage)

Exposed bone and/or hardware is the most common indication for vascular tissue coverage versus skin substitute or skin graft coverage

A skin graft or skin substitute requires a healthy vascular wound bed to heal

Defect-centered reconstruction that replaces like-with-like is critical

Location: traditional upper, middle, and lower third leg options

Upper third:

Gastrocnemius

Blood supply: medial and lateral sural vessels

May use medial or lateral head, although medial head is more often used due to larger size and more favorable arch of rotation by avoiding crossing over the fibula

Peroneal nerve at risk for injury with lateral head

Middle third:

Soleus

Blood supply: popliteal vessels (proximal), posterior tibial vessels (medial belly), and peroneal vessels (lateral belly)

Divide distally to rotate into defect

May split in half if necessary

Lower third:

Considerations:

Pick a reconstruction that will support weight-bearing and/or restoring protective sensation

While local flaps exist, lower third injuries generally require free tissue transfer

Free flaps:

Considerations with flap selection: pedicle length, OR positioning (concomitant injuries), durability on heel, bony need, sensation

Defect-centered reconstruction that optimizes contour and replaces tissue loss is essential (Fig. 2)

Fasciocutaneous flaps may be easier to re-elevate for secondary hardware operations

Recipient vessel selection:

Consider pre-operative imaging with CT angiography (diagnostic only) or formal angiography (allows intervention), especially if concerns for vessel injury, peripheral vascular disease, or large zone of injury

End-to-side anastomoses recommended when critical to preserve blood flow or vessel depleted limbs (i.e., single vessel limb)

Vein grafts may be needed if large zone of injury

Figure 2. Pure skin perforator superficial circumflex iliac artery perforator flap for dorsal foot reconstruction. A 71-year-old woman presented with a dorsal foot wound and exposed tendon allograft following repair of a ruptured left tibialis anterior tendon. The patient had comorbid PVD and DM (hemoglobin A1C of 9.7). Attempts at skin substitute application with podiatry had failed and, ultimately, required free tissue transfer to bring vascularized tissue to heal the wound. (Above, right, and below, left) A pure skin perforator superficial circumflex iliac artery perforator flap from right groin was selected, as thin skin coverage was required for dorsal foot resurfacing. (Below, right) The 3-month postoperative outcome shows a well-healed flap and good contour for footwear. From Parikh RP, Sacks JM. Limb Salvage for Chronic Lower Extremity Wounds. Plast Reconstr Surg. 2025 Jun 1;155(6):1056e-1070e.

Reverse sural flap

Blood supply: peroneal vessel perforators

Controversy over whether reliable and truly more simple than free flap

If chosen, consider surgical delay to improve the perfusion and delineate viable tissue

Medial plantar flap

Blood supply: medial plantar vessels

Sensate flap

Free-style perforator flaps

Locoregional flaps based off perforators near the defect

Not necessarily a simpler option, need to consider zone of injury

Bony gaps may be filled with grafts, flaps, or distraction techniques depending on length and quality of remaining bone

Post-operative care

Elevate extremity

Splinting

Dangle protocols

Want to slowly get flap used to being in a dependent position as it will swell and get congested at first

2-vein repair may help with congestion

No hard evidence for best timeline of when to start and how quickly to advance

Physical therapy to help patient improve mobility with their new acute limitations postoperatively

REFERENCES

Godina M. Early microsurgical reconstruction of complex trauma of the extremities. Plast Reconstr Surg. 1986;78:285-292.

Parikh RP, Sacks JM. Limb Salvage for Chronic Lower Extremity Wounds. Plast Reconstr Surg. 2025;155(6):1056e-1070e.

Gould LJ, et al. Modalities to Treat Venous Ulcers: Compression, Surgery, and Bioengineered Tissue. Plast Reconstr Surg. 2016;138(3 Suppl):199S-208S.

Packer CF, Ali SA, Manna B. Diabetic Foot Ulcer. [Updated 2023 Jul 17]. In: StatPearls [Internet]. Treasure Island: StatPearls Publishing, 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK499887/

Maronese CA, et al. Pyoderma Gangrenosum: An Updated Literature Review on Established and Emerging Pharmacological Treatments. Am J Clin Dermatol. 2022;23(5):615-634.

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

Knobloch K, et al. Mangled extremity severity score in foot and ankle free flap reconstruction. Plast Reconstr Surg. 2010;126:685-686.

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.

Lee ZH, et al. Updates in Traumatic Lower Extremity Free Flap Reconstruction. Plast Reconstr Surg. 2023;152(5):913e-918e.

Durrant CA, Mackey SP. Orthoplastic classification systems: The good, the bad, and the ungainly. Ann Plast Surg. 2011;66:9-12.

Bosse MJ, et al. The insensate foot following severe lower extremity trauma: An indication for amputation? J Bone Joint Surg Am. 2005;87:2601-2608.

Daugherty THF, et al. Surgical Technique for Below-knee Amputation with Concurrent Targeted Muscle Reinnervation. Plast Reconstr Surg Glob Open. 2020 Jul 16;8(7):e2990

Parikh RP, Sacks JM. Lower Extremity Reconstruction After Soft Tissue Sarcoma Resection. Clin Plast Surg. 2021 Apr;48(2):307-319.

Chapter 21
Facial Aesthetic Surgery

Christina Shree Chopra, MD
Michael Plastini, MD

FOUNDATIONAL PRINCIPLES IN FACIAL AESTHETICS

Facial Aging

Several factors are cumulatively responsible for the aging face, each requiring unique strategies to mitigate their effects (Fig. 1)

Skin changes:

Thinning of the dermis, reduced collagen and elastin → fine lines and wrinkles

Increased solar elastosis and pigmentation → dyschromia and rough texture

Decreased hydration and sebaceous activity → dull, dry skin appearance

Soft tissue descent and volume loss:

Deflation of facial fat compartments (especially in midface, temples, periorbital areas)

Descent of fat pads, notably the malar and jowl fat, due to ligament laxity

Results in deep nasolabial folds, marionette lines, tear troughs, and jowling

Ligamentous laxity:

Facial retaining ligaments (e.g., zygomatic, mandibular) weaken with age, reducing soft tissue support

Contributes to ptosis and deepening of facial folds

Muscle changes:

Hyperactivity of facial mimetic muscles (frontalis, orbicularis oculi, corrugators) leads to dynamic wrinkles: forehead lines, crow’s feet, glabellar rhytids

Muscle thinning may also occur with age

Skeletal remodeling;

Bone resorption affects the orbit (enlarged), maxilla (retruded), and mandible (narrowed angle, reduced projection)

Leads to loss of structural support, particularly around the eyes, midface, and jawline

Figure 1. Common patterns of facial aging. From Bustos SS, et al. Pharmacologic and Other Noninvasive Treatments of the Aging Face: A Review of the Current Evidence. Plast Reconstr Surg. 2024 Oct 1;154(4):829e-842e.

Relevant anatomy

Aesthetic units (AUs) are often used to describe the face, dividing it into sections that can be addressed individually or in groups

Include forehead, ear, eyebrow, upper eyelid, lower eyelid, cheek, upper lip, lower lip, chin, anterior neck

Zones of adherence (ZA): anatomic areas of the face where tissues are ‘" ixed"

Areas are of interest in facial rejuvenation and can be linear or diffuse

Become relevant in face lifts seeking to re-drape tissue naturally across the face

Facial fat pads (Fig. 2):

Superficial fat pads: located above the SMAS (superficial musculoaponeurotic system) layer, within the subcutaneous tissue

within the subcutaneous tissue

Partitioned by retaining ligaments (e.g., zygomatic, mandibular)

Major contributors to facial contour and surface volume

Undergo descent and deflation with aging, leading to hollowing and skin laxity

Deep fat pads: located beneath the SMAS, deep to facial muscles and ligaments

Provide central facial support and maintain youthful projection

Tend to deflate with aging, contributing to midface hollowing and tear troughs

Figure 2. Fat pads of the face. From Rohrich RJ, Avashia YJ, Savetsky IL. Prediction of Facial Aging Using the Facial Fat Compartments. Plast Reconstr Surg. 2021 Jan 1;147(1S-2):38S-42S.

Facial nerve:

Function: provides motor innervation to muscles of facial expression.

Course: exits the stylomastoid foramen, enters the parotid gland, and divides into five major branches

Five main motor branches (mnemonic: “To Zanzibar By Motor Car”)

Temporal: at risk in brow lifts and upper SMAS dissection

Zygomatic: innervates orbicularis oculi; at risk in deep plane dissection

Buccal: innervates muscles around nose, lip, and cheek

Marginal mandibular: innervates depressor anguli oris; vulnerable near mandibular border

Cervical: innervates platysma

Surgical danger zones:

Temporal branch: courses within the "zone of caution" — between a line from 0.5 cm below the tragus to 1.5 cm above lateral brow

Marginal mandibular branch: typically 1-2 cm below the mandibular border anteriorly but variable; often superficial near the anterior facial artery

Blood supply:

Facial artery: major supplier to lower face; courses over the mandible anterior to the masseter, then ascends toward the medial canthus (as angular artery)

Superficial temporal artery: supplies lateral forehead and scalp

Transverse facial artery: crosses superficial to parotid duct, supplying cheek

Critical to avoid the facial artery during filler injections and in flap design

Facial vein follows a similar course to the facial artery, draining into the internal jugular vein

No valves in facial veins → risk of retrograde infection (e.g., cavernous sinus thrombosis from danger triangle of face)

Danger zones in injections: use blunt cannulas, aspiration, and slow, low- pressure injection in high-risk zones

Glabella (supratrochlear/supraorbital arteries)

Nasolabial fold (angular artery)

Nasal sidewalls and tip (dorsal nasal and lateral nasal arteries)

Forehead (temporal artery branches)

Facial analysis

The process of evaluating facial proportions, contours, symmetry, and aging patterns to guide cosmetic or reconstructive procedures. A systematic approach ensures that treatments (e.g., fillers, facelifts, rhinoplasty) enhance the natural harmony of the face rather than overcorrect or distort it. Below is a systematic approach one could employ in performing a comprehensive facial analysis.

Divide the face into thirds

The face is classically divided horizontally into three equal parts:

Upper third: hairline to glabella (between eyebrows)

Middle third: glabella to subnasale (base of the nose)

Lower third: subnasale to menton (chin point)

Disproportion (e.g., a long lower third) may signal chin retrusion, lip imbalance, or vertical maxillary excess (treated with orthognathic surgery)

Assess facial fifths

Vertically, the face is divided into five equal segments, each roughly the width of one eye:

The central fifth includes the nose

Lateral fifths contain the ears and hairline

Facial symmetry and harmony are assessed using these proportions

Evaluate facial shape

Common aesthetic facial shapes:

Oval (ideal): balanced proportions

Round: short lower face, wide cheeks

Square: strong jawline

Heart: wide forehead, narrow chin

Shape guides filler placement, fat grafting, or skeletal augmentation

Analyze skin and soft tissue

Skin quality: wrinkles, texture, pigmentation

Volume loss: especially in midface (malar fat pads), temples, lips

Laxity: sagging skin, jowls, or nasolabial folds

These help determine if a patient needs lifting, volumization, or resurfacing

Assess key areas

Forehead/brows: position and symmetry

Eyes: lid position, tear troughs, periorbital hollowing

Nose: dorsal height, tip projection, deviation

Lips: volume, definition, proportion (ideal ratio: upper:lower ≈1:1.6)

Chin/jawline: projection and definition, especially in profile

Neck: skin laxity, platysmal bands, fat deposits

Each area may need a tailored intervention such as neuromodulators, fillers, or surgery

Perform profile analysis

Ideal angles:

Nasolabial angle (columella-lip): ~95-105° in women (more acute in men)

Mentocervical angle (chin-neck): ~105-120°

Facial convexity: A straight or gently convex profile is often preferred

Guides surgical planning for rhinoplasty, genioplasty, or neck lift

NON-SURGICAL AESTHETIC INTERVENTIONS

A more comprehensive review of nonsurgical aesthetic interventions that may be employed in facial rejuvenation can be found in Chapter 24.

UPPER THIRD: BROW AND PERI-ORBITAL AESTHETICS

Brow lift (Fig. 3):

Relevant anatomy:

Brow is supported by the frontalis muscle, opposed by brow depressors (procerus, corrugator supercilii, orbicularis oculi), and receives innervation from the facial nerve's temporal branch

Sensory innervation is from the supratrochlear and supraorbital nerves, which exit near the orbital rim

Understanding the retaining ligaments (e.g., orbital retaining ligament, temporal ligamentous adhesion) is essential for safe and effective release during elevation

Indications:

Lateral or medial brow ptosis

Asymmetry

Visual field obstruction (in functional cases)

Aesthetic rejuvenation of the upper face and periorbital region

Patient evaluation:

Brow symmetry, position (normally at/above the supraorbital rim in women, slightly lower in men)

Skin quality

Forehead height

Hairline position

Dynamic function (muscle overactivity) and contribution to upper lid hooding

Photographic analysis and functional visual field testing (for insurance coverage)

Coronal brow lift:

Long incision behind the hairline

Lifts entire forehead and brow en bloc

Excellent exposure and control; risk of scalp numbness or alopecia

Endoscopic brow lift:

Multiple small incisions behind the hairline

Minimally invasive; uses a camera and instruments to release brow depressors and elevate brow

Less scarring, faster recovery; technically demanding

Hairline (pretrichial) brow lift:

Incision at the hairline, ideal for patients with long foreheads (>6 cm)

Preserves or lowers hairline height; risk of visible scar

Direct brow lift:

Incision immediately above the eyebrow hairs

Used in older male patients or in cases needing strong correction (e.g., facial palsy)

Visible scar is main drawback

Lateral temporal (limited lncision) brow lift::

Short incision at the lateral hairline or temporal scalp

Elevates lateral brow only; often combined with blepharoplasty

Limited effect medially

Pearls:

Release brow depressor muscles for durable elevation

Tailor approach to hairline, forehead height, and aesthetic goals

Protect sensory nerves (especially supraorbital/supratrochlear)

Pitfalls:

Overcorrection → unnatural expression

Nerve injury (temporal branch or supraorbital/supratrochlear)

Visible scarring in direct or hairline approaches

Asymmetry if release is incomplete

Upper blepharoplasty: upper eyelid rejuvenation (Fig. 3)

Relevant Anatomy:

Upper eyelid consists of five layers: skin, subcutaneous tissue, orbicularis oculi muscle, orbital septum, and preaponeurotic fat, with the levator aponeurosis lying deep to the fat pad and inserting into the tarsus

Supratarsal crease forms where the levator extends to the skin

Lacrimal gland lies superolaterally and must be preserved

Supraorbital and supratrochlear nerves supply sensation and course just deep to the orbital rim

Indications:

Dermatochalasis (redundant upper eyelid skin)

Visual field obstruction (often confirmed by visual field testing)

Aesthetic concerns including loss of eyelid crease or hooding

Asymmetry or eyelid contour deformity

Adjunct to brow ptosis correction or lower blepharoplasty

Patient evaluation:

Skin excess, fat prolapse, and levator function

Brow position (to rule out brow ptosis masquerading as dermatochalasis)

Presence of asymmetry, eyelid crease height, and fat distribution

Snap-back test and dry eye evaluation (Schirmer’s or OSDI if indicated)

Standardized photography (frontal, oblique, profile, and gaze positions)

Visual field testing if surgery is to be considered medically necessary

Surgical approaches:

Skin-only resection:

For mild dermatochalasis without fat herniation

Incision placed in the natural supratarsal crease

Skin-muscle resection:

Removes both skin and orbicularis muscle for a more sculpted lid

Can be combined with fat modification

Fat pad management:

Selective removal or repositioning of medial and central fat pads

Avoid over-resection to prevent hollowing

Crease re-formation (Asian blepharoplasty)

May involve fixation of skin to levator aponeurosis

Preserves ethnic features while enhancing crease definition

Pearls:

Preserve at least 10-12 mm of upper eyelid skin to avoid lagophthalmos

Conservative fat removal prevents postoperative hollowing

Mark incisions with the patient sitting upright and looking forward

Symmetry depends on careful pre-operative planning and brow evaluation

Consider brow ptosis correction first if contributing to upper lid hooding

Pitfalls:

Over-resection of skin → lagophthalmos, dry eye

Excessive fat removal → hollow upper lids, A-frame deformity

Asymmetric markings or lid crease height

Undiagnosed brow ptosis → persistent hooding postoperatively

Damage to levator aponeurosis → ptosis

Injury to lacrimal gland laterally → dry eye complications

Figure 3. The above image demonstrates correction of brow ptosis and dermatochalasis with brow lift and upper blepharoplasty. From Vaca EE, Alghoul MS. Upper Blepharoplasty with Endoscopically Assisted Brow Lift to Restore Harmonious Upper Lid Arc Curvatures. Plast Reconstr Surg. 2020 Nov;146(5):565e-568e.

Lower blepharoplasty: lower eyelid rejuvenation (Fig. 4)

Relevant anatomy:

Anterior lamella: skin and orbicularis oculi muscle

Skin is thin and prone to retraction; muscle contributes to lower lid tone

Middle lamella: orbital septum and orbital fat pads

Three distinct fat compartments: medial, central, lateral

Orbital septum attenuates with age, allowing fat herniation

Posterior lamella: tarsal plate and conjunctiva

Tarsal plate provides structural integrity

Levator aponeurosis (for upper lid) has no role here, but lower lid retractor and capsulopalpebral fascia are relevant

Indications:

Orbital fat herniation (puffy lower eyelids)

Skin laxity and fine rhytids

Tear trough deformity or hollowing

Eyelid malposition (e.g., lid laxity, ectropion)

Aesthetic lower eyelid rejuvenation or functional concerns

Patient evaluation:

Lid ptosis vs. brow ptosis

Differentiate lower-lid laxity from gravitational descent of midface and brow

Brow ptosis may exacerbate lower lid redundancy

Assess canthal support

Snap-back test and distraction test assess horizontal lid laxity

Canthal tendon integrity determines need for canthopexy or canthoplasty

Perform vector analysis

If the globe is anterior to the malar eminence (negative vector), patient is at higher risk for ectropion and scleral show

Midface support evaluation is critical in surgical planning

Surgical approaches:

Transconjunctival:

Incision through the conjunctiva; avoids anterior lamella dissection

Ideal for patients with fat herniation but good skin tone

Lower risk of ectropion, preserves pretarsal orbicularis and septum

Subciliary:

Incision 1-2 mm below the lash line

Allows skin and muscle excision, fat manipulation

Greater risk of lower lid malposition, especially in patients with poor tone

Fat management strategies

Fat preservation

Selective debulking of herniated fat pads without over-resection

Prevents hollowing and A-frame deformity

Fat repositioning

Transposes fat over the orbital rim into the tear trough (preperiosteal or subperiosteal planes)

Smooths lid-cheek junction and restores volume

Pearls/pitfalls:

Canthopexy: reinforces lateral canthal tendon; prevents lid malposition

Recommended in patients with marginal laxity or negative vector

Orbital fat grafting: augments hollowed tear trough or midface

May be autologous (fat) or synthetic (fillers); complements volume preservation

Complications and prevention:

Retrobulbar hematoma:

Emergency vision-threatening complication due to orbital compartment syndrome

Signs: sudden pain, vision loss, proptosis, afferent pupillary defect

Avoid by maintaining meticulous hemostasis; treat emergently with lateral canthotomy/cantholysis

Ectropion and scleral show:

Results from excessive skin removal, scarring, or poor support

Prevent by conservative excision and performing canthopexy when needed

Lagophthalmos:

Inability to close eyelids due to over-resection or scarring

Prevent with careful tissue handling and pre-operative evaluation of eye closure

Figure 4. The above image demonstrates the effects of a lower blepharoplasty with fat pad resection. From Miranda SG, Codner MA. Micro Free Orbital Fat Grafts to the Tear Trough Deformity During Lower Blepharoplasty. Plast Reconstr Surg. 2017 Jun;139(6):1335-1343.

MIDDLE THIRD: MIDFACE AND CHEEK AESTHETICS

Facelift: highly sought-after procedure for patients seeking surgical correction of facial aging, especially in the lower two-thirds of the face and neck

Common indications:

Jowling and loss of mandibular definition

Deep nasolabial folds and marionette lines

Laxity of the lower face and platysmal bands

Midface descent (may be addressed with extended SMAS or deep plane)

Redundant skin and fat in the neck

Anatomy review:

Facial soft tissue layers (Mendelson's 5-layer model): skin, subcutaneous fat, SMAS (Superficial Musculoaponeurotic System), loose areolar tissue (glide plane for deep plane dissection), deep fascia and periosteum

Facial retaining ligaments:

Zygomatic, mandibular, and masseteric ligaments must be released to mobilize facial tissues

Ligaments anchor the soft tissues to deeper structures

Facial nerve branches:

At risk during deep dissections, especially the marginal mandibular (most common symptomatic motor nerve injury), buccal, and temporal branches

The facial nerve generally lies deep to the SMAS in early dissection zones

Knowledge of danger zones minimizes nerve injury

Vascular supply:

Preserve subdermal plexus and facial artery branches for flap viability

Avoid excessive tension and wide undermining to minimize hematoma and necrosis

SMAS facelift (Fig. 5):

SMAS anatomy:

Organized fibrous network inclusive of the platysma muscle, parotid fascia, and fibromuscular layer overlying the cheek

Separates the deep and superficial adipose layers of the face.

