Review of Plastic Surgery – Donal W. Buck II

Review of
Plastic
Surgery

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Review of
Plastic
Surgery
Donald W. Buck II, MD
Assistant Professor
Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Foreword by
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Professor of Surgery, Division of Plastic Surgery
University of Washington
Seattle, WA, USA
Elsevier | ExpertConsult.com
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v
Contents
Foreword................................................................................ vi
Preface.................................................................................. vii
List of Question Contributors.................................................viii
Acknowledgments...................................................................xii
Dedication..............................................................................xii
1. Anesthesia, Practice Management, Patient Safety,
and Coding.......................................................................1
Section 1: Craniofacial, Head, and Neck
2. Head and Neck Anatomy and Facial Palsy........................9
3. Head and Neck Cancer, Odontogenic Tumors, and
Vascular Anomalies........................................................ 19
4. Craniofacial Trauma........................................................ 26
5. Craniosynostosis and Craniofacial Syndromes............... 35
6. Clefts and Orthognathic Surgery.................................... 44
7. Ear Reconstruction......................................................... 60
Section 2: Breast
8. Breast Anatomy, Embryology, and Congenital
Defects.......................................................................... 75
9. Breast Cancer and Breast Reconstruction...................... 83
10. Noncancer Breast Surgery.............................................. 91
Section 3: Trunk and Lower Extremity
11. Trunk Reconstruction and Pressure Sores...................... 97
12. Peripheral Nerve Injuries, Brachial Plexus, and
Compression Neuropathies.......................................... 112
13. Lower Extremity Reconstruction and
Lymphedema............................................................... 125
Section 4: Hand
14. Congenital Hand Disorders........................................... 140
15. Hand Masses, Vascular Disorders, and Dupuytren’s
Contracture.................................................................. 151
16. Hand Fractures and Dislocations................................. 160
17. Nail-Bed Injuries, Soft-Tissue Amputations, and
Replantation................................................................ 173
18. Carpal Injuries and Hand Arthritis................................ 184
19. Tendon Injuries and Reconstruction............................. 195
Section 5: Integument
20. Wound Healing and Tissue Expansion.......................... 212
21. Soft-Tissue and Hand Infections................................... 219
22. Burns and Burn Reconstruction................................... 224
23. Benign Skin Conditions and Skin Disorders................. 228
24. Malignant Skin Conditions........................................... 235
25. Flaps and Microsurgery................................................ 243
Section 6: Aesthetic
26. Eyelid Anatomy, Reconstruction, and
Blepharoplasty............................................................. 260
27. Rhinoplasty and Nasal Reconstruction......................... 269
28. Rhytidectomy and Neck Rejuvenation.......................... 284
29. Body Contouring and Suction-Assisted
Lipectomy.................................................................... 294
30. Injectables, Skin Resurfacing, Lasers, and Hair
Restoration.................................................................. 299
Appendix............................................................................ 308
Index.................................................................................. 353

vi
Foreword
This book by Donald Buck is unique in several ways. It fills a niche
segment of the plastic surgery literature, as it is aimed at residents
and fellows training in plastic surgery. However, it is also of use to
the full spectrum of those interested in plastic surgery, from medical
students to attending physicians. This is not an encyclopedic text­
book nor is it meant to be. It is meant as a review and that is exactly
what it achieves. Each topic is presented in point format, excluding
the fluff and including only what has to be known. Condensing
material like this requires a lot of skill and knowledge, and Dr. Buck
has achieved this with flying colors. The format and layout make it
easy to read yet it is small enough to fit in a backpack or satchel. It
is easy to find one’s way round this book and it is ideal for quickly
revisiting a topic before rounds or the operating room. It is
extremely useful as a review for exams and for testing one’s
knowledge. This is really the genius of this book. Dr. Buck has
invited renowned and recognized experts not specifically to write
chapters, as most textbook editors do, but rather to write self-
assessment questions that are fashioned as board-type questions.
These individuals are not only household names in the specialty,
but they are obviously experienced in the topic, as well as in edu­
cating residents and, more importantly, in examining them. This
makes this book unique and incredibly useful.
Dr. Buck is to be congratulated not only in compiling this book
but in having the wit to use his experts in an ingenious way. In
doing so he has contributed invaluably to the education of the next
generation of plastic surgeons. I think this book will become a
standard resource for medical students, residents, and fellows.
by Peter C. Neligan

vii
Preface
Plastic surgery is a vast specialty, encompassing the management
of diseases and conditions from head to toe, in patients who are
both young and old. With such a diverse and overarching surgical
discipline, it comes as no surprise that our textbooks read like
encyclopedias with seemingly limitless pages of detail and descrip­
tions. An entire bookcase can easily be filled with textbook after
textbook attempting to cover the topics that we encounter as plastic
surgeons. As a student, resident, or young attending, the vastness
of plastic surgery can become overwhelming, and it is easy to get
lost in the details. One quick look at the six volumes required to
cover our specialty in Plastic Surgery 3rd Edition alone can generate
a tremendous amount of heartburn. This is particularly true during
examination time, be it the in-service examination for trainees or
the written examination for plastic surgery certification.
I vividly remember the anxiety surrounding the exam prepara­
tion process and my disbelief at the lack of a “go-to” plastic surgery
review book highlighting frequently tested, high-yield facts for
the in-service exam and written boards. It seemed that all other
specialties had one: a handy companion book with tattered pages
of fruitful facts, figures, and illustrations that covered the broad
topics and themes of the specialty, perfect for focused studying and
examination review. The purpose of this book is to fill that void
and serve as a trustworthy companion to students, residents, and
young plastic surgeons alike.
This book is not intended to be a replacement for your favorite
plastic surgery textbooks or “encyclopedias,” nor is it meant to
cover the minutiae of our specialty. Instead, it is intended to provide
a foundation of plastic surgery fundamentals and themes upon
which further details can be added. It is also intended to serve as
an added resource for treating the anxiety and heartburn of exami­
nation preparation by providing a useful, relevant, and easily acces­
sible collection of high-yield topics and facts covering plastic
surgery.
The book consists of 30 chapters, conveniently designed to align
with the defined topics that are frequently covered in plastic surgery
examinations. Within each chapter are numerous pearls of wisdom
and abundant facts in bulleted format that cover some of the most
frequently tested topics. These pearls are complemented by beauti­
ful figures and illustrations that further drive home important con­
cepts and themes. In addition, each chapter has dedicated exam-style
multiple-choice questions written by topic experts from around the
world, to test your knowledge and enhance your preparation
through creation of a practice exam.
It is my sincere hope that you find this book useful and comfort­
ing and that it will help to alleviate some of the anxiety associated
with rotations, examinations, and review of our awesome specialty.
Best of luck!
Donald W. Buck II

viii
List of Question Contributors
Sonya Agnew, MD
Assistant Professor
Division of Plastic Surgery, Department of
Surgery
Department of Orthopaedic Surgery and
Rehabilitation
Loyola University Medical Center
Maywood, IL, USA
Chapter 15. Hand Masses, Vascular
Disorders, and Dupuytren’s Contracture,
Questions 1–5
Jamil Ahmad, MD, FRCSC
Lecturer, Division of Plastic and
Reconstructive Surgery
Department of Surgery
University of Toronto
Toronto, Ontario, Canada
Chapter 27. Rhinoplasty and Nasal
Reconstruction, Questions 1–5
C. Bob Basu, MD, MPH, FACS
Director, Basu Center for Aesthetics &
Plastic Surgery
Chief of Plastic Surgery
North Cypress Medical Center
Houston, TX, USA
Chapter 1. Anesthesia, Practice Management,
Patient Safety, and Coding, Questions 1–5
Phillip Blondeel, MD, PhD
Professor of Plastic Surgery
Department of Plastic and Reconstructive
Surgery
University Hospital Ghent
Ghent, Belgium
Chapter 9. Breast Cancer and Breast
Reconstruction, Questions 1–5
Lucas Boehm, PharmD
Medical College of Wisconsin
Milwaukee, WI, USA
Chapter 8. Breast Anatomy, Embryology,
and Congenital Defects, Questions 1–15
Marco Ellis, MD
Director of Craniofacial Surgery
Northwestern Specialists in Plastic Surgery
Northwestern University
University of Illinois Chicago
Chicago, IL, USA
Chapter 26. Eyelid Anatomy, Reconstruction,
and Blepharoplasty, Questions 6–10
Neil A. Fine, MD
President NSPS
Clinical Associate Professor
Division of Plastic Surgery
Northwestern University, Feinberg School
of Medicine
Chicago, IL, USA
Chapter 9. Breast Cancer and Breast
Reconstruction, Questions 6–13
Ida Fox, MD
Assistant Professor of Plastic Surgery
Department of Surgery
Washington University School of Medicine
St. Louis, MO, USA
Chapter 12. Peripheral Nerve Injuries,
Brachial Plexus, and Compression
Neuropathies, Questions 1–5
Robert D. Galiano, MD, FACS
Associate Professor
Director of Research
Division of Plastic Surgery
Northwestern University, Feinberg School
of Medicine
Chicago, IL, USA
Chapter 20. Wound Healing and Tissue
Expansion, Questions 6–10
Catharine B. Garland, MD
Chief Resident, Plastic Surgery
Department of Surgery
University of California San Francisco
San Francisco, CA, USA
Chapter 27. Rhinoplasty and Nasal
Reconstruction, Questions 6–10
Donald W. Buck II, MD
Assistant Professor
Plastic & Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Chapter 2. Head and Neck Anatomy and
Facial Palsy, Questions 1–5
Chapter 4. Craniofacial Trauma, Questions
1–5
Chapter 7. Ear Reconstruction, Questions 1–5
Chapter 19. Tendon Injuries and
Reconstruction. Questions 1–5
Chapter 20. Wound Healing and Tissue
Expansion, Questions 1–5
Chapter 22. Burns and Burn Reconstruction,
Questions 1–10
Chapter 25. Flaps and Microsurgery,
Questions 1–5
Ming-Huei Cheng, MD, MBA, FACS
Professor and Vice President
Department of Plastic and Reconstructive
Surgery
Chang Gung Memorial Hospital
Taoyuan, Taiwan
Chapter 13. Lower Extremity Reconstruction
and Lymphedema, Questions 1–5
Brian M. Derby, MD
Private Practice
Sarasota Plastic Surgery Center
Sarasota, FL, USA
Chapter 26. Eyelid Anatomy, Reconstruction,
and Blepharoplasty, Questions 1–5
Brent Egeland, MD
Attending Surgeon
Institute of Reconstructive Plastic Surgery
University Medical Center Brackenridge
Austin, TX, USA
Chapter 19. Tendon Injuries and
Reconstruction, Questions 6–10

ix
Patrick B. Garvey, MD, FACS
Associate Professor of Plastic Surgery
Department of Plastic Surgery
The University of Texas MD Anderson
Cancer Center
Houston, Texas, USA
Chapter 11. Trunk Reconstruction and
Pressure Sores, Questions 1–5
Amanda Gosman, MD
Associate Professor
Division of Plastic Surgery
University of California San Diego
San Diego, CA, USA
Chapter 4. Craniofacial Trauma, Questions
6–10
Ronald P. Gruber, MD
Clinical Associate Professor
Divisions of Plastic and Reconstructive
Surgery
University of California
San Francisco, CA, USA
Adjunct Clinical Associate Professor
Stanford University Medical Center
Stanford, CA, USA
Chapter 27. Rhinoplasty and Nasal
Reconstruction, Questions 6–10
Anandev Gurjala, MD, MS
Attending Surgeon
Department of Plastic and Reconstructive
Surgery
Kaiser Permanente San Francisco
San Francisco, CA, USA
Chapter 24. Malignant Skin Conditions,
Questions 1–5
Jeffrey A. Gusenoff, MD
Associate Professor of Plastic Surgery
Co-Director, Life After Weight Loss
Program
Department of Plastic Surgery
University of Pittsburgh
Pittsburgh, PA, USA
Chapter 29. Body Contouring and Suction-
Assisted Lipectomy, Questions 1–5
Kristy L. Hamilton, MD
Plastic Surgery Resident
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Chapter 11. Trunk Reconstruction and
Pressure Sores, Questions 1–5
James P. Higgins, MD
Chief, Curtis National Hand Center
Union Memorial Hospital
Baltimore, MD, USA
Chapter 18. Carpal Injuries and Hand
Arthritis, Questions 1–5
John B. Hijjawi, MD, FACS
Program Director
Reconstructive Microsurgery Fellowship
Associate Professor
Department of Plastic Surgery
Medical College of Wisconsin
Milwaukee, WI, USA
Chapter 8. Breast Anatomy, Embryology,
and Congenital Defects, Questions 1–15
Elliot M. Hirsch, MD
Division of Plastic and Reconstructive
Surgery
Feinberg School of Medicine
Northwestern University
Chicago, IL, USA
Chapter 23. Benign Skin Conditions and
Skin Disorders, Questions 1–5
Peter S. Kim, MD
Clinical Instructor of Surgery
Department of Surgery
Beth Israel Deaconess Medical Center
Harvard Medical School
Boston, MA, USA
Chapter 16. Hand Fractures and
Dislocations, Questions 1–10
Grant M. Kleiber, MD
Assistant Professor of Surgery
Division of Plastic and Reconstructive
Surgery
Washington University School of Medicine
St. Louis, MO, USA
Chapter 15. Hand Masses, Vascular
Disorders, and Dupuytren’s Contracture,
Questions 6–10
Jason H. Ko, MD
Assistant Professor of Surgery
Division of Plastic Surgery and Department
of Orthopaedics and Sports Medicine
University of Washington School of
Medicine
Seattle, WA, USA
Chapter 17. Nail-Bed Injuries, Soft-Tissue
Amputations, and Replantation, Questions
1–10
Jeffrey H. Kozlow, MD, MS
Assistant Professor
Section of Plastic Surgery
University of Michigan Health System
Ann Arbor, MI, USA
Chapter 21. Soft-Tissue and Hand Infections,
Questions 1–5
Brian I. Labow, MD, FACS, FAAP
Associate Professor of Surgery
Boston Children’s Hospital, Harvard
Medical School
Boston, MA, USA
Chapter 14. Congenital Hand Disorders,
Questions 1–5
Victor L. Lewis, Jr., MD
Professor of Clinical Surgery
Division of Plastic Surgery
Feinberg School of Medicine
Northwestern University
Chicago, IL, USA
Chapter 23. Benign Skin Conditions and
Skin Disorders, Questions 6–11

x
Frank Lista, MD, FRCSC
Assistant Professor
Division of Plastic and Reconstructive
Surgery
Department of Surgery
University of Toronto
Toronto, Ontario, Canada
Chapter 10. Noncancer Breast Surgery,
Questions 1–5
Samir Mardini, MD
Professor of Surgery
Program Director
Division of Plastic Surgery
Department of Surgery
Mayo Clinic College of Medicine
Rochester, MN, USA
Chapter 3. Head and Neck Cancer,
Odontogenic Tumors, and Vascular
Anomalies, Questions 1–5
Derek L. Masden, MD
Plastic Surgery/Hand Surgery, Washington
Hospital Center
Assistant Clinical Professor
Department of Plastic Surgery, Georgetown
University Hospital
Washington, DC, USA
Chapter 18. Carpal Injuries and Hand
Arthritis, Questions 6–14
Martha S. Matthews, MD, FACS
Professor of Surgery
Department of Surgery
Division of Plastic Surgery, Cooper
Medical School of Rowan University
Camden, NJ, USA
Chapter 1. Anesthesia, Practice Management,
Patient Safety, and Coding, Questions 6–10
Mary H. McGrath, MD, MPH, FACS
Professor of Surgery and Associate Chair
Department of Surgery
Division of Plastic Surgery
University of California San Francisco
San Francisco, CA, USA
Chapter 24. Malignant Skin Conditions,
Questions 6–10
Amy M. Moore, MD
Assistant Professor of Surgery
Division of Plastic and Reconstructive
Surgery
Department of Surgery
Washington University School of Medicine
St. Louis, MO, USA
Chapter 14. Congenital Hand Disorders,
Questions 6–10
Gerhard S. Mundinger, MD
Craniofacial Surgery Fellow/Acting
Instructor
Division of Craniofacial and Plastic Surgery
Seattle Children’s Hospital
Harborview Medical Center
University of Washington Medical Center
Seattle, WA, USA
Chapter 3. Head and Neck Cancer,
Odontogenic Tumors, and Vascular
Anomalies, Questions 6–10
Terence Myckatyn, MD
Associate Professor
Division of Plastic and Reconstructive
Surgery
Washington University School of Medicine
St. Louis, MO, USA
Chapter 10. Noncancer Breast Surgery,
Questions 6–10
Maurice Y. Nahabedian, MD
Professor and Vice Chairman
Department of Plastic Surgery
Georgetown University
Washington, DC, USA
Chapter 8. Breast Anatomy, Embryology,
and Congenital Defects, Questions 16–20
Peter C. Neligan, MB, FRCS(I), FRCSC,
FACS
Professor of Surgery
Division of Plastic Surgery
University of Washington
Seattle, WA, USA
Chapter 25. Flaps and Microsurgery,
Questions 6–10
Ashit Patel, MBChB, FACS
Associate Professor
Division of Plastic Surgery
Albany Medical Center
Albany, NY, USA
Chapter 21. Soft-Tissue and Hand Infections,
Questions 6–10
Kamlesh B. Patel, MD
Assistant Professor of Plastic Surgery
Department of Surgery
Washington University St. Louis
St. Louis, MO, USA
Chapter 5. Craniosynostosis and Craniofacial
Syndromes, Questions 1–5
Pravin K. Patel, MD, FACS
Professor of Surgery and Chief of
Craniofacial Surgery
Division of Plastic, Reconstructive, and
Cosmetic Surgery
The University of Illinois at Chicago
Chicago, IL, USA
Chapter 6. Clefts and Orthognathic Surgery,
Questions 1–5
Jason Roostaeian, MD
Assistant Clinical Professor
Division of Plastic Surgery
David Geffen School of Medicine
University of California Los Angeles
Los Angeles, CA, USA
Chapter 28. Rhytidectomy and Neck
Rejuvenation, Questions 1–10
Michel Saint-Cyr, MD, FRCS(C)
Director, Division of Plastic Surgery
Wigley Professorship in Plastic Surgery
Baylor, Scott & White Health
Scott & White Memorial Hospital
Temple, TX, USA
Chapter 11. Trunk Reconstruction and
Pressure Sores, Questions 6–10