Continuous with platysma (inferiorly) and temporoparietal fascia (superiorly)

Structural layer for lifting soft tissues in SMAS plication, imbrication, or extended flap techniques

SMAS manipulation:

SMAS plication: imbrication of the SMAS to itself or deeper fascia without formally elevating a separate SMAS flap

SMASectomy: resection of an oblique strip of SMAS (usually from posterior border of mandible to malar prominence) with primary approximation of SMAS edges; allows skin and SMAS to be manipulated along different vectors

Pearls/pitfalls:

Undermine adequately, but conservatively

Perform multivector SMAS elevation (vertical for midface, horizontal for jowls)

Avoid overdissection, which can devascularize the skin or increase seroma risk

Anchor the SMAS to strong, immobile structures (e.g., parotid fascia, zygomatic arch periosteum)

Avoid placing tension on the skin—lift on the SMAS, redrape the skin passively

Control hemostasis meticulously; hematoma is the most common complication

Check for bleeding before closure, especially in hypertensive patients

Deep plane facelift:

Relevant anatomy:

Operates below the SMAS, in what is often referred to as the ‘gliding plane’

Dissection principally involves 1) mobilization of the deep fat compartments, and 2) release of the retaining ligaments

Deep fat compartments:

Deep medial cheek fat: key target for midface lift in deep plane

Mobilized with SMAS and skin en bloc

Releasing its tethering ligaments allows elevation of nasolabial fold and malar region

Retaining ligaments:

Zygomatic cutaneous ligament (McGregor’s patch): tethers SMAS to zygomatic arch

Masseteric cutaneous ligament: over the anterior edge of the masseter

Figure 5. The above images demonstrate the postoperative changes seen in a SMAS facelift at 5 months and 11 years. From Liu TS, Owsley JQ. Long-term results of face lift surgery: patient photographs compared with patient satisfaction ratings. Plast Reconstr Surg. 2012 Jan;129(1):253-262.

Mandibular ligament: defines the jowl and lower border

Parotid cutaneous ligaments: limit lateral skin movement

Facial nerve branches

Buccal and zygomatic branches: travel within the deep plane, initially deep to the deep fascia and become more superficial as they traverse toward the mimetic muscles

Greatest nerve injury risk occurs near the malar region, where the zygomatic branch may course more superficially

Preserving deep plane (beneath SMAS) helps protect nerve branches, as they are typically deep to dissection plane in early portions of the surgery

Key surgical steps:

Lift skin and enter the deep plane

A small amount of skin is lifted to expose the layer under the facial muscles (SMAS), which is then entered to access the deep plane below

Release ligaments and mobilize the tissue

Key retaining ligaments are released to free up the midface and jowls, allowing them to be lifted more naturally

Lift and fix the tissue

SMAS and deep tissues (along with some overlying fat and skin) are lifted together and secured in a higher position to restore youthful contour

Re-drape the skin and close the incisions

Excess skin is trimmed without tension, then the incisions are closed with care to hide scars and preserve natural anatomy

Pearls/pitfalls:

Facial nerve injury is the most feared complication associated with deep plane facelifts; careful dissection is key to success

Endoscopic facelift:

Indications:

Ideal in patients without significant skin redundancy

Brow ptosis (often combined with endoscopic brow lift)

Patients with good skin tone, minimal excess skin

Patients desiring midface rejuvenation without visible scars

Surgical approach:

Incisions: small (~1.5-2 cm) hidden incisions in the temporal hairline and preauricular/postauricular scalp

Endoscopic dissection: using a camera and instruments, subperiosteal or sub-SMAS dissection is performed

Focused on midface, brow, and malar fat pad

Ligament release: key retaining ligaments are released to allow tissue mobilization

Tissue suspension: elevation and fixation of soft tissues to the deep temporal fascia or bone using sutures, screws, or Endotines™

Closure: incisions are closed with minimal scarring

Pearls/pitfalls:

Ideal for younger patients with early midface descent and good skin elasticity

Allows precise lifting of the midface and brow with minimal scarring

Subperiosteal plane protects nerves and allows safe ligament release

Limited skin laxity correction — not ideal for older patients with excess skin

Technically demanding; requires specialized instrumentation and training

Risk of temporary nerve weakness, especially temporal branch injury if dissection is too superficial

Fixation failure can lead to loss of result if tissues aren't securely anchored

LOWER THIRD: JAWLINE AND NECK REJUVENATION

Lower third aging patterns:

Jowls

Sagging of facial tissue below the mandibular border due to ptosis of the buccal fat pad and lower cheek soft tissues, creating a disrupted jawline and pre-jowl sulcus

Caused by loss of skin elasticity, weakening of mandibular retaining ligaments, and volume descent

Jawline descent

Progressive blunting and softening of the mandibular contour as tissues descend below the bony border

Aggravated by laxity of the SMAS, descent of deep fat compartments, and skin redundancy

Neck laxity

Combination of skin redundancy, platysmal banding, and accumulation of subcutaneous or subplatysmal fat, resulting in a "turkey neck" or obtuse cervicomental angle

Can be isolated or extend from facial aging and is central to neck rejuvenation goals

Relevant neck anatomy:

Platysma: superficial neck muscle arising from the clavicle and inserting into the lower face (mandible, modiolus, SMAS)

With aging, its medial borders separate, forming visible platysmal bands; it is often manipulated or sutured during neck lift procedures (e.g., corset platysmaplasty) (Fig. 6)

Subplatysmal fat: deep fat located beneath the platysma, distinct from superficial cervical fat; may contribute to fullness or blunting of the neck angle

Often requires direct excision during more invasive neck lifts; not accessible via liposuction

Submandibular glands: paired salivary glands located beneath the mandible, just deep to the platysma and anterior digastric muscles

Prominent submandibular glands can impair neck contour, and in select cases may require partial excision or suspension during rejuvenation procedures

Figure 6. The above illustration demonstrates the platysma work that can be involved in a neck lift. From Narasimham K, Stuzin JM, Rohrich RJ. Five-step neck lift: integrating anatomy with clinical practice to optimize results. Plast Reconstr Surg. 2013 Aug;132(2):339-350.

Surgical approaches to neck lift (Fig. 7):

Cervicoplasty (skin-only neck lift):

Excision of redundant neck skin without manipulation of platysma or fat

Indication: patients with skin laxity and good underlying muscle tone

Limitations: does not correct platysmal bands or deep submental fat

Incisions: often combined with facelift incisions or performed via a submental approach

Platysmaplasty (anterior neck lift):

Tightening or resection of medial platysmal bands, often via a submental incision

Can involve:

Midline approximation (corset platysmaplasty)

Partial resection of medial platysma

Indication: prominent platysmal banding, central neck laxity, or blunted cervicomental angle

Submental liposuction or lipectomy:

Suction or direct excision of subcutaneous and/or subplatysmal fat through a small submental incision

Indication: excess fat in the submental area with good skin elasticity

Often combined with platysmaplasty or skin tightening procedures

Lateral neck lift or lateral platysma suspension

Definition: tightening of lateral platysma and neck skin through preauricular and postauricular incisions

Indication: lower face and neck laxity, jawline softening, and jowling

Can be used as an isolated procedure or as part of lower facelift

Composite or deep plane neck lift:

Elevation of skin, platysma, and deep neck fat as a unit, often with ligament release

Indication: advanced neck aging, platysmal bands, deep fat compartments, and skeletal deficiency

Often includes digastric muscle contouring, subplatysmal fat resection, and submandibular gland management

May involve a deep cervical dissection for full contour restoration

Extended neck lift with submandibular gland contouring:

Traditional neck lift techniques plus exposure, partial excision, or suspension of submandibular glands

Indication: patients with bulky or low-positioned submandibular glands causing contour deformity

Requires careful planning due to bleeding and salivary complications

Figure 7. The above images depict before and 2.5 years after a neck lift procedure. From Narasimham K, Stuzin JM, Rohrich RJ. Five-step neck lift: integrating anatomy with clinical practice to optimize results. Plast Reconstr Surg. 2013 Aug;132(2):339-350.

Non-surgical options/adjuncts (described in more detail in Chapter 24):

Deoxycholic acid (Kybella®): injectable treatment that permanently reduces submental fat by lysing fat cells; best for patients with mild to moderate fullness and good skin elasticity

RF and ultrasound-based skin tightening: devices like Thermage®, FaceTite®, and Ultherapy® use thermal energy to stimulate collagen production and skin contraction, offering subtle improvement in mild skin laxity

Jawline contouring with fillers and neuromodulators: dermal fillers enhance jawline definition and neuromodulators (e.g., Botox®) reduce platysmal banding, providing temporary, noninvasive refinement of the lower face and neck contour

RHINOPLASTY

Goals:

Aesthetic: improve nasal shape, size, and symmetry in harmony with the face; refining the dorsum, tip, and overall proportions

Functional: preserve or improve nasal airflow by maintaining valve patency, septal alignment, and internal nasal structure integrity

Successful rhinoplasty balances beauty and breathing

Surface analysis and facial proportions:

Facial analysis evaluates how the nose fits into vertical facial thirds and horizontal fifths, and its proportions to key landmarks (Fig. 8):

Ideal nasofrontal angle: 115-130°

Ideal nasolabial angle: ~90-105° (men more acute angle vs. women)

Ideal nasal length: ~0.67 × midface height

Surface exam includes dorsal contour, tip definition, alar base width, columellar show

Nasal anatomy:

Upper third: nasal bones and radix

Nasal bones form the upper bony vault; over-resection may cause inverted-V deformity (when upper lateral cartilage becomes detached from nasal bones)

Radix is the nasion’s soft tissue depth; adjusting it alters dorsal profile and nasal root harmony

Figure 8. The above image demonstrates the relationship of the nose to the face in aesthetic facial proportions. From Boustany AN, et al. Cosmetic Rhinoplasty. Plast Reconstr Surg. 2023 Feb 1;151(2):315e-329e.

Middle third: upper lateral cartilages, internal valve

Upper lateral cartilages articulate with the nasal bones and septum

Internal nasal valve is the narrowest segment (between septum and ULCs at ~10-15°)

Collapse here is a major cause of nasal obstruction; spreader grafts help restore patency

Lower third: tip cartilages, external valve

Lower lateral (alar) cartilages divided into medial, intermediate, and lateral crura

External valve includes the alar rim and nostril opening; key for airflow and tip shape

Precise control of tip projection, rotation, and support depends on these structures

Septum and turbinates:

Nasal septum is both a structural support and source of graft material

Septal deviation can cause airflow obstruction and tip asymmetry

Inferior turbinates modulate airflow and humidification; reduction may be needed in select patients

Septoplasty is often combined with cosmetic rhinoplasty to improve function

Nasal subunits:

Nine anatomic subunits of distinct contour, skin quality, and aesthetic boundary; help guide reconstructive planning, especially in skin cancer surgery and scar placement

Nasal dorsum

Right and left nasal sidewalls

Nasal tip

Columella

Right and left alae

Right and left soft triangles

If >50% of a subunit is lost, complete subunit reconstruction is preferred to camouflage scars in natural borders

This principle ensures that contour and shadow are restored and avoids a patchwork appearance

Surgical approaches:

Open (external):

Definition: involves a transcolumellar incision with full elevation of the nasal skin to expose underlying cartilage and bone

Indications: precise tip work, complex revision cases, grafting, asymmetry correction

Advantages: direct visualization of anatomy; facilitates complex maneuvers and structural grafting

Disadvantages: small visible scar; longer postoperative edema

Closed (endonasal):

Definition: all incisions are made within the nostrils, without external scarring

Indications: minor dorsal hump removal, subtle tip refinement, primary cases with good anatomy

Advantages: no external scar; faster recovery; less swelling.

Disadvantages: limited exposure; more difficult for complex or revision cases

Preservation rhinoplasty (emerging technique):

Definition: seeks to preserve native dorsal lines, ligamentous attachments, and septal support, rather than resecting and rebuilding

Techniques: dorsal preservation, subdorsal septal strip, push-down or let-down maneuvers

Advantages: more natural aesthetic; less postoperative swelling

Disadvantages:

Limited indications – not ideal for severely deviated or revision noses

Technical complexity – steep learning curve and precise anatomical demands

Unpredictable dorsal outcome – risk of residual hump or contour irregularities

Restricted tip modification – less flexibility for major changes in tip projection or rotation

Graft placement limitations – difficult to perform structural grafting without disrupting preserved dorsum

Septoplasty:

Purpose: corrects deviations of the nasal septum to improve airflow and provide structural support for cosmetic work

Technique: involves mucoperichondrial flap elevation, excision or scoring of deviated cartilage, and preservation of the L-strut (1 cm dorsal and caudal)

Relevance: often performed with rhinoplasty to address both functional obstruction and to harvest cartilage for grafting

Osteotomies:

Performed to mobilize and reposition the nasal bones – typically after dorsal hump reduction or to correct bony deviation or excess width

“Low-low,” “low-high,” and “double-level” terminology refers to the trajectory and positioning of the lateral osteotomies

Terminology is related to the relative dorsal position of the start and end of the osteotomy

Low-low osteotomy

Pathway: begins low at the piriform aperture and stays low along the nasofacial groove, close to the maxilla

Effect: allows maximum medialization of the nasal bones, effective for broad bony dorsum or flattened nasal sidewalls

Risks: can increase the risk of bony instability or inward collapse if overdone

Best for: wide nasal bones or aggressive narrowing

Low-high osteotomy

Pathway: begins low near the piriform aperture, then curves high toward the dorsal aspect of the nasal bone

Effect: preserves the upper lateral nasal wall, allowing more controlled narrowing with better dorsal aesthetic lines

Advantages: lower risk of inverted-V deformity and preserves dorsal support

Best for: mild-moderate narrowing or when preservation of the upper bony vault is desired

Double-level (or double) osteotomy

Pathway: involves two cuts – a low lateral cut and a second, higher cut, typically along the ascending process of the maxilla

Effect: used for very thick or convex nasal bones that resist movement with a single osteotomy

Advantages: improves bony mobilization and reduces the risk of greenstick fractures or incomplete narrowing

Best for: thick or S-shaped nasal bones, revision cases, or major bony deviation

Grafts:

Cartilage grafts are frequently utilized in rhinoplasty to help create a durable, aesthetic nose

Typically, multiple grafts will be used in one procedure, with the specific type of graft(s) utilizing depending on the needs of the patient

Spreader graft: cartilage placed between the septum and upper lateral cartilages to restore or maintain the internal nasal valve angle and dorsal aesthetic lines

Columellar strut graft: a structural graft placed between the medial crura of the lower lateral cartilages to support tip projection and rotation

Shield graft: a tip-defining graft shaped like a shield to enhance projection and definition of the nasal tip

Alar batten graft: a graft placed over the lateral crura or alar rim to correct or prevent external nasal valve collapse

Septal extension graft: a graft fixed to the caudal septum to provide a rigid framework for precise control of tip projection and rotation

Onlay dorsal graft: a dorsal augmentation graft placed over the nasal dorsum to increase height or correct saddle nose deformity

Rim graft: a small graft placed along the alar rim to reinforce the external valve or smooth contour irregularities

Spreader flap: an autologous flap created by folding the upper lateral cartilage medially, mimicking the function of spreader grafts without requiring additional graft material

Alar rim strut: a thin graft placed along the caudal margin of the lower lateral cartilage to prevent alar retraction or notching

Allograft vs. autologous rib cartilage

Allograft (irradiated cadaveric cartilage): readily available, avoids donor-site morbidity, and is often used for dorsal augmentation or minor structural grafting

Higher resorption and warping risk compared to autologous grafts

Rib cartilage (autologous costal cartilage): robust, abundant source of graft material for major structural needs in revision or reconstructive rhinoplasty

Associated with donor-site morbidity and a risk of warping if not carved precisely

Revision rhinoplasty (Fig. 9):

About 5-15% of rhinoplasty patients seek revision

Indications:

Persistent aesthetic deformity (e.g., pollybeak, crooked nose, asymmetry)

Functional issues (e.g., nasal obstruction, valve collapse)

Graft visibility, warping, or displacement

Timing:

Wait at least 12 months post-primary surgery before performing revision

Allows swelling to resolve and scar tissue to mature

Common deformities:

Pollybeak (supratip fullness due to under-resected cartilage or scar)

Inverted-V (middle vault collapse from dorsal over -resection)

Alar retraction, pinched tip, asymmetric nostrils, columellar show

Grafting is often required

Figure 9. The above images demonstrate the benefits of a well-performed revision rhinoplasty to correct nare deformity, provide tip support, allow tip refinement, and improve breathing. From Datta S, et al. Nasal Tip Deprojection in Rhinoplasty. Plast Reconstr Surg. 2025 Mar 1;155(3):439-444.

Septal cartilage may no longer be available

Alternatives: conchal cartilage, costal cartilage, or irradiated homologous grafts (allograft)

Spreader grafts, columellar struts, alar batten grafts, and tip grafts are commonly used

Approach:

Often requires open rhinoplasty for exposure and precision

Careful dissection through scar tissue is critical

Must reconstruct support structures, not just reshape the nose

Risks:

Higher risk of poor healing, infection, scar contracture, or persistent deformity

Outcomes may be limited by scar tissue, thin skin, or prior graft failure

Pearls:

Always assess both functional and aesthetic issues

Be conservative in primary cases to reduce need for revision

Master nasal anatomy and structural grafting principles

Set realistic expectations: revision is more complex and less predictable

Complications and prevention:

Airway compromise

Cause: over-resection of the septum, upper lateral cartilages, or inadequate support of the internal nasal valve

Prevention:

Preserve at least 10 mm of dorsal and caudal septum

Use spreader grafts to maintain internal valve angle (~10-15°)

Avoid aggressive cephalic trimming of alar cartilages

Tip over-reduction:

Cause: excessive resection of the lower lateral cartilages, especially the intermediate and lateral crura

Results in loss of projection, poor support, bossae, or pinched tip deformity

Prevention:

Preserve adequate medial and lateral crural length

Consider columellar strut, lateral crural strut, or shield grafts for structural support

Graft warping

Cause: autologous costal cartilage undergoing intrinsic tension remodeling after harvest

Prevention:

Use balanced carving techniques and centered grafts

Let grafts "rest" in saline before implantation

Consider diced cartilage in fascia (e.g., DCF technique) for dorsal augmentation

COMPREHENSIVE REJUVENATION STRATEGIES

Combining procedures: sequence, synergy, and safety

Sequencing is critical to surgical planning

Typically, procedures are performed deep to superficial: e.g., facelift first, then eyelids, followed by skin resurfacing

Combining procedures (e.g., facelift + blepharoplasty + fat grafting) can create synergistic results, enhancing global harmony and rejuvenation

Safety must be prioritized: cumulative operative time (ideally less than 6-8 h), anesthetic risk, and bleeding potential must be assessed

Common combinations:

Facelift + neck lift + fat grafting (Fig. 10)

Blepharoplasty + brow lift

Rhinoplasty + chin augmentation

Multimodal approaches often yield more natural and balanced outcomes

Figure 10. The above figure demonstrates the synergistic effect of a face lift with fat grafting. From Strong AL, et al. Technical Precision with Autologous Fat Grafting for Facial Rejuvenation: A Review of the Evolving Science. Plast Reconstr Surg. 2024 Feb 1;153(2):360-377.

Staging versus single-session treatment:

Single-session:

Advantages: one anesthesia event, unified recovery, patient convenience

Disadvantages: longer OR time, increased perioperative risk, less flexibility in managing tissue response

Staged approach:

Useful in high-risk patients, complex anatomy, or when combining energy-based treatments (e.g., laser resurfacing) with structural surgery

Allows tissue healing and objective reassessment before secondary refinement

Decision should be individualized based on patient goals, comorbidities, and procedural complexity

Long-term maintenance and follow-up care:

Aesthetic surgery results evolve; follow-up includes:

Monitoring for healing, symmetry, scar quality, and recurrence of laxity

Discussion of adjunctive nonsurgical maintenance (e.g., neuromodulators, fillers, skincare)

Photography at standardized intervals aids in tracking outcomes and setting expectations

Patient education on UV protection, weight stability, and aging processes supports long-term results

Role of photography and documentation

Pre-operative and postoperative photographs are essential for:

Surgical planning and patient counseling

Medico-legal documentation

Tracking outcomes over time

Should be performed using standardized views, lighting, and positioning.

Digital morphing tools may be used to help set expectations, though should be framed with caution

REFERENCES

Toriumi, D. M. Structure approach to primary rhinoplasty. Facial Plast Surg Clin North Am. 2005 Feb;13(1):93-113.

Gunter JP, Rohrich RJ. Management of the nasal tip: A modified caudal septal extension graft. Plast Reconstr Surg. 1997;100(4):1171-1182.

Daniel RK. Rhinoplasty: The shield graft. Aesthetic Plast Surg. 1993;17:89-91.

Becker DG, Becker SS. Alar batten grafts: Preventing and correcting alar collapse. Facial Plast Surg. 2001;17(2):129-134.

Byrd HS, Dyer WK, Meade RA. Septal extension grafts: A method of controlling tip projection and rotation. Plast Reconstr Surg. 2007;119(1):321-328.

Yoon ES, Kim DW, Choi JY. Dorsal augmentation in Asian rhinoplasty. Plast Reconstr Surg. 2010; 126(6):2026-2033.

Daniel RK, Calvert JW. Dorsal grafting in rhinoplasty: A clinical and anatomical study. Plast Reconstr Surg . 2012;130(6):1340-1350.

Constantian MB. Alar rim grafts in secondary and primary rhinoplasty. Plast Reconstr Surg. 1994;93(5):948-964.

Clark JM, Cook TA. The ‘spreader flap’ in primary rhinoplasty. Plast Reconstr Surg. 2002;109(6):1838-1840.

Toriumi DM, Checcone MA. New concepts in nasal tip contouring. Facial Plast Surg Clin North Am. 2009;17(1):55-90.

Godin MS, Waldman SR, Johnson CM. Jr. Nasal augmentation using diced cartilage grafts. Arch Facial Plast Surg. 1999;1(2):118-121.

Daniel RK. Rhinoplasty and rib grafts: Evolving a flexible operative technique. Plast Reconstr Surg. 2001; 108(5):1344-1353.

Mendelson BC, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2008;32(3):251-259.

Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83(1):11-16.

Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2007;119(5):1409-1417.

Kirwan L. Aesthetic Units and Zones of Adherence: Relevance to Surgical Planning in the Head and Neck. Plast Reconstr Surg Glob Open. 2023 Aug 14;11(8):e5186.

Whitney ZB, Jain M, Zito PM. Anatomy, Skin, Superficial Musculoaponeurotic System (SMAS) Fascia. [Updated 2024 Jan 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan. Available from: https://www.ncbi.nlm.nih.gov/books/NBK519014/

Knize DM. An anatomically based study of the supraorbital nerve. Plast Reconstr Surg. 1996;97(7):1329-1338.

Guyuron B, Behmand RA. Brow lift. Plast Reconstr Surg. 2003;111(2):964-971.