xi
Clark Schierle, MD, PhD, FACS
Director of Aesthetic Surgery
Northwestern Specialists in Plastic Surgery,
S.C.
Adjunct Assistant Professor, University of
Illinois at Chicago
Chicago, IL, USA
Chapter 30. Injectables, Skin Resurfacing,
Lasers, and Hair Restoration, Questions 1–10
Basel Sharaf, MD, DDS
Mayo Clinic
Rochester, MN, USA
Chapter 3. Head and Neck Cancer,
Odontogenic Tumors, and Vascular
Anomalies, Questions 1–5
John W. Shuck, MD
Resident Physician
Department of Plastic Surgery
Georgetown University Hospital
Washington, DC, USA
Chapter 18. Carpal Injuries and Hand
Arthritis, Questions 1–5
Alison Snyder-Warwick, MD
Assistant Professor of Surgery
Department of Surgery, Division of Plastic
and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Chapter 2. Head and Neck Anatomy and
Facial Palsy, Questions 6–10
Jason M. Souza, MD
Lieutenant Commander
Medical Corps, US Navy
Division of Plastic and Reconstructive
Surgery
Walter Reed National Military Medical
Center
Bethesda, MD, USA
Chapter 12. Peripheral Nerve Injuries,
Brachial Plexus, and Compression
Neuropathies, Questions 6–10
Jordan P. Steinberg, MD, PhD
Pediatric Craniofacial Surgery Fellow
Children’s Healthcare of Atlanta
Atlanta, GA, USA
Chapter 5. Craniosynostosis and Craniofacial
Syndromes, Questions 6–10
Jon Ver Halen, MD, FACS
Associate Professor of Surgery
Division of Plastic Surgery
Texas A&M University, Baylor Scott &
White Health
Temple, TX, USA
Chapter 29. Body Contouring and Suction-
Assisted Lipectomy, Questions 6–10
Aparna Vijayasekaran, MBBS, MDS
Plastic Surgery Resident
Department of Plastic and Reconstructive
Surgery
The Mayo Clinic
Rochester, MN, USA
Chapter 11. Trunk Reconstruction and
Pressure Sores, Questions 6–10
Albert S. Woo, MD
Chief, Pediatric Plastic Surgery
Director, Cleft Palate–Craniofacial Institute
St. Louis Children’s Hospital
Associate Professor of Plastic Surgery
Department of Surgery
Washington University School of Medicine
St. Louis, MO, USA
Chapter 6. Clefts and Orthognathic Surgery,
Questions 6–10
Akira Yamada, MD, PhD
Department of Plastic Surgery
Northwestern University, Feinberg School
of Medicine
Ann & Robert Lurie Children’s Hospital of
Chicago
Chicago, IL, USA
Chapter 7. Ear Reconstruction, Questions
6–10
Shuji Yamashita, MD, PhD
Assistant Professor
Department of Plastic and Reconstructive
Surgery
The University of Tokyo
Tokyo, Japan
Chapter 13. Lower Extremity Reconstruction
and Lymphedema, Questions 6–10

xii
Acknowledgments
I must first thank the wonderful team at Elsevier for the
incredible opportunity to create this book. It has been a true
privilege working alongside Belinda Kuhn, Poppy Garraway, Alex
Mortimer, and Trinity Hutton. I am indebted to their support,
encouragement, expertise, and patience along the way. I would
also like to thank all of the contributors to the book who have
graciously added their expertise to this work—I am truly grateful!
Finally, and most important, I would like to thank my beautiful
wife, Jennifer, and my children, Benjamin and Brooke, for their
unwavering love and support. They inspire me to be better every
day, and without them, none of this would have been possible.
DWB
Dedication
This book is dedicated to my family, teachers, mentors, and
colleagues and to all plastic surgeons—past, present, and future—
who carry the legacy of our specialty forward.

Anesthesia, Practice
Management, Patient
Safety, and Coding
Chapter
1 
General Anesthesia
1. Intravenous agents: Primarily used for induction of anesthesia
or sedation anesthesia, such as monitored anesthesia care
(MAC) sedation.
• Propofol is commonly used because it is short acting,
associated with smooth emergence, and reduction of
nausea and vomiting. Limitations of propofol include
hypotension and pain on injection
• Ketamine causes a dissociative state and is the only
induction agent that increases blood pressure and
heart rate.
■ Frequently used for conscious sedation in children
■ Intravenous ketamine has more rapid onset, shorter
duration of action, and a lower risk of laryngospasm
than intramuscular ketamine (see Table 1.1).
2. Inhalational agents: Often used today for maintenance of
anesthesia after intravenous induction.
• Supplemented by intravenous opioids for pain and muscle
relaxants or paralytics
• Most commonly used today are isoflurane, sevoflurane,
and desflurane (see Table 1.2)
Table 1.1  Clinical Characteristics of Intravenous Induction Agents
IV INDUCTION
AGENT
DOSE
(MG/KG)
COMMENTS
SIDE EFFECTS
SITUATIONS
REQUIRING CAUTION
RELATIVE INDICATIONS
Thiopental
2-5
Inexpensive; slow emergence
after high doses
Hypotension
Hypovolemia;
compromised cardiac
function
Suitable for induction in
many patients
Ketamine
1-2
Psychotropic side effects
controllable with
benzodiazepines; good
bronchodilator; potent
analgesic at subinduction
doses
Hypertension;
tachycardia
Coronary disease;
severe hypovolemia
Rapid-sequence induction
of asthmatics, patients in
shock (reduced doses)
Propofol
1-2
Burns on injection; good
bronchodilator; associated with
low incidence of postoperative
nausea and vomiting
Hypotension
Coronary artery disease;
hypovolemia
Induction of outpatients;
induction of asthmatics
Etomidate
0.1-0.3
Cardiovascularly stable; burns
on injection; spontaneous
movement during induction
Adrenal suppression
(with continuous
infusion)
Hypovolemia
Induction of patients
with cardiac contractile
dysfunction; induction of
patients in shock (reduced
doses)
Midazolam
0.15-0.3
Relatively stable
hemodynamics; potent
amnesia
Synergistic ventilatory
depression with
opioids
Hypovolemia
Induction of patients with
cardiac contractile
dysfunction (usually in
combination with opioids)
Reprinted from Townsend, C.M., Beauchamp, R.D., Evers, B.M., et al. (Eds.), 2012. Sabiston Textbook of Surgery, 19th ed. Saunders.

Anesthesia, Practice Management, Patient Safety, and Coding
2
3. Neuromuscular blocking agents: Useful for muscle paralysis
as well as rapid induction
• Two categories of agents: Depolarizing and
nondepolarizing
• Succinylcholine
■ The only depolarizing agent still in use
■ Typically used only for rapid sequence intubation
(produces rapid onset and short duration of action)
■ Disadvantages: Associated with malignant hyperthermia
and hyperkalemia (especially with burns, paralyzed
patients, and massive trauma patients)
• Nondepolarizing agents
■ Most commonly used today
■ Longer duration of action
4. Opioids: Used as adjuncts to anesthesia for analgesia
• Most common agents: Fentanyl- and synthetic fentanyl–
based agents (e.g., sulfentanil, remifentanil, and alfentanil),
morphine, hydromorphone, and meperidine
■ Fentanyl, and its synthetic derivatives, is frequently used
because it is 100-150 times more potent than morphine
and has a rapid onset and short duration of action.
• Disadvantages of opioids: Respiratory depression
Table 1.2  Important Characteristics of Inhalational Agents
ANESTHETIC
POTENCY
SPEED OF INDUCTION
AND EMERGENCE
SUITABILITY FOR
INHALATIONAL INDUCTION
SENSITIZATION TO
CATECHOLAMINES
METABOLIZED (%)
Nitrous oxide
Weak
Fast
Insufficient alone
None
Minimal
Diethyl ether
Potent
Very slow
Suitable
None
10
Halothane
Potent
Medium
Suitable
High
20+
Enflurane
Potent
Medium
Not suitable
Medium
<10
Isoflurane
Potent
Medium
Not suitable
Minimal
<2
Sevoflurane
Potent
Rapid
Suitable
Minimal
<5
Desflurane
Potent
Rapid
Not suitable
Minimal
0.02
Reprinted from Townsend, C.M., Beauchamp, R.D., Evers, B.M., et al. (Eds.), 2012. Sabiston Textbook of Surgery, 19th ed. Saunders.
5. Benzodiazepines: Frequently used for anxiolysis before
induction, amnesia, as well as in some conscious sedation
protocols
• Common agents include diazepam and midazolam
• Useful for the treatment of local anesthetic toxicity
Local Anesthesia
1. Delivery of anesthetic to local tissues to provide focused
anesthesia to the surgical site/field
2. Local anesthetic agents are frequently used with regional
blocks, conscious sedation, and deep sedation techniques;
may also be used with general anesthesia to provide
postoperative anesthesia or assist with hemostasis (e.g.,
epinephrine effects).
3. Two classes: Esthers and amides
• Esther compounds are more rapidly hydrolyzed by plasma
pseudocholinesterases and have shorter durations of action.
■ Allergic reactions to local anesthetics are much more
common with ester compounds.
• Amide compounds are degraded by the liver.
4. Commonly used local anesthetic agents (see Table 1.3)
Table 1.3  Commonly Used Local Anesthetic Agents
AGENT
CLASS
DURATION OF
ACTION (MIN)
RECOMMENDED DOSAGE
GUIDELINES (MG/KG)
MAXIMUM TOTAL
DAMAGE (MG)
Procaine (Novocain)
Ester
15-60
7
35-600
Chloroprocaine (Novocain)
Ester
15-30
Without epinephrine: 11
800
With epinephrine: 14
1000
Lidocaine (Xylocaine)
Amide
30-60
Without epinephrine: 4.5
300
120-360
With epinephrine: 7
Mepivacaine (Carbocaine)
Amide
45-90
7
400
Bupivacaine (Marcaine)
Amide
120-240
Without epinephrine: 2.5
175
180-420
With epinephrine: 2.5-4
225-400
Prilocaine (Citanest)
Amide
30-90
8
500-600
Reprinted from Mustoe, T.A., Buck, D.W., Lalonde, D.H., 2010. Plast. Reconstr. Surg. 126 (4), 165–176. Adapted from multiple sources.

Local Anesthesia
3
1
5. 4% topical cocaine
• Was commonly used for nasal surgery (e.g., rhinoplasty,
septoplasty) because of rapid mucosal absorption and
subsequent onset of action.
• Maximum dosage: 1.5 mg/kg
• Infrequently used today because of the potential for
coronary vasoconstriction
6. Epinephrine
• Frequently added to local anesthetics to provide
■ A slight increase in the maximum dosage of anesthetic
allowed
■ Local vasoconstriction
○ Reduces the amount of anesthetic required
for effect due to reduction in diffusion of the
compound
○ Assists with hemostasis
• Epinephrine-containing lidocaine compounds have been
safely used in the digits
■ Treatment of ischemia related to epinephrine (e.g., a
pale finger) injection includes conservative measures
(e.g., elevation; consider warm/cold compresses) and
phentolamine injection.
7. Toxicity
• Although rare, systemic toxicity can be observed with
excess local anesthetic administration.
• Signs of toxicity
■ Headache, tinnitus, perioral and tongue paresthesias
(early findings)
■ Restlessness
■ Seizures
■ Respiratory arrest and cardiac collapse (late finding)
• Treatment
■ Respiratory and circulatory support (e.g., airway control,
100% oxygen administration, intravenous fluids)
■ Benzodiazepines (useful for early neurologic signs)
■ Intravenous lipid administration
• Intra-arterial injection of bupivacaine can cause irreversible
heart block and cardiac collapse.
8. Tumescent solution (also known as “wetting solution”)
• Prepared by combining lidocaine and epinephrine to saline
to create a dilute solution of local anesthetic that can be
safely infiltrated into the soft tissues.
• Allows for much larger dosages of lidocaine use (up to
35 mg/kg).
• Systemic levels of lidocaine peak at 12 to 14 hours below the
clavicles and 6 to 12 hours above the clavicles.
■ This is important when performing both trunk and head
and neck procedures to prevent overlap of peaks and
potential for toxicity
9. Topical anesthetics
• Topical combination anesthetic formulations that are
useful in children to provide anesthesia without the trauma
of injection
• Common agents
■ LET (lidocaine, epinephrine, and tetracaine)
■ Eutectic mixture of local anesthetics (EMLA), lidocaine,
and prilocaine; small risk of methemoglobinemia
because of the prilocaine
■ ELA-Max (liposomal lidocaine): More rapid onset of
action
• Disadvantages: Requires prolonged contact with site for
anesthetic effect (e.g., 30-60 minutes)
10. Regional nerve block
• Involves infiltration of local anesthetic in the vicinity of a
sensory nerve distant from the surgical site to provide local
anesthesia.
• Advantages: Avoid tissue distortion from anesthetic
infiltration; reduce the amount of anesthetic required for
effect.
• Bier block: Use of a double tourniquet and intravenous
administration of lidocaine to provide upper extremity
anesthesia
■ Lidocaine toxicity can occur with a nonfunctioning
tourniquet, inappropriate early release of the tourniquet,
and a poorly functioning tourniquet (e.g., a tourniquet
that is too small or too large for the given extremity).
11. Conscious sedation
• Uses a combination of anesthetics and opioids to provide
an altered level of consciousness to a relaxed state while
maintaining airway protection.
• Titration of medications is tailored to the patient’s vital
signs and state of alertness.
• Most recommend small, incremental dosing of sedation
agents to maintain a stable level of anesthesia and reduce
the risk for overmedication and oversedation.
• Advantages: Reduced risk of deep venous thrombosis,
postoperative nausea and vomiting, faster recovery, and
fewer unplanned admissions.
• Common agents for conscious sedation (see Table 1.4)

Anesthesia, Practice Management, Patient Safety, and Coding
4
Table 1.4  Commonly Used Agents for Conscious Sedation
AGENT
CLASS
COMMON DOSAGE
GUIDELINES
SIDE EFFECTS
Midazolam
Benzodiazepine
0.5-1 mg every 5-10 min per
patient alertness
Respiratory depression, somnolence, amnesia
Diazepam
Benzodiazepine
10-50 mg preoperatively
Respiratory depression, somnolence
Lorazepam
Benzodiazepine
0.5-2 mg per os
0.25-1 mg intravenously
Respiratory depression, somnolence
Ketamine
Dissociative anesthetic
200-750 mcg/kg bolus, followed
by 5- to 20-mcg/kg/min infusion
Hallucinogens, delirium, intracranial hypertension,
increased respiratory secretions, cardiac simulation
Clonidine
Alpha-2 agonist
0.1-0.2 mg preoperatively
Hypotension, rebound tachycardia, flushing
Fentanyl
Opioid receptor agonist
25-50 mcg every 5-10 min per
patient alertness
Respiratory depression, somnolence, nausea, vomiting
Reversal agents
Flumazenil
Benzodiazepine receptor
antagonist
0.2-mg incremental doses to
maximum of 1 mg
Dizziness, blurred vision, headache, nausea, flushing,
injection-site pain, agitation
Naloxone
Opioid antagonist
0.1- to 0.2-mg incremental
doses every 2-3 min to desired
degree of reversal
Hypotension, hypertension, arrhythmias, dyspnea,
pulmonary edema, agitation, flushing, nausea
Reprinted from Mustoe, T.A., Buck, D.W., Lalonde, D.H., 2010. Plast. Reconstr. Surg. 126 (4), 165–176. Adapted from multiple sources.
Complications of Anesthesia
1. Allergy
2. Cardiovascular toxicity
3. Postoperative nausea and vomiting (PONV)
• Affects approximately one-third of all surgical patients
• Multifactorial etiology and includes the chemoreceptor
trigger zone within the brain stem
■ The chemoreceptor trigger zone has receptors for
dopamine, acetylcholine, histamine, and serotonin.
• Risk factors: Female gender, nonsmoking status, history of
PONV, history of opioid-induced nausea and vomiting,
inhalational anesthetics, long operative duration
• Treatment is pharmacologic, with a focus on prophylaxis
in high-risk patients (see Table 1.5)
4. Malignant hyperthermia
• Life-threatening hypermetabolic event that occurs after
exposure to inhalational anesthetics (e.g., halothane,
enflurane, isoflurane, sevoflurane) and depolarizing muscle
relaxants (e.g., succinylcholine)
• Autosomal dominant inheritance with variable penetrance
• Clinical manifestations
■ Fever
■ Tachycardia
■ Arrhythmia
■ Acidosis
■ Muscle rigidity
■ Tachypnea
■ Skin flushing
■ Hypotension
Table 1.5  Commonly Used Antiemetic Agents
DRUG CLASS
COMMON SIDE EFFECTS
Dopamine Receptor Antagonists (DA-2)
Phenothiazines
Sedation
  Fluphenazine
Dissociation
  Chlorpromazine
Extrapyramidal effects
  Prochlorperazine
Butyrophenones
  Droperidol
  Haloperidol
Substituted benzamide
Metoclopramide
Antihistamines (H)
Diphenhydramine
Sedation
Promethazine
Dry mouth
Anticholinergics
  Scopolamine
Sedation
  Atropine
Dry mouth
Tachycardia
Serotonin Receptor Antagonists
  Ondansetron
Headache
  Dolasetron
Corticosteroids
  Dexamethasone
Glucose intolerance
  Methylprednisolone
Altered wound healing
  Hydrocortisone
Immunosuppression
Renal effects
Reprinted from Townsend, C.M. (Eds.), 2012. Sabiston Textbook of
Surgery, 19th ed. Saunders.