Ramirez OM. Endoscopic techniques in facial rejuvenation: An overview. Clin Plast Surg. 1995;22(4):663-677.

Kamer FM, McQuown SA. Endoscopic forehead lift: A logical evolution. Arch Otolaryngol Head Neck Surg. 1994;120(6):645-652.

Marten TJ. Hairline lowering foreheadplasty. Plast Reconstr Surg. 1999;103(1):224-236.

Guyuron B, Davies B. Subcutaneous anterior hairline forehead rhytidectomy. Aesthetic Plast Surg.2001;25(5):316-320.

Jones BM, Grover R. Endoscopic brow lift: A personal review of 538 patients and comparison of techniques. Plast Reconstr Surg. 2004;113(4):1242-1250.

McCord CD, Nahai F. Simplified Blepharoplasty: Surgical Techniques. Mosby: 1995.

Lee WP, Holds JB. Upper eyelid blepharoplasty. Facial Plast Surg Clin North Am. 2004;12(2):207-214.

Codner MA, et al. Blepharoplasty and brow lift. Plast Reconstr Surg. 2008;121(4 Suppl):1-13.

Patel BC, Malhotra R. Complications of blepharoplasty: prevention and management. Indian J Ophthalmol. 2007;55(1), 9–15.

Rohrich RJ., Ghavami A., Constantine FC. Lift-and-fill face lift: Integrating the fat compartments. Plast Reconstr Surg. 2009;123(2):745-753.

Mendelson BC, Wong CH. Changes in the facial skeleton with aging: Implications for facial rejuvenation. Aesthetic Plast Surg. 2007;31(2):111-118.

Guyuron B. Neck rejuvenation. Clin Plast Surg. 2002;29(3), 429–439.

Ellenbogen R, Karlin JV. Visual criteria for success in restoring the youthful neck. Plast Reconstr Surg. 1980;66(6):826-837.

Feldman JJ. Neck lift myotomy: The rationale for a central approach. Plast Reconstr Surg. 2005;115(7):2078-2086.

Knize DM. Limited platysma muscle resection for improved submental contour in rhytidectomy. Plast Reconstr Surg. 1998;101(6):1505-1513.

Rohrich RJ, Pessa JE. The beauty of the aging face: Can we map out the changes? Plast Reconstr Surg. 1998;120(4):1361-1369.

American Society of Plastic Surgeons (ASPS) In-Service Exam Core Curriculum.

Tonnard P, Verpaele A. Short-Scar Face Lift: Operative Strategies and Techniques. Springer:2013.

Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219-2227.

Mendelson BC, Wong CH. Changes in the facial skeleton with aging: implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2008;32(3), 251–259.

Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83(1):11-16.

Rittié L, Fisher GJ. UV-light-induced signal cascades and skin aging. J Invest Dermatol. 2002;122(5):144-150.

Gierloff M, et al. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012;129(1):263-273.

Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg. 1985;76(2):239-247.

Baker DC, Stuzin JM. Retaining ligaments of the face: Review of anatomy and clinical applications. Clin Plast Surg. 2001;28(3):311-319.

Feldman, JJ. Neck lift myotomy: The rationale for a central approach. Plast Reconstr Surg. 2005;115(7):2078-2086.

Hamra ST. The deep-plane rhytidectomy. Plast Reconstr Surg. 1990;86(1):53-61.

Jacono, AA. Extended deep-plane facelift with platysma release: A critical evaluation of 100 patients. Aesthet Surg J. 2014;34(4):570-585.

Knize DM. Limited platysma muscle resection for improved submental contour in rhytidectomy. Plast Reconstr Surg. 1998;101(6):1505-1513.

Matarasso A, Elkwood AI. Surgical rejuvenation of the aging neck. Clinics in Plast Surg. 2005;32(3):431-446.

Rohrich, RJ., Ghavami A, Constantin FC. The role of subplatysmal fat in rejuvenation of the aging neck: Anatomy revisited. Plast Reconstr Surg. 2009;123(4):1337-1343.

Stuzin JM, Baker TJ, Gordon HL. The relationship of the superficial and deep facial fascias: Relevance to rhytidectomy and aging. Clinics Plast Surg. 1995;22(2):295-308.

Keller GS, Ramirez OM. Endoscopic facelift: Analysis of 200 cases. Aesthet Surg J.1999;19(2):125-135.

Humphrey S, et al. ATX-101 (deoxycholic acid injection) for reduction of submental fat: A phase III randomized controlled trial. Dermatol Surg. 2015;41(Suppl 1):S339–S351.

Elsaie ML. Cutaneous remodeling and photorejuvenation using radiofrequency devices. J Cosmet Dermatol. 2009;8(1):1-4.

Sundaram H, et al. Comparing the efficacy and longevity of two hyaluronic acid-based dermal fillers in the treatment of nasolabial folds. Dermatol Surg. 2010;36(Suppl 3):730-740.

Chapter 22
Aesthetic Surgery of the Breast

Courtney Leonard, MD
Michael Plastini, MD

Aesthetic surgery of the breast aims to create a youthful, pleasing-appearing breast in addition to alteration of size, ptosis, and shape. Techniques include breast reduction, breast augmentation, and mastopexy. Important considerations for all patients include an assessment of their breast history (such as history of breast cancer and mammographic history) and measurements of the breast/chest wall (sternal-notch to nipple, nipple to inframammary fold, inter-nipple distances, breast width, and areolar diameter).

MASTOPEXY

Goals:

Correct breast ptosis through skin re-draping and parenchymal remodeling of the breast to reduce the mismatch between skin and breast tissue

Generally minimal volume is removed but can result in a decrease in cup size

Place the nipple-areolar complex (NAC) into a more youthful more superior position (Fig. 1)

Figure 1. Ideal nipple position is based on its relationship to the inframammary fold. From Nahabedian MY. Breast deformities & mastopexy. Plast Reconstr Surg 2011 Apr;127(4):91e-102e.

Regnault classification of breast ptosis based on two important anatomic landmarks: (1) inframammary fold (IMF) and (2) nipple position

Grade I: nipple at level of the IMF

Grade II: entire nipple below the level of IMF but not at the lowest point of the breast

Grade III: nipple at the lowest point of the breast

Pseudoptosis: nipple at the level of IMF but majority of glandular tissue below the level of the IMF (results in increased nipple to IMF distance)

Patient concerns:

Usually bothered by the “shape” of the breast or size and position of NAC

Often report deflation and sagging of breasts.

Commonly seen in patients with history of massive weight loss

Types of mastopexy:

Periareolar (circle scar) (Fig. 2)

Incision made around areola as an eccentric oval

Can be used to raise the nipple up to 2 cm

Generally only used for mild ptosis (grade I)

Disadvantages: often results in widened periareolar scar, can flatten and de-project the central portion of the breast

Circumvertical or vertical (lollipop scar) (Fig. 3)

Incision made around the areola, extending down the meridian of the breast towards the IMF

Ideal for moderate to severe ptosis without much horizontal skin excess (grade II, III)

Usually involves removal of breast skin and underlying tissue from the lower pole of the breast with sutures to bring the medial and lateral pillars of the breast together, supporting the new, elevated position of the NAC

Figure 2. Periareolar mastopexy with mesh support. From Hidalgo D, Spector J. Mastopexy. Plast Reconst Surg 2013 Oct;132(4)642e-656e.

Figure 3. Vertical mastopexy. From Hidalgo D, Spector J. Mastopexy. Plast Reconst Surg 2013 Oct;132(4)642e-656e.

Disadvantages: may require additional horizontal skin excision if redundant skin does not retract and can result in long nipple to IMF distance

Wise-pattern (anchor scar) (Fig. 4)

Incision made in an “inverted T” shape around the areola, vertically down the breast meridian, and along the IMF towards the medial and lateral edges of the breast

Ideal for severe ptosis (grade II, III), patients with significant excess skin or poor skin quality (e.g., massive weight loss patients)

Inferior wedge of breast parenchyma can often be sutured under pedicle to pectoralis fascia or used as sling for extra lower pole support

Disadvantages: largest scar burden of any mastopexy technique, can lead to “bottoming out” or recurrent ptosis of glandular tissue when used with inferior pedicle

Figure 4. Wise pattern or inverted T mastopexy incision types. From Nahabedian M. Breast deformities and mastopexy. Plast Reconstr Surg 2011 Apr;127(4):91e-102e.

AUGMENTATION

Goals:

Increase the size of the breast parenchyma either using the patient’s own tissue (autologous) or a prosthetic device (saline or silicone implant)

Improve upper breast pole fullness

Patient concerns:

Usually bothered by the size of the breasts or lack of “cleavage” (i.e., sloping of upper pole of breast in clothing, bras)

Important parameters in pre-operative evaluation:

Base width: width of the breast parenchyma on the chest wall

Pinch thickness of the upper pole breast skin and subcutaneous tissue

Elasticity of skin

Baseline chest wall or breast asymmetries (e.g., pectus carinatum, tuberous breast deformity)

Augmentation with an implant:

Implants: can be round or anatomic, smooth or textured, saline or silicone

Silicone (more common)

Only FDA approved for women 22 years of age and older unless used in reconstruction after mastectomy for cancer

More “natural” feel and appearance, come in set sizes and projection profiles, ruptures are difficult to detect

Saline

FDA approved for women 18 years of age and older

Size is more customizable, implants are more prone to rippling, breast deflates with rupture/leak

Planes of implant placement: implant should be covered with durable soft tissue, which can include any combination of skin, parenchyma, and muscle.

Subglandular: implant placed beneath the breast tissue but above the pectoralis muscle fascia

More prone to implant visibility

Subfascial: implant placed beneath the pectoralis fascia but above the pectoralis muscle fibers

Total subpectoral: implant placed entirely beneath the pectoralis major muscle (Fig. 5)

More prone to animation deformity (implant lateralizes during activation of pectoralis muscle)

Figure 5. Subpectoral implant placement. Release of pectoralis muscle allows the muscle to rise above the implant. From Hidalgo D, Spector J. Breast augmentation. Plast Reconst Surg 2014 Apr;133(4):567e-83e.

Dual plane: the upper pole of the implant sits below pectoralis major, while the lower pole of the implant sits in the subglandular plane

Achieved through release of the inferior attachments of pectoralis major while preserving medial attachments and release of the glandular tissue from the muscle to varying degrees (type I-III)

Incision choices: IMF (most common), periareolar, transaxillary, transumbilical

\

Breast implant-associated anaplastic large cell lymphoma (BIA-ALCL):

Associated with textured breast implants

An area of evolving research

Prevalence estimated to be 30.54 per 100,000 implanted patients with textured implants and 6.70 per 100,000 implanted patients with any type of implant

Presents with a delayed seroma

Cytology: CD30+ and ALK-

Treatment: implant removal and total capsulectomy, possible need for adjuvant treatments such as chemotherapy

Requires multidisciplinary team approach including medical oncologist involvement

Augmentation with autologous tissue:

Fat can be harvested through liposuction from another part of the body (i.e., abdomen or thighs) and injected in the various planes of the breast to increase the size of the breast

Auto-augmentation:

Various flaps can be designed on lateral axillary tissue or adjacent tissue and rotated, advanced or folded onto the existing breast mound to reshape and increase the size of the breast

Commonly performed in massive weight loss patients

Free tissue transfer: DIEP or msTRAM flaps most common and had traditionally been used in reconstruction after cancer surgery, though still an emerging technique for cosmetic breast surgery

Mastopexy-augmentation:

Combined procedure to both increase the size, improve ptosis, and improve breast shape

Very high revision rates (up to 30%)

Can be performed in one or two stages

Higher rates of revision and malpractice claims for single-stage procedures

“Internal bra”:

Some surgeons use synthetic mesh or acellular dermal matrix during mastopexies and augmentations to provide increased support of the implant in the lower pole of the breast

Types of synthetic mesh include P4HB and polydioxanone

BREAST REDUCTION

Goals:

Decrease the size of the breast (has highest rate of patient satisfaction among all plastic surgical procedures)

Restore NAC location to a more youthful position

Patient concerns:

Macromastia symptoms: neck, shoulder, or mid-thoracic back pain that has not improved with medications or physical therapy, erythema intertrigo (rashes, moisture, redness) underneath the breasts, hygiene complaints, bra strap grooving, difficulty finding clothing that fits, occasionally hand numbness/tingling

Reductions can be performed in asymptomatic patients for cosmetic reasons

Skin incision patterns and pedicles (portion of breast parenchyma providing blood supply to the nipple areola complex) are the two main considerations in breast reduction and should be determined prior to surgery

Skin incisions: vertical or Wise pattern (inverted T)

Basis of pedicles for blood supply to the NAC (Fig. 5):

Inferior: 4th intercostal perforator

Superior: 1st and 2nd intercostal perforators

Superomedial: 2nd intercostal perforator

Medial: 2nd or 3rd intercostal perforator

Lateral: lateral intercostal perforators

Central: musculocutaneous perforators from thoracoacromial artery

Figure 6. Breast reduction pedicles and their blood supply. From Hall-Findlay E, Shestak K. Breast Reduction. Plast Reconst Surg 2015 Oct;136(4):531e-44e.

Other techniques:

Breast amputation with free nipple grafting: for very large and ptotic breasts requiring significant reductions

Liposuction: for a small to moderate decrease in breast size in patients with minimal ptosis

Complications:

Loss in ability to breast feed

Changes in nipple sensation

Hypersensitivity, decreased sensitivity, or no change in sensation

NAC necrosis due to inadequate blood supply

If a change in color is noted, must release sutures, assess pedicle, etc.

If remains ischemic or congested despite intraoperative maneuvers, an option includes converting the nipple to a free nipple graft with similar principles to skin grafting for survival

Medications such as nitropaste can help in cases of venous congestion, but can systemic effects for the patient (hypotension, syncope, headache)

REFERENCES

Adams WP Jr, Mallucci P. Breast augmentation. Plast Reconstr Surg. 2012 Oct;130(4):597e-611e.

Hall-Findlay EJ, Shestak KC. Breast Reduction. Plast Reconstr Surg. 2015 Oct;136(4):531e-44e.

Hidalgo DA, Spector JA. Mastopexy. Plast Reconstr Surg. 2013 Oct;132(4):642e- 656e.

Hidalgo DA, Spector JA. Breast augmentation. Plast Reconstr Surg. 2014 Apr;133(4):567e-83e

Nahabedian MY. Breast deformities and mastopexy. Plast Reconstr Surg. 2011 Apr;127(4):91e-102e.

Ward JA, et al. Estimating the prevalence of breast implant–associated anaplastic large-cell lymphoma: A systematic review. Plast Reconstr Surg. 2025 Apr;155(4):660e-669e.

Chapter 23
Body Contouring

Christina Shree Chopra, MD
Omar E. Beidas, MD

Body contouring refers to a comprehensive category of aesthetic procedures designed to reshape and refine the body’s silhouette. It encompasses both surgical and non-surgical interventions targeting the trunk and extremities. While traditionally associated with cosmetic enhancement, body contouring is increasingly recognized for its role in individuals who have undergone massive weight loss.
Procedures can be done in isolation or in combination. Procedures include skin excision, liposuction, and an expanding array of non-invasive technologies such as cryolipolysis and dermal tightening. Together, these tools are used to restore proportionality, reduce excess tissue, and help patients achieve functional and aesthetic balance in alignment with their personal goals.

PRINCIPLES OF BODY CONTOURING AFTER MASSIVE WEIGHT LOSS (MWL)

MWL: commonly defined as a loss of 50% or more of excess body weight.

Typically seen following bariatric surgery, sustained lifestyle interventions, or with the help of GLP-1 medications. Clinically, MWL is associated with significant changes in skin elasticity, subcutaneous tissue volume, and musculoskeletal support, often leading to functional impairments and aesthetic deformities that require surgical correction.

Physiology of skin and fat after MWL: Loss of dermal elasticity and subcutaneous fat leads to deflated, inelastic skin with poor recoil

Patterns of skin redundancy: predictable zones of excess skin develop based on weight loss trajectory — common areas include face, arms, breasts, abdomen, flanks, and thighs

Psychosocial and quality of life considerations: excess skin can impair mobility, body image, intimacy, and contribute to depression or social withdrawal

Insurance coverage and criteria for medical necessity: coverage often requires documentation of rashes, infections, or functional interference, with stable weight thresholds

Comorbidities: array of comorbidities to be mindful of when assessing MWL patient for body contouring procedures; most common conditions and associated investigations/recommendations listed below

Obesity/weight stability: BMI (target ≤32 kg/m²), history of weight regain

Diabetes: glycemic control (HbA1c), infection and wound- healing risk

Nutritional deficiencies: evaluate protein, micronutrients (A, D, B12, iron, zinc), supplement history

Cardiovascular/COPD: frailty index, mFI-5 score, METS, pulmonary/cardiac clearance

Clotting history/disorders: assess risk of DVT/PE; implement VTE prophylaxis

Nicotine use status: nicotine increases infection/wound dehiscence risk; advise cessation

Psychosocial health: screen for depression, body dysmorphia, unrealistic expectations

PRE-OPERATIVE EVALUATION AND PLANNING

History and physical exam:

Assess prior weight loss method, stability, and comorbidities.

On exam, evaluate skin quality (elasticity, striae), fat distribution, presence of surgical scars, and check for hernias or abdominal wall defects that may require repair

Pre-operative markings and photography:

Detailed markings are made in standing position to guide incision planning and symmetry

Standardized pre-op photography documents baseline deformity and supports insurance authorization

Nutritional optimization (albumin, smoking cessation):

Ensure serum albumin >3.5 g/dL for wound healing

Screen for micronutrient deficiencies

Nicotine cessation is essential for at least 4-6 weeks pre- op to reduce flap necrosis and wound dehiscence risk

Multidisciplinary coordination:

Coordinate with PCP, nutrition, bariatric surgery and mental health providers to confirm medical stability, optimize metabolic status, and ensure realistic expectations and psychological readiness for body image changes

Risk stratification:

Use tools like the Caprini score to assess VTE risk

Develop a DVT prophylaxis plan, including sequential compression devices (SCDs), chemoprophylaxis (e.g., heparin), and early ambulation strategies tailored to the patient’s score and comorbidities

NONINVASIVE BODY CONTOURING TECHNIQUES

There exist several noninvasive procedures that may be utilized in helping patients achieve an aesthetic result when seeking body contouring. These techniques are described in more detail in Chapter 24.

LIPOSUCTION

Classic liposuction utilizes a cannula and vacuum to remove subcutaneous fat. It’s widely used for localized fat removal in ‘stubborn’ areas. Desirable results require good skin elasticity and patient selection.

Cannulas and technologies

Cannula types by tip design:

Mercedes: triple hole along the circumference of the cannula

Triport: triple hole along one side of the cannula

Basket tip: blunt, rounded tip with multiple circumferential fenestrations

Spatula tip: blunt tip for delicate areas (face, neck)

Exploded tip: most aggressive

Cannula diameter:

Microcannulas (≤2 mm): for superficial contouring or facial liposuction

Standard (3-4 mm): used in body contouring procedures

Large bore (≥5 mm): for bulk removal in non-aesthetic zones (less common today)

Cannula shape:

Straight: most common; suitable for uniform fat planes

Curved/angled: useful for access under the inframammary fold, flanks, or submental area

Power types:

Power-assisted liposuction (PAL): vibrating cannula facilitates faster fat removal, reduces surgeon fatigue

Ultrasound-assisted liposuction (UAL): utilizes ultrasound-induced cavitation to emulsify fat; effective in fibrous areas, may reduce blood loss

LASER-assisted lipolysis (LAL): uses laser to liquefy fat and stimulate collagen; improves skin tightening but may carry higher burn or scarring risk

Safety and fluid management:

Tumescent

Infiltration of large volumes of epinephrine solution with or without lidocaine

Provides anesthesia and vasoconstriction; enhances safety, minimizes blood loss

Considered the gold standard for large-volume liposuction under local anesthesia

Below is a table outlining the various degrees of fluid infiltration that can be pursued, with tumescent the most common for large body contouring procedures and dry ill-advisable due to otherwise avoidable blood loss (Table 1)

Lidocaine dosing and toxicity:

Safe tumescent lidocaine doses: up to 35mg/kg, with low systemic toxicity; peak plasma levels depend on infiltration rate.

Monitoring required; rare systemic toxicity if guidelines are followed

If performing > 5L of lipoaspirate, special formulas are used for IV resuscitation

Overnight monitoring is recommended when more than 5 L of lipoaspirate is retrieved

Indications and limitations:

Optimal for localized fat in patients with good skin elasticity and near -ideal body weight

Not indicated for treating skin redundancy—does not remove excess skin

Adjunctive technologies (UAL, LAL, PAL) can enhance outcomes but still require proper skin tone

Technique:

Patient preparation and marking:

Pre-operative markings are performed with the patient standing to define areas of contour irregularity, fat accumulation, and planned aspiration zones

Markings should consider natural fat compartments, aesthetic units, and danger zones (e.g., lateral femoral cutaneous nerve path)

Infiltration of tumescent solution is typically performed using a peristaltic or pressure pump, and care is taken to allow sufficient time for vasoconstriction prior to suction

Incisions and access sites:

Small stab incisions (~2-3 mm) are placed in hidden areas to allow multiple trajectories for the cannula, minimizing visible scarring

A skin protector may be inserted at each incision site to reduce friction and trauma

Cannula insertion:

Cannulas are introduced through access sites using a cross-tunneling technique to ensure even fat removal and prevent step-offs or contour irregularities

Fan pattern movement:

Cannula is moved in a radial "fan-shaped" pattern from each incision point, with smooth reciprocating motions

Liposuction is performed in layers, beginning in the deep plane, progressing toward the superficial subcutaneous layer, avoiding injury to dermis or muscle fascia

End-point determination:

Surgeons judge adequacy of fat removal by observing skin pliability, resistance, and contour symmetry, supplemented by intraoperative palpation and visualization

High-definition liposuction (Fig. 1):

Targets both deep and superficial fat layers to sculpt muscular contours and enhance definition, such as the “six- pack” abs or the V-shaped torso

Figure 1. Cross-section of abdomen demonstrating the effect of HDL on linea semilunaris and linea alba. Similar effects can be achieved in areas of tendinous intersection to create muscle definition. From Willet JW, et al. A Systematic Review of Efficacy and Complications of High-Definition Liposuction. Plast Reconstr Surg. 2023 Jul 1;152(1):57-63.