Practice Management
5
1
2. Many analgesics today can be administered orally,
intravenously, intramuscularly, or locally through indwelling
pain “pumps” and patient-controlled systems.
3. For severe pain, multimodality and/or multidrug treatment is
often necessary.
4. Commonly used analgesic agents (see Table 1.6)
Practice Management
1. HIPAA: Health Insurance Portability and Accountability Act
• Created to protect patient privacy. Covers medical records
and photography.
• Patients must be notified of their rights with respect to
their personal medical information.
■ Right to restrict use/disclosure
■ Right to inspect/copy records
■ Right to amend records
■ Right to audit the disclosure of records
• Personal medical information must be recorded in a
de-identified manner for research purposes. This
information includes
■ Patient name
■ Contact information
○ Address
○ Telephone/fax numbers
○ Email address
■ Rhabdomyolysis
■ Increased end-tidal CO2
• Treatment: Hyperventilation with 100% oxygen,
dantrolene administration, termination of surgery,
supportive care
5. Methemoglobinemia
• Rare, life-threatening complication associated with topical
and local anesthetics (e.g., prilocaine, benzocaine, and
lidocaine)
• The anesthetic oxidizes the iron component of
hemoglobin such that it cannot bind and transport
oxygen.
• Characterized by progressive signs including graying
of skin, headache, weakness, cyanosis with brown
discoloration of blood, arrhythmias, seizures, and finally
anoxic brain injury and death.
• Treatment: Administration of 100% oxygen, intravenous
methylene blue
Pain Control
1. Effective postoperative pain control is important for patient
comfort, as well as surgical outcome, because untreated pain
is associated with prolonged hospital stay, deep venous
thrombosis, pulmonary embolus, pneumonia, bowel
dysmotility, insomnia, and impaired wound healing.
Table 1.6  Commonly Used Analgesics
AGENT
CLASS
ROUTE
DOSAGE GUIDELINES
MAXIMUM DAILY
DOSAGE
SIDE EFFECTS/ADVERSE
REACTIONS
Acetaminophen
NSAID
PO, PR
325-650 mg every 6-8 hr
4000 mg
Hepatic dysfunction in overdose;
reduce dose in alcoholics
Ibuprofen
NSAID
PO
200-800 mg
2400 mg
Bleeding, gastrointestinal discomfort,
renal failure
Ketorolac
NSAID
IV
30 mg every 8 hr
90 mg
Bleeding, gastrointestinal discomfort,
renal failure
Diclofenac
COX-2 inhibitor
PO
75 mg BID
150 mg
Bleeding, gastrointestinal discomfort,
renal failure
Celecoxib
COX-2 inhibitor
PO
100-200 mg BID
200-400 mg
Gastrointestinal discomfort, CV risk
Rofecoxib
GABA analog
PO
12.5 mg daily
25 mg
Gastrointestinal discomfort, CV risk
Gabapentin
GABA analog
PO
300-600 mg TID
3600 mg (limit dose in
renal failure patients)
Dizziness, somnolence, peripheral
edema
Pregabalin
Weak opioid
PO
75-150 mg BID
300-450 mg
Dizziness, somnolence, confusion,
dry mouth, blurred vision
Tramadol
Weak opioid
PO, IV, IM
50-100 mg QID
Sedation
Codeine
Weak opioid
PO
15-60 mg every 4 hr
3 mg/kg/day
Sedation
Morphine
Strong opioid
IV
1-2 mg every 2-4 hr
Respiratory depression, nausea,
vomiting
Hydromorphone
Strong opioid
PO
2-10 mg every 6 hr
Respiratory depression, constipation,
nausea, hypotension
IV
0.25-1 mg every 2-4 hr
Acetominophen/
hydrocodone
Mixed
PO
500 mg/5 mg every 4-6 hr
4000 mg
acetaminophen
Lightheadedness, dizziness, nausea,
vomiting
Reprinted from Mustoe, T.A., Buck, D.W., Lalonde, D.H., 2010. Plast. Reconstr. Surg. 126 (4), 165–176. Adapted from multiple sources.
BID, Twice daily; COX-2, cyclooxygenase-2; CV, cardiovascular; GABA, gamma-amniobutyric acid; IM, intramuscularly; IV, intravenously;
NSAID, nonsteroidal anti-inflammatory drug; PO, per os (by mouth); PR, per rectum; QID, four times daily; TID, three times daily.

Anesthesia, Practice Management, Patient Safety, and Coding
6
2. Deep venous thrombosis
• Risk factors
■ History of prior venous disease
■ Obesity (body mass index [BMI] >30)
■ Immobility
■ Diabetes
■ Smoking
■ History of cancer
■ Increased age
■ Long duration of surgery
■ General anesthesia
■ Abdominoplasty and/or suction-assisted lipectomy
■ Prolonged hospital stay >4 days
■ Caprini score >8
• Prophylaxis
■ Compression stockings
■ Intermittent pneumatic compressive devices
○ Must be placed before induction of anesthesia
■ Preoperative and/or postoperative anticoagulation (e.g.,
low-molecular-weight heparin, subcutaneous heparin) is
generally recommended for high-risk patients.
• Characterized by localized swelling and pain of the affected
extremity, exacerbation in the dependent position
■ Often asymptomatic
■ Occasionally present with pulmonary embolus,
tachycardia, hypotension, and respiratory distress.
• Diagnosis: High index of suspicion, duplex ultrasound
■ Ventilation-perfusion (VQ) scan, spiral chest CT for
pulmonary embolus
• Treatment
■ Supportive care (e.g., supplemental oxygen, airway
protection)
■ Anticoagulation (e.g., heparin, low-molecular-weight
heparin, coumadin, fondaparinux in patients with
heparin-induced thrombocytopenia)
■ Identification numbers
○ Social security number
○ Medical record number
○ Insurance numbers
○ Other account numbers
○ Driver’s license number
○ Medical device serial numbers
■ Photographs involving the full face or other identifiable
body markers (e.g., tattoos)
■ Date of birth
■ Age and gender are not considered identifiers.
• Medical information cannot be discussed with anyone
other than the patient unless prior consent and permission
has been obtained from the patient or the patient is a
minor (i.e., <18 years old).
2. Informed consent
• Elements of discussion and documentation that are
required for adequate consent
■ Diagnosis requiring treatment
■ Procedural risks, potential complications, and potential
side effects
■ Probability of success based on the patient’s medical
condition
■ Available alternative methods of treatment
■ Risks associated with noncompliance with postprocedure
recommendations and/or restrictions
3. Employment policies/practices
• It is illegal to discriminate against an applicant, or
employee, because of
■ Age
■ Religion
■ Nation of origin
■ Race
■ Sex
■ Child care responsibilities
■ Health-related disabilities
■ Arrest history
• As such, inquiries into any of the above aspects during the
application or interview process are unethical and
considered illegal.
• It is legal to ask questions about an applicant’s or
employee’s background or to require a background check.
Patient Safety
1. American Society of Anesthesiologists (ASA) classification
(see Table 1.7)
• Correlates with overall health of the patient and surgical
outcome (i.e., higher ASA is associated with a patient in
poorer health and with a greater risk for morbidity and/or
mortality from surgery/anesthesia).
Table 1.7  ASA Classification
ASA I
Normal healthy patient without active disease
ASA II
Patient with mild systemic disease (e.g.,
hypertension under medical control)
ASA III
Patient with severe systemic disease
ASA IV
Patient with severe systemic disease that is a
constant threat to life
ASA V
Patient who is moribund and not expected to
survive without surgery
ASA VI
Patient who has been declared brain dead for
organ donation
Reprinted from Halperin, B., 2013. In: Neligan, P.C. (Ed.), Plastic
Surgery, 3rd ed. Elsevier, China.
ASA, American Society of Anesthesiologists.

Common CPT Code Definitions
7
1
• Use of the surgical microscope is included in all
microsurgery/free-flap codes, except for codes involving
nerve repair.
4. Billing for combined reconstructive cosmetic and
reconstructive procedures (e.g., abdominoplasty and
umbilical hernia repair)
• The patient must be billed separately for the cosmetic
portion of the operation, including the associated hospital
and anesthesia fees.
• This separation is based on time during the operation.
■ The surgeon informs the operating room staff when the
cosmetic surgery portion is being performed and the
time is documented.
Common CPT Code Definitions
1. Lesion excisions are coded according to the longest diameter
of lesion plus the margin.
2. Skin closure methods are coded according to the length of the
closure.
• If multiple closure procedures are performed on a patient,
the closure method is coded according to the sum of the
lengths closed using that particular method (e.g., all simple
closure lengths are added, intermediate closure lengths are
added, etc.).
3. Skin closure definitions
• Simple repair includes all simple one-layered closures.
■ Simple repair is included in all excision codes.
• Intermediate repair includes all multilayer closures or
single-layer closure of heavily contaminated wounds.
• Complex repair includes wounds requiring more than a
one-layered closure (e.g., scar revision, debridement,
extensive undermining, stents or retention sutures, etc.).
• Adjacent tissue transfer includes all types of local tissue
rearrangement (e.g., local flaps, Z plasty, rotation-
advancement flaps, bilobed flaps, rhomboid flaps, Ryan
flaps, etc.) that is not based on a defined pedicle or axial
blood supply.
■ Coded according to the area of the defect plus the
donor site
■ Coded per defect, not per flap
■ Excision of a lesion is included in all adjacent tissue
transfer codes
4. Code modifiers: Used to further define or describe the
procedure
• 22 modifier identifies increased complexity or procedural
services required for that particular code.
• 52 modifier identifies decreased complexity or procedural
services required for that particular code.
• 50 modifier identifies bilateral cases (e.g., breast reduction,
brachioplasty, etc.).
• 51 modifier identifies multiple combined procedures
performed.
• 59 modifier identifies procedures that were distinct and
should be considered independent (e.g., resection of
multiple malignant lesions from the same anatomic area).
Billing and Coding
1. Billing is performed based on current procedural terminology
(CPT) codes used to describe the operation being performed,
and/or the evaluation being conducted.
• Evaluation and management (E/M) codes: Used to report
evaluation and management services that are provided in
the office, outpatient facility, ambulatory facility, hospital,
and in consultation.
■ Level of service is dependent on evaluation of six of
seven components (in order of importance): History,
examination, medical decision making, counseling,
coordination of care, nature of the presenting problem,
time
• Procedural Codes: Used to report the procedures/
operations that were performed.
■ Surgical codes include preoperative visits, if the decision
for surgery was made at a prior visit; local anesthesia;
immediate postoperative care; writing orders; evaluation
of the patient in the postanesthesia care unit; typical
postoperative follow-up care (as defined by the global
period)
2. Global period: Period following a procedure in which any
associated aftercare, including office visits, is considered to be
“included” in the CPT code billed.
• The global period varies according to operation and is
often based on complexity (e.g., most operations have a
global period of 90 days, whereas skin excisions often have
a global period of 10 days).
3. Many bundled or global CPT codes include most steps or
components of an operation or procedure, such that each
individual step cannot be coded separately. Common
examples relevant to plastic surgery:
• Excision of lesion codes (both benign and malignant)
include simple closure (single layer); however, intermediate
and/or complex closure codes can be listed separately.
• Debridement codes cannot be used with wound closure
codes because they are only used for wounds, which are
allowed to heal secondarily.
■ Debridement codes are reported by the depth of tissue
removed and surface area.
■ If debridement is performed in the operating room
before wound closure, the “surgical preparation of
wound bed” codes should be used.
• Free-flap CPT codes include exposure of recipient vessels,
microvascular anastomosis and use of the surgical
microscope, flap harvest and elevation, and primary
closure of the donor site.
■ If closure of the donor site requires additional
procedures (e.g., split thickness skin graft, adjacent tissue
transfer, etc.), these procedures can be coded as well.
• Adjacent tissue transfer codes include the excision of a skin
lesion, and thus, the excision cannot be separately coded.
• Nerve decompression codes generally include external
neurolysis but do not include internal neurolysis (e.g.,
carpal tunnel release).

Anesthesia, Practice Management, Patient Safety, and Coding
8
McDaniel, W.L., Jarris, R.F., 2011. Chapter 5: Local and topical anesthetic
complications. In: Pfenninger, J.L., Fowler, G.D. (Eds.), Pfenninger and
Fowler’s Procedures for Primary Care, 3rd ed. Elsevier Mosby, pp. 25–27.
Mottura, A.A., 2013. Chapter 9: Local anesthetics in plastic surgery. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, China, pp. 137–149.
Murphy-Lavoie, H., LeGros, T.L., 2013. Chapter 188: Local and regional
anesthesia. In: Adams, J.G. (Ed.), Emergency Medicine, 2nd ed. Saunders,
pp. 1578–1586.
Mustoe, T.A., Buck, D.W., Lalonde, D.H., 2010. The safe management of
anesthesia, sedation, and pain in plastic surgery. Plast. Reconstr. Surg. 126
(4), 165–176.
Pannucci, C.J., Dreszer, G., Wachtman, C.F., et al., 2011. Postoperative
enoxaparin prevents symptomatic venous thromboembolism in high-risk
plastic surgery patients. Plast. Reconstr. Surg. 128 (5), 1093–1103.
Prohibited Employment Policies/Practices. U.S. Equal Employment Opportunity
Commission. Found at: <> Accessed on:
November 30, 2014.
Reisman, N.R., 2013. Chapter 6: Medico-legal issues in plastic surgery. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, China, pp. 92–103.
Sherwood, E.R., Williams, C.G., Prough, D.S., 2012. Chapter 16:
Anesthesiology principles, pain management, and conscious sedation. In:
Townsend, C.M., Beauchamp, R.D., Evers, B.M., et al. (Eds.), Sabiston
Textbook of Surgery, 19th ed. Saunders, pp. 389–417.
Summary of the HIPAA Privacy Rule. United States Department of Health
& Human Services. Found at: <
understanding/summary/privacysummary.pdf.> Accessed on: November 30,
2014.
• 62 modifier identifies procedure that was performed with a
cosurgeon, where each surgeon is performing a separately
documented part of the operation.
Suggested Reading
American Medical Association, 2014. CPT 2015 Standard Codebook, Standard
Ed. American Medical Association, pp. 1–770.
Buck, D.W., Mustoe, T.A., Kim, J.Y.S., 2006. Postoperative nausea and
vomiting in plastic surgery. Semin. Plast. Surg. 20 (4), 249–255.
Haeck, P.C., 2013. Chapter 4: The role of ethics in plastic surgery. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, China, pp. 55–63.
Halperin, B., 2013. Chapter 8: Patient safety in plastic surgery. In: Neligan,
P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, China, pp. 124–136.
Hill, J., Singh, V.M., Sen, S.K., 2013. Chapter 4: Anesthesia for upper
extremity surgery. In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier,
China, pp. 92–105.
Hultman, C.S., 2013. Chapter 5: Business principles for plastic surgeons. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, China, pp. 64–91.
Krizek, T.J., 2010. Chapter 11: Ethics in plastic surgery. In: Weinzweig, J.
(Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby Elsevier, Philadelphia,
pp. 61–71.
Kulaylat, M.N., Dayton, M.T., 2012. Chapter 13: Surgical complications. In:
Townsend, C.M., Beauchamp, R.D., Evers, B.M., et al. (Eds.), Sabiston
Textbook of Surgery, 19th ed. Elsevier Saunders, Philadelphia, pp. 281–327.

SECTION 1: Craniofacial, Head, and Neck
Head and Neck Anatomy
and Facial Palsy
Chapter
2 
1. Facial nerve (cranial nerve VII)
• Facial nerve anatomy
■ Course
○ Brain stem → pontomedullary junction → traverses
internal auditory meatus → geniculate ganglion →
stylomastoid foramen → parotid → muscles of
facial expression
■ Intratemporal branches
○ Chorda tympani: Parasympathetic, taste to anterior
two-thirds of tongue
○ Stapedius nerve: Motor to stapedius muscle
○ Greater petrosal nerve: Parasympathetic
■ Stylomastoid foramen branches
○ Posterior auricular nerve
○ Posterior belly of digastric nerve
○ Stylohyoid nerve
■ Parotid branches
○ Temporal/frontal branch: Found within the
superficial temporal or temporoparietal fascia
○ Zygomatic branch: Overlap with buccal branch; near
parotid duct, superficial to masseter muscle
○ Buccal branch: Overlap with zygomatic branch; near
parotid duct, superficial to masseter muscle
○ Marginal mandibular nerve: Motor to lower lip
depressors and mentalis muscles, located up to 1 cm
below mandibular border, crosses facial vessels.
○ Cervical nerve: Lowest division, motor to platysma
(see Figure 2.1)
• Temporal anatomy
■ Layers from superficial to deep in this region include
(1) skin, (2) subcutaneous tissue, (3) superficial
temporal fascia, also known as the temporoparietal
fascia, (4) superficial layer of the deep temporal
fascia, (5) superficial temporal fat pad, (6) deep
layer of the deep temporal fascia, and (7) temporalis
muscle.
○ When the coronal flap is raised, as soon as the
yellow superficial temporal fat pad is seen beneath
the superficial layer of the deep temporal fascia, the
superficial layer of the deep temporal fascia must be
incised and included with the coronal flap to protect
the frontal branch, which is in the superficial
temporal fascia (temporoparietal fascia), one layer
superficial to this (see Figure 2.2).
2. Facial palsy
• Etiology
■ Most common cause in children is idiopathic (Bell’s
palsy), followed by infectious (and traumatic,
neoplastic, and congenital) etiologies
■ Bell’s palsy: Most common, suddenly acquired,
unilateral facial palsy
○ Associated with diabetes mellitus (DM), pregnancy,
upper respiratory infections; must exclude stroke,
tumor
○ Other symptoms include pain, epiphora, oral
incompetence, hyperacusis, taste impairment.
○ Treatment: Observation; 85% will show
improvement in neurologic function within 3 weeks.
○ No evidence for facial nerve decompression
■ Pontine lesions (tumor, motor neuron disease, Mobius,
infarction)
○ Millard-Gruber and Raymond-Foville syndromes:
Pontine stroke
♦ Facial and abducens palsy, contralateral
hemiplegia
○ Mobius: Most common, bilateral, congenital facial
palsy
♦ Often associated with abducens palsy as well
■ Infranuclear lesions (Guillain-Barré, Bell’s), muscle
diseases (myasthenia gravis, myotonic dystrophy,
facioscapulohumeral dystrophy)
○ Ramsay Hunt syndrome: Herpes zoster virus
involvement of facial nerve leading to extreme ear
pain, with shingles/vesicles along the facial nerve
course, accompanying facial palsy
■ Trauma
○ Location is important
♦ Penetrating injury anterior to a vertical line
drawn down from the lateral canthus often not
explored (ends too difficult to find due to small

Head and Neck Anatomy and Facial Palsy
10
Figure 2.1.  Typical pattern of facial nerve branching. The main branch is divided into two components, each of which then branches in
a random manner to all parts of the face. Extensive distal arborization and interconnections are apparent. (Reprinted with permission from
©Elsevier Inc. All rights reserved.)
Greater petrosal nerve
Facial nerve (VII)
Geniculate ganglion
Internal carotid plexus
(on internal carotid artery)
Lesser petrosal nerve
Nerve (Vidian) of pterygoid canal
Otic ganglion
Pterygopalatine ganglion
Facial muscles
Frontal belly (frontalis)
of occipitofrontalis
Orbicularis oculi
Corrugator supercilii
Zygomaticus major
Zygomaticus minor
Procerus
Levator labii
superioris
Levator labii
superioris
alaeque nasi
Levator
anguli oris
Nasalis
Depressor
septi nasi
Orbicularis
oris
Depressor
anguli oris
Depressor labii
inferioris
Mentalis
(Risorius)
(not shown)
Buccinator
Platysma
Efferent fibers
Afferent fibers
Parasympathetic fibers
Sympathetic fibers
Chorda tympani nerve
Lingual nerve (from trigeminal nerve)
Submandibular ganglion
Submandibular gland
Sublingual gland
Marginal
mandibular
branch
Buccal
branches
Zygomatic
Temporal branches
Cervical branch
Caroticotympanic nerve (from internal carotid plexus)
Digastric muscle (posterior belly)
Glossopharyngeal nerve (lX)
Tympanic nerve (of Jacobson)
(from glossopharyngeal nerve)
Tympanic plexus
Stylohyoid muscle
Stylomastoid foramen
Nerve to stapedius muscle
Posterior auricular nerve
Branches to auricular muscles
Occipital
belly
(occipitalis) of
occipitofrontalis
muscle
Internal acoustic meatus
Intermediate nerve
Motor nucleus of facial nerve
Superior salivatory nucleus
Solitary tract nucleus
Occipital
branch of
posterior
auricular
nerve
Deep petrosal nerve (from internal carotid plexus)
branches
Ta
ste
: A
nt
er
io
r

tw
o-t
hir
ds
o
f t
on
gu
e

Head and Neck Anatomy and Facial Palsy
11
2
Figure 2.2.  Facial layers of the temporal region. The fat/fascia in
the subaponeurotic plane (red arrow; between the temporal fascia
and deep temporal fascia) is intimately related to the facial nerve.
Some investigators believe that there is a separate fascial layer in
this space, referred to as the parotidomasseteric fascia. (Reprinted
from Neligan, P.C., 2013. Plastic Surgery, 3rd ed. pp. 3–22.)
Deep temporal fascia
Zygomatic
arch
Coronoid process
of mandible
Masseter
Temporalis
Middle temporal fat pad
Sentinel vein
Temporal bone
Hair
Skin
Ear
SMAS
Facial nerve
Parotid-masseter
fascia
Frontal branch
of facial nerve
Subcutaneous fat
Superficial
temporal
fascia
diameter); in addition, with buccal branch injury,
extensive overlap may allow reinnervation.
➔ Some would argue that even these anterior
injuries should be explored operatively, even if
repair is unlikely.
○ Major buccal branch of facial nerve travels with
parotid duct; suspect injuries to duct for any
lacerations that violate a line from tragus to upper
lip or when upper lip dysfunction is noted.
♦ For parotid duct injuries: Cannulate Stensen duct
intraorally, inject saline or methylene blue to
diagnose duct injury, and repair over stent or
feeding tube if disrupted.
○ Distal nerve end can be stimulated up to 72 hours
after injury, after which time it undergoes Wallerian
degeneration (important implications for direct
repair)
■ Tumors
3. Facial nerve repair/reconstruction
• Primary direct repair
■ Gives best results when end-to-end coaptation can be
performed without significant tension (otherwise, nerve
graft is advised).
■ Performed in a clean wound, ideally within 72 hours of
injury because during this time, the distal nerve end
can still be stimulated to ensure proper target
identification.
• Nerve grafting
■ Success depends on relative number of axons, potential
for regeneration through the graft, and status of facial
muscles (motor end plate loss occurs from 12 to 24
months postinjury).
■ Common donor nerves for facial palsy include great
auricular, branches of cervical plexus, and sural.
• Nerve transfer
■ Useful when distal stumps are present and facial
musculature motor end plates are still intact.
■ Cranial nerve donors include trigeminal and
hypoglossal.
■ Ipsilateral motor nerve to masseter also now used.
■ Cross-face nerve grafting is most favorable option in
terms of restoring spontaneous facial movement.
○ Note that temporal and marginal mandibular
branches have less overlap with other branches in
terms of function, so degree of donor morbidity
may be higher for cross-face nerve grafting.
○ Often better to graft from larger branch over to
affected side and leave smaller branch behind on
normal side, such that function is slightly weakened
on the normal side; will give better symmetry.
○ Cross-face nerve grafts are passed through the upper
buccal sulcus region to the opposite side and
coapted to the distal stumps on the affected side.
• Free neurotized muscle transfer (e.g., for reanimation)
■ More likely to get spontaneous smile development
compared to that with regional muscle transfer (e.g.,
temporalis transfer, where biting motion must initiate
the smile); regional muscles also have suboptimal
vector of pull.
■ Use of gracilis popularized by Zuker and Manktelow
○ Can be harvested in segmental fashion (1/2 to 1/3 of
muscle) to reduce bulk in face; harvested with
obturator nerve.
■ Inset to deep temporal fascia and oral commissure
(modiolus) with appropriate tensioning; vector
parallels course of zygomaticus major m (see Table 2.1).
■ Cross-face nerve grafting can be used to innervate
versus ipsilateral motor nerve to masseter.
○ Cross-face nerve graft is not as powerful but allows
total spontaneity of smile.
♦ Must wait for Tinel’s sign with cross-face nerve
graft (or nerve biopsy) to establish that axons
have reached the distal end before free muscle
transfer.

Head and Neck Anatomy and Facial Palsy
12
○ Cross-face nerve graft with free gracilis is a
two-stage procedure, whereas coaptation
to ipsilateral masseteric nerve is done
in one stage.
• Brow asymmetry
■ For recent occurrence of facial paralysis in which extent
of recovery is unclear, asymmetry can be addressed
with botulinum toxin injection into the unaffected side
to weaken it.
■ Once it is clear that recovery is unlikely and
denervation probable, can consider static procedures
to correct asymmetry (e.g., forehead lift, brow lift,
blepharoplasty, canthoplasty).
• Facial dyskinesis
■ Hyperkinesis after facial reanimation surgery can be
addressed with injection of botulinum toxin into facial
muscles that are most hyperkinetic.
■ Synkinesis may also be addressed with injection of
botulinum toxin (e.g., eyelid closure with chewing in
patient who has recovered from Bell’s palsy) (see
Box 2.1)
4. Trigeminal nerve (cranial nerve V)
• Trigeminal nerve anatomy
■ The ophthalmic division of the trigeminal nerve (V1)
○ Sensation to the forehead and anterior scalp
○ Exits the skull through the supraorbital foramen.
♦ Three sensory branches: Lacrimal, frontal, and
nasociliary nerves
♦ Nasociliary nerve courses above the optic nerve
and below the superior rectus muscle.
➔ First branch is the posterior ethmoidal nerve,
which provides sensation to the posterior
ethmoid sinuses.
➔ The terminal branches are the anterior
ethmoidal nerve and the infratrochlear nerves,
which supply the septum and lateral walls.
➔ The dorsal nasal nerve, which supplies
innervation to the tip
■ The maxillary division of the trigeminal nerve (V2)
○ Sensation to the cheek and upper lip and
to the upper teeth via the superior alveolar
nerve
○ Transmitted through the infraorbital foramen
Reprinted from Zuker, R.M., Gur, E., Hussain, G., et al., 2013. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, China.
BOX 2.1  MOST COMMON SURGICAL OPTIONS FOR
EACH REGION OF THE FACE
Brow (Brow Ptosis)
Direct brow lift (direct excision)
Coronal brow lift with static suspension
Endoscopic brow lift
Upper Eyelid (Lagophthalmos)
Gold weight
Temporalis transfer
Spring
Tarsorrhaphy
Lower Eyelid (Ectropion)
Tendon sling
Lateral canthoplasty
Horizontal lid shortening
Temporalis transfer
Cartilage graft
Nasal Airway
Static sling
Alar base elevation
Septoplasty
Commissure and Upper Lip
Nerve transfer either directly or via nerve graft to
reinnervate recently paralyzed muscles
Microneurovascular muscle transplantation with the use
of ipsilateral seventh nerve, cross-facial nerve graft, or
other cranial nerve for motor innervation
Temporalis transposition with or without masseter
transposition
Static slings
Soft-tissue balancing procedures (rhytidectomy, mucosal
excision, or advancement)
Lower Lip
Depressor labii inferioris resection (on normal side)
Muscle transfer (digastric, platysma)
Wedge excision
■ Mandibular division (V3): Inferior alveolar, buccal,
mandibular nerves
○ Inferior alveolar nerve
♦ Enters the mandible on the medial side of the
ramus ~10 mm below the sigmoid notch.
♦ Courses through the canal closest to the buccal
cortical plate in the region of the ramus, angle,
and down to the third molar with an average
distance of 1.8 mm ± 1 mm.
♦ The nerve then swerves away at a position of
4.1 mm + 1 mm from the buccal cortex as it
passes the region of the first and second molars.
♦ As it traverses the mandibular body, it is lowest
and closest to the inferior cortex (7.5 mm +
1.5 mm) near its exit site at the level of the first
molar and second premolar via the mental
foramen on the anterior surface of the mandible.
♦ The mental nerve supplies the skin of the lower
lip and chin, right up to the midline.
Table 2.1  Dimensions of the Levators of the Upper Lip
MUSCLE
LENGTH
(MM)
WIDTH
(MM)
THICKNESS
(MM)
Zygomaticus major
70
8
2
Levator labii superioris
34
25
1.8
Levator anguli oris
38
14
1.7
Reprinted from Freilinger, G., Gruber, H., Happak, W., et al., 1987.
Surgical anatomy of the mimic muscle system and the facial nerve:
Importance for reconstructive and aesthetic surgery. Plast. Reconstr.
Surg. 80, 686.

Head and Neck Anatomy and Facial Palsy
13
2
• Sensory innervation of the forehead
■ Supraorbital nerve (SON): Superficial division—
paramedian forehead and anterior scalp; deep
division—frontoparietal scalp
○ The deep division travels initially along the temporal
periosteum and then more cephalad pierces the
deep galea plane and enters the galea fat pat. This
information is key to avoiding injury when
performing a forehead lift.
○ Superficial branch travels superficial to frontalis.
■ Supratrochlear nerve: Medial skin of the forehead.
The supratrochlear nerve also runs superficial to the
frontalis muscle.
• Innervation to tongue
■ Sensory
○ Anterior two-thirds: Lingual nerve (branch of
CN V3)
○ Posterior third: Glossopharyngeal (CN IX)
■ Motor
○ Hypoglossa nerve: If injured, results in ipsilateral
tongue paralysis
■ Sense of taste
○ Anterior 2/3rds: Chorda tympany from CN VII (join
linguinal nerve)
○ CN V (lingual): Sensations of salt, bitter, sweet, and
sour
♦ A 7-9% decrease in taste of these sensations after
septoplasty/rhinoplasty
○ Post 1/3rd: Glossopharyngeal (CN IX)
5. Essential sensory innervation of head and neck structures
(see Figures 2.3 and 2.4)
• Sensory innervation of the ear
■ Great auricular nerve: Sensory to earlobe and lower
half of ear
■ Auricular branch of vagus nerve (Arnold’s nerve): Concha
■ Auriculotemporal nerve: Anterior and superior helix/
external auditory canal
■ Lesser occipital nerve: Posterior superior ear
• Sensory innervation of the nose
■ See above
• Sensory innervation of the lips
■ Infraorbital nerve
○ The maxillary canine may be used as a landmark for
needle insertion toward the infraorbital foramen
during infiltration of the infraorbital nerve.
○ Bilateral blockade of the infraorbital nerve in the
midline provides complete anesthesia to all central
components of the upper lip, including the
vermillion, Cupid’s bow, and philtrum.
■ Mental nerve
○ Bilateral mental nerve blocks effectively anesthetize
the central section of the lower lip.
■ Buccal nerve: Branch of cranial nerve (CN) V3; supplies
sensory to the commissure
○ For lacerations near the commissure, you must
inject anesthetic locally
• Sensory innervation of the cheek
■ Buccal nerve: Central cheek
■ Landmark: Retromolar fossa, posterior to the
mandibular third molar
Figure 2.3.  Sensory supply of the face. (Reprinted from Neligan, P.C., 2013. Plastic Surgery, 3rd ed. pp. 3–22.)
A1
A1 - external nasal
B1
B1 - infraorbital
C1
C1 - mental
A3
A3 - supratrochlear
B3
B3 - zygomaticotemporal
C3
C3 - auriculotemporal
A2
A2 - infratrochlear
B2
B2 - zygomaticofacial
C2
C2 - buccal
GAN
GON - greater occipital nerve
LON
LON - lesser occipital nerve
GON
GAN - great auricular nerve
A4
A4 - supraorbital

Head and Neck Anatomy and Facial Palsy
14
Figure 2.4.  A-C, Sensory nerves of the face. (Reprinted with permission from ©Elsevier Inc. All rights reserved.) n, nerve.
1
2
3
4
5
7
8
6
1. Trigeminal n.
2. Trigeminal ganglion
3. Ophthalmic division
4. Lacrimal n.
5. Supraorbital n.
6. Supratrochlear n.
7. Infratrochlear n.
8. External nasal n.
A
1
4
5
3
2
1. Maxillary division of the trigeminal n.
2. Zygomatic n.
3. Infraorbital n.
4. Zygomaticofacial n.
5. Zygomaticotemporal n.
B
1
2
3
4
1. Mental n.
2. Buccal n.
3. Mandibular division of the trigeminal n.
4. Auriculotemporal n.
C
6. Essential anatomical foramen/structures
• Foramen
■ Foramen lacerum: Internal carotid artery
■ Foramen ovale: Mandibular division trigeminal
nerve (V3)
■ Foramen rotundum: Maxillary division trigeminal
nerve (V2)
■ Stylomastoid foramen: Facial nerve
■ Jugular foramen: Glossopharyngeal nerve (CN IX),
vagus (CN X), spinal accessory (CN XI) (see Figures 2.5
and 2.6)
• Stensen duct
■ The maxillary second molar is a landmark typically
used to locate the opening of the Stensen duct.
■ The parotid (Stensen) duct opens into the mouth at the
level of the upper second molar. It is ~4 to 7 cm long,

Head and Neck Anatomy and Facial Palsy
15
2
extends from the anterior border of the superficial lobe
of the parotid gland, and is frequently accompanied by
accessory parotid tissue. The duct runs anteriorly over
the masseter muscle about halfway between the
zygomatic arch and the angle of the mouth. It turns
medially beyond the anterior border of the masseter
muscle, pierces the buccinator muscle, and opens into
the mouth through the parotid papilla at about the
level of the upper second molar.
○ Zygomatic and buccal branches of the facial (VII)
nerve may cross superficially over the parotid duct.
■ Location of the parotid duct has implications for
placement of surgical incisions.
○ Vertical incisions at the anterior border of the
parotid gland may cause injury to the parotid duct
or to branches of the facial (VII) nerve. Horizontal
incisions are less likely to damage these structures.
♦ Because of the parotid septae, parotid abscesses
tend to be compartmentalized and may not be
fluctant.
♦ Pitting edema over the parotid gland usually
indicates an abscess.
♦ Abscesses may need to be drained via multiple
horizontal incisions.
• The buccinator muscle is the only muscle of facial
expression that compresses the cheeks, an essential
function for playing air-based instruments such as the
trumpet.
■ Ordinarily contributes to the function of forming a
food bolus during mastication.
Figure 2.5.  Anterior aspects of the skull showing foramina and
their contents. (Reprinted from Craven, J., 2014. Anatomy of the skull
learning objectives. Anaesth. Intensive Care Med. 15 (4), 146–148.)
Frontal bone
Supraorbital
foramen
(supraorbital N
from ophthalmic
division of fifth
cranial N)
Superior
orbital fissure
(third, fourth,
and sixth
cranial Ns;
nasociliary,
lacrimal,
and frontal
branches of
fifth cranial N;
orbital
branch of
middle
meningeal A;
ophthalmic veins,
sympathetic
fibers)
Inferior orbital
fissure (maxillary
and zygomatic
Ns, infraorbital
vessels)
Infraorbital
foramen (infraorbital N
from maxillary branch
of fifth cranial N)
N, nerve; A, artery
Mental foramen
(mental N from mandibular
branch of fifth cranial N)
Nasal septum
Mandible
Maxilla
Inferior concha
Middle concha
Optic canal
(second cranial
N, ophthalmic A)
Greater wing
of sphenoid
Parietal
bone
Frontozygomatic
suture
Figure 2.6.  Inferior aspect of the skull showing foramina and their contents. (Reprinted from Craven, J., 2014. Anatomy of the skull learning
objectives. Anaesth. Intensive Care Med. 15 (4), 146–148.)
Incisive canal (nasopalatine N and greater palatine A)
Vomer
Greater palatine foramen
(greater palatine N and vessels)
Maxillary tuberosity
Posterior nasal choanae
Foramen ovale (mandibular division
of fifth cranial N)
Mandibular fossa
Styloid process
External acoustic meatus
Stylomastoid foramen (seventh cranial N)
Hypoglossal canal (12th cranial N)
Inferior nuchal line
Superior nuchal line
External occipital protuberance
N, nerve; A, artery
Maxilla
Palate
Hamulus of the medial pterygoid plate
Lateral pterygoid plate
Foramen lacerum (filled with cartilage only)
Foramen spinosum (middle meningeal A)
Carotid canal (internal carotid A,
sympathetic fibers.)
Jugular foramen (internal jugular vein;
ninth, 10th, 11th cranial Ns)
Condyle
Mastoid process
Foramen magnum (spinal cord,ascending
part of eleventh cranial N, spinal and
vertebral As, branches of spinal Ns C1-C3)