Often incorporates energy-assisted modalities (e.g., VASER ultrasound) and fat grafting for volume restoration in specific areas

Ideal candidates: BMI <30, good skin elasticity, realistic expectations.

Operative technique:

Pre-operative markings to delineate zones for deep debulking (“negative spaces”) and superficial definition

Multi-layered liposuction: deep first, then superficial to sculpt fine detail

Optional fat grafting to enhance muscular contours (e.g., pecs, deltoids, gluteals)

Often performed using VASER or other energy-assisted devices for precision and reduced trauma

Complications:

Contour irregularities and asymmetry: common in areas with fibrous attachments; precise technique essential

Seroma formation: fluid accumulation managed with drainage or compression; leaving incision slightly open may aid drainage

Fat embolism: rare but life-threatening; more common in large-volume procedures or gluteal augmentation

Other risks: burns (especially with UAL/LAL), fluid overload or imbalance, infection, skin necrosis, sensory changes

Post-op care essentials:

Compression garments: reduce swelling, promote contour.

Drainage/incision management: leave small openings or suction to prevent seromas

Monitor fluid balance: vital in high-volume sessions

Follow-up appointments: early detection of complications like embolism or hematoma

Patient education: emphasize realistic expectations, skin tone limitations, and wound care

EXCISIONAL PROCEDURES BY ANATOMIC REGION

Trunk

Variety of body contouring procedures available to patients depending on the distribution of their excess skin and aesthetic goals

Panniculectomy: excision of the pannus (overhanging abdominal skin and fat)

Indications: symptomatic pannus (e.g., intertrigo, hygiene issues, immobility); often covered by insurance

Operative steps: transverse elliptical skin excision below the umbilicus; umbilicus may be preserved or removed; no rectus plication or aesthetic contouring

Recovery: 2–4 weeks; longer if pannus was large; compression garment use encouraged

Complications: wound dehiscence, seroma, infection, delayed healing

Pearls: ideal for functional improvement, not aesthetics; stable weight (≥6 months) and BMI <35 improve outcomes

Abdominoplasty: removal of excess abdominal skin with rectus plication and umbilical transposition for aesthetic contouring (Fig. 2)

Indications: abdominal laxity, diastasis recti, and excess skin/fat in patients with good general health and weight stability.

Operative steps: low transverse incision, flap elevation to xiphoid, rectus muscle plication, umbilical repositioning, skin re-draping

Recovery: 2–4 weeks; earlier ambulation encouraged; no lifting for 4–6 weeks

Complications: seroma, hematoma, umbilical necrosis, contour irregularity

Pearls: drainless approaches use progressive tension sutures; good skin quality = better result

Figure 2. The above image demonstrates a classic abdominoplasty before and after, with noticeable improvement in waist contour and flattening of the abdomen with plication of the rectus abdominus muscle. From Saldanha O, et al. Lipoabdominoplasty with Anatomical Definition. Plast Reconstr Surg. 2020 Oct;146(4):766-777.

Reverse abdominoplasty: removal of excess skin from the upper abdomen

Indications: excess skin of upper abdomen

Operative steps: incision in inframammary fold of breast, often connects across midline sternum, skin lifted and excised

Recovery: 2-4 weeks

Complications: seroma, hematoma, upwards pull of belly button

Pearls: cannot be combined with traditional tummy tuck in same stage due to risk of vascular compromise

Fleur-de-lis panniculectomy/abdominoplasty (Fig. 3):

Indications: excess vertical laxity in the abdomen that would not be sufficiently addressed with a transverse-only incision; serves as a modification to the traditional panniculectomy/abdominoplasty

Operative steps: elevation of lateral skin flaps with elliptical incision of medial excess tissue

Figure 3. The above schematics demonstrates the markings and subsequent skin excision for an FDL abdominoplasty. From Fernando da Costa L, Landecker A, Marinho Manta A. Optimizing Body Contour in Massive Weight Loss Patients: The Modified Vertical Abdominoplasty. Plast Reconstr Surg. 2004 Dec;114(7):1917-23.

May also require release of fascial bands in cases of ‘double apron’ belly where thick fascial attachments disallow a smooth contour after skin resection

Recovery and complications are similar to abdominoplasty

Pearls: careful pre-operative markings and conservative skin flap undermining are key to a successful operation

In the case of umbilicus preservation, minimize tension on the closure to prevent vertical distortion along the vertical scar

Monsplasty: elevation and excision of redundant mons pubis tissue

Indication: ptotic mons pubis is often unmasked or worsened after abdominal pannus removal

Operative steps: after appropriate excision of excess skin/ adiposity, the mons is lifted

Securing the skin flap to the rectus fascia or pubic symphysis periosteum using sutures ensures cephalad repositioning and tension-free closure

Complications: similar to those in an abdominoplasty, most notably scar widening, wound dehiscence, or skin necrosis if too much undermining or closure under excessive tension

Pearls: often incorporated into abdominoplasty for a complete result

Circumferential lower body lift: 360° excision of skin and fat from abdomen, flanks, outer thighs, back, and buttocks; repositions tissues both anteriorly and posteriorly

Indications: global truncal skin laxity following massive weight loss; redundant lower back, outer thigh, and buttock skin

Operative steps: posterior and anterior incisions connected laterally; abdominoplasty, lateral thigh lift, and buttock reshaping; performed prone-to-supine (can be staged)

Recovery: 2-4 weeks; increased pain and wound burden; limited sitting initially

Complications: wound breakdown, seroma, posterior scar tension, buttock flattening

Pearls: preserve and reshape buttock projection; address scar placement to avoid visible high-riding scars

Upper back lift: resection of upper back rolls, bra-line folds, and lateral chest wall skin

Also known as ‘bra lift’, as scar is hidden in bra line in women

Indications: lateral thoracic or upper back skin redundancy

Operative steps: excision along bra line; direct closure with tension re-distributed

Recovery: 2–3 weeks; avoid heavy lifting; compression garment recommended.

Complications: scar visibility, tension-related dehiscence, hypertrophic scars

Pearls: proper pre-op marking in upright position critical; align scar with bra line or desired garment concealment

Buttock lift: elevation and reshaping of the gluteal region via skin excision and re-draping; often included in lower body lift

Indications: sagging buttocks, skin laxity over gluteal region, often after MWL

Operative steps: crescent or elliptical excision over superior buttocks; deep fixation to fascia; preserve fat pads to avoid flattening

Recovery: 3-4 weeks; avoid prolonged sitting; scar across upper buttock may be visible in swimwear

Complications: buttock flattening, wide scars, delayed wound healing

Pearls: consider fat grafting or flap preservation techniques to maintain volume and contour

Breast

A detailed review on aesthetic breast surgery can be found in Chapter 22. While these breast procedures are also classified as body contouring procedures, in this chapter we will describe them as they relate to the MWL patient population, who often experience unique challenges in achieving a satisfying aesthetic result.

Evaluation of the MWL breast:

Patients will have:

Loss of parenchymal volume

Severe ptosis (Grade II-III)

Deflated upper pole with stretched skin envelope

Lateral chest wall rolls

Lack of IMF support

Medialized nipple

Goals include restoring shape, projection, symmetry, and volume – often requiring combinatorial techniques

Patient history:

Weight loss history: degree of loss, time since weight stabilization (ideally ≥6 months), bariatric surgery history, nutritional supplementation

Breast history: prior surgery, radiation, breastfeeding, or trauma

Symptoms: physical discomfort (e.g., neck/back pain), intertrigo under the breasts, dissatisfaction with shape or volume

Physical examination:

Skin quality:

Evaluate for elasticity, striae, thinness, and redundancy

MWL skin is often inelastic and prone to poor recoil – impacts longevity of results

Volume assessment:

Is there true hypertrophy or parenchymal deflation?

Palpate for residual breast tissue vs. fat; consider imaging if needed

Degree of ptosis (NAC position):

Grade I–III ptosis (Regnault classification)

Measure sternal notch to nipple distance, inframammary fold (IMF) position, and nipple to IMF distance

Breast footprint and shape:

Note base width, projection, and upper vs. lower pole fullness

Identify lateral chest wall rolls or axillary excess that may require additional excision

Asymmetry:

Document pre-existing asymmetry in size, shape, or nipple position

Mastopexy (breast lift):

Indication: moderate-to-severe ptosis with adequate native volume

Technique: skin envelope reshaping via vertical, Wise-pattern, or crescent/lollipop incisions, with parenchymal reshaping

MWL consideration:

Skin often lacks elasticity; high recurrence of ptosis without internal support

Consider dermal suspension or mesh reinforcement

Augmentation-mastopexy:

Indication: ptosis + volume loss (especially upper pole fullness)

Technique: combines mastopexy with implant placement; may be staged or performed in one operation

MWL consideration:

Thin tissue envelope increases implant visibility and risk of complications

Staging (mastopexy first, augmentation later) may reduce risks in severe cases

Reinforcement (e.g., mesh) helpful

Dermal suspension auto-augmentation (Fig. 4):

Indication: deflated ptotic breast with sufficient inferior pole tissue

Technique: central flap of breast tissue is deepithelialized and folded to auto-augment volume, anchored to the chest wall (e.g., Dr. Peter Rubin’s technique, autologous internal bra techniques)

MWL consideration:

Excellent option to avoid implants

Allows auto-projection with durable result if skin quality is adequate

May need to combine with lateral chest wall excision or bra-line lift

Figure 4. The above patient underwent a dermal suspension auto-augmentation after a 130-lb weight loss. From Rubin JP, Gusenoff JA, Coon D. Dermal suspension and parenchymal reshaping mastopexy after massive weight loss: statistical analysis with concomitant procedures from a prospective registry. Plast Reconstr Surg. 2009 Mar;123(3):782-789.

Reduction mammaplasty:

Indication: macromastia, desires smaller breast size

Technique: removal of glandular tissue and skin; reshaping of parenchyma and repositioning of nipple

MWL consideration:

Patients may have deflated tissue, not true hypertrophy—assess carefully

May require volume preservation rather than reduction

Lateral extensions or rolls may need separate excision (axilloplasty or bra-line lift)

Arms

MWL patients may have excess skin in the upper extremity. This excess skin can be bothersome and unsightly. There are several incision patterns for skin excision of the upper extremity, each with a unique target patient demographic.

Standard medial brachioplasty:

Indications:

Moderate to severe upper arm skin laxity, commonly seen after MWL

Redundant tissue in the upper third to half of the arm

Patients typically willing to “trade skin for scar”

Basic steps:

Medial incision from axilla to medial epicondyle

Skin and subcutaneous tissue excised en bloc or via skin flaps

Deep dermal sutures and layered closure

Optional liposuction for contouring before or after skin excision

Drain:

May be used or avoided (surgeon preference)

Used more often in MWL patients or high-volume resections, although surgeons are trending away from them

Not necessary in small cases with hemostasis and progressive tension sutures.

Recovery:

2–3 weeks for return to light activity; full healing over 6 weeks

Compression garment recommended for 3-6 weeks

Avoid heavy lifting initially

Pearls:

Mark with patient standing and arms abducted 90°

Keep incision along medial bicipital groove to reduce visible scarring

Preserve medial antebrachial cutaneous nerve (MABC) – injury can cause sensory deficits

Avoid aggressive undermining to reduce seroma risk

Posterior brachioplasty (Fig. 5):

Indications: moderate to severe laxity with preference for scar hidden in posterior arm position

Basic steps:

Incision placed along posterior arm (over triceps groove)

Skin and soft tissue resected as per medial approach, but plane shifted posteriorly

Closure and management as per medial technique

Pearls:

Scar can be visible from behind patient in arms-down posture

Careful positioning during closure is important to avoid dog-ears or lateral bunching

Avoid over-resection that may tether posterior deltoid area

Extended brachioplasty:

Indications:

Severe skin laxity of upper arm and lateral chest wall (bra roll, axillary fold)

MWL patients with extensive upper torso skin excess

Figure 5. A 46-year-old patient with a body mass index 24.4 kg/m2 (48-kg weight loss following sleeve gastrectomy). (Left) Pre-operative views. (Right) One-year postoperative views. From Simone P, et al. Postbariatric Brachioplasty with Posteromedial Scar: Physical Model, Technical Refinements, and Clinical Outcomes. Plast Reconstr Surg. 2018 Feb;141(2):344-353.

Basic steps:

Incision begins at elbow, traverses medial or posterior upper arm, and extends across axilla to lateral chest wall

May include back or breast contouring procedures in combination

Wide undermining often required laterally

Pearls:

Must address lateral chest fold in continuity to avoid dog- ear and contour distortion

Carefully position lateral scar to fall beneath bra line or natural skin fold

Higher risk of delayed wound healing, particularly in axilla

Scar burden is greater—patient counseling is key

Watch for lymphatic disruption in axillary region

Short-scar brachioplasty (crescent or transverse axillary):

Indications:

Mild skin laxity confined to proximal upper arm

Good candidates with localized axillary excess and excellent skin quality

Basic steps:

Crescent-shaped or transverse excision confined to axillary fold

Limited undermining; skin re-draped and closed with suspension sutures to axillary fascia

Pearls:

Less dramatic improvement; not appropriate for MWL patients

Good option for younger, fit patients concerned about visible scars

Watch for scar migration or hypertrophy in axilla

Thighs

MWL patients often suffer from excess skin in the thighs that is best addressed with a thighplasty (sometimes referred to as ‘thigh lifts’ colloquially). Thighplasty must be tailored to the pattern and severity of skin excess (vertical, horizontal, circumferential) and may involve medial, spiral, lateral, or combined approaches. Proper patient selection and expectation management are key due to the relatively high complication and scar burden.

Thighplasties carry a high visible scar burden with a range of aesthetic improvements, but are nonetheless commonly performed and praised for the following benefits:

Restores proportion and silhouette: balances lower body aesthetics with concurrent trunk or upper body procedures

Improves function and hygiene: reduces friction, moisture retention, and intertrigo in the medial thigh

Enhances mobility: removes bulky, pendulous skin that may impair walking or exercise

Complements global reshaping: often performed after or with lower body lift, abdominoplasty, or buttock lift to achieve cohesive results

Addresses psychosocial concerns: improves body image, clothing fit, and self-esteem in post-MWL patients

Horizontal (inguinal crescent) thighplasty:

Indications: mild to moderate excess in upper third of medial thigh

Technique: crescent excision placed in inguinal crease, with fixation to Colles' fascia to prevent scar migration

Pearls:

Best for patients with vertical skin laxity only

Anchor flap to deep fascia to prevent labial distortion or scar descent

Risk of wound dehiscence if tension is high or anchoring inadequate

Vertical medial thighplasty (Fig. 6):

Indications: moderate to severe horizontal laxity along inner thigh, often extending to the knee

Technique: longitudinal excision from groin to above knee, usually along medial thigh

Pearls:

Good for MWL patients with "curtain-like" vertical redundancy

Scar is visible; patient counseling is key

Avoid femoral triangle to preserve lymphatics and prevent lymphedema

Figure 6. The above photos depict intraoperative markings, skin resection, and closure for a medial vertical thighplasty. From Schmidt M, et al. Concomitant Liposuction Reduces Complications of Vertical Medial Thigh Lift in Massive Weight Loss Patients. Plast Reconstr Surg. 2016 Jun;137(6):1748-1757.

Combined (T- or L-Shaped) medial thighplasty

Indications: combined horizontal and vertical skin excess (common in MWL)

Technique: combines horizontal (inguinal) and vertical (medial thigh) excisions; forms T or L shape

Pearls:

T-pattern preferred for more symmetric tension distribution

Increased scar burden, but better contour in severe deformities

May combine with liposuction for improved outcome

Spiral thighplasty:

Indications: circumferential thigh skin laxity, including anterior, posterior, and lateral thigh; especially in MWL patients

Technique: oblique spiral excision that lifts the thigh circumferentially, often integrated with buttock or lower body lift

Pearls:

Targets 360° laxity, not just the medial aspect

Often part of posterior body lift procedures

Requires experience in flap tension control and scar placement over visible areas (posterolateral thigh)

Lateral thighplasty:

Indications: significant lateral thigh and hip skin laxity, often in MWL patients

Technique: incision along the iliac crest or lateral thigh, often extending from the buttock or posterior lift incision

Pearls:

Often performed with circumferential body lift or extended abdominoplasty

Improves outer thigh contour and buttock lift synergy

Scar placement should follow natural gluteal-lateral crease to minimize visibility

LIPEDEMA

Lipoedema is a chronic, progressive adipofascial disorder characterized by the symmetrical deposition of pathologic adipose tissue predominantly affecting the lower extremities and, in some cases, the arms. Unlike generalized obesity, lipedema spares the hands and feet, and is often resistant to diet and exercise. The condition primarily affects women and may be hormonally mediated, with onset frequently around puberty, pregnancy, or menopause.
Lipedema remains significantly underdiagnosed and is frequently misclassified as simple obesity or lymphedema, leading to delays in appropriate treatment; ongoing research aims to clarify its distinct pathophysiology, diagnostic criteria, and optimal management strategies.

Diagnosis: clinical diagnosis based on history and physical examination

Symmetrical enlargement of the lower extremities, sparing the feet

Tenderness to palpation, easy bruising, negative Stemmer sign (unlike lymphedema)

Disproportion between trunk and limb girth (Fig. 7)

Figure 7. Contour deformity of the ankle in lipedema. The excess subcutaneous fat seen in the lower leg ceases abruptly at the level of the malleoli, sparing the feet and leading to a ring-like appearance of the ankle. From Warren AG, et al. Evaluation and management of the fat leg syndrome. Plast Reconstr Surg. 2007 Jan;119(1):9e-15e.

Progressive nature, with worsening pain, mobility issues, and secondary lymphedema in advanced stages

Staging: typically based on cutaneous and fascial changes

Smooth skin surface, thickened subcutaneous tissue with palpable nodules

Uneven skin surface, larger nodules and lobules, fibrosis begins

Significant deformity, lipomas, and redundant overhanging tissue

Lipo-lymphedema: Coexisting secondary lymphedema and fibrosis

Treatment:

Conservative management:

Compression therapy

Manual lymphatic drainage (MLD)

Exercise and anti-inflammatory nutrition

Does not reduce the pathologic adipose tissue; for patients with significant symptom burden or deformity, liposuction is the only evidence-supported intervention to reduce limb volume and improve quality of life

Surgical management:

Tumescent liposuction (particularly power-assisted and water-assisted variants) is the most studied and preferred method for surgical treatment (Fig. 8)

Compared to traditional liposuction, these modalities preserve lymphatic structures and reduce long-term complications

Figure 8. Before and after photos of multi-stage liposuction for advanced stage lipedema. From Kruppa P, et al. A 10-Year Retrospective before-and-after Study of Lipedema Surgery: Patient-Reported Lipedema-Associated Symptom Improvement after Multistage Liposuction. Plast Reconstr Surg. 2022 Mar 1;149(3):529e-541e.

Indications: pain, limited mobility, cosmetic deformity, psychosocial distress

Contraindications: uncontrolled comorbidities, active infection, or unrealistic expectations

Operative considerations:

Staged procedures are common due to the extensive surface are

General or tumescent local anesthesia may be used

In advanced-stage lipedema (particularly Stage III-IV) or in patients with significant skin redundancy following prior liposuction or weight loss, adjunctive skin excision procedures may be required to optimize functional and aesthetic outcomes

Long-term compression garments are recommended postoperatively

Avoid energy-based liposuction (e.g., ultrasound, laser) which may increase lymphatic injury risk

Outcomes and complications

Numerous studies report improvement in pain, function, and cosmetic appearance with a low complication rate when lymphatic-sparing techniques are employed

Risks include seroma, infection, skin laxity, and transient sensory changes

Pearls

Distinguish from obesity and lymphedema; misdiagnosis is common

Psychological support is critical; many patients report prior medical dismissal

Lipedema is often under-recognized – early intervention improves outcomes

STAGING AND COMBINING PROCEDURES

In cases of massive weight loss or situations where patients otherwise have various areas they’d like addressed, staging body contouring may be necessary

Many surgeons follow the principle of only operating on either the upper or lower extremities at any given time

Timing between procedures is ultimately at the discretion of the operating surgeon, but generally speaking, it is wise to wait until the scars from the first stage are well-healing, at a minimum of 3 months post-operatively

The decision to stage a procedure should take into consideration the anticipated time under anesthesia and the necessity of an overnight stay

POST-OPERATIVE CARE AND COMPLICATIONS

The below guidelines are generic and should be tailored according to the procedure(s) being performed, as well as the specific needs of the patient.

Compression garments:

Purpose: reduce edema, support tissues, minimize seroma, and improve contour adherence

Duration: typically worn 24/7 for 4-6 weeks, then tapered

Pearl: should be snug but not cause skin folds, ischemia, or nerve compression

Wound care and seroma prevention:

Wound care: keep incisions clean and dry; remove sutures/ drains per protocol; monitor for signs of infection or dehiscence

Seroma prevention:

Use progressive tension sutures and limited undermining to obliterate dead space

Closed suction drains may be placed; typically removed when output is <30 mL/24 hrs for 2 consecutive days

Liposuction-assisted techniques reduce seroma risk in thighplasty and abdominoplasty

DVT prophylaxis and early ambulation:

Risk stratification: use Caprini score to guide prophylaxis

Pharmacologic prophylaxis: LMWH or heparin for moderate-high risk patients (especially in MWL)

Mechanical measures: SCDs during and after surgery

Ambulation: Initiate within 12-24 hours post-op to reduce VTE risk

Scar management:

Typically should start at 3 weeks postoperatively

Silicone gel/sheets to reduce hypertrophy

Sun protection for at least 6-12 months

Massage to improve pliability

Hypertrophic risk is higher in MWL patients, with the exact etiology not fully elucidated but often attributed to tension, scar positioning, or skin quality

Patient education: expectations and healing

Timeline: major swelling resolves in 6 weeks; full results take 3-6 months, scars mature over years

Realistic outcomes: emphasize function over perfection, and potential need for revisions

Early concerns: numbness, firmness, asymmetry are common and often improve

Follow-up: regular visits for wound check, drain removal, scar monitoring, and reassurance

REFERENCES

Achauer BM, et al., eds. Plastic Surgery Indications, Operations, and Outcomes, Vol. 5. Mosby: 2000.