Head and Neck Anatomy and Facial Palsy
16
■ Dissection superficial to the SMAS layer is safe because
the muscles of facial animation are innervated from
below, except for the buccinator, mentalis, and levator
anguli oris muscles, which are innervated via their
superficial surfaces.
○ The depressor anguli oris, orbicularis oculi,
orbicularis oris, and zygomaticus major are all
innervated from their deep surfaces.
■ When dissecting below the SMAS plane, the
zygomaticus major muscle serves as an important
landmark. In this plane, dissection should proceed
more superficially to preserve innervation of the
zygomaticus major muscle.
8. Orbital anatomy
• Seven bones make up the orbit: Frontal bone, maxilla,
zygoma, ethmoid, lacrimal, greater and lesser wings of the
sphenoid, and palatine
■ The frontal, maxilla, zygoma, and ethmoid bones
constitute the strong outer rim of the orbit and protect
the more delicate bones in the interior orbit.
■ The lesser wing of the sphenoid forms the posterior
aspect of the roof of the orbit and transmits the
optic nerve and ophthalmic artery through the
optic canal.
■ The greater wing of the sphenoid contains the superior
orbital fissure, which transmits the lacrimal nerve,
frontal nerve, trochlear nerve, superior and inferior
branches of the oculomotor nerve, the nasociliary
nerve, and the abducens nerve (see Figure 2.7).
9. Tooth eruption
• First molar is the first permanent tooth to erupt; this
typically occurs between ages 6 and 7 years.
■ Age of mixed dentition, in which both deciduous
(primary) and permanent (secondary) teeth erupt in
the oral cavity simultaneously, begins with eruption of
the first molars.
• Central incisors erupt between ages 6 and 8 years, lateral
incisors between ages 7 and 9, canine teeth between ages 9
and 12, and first premolars between ages 10 and 12.
■ Both the buccinator and the orbicularis oris compress
the lips, also necessary for playing trumpets.
• The levator labii superioris, risorius, and zygomaticus
major muscles all have a function that contributes to
separating the lips, which releases pressure from inside
the mouth.
■ These muscles arise from bone and fascia and attach to
the lips.
• Only two muscles would be in the area of a high
bifurcation of the carotid that may need to be cut for
better exposure during microsurgical cases: Posterior belly
of the digastric and the stylohyoid, which span across the
skull base to the hyoid.
• The supraorbital and supratrochlear arteries are branches
of the internal carotid artery via the ophthalmic artery,
and therefore, receive their blood supply from the
internal carotid.
• The branches of the external carotid artery, from
proximal to distal, are as follows:
■ Superior thyroid
■ Ascending pharyngeal
■ Lingual, occipital, facial
■ Posterior auricular
■ Maxillary arteries
• The arteries of the scalp travel through the subcutaneous
fat from the periphery toward the vertex, then
anastomose in the midline with branches of the
ophthalmic artery. They are branches of the external
carotid directly (occipital, posterior auricular) or from the
superficial temporal.
7. Layers of the face: The skin, subcutaneous tissue, superficial
muscular aponeurotic system (SMAS), fascia, and facial
(VII) nerve
• Dissection within the subcutaneous plane is safe because
this plane does not contain the facial (VII) nerve.
• The SMAS is a heterogenous structure, consisting of facial
muscles and fibrous and adipose tissue.
■ Cephalad: The SMAS continues as the temporoparietal
fascia.
Coronal
Frontal
Sphenoid
Lacrimal
Maxilla
Zygoma
Roof
Medial wall
Lateral wall
Floor
Ethmoid
Figure 2.7.  Surgical anatomy of the orbits. (Reprinted from
Guyuron, B., Eriksson, E., Persing, J.A., et al. [Eds.], 2009. Plastic
Surgery: Indications and Practice, Elsevier, pp. 619–644.)

Head and Neck Anatomy and Facial Palsy
17
2
10. Commonly tested congenital disorders
• Choanal atresia
■ Cyanosis that is relieved by crying (paradoxical
cyanosis): Classic symptoms
○ Inability to pass catheter through the nose to
nasopharynx. Computed tomography (CT) scan
shows narrow posterior nasal cavity secondary
to medial displacement of lateral nasal wall and
pterygoid plates
• Thyroglossal duct cyst
■ May form anywhere along the thyroglossal duct, which
extends from the foramen cecum of the tongue to the
final position of the thyroid gland in the neck, below
the laryngeal cartilage.
■ Normally, the thyroglossal duct atrophies and
disappears.
○ However, a remnant of it may persist and form a
cyst in the tongue or anterior midline of the neck,
most commonly inferior to the hyoid bone.
■ Often asymptomatic unless it becomes infected
• Reactive lymph nodes
■ Most common neck mass in children.
■ Usually found laterally in the submandibular and
jugulodigastric areas
• Branchial cleft remnants (sinuses and cysts)
■ Arise from a remnant cleft between the 2nd and 3rd
branchial arches. They are located laterally, along the
anterior border of the sternocleidomastoid muscle,
usually just inferior to the angle of the mandible.
■ Can be bilateral in 30% of cases.
■ Histo: Lined with squamous epithelium, contains
keratin, hair follicles, sweat glands, and sebaceous
glands.
■ Must be completely excised to prevent recurrence.
• Lingual thyroid glands
■ A type of ectopic thyroid located within the tongue,
along the course of the thyroglossal duct, resulting
from failure of thyroid to descend.
■ Unlike thyroglossal duct cysts, they represent the only
thyroid tissue present in the patient.
• Ranula
■ A mucocele or mucous extravasation phenomenon in
the floor of the mouth, arising from the ducts of the
sublingual or submandibular glands, often as a sequela
of obstruction of the sublingual gland
■ Usually presents as a unilateral swelling of the floor of
the mouth that is fluctuant and tinted blue or glossy
white
■ Treatment includes marsupialization or surgical
excision including the sublingual gland.
■ The ranula may herniate through the muscles of the
floor of the mouth and present as a cervical mass.
• Failed closure of the fonticulus frontalis, an embryonic
fontanel between the inferior frontal bone and nasal
bone, may result in three main types of midline anterior
anomalies: Nasal dermal sinus, anterior cephalocele, and
nasal glioma.
■ Although closure may be affected by various factors
such as gender and race, the anterior fontanel closes by
24 months of age in 96% of children.
■ Nasal gliomas: Thought to originate as encephaloceles
but fail to maintain their intracranial connections
○ May be external, internal, or a combination of both
○ External gliomas typically appear at or just lateral to
the nasal root.
♦ They are reddish, firm, noncompressible, lobular
lesions that exhibit telangiectasias of the overlying
skin but do not transilluminate or pulsate.
♦ Bony defects, intracranial connections, and
cerebrospinal fluid leakage occur only rarely.
♦ Histologic evaluation shows astrocytic neuroglial
cells and fibrous and vascular connective tissue
that is covered with skin or nasal mucosa.
■ Nasal dermoid cyst arises from a dermoid sinus, the
cutaneous inward passage lined with stratified
squamous epithelium.
○ May also be external or internal
○ External nasal dermoid: Firm, noncompressible,
nonpulsatile lesion that does not transilluminate
and may be lobulated
○ Although bony defects are infrequent, cerebrospinal
fluid leakage and meningitis may occur.
○ Derived from ectoderm and mesoderm and thus
contains adnexal structures including hair follicles,
pilosebaceous glands, and smooth muscles.
■ Encephaloceles involve herniation of cranial tissue
through a skull defect.
○ Classified as meningoceles (containing meninges
only), meningoencephaloceles (containing meninges
and brain), or meningoencephalocystoceles
(containing meninges, brain, and part of the
ventricular system)
○ External, or sincipital, encephaloceles are soft,
bluish, compressible, pulsatile masses located at the
nasal root and transilluminate.
♦ They typically enlarge with crying and Valsalva
maneuver.
Suggested Readings
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palsy: A protocol for differential diagnosis. Am. J. Otol. (Suppl.), 68–73.
Afifi, A.M., Djohan, R., 2013. Chapter 1: Anatomy of the head and neck. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 3–22.
Berkovitz, B.K.B., Moxham, B.J., 2002. The face. In: Berkovitz, B.K.B.,
Moxham, B.J. (Eds.), Head and Neck Anatomy: A clinical reference. Informa
Healthcare, London, pp. 108–113.
Burggasser, G., Happak, W., Gruber, H., et al., 2002. The temporalis: Blood
supply and innervation. Plast. Reconstr. Surg. 109, 1862–1869.
Clemente, C.D., 1997. Neck and head. In: Clemente, C.D. (Ed.), Anatomy: A
Regional Atlas of the Human Body, 4th ed. Williams & Wilkins, Baltimore,
pp. 435–576.
Coker, N.J., Vrabec, J.T., 2001. Acute paralysis of the facial nerve. In: Bailey,
B.J. (Ed.), Head and Neck Surgery/Otolaryngology, 3rd ed. Lippincott
Williams & Wilkins, Philadelphia, pp. 1843–1858.

Head and Neck Anatomy and Facial Palsy
18
Moore, K.L., Persaud, T.V.N., 2008. The Developing Human: Clinically
Oriented Embryology, 8th ed. WB Saunders, Philadelphia, pp. 159–196.
Netter, F., 1989. Head and neck. In: Netter, F.H. (Ed.), Atlas of Human
Anatomy, Ciba-Geigy Corporation, Tarrytown, New York, p. 56.
Roth, J.J., Granick, M.S., Solomon, M.P., 1997. Pediatric neck masses. In:
Bentz, M. (Ed.), Pediatric Plastic Surgery, Appleton & Lange, Stamford,
pp. 494–498.
Snell, R.S., 2006. Skeletal muscles. In: Snell, R.S. (Ed.), Clinical Anatomy by
Systems, Lippincott Williams & Wilkins, Philadelphia, pp. 441–445.
Snell, R.S., 2006. The upper and lower airway and associated structures. In:
Snell, R.S. (Ed.), Clinical Anatomy by Systems, Lippincott Williams & Wilkins,
Philadelphia, pp. 55–56.
Wexler, A., 1997. Anatomy of the head and neck. In: Ferraro, J.W. (Ed.),
Fundamentals of Maxillofacial Surgery, Springer-Verlag, New York,
pp. 53–114.
Ziccardi, V.B., Zuniga, J.R., 2005. Traumatic injuries of the trigeminal nerve.
In: Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.), Oral and Maxillofacial
Trauma, 3rd ed. Elsevier Saunders, Philadelphia, pp. 877–914.
Zide, B.M., Swift, R., 1998. How to block and tackle the face. Plast. Reconstr.
Surg. 101, 840–851.
Zuker, R.M., Gur, E., Hussain, G., et al., 2013. Chapter 11: Facial paralysis.
In: Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 278–306.
Goldenberg, D.V., Alonso, N., Ferreira, M.C., 2009. Chapter 48: Facial
trauma. In: Guyuron, B., Eriksson, E., Persing, J.A., et al. (Eds.), Plastic
Surgery: Indications and Practice, Elsevier, pp. 619–644.
Hedlund, G., 2006. Congenital frontonasal masses: Developmental anatomy,
malformations, and MR imaging. Pediatr. Radiol. 36, 647–662 quiz 726–727.
Janfaza, P., Cheney, M.L., 2001. Superficial structures of the face, head, and
parotid region. In: Janfaza, P., Nadol, J.B., Galla, R., et al. (Eds.), Surgical
Anatomy of the Head and Neck, Lippincott Williams & Wilkins, Philadelphia,
pp. 2–48.
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Galla, R.J., (Eds.), Surgical Anatomy of the Head and Neck, Lippincott
Williams & Wilkins, Philadelphia, pp. 149–222.
Kendell, B.D., Frost, D.E., 2005. Applied surgical anatomy of the head and
neck. In: Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.), Oral and
Maxillofacial Trauma, 3rd ed. Elsevier Saunders, St. Louis, pp. 281–328.
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96, 564–569.
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Anatomy, vol. 2. Williams & Wilkins, Baltimore, p. 935.
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Williams & Wilkins, Philadelphia, pp. 1082–1096.

Head and Neck Cancer,
Odontogenic Tumors, and
Vascular Anomalies
Chapter
3 
Salivary Gland Tumors
1. Salivary glands include the parotid, submandibular, and
sublingual glands.
2. The majority (80%) of salivary gland tumors occur in the
parotid gland and are benign pleomorphic adenomas (80%).
Tumors that arise in the submandibular and/or sublingual
glands are more likely to be malignant (see Table 3.1).
• Hemangioma
■ Most common parotid mass in children
■ Characterized by typical growth pattern of
hemangiomas: Rapid growth after birth, followed by
involution
■ Treatment: Oral prednisone for enlarging lesions
○ If lesion regresses with prednisone, treatment
continues
○ If lesion continues to grow despite treatment, surgical
excision may be indicated.
5. Malignant salivary gland tumors
• Mucoepidermoid carcinoma
■ Most common malignant salivary gland tumor
■ Characterized by slow-growing, firm mass that can cause
facial nerve dysfunction
■ Treatment is based on tumor grade (low vs. high)
○ Low-grade tumors can be treated with superficial
parotidectomy +/− radiation therapy, depending on
surgical margins.
○ High-grade tumors are more aggressive and have
a higher rate of lymph node and facial nerve
involvement. These tumors require total
parotidectomy, resection of involved nerve
branches, neck dissection, and adjuvant radiation
therapy.
• Adenoid cystic carcinoma
■ 2nd most common malignant tumor of the parotid
gland; most common malignancy of the submandibular
and sublingual glands
■ Characterized by a painful, firm, fixed lesion with an
affinity for nerve invasion resulting in facial nerve and/
or trigeminal nerve dysfunction
■ Treatment: Total parotidectomy and resection of all
involved nerves in the path of the tumor
• Acinic cell carcinoma
■ Characterized by solid or cystic multifocal masses in the
parotid gland
■ Can be bilateral in ~3% of patients
■ Treatment: Total parotidectomy, resection of the facial
nerve, and repair with nerve grafts, neck dissection
Table 3.1  Tumors of the Salivary Glands
BENIGN (%)
MALIGNANT (%)
Parotid
80
20
Submaxillary
60
40
Sublingual
40
60
Minor salivary glands
20
80
Reprinted from Neligan, P.C., Rodrigueze, E.D. (Eds.), 2013. Plastic
Surgery, vol. 3, 3rd ed. Elsevier, China, 360–379.
3. Diagnosis of neck masses often includes fine-needle aspiration
and imaging (ultrasound, computed tomography [CT], and/
or magnetic resonance imaging [MRI])
4. Benign salivary gland tumors
• Pleomorphic adenoma (“benign mixed tumor”)
■ Most common tumor of the salivary glands
(parotid)
■ Characterized by a painless, firm mass that does not
cause facial nerve dysfunction.
■ Treatment: Superficial parotidectomy with protection of
the facial nerve
• Papillary cystadenoma lymphomatosum (“Warthin’s
tumor”)
■ 2nd most common tumor of the parotid glands
■ Male predilection, between 50 and 60 years old
■ Characterized by a smooth, painless mass that can be
bilateral in ~10% of patients.
■ Treatment: Surgical excision with narrow margins

Head and Neck Cancer, Odontogenic Tumors, and Vascular Anomalies
20
• Adenocarcinoma
■ Characterized by slow-growing, firm, fixed masses
■ Often involve the facial nerve, with metastases to cervical
nodes or systemically
■ Treatment: Total parotidectomy, resection of the facial
nerve, cervical node dissection, and adjuvant radiation
6. Frey’s syndrome
• Gustatory sweating that can occur after parotidectomy,
secondary to interconnection of the parasympathetic nerve
fibers from the parotid gland and the sympathetic nerve
fibers of the sweat glands in the overlying skin
• Diagnosis: Clinical history, starch-iodine test
• Treatment options
■ Reelevation of the cheek flap with insertion of fascia or
acellular dermal matrix to separate the nerve endings
■ Botox chemodenervation
Figure 3.1.  Drainage pattern of head and neck lymph nodes. (Reprinted from Neligan, P.C., Rodrigueze, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed.
Elsevier, China, 420–439).
Sternocleidomastoid
Level IA
• Floor of mouth, anterior oral tongue, anterior
mandibular alveolar ridge, lower lip
Level IIA & IIB
• Oral cavity, nasal cavity, nasopharynx, oropharynx,
hypopharynx, larynx, parotid gland
(Greater risk of metastases from oral and larynx
tumors to level IIA. Greater risk of metastases from
oropharynx tumors to level IB)
Level III
• Oral cavity, nasopharynx, oropharynx,
hypopharynx, larynx
Level IV
• Hypopharynx, thyroid, cervical esophagus,
larynx
Level VA & VB
• Nasopharynx, oropharynx, posterior scalp/neck skin
Level VI
• Thyroid gland and subglottic larynx, apex
of piriform sinus, cervical esophagus
Level IB
• Oral cavity, anterior nasal cavity, soft
tissue of midface, submandibular gland
Spinal accessory
nerve
Hyoid
Larynx
Trachea
Oral Cavity and Pharyngeal Cancer
1. Cancer of the oral cavity and pharynx in the United States is
commonly caused by chronic substance abuse, including
tobacco and alcohol, and in South Asia by tobacco and betel
nut use. In addition, these cancers are secondary to viral
infections (e.g., Epstein-Barr virus, human papilloma virus).
• There is also an association with some occupational
exposure, including nickel and radium.
2. Most cancers of the oral cavity and pharynx present as
squamous cell carcinoma (SCC), with advanced disease,
including nodal metastases (see Figure 3.1).

Oral Cavity and Pharyngeal Cancer
21
3
■ Stable bony hardware may be left in place and mobile
hardware must be removed.
• Suture dehiscence and salivary fistula
• Osteoradionecrosis
■ Devitalization and necrosis of bone secondary to
radiation therapy
■ Mandible is most commonly affected.
■ Risk factors: Infection, higher levels of radiation, trauma,
dental caries
■ Treatment: Hyperbaric oxygen and limited
sequestrectomy may be an option for early-stage disease,
with radical debridement and free vascularized bone
graft (e.g., free fibula flap) for advanced disease.
6. Lip Cancer
• Greater than 90% of cases are SCC.
• Most common site of head and neck cancer, excluding skin
malignancies
• Characterized by an ulcerated or exophytic lesion
(especially of the lower lip)
• Lesions >2 cm should have a CT scan to evaluate for
cervical nodal metastases.
■ Commonly metastasize to level-I nodes (submandibular
or submental area)
• Treatment: Surgical excision is the primary management.
Radiation therapy is limited to patients who cannot
tolerate surgery.
• Reconstructive options depend on defect location and size.
The primary goal is oral competence. Layered closure of
the defect, including the orbicularis oris, is critical (see
Figures 3.2 and 3.3).
4. Treatment often depends on stage. In general,
• For stage-I or -II disease (no nodal metastases), complete
surgical resection +/− neck dissection versus radiation
therapy to the primary site
■ Radiation therapy is frequently used for stage-I or -II
lesions of the larynx, hypopharynx, and nasopharynx.
■ Surgery is frequently recommended for lesions of the
oropharynx, oral cavity, and paranasal sinuses (e.g.,
maxillary sinus).
• For stage-III or -IV disease, complete surgical resection,
neck dissection, adjuvant radiation therapy
5. Complications of head and neck cancer resection and
reconstruction
• Recurrence
• Wound Infection
■ Treated with antibiotics, debridement of nonviable
tissue, and local wound care
Figure 3.2.  Algorithmic approach to lip reconstruction. (Reprinted
from Neligan, P.C., Rodrigueze, E.D. [Eds.], 2013. Plastic Surgery, vol. 3, 3rd ed.
Elsevier, China, 254–277.)
Lip reconstruction
No
defect
Direct repair
Small
defect
Total lip
defect
Upper lip <25%
Lower lip <30%
Free tissue
transfer
Local flap
e.g., lip switch
Karapandzic
Intermediate
defect
3. Staging of lip, oral cavity, and pharyngeal cancer follows the
tumor/node/metastasis (TNM) classification (see Table 3.2).
Table 3.2  TNM Clinical Staging System for Lip
and Oral Cavity
Tx
Primary tumor cannot
be assessed
Nx
Nodes cannot be assessed
T0
No evidence of
primary tumor
N0
No evidence of nodal
metastasis
Tis
Carcinoma in situ
T1
≤2 cm in greatest
dimension
N1
Single ipsilateral node <3 cm
T2
2-4 cm
N2a
Single ipsilateral node
3-6 cm
N2b
Multiple ipsilateral nodes
3-6 cm
N2c
Bilateral or contralateral
nodes <6 cm
N3
Any lymph node >6 cm
T3
>4 cm
T4a
Lip: Invasion of
mandible, skin, floor
of mouth, nerve
OC: Invasion of
mandible, extrinsic
tongue, maxilla, skin
T4b
Invasion of masticator
space, skull base, or
carotid sheath
Stage
0
TisN0M0
IVA T4aN012M0
I
T1N0M0
T123N2M0
II
T2N0M0
IVB T4B any NM0
III
T3N0M0
T1-4A N3
T123N1M0
IVC any T any NM1
Modified from Patel, S.G., Shah, J.P., 2005. TNM staging of cancers
of the head and neck: Striving for uniformity among diversity. CA
Cancer J. Clin. 55, 242–258.
OC, Occult; TNM, tumor, node, metastasis.
■ In general, primary closure can be performed for lesions
<1/3rd of the lower lip and <1/4th of the upper lip.
■ Lesions involving commissure typically require an
Estlander flap.
■ Large central lesions can be reconstructed with
Karapandzic, Gillies, or Webster-Bernard flaps.
■ Central upper lip defects can often be reconstructed with
an Abbe or lip-switch flap.

Head and Neck Cancer, Odontogenic Tumors, and Vascular Anomalies
22
■ Total lower lip reconstruction can be performed with a
free radial forearm flap, commonly using the palmaris
tendon as a fascial sling for oral competence.
Figure 3.3.  Full-thickness musculocutaneous flaps for lip reconstruction. These flaps can be based on the right or left superior or inferior
labial arteries and are useful for lip and oral sphincter reconstruction. A, Abbe flap arc to central upper lip. B, Estlander flap arc to oral
commissure and lower lip. C, Gillies fan flap to central upper lip. D, McGregor flap arc to central lower lip. E, Karapandzic flap arc to central
lower lip. (Reprinted from Weinzweig, J. [Ed.], 2010. Plastic Surgery Secrets Plus, 2nd ed. Mosby, 401–408.)
A
B
C
D
E
7. Floor of mouth (FOM) cancer
• Difficult to evaluate because of proximity to mandible and
dentition
• Approximately 30% will present with nodal metastasis.
• Treatment: Surgical excision plus adjuvant radiation
therapy in patients with >1 positive lymph node, extranodal
invasion, perineural invasion, close margins
■ May require a mandibulotomy for exposure
■ A marginal mandibular resection is required for tumors
that abut the lingual mandibular cortex. Involves
surgical excision of the alveolus only
■ A segmental mandibular resection is required for tumors
that invade the mandible.
• Reconstructive options depend on defect size.
■ For large FOM resections without segmental mandibular
resection, a free radial forearm flap is an excellent
option.
■ For large composite defects, including bone, a
vascularized osteocutaneous flap may be necessary (e.g.,
fibula flap, scapular flap).
8. Tongue cancer
• Most commonly, SCC that arises from areas of preexisting
leukoplakia or erythroplasia
• Tongue cancer has the highest rate of regional metastases
of all oral cavity cancers.
• Base of tongue tumors are often more infiltrative and have
a higher incidence of nodal metastases, including the
possibility of bilateral nodal metastases.
• Treatment: Most recommend surgical excision with wide
margins, neck dissection, and adjuvant radiation therapy.
• Reconstructive options depend on defect size.
■ Lesions <4 cm of the anterior and middle 1/3rd of the
tongue can often be closed primarily.
■ Larger, more posterior lesions can be reconstructed with
a skin graft or fasciocutaneous free flaps (e.g., radial
forearm free flap, anterolateral thigh [ALT] free flap)
■ Subtotal tongue reconstruction is often performed with
a free ALT flap.
9. Hypopharyngeal and laryngeal cancer
• The hypopharynx is the area inferior to the oropharynx
and base of tongue, behind the larynx, and superior to the
cervical esophagus.
■ Most patients with cancer of the hypopharynx present
with dysphagia, whereas most patients with laryngeal
cancer present with hoarseness.
■ Majority develop in the piriform sinus and invade
surrounding structures (e.g., larynx, thyroid, thyroid
cartilage, esophagus).
■ Treatment often requires total laryngopharyngectomy
with adjuvant radiation therapy in advanced disease.
Small, localized lesions can be treated with radiation
therapy alone or partial laryngopharyngectomy.
• Larynx consists of the epiglottis, glottis (vocal cords), and
subglottis (1 cm below the vocal cords to the inferior edge
of the cricoid cartilage).
■ Most patients with laryngeal cancer present with
hoarseness.
■ Treatment
○ Small supraglottic cancers are often treated with
radiation therapy, whereas other small lesions can
be removed via transoral laser resection or partial
laryngectomy.
○ Advanced disease and/or larger lesions often require
total laryngectomy with or without adjuvant
radiation.
• Reconstructive options often depend on defect size and
typically rely on free-flap reconstruction including jejunum
flaps, tubed ALT flaps, or tubed radial forearm flaps (see
Table 3.3).

Mandibular Tumors
23
3
2. Ameloblastoma
• Benign, odontogenic tumor that can arise from the lining
of an odontogenic cyst (intraosseous ameloblastoma) or
the gingiva or alveolar mucosa (peripheral ameloblastoma).
• Intraosseous ameloblastomas occur in the mandible in 80%
of cases.
• Classically described as a radiolucent, well-demarcated
cystic lesion with a “soap bubble” or “honeycomb”
appearance on X ray
• Pathologic features include columnar basilar cells in a
palisading pattern.
• Most aggressive of the benign odontogenic tumors and can
spread locally through cortical bone and periosteum into
adjacent vital structures
• Treatment: Recommended is segmental mandibular
resection with 1-cm margins. If tumor is contained within
the mandibular cortex or periosteum, soft tissue need not
be excised.
■ Although successful results with enucleation and
curettage have been reported, recurrence can occur.
• Reconstructive options depend on defect location and size
and can include nonvascularized or vascularized bone
grafts.
3. Bisphosphonate-related osteonecrosis (BRON)
• Necrosis of the mandible after therapeutic dosages of
bisphosphonates
• Risk factors: Patients taking bisphosphonates with a history
of cancer, dentoalveolar surgery, periodontal, and/or dental
abscess; age older than 65; chemotherapy
• Characterized by swelling, pain, infection, exposed bone,
halitosis
Mandibular Tumors
1. Odontogenic keratocyst (OKC)
• OKCs are benign cystic lesions, lined by keratinized
epithelium, that occur over a large age range and typically
begin after odontogenesis of the first permanent tooth.
• Peak incidence is in the 2nd to 3rd decade of life, with a
predilection for the mandible (especially in the mandibular
third molar area).
• Characterized by a radiolucent, well-demarcated, cystic
mass within the mandible that can cause scalloping of the
mandibular border.
• Treatment often centers on enucleation, with removal of
the entire cyst lining for small lesions and resection for
larger lesions.
• Recurrence rate is relatively high, and patients should be
followed regularly.
• Multiple OKCs is suggestive of nevoid basal cell carcinoma
syndrome or Gorlin syndrome.
■ Autosomal dominant disease with multiple
manifestations
○ Basal carcinomas
○ OKCs
○ Palmar and plantar pits
○ Calcification of the falx cerebri
○ Bifid ribs
○ Skeletal abnormalities
○ Cardiac and ovarian fibromas
○ Brain tumors
■ Treatment involves close observation and individual
treatment of manifestations.
Table 3.3  Advantages and Disadvantages of Commonly Used Flaps for Pharyngoesophageal Reconstruction
ALT
JEJUNUM
RADIAL FOREARM
PECTORALIS
Flap elevation
Moderately difficult
Moderately difficult
Easy
Easy
Flap reliability
Good
Good
Good
Variable
Flap thickness
Can be too thick
Good
Good
Too thick
Primary healing
Good
Best
Good
Can be poor
Donor site morbidity rates
Low
High
Moderate
Moderate
Recovery time
Quick
Can be slow
Quick
Quick
Fistula rates
Low
Low
Moderate
High
Stricture rates
Low
High
Moderate
Moderate
TEP voice
Good
Poor
Good
Unknown
Swallowing
Good
Good
Good
Fair
Use for circumferential
defects
Yes
Yes
Second choice
No
Use for partial defects
Yes
No
Yes
Yes
Contraindications
Obesity, with a
very thick thigh
High-risk disease, severe
COPD, prior abdominal surgery
Thin patient with a small
arm, radial dominance
Female gender, obesity,
smoking, circumferential defects
Reprinted from Yu, P., 2009. Intraoral, pharynx, and esophagus. In: Butler, C.E. (Ed.), Head and Neck Reconstruction, Elsevier, 167–196.
ALT, Anterolateral thigh (flap); COPD, chronic obstructive pulmonary disease; TEP, tracheoesophageal puncture.

Head and Neck Cancer, Odontogenic Tumors, and Vascular Anomalies
24
2. Vascular malformations (VMs)
• Arise from disorders in the embryologic development of
the vascular system
• Characterized by a lesion that is present at birth, grows
proportionately with the child, and never involutes
• Categorized based on vascular flow: Low or high
■ High-flow VMs
○ Contain an arterial component (e.g., arterial
malformation, arteriovenous malformation [AVM])
◆ Painless mass that is not compressible
◆ May lead to distal ischemia or high-output cardiac
failure.
○ Treatment: Selective embolization with subsequent
resection
■ Low-flow VMs
○ Venous malformation
◆ Most common low-flow VM
◆ Bluish discoloration, compressible, painful
secondary to thrombus formation or dependent
position
◆ Treatment: Sclerotherapy for symptomatic lesions,
followed by surgical excision when amenable
○ Lymphatic malformation
◆ Enlarge as a result of fluid accumulation, cellulitis,
or inadequate drainage
◆ Propensity for infection
◆ May cause bone hypertrophy.
◆ Treatment: First-line treatment is sclerotherapy for
symptomatic lesions, and this can be followed by
surgical resection when amenable.
○ Capillary malformation
◆ “Port-wine stain”
◆ Red or pink macular stains that can follow
dermatomal distribution
◆ Treatment: Pulse dye laser
◆ Sturge-Weber syndrome
➔ Characterized by capillary malformation in the
distribution of the 1st and 2nd divisions of the
trigeminal nerve (V1, V2), ocular abnormalities
(e.g., glaucoma), and leptomeningeal VM.
➔ Can be associated with soft-tissue or bony
overgrowth
➔ Requires close ophthalmology follow-up and
MRI
3. Syndromic vascular anomalies
• Sturge-Weber syndrome (see above)
• Klippel-Trenaunay syndrome
■ Characterized by presence of a slow-flow capillary-
lymphatic-venous malformation of an extremity with
underlying soft-tissue or bony overgrowth.
■ Most commonly affects the lower extremities.
■ MRI will assist in diagnosis.
■ Treatment: Epiphysiodesis for limb-length discrepancies,
sclerotherapy and compression of lymphatic and venous
malformation components, staged contour resection for
circumferential overgrowth
• Treatment: Chlorhexidine mouth rinse, antibiotics.
Superficial debridement or resection is recommended only
in advanced disease with exposed necrotic bone that
extends beyond the alveolus, concomitant pathologic
fracture, or extraoral fistula.
Vascular Anomalies
1. Hemangioma
• Vascular tumors that frequently appear within the first 4
weeks of life
■ Affects females more commonly than males.
• Characterized by a red, spongy lesion with a rapid growth
phase, followed by involution.
■ In general, 70% of hemangiomas will involute by 7 years
of age.
■ Two types of congenital hemangiomas are possible.
Compared to infantile hemangioma, congenital
hemangiomas are negative for glucose transporter-1
(GLUT-1).
○ Rapidly involuting congenital hemangioma (typically
involutes by 12 months of age)
○ Noninvoluting congenital hemangioma (will not
involute)
• Diagnosis: Often made through history, physical
examination, and growth patterns
■ MRI and CT scan are useful for evaluation and
demonstrate a well-defined vascular tumor.
• Treatment options
■ Initial observation
■ Involution may be induced by steroid administration or
propranolol treatment.
○ Cardiac monitoring is necessary for propranolol
treatment
■ Surgical excision is indicated for persistent bleeding,
when tumor location or growth impairs function or
cosmesis (e.g., obstruction of globe, ear), or if the
patient develops a platelet consumptive coagulopathy
(Kassabach-Merritt syndrome).
■ Laser ablation is also a possibility.
• Syndromic hemangioma disorders
■ von Hippel-Lindau syndrome
○ Characterized by retinal hemangiomas and
hemangioblastomas of the cerebellum and
viscera.
○ Associated with seizures and mental retardation.
■ PHACE Syndrome
○ Characterized by posterior fossa cerebrovascular
anomalies, large facial hemangiomas, arterial
anomalies, cardiovascular abnormalities, and eye
abnormalities.
○ Diagnosis can be made by the presence of a
hemangioma of the face plus one of the above
extracutaneous manifestations discovered by MRI/
magnetic resonance angiogram (MRA) of the brain,
echocardiogram, and ophthalmologic exam.