Sherrell A, et al., eds. Grabb and Smith’s Plastic Surgery. 7th ed. Lippincott-Raven: 1997.

McCarthy, et al, eds. Current Therapy in Plastic Surgery. Saunders, Elsevier: 2006.

Shestak KG, ed. Abdominoplasty. Clin Plast Surg. 2004 Oct; 31(4).

Shridharani SM, Broyles JM, Matarasso A. Liposuction devices: technology update. Medical Devices: Evidence and Research. Med Devices. 2014 Jul 21;7:241-51.

Chase DD, Shridharani SM, Broyles JB. The Safety and Efficacy of Cryolipolysis: A Systematic Review of Available Literature. Aesthet Surg J. 2015 Sep;35(7):830-6.

Shridharani SM. Abdominoplasty with Liposuction. Plastic Surgery Education Network. 2016 February 1. (ePub).

Shridharani SM, Wang HD, Singh NK. Liposuction. Eplasty. 2013 Jan 15;13:ic4.

Shridharani SM, Bellamy JL, Mofid MM, Singh, NK. Breast augmentation. Eplasty. 2013 June 13;13:ic46.

Chapter 24
Injectables, Lasers, and Non-Invasive Procedures

Christina Shree Chopra, MD
Andrew McGregor, MD

FOUNDATIONS OF NON-SURGICAL AESTHETIC MEDICINE

Interest and pursuit of aesthetic noninvasive procedures has steadily increased as patients seek more holistic and longitudinal means to achieving a youthful, healthy look. Patient evaluation is key to selecting the appropriate treatments for patients, noting that both surgical and non-surgical options exist, and some patients may benefit from just one, while others may benefit from both. Patient evaluation should include ethnic, gender, and age-specific considerations. All patients should undergo standardized photography and expectation management as a part of their evaluation.

SKIN CARE

While initially thought to be outside the world of plastic surgery practice, skincare is of growing interest to plastic surgeons for many reasons, including:

Improved skin quality in the perioperative/peri-procedure period

Addressing patient concerns that are mistakenly identified as helped by more invasive procedures

Commonly recommended skincare products

Cleansers

Ingredients: gentle, non-soap surfactants

Purpose: cleanse without disrupting skin barrier

Exfoliants

Ingredients: AHAs (glycolic, lactic), BHAs (salicylic)

Purpose: improve skin texture and unclog pores

Retinoids

Ingredients: retinol (OTC), tretinoin (rx), adapalene

Purpose: boost collagen, reduce fine lines and pigmentation

Antioxidants

Ingredients: vitamin C (L-ascorbic acid), ferulic acid

Purpose: neutralize free radicals, brighten complexion

Pigment regulators

Ingredients: hydroquinone (rx), tranexamic acid, niacinamide

Purpose: treat melasma, post-inflammatory hyperpigmentation (PIH), uneven skin tone

Moisturizers

Ingredients: ceramides, hyaluronic acid, glycerin

Purpose: repair skin barrier, maintain hydration

Sunscreens (broad-spectrum)

Ingredients: zinc oxide, titanium dioxide, Mexoryl SX

Purpose: protect against UV-induced aging and pigmentation

While the individual needs of patients will vary, it is generally agreed upon that some combination of the above skincare will help promote healthy, youthful skin and improved procedural outcomes when pursued

Skin care is a crucial step in a patient’s facial aesthetics and is key to optimizing outcomes in both non-surgical and surgical facial procedures

NEUROMODULATORS

Purpose: to paralyze specific muscles, resulting in decreased rhytids (wrinkles)

Mechanism of action: botulinum toxin A inhibits acetylcholine release at the NMJ, resulting in flaccid paralysis of the targeted muscle due to impaired neuromuscular transmission

Number of units needed will vary depending on the patient

FDA-approved uses and injection patterns:

Glabella (“11" lines): 5-point pattern: procerus (1), corrugators (2 each side); deep intramuscular injection

Forehead rhytids: superficial intramuscular or subdermal injections in frontalis; dose adjusted to preserve brow position

Lateral canthal lines: 3-point fan lateral to orbital rim; superficial injection; avoid zygomatic muscles

Off-label uses and injection patterns with average doses:

Masseter hypertrophy: 2–3 deep injections into masseter body per side; avoid parotid duct and facial artery (Fig. 1)

Figure 1. Left, hypertrophied temporalis and masseter muscles. Right, contoured facial line after botulinum neurotoxin treatment. From Yi K, et al. Guidelines for Botulinum Neurotoxin Injection for Facial Contouring. Plast Reconstr Surg. 2022 Sep 1;150(3):562e-571e.

Gummy smile: 1-2 units per side to levator labii superioris alaeque nasi; superficial injection.

Platysmal banding: multiple small aliquots injected directly into visible bands; avoid diffusion into deeper neck structures

Bunny lines: 1-2 units per side into nasalis muscle; superficial along upper nasal sidewall

Perioral lines: 0.5–1 unit per site intradermally around upper/lower vermilion border; avoid lip incompetence.

Brow lift/asymmetry: small dose (1-2 units) in lateral frontalis just above brow peak; avoid overt ptosis

Nasal tip rotation: 1-2 units into depressor septi nasi at columellar base; may aid tip elevation

Nefertiti lift: series of injections along lower jawline and upper platysma; targets downward pull and defines mandibular border

Various neuromodulator agents on the market (Table 1)

Individual results will vary, with it being well-understood that those individuals receiving long-term neuromodulator treatment will likely have increased tolerance requiring higher doses to achieve a similar effect

Men tend to require higher doses to achieve the same therapeutic effect as women, as do those who are more ‘expressive’ than others

Best practice dictates that patients are counselled and closely monitored for therapeutic effect, with changes in dose occurring slowly over time to accommodate for desired mobility

Emerging trends:

"Microbotox" or “baby Botox”: involves multiple microdroplet injections of highly diluted botulinum toxin into the superficial dermis, targeting fine lines, pore size, and skin texture without compromising facial movement

Ideal for patients seeking subtle, natural-looking results with preserved expression.

Sebaceous suppression: intradermal microinjections of diluted botulinum toxin ("microbotox") have been shown to reduce sebum production by inhibiting acetylcholine-mediated stimulation of sebaceous glands

Can lead to smaller pores, less oiliness, and improved skin texture, especially in patients with oily or acne-prone skin

Rosacea and flushing: may help modulate neurovascular signaling and reduce vasodilation, leading to decreased facial flushing, erythema, and burning sensations

Studies have shown that low-dose intradermal doses can calm inflammatory responses in erythematotelangiectatic rosacea

Scars: when injected early in the healing process, can reduce tension across a wound, inhibit myofibroblast contraction, and limit hypertrophic scarring

May also help improve the appearance of existing scars by relaxing surrounding muscle pull and enhancing remodeling

SOFT-TISSUE FILLERS

Dermal fillers can be categorized into four main types:

Hyaluronic acid (HA) fillers: provide immediate, reversible volumization

Biostimulatory fillers: stimulate collagen production for gradual, long- lasting results

Autologous fillers: fat grafting, derived from the patient’s own tissue (i.e., fat grafting)

Allogeneic/homologous fillers: offer structural support and tissue integration from donor-derived materials (i.e., acellular dermal matrices)

Filler science:

Rheology: flow and mechanical behavior of filler in tissue

G’ (elastic modulus): measures stiffness or ability to resist deformation

High G′ fillers are ideal for deep support (e.g., cheeks, jawline)

Low G′ for mobile or superficial areas (e.g., lips, perioral lines)

Cohesivity: degree to which filler molecules stick together

High cohesivity helps maintain shape and resist spreading; important in rhinoplasty or deep bolus areas

Viscosity: thickness/resistance to flow through tissue

High viscosity aids in volumization; low viscosity spreads easily, suited for fine lines

Longevity: varies by filler type, crosslinking, injection site, and metabolism:

HA fillers: 6-24 months

Biostimulatory fillers: 12-36 months

Fat grafting: variable, partially permanent

Reversibility:

HA fillers are reversible with hyaluronidase

Biostimulatory, autologous, and allogeneic fillers are not reversible; require observation, steroids, or excision for complications

HA fillers: Juvederm™, Restylane™, Belotero™, RHA™(Table 2)

Indications: principally volume replacement, nonsurgical rejuvenation

Specific indications depend on the treatment area(s) of interest

Mechanism of action: cross-linked HA gel is injected into soft tissue → attracts water and volumizes tissue, supports collagen matrix, and integrates into the dermal or subdermal layers for contour and lift

Duration: typically 6-24 months, depending on product properties (e.g., crosslinking, viscosity), treatment area, and individual metabolism

Shorter duration in dynamic, mobile areas (e.g., lips)

Longer duration in deep structural areas (e.g., cheeks, jawline)

Biostimulatory fillers: Sculptra™(PLLA), Radiesse™(CaHA) (Table 3)

Indications: volume restoration and collagen induction

Mechanism of action: injected particles (PLLA or CaHA) act as foreign-body stimulants, triggering fibroblast activation → neocollagenesis (primarily Type I collagen)

Carrier gel provides initial volume (esp. with CaHA), while long-term correction results from endogenous collagen deposition

Duration:

Sculptra™(PLLA): ~2-3 years (after a series of treatments)

Radiesse™(CaHA): ~12-18 months for volume; longer-lasting collagen stimulation

Results are progressive, peaking over several months

Autologous: fat grafting (structural fat, nanofat)

Structural fat: harvested via liposuction, processed (e.g., centrifuged), and injected in larger particles into deep planes for volume restoration (e.g., cheeks, buttocks, hands)

Nanofat: emulsified and filtered fat – no volume effect – used superficially to improve skin quality via stromal vascular fraction (SVF) and growth factors

Indications: volume loss, contouring, skin rejuvenation

Recovery: variable swelling, bruising; resorption 20-50%

Complications: fat necrosis, nodules, overcorrection, oil cysts

Allogeneic/homologous:

Acellular dermal matrix (ADM)(Alloderm™)

Derived from cadaveric human dermis; decellularized to remove antigenic components

Used for soft tissue support in facial, breast, and reconstructive surgery (e.g., deep nasolabial folds, lip augmentation, periorbital hollows)

Provides a scaffold for cellular ingrowth and tissue integration

Implanted surgically or via a tunneling technique

Micronized/injectable ECM Products (e.g., Renuva™, micronized Alloderm)

Processed to fine particles or injectable suspension

Intended to stimulate native fat regeneration and soft tissue fill without donor site morbidity

May be used for small volume contour correction or skin quality improvement

Recovery: minimal downtime; swelling possible

Complications: rare rejection, cost, variable longevity

Pearls: Alloderm must be placed deep to avoid palpability; micronized forms are more versatile but do not produce immediate volumization like HA or fat

Injection techniques

Planes of injection of filler will depend on several factors, including:

Anatomic area/condition being treated (e.g., midface volume loss may require deep structural support (supraperiosteal), while fine perioral lines need superficial placement (intradermal)

Desired effect

Lifting and projection → deeper planes

Line filling or hydration → more superficial planes

Type of filler

High G’ fillers (e.g., Voluma™, Lyft™): better suited for deep support

Low G’ fillers (e.g., Belotero Balance™, Volbella™): ideal for superficial correction

Layers of the skin subject to injection:

Supraperiosteal: directly on bone, beneath muscle/fat

Useful for structural support (e.g., cheeks, chin, jawline)

Use high-viscosity filler; low mobility; aspirate to avoid vessels

Subcutaneous: between dermis and SMAS layer

Useful for moderate-depth volume (e.g., lips, nasolabial folds)

Good for contouring and soft volume; beware of vascular anatomy

Intradermal: within the dermis (papillary or reticular)

Useful for fine lines, skin hydration (e.g., perioral, forehead)

Risk of Tyndall effect with improper product choice or technique

Use of a cannula vs. needle

Cannulas have a blunt and rounded tip. They are also longer and more flexible. Their benefit in dermal fillers to minimize bruising and swelling.

Needles have sharp and rigid tips. They allow for precise placement of fillers, but carry a higher risk of bruising and potential injury to blood vessels

Must be mindful of branches of facial artery when injecting into temporal and frontal regions of the face (Fig. 2)

Figure 2. Skin access points for temporal (above) and frontal (below) filler injection techniques. From Colucci L, Rengifo J. Hyaluronic Acid Filler Usage and Technique for the Facial Upper Third: A Comprehensive Review. Plast Reconstr Surg Glob Open. 2025 Apr 28;13(4):e6668.

Common indications for HA filler by facial subunit:

Temples: fills hollowing from fat/volume loss; softens contour transition between forehead and lateral face;

Inject deep (preferably supraperiosteal) to avoid vascular injury

Tear troughs: improves hollowness and shadowing; requires low-viscosity filler with deep supraperiosteal placement

High risk of Tyndall effect and swelling

Nose: non-surgical rhinoplasty; improves dorsum contour, camouflages humps, refines tip

High risk area; precise technique and aspiration critical to avoid vascular occlusion (esp. dorsal nasal artery)

Nasolabial folds: softens static folds by restoring volume in the fold or adjacent cheek; may be treated secondarily after midface support

Avoid overfilling to prevent unnatural look

Midface/cheeks: restores youthful contour, improves malar projection, supports lower lid and nasolabial fold

Deep bolus or layered techniques often used

Lips: enhances volume, defines vermilion border, improves symmetry, softens perioral lines

Risk of overfilling, migration, and vascular compromise (e.g., labial artery)

Chin: enhances projection and length, balances facial thirds, can smooth cleft or dimpling

Inject deep on bone, watch for mentalis strain.

Jawline: defines mandibular border, improves jowling and contour; high G’ fillers placed deep along mandible and gonial angle

Avoid parotid duct and marginal mandibular nerve

Complications and management:

Vascular occlusion

Inadvertent intravascular injection → arterial blockage → ischemia or necrosis.

Early signs: blanching, pain, livedo, reticulated skin.

Treatment:

Immediate hyaluronidase (150-450 IU per site); repeat hourly if needed; consider ultrasound guidance

Warm compress

Massage

Aspirin

Topical nitroglycerin

Tyndall effect: from superficial injection, causing bluish discoloration due to light refraction through gel. Common under thin skin (e.g., tear trough).

Prevention: correct plane and product selection.

Treatment: low-dose hyaluronidase (10-20 IU) or aspiration/removal

Granuloma: firm, persistent, delayed nodules due to chronic foreign body reaction (weeks – months later); rare

Treatment:

Rule out biofilm

Hyaluronidase, intralesional steroid (e.g., triamcinolone), ± oral doxycycline or 5-FU

Consider biopsy if persistent

Delayed hypersensitivity: swelling, erythema, and induration weeks to months later; possibly immune-mediated or triggered by illness/vaccine

Treatment:

Oral steroids (e.g., prednisone taper), antihistamines

May require hyaluronidase in severe cases

Rule out infection.

Hyaluronidase

Function: Enzyme that breaks down hyaluronic acid (both native and filler- derived)

Indications: vascular occlusion, overcorrection, nodules, Tyndall effect, uneven results

Dosage: ranges from 10 IU (Tyndall) to 450+ IU (vascular compromise); titrated to effect

Brands: Vitrase™, Hylenex™, Hyalase (regional differences)

Contraindications: known allergy to ovine/bovine proteins (some formulations); skin testing optional

Caution: may dissolve native HA in surrounding tissue; always consent patient

Ultrasound-guided safety

High-resolution ultrasound is increasingly used in aesthetic practice for:

Vessel mapping: to avoid key arteries (e.g., angular, supratrochlear, facial)

Real-time guidance: during injection to ensure proper filler plane and avoid vasculature

Complication management: localize and target hyaluronidase precisely during vascular events or nodules

Benefits:

Increases safety in high-risk areas (glabella, nose, tear troughs)

Helps visualize vascular occlusion sites for targeted reversal

Valuable tool for training and complication management

LASER AND ENERGY-BASED DEVICES

Laser and energy-based devices (EBDs) are used in skin rejuvenation to target chromophores like water, melanin, and hemoglobin, delivering controlled thermal injury that stimulates collagen remodeling, improves texture, and treats pigment or vascular irregularities. They include modalities such as ablative and non-ablative lasers, IPL, RF microneedling, and ultrasound-based tightening, each tailored to specific skin concerns and downtime tolerances.

Lasers

Laser physics simplified

Chromophores: molecular targets that absorb specific wavelengths of laser light, converting it into heat for selective photothermolysis.water, melanin, hemoglobin

Water:

>1,300 nm (esp. 2,940 nm Er:YAG, 10,600 nm CO₂)

Dominant in ablative resurfacing; vaporizes tissue, tightens skin

Melanin:

400–1,060 nm (e.g., 755 nm Alexandrite, 810 nm Diode)

Target for hair removal, lentigines, melasma; caution in darker skin types

Hemoglobin:

532 nm (KTP), 585–595 nm (PDL), 1,064 nm (Nd:YAG)

Used for vascular lesions (e.g., telangiectasias, rosacea, hemangiomas)

Ablative vs. non-ablative; fractional vs. non-fractional (Table 4)

Ablative lasers (Table 5)

Target both the epidermis and dermis, using water as the primary chromophore

Vaporize superficial skin layers, creating controlled wounds that stimulate a robust healing response

Mechanism of action: precise removal of epidermis and partial dermis → collagen remodeling and re-epithelialization

Downtime is typically 5–10+ days due to open wounds, crusting, and peeling

Often requires topical anesthetic, nerve blocks, or sedation depending on depth

Typically 1–2 sessions may achieve substantial results in wrinkle reduction, texture improvement, scarring, and skin tightening

Results tend to be more dramatic and longer-lasting than non-ablative options, but with increased risk

Higher risk of post-inflammatory hyperpigmentation, especially in Fitzpatrick IV–VI

Infection, delayed healing, and scarring are also possible with improper care or technique

Non-ablative lasers (Table 6)

Target the dermis (water or pigmented structures)

No epidermal disruption, so the skin surface remains intact

Mechanism of action: controlled thermal injury to dermis → neocollagenesis

Downtime is typically minimal (1–3 days of redness or swelling)

These procedures are usually well-tolerated with local anesthetic.

Typically require multiple sessions (3–6+) for optimal results, which are gradual and include improved tone, texture, and mild tightening over time

Risk of PIH is lower in non-ablative than ablative lasers, making it safer for darker skin types

Energy-based technologies

RF Microneedling (Morpheus8™, Profound™)

Mechanism of action: delivers radiofrequency energy via insulated or semi- insulated microneedles into the dermis/subdermis → causes controlled thermal injury → neocollagenesis, elastin formation (Fig. 3), dermal remodeling

Figure 3. Illustration of atrophy of the extracellular matrix during the aging process and the effect it has on skin. From Shridharani SM, Ribaudo JG, Kennedy ML. Skin Tightening Technologies in Body Contouring. Plast Reconstr Surg. 2025 May 1;155(5):935e-946e.

Indications: skin laxity, jowls, acne scars, wrinkles, enlarged pores, stretch marks, early submental fullness

Recovery: mild erythema, swelling, pinpoint crusting for 2-4 days; makeup typically allowed after 48 hours

Complications/pearls:

Risk of PIH (esp. Fitzpatrick IV–-to prevent burns or post-treatment texture changes

Depth and pulse duration matter (Profound™ targets SMAS level for more lift; Morpheus8 has adjustable depths)

Deeper energy delivery may cause facial hollowing as the energy delivered may target deeper subcutaneous tissue

Avoid use over implants, keloid-prone areas

Ultrasound-based (Ultherapy™)

Mechanism of Action: Uses microfocused ultrasound with visualization (MFU-V) to deliver heat at precise depths (1.5, 3.0, 4.5 mm) → coagulation zones in SMAS, deep dermis → triggers collagen contraction and neocollagenesis

Indications: mild to moderate skin laxity (brow lift, jawline, neck), non- surgical lifting, fine lines, décolletage wrinkles

Recovery: no visible downtime; mild tenderness, tingling, or edema for 1–3 days

Complications/pearls:

Painful during treatment → topical + oral analgesia helpful

Deep delivery requires precise visualization to avoid fat atrophy

Results are gradual (3–6 months) and best in younger patients with mild laxity

May cause transient nerve irritation if improperly delivered

Intense Pulsed Light (IPL)

Mechanism of action: emits broad-spectrum light (500–1,200 nm) absorbed by chromophores: melanin, hemoglobin → heats pigment or vessels → photothermolysis → destruction and gradual clearance

Indications: sunspots, lentigines, telangiectasias, rosacea, photodamage, uneven tone; off-label: acne and hair reduction

Recovery:

1-2 days: erythema and mild swelling

3-7 days: darkening/sloughing of pigmented spots

Complications/pearls:

Not a true laser (broadband light, not collimated)

Risk of burns or hyperpigmentation in darker skin tones → lower fluence, use with caution

Multiple sessions needed (3-5) for best results

No tanning pre/post procedure to minimize PIH risk

Treatment planning

Device selection based on indication (wrinkles, pigment, scars, vascular lesions)

Downtime, risks, and contraindications

CHEMICAL PEELS

Chemical peels are topical treatments that use acids—such as glycolic, salicylic, TCA, or phenol—to exfoliate the skin at varying depths, stimulating cell turnover and improving texture, tone, fine lines, and pigmentation. They are classified as superficial, medium, or deep peels based on how deeply they penetrate the epidermis and dermis.

Indications: dyschromia, photoaging, acne scars, melasma

Mechanism of action: protein denaturation → exfoliation and regeneration

Peel depths and agents

Superficial: glycolic acid, salicylic acid, Jessner’s solution

Medium: TCA (10-35%)

Deep: Phenol (Baker-Gordon, Hetter’s)

Pretreatment care (priming protocol)

Purpose: prepares skin for even penetration of peel, reduces risk of PIH, and enhances efficacy.