Vascular Anomalies
25
3
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Metry, D., Heyer, G., Hess, C., et al., 2009. Consensus statement on
diagnostic criteria for PHACE syndrome. Pediatrics 124 (5), 1447–1456.
Mulliken, J.B., 2007. Chapter 22: Vascular anomalies. In: Thorne, C.H.,
Beasley, R.W., Aston, S.J., et al. (Eds.), Grabb and Smith’s Plastic Surgery, 6th
ed. Wolters Kluwer, pp. 191–200.
Neligan, P.C., 2013. Chapter 10: Cheek and lip reconstruction. In: Neligan,
P.C., Rodrigueze, E.D. (Eds.), Plastic Surgery, vol. 3, 3rd ed. Elsevier, China,
pp. 254–277.
Saadeh, P.B., Delacure, M.D., 2007. Chapter 32: Head and neck cancer and
salivary gland tumors. In: Thorne, C.H., Beasley, R.W., Aston, S.J., et al.
(Eds.), Grabb and Smith’s Plastic Surgery, 6th ed. Wolters Kluwer, pp.
333–346.
Seki, J.T., 2010. Chapter 60: Lip reconstruction. In: Weinzweig, J. (Ed.), Plastic
Surgery Secrets Plus, 2nd ed. Mosby, pp. 401–408.
Yu, P., 2009. Chapter 8: Intraoral, pharynx, and esophagus. In: Butler, C.E.
(Ed.), Head and Neck Reconstruction, Elsevier, pp. 167–196.
Yu, P., 2013. Chapter 13: Hypopharyngeal, esophageal, and neck
reconstruction. In: Neligan, P.C., Rodrigueze, E.D. (Eds.), Plastic Surgery,
vol. 3, 3rd ed. Elsevier, pp. 336–359.
• Parkes Weber syndrome
■ Characterized by a fast-flow VM (typically an AVM),
with associated soft-tissue and/or bony overgrowth and
an overlying capillary malformation.
■ Most commonly affects the lower extremities.
■ Angiography will demonstrate the AVM.
■ Treatment depends on symptoms. Development of
high-output cardiac failure because of shunting requires
embolization.
Suggested Readings
Ariyan, S., Narayan, D., Ariyan, C.E., 2013. Chapter 14: Salivary gland
tumors. In: Neligan, P.C., Rodrigueze, E.D. (Eds.), Plastic Surgery, vol. 3, 3rd
ed. Elsevier, pp. 360–379.
Basal Cell Carcinoma Nevus Syndrome Life Support Network. Found at:
<> Accessed on: October 23,
2014.
Boutros, S., 2007. Chapter 36: Reconstruction of the lips. In: Thorne, C.H.,
Beasley, R.W., Aston, S.J., et al. (Eds.), Grabb and Smith’s Plastic Surgery, 6th
ed. Wolters Kluwer, pp. 367–374.
Cheng, M.H., Huang, J.J., 2013. Chapter 12: Oral cavity, tongue, and
mandibular reconstructions. In: Neligan, P.C., Rodrigueze, E.D. (Eds.), Plastic
Surgery, vol. 3, 3rd ed. Elsevier, pp. 307–335.
Coleman, J.J., Tufaro, A.P., 2013. Chapter 16: Tumors of the lips, oral cavity,
oropharynx, and mandible. In: Neligan, P.C., Rodrigueze, E.D. (Eds.), Plastic
Surgery, vol. 3, 3rd ed. Elsevier, pp. 398–419.
Greene, A.K., Mulliken, J.B., 2013. Chapter 29: Vascular anomalies. In:
Neligan, P.C., Gurtner, G. (Eds.), Plastic Surgery, vol. 1, 3rd ed. Elsevier,
China, pp. 676–706.

Craniofacial Trauma
Chapter
4 
General Anatomy
1. Facial buttresses: Provide structural support to the facial
skeleton. Stability of buttresses is critical for maintenance of
skeletal integrity, facial width and height, and balance of
forces (see Figure 4.1).
• Vertical buttresses (four)
■ Nasomaxillary
■ Zygomaticomaxillary
■ Pterygomaxillary
■ Mandibular ramus and condyle
• Horizontal buttresses (four)
■ Supraorbital rim
■ Infraorbital rim (upper transverse maxillary)
■ Nasal floor and maxillary alveolus
■ Mandibular arch
Figure 4.1.  A, Horizontal and B, vertical facial buttresses. (Reprinted from Goldenberg, D.C., Alonso, N., Ferreira, M.C., et al. (Eds.), 2009. Plastic Surgery:
Indications and Practice, 1st ed. Elsevier, 619–644.)
A
B

Frontal Sinus and Frontal Bone Fractures
27
4
2. Scalp layers
• Skin
• Subcutaneous fat
• Galea aponeurosis
• Loose areolar tissue
■ Layer at which traumatic avulsion injury occurs
• Pericranium
Preoperative Considerations
1. Airway, breathing, circulation (ABC), and trauma
resuscitation
2. In high-energy injuries (e.g., motor vehicle collisions,
“whiplash” injuries, facial injury from relatively fixed object),
must rule out concomitant cervical spine injury.
• Reported incidence of 5% to 15%
3. Operating room airway control is important when planning
fixation of fractures.
• In the setting of nasal, midface, and mandibular fractures,
tracheostomy should be considered.
• For mandible fractures, nasotracheal intubation is
preferred.
4. Presence of facial laceration warrants thorough facial nerve
examination.
• Ask the patient to elevate brow, close eyes, smile, evert
lower lip, and purse lips.
• Intact facial nerve motor function on exam obviates the
need for facial nerve exploration.
5. Presence of cheek laceration warrants evaluation for
concomitant parotid duct (Stenson duct) injury.
• The course of the parotid duct (~5 cm in length) loosely
follows a line drawn from the lower margin of the concha
to midway between the red margin of the upper lip and the
ala of the nose.
• The papilla of the duct can be found within the mucosa of
the cheek at the level of the 2nd maxillary molar.
• Diagnosis of parotid duct injury
■ Cannulation of the intraoral papilla and subsequent
saline (or methylene blue) flush: Presence of fluid rush
or methylene blue within the laceration during the flush
is consistent with injury.
• Treatment of parotid duct injuries
■ Distal duct injuries can be treated with silastic stenting
or intraoral drainage.
■ Proximal duct injuries can be treated with direct repair
over a stent or ligation (if repair is impossible).
○ Ligation often leads to atrophy of the parotid gland
but can also result in sialocele formation.
Frontal Sinus and Frontal Bone Fractures
1. Frontal sinus development
• Absent at birth
• Begins to develop at age 2
• Appears on radiographs near age 7
• Fully developed at age 15
2. Frontal sinus anatomy
• Anterior “table”
■ Forms part of the forehead, brow, and glabella
■ Most resistant facial bone to fracture
■ Thickness or width can range from 4 to 12 mm.
• Posterior “table”
■ Adjacent to the dura and cranial fossa
■ Thickness or width can range from 0.1 to 4.8 mm.
• Nasofrontal duct (also known as frontonasal duct or
nasofrontal outflow tract [NFOT])
3. Injury pattern, nasofrontal duct (or NFOT) function, and
presence or absence of cerebrospinal fluid leak dictates
general management algorithms (see Figure 4.2).
4. Isolated anterior table fractures
• Nondisplaced (patent nasofrontal duct): No operative
treatment warranted unless cosmetic concerns; consider
antibiotic prophylaxis.
• Displaced: Open reduction and internal fixation (ORIF) for
improved contour
• Fracture with involvement of nasofrontal duct:
Obliteration of nasofrontal duct and sinus
5. Posterior table fractures
• Nondisplaced posterior table fractures: No operative
fixation warranted; antibiotic prophylaxis, observation for
cerebrospinal fluid (CSF) leak
• Displacement of fractures by 1 table width or greater: Many
advocate for cranialization of the sinus with obliteration of
the nasofrontal duct.
• Significant displacement of both the anterior and posterior
tables: Cranialization of the sinus with obliteration of the
nasofrontal duct
• Fracture with involvement of nasofrontal duct:
Obliteration of the nasofrontal duct and cranialization
depending on the degree of comminution and/or
displacement
6. Nasofrontal duct injury
• Warrants operative treatment with removal of sinus
mucosa and duct obliteration. If posterior table is also
involved, see recommendations above for general
cranialization indications.
• Obliteration can be accomplished with vascularized
soft-tissue (e.g., pericranium) flaps, cancellous bone,
muscle, fat, and/or synthetic bone cements.
■ Pericranium and cancellous bone are preferred.
■ Free fat and muscle grafts are associated with high rates
of necrosis and resorption.
• Mucocele
■ Sterile fluid-filled cyst
○ Can become infected (mucopyocele)
■ Typically occurs in patients with untreated frontal sinus
fractures with missed nasofrontal duct injury
■ Can also develop after treatment/obliteration of the
sinus secondary to retained sinus mucosa
7. CSF leak
• Greater risk leak with posterior table fractures displaced >1
table width because of higher risk for associated dural tear

Craniofacial Trauma
28
• Diagnosis
■ Clear appearing fluid
■ Positive beta-2 transferrin test (“send out test”); most
reliable
■ “Halo” sign
○ Place drop of fluid on filter paper. CSF fluid will
diffuse faster than blood and give the appearance of a
“halo” around a center stain.
■ Elevated glucose on fluid chemistry
• CSF rhinorrhea is caused by a fracture of the cribriform
plate with underlying dural injury.
• Treatment options
■ Observation with head elevation >30 degrees, bed rest,
and antibiotics
■ If CSF leak lasts >4 days, can place a lumbar drain.
■ If CSF leak lasts >7-10 days, despite lumbar drainage, can
proceed to craniotomy, dural repair, and treatment of
frontal sinus injury (obliteration vs. cranialization).
Orbital Fractures
1. Commonly occur after assault, falls, or motor vehicle
collisions.
2. A direct blow to the orbit typically results in force
transmission and dissipation of the acute increase in
intraorbital pressure through the weak points within the
orbital framework (e.g., lamina papyracea, medial orbital wall,
orbital floor; see Figure 4.3).
Figure 4.2.  Frontal sinus fracture treatment algorithm. CSF,
cerebrospinal fluid; fx, fracture; NFOT, nasofrontal outflow tract;
ORIF, open reduction and internal fixation; o/w, otherwise. (Reprinted
from Echo, A., Troy, J.S., Hollier, L.H., 2010. Frontal sinus fractures. Semin.
Plast. Surg. 24 (4), 375–382.)
Frontal Sinus Fracture
1. Cranialization Criteria
a. Severe posterior wall fx
b. CSF leak >1-2 weeks
c. Craniotomy o/w indicated
Yes
Yes
Yes
NO
NO
NO
Cranialization
2. Obliteration Criteria
a. NFOT obstruction suspected
b. Severe medial sinus fx
c. Severe sinus floor fx
d. Severe ethmoid fx
Obliteration
3. Reconstruction Criteria
a. Severely displaced anterior
table fracture
b. Comminuted fx
Observation
Reconstruction:
ORIF/mesh
Figure 4.3.  Surgical anatomy of the orbits. (Reprinted from
Goldenberg, D.C., Alonso, N., Ferreira, M.C., et al. (Eds.), 2009. Plastic Surgery:
Indications and Practice, 1st ed. Elsevier, 619–644.)
Frontal
Sphenoid
Ethmoid
Lacrimal
Roof
Medial
wall
Lateral
wall
Floor
Maxilla
Zygoma
3. In the trauma setting, orbital fractures are often associated
with concomitant zygoma and midface and nasal fractures.
4. Fractures of the orbit require careful examination to rule out
entrapment of extraocular muscles, direct trauma to the
globe, and/or optic nerve injury.
• An ophthalmology exam is generally warranted for all orbit
fractures.
• Entrapment of the inferior rectus requires emergent
operative treatment, especially in the pediatric population.
■ Delayed repair of entrapment in the pediatric population
(typically >72 hours) can result in permanent visual
deficit.

Isolated Nasal Fractures
29
4
8. Approaches
• Transconjunctival
■ No external scar
■ Can use pre- or postseptal dissection to orbital floor
■ Can be extended medially (transcaruncular) or laterally
(lateral canthotomy)
○ Transcaruncular approach allows access to the medial
orbital wall
◆ Approach is through the medial conjunctiva,
between the orbital septum and Horner’s muscle,
to the periosteum of the posterior lacrimal crest
◆ Subciliary
➔ Well-hidden scar
➔ Potential for ectropion
◆ Subtarsal (midlid)
➔ Potential for scar visibility
➔ Potential for ectropion
◆ Rim incision
➔ Poorest cosmesis but best exposure for entire
inferior orbital rim
◆ Lateral brow
➔ For access to lateral orbital rim and
zygomaticofrontal (ZF) suture
9. Complications
• Vertical dystopia: Abnormal vertical position of globe
within the orbit
■ In the acute period, warrants evaluation of hardware
placement and likely return to the operating room for
hardware repositioning.
• Enophthalmos: Posterior displacement of the globe within
the orbit
■ If this occurs in the acute period, may be treated by
repositioning hardware. In the chronic setting, requires
orbital reconstruction with osteotomies.
• Chemosis: Edema of the conjunctiva
• Ectropion: Eversion of the lid
■ Most common with cutaneous lower lid approaches
(e.g., subciliary)
■ Acute treatment: Lid massage and lubricating eye drops
■ If no improvement after 6 months, consider operative
repair techniques with lamellar release and replacement
(e.g., scar release and skin grafting for anterior lamella
cicatrix)
Isolated Nasal Fractures
1. One of the most common fractures of the facial skeleton
2. Often presents with a forceful blow to the nose, with
deviation, pain, and swelling.
3. Septal fracture and hematoma can occur
• Septal hematoma is an emergency and should be drained
immediately with postdrainage quilting sutures, packing,
antibiotics, and follow-up.
• Untreated septal hematoma can result in nasal airway
obstruction, infection, septal perforation, and loss of dorsal
support or saddle nose deformity.
5. Fractures of the orbital rim can be repaired with titanium
plates.
6. Orbital floor reconstruction can be performed with titanium
mesh plates, porous polyethylene mesh plates (e.g., Stryker
MEDPOR,), and/or autogenous bone graft.
• Forced duction testing should be performed at the
conclusion of fixation to rule out entrapment or restriction
of the orbital contents by the reconstruction.
7. Preoperative considerations
• Absolute indication for orbital floor repair: Floor defect
>50% of the floor, entrapment of inferior rectus m.,
enophthalmos >2 mm.
■ Entrapment with vagal symptoms including nausea,
vomiting, and bradycardia (oculocardiac reflex) requires
emergent operative fracture repair.
○ Entrapment of inferior rectus m. with minimal
displacement on computed tomography (CT) is a
“trapdoor” fracture.
○ The inferior rectus m. and inferior oblique m. are the
most common extraocular muscles to be entrapped.
■ Enophthalmos is caused by an increase in orbital
volume. It may not be evident in the acute period due to
periorbital edema.
• Diplopia in the absence of bony displacement or
entrapment can be observed (often due to edema) and
repair can be performed at a later time if indicated.
• Traumatic optic neuropathy has been reported in 2% to
5% of patients with severe facial trauma.
■ Marcus Gunn pupil: Abnormal pupil dilation in
presence of light
○ Indicative of optic nerve injury anterior to the optic
chiasm
○ Diagnosed by “swinging flashlight test”
■ Symptoms: Vision complaints with diminished color
perception
■ Most common etiologies: Shear force injury, fracture
fragment impingement, thrombosis of retinal artery, and
retinal detachment
• Emergent ophthalmology consult warranted with the
following symptoms on presentation:
■ Blindness, hyphema, blurred vision, eye pain, globe
rupture, or retrobulbar hematoma
○ Hyphema: The presence of blood in the anterior
chamber of the eye
○ Retrobulbar hematoma/orbital hemorrhage: Bleeding
posterior to septum, resulting in elevated intraocular
pressure, pain, and loss of vision
◆ Requires urgent (bedside) lateral canthotomy/
cantholysis to relieve pressure
• Posttraumatic carotid-cavernous fistula: Abnormal fistula
that can form between the internal carotid artery and
cavernous sinus after a basilar skull fracture
■ Symptoms: Pulsatile proptosis, ocular and orbital
erythema, chemosis, diplopia, headaches, and visual loss
■ Diagnosis: Cerebral angiogram
■ Treatment: Embolization