Common agent

Retinoids (e.g., tretinoin): promote epidermal turnover and thin the stratum corneum

Hydroquinone (2-4%): suppresses melanogenesis to reduce risk of PIH

Timing: begin 2-4 weeks before peel (unless contraindicated); discontinue 3-5 days before the procedure.

Pearl: for deep peels or in those patients with a history of herpes infection, prescribe prophylactic antivirals (e.g., valacyclovir)

Treat active infections promptly with antibiotics or antivirals

Post-treatment care (wound healing support)

Cleansing: use a gentle, non-foaming cleanser to avoid irritation

Moisturization: keep skin hydrated with petrolatum-based or non-comedogenic ointments

Sun protection: broad-spectrum sunscreen is critical; strict sun avoidance for 2-4 weeks postprocedure

Avoidance: no picking, exfoliating, or active skincare (retinoids, acids) during recovery

OTHER MINIMALLY INVASIVE SKIN TREATMENTS

Dermabrasion vs. microdermabrasion (Table 7)

Dermabrasion: surgical, ablative procedure best for deep scarring, with significant recovery and pigmentation risk

Microdermabrasion: superficial cosmetic treatment for brightening and smoothing, with minimal risk and downtime

Microneedling

Mechanism of action: controlled micro-injury using fine needles stimulates collagen and elastin production

Often combined with PRP or RF

Technique: manual or motorized pen with adjustable depth; often repeated in series

Applications: acne scars, fine lines, enlarged pores, under-eye crepiness, stretch marks, and skin texture

PRP and biologic injectables

Mechanism of action: autologous platelets release growth factors that promote tissue regeneration and vascularization.

Technique: blood draw → centrifuge → injection into skin/scalp or applied post-treatment

Applications: hair loss (especially androgenetic alopecia), dark circles, fine lines, skin tone, and wound/scar healing

Threads

Mechanism of action: polydioxanone (PDO) or other biocompatible threads inserted subdermally to provide mechanical lift and stimulate collagen production via foreign-body reaction

Technique: threads placed with blunt or sharp cannulas in vectors tailored to lift (barbed threads) or rejuvenate (smooth threads)

Applications: mild lifting of jawline, cheeks, brows, and skin tightening.

Results are modest at best and temporary; outcomes are technique- and patient- dependent

Micro-coring devices (Ellacor®)

Novel, minimally invasive skin-tightening modality that mechanically removes full-thickness cores of dermal and epidermal tissue without the use of thermal energy

Device employs hollow needles to excise micro-cores – typically 0.5 mm in diameter – in a fractional, grid-like pattern, which induces tissue contraction and neocollagenesis during the healing process

Mechanism of action: full-thickness removal of micro-columns of skin, resulting in immediate skin contraction due to reduced surface area and gradual dermal remodeling and collagen deposition over weeks to months

Indications:

Mild to moderate age-related skin laxity

Perioral rhytids

Jowling and lower face laxity

Patients desiring minimal downtime and no thermal injury

Combined modalities

Oftentimes, multiple synergistic treatments can/should be used to address different components of facial aging (volume loss, wrinkles, laxity, texture) (Fig. 4)

Approach:

Filler → restores volume

Neurotoxin → softens dynamic lines

Energy-based device → stimulates collagen and improves tone

Delivery: can be sequential (e.g., RF first, filler later) or simultaneous, depending on safety and indication

Applications: comprehensive facial rejuvenation, neck and periorbital aging

Figure 4. Left, preintervention photograph. Center, photograph following rhytidectomy alone. Right, A 60% phenol peel was performed 12 months after rhytidectomy (photograph taken 18 months after phenol peel and 30 months after rhytidectomy). From Weissler JM, et al. The Evolution of Chemical Peeling and Modern-Day Applications. Plast Reconstr Surg. 2017 Nov;140(5):920-929.

NON-SURGICAL AND MINIMALLY INVASIVE BODY CONTOURING TECHNIQUES

The techniques described below help surgeons comprehensively address the sometimes complex and diverse needs of body contouring patients. They offer safe, gradual improvements and can serve as stand-alone treatments or adjuncts to surgical body contouring.

Cryolipolysis (CoolSculpting™)

Non-invasive fat reduction technique that uses controlled cooling to selectively induce apoptosis in subcutaneous adipocytes without damaging surrounding tissues; crystallized fat cells are gradually cleared through the lymphatic system over several weeks

Patient selection: ideal candidates are healthy individuals near their goal weight with localized pockets of diet- and exercise-resistant fat (e.g., flanks, abdomen, thighs)

Not a weight loss treatment and is contraindicated in patients with cold- induced disorders (e.g., cryoglobulinemia, cold urticaria)

Outcomes and limitations:

Patients may experience a reduction in adiposity of 20-25% per treatment area

Visible results in typically present at 2-3 months

Some adverse effects may include: transient numbness, erythema, rare paradoxical adipose hyperplasia

Results are modest compared to surgical excision, and multiple sessions may be required for optimal contouring

Cryolipolysis cannot address skin laxity or visceral fat

High-intensity focused ultrasound (HIFU) (UltraShape™, Liposonix™)

Delivers focused ultrasound energy deep into subcutaneous tissue, causing thermal coagulative necrosis of adipocytes and stimulating collagen remodeling

Bypasses the epidermis, minimizing surface damage

Patient selection:

Mild to moderate skin laxity and small areas of unwanted fat particularly ' in the lower face, jawline, and neck

Not intended for significant fat reduction or large body areas

Outcomes and limitations:

Modest fat reduction and skin tightening over several weeks to months

Non-invasive, with minimal downtime, but its effects are variable and often subtle.

Not appropriate for patients seeking dramatic contour changes or with extensive skin redundancy

Radiofrequency (RF) & LASER-assisted lipolysis (Vanquish™, SculpSure™)

Work by delivering thermal energy to subcutaneous fat

RF heats tissue through electromagnetic waves, stimulating adipocyte disruption and dermal collagen contraction

LASER lipolysis uses targeted laser wavelengths (e.g., 1064-1440 nm) to liquefy fat and promote dermal tightening via neocollagenesis

Patient selection:

Localized fat deposits and mild skin laxity

Often as an adjunct to traditional liposuction

Outcomes and limitations:

Offer improved contour and skin firmness with less downtime than conventional liposuction

Results depend on device type, operator skill, and patient factors

Risks include burns, fibrosis, and seroma

Efficacy decreases with severe laxity or inelastic skin

Injectable fat-dissolving agents

Deoxycholic acid (e.g., Kybella ): bile salt that emulsifies and destroys fat cell membranes via cytolysis

FDA-approved for submental fat and sometimes used off-label in small body areas

Patient selection: patients with discrete, well-defined fat deposits in the chin or jowls and good overlying skin tone

Outcomes and limitations:

Results emerge after 2-4 sessions, spaced ~1 month apart

Once destroyed, fat cells are permanently eliminated

Common side effects include swelling, bruising, tenderness, and numbness; rare risks include nerve injury

Unsuitable for large-volume reduction or areas with loose skin

Figure 5. Injection area for deoxycholic acid. From Shridharani SM, Chandawakar AA. Novel Expanded Safe Zone for Reduction of Submental Fullness with ATX-101 Injection. Plast Reconstr Surg. 2019 Dec;144(6):995e-1001e.

Figure 6. Before and after treatment with deoxycholic acid. From Shridharani SM, Chandawakar AA. Novel Expanded Safe Zone for Reduction of Submental Fullness with ATX-101 Injection. Plast Reconstr Surg. 2019 Dec;144(6):995e-1001e.

Electromagnetic Muscle Stimulation (Emsculpt™)

FDA 510(k) clearance since 2017 for muscle toning of the abdomen, buttocks, and longer clearance in 2019 for noninvasive lipolysis of the abdomen

Mechanism of action: inducing supramaximal involuntary contractions (~20,000 in 30 minutes) and generating localized hypermetabolism that may stimulate both muscle hypertrophy and fat apoptosis

Most studies review modest numeric changes – approximately 5 mm fat reduction and 2 mm muscle increase – with high variability in outcomes

While safe, evidence for its efficacy is still tenuous; many studies lack neutral control and publish bias toward positive results

COMPLICATIONS AND MEDICO-LEGAL CONSIDERATIONS

It is essential to have an informed discussion with patients regarding the potential risks associated with non-surgical treatments. Every intervention carries some degree of risk, and these should be thoroughly reviewed with the patient prior to initiating therapy. While some complications may be mild and manageable with supportive care, others can be serious and require urgent medical attention. A clear understanding of these potential outcomes is crucial before proceeding with any noninvasive procedure.

Filler embolization

Prevention:

Use blunt cannulas in high-risk zones

Inject slowly, aspirate when appropriate

Avoid bolus injections in danger zones (glabella, nose, nasolabial folds)

Recognition:

Immediate blanching, pain, coolness, livedo reticularis, vision changes

Management:

Stop injection immediately

High-dose hyaluronidase in pulses

Warm compress, massage, nitropaste

Urgent ophthalmology referral if vision changes

Burns from lasers

Prevention:

Use appropriate settings for skin type

Perform test spots on darker skin

Avoid overlapping passes or treating inflamed skin

Recognition:

Pain, blistering, excessive erythema, crusting

Management:

Cool compresses, topical steroids, non-adherent dressings

Antibiotics for secondary infection

Delay further treatments until healed

Dyschromia from lasers

Prevention:

Use conservative settings on Fitzpatrick IV-VI

Pre-treat with hydroquinone and avoid sun exposure

Recognition:

Hyperpigmentation appears 1-3 weeks post-treatment; hypopigmentation may be delayed

Management:

For PIH: hydroquinone, retinoids, sunscreen

For hypopigmentation: often irreversible – sun protection and camouflage

Lid ptosis

Prevention:

Avoid injecting <1 cm above orbital rim

Do not cross mid-pupil line in forehead

Recognition:

Drooping upper eyelid within 2-5 days post-injection

Management:

Apraclonidine 0.5% eye drops (2-3 times daily)

Reassurance—resolves in 2-6 weeks

Asymmetry from neurotoxin

Prevention:

Symmetrical dosing and precise anatomic injection

Adjust for pre-existing asymmetries

Recognition:

Uneven brow position, smile deviation, lip pull

Management:

Add corrective units to opposite side if appropriate

Reassure—effects are temporary

Documentation and informed consent

Document treatment plan, product used (lot, site, amount), pre- and post- photos, and patient education.

Consent must include:

Risks, benefits, alternatives

Off-label use disclosures

Expected onset and duration

Potential complications and recovery timelines

Off-label use and scope of practice issues

Many uses of injectables and energy devices (e.g., neurotoxin for platysma, PRP for hair loss) are off-label

Providers must:

Use scientific rationale and peer-reviewed support

Clearly disclose off-label status in consent

Practice within licensure and training scope, especially for non-physician injectors

PATIENT-CENTERED REJUVENATION PLANNING

Creating a treatment plan

Panfacial vs. regional intervention:

Panfacial approach addresses overall harmony and aging patterns

Regional treatments target specific concerns (e.g., lips, tear troughs) but may require more sessions for balance

Patient budget, downtime tolerance, event planning:

Plans should align with the patient's financial resources, recovery tolerance, and timeline (e.g., upcoming events), prioritizing staged treatments if needed

Aesthetic maintenance

Recommended follow-up and maintenance intervals: common maintenance includes neurotoxins every 3-4 months, HA fillers annually, and energy-based treatments semiannually

Home skincare regimens and adjunctive topical therapies: daily regimens with sunscreen, antioxidants, retinoids, and pigment modulators enhance and prolong in-office results

REFERENCES

Alster TS, Lupton JR. Lasers in dermatology and medicine. J Am Acad Dermatol. 2003 Jul;49(1):1-31;quiz 31-4.

Gold MH. Update on tissue tightening: Introduction to a new class of technology. J Clin Aesthet Dermatol. 2010 May;3(5):36–41.

Nestor MS, Newburger A, Zarraga MB. Non-invasive skin tightening: Focus on new ultrasound techniques. Clin Cosmet Investig Dermatol. 2015 Feb 5:8:47-52.

Dover JS, et al. Laser skin resurfacing with the erbium:YAG laser: A retrospective study of 50 patients. Dermatol Surg. 2007; 26(4), 335–340.

Fabi SG, Goldman MP. Retrospective evaluation of safety and patient satisfaction of the hybrid fractional laser for skin rejuvenation. J Drugs Dermatol. 2014;13(5), 555–559.

Narurkar VA, Goldman MP, Taub AF. Fractional photothermolysis for skin rejuvenation. Semin Cutan Med Surg. 2010;29(3), 142–150.

Farkas JP, Richardson JA, Turer DM. Complications of injectable fillers. In Mustoe TA, Chung MT, and Fan JW (eds.), Aesthetic Surgery of the Face (pp. 289–308). Elsevier: 2020.

Benedetto AV. The cosmetic uses of hyaluronidase. J Cosmet Laser Ther. 2005;7(3-4), 135–137.

Schelke LW, Decates TS, Velthuis PJ. Ultrasound to improve the safety of hyaluronic acid filler treatments. J Cosmet Dermatol. 2020;19(5), 1065–1070.

Goodman GJ, Roberts S. Complications and adverse events of dermal fillers: A primer. Aust J Gen Pract. 2021;50(7), 453–458.

Kesty K, Goldberg DJ. The use of botulinum toxin for the treatment of oily skin. J Drugs Dermatol. 2017;16(5), 519–522.

Park JH, Ahn BY. Botulinum toxin for the treatment of facial flushing and erythema of rosacea. Dermatol Surg. 2015;41(7), 898–903.

Gassner HG, et al. Botulinum toxin to improve facial wound healing: A prospective, blinded, placebo-controlled study. Mayo Clin Proc. 2006;81(8), 1023–1028.

Zhibo X, Miaobo Z. Botulinum toxin type A affects cell cycle distribution of fibroblasts derived from hypertrophic scar. J Cosmet Dermatol. 2008;7(3), 199–204.

Hexsel D, Dal’Forno T, Hexsel CL. Botulinum toxin for oily skin. Dermatol Surg. 2011;37(10), 1427–1435.

Chapter 25
Gender Affirmation Surgery

Katelyn Lewis, MD
Omar E. Beidas, MD

GENDER IDENTITY DISORDER

Gender dysphoria is defined as a marked incongruence between one’s experienced gender identity and assigned gender at birth

Prevalence

1.6 million people ages 13+ identify as transgender in the US (approximately 0.5% of the US population)

39% are transgender women

36% are transgender men

25% are gender nonconforming

Distinct entity from those individuals with congenital disorders of sexual development/ambiguous genitalia

Surgery plays a role in relieving their psychological discomfort

Gender affirming surgeries (GAS) are associated with improved quality of life measures, high rates of satisfaction, and reduction in gender dysphoria

Transgender males are twice as likely to seek surgical correction

DSM-5 criteria for diagnosis

Desire to dress and live as opposite gender (and make his/her body a closer resemblance to the opposite gender)

Gender identity present for >6 months

Not a symptom of another genetic or psychiatric disorder

Treatment of these individuals requires a multidisciplinary team

Primary care/internal medicine

Overall care coordination

Endocrinology: hormone therapy

Feminization via suppression of androgens and induction of female characteristics

GnRH antagonists

Estrogens: breast growth, redistribution of body fat, decreased body hair growth, decrease in testicular size and erectile function

Masculinization

Testosterone: induces clitoral hypertrophy, voice changes, hair growth, male-pattern baldness

Psychiatry/mental health

One letter of readiness required for top surgery

Surgery

Plastic surgery

Otolaryngology, facial plastic surgery

Urology

General criteria for surgery:

Two letters of readiness for bottom surgery

No letters indicated at this time for facial feminizing or masculinizing procedures

Patients need to demonstrate that they have been living in their gender role for some time

Usually 12 months for bottom surgery

HISTORY

Transsexualism is recorded throughout history, particularly in Greek and Roman literature

1923: Transsexualism term coined by Magnus Hirschfeld, a German physician

1931: Dr. Felix Abraham, a German surgeon, first to report staged vaginoplasty

1940s: evolution of the modern use of the word transsexual

1973: “gender dysphoria syndrome” coined to describe individuals who had a conflict between their natal and desired gender

Current term is “gender identity disorder”

Needs to be contrasted from transvestitism, which describes those who like to dress as the opposite gender but have no desire to change their gender

Does not relate to sexual orientation or homosexualism

1978: the Harry Benjamin International Gender Dysphoria Association was founded

Plays a major role in research and treatment of these patients

Now known as the World Professional Association for Transgender Health (WPATH)

Publishes “Standards of Care for the Health of Transsexual, Transgender, and Gender Nonconforming People,” which is now in its 8th edition

1983: Dr. Douglas Ousterhout performed the first facial feminization surgery in San Francisco

2014: Medicare lifts the 30-year ban on coverage for GAS

Number of surgeries tripled from 2016 to 2020

MALE-TO-FEMALE

Facial surgery (facial feminization)

Frontonasal-orbital complex is greatest defining feature of male vs. female face

Male face (Fig. 1, 2):

Increased supraorbital bossing, prominent forehead/glabella, forehead more angled

Hairline with frontotemporal and overall recession (M-shaped)

Squarer chin and jaw, mandible is larger and thicker with greater body height

Malar area flatter but larger

Larger in all dimensions than female face

More muscle bulk

Prominent thyroid cartilage

Female face (Fig. 1, 2):

Curved forehead

O-shaped rounded hairline

Pointed chin, heart-shaped face

Smaller nose

More prominent malar region

Less acute glabellar angle

Orbits are higher, more rounded, and larger

Smaller overall than male, about four-fifths the size

Typical procedures:

Brow lift

Frontal sinus setback

Forehead/supraorbital bar reduction

Frontal hairline advancement/hair transplant

Feminizing rhinoplasty

Genioplasty

Masseter resection/mandibular contouring with gonial angle reduction

Malar implants

Thyroid cartilage reduction, tracheal shave

Vocal cord shortening

Fat grafting

Figure 1. A more acute glabellar angle, a more acute nasal tip angle, a less open nasolabial angle, and a more pronounced chin are preferred in males. From Hage J, et al. Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg. 1997;99(7):1799-1807.

Figure 2. Differences in skeletal anatomy between males and females. The female skull has a more round, smooth forehead with a shorter tapered lowered jaw. From Safa B, Lin WC, Salim AM, Deschamps-Braly JC, Poh MM. Current Concepts in Feminizing Gender Surgery. Plast Reconstr Surg. 2019;143(5):1081e-1091e. doi:10.1097/prs.0000000000005595

Top surgery (breast augmentation)

Some breast growth from hormones, about ½ to 1 cup size

Transwomen should undergo feminizing hormone therapy for a minimum of one year for best aesthetic result

Male chest different than natal female: chest is wider, nipple to IMF distance is less, areolae are smaller and lateralized, pectoralis major more developed

Implant can be placed pre- or sub-pectoral

Adjunct techniques include lowering of the IMF, lower pole parenchymal scoring, NAC repositioning

Bottom surgery

Goals:

Create normal appearing vagina and mons pubis

Create a sensate neoclitoris

Create a large and deep enough canal for penetration (if desired by patient)

Pre-operative considerations:

Hair removal from the base of the penis to the scrotum

Hormone therapy

Letters from mental health provider

Consider fertility preservation

Patient desire for canal for penetrative intercourse

Types of feminizing genital reconstruction:

Vulvoplasty

“Zero depth vaginoplasty”

Only external genitalia, no vaginal canal

Penile inversion vaginoplasty (Fig. 3)

Most common operation

Neoclitoris created from the glans penis

W- shaped flap

Based off the dorsal penile neurovascular bundle

Placed at the level of the pubic symphysis

Labia minora from the prepuce or distal penile shaft skin

Labia majora from scrotal skin

Sutured in the groin crease

Vagina lined with inverted penile shaft skin

Pros: lined cavity, minimal shrinking, sensate

Cons: need for dilation, need for pre-op hair removal, may need revisions/labiaplasty for further feminization, stenosis

Figure 3. Penile inversion vaginoplasty performed in a 51- year-old transgender woman. (Above, left) erative genital area. (Above, right) An incision is made along the pre-operatively marked pattern. (Second row, left) Blunt dissection of the neovaginal cavity is performed. Caution is taken not to sever the rectum. This is checked by bimanual palpation. (Second row, right) Bilateral orchiectomy is performed. (Third row, left) Penile skin is separated from the penile shaft and closed at the distal end. (Third row, right) The dorsal neurovascular bundle is separated from the roof of the corpora cavernosa, and from a part of the glans penis, the preputium the neoclitoris and the labia minora are sculptured. (Below, left) A linear incision is made into the raphe of the penile skin, and the penoscrotal flap is imbedded. (Below, right) Postoperative genital area. From Buncamper M, et al. Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women. Plast Reconstr Surg. 2016;138(5):999-1007.

FEMALE-TO-MALE

Top surgery

Mastectomies in transmen are most commonly performed GAS

Pre-operative considerations

Cosmetic operation, unlike cancer surgery, as some breast tissue is left behind

If patient has a significant family history of breast cancer:

Refer for genetics

Surgical oncology should perform risk-reducing mastectomies

Chest wall contouring/mastectomy

Typically the first surgical procedure for FTM

Need to decrease breast/skin, obliterate IMF, reduce and lateralize nipple/ areola

Incision choices depend on amount of ptosis

Subcutaneous keyhole or periareolar mastectomy for small breasts with minimal skin excess (Fig. 4, 5)

Double incision mastectomy with free nipple grafts for medium and large/ptotic breasts (Fig. 6)

Figure 4. Semicircular technique. From Monstrey S, et al. Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm. Plast Reconstr Surg. 2008;121(3):849-859

Figure 5. “Doughnut excision” technique. Best for patients who will require reduction of the NAC complex and skin followed by parenchymal reduction.

Figure 6. Pre-operative markings for double-incision mastectomy. The patient is marked in the standing position with arms raised to help accentuate the inferior and lateral borders of the pectoralis muscle. The superior incision is marked straight across the inferior border of the pectoralis major and is angled superiorly toward the axilla to follow the inferolateral border of the pectoralis muscle. From Salibian AA, Gonzalez E, Frey JD, Bluebond-Langner R. Tips and Tricks in Gender-Affirming Mastectomy. Plast Reconstr Surg. 2021;147(6):1288-1296.

Bottom surgery

Pre-operative considerations and goals:

Neourethra capable of voiding

Phallus

Aesthetically pleasing

Staging

Hysterectomy, oophorectomy, and vaginectomy often performed before phalloplasty operations

Scrotal implants performed later

Operations for phalloplasty:

Metoidioplasty/metaoidioplasty (Fig. 7)

Stretching the hormonally hypertrophied clitoris, lengthening urethra with local flaps

Complications are usually urethral fistulas/strictures

Scrotoplasty from labia majora (can be concomitant or staged)

Pros: tactile and erogenously sensate clitoral tissue, sustained erectile rigidity without prostheses, minor donor site scarring, shorter hospitalization

Cons: very small phallus so unlikely to be able to provide penetration, impaired standing urination

Figure 7. Result of metoidioplasty and scrotum reconstruction. From Berli JU, Monstrey S, Safa B, Chen M. Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging. Plast Reconstr Surg. 2021;147(5):801e-811e.

Pedicled flaps: urethroplasties are via tube within a tube design

ALT (Fig. 8)

Pros: Reliable vascular supply, reduced total flap failure risk, hidden donor site, able to be innervated

Cons: donor site may be too thick

Figure 8. Illustration of the pedicled anterolateral thigh flap. A tube-within-a-tube design is used. The inner conduit becomes the neourethra, and the outer tubularized tissue represents the neophallus. The semicircular extension at the distal portion of the flap more accurately approximates the circumcised male phallus. From Morrison S, et al. Phalloplasty: A Review of Techniques and Outcomes. Plast Reconstr Surg.2016;138(3):594-615.

Inferiorly based abdominal flaps

Less aesthetic and higher complication rate

Easier to hide donor site scars

Diminished sensation

Variability in vascular pattern

Limited ability to void standing and unable to provide sexual penetration

Pedicled groin flaps (Fig. 9)

Similar to abdominally based flaps

Insensate

Functional problems the same as abdominal flaps

Gracilis flap (Fig. 10)

Bipedicled design with two flaps

Urethra made from skin graft

Free flaps

Radial forearm (Fig. 11, 12)

Most commonly used

Tube within a tube neourethra

Can be sensate

Pros: aesthetic reconstruction, standing urination, tactile and erogenous sensation

Cons: donor site morbidity, urinary fistulas/strictures, requires prosthesis

Figure 9. Illustration of groin flap. The groin flap with or without the iliac bone can be performed in either one or two stages. The two- stage procedure is based on the superficial circumflex iliac artery and the deep circumflex iliac artery. The lateral and medial skin edges of the flap are sutured together, constructing a tube still attached to the body. After some time, the flap is raised on its pedicle. The neourethra is reconstructed using a full thickness skin graft from the contralateral groin. From Morrison S, et al. Phalloplasty: A Review of Techniques and Outcomes. Plast Reconstr Surg. 2016;138(3):594-615.

Figure 10. Illustration of the gracilis flap. A bipedicled gracilis muscle flap is harvested and pedicled into the groin. Once joined together around a skin graft used for the neourethra, another skin graft is placed around the muscle. From Morrison S, et al. Phalloplasty: A Review of Techniques and Outcomes. Plast Reconstr Surg, 2016;138(3):594-615.

Figure 11. Illustration of the radial forearm free flap and the fibula osteocutaneous free flap. In the osteocutaneous free fibula flap, the fibula is harvested with a cuff of muscle, the peroneal artery, and either the lateral or posterior sural nerve to create the sensate phallus. The neourethra is created from a groin skin flap. In the radial forearm free flap, the tube-in-tube design is used to create a neophallus and neourethra in a single flap. The radial artery and the antebrachial nerves are harvested to create the sensate phallus. The Norfolk technique is used for the radial forearm free flap to create a glans. From Morrison S, et al. Phalloplasty: A Review of Techniques and Outcomes. Plast Reconstr Surg. 2016;138(3):594-615.

Figure 12. Illustration of the Norfolk technique. A distal circumferential portion of the neophallus shaft is elevated and rolled to create the corona. A split- or full- thickness skin graft is then placed over the defect on the shaft. From Morrison S, et al. Phalloplasty: A Review of Techniques and Outcomes. Plast Reconstr Surg. 2016;138(3):594-615.

Osteocutaneous fibula (Fig. 10)

Can be made sensate

Does not require a prosthesis

Con: always erect

ALT

Latissimus flap: can be made functional with inclusion of muscle/nerve and maybe able to have erectile function

Penile epithesis

Scrotoplasty with testicular prosthesis

Labia major flaps ± implants or tissue expanders

Good color and texture match

Embryologically from the same area

Have erogenous sensation

Can use pump for prosthesis to make one testicle

REFERENCES

Hage JJ, et al. Gender-confirming facial surgery: considerations on the masculinity and femininity of faces. Plast Reconstr Surg. 1997;99(7):1799-1807.

Buncamper ME, et al. Surgical Outcome after Penile Inversion Vaginoplasty: A Retrospective Study of 475 Transgender Women. Plast Reconstr Surg. 2016; 138(5):999-1007.

Monstrey S, et al. Chest-wall contouring surgery in female-to-male transsexuals: a new algorithm. Plast Reconstr Surg. 2008;121(3):849-859.

Morrison SD, et al. Phalloplasty: A Review of Techniques and Outcomes. Plast Reconstr Surg. 2016;138(3):594-615.

Hage JJ, van Kesteren PJ. Chest-wall contouring in female-to-male transsexuals: basic considerations and review of the literature. Plast Reconstr Surg. 1995; 96(2): 386-391.

Frey JD, et al. An Update on Genital Reconstruction Options for the Female-to-Male Transgender Patient: A Review of the Literature. Plast Reconstr Surg. 2017;139(3): 728-737.

Capitán L, et al. Facial Feminization Surgery: Simultaneous Hair Transplant during Forehead Reconstruction. Plast Reconstr Surg. 2017; 139(3):573-584.

Capitán L, et al. Facial feminization surgery: the forehead. Surgical techniques and analysis of results. Plast Reconstr Surg. 2014;134(4):609- 619.

Selvaggi G, et al. Scrotal reconstruction in female-to-male transsexuals: a novel scrotoplasty. Plast Reconstr Surg. 2009;123(6):1710-1718

Monstrey S, et al. Penile reconstruction: is the radial forearm flap really the standard technique? Plast Reconstr Surg. 2009;124(2):510- 518.

Safa B, et al. Current Concepts in Feminizing Gender Surgery. Plast Reconstr Surg. 2019;143(5):1081e-1091e.

Safa B, et al. Current Concepts in Masculinizing Gender Surgery. Plast Reconstr Surg. 2019;143(4):857e-871e.

Salibian AA, et al. Tips and Tricks in Gender-Affirming Mastectomy. Plast Reconstr Surg. 2021;147(6):1288-1296.

Coleman E, et al. Standards of Care for the Health of Transgender and Gender Diverse People, Version 8. Int J Transgend Health. 2022;23(Suppl 1): S1-s259.

Berli JU, et al. Neourethra Creation in Gender Phalloplasty: Differences in Techniques and Staging. Plast Reconstr Surg. 2021;147(5):801e-811e.

Kailas M, et al. Prevalence and Types of Gender-Affirming Surgery Among A Sample of Transgender Endocrinology Patients Prior to State Expansion of Insurance Coverage. Endocr Pract. 2017;23(7):780-786.

Chapter 26
Composite Tissue Allotransplantation

Olivier F. Noel, MD, PhD
David A. Hill, MD

INTRODUCTION

Also referred to as vascularized composite allotransplantation (VCA) or composite tissue allograft (CTA)

Allograft (graft from cadaveric donor) composed of different tissue types (e.g. skin, muscle, bone, nerves, vessels)

Introduced for major reconstruction of tissue defects from surgical excision of tumors, traumatic injury, and congenital malformations

Option for limb replacement and reconstruction of other non-reconstructible tissue defects including facial, abdominal wall, and others

Couples the principles of microsurgical reconstruction with those of human organ transplantation

Goal: improve function, quality of life, integration with society

HISTORY

348 AD: "The legend of the black leg" or the "Legend of Saints Cosmos and Damien"

Tale of twin brothers Cosmas and Damian who replaced the diseased leg of a man with that of a recently deceased person

1954: first successful human organ isograft, a kidney donated between identical twins; USA (Joseph E. Murray, John P. Merrill, and J. Hartwell Harrison)

1964: first case of hand CTA, failed due to rejection after 3 weeks; Ecuador (Robert Gilbert)

1990s: progress in immunosuppression → composite tissue renaissance

1998: first successful hand CTA; France (Jean-Michel Dubernard)

2000: first successful bilateral hand CTA; France (Jean-Michel Dubernard)

2005: first successful partial face transplantation; France (Devauchelle, Dubernard)

DONOR GRAFT PROCUREMENT

In its first decade, approved largely by local or university committees as part of experimental/clinical research endeavors

1984: Congress passes the National Organ Transplant Act (NOTA), which establishes the legal framework for a national organ transplant system and prohibits the sale of human organs

1986: Organ Procurement and Transplantation Network (OPTN) is created, and UNOS is assigned to operate the OPTN

2014: VCA (face, hand) added to OPTN’s jurisdiction

Treated similarly as solid organ transplantation

Additional donor permission may be required due to highly identifiable and sensitive nature of facial tissue

For organ donation (including face transplants), U.S. uses an “opt in” tissue donation model vs. Europe and other parts of the world use an “opt out” model (i.e., automatically considered a donor unless choosing otherwise)

ANATOMY/SURGICAL PLANNING

Typically involves anastomosis of at least moderate to large arteries and veins (at least 1-4 mm in diameter) to supply the graft and nerve coaptation to preserve motor and sensory functions (Fig. 1)

Involves meticulous tagging of important donor and recipient anatomic structures which need to be connected (i.e., nerves, tendons, and vessels in hand transplantations)

Face transplants can be soft tissue only; can also include bone such as part of the maxilla or even part of the central nervous system (i.e. eye)

Virtual surgical planning can be a useful tool in pre-operative planning

Recent face transplant included whole eye transplant as part of composite graft

In face transplantation, the facial nerve can be coapted at the trunk level or more commonly at each individual branch

Bilateral hand transplant more common than unilateral hand transplant

Figure 1. Full facial allograft containing all structures needed to be affixed and/or coapted in a transplantation procedure for a hypothetical patient lacking all nervous, vascular, and soft-tissue anatomy. From Pomahac B et al. Novel Surgical Technique for Full Face Transplantation. Plast Reconstr Surg. 2012 Sep;130(3):549-555.

INDICATIONS

Most common mechanisms of injury:

Face: ballistic injuries, burns, neurofibromatosis

Hand: blunt trauma, blast injury, sepsis

Penis: blast injury

Abdominal wall: multi-visceral organ transplantation

Scalp: malignancy

CONTRAINDICATIONS

Active cancer

Active psychiatric disorders

Poor social environment

Inability to commit to lifelong immunosuppressants

MULTIDISCIPLINARY INVOLVEMENT/CARE

A CTA program involves more than just plastic surgeons

Other key members of the team include:

Psychiatry

Transplant surgery

Transplant nephrology

ENT (tracheostomy prior to transplant)

Social work

Long-term follow up with all different specialties likely for the rest of the patient’s life

IMMUNOGENICITY

CTAs are histologically heterogeneous, composed of different tissue types including skin, fat, muscle, nerves, lymph nodes, blood vessels, bone, cartilage, ligaments, and bone marrow

Each tissue has different antigenicity

Skin is most antigenic, likely owing to dendritic cell population and antigen variety

Immunogenicity of a CTA is not the sum of its different components

Whole limb allograft elicits a less intense immune response than does allografts of each of the individual components

CTAs elicit a stronger immune response as compared to solid organ transplants

Split tolerance phenomenon: simultaneous tolerance to one tissue and rejection of another from the same donor

Some form of acute rejection seen in more than 50% of face transplant patients within first year

TYPES OF CTA PERFORMED TO DATE

Hand/upper extremity:

Most common transplant

First 4 successful cases:

Right hand – transplanted in Lyon, France, on September 23, 1998

Left hand – transplanted in Louisville, KY on January 23, 1999

2 right hands – transplanted to two individuals in Guangzhou, China, on September 21, 1999

>100 upper limb transplants reported to date

Partial or total face:

First partial face transplant in 2005 in France

>50 cases reported to date

Abdominal wall: typically in the setting of abdominal multi-organ transplant

Knee

Larynx

Flexor tendon apparatus

Peripheral nerve

Tongue

Trachea

Esophagus

Scalp: in the setting of active malignancy, and with simultaneous solid organ transplantation

Penis (5-7 cases globally)

Uterus: first successful pregnancy following uterus transplant in 2015

ADVANTAGES

Replace “like with like”

An option when standard reconstructive options are exhausted or autologous tissues are not available

Can achieve structural, functional, esthetic, and psychological improvements

Avoidance of any donor site morbidity

Good functional outcomes

For example, for hand transplants:

Sensibility recovered in 6-12 months

Motor function allows return to most daily activities (eating, driving, grasping objects, riding a bicycle, shaving, using the telephone, and writing)

Majority of patients are satisfied and report improved quality of life

Positive long-term follow-ups

DISADVANTAGES/LIMITING FACTORS

Need for lifetime immunosuppressants

Susceptible to opportunistic infections

Similar to solid organ transplants, grafts not expected to last forever

One case of loss of facial graft requiring re-transplant

Expensive and high expertise surgery

Only certain centers can afford programs with government-sponsored grants or institutional support

FUTURE DIRECTIONS

Development of novel immunosuppression and donor-specific tolerance regimens to help decrease episodes of rejection

Increasing application for a wider group of patients as surgery is streamlined, tolerance regimens are perfected, and outcomes are improved

Pushing the boundaries of what other components can be included as part of the composite graft depending on the patient needs

REFERENCES

Cendales LC, Kirk AD, Moresi JM, Ruiz P, Kleiner DE. Composite tissue allotransplantation: classification of clinical acute skin rejection. Transplantation. 2006;81(3):418-422.

Cendales LC, Rahmel A, Pruett TL. Allocation of vascularized composite allografts: what is it? Transplantation. 2012;93(11):1086-1087.

Eun SC. Composite tissue allotransplantation immunology. Arch Plast Surg. 2013;40(2):141-153.

Noel OF, et al. Vascularized Composite Allograft Versus Prosthetic for Reconstruction After Facial and Hand Trauma: Comparing Cost, Complications, and Long-term Outcome. Ann Plast Surg. 2024 Jan 1;92(1):100-105.

Ceradini DJ, et al. Combined Whole Eye and Face Transplant: Microsurgical Strategy and 1-Year Clinical Course. JAMA. 2024 Nov 12;332(18):1551-1558.

Gander B, et al. Composite tissue allotransplantation of the hand and face: a new frontier in transplant and reconstructive surgery. Transpl Int. 2006;19(11):868-880.

Petit F, et al. Composite tissue allotransplantation and reconstructive surgery: first clinical applications. Ann Surg. 2003;237(1):19-25.

Swearingen B, et al. Science of composite tissue allotransplantation. Transplantation. 2008;86(5):627-635.

Tobin GR, et al. The history of human composite tissue allotransplantation. Transplant Proc. 2009;41(2):466

Wu S, et al. Composite tissue allotransplantation: past, present and future-the history and expanding applications of CTA as a new frontier in transplantation. Transplant Proc. 2009;41(2):463-465.

Barker JH, et al. Composite tissue allotransplantation. Transplantation. 2002;73(5):832-835.

Siemionow MZ, Kulahci Y, Bozkurt M. Composite tissue allotransplantation. Plast Reconstr Surg. 2009;124(6 Suppl):e327-339.

Iyer S. Vascularised composite allotransplants: Transplant of upper extremities and face. Indian J Plast Surg. 2015;48(2):111-118.

Murphy BD, Zuker RM, Borschel GH. Vascularized composite allotransplantation: an update on medical and surgical progress and remaining challenges. J Plast Reconstr Aesthet Surg. 2013;66(11):1449-145

Pomahac B, et al. Novel surgical technique for full face transplantation. Plast Reconstr Surg. 2012 Sep;130(3):549-555.

Chapter 27
Lymphedema

Sophia Chryssofos, BS
Efstathios Karamanos, MD

DEFINITION

Chronic, progressive soft tissue swelling due to insufficient drainage of interstitial fluid

EPIDEMIOLOGY

Over 300 million cases worldwide

Can be primary (1%) or secondary (99%)

Primary incidence is ~1.33:100,000

Most common cause of secondary lymphedema worldwide is lymphatic filariasis

By location: 90% lower extremity, 10% upper extremity, <1% genitalia

ETIOLOGY

Primary lymphedema: inherent lymphatic channel dysfunction due to abnormal lymphatic development

Lymphedema congenita (presents <1 year old)

Milroy disease: AD inheritance, associated with VEGF-R3 and VEGF-C mutations, bilateral lower limb involvement

Lymphedema praecox (presents 1-35 years old)

Meige disease: presents around puberty with lower limb involvement

Lymphedema tarda (presents >35 years old)

Rarest form; lower limb involvement

Secondary lymphedema: acquired insult to lymphatic drainage

Cancer-related lymphedema: most common form in developed countries

Radiation therapy and surgical lymph node disruption (e.g. during axillary lymph node dissection for breast cancer) are most common cause

Most frequently seen with cancers of the breast, prostate, testis, uterus, cervix, ovary, and head and neck

Infectious: most common form worldwide

Lymphatic filariasis

Most commonly the parasite, Wucheria bancrofti, which obstructs lymphatic vessels

Obesity

Trauma

Vascular anomaly

PATHOPHYSIOLOGY

Normal lymphatic flow: lymphatic capillaries absorb interstitial fluid from tissues → lymphatic vessels → venous circulation; lymph nodes filter lymphatic fluid along the way

Mechanical disruption of lymphatic flow leads to:

Backup of lymphatic fluid

Accumulation of protein-rich fluid in interstitium

Pitting edema and chronic fluid stasis

Activation of inflammatory pathways

Fibroadipose tissue deposition in edematous regions

Non-pitting edema and chronic dermal inflammation

Skin changes (hyperkeratosis, skin infections)

DIFFERENTIAL DIAGNOSIS FOR LIMB ENLARGEMENT

Edema

Cardiac insufficiency

Renal Insufficiency

Hepatic insufficiency

Venous insufficiency

Nutritional insufficiency (Starling forces)

Deep venous thrombosis

Thyroid disease

Lipidema (a.k.a. Adiposis Dolorsa or Painful Fat Syndrome — abnormal fat accumulation that may be triggered by stress or hormonal changes)

CLINICAL PRESENTATION

History

Swelling of affected body part

Pain and/or heaviness

Inability to find properly fitting clothing

Decrease use of involved region

Aesthetic concerns

Speech concerns (head and neck lymphedema)

Recurrent infections (cellulitis, erysipelas, lympangitis)

Physical exam

Edema of affected region

Pitting in earlier stages, non-pitting in later stages (Fig. 1)

Limb circumference measurements

Limb volumetry

Stemmer Sign: inability to pinch skin on the dorsum of the second toe

Skin changes: hyperpigmentation, hyperkeratosis, acanthosis, skin ulcerations, plaques

Figure 1. Finger pressure produces pitting edema in a patient with Stage 1 lymphedema. From Kung, T, et al. Current concepts in the surgical management of lymphedema. Plast Reconstr Surg 2017;139(4):1003e-1013e.

Objective measurements

Limb circumference

Circumference measurements taken at standardized landmarkes along the length of the extremity

Limb volume

Truncated cone method (uses multiple circumference measurements to calculate the volume of each segment as a truncated cone)

Water displacement volumetry

CLASSIFICATION

International Society of Lymphology (ISL) classification: clinical assessment (Table 1)

Indocyanine Green (ICGN) staging: physiologic function via ICG angiography (Fig. 2)

Campisi Score: also based on clinical assessment

Figure 2. Indocyanine Green Staging Scale, modified from Chang et al. This scale evaluates the physiologic function of the lymphatic vessels within the limb, including the distribution and severity of dermal backflow, visualization of patent lymphatic vessels, and lymphatic vessel contractility. From Schaverien et al. Surgical treatment of Lymphedema. Plast Reconstr Surg 2019;144(3):738-758.

WORK-UP

Radionuclide lymphoscintigraphy: gold standard diagnostic test; visualizes lymphatics and dermal backflow, though with low resolution

Magnetic resonance lymphangiography (MRL): capable of generating three-dimensional renderings for pre-operative planning (Fig. 3a, b)

ICG lymphography: good resolution for superficial structures, may be used intraoperatively (Fig. 3c)

CT angiography: may assess extent of soft tissue involvement

Venous duplex ultrasound: useful to rule out DVT

Figure 3. Imaging used to identify lymphatic channels. Magnetic resonance lymphangiogram showing (a) veins with a smoother appearance and (b) lymphatic channels with beadlike characteristics. Laser angiography with subdermal injection of indocyanine green (ICG) can also be used to observe lymphatic channels (c) that preferentially take up ICG in the interstitium. Arrows demonstrate shadow from an overlying vein that has not taken up ICG in this study. From Kung, T, et al. Current concepts in the surgical management of lymphedema. Plast Reconstr Surg 2017;139(4):1003e-1013e.

MANAGEMENT

In general, patients should undergo 3-6 months of conservative treatment for early to mid-stage lymphedema. Those who fail conservative management or have persistent cellulitis my be candidates for surgical intervention.

Non-surgical

Complete decongestive therapy (CDT): a combination of non-surgical treatment modalities aimed at reducing disease burden and tailored to individual needs

Manual lymphatic drainage (MLD)

Sequential pneumatic compression

Compression garments

Weight loss

Skin care: hygiene, topical antifungals

Physical therapy/exercise

Acupuncture

Laser therapy, extracorporal shock wave therapy (ESWT)

Anti-parasitics, if lymphatic filariasis present

Diethylcarbamazine (DEC): #1 choice in North America

Ivermectin

Albendazole

Doxycycline

Surgical

Physiological procedures: restore lymphatic outflow with the goal of soft tissue volume reduction

Lymphaticovenular anastomosis/bypass (LVA/B)

Connection of lymphatic vessel to venule to restore lymphatic outflow tract –known as supermicrosurgery (connecting vessels <0.8 mm in diameter)

Indicated for early stages with intact venous flow

May be done prophylactically, commonly at the time of breast surgery to prevent breast-cancer related lymphedema

Vascularized lymph node transfer (VLNT)

Surgical transfer of lymph nodes on a vascular pedicle from an unaffected region; lymphangiogenesis bridges donor vessels with local lymphatic channels to restore flow

Common donor sites: axilla, supraclavicular, submental, groin, omentum

Recipient location may be orthotopic (i.e., anatomical) or heterotopic (distal to the anatomical location)

Indicated in later cases with significant dermal backflow (i.e., lymphatic that are present are not working)

Of note, LVA and VLNT may be performed in combination for moderate-stage lymphedema

Reductive procedures: remove excess adipose and fibrotic tissue

Liposuction: removes fibrous adipose tissue

Staged direct excision (Homan’s procedure)

Charles procedure: radical excision of lymphedematous tissue and replacement of excised skin with circumferential skin grafts

Typically reserved for extreme cases

Post-operative compression and multidisciplinary follow-up is generally recommended

Figure 4. An evidence-based algorithm for surgical management of extremity lymphedema. From Schaverien et al. Surgical treatment of Lymphedema. Plast Reconstr Surg 2019;144(3):738-758.

COMPLICATIONS

Disease complications:

Functional disability

Chronic wounds and cutaneous changes

Venous insufficiency, DVT

Recurrent infections (may be life-threatening)

Psychosocial morbidity

Stewart-Treves Syndrome: cutaneous angiosarcoma that develops in the setting of chronic lymphedema; best treated by wide local excision or amputation

Surgical complications:

Failure to restore lymphatic flow

Donor-site lymphedema (VLNT)

Phrenic nerve injury or lymphatic leak (supraclavicular LN donor site)

Hematoma, seroma, infection, delayed wound healing

REFERENCES

Alexander NDE. Are we nearly there yet? Coverage and compliance of mass drug administration for lymphatic filariasis elimination. Trans R Soc Trop Med Hyg. 2015 Mar;109(3):173-4.

Centers for Disease Control (CDC). 2013. Parasites – Lymphatic Filariasis. https://www.cdc.gov/parasites/lymphaticfilariasis/. Accessed Aug 2017.

Chang DW, et al. Lymphedema: surgical and medical therapy. Plast Reconstr Surg. 2016 Sep;138(3 Suppl):209S-218S.

Dayan JH, Dayan E, Smith M. Reverse lymphatic mapping: a new technique for maximizing safety in vascularized lymph node transfer. Plast Reconstr Surg. 2015 Jan;135(1):277-285.

Dayan, JH, et al. Lymphedema: pathogenesis and novel therapies. Annu Rev Med. 2018 Jan 29:69:263-276.

Immanuel C, et al. Immunoprophylaxis of multi-antigen peptide (MAP) vaccine for human lymphatic filariasis. Immunol Res. 2017 Jun;65(3):729-738.

International Society of Lymphology. The diagnosis and treatment of peripheral lymphedema: consensus document of the International Society of Lymphology. Lymphology. 2003 Jun;36(2):84-91.

Ishiura R, et al. Comparison of lymphovenous shunt methods in a rat model: supermicrosurgical lymphaticovenular anastomosis versus microsurgical lymphaticovenous implantation. Plast Reconstr Surg. 2017 Jun;139(6):1407-1413.

Kung TA, et al. Current concepts in the surgical management of lymphedema. Plast Reconstr Surg. 2017 Apr;139(4):1003e-1013e.

Levine SM, Chang DW, Mehrara BJ. Lymphedema: Diagnosis and Treatment. In: Thorne, CH, et al., eds. Grabb & Smith’s Plastic Surgery. 7th ed. Philadelphia: Lippincott Williams & Wilkins, 2014.

Schook C, et al. . Primary lymphedema: clinical management in 138 pediatric patients. Plast Reconstr Surg. 2011 Jun;127(6):2419-2431.

Yamamoto T, et al. Practicality of the lower extremity lymphedema index: lymphedema index versus volumetry-based evaluations for body-type-corrected lower extremity volume evaluation. Ann Plast Surg. 2016 Jan;77(1):115-8.

Masià J, et al. Barcelona Consensus Paper on Reconstructive Lymphedema Surgery: A Delphi Study. Plast Reconstr Surg. 2025 May 13. Online ahead of print.

Brown S, et al. The Vicious Circle of Stasis, Inflammation, and Fibrosis in Lymphedema. Plast Reconstr Surg. 2023 Feb 1;151(2):330e-341e.

Brouillard P, et al. Primary lymphoedema. Nat Rev Dis Primers. 2021 Oct 21;7(1):77.

Rockson SG, et al. Cancer-associated secondary lymphoedema (primer). Nat Rev Dis Primers. 2019 Mar 28;5(1):23.

Letellier ME, et al. Incidence of lymphedema related to various cancers. Med Oncol. 2024 Sep 17;41(10):245.

Schaverien MV, Coroneos CJ. Surgical Treatment of Lymphedema. Plast Reconstr Surg. 2019 Sep;144(3):738-758.

Chang DW, et al. Surgical Treatment of Lymphedema: A Systematic Review and Meta-Analysis of Controlled Trials. Results of a Consensus Conference. Plast Reconstr Surg. 2021;147(4):975-993.

Chapter 28
International Plastic Surgery

Cynthia Yusuf, MD
Marc E. Walker, MD, MBA

INTRODUCTION

Plastic surgery, while hailing from historically global influences, was formally organized and predominantly practiced in Western countries in modern times

The field has evolved into a global field once more that transcends borders, addressing the diverse needs of patients across the world

With a broad international presence, plastic surgery has become essential in not only improving physical appearance but also restoring functionality and enhancing the quality of life for patients with life-altering injuries or conditions

However, clinical and technological advancements in the past century have not benefited patients in the developing and developed world equally

GLOBAL PRACTICE IN PLASTIC SURGERY

Plastic surgery practice in low- and middle-income countries (LMIC) focuses largely of chronic wound care, burn care, and congenital face and hand deformity reconstruction

However, there is a growing demand for reconstructive surgery in post-conflict zones and disaster-stricken regions with limited access to specialized medical services in rural or underdeveloped areas

Challenges in global practice in plastic surgery include economic and resource constraints, limited medical infrastructure, uneven access to education, and surgical burnout seen in surgeons working in resource-poor settings

INTERNATIONAL PLASTIC SURGERY OUTREACH

Global collaboration through fellowships and exchange programs helps to address this gap by allowing surgeons from less developed regions to learn advanced techniques and gain exposure to global best practices

Conferences, academic exchange programs, and global outreach initiatives have facilitated the transfer of knowledge, leading to greater standardization of surgical techniques and better patient outcomes across different regions

Plastic surgical charities/NGOs such as Operation Smile, Smile Train, Resurge International (formerly Interplast), Hand Help, Rotaplast, Doctors Without Borders, Facing The World, and SHARE spearhead these efforts

Volunteers in Plastic Surgery (an effort supported by the Plastic Surgery Foundation) plays a key role in coordinating efforts, standardizing guidelines, and supporting surgeons

Plastic surgeons in the United States, smaller groups of surgeons, and even individuals have organized surgical missions to LMICs in the efforts to provide free surgical care

Surgical missions provide numerous benefits to LMICs:

They can provide resources and improve manpower and training for local partners

They improve cost-conscious practice, cultural and clinical skills in volunteers

Promote sustainable medical practices and empower local healthcare systems to handle similar cases independently in the future

Walker et al. demonstrate that surgeon consultation in the mission setting can improve patient knowledge in populations being served

Attract attention and funding, leading to more partnerships with NGOs, government bodies, and international organizations

ETHICS IN GLOBAL PLASTIC SURGERY MISSIONS

Providing care in resource-poor settings raises ethical questions worth considering

For extremely vulnerable patients, whose healthcare rights and autonomy are at risk, upholding core ethical principles is essential to ensure safety and well-being

Chikoti et al. describes core medical ethics in global plastic surgery as being analogous to Beauchamp and Childress’ proposed set of four ethical principles: autonomy, beneficence, nonmaleficence, and justice

Advocates shifting from the paternalistic “white savior” model to training local physicians in LMICs, evaluating these strategies through the lens of medical ethics

EDUCATION

The current cohort of residents and fellows represents the next generation of global surgeons

Several residency programs have obtained approval from the Residency Review Committee of the ACGME to include global health or international rotations to LMICs as part of surgical training

Such rotations benefit residents by exposing them to different pathologies and innovative operative and treatment approaches

Global surgery fellowships focused on plastic surgery also provide post-residency clinical and research training for advanced trainees with a career interest in global surgery (Table 1)

Table 1. Global surgery fellowship list. From Chung K. Plastic and Reconstructive Surgery in Global Health: Let's Reconstruct Global Surgery. Plast Reconstr Surg Glob Open. 2017 Apr 25;5(4):e1273.

REFERENCES

Walker ME et al. The Hand Surgeon Consultation Improves Patient Knowledge in a Hand Surgery Mission to Honduras. J Hand Surg Asian Pac Vol. 2018 Mar;23(1):11-17.

Chung KY. Plastic and Reconstructive Surgery in Global Health: Let's Reconstruct Global Surgery. Plast Reconstr Surg Glob Open. 2017 Apr 25;5(4):e1273.

Hughes CD, et al. American plastic surgery and global health: a brief history. Ann Plast Surg. 2012 Feb;68(2):222-5.

Chikoti R, et al. Ethics in Global Plastic Surgery Missions. Plast Reconstr Surg Glob Open. 2024 Oct 25;12(10):e6245.

Chapter 29
Innovations and Emerging Technologies in Plastic Surgery

Jaime Pardo-Palau, MD
Rajendra Sawh-Martinez, MHS, MD

As aspiring plastic surgeons, you are entering a dynamic field where innovation is not just a buzzword, but a daily reality. The future of plastic surgery will be shaped by groundbreaking technologies that enhance precision, expand capabilities, and improve patient outcomes. This chapter provides a brief overview of key emerging technologies that will redefine your practice.

ROBOTICS IN PLASTIC SURGERY

Enhanced precision and dexterity

Microsurgery: Robotics are revolutionizing delicate procedures like re- attaching tiny blood vessels and nerves in reconstructive surgery, overcoming human tremor and fatigue. This is particularly crucial in complex cases such as replantation of digits or advanced flap reconstructions, where vessel diameters can be less than 1 millimeter. The stable platform and fine motor control offered by robotic systems allow for sustained, high-magnification suturing with unparalleled accuracy.

Increased range of motion: Robotic arms can access confined spaces with greater articulation than the human hand, enabling less invasive approaches. This is evident in areas like transoral robotic surgery (TORS) for head and neck cancers, where traditional open approaches can be highly morbid. In plastic surgery, this translates to improved access in deep abdominal wall reconstructions or even certain types of breast reconstruction.

Example systems: Familiarize yourselves with systems like the da Vinci surgical system, which has seen widespread adoption in various surgical specialties, and newer platforms like the Symani surgical system, specifically designed for microsurgery (Fig. 1). The ongoing development of smaller, more specialized robotic instruments will further expand their utility in plastic surgery.

Figure 1. Symani surgical system. A, Image of the Symani surgical system highlights the system’s ergonomic seating and dual-armed robot (image courtesy of MMI, Inc.). B, Image courtesy of MMI, Inc., showing a demonstration of the Symani’s teleoperative capabilities and its use in vascular anastomosis. From Brown HG, et al. Robotic-assisted Supermicrosurgery in Plastic Surgery and Reconstruction: A Systematic Review. Plast Recon Surg Glob Open. 2025 Jul 17;13(7):e6912.

Benefits for surgeons

Ergonomics: Robotic platforms allow surgeons to operate in more comfortable positions, often seated at a console. This can significantly reduce physical strain, potentially extending career longevity and mitigating musculoskeletal injuries common in long, intricate, traditional surgeries.

Magnification and 3D visualization: Enhanced optics provide magnified, high- definition 3D views of the surgical field, improving visualization of intricate anatomy. This immersive visual feedback is critical for distinguishing fine structures and tissue planes, leading to more precise dissections and safer procedures.

Current limitations and future directions

Cost and setup time: High initial investment for robotic systems and the associated instruments, coupled with longer setup times for each case, remain significant hurdles to broader adoption, especially in smaller institutions or for less complex cases.

Tactile feedback: The absence of direct tactile feedback, or "haptics," is a major limitation. Surgeons rely heavily on touch to discern tissue tension, density, and texture. Research is actively focused on developing sophisticated haptic feedback systems that can simulate these sensations, allowing surgeons to "feel" the tissues through the robotic instruments.

Training and certification: The need for standardized robotic surgery training and certification within plastic surgery residencies and for practicing surgeons is critical to ensure safe and effective utilization of these complex systems. Establishing clear pathways for proficiency and credentialing will be vital.

AUGMENTED REALITY (AR) IN PLASTIC SURGERY

Pre-operative planning and visualization

3D overlay: AR can overlay 3D models of patient anatomy, desired outcomes, and surgical plans directly onto the patient's body in real-time. Imagine projecting a patient's CT scan data directly onto their face during a rhinoplasty consultation, allowing both surgeon and patient to visualize precise bone and cartilage contours. This builds on current workflows employing virtual surgical planning and 3D printed guides and plates (Fig. 2).

Figure 2. Example of virtual surgical planning for a patient with sagittal craniosynostosis and subsequent output of custom guides for surgery. From Sawh-Martinez, 2025.

Patient consultation: Patients can visualize potential aesthetic outcomes (e.g., rhinoplasty, breast augmentation) in a highly realistic and interactive manner, improving communication and managing expectations. This fosters shared decision-making and enhances patient satisfaction.

Perforator mapping: AR can assist in identifying and mapping perforator vessels for complex flap reconstructions (e.g., DIEP flaps). By projecting pre- operative CT angiography data onto the patient's skin, surgeons can accurately locate and track these vital vessels, improving surgical efficiency and reducing complications

Intraoperative guidance

"X-Ray vision": AR headsets (e.g., Microsoft HoloLens) can project internal anatomical structures (bones, nerves, vessels) onto the skin surface during surgery, aiding in precise dissections and avoiding critical structures. This is particularly useful in craniofacial surgery, tumor resections, or deep dissections where vital structures are not immediately visible.

Real-time data display: Display of vital signs, imaging data, and pre-planned surgical trajectories within the surgeon's field of view eliminates the need to constantly look away from the surgical field, improving focus and efficiency.

Surgical education and training

Immersive simulations: AR provides realistic, interactive environments to practice complex procedures without risk to patients. This allows for repetitive practice of delicate maneuvers, anatomical dissections, and emergency scenarios, accelerating skill acquisition.

Remote mentoring: Expert surgeons can virtually "join" an operating room via AR streaming to provide real-time guidance and feedback to trainees in remote locations. This democratizes access to specialized expertise and facilitates collaborative learning.

ARTIFICIAL INTELLIGENCE (AI) IN PLASTIC SURGERY

Image analysis and diagnosis

Skin cancer detection: AI algorithms, particularly deep learning models, can analyze dermatoscopic images with high accuracy to identify suspicious lesions (melanoma, basal cell carcinoma, squamous cell carcinoma), assisting in early diagnosis and referral.

Facial analysis and symmetry: AI can objectively analyze facial aesthetics, identify subtle asymmetries, and assist in planning corrective procedures for both aesthetic and reconstructive purposes. This can lead to more consistent and predictable outcomes.

Wound healing prediction: Predictive analytics powered by AI can assess various wound characteristics (e.g., size, depth, presence of infection, patient comorbidities) and predict healing trajectories, guiding personalized treatment strategies and identifying patients at risk for delayed healing.

Predictive analytics and risk assessment

Outcome prediction: AI can analyze vast datasets of patient characteristics, surgical techniques, and postoperative outcomes to predict individualized results and potential complications for specific procedures. This aids in patient counseling and informed consent.

Patient selection: Identifying patients who are most likely to benefit from specific procedures or who are at higher risk for adverse events, allowing for more tailored patient selection and pre-optimization strategies.

Personalized medicine and treatment planning

Tailored approaches: AI can help customize treatment plans based on a patient's unique anatomy (derived from imaging), genetics, and desired outcomes, moving beyond a "one-size-fits-all" approach.

Surgical simulation: AI-powered simulations allow surgeons to virtually perform procedures multiple times, optimizing their approach, anticipating challenges, and minimizing errors before touching the patient.

Ethical considerations and limitations

Data privacy: Ensuring the security and privacy of sensitive patient data used by AI algorithms is paramount, requiring robust anonymization and secure data handling protocols.

Algorithmic bias: Addressing potential biases in AI algorithms that could arise from nonrepresentative training data. If AI models are trained predominantly on data from certain demographics, they may perform suboptimally or even inequitably for other groups.

Human oversight: Emphasizing that AI is a tool to augment, not replace, human surgical expertise and judgment. The surgeon remains ultimately responsible for patient care, and AI should serve as a powerful assistant.

NEXT-GENERATION MRI IN PLASTIC SURGERY

Enhanced imaging for soft tissue and vascular structures

Improved resolution: Next-gen MRI offers significantly higher spatial and contrast resolution, providing unprecedented detail of soft tissues, nerves, and small vessels crucial for plastic and reconstructive surgery. This is invaluable for delineating tumor margins, assessing nerve integrity, and planning intricate microvascular reconstructions.

Dynamic imaging (4D Flow MRI): Capturing blood flow in real-time, 4D flow MRI aids in the precise planning of microvascular anastomoses and the detailed assessment of flap perfusion. This can help identify dominant perforators and assess flap viability noninvasively, reducing the need for exploratory surgery.

Pre-operative planning and reconstruction

Detailed anatomy: Precise visualization of complex anatomical regions (e.g., head and neck, breast, perineum) for accurate tumor resection and comprehensive reconstructive planning. MRI can differentiate various tissue types (muscle, fat, scar tissue, glandular tissue) with superior clarity compared to other modalities.

Nerve mapping: High-resolution MRI sequences can aid in mapping peripheral nerves (e.g., brachial plexus, facial nerve branches) for targeted nerve transfers and reconstructions in cases of paralysis or nerve injury, improving functional outcomes.

Black bone MRI: Novel capture protocols allow for bony capture with MRI. This technique uses gradient echo sequences with short echo times and optimized contrast settings to enhance the signal from cortical bone, which traditionally appears dark on standard MRI. Black Bone MRI provides high-resolution 3D images of craniofacial skeletal anatomy without radiation exposure, making it particularly valuable in pediatric patients. It is increasingly being explored for applications in surgical planning, craniosynostosis assessment, and even virtual surgical modeling.

Monitoring and assessment

Flap viability: Non-invasive monitoring of reconstructive flaps for perfusion and early detection of complications like arterial thrombosis or venous congestion, allowing for timely intervention and salvage.

Quantitative analysis: Providing objective measurements of tissue volume changes, fluid accumulation, and inflammation, which can be critical for assessing postoperative swelling, hematoma formation, or response to therapy.

Future potential

Faster scan times: Innovations aimed at reducing scan times through advanced sequences and AI-powered reconstruction, improving patient comfort and increasing throughput.

Integration with AI: AI algorithms can be applied to MRI data for automated image analysis, segmentation (e.g., identifying specific muscle groups or fat compartments), and advanced diagnostics, streamlining workflow and improving diagnostic accuracy.

CONCLUSION

The landscape of plastic surgery is rapidly evolving, driven by these technological advancements. As future leaders in this field, it is imperative to not only understand these innovations but also actively engage with them. Embrace lifelong learning, critical thinking, and ethical considerations as you navigate this exciting era of transformative medical technology. Your ability to integrate these tools thoughtfully and skillfully will define the future of patient care in plastic surgery.

REFERENCES

Selber JC. Robotics in Plastic and Reconstructive Surgery. Springer International Publishing: 2021.

Henn D., et al. Robotics in plastic surgery: it's here. Plast Reconstr Surg. 2023 Jul 1;152(1):239-249.

Kawashima K, et al. Recent advancements in robotic-assisted plastic surgery procedures: a systematic review. Plast Reconstr Surg Glob Open. 2025 Jan 23;13(1):e6476.

Solari M. Augmented Reality in Plastic and Reconstructive Surgery: What It Is, How Far It’s Come, and the Limitations Impacting Further Adoption. Plast Reconstr Surg. 2023:152(4), NP323-NP328.

Wang R, et al. Augmented reality in plastic surgery education. J Plast Reconstr Aesthet Surg. 2020:73(1), 1-8.

Barone M, De Bernardis R, Persichetti P. Artificial Intelligence in Plastic Surgery: Analysis of Applications, Perspectives, and Psychological Impact. Aesthetic Plast Surg. 2025 Mar;49(5):1637-1639.

Lee MS, Kim YH. The Role of Artificial Intelligence in Predicting Outcomes and Patient Satisfaction in Aesthetic Surgery. Aesthetic Surgery Journal. 2024.

Saha PK, Sharma MP. Next-Generation MRI in Reconstructive Surgery: A Review of Advanced Applications. J Reconstr Microsurg. 2023;39(6), 373-380.

Johnson PM, et al. Clinical Impact of Deep Learning Reconstruction in MRI. RadioGraphics. 2023; 43(1), e220133.

Siemens Healthineers. FDA Clears New Energy-Efficient MRI Scanner for Human and Veterinary Use. [Press Release]. (Published online, June 26, 2025).

Liu K, et al. Augmented reality navigation method for recontouring surgery of craniofacial fibrous dysplasia. Sci Rep. 2021;11, 10043.

Brown HG, et al. Robotic-assisted Supermicrosurgery in Plastic Surgery and Reconstruction: A Systematic Review. Plast Recon Surg Glob Open. 2025 Jul 17;13(7):e6912.

Zhang Z, et al. Preliminary study of the accuracy and safety of robot-assisted mandibular distraction osteogenesis with electromagnetic navigation in hemifacial microsomia using rabbit models. Sci Rep. 2022;12, 19572.

Ryu JY, Chung HY, Choi KY. Potential role of artificial intelligence in craniofacial surgery. Arch Craniofac Surg. 2021 Oct;22(5):223-231.