Craniofacial Trauma
30
Zygoma and Zygomaticomaxillary Complex
(ZMC) Fractures
1. The zygoma is a tetrapod-shaped bone that is important in
providing midface stability and in establishing facial width
and height.
2. Zygoma anatomy
• Inferior orbital rim
• ZF suture
• Zygomaticomaxillary buttress
• Zygomaticotemporal suture (arch)
• Zygomaticosphenoid junction (fusion with greater wing of
the sphenoid to form lateral orbital wall)
• Zygomaticus major and minor m.
• Masseter m.
3. Physical signs depend on location and degree of fracture.
• Malar flattening and increased facial width
■ Secondary to lateral displacement of the zygomatic arch
• Contour irregularity/indentation
• Enophthalmos
■ Suggests an orbital component to the zygoma fracture
(orbital floor and lateral orbital wall)
• Downward canthal tilt
■ Secondary to lateral rotation and inferior displacement
of the zygoma, thereby disrupting the lateral canthal
attachment to the lateral orbit (Whitnall’s tubercle)
• Reduced mandibular motion
■ Secondary to obstruction of the mandibular condyle
from a zygomatic arch fracture or poor zygomaticus
major and minor m. and/or masseter m. function
4. Treatment recommendations
• In general, three points of fixation are required for
stability.
• Miniplates are effective in providing fixation of fractures.
• Exposure of the zygoma can involve intraoral
(gingivobuccal sulcus), orbital/lid (transconjunctival,
subciliary, midlid, lateral brow, existing laceration), and
scalp (coronal, Gilles) incisions.
■ Gingivobuccal sulcus: Exposure of zygomaticomaxillary
buttress
■ Orbital/lid: Exposure of ZF suture, inferior orbital rim,
zygomaticosphenoid region
■ Coronal: Exposure of zygomatic arch,
zygomaticotemporal suture, zygomaticosphenoid region
• Isolated zygomatic arch fracture
■ Nondisplaced: Observation
■ Displaced: Gilles reduction
○ For Gilles approach: Incision is placed in hair-bearing
portion of temporal region and extends down
through the deep temporal fascia to expose the
temporalis m. Elevator is then passed bluntly in this
plane to reduce the arch fracture.
4. Closed reduction is often performed using a butter knife and
an outward directed force.
• Often delayed for 3 to 5 days in the setting of swelling
• Should not include nasal osteotomies because of risk for
nasal collapse and airway obstruction
Naso-Orbital Ethmoid (NOE) Fractures
1. The NOE complex involves the sinuses (frontal, ethmoid),
medial orbital bones, frontal bone, and nasal bones.
2. NOE fractures involve disruption of all NOE complex
structures.
• Degree of injury and/or comminution often determines
necessary repair techniques.
3. Physical signs
• Telecanthus: Abnormal distance between medial canthi
secondary to medial canthal tendon (MCT) disruption
(can be bony, ligamentous, or both)
• Deep nasofrontal angle or midface retrusion
• Epiphora from occluded puncta
• Upturning of the nasal tip secondary to lack of nasal bone
support
4. Markowitz and Manson classification of NOE fractures (see
Figure 4.4)
• Type I: Large central fragment
• Type II: Comminution of central fragment but MCT
insertion intact
• Type III: Extensive comminution of segment with
disruption of MCT insertion
Figure 4.4.  Classification of NOE fractures according to Markowitz
and Manson. (Reprinted from Goldenberg, D.C., Alonso, N., Ferreira, M.C.,
et al. (Eds.), 2009. Plastic Surgery: Indications and Practice, 1st ed. Elsevier,
619–644.)
Type I
Type II
Type III
5. Treatment recommendations
• Goal: Fixation of fractures to achieve NOE complex
stability and restore MCT position
• Requires coronal incision for exposure
• Type-I fractures may be repaired via fracture fixation only.
• Type-II and -III fractures will likely require ORIF, possible
bone grafting, and transnasal wiring of the MCT.
■ The MCT should be positioned posterior and superior
to lacrimal fossa or anterior lacrimal crest with slight
overcorrection.
6. Exploration of lacrimal system not indicated in absence of
obvious injury to ducts (i.e., lacerations)

Midface/Maxillary Fractures
31
4
6. Primary bone grafting of the buttresses in the setting of bone
gaps >5 mm to 1 cm are recommended.
• Common bone graft donor sites include iliac crest, rib, and
split calvarium.
7. Repair of midface fractures often requires placement of
maxillomandibular fixation (MMF) before fracture fixation to
ensure proper occlusion postoperatively.
• “Tripod” or “Tetrapod” fracture
■ Requires fixation of at least three of four parts for
stability and to prevent rotation
○ Inferior orbital rim
○ ZF suture
○ Zygomaticomaxillary buttress
○ Zygomaticotemporal suture
■ Proper alignment and reduction of the lateral orbital
wall/zygomaticosphenoid suture is most important to
reduce the risk of postoperative enophthalmos and/or
malar flattening.
○ Reduction of the zygomatic arch is critical in
reestablishing facial width.
5. Postoperative complications
• Malar flattening
• Temporal hollowing
■ Often secondary to atrophy of fat; can be treated with fat
grafting
• Enophthalmos
• Malocclusion
■ Can be treated with a LeFort I osteotomy procedure
Midface/Maxillary Fractures
1. Midface fractures often involve the facial buttresses resulting
in instability, malocclusion, midface retrusion, and
occasionally orbital injury.
2. Isolated, single buttress, nondisplaced fractures can be
managed conservatively; however, most midface fractures
require operative reduction and fixation at the buttresses
(e.g., zygomaticomaxillary buttress and nasomaxillary
buttress).
3. Fractures to the midface classically follow particular fracture
patterns as described by Rene LeFort (LeFort fracture
patterns).
• For a true LeFort fracture, the pterygoid plates must also
be fractured (see Figure 4.5).
4. Approaches to the maxilla
• Orbital approach (e.g., transconjunctival, subtarsal,
subciliary for orbital components, and/or lateral brow for
LeFort III patterns through the ZF suture)
• Upper gingivobuccal sulcus (for the zygomaticomaxillary
and nasomaxillary buttresses)
• Coronal (for LeFort III fractures involving the zygomatic
arch or LeFort II fractures with an associated NOE
component)
5. LeFort fractures are often misnamed as “panfacial” fractures.
In reality, panfacial fractures involve fractures of the frontal
bone, midface, and mandible.
• Classic descriptions for the repair of panfacial fractures
include “bottom up,” “top down,” and “outside in.”
• Regardless of technique, important considerations include
establishing proper facial width and height, restoring
premorbid occlusion, and working from stable to
unstable.
A
B
Figure 4.5.  A, Le Fort I fracture. B, Le Fort II fracture. C, Le Fort III
fracture. (Reprinted from Fonseca, R.J., et al. (Eds.), 2005. Oral and
Maxillofacial Trauma, 3rd ed. Elsevier, 645–646.)
C

Craniofacial Trauma
32
• Masseter originates on the zygomatic arch and maxilla and
inserts onto the inferior border of the mandibular ramus,
angle, and posterior body. It functions to close the lower
jaw. The masseter can cause displacement of unfavorable
angle and/or body fractures.
3. Fractures are classified according to their location and
presence or absence of teeth on either side of the fracture
fragment.
• Class-I fracture: Fracture with teeth on either side of the
fracture line (e.g., symphysis, parasymphysis, body)
• Class-II fracture: Teeth present only on one side of the
fracture line (e.g., posterior body, angle)
• Class-III fracture: No teeth on either side of the fracture
line (e.g., ramus, condyle) (see Figures 4.6 and 4.7)
4. Failure to treat mandible fractures appropriately can lead to
gross malocclusion, ankylosis of the temporomandibular
joint, and/or significant functional deficit.
• The normal interincisal opening in adults is approximately
4 to 5 cm.
• Premorbid occlusion should be reestablished based on
wear facets.
• It is imperative to ensure that the condyles are seated
within the glenoid fossa during reduction and fixation to
prevent postoperative malocclusion.
• Repair of mandible fractures requires placement of MMF
during fracture reduction and fixation.
■ At the conclusion of fracture repair, the MMF should be
released temporarily to ensure adequate opening and
closing of mandible with reestablishment of premorbid
occlusion.
■ If occlusion is incorrect at this stage, the plates should be
removed and reduction/fixation should be corrected.
• For some nondisplaced or favorable mandible fractures,
treatment with MMF alone is possible.
5. Approaches to the mandible
• Intraoral approach (e.g., gingivobuccal sulcus for
symphysis, parasymphysis, mandibular body, and angle
fractures)
8. Complications
• Malocclusion
• Enophthalmos
• Diplopia
• Nonunion/malunion
Mandible Fractures
1. Mandible fractures are extremely common and can occur
after assault, motor vehicle collisions, and falls.
2. Mandible fractures often result in gross malocclusion and
displacement as a result of external muscular forces acting on
the segments.
• Lateral pterygoid originates on the lateral side of the lateral
pterygoid plate and functions to open and protrude the
lower jaw. The lateral pterygoid causes medial and anterior
displacement of a fractured condyle.
• Medial pterygoid originates on the medial side of the
lateral pterygoid plate and functions to close the lower jaw.
Figure 4.6.  Classification of mandibular fractures. (Reprinted from
Neligan, P.C., Buck, D.W., 2013. Core Procedures in Plastic Surgery, 1st ed.
Elsevier, 91–109.)
Alveolar process
Canine root
Mental foramen
Coronoid
Parasymphysis
Body
Third
molar
Angle
Ramus
Condyle
Figure 4.7.  Classification of mandibular fractures according to the presence of teeth. (Reprinted from Guyuron, B., Eriksson, E., Persing, J.A., et al.
(Eds.), 2009. Plastic Surgery: Indications and Practice, 1st ed. Elsevier, 619–644.)
Type I
Type I I
Type III

Ballistic Injuries to the Face
33
4
Pediatric Fractures
1. Mandible fractures are the most common facial fracture in
the pediatric population.
• Fractures heal quickly in pediatric patients; thus MMF is
generally recommended only for 2 weeks to reduce the risk
of ankylosis.
• MMF can be established with circummandibular,
circumorbital, and/or circumpiriform wires in children
with mixed dentition and/or absent dentition to reduce the
risk for injury to developing teeth. In children with stable
dentition, arch bars and/or monocortical screws can be
used.
• Fixation can be performed with titanium hardware or
“absorbable” hardware.
■ Some surgeons recommend removal of titanium
hardware after fracture healing to limit potential effects
on growth.
• The condyle is a major growth center for the mandible.
Fractures in this area can lead to growth disturbances.
■ Bilateral condyle fractures require fixation of at least one
side to reestablish posterior facial height.
2. Pediatric fractures of the orbital floor can lead to inferior
rectus entrapment (“trapdoor” fracture).
• Patients may present with severe eye pain, restricted
upward gaze, and oculocardiac reflex (nausea, vomiting,
bradycardia, and/or syncope).
• Requires emergent operative reduction and orbital floor
reconstruction
3. Fractures to the superior orbital rim and/or orbital roof can
cause underlying injury to the dura and result in dysoptia
and/or a “growing skull fracture.”
• Requires reduction and dural repair where indicated
Ballistic Injuries to the Face
1. Result in complex bone and soft-tissue injuries
2. Management requires initiation of standard advanced
trauma life support measures, including ABC and airway
protection.
3. Once the patient is stable, the general approach to ballistic
injuries is immediate reconstruction and soft-tissue closure
with serial second-look procedures at 48-hour intervals to
remove subsequent necrotic tissue and bone.
4. Bony deficits and soft-tissue injuries should be addressed
individually.
5. Complex reconstructions (e.g., free fibula flap reconstruction
of the mandible) are generally performed at a later date once
the patient has stabilized and the initial inflammatory
response from the injury has resolved.
• External approach (e.g., Risdon—submandibular;
retromandibular)
■ Indicated for condylar fractures requiring fixation,
comminuted fractures requiring large reconstruction
plate fixation, and fracture repair in the edentulous
patient with an atrophic mandible
6. Indications for open reduction internal fixation (ORIF) of
Class I and II mandible fractures (e.g., symphysis to angle)
• Displacement or unfavorable fractures
• Malocclusion
• Comminution with instability
• Multiple fractures (e.g., parasymphyseal fracture with
contralateral angle fracture)
7. Indications for ORIF of condylar fractures
• Displacement of the condyle into the middle cranial fossa
• Inability to establish proper occlusion with closed reduction
• Lateral extracapsular displacement of the condyle
• Invasion by foreign body precluding reduction
• Bilateral condylar fractures with anterior open bite and loss
of posterior facial height.
8. General operative techniques
• Rigid fixation typically requires an inferior border plate to
counteract compression forces and a superior plate to
counteract tension forces
• Large reconstruction plates can be used in comminuted
fractures along the inferior border to provide stability.
These are often used in conjunction with locking screws to
compensate for any discrepancies between bone and plate
contact.
• A plate along the oblique ridge (“Champy plate”) can be
used for fixation of simple angle fractures.
• In comminuted fractures of the atrophic mandible,
periosteal stripping of the bone fragments should be
avoided to limit the potential for resorption.
9. Indications for tooth extraction in the setting of mandible
fractures
• The tooth is preventing proper reduction of the fracture
• Presence of periapical infection
• Presence of dental caries
• Fracture of, or injury to, the tooth root
10. Complications
• Malocclusion
■ If noted early, should be aggressively corrected with
hardware removal, re-reduction, and fixation
• Infection
■ Should be treated with operative washout. Hardware
generally requires removal if it is loose or unstable.
• Hardware exposure
■ If exposure occurs after fracture healing, hardware can
be removed and wounds allowed to heal secondarily.
• Malunion or nonunion
■ May require osteotomies and/or bone grafting, typically
via external approach

Craniofacial Trauma
34
Indresano, A.T., Beckley, M.L., 2005. Chapter 24: Nasal fractures. In: Fonseca,
R.J., Walker, R.V., Betts, N.J., et al. (Eds.), Oral and Maxillofacial Trauma,
2nd ed. Elsevier, pp. 737–750.
Kendell, B.D., Frost, D.E., 2005. Applied surgical anatomy of the head and
neck. In: Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.), Oral and
Maxillofacial Trauma, 2nd ed. Elsevier, pp. P281–P328.
Losee, J.E., Smith, D.M., 2013. Chapter 31: Pediatric facial fractures. In:
Neligan, P.C. (Ed.), Plastic Surgery, 3rd ed. Elsevier, pp. 671–685.
Morin, R.J., Burke, R., Wolfe, S.A., 2010. Chapter 48: Fractures of the
maxilla. In: Weinzweig, J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby,
pp. 316–319.
Neligan, P.C., Buck, D.W., 2013. Chapter 6: Facial injuries. In: Neligan, P.C.,
Buck, D.W. (Eds.), Core Procedures in Plastic Surgery, Elsevier, pp. 91–109.
Rodriguez, E.D., Dorafshar, A.H., Manson, P.N., 2013. Chapter 3: Facial
fractures. In: Neligan, P.C., Rodriguez, E.D. (Eds.), Plastic Surgery, vol. 3, 3rd
ed. Elsevier, pp. 49–88.
Salin, M.B., Smith, B.M., 2005. Chapter 21: Diagnosis and treatment of
midface fractures. In: Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.),
Oral and Maxillofacial Trauma, 2nd ed. Elsevier, pp. 643–692.
Sharabi, S.E., Koshy, J.C., Thornton, J.F., et al., 2011. Facial fractures. Plast.
Reconstr. Surg. 127 (2), 25e–34e.
Tollefson, T.T. Frontal Sinus Fractures. Meyers, A.D., emedicine.com. Found
at: <> Accessed on:
August 20, 2014.
Suggested Readings
Barber, H.D., Bahram, R., Woodbury, S.C., et al., 2005. Chapter 18:
Mandibular fractures. In: Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.),
Oral and Maxillofacial Trauma, 2nd ed. Elsevier, pp. 479–522.
Chuang, S.K., Dodson, T.B., 2005. Chapter 23: Evaluation and management of
frontal sinus injuries. In: Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.),
Oral and Maxillofacial Trauma, 2nd ed. Elsevier, pp. 721–736.
Echo, A., Troy, J.S., Hollier, L.H., 2010. Frontal sinus fractures. Semin. Plast.
Surg. 24 (4), 375–382.
Ellis, E., 2005. Chapter 14: Advances in maxillofacial trauma surgery. In:
Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.), Oral and Maxillofacial
Trauma, 2nd ed. Elsevier, pp. 329–376.
Ellis, E., 2005. Chapter 20: Fractures of the zygomatic complex and arch. In:
Fonseca, R.J., Walker, R.V., Betts, N.J., et al. (Eds.), Oral and Maxillofacial
Trauma, 2nd ed. Elsevier, pp. 569–624.
Freeman, M.B., Harshbarger, R.J., 2010. Chapter 44: Fractures of the frontal
sinus. In: Weinzweig, J. (Ed.), Plastic Surgery Secrets Plus, 2nd ed. Mosby,
pp. 291–294.
Goldenberg, D.C., Alonso, N., Ferreira, M.C., 2009. Chapter 48:
Facial trauma. In: Guyuron, B., Eriksson, E., Persing, J.A., et al. (Eds.),
Plastic Surgery: Indications and Practice, 1st ed. Elsevier,
pp. 619–644.

Craniosynostosis and
Craniofacial Syndromes
Chapter
5 
General Craniosynostosis Nomenclature
and Information
1. Craniosynostosis: Abnormal fusion of cranial sutures leading
to abnormal head shape
• May lead to increased intracranial pressure (ICP) and
developmental delay
■ Increased ICP can be diagnosed by papilledema and
“thumb printing” on radiographic studies.
• Prevalence: ~1:2500 live births
• Most common synostosis: Sagittal, followed by unilateral
coronal, bilateral coronal, metopic, and lambdoid
• Most infants with single-suture synostosis are
nonsyndromic, whereas most with multisuture synostosis
do have a syndrome.
• Most syndromic craniosynostoses are related to fibroblast
growth factor receptor (FGFR) genes and present with
bilateral coronal craniosynostosis in isolation or in
association with other suture synostoses.
• Syndromic craniosynostoses and their related gene
mutations
■ Apert syndrome: FGFR-2
■ Crouzon syndrome: FGFR-2
■ Pfeiffer syndrome: FGFR-2
■ Saethre-Chotzen syndrome: TWIST 1
2. Cranial sutures (see Figure 5.1)
• Act as growth centers for the cranium and allow skull
deformation for passage through the birth canal
• With an open suture, the bone grows perpendicular to the
suture line.
• When the suture is fused, compensatory bone growth
occurs parallel to the suture line (see Table 5.2).
Figure 5.1.  Normal sutures and fontanels. Posterior and lateral views of a three-dimensional (3D) CT of a newborn. (Left) Posterior view
of the skull, demonstrating the posterior fontanel (blue), the sagittal and the paired lambdoid sutures (white lines). The sagittal suture
contains an incidental wormian bone. (Right) Right lateral view demonstrating the mastoidal fontanel posteriorly, the sphenoidal fontanel
anteriorly, and at the vertex the anterior fontanel (blue), which is only partially seen. The right coronal, squamosal, and right lambdoid
sutures are patent (white lines). (Reprinted from Kirmi, O., Lo, S.J., Johnson, D., et al., 2009. Craniosynostosis: a radiological and surgical perspective. Sem.
Ultrasound CT MRI 30 (6), 492–512.)

Craniosynostosis and Craniofacial Syndromes
36
3. Suture closure (see Figure 5.2)
• Order of closure: Metopic suture (8-9 months), sagittal
suture (22 years of age), coronal suture (24 years),
lambdoid suture (26 years), and squamosal suture
(>60 years)
4. Common craniofacial terms
• Hypertelorism: Abnormal increase in the distance between
the bony orbits
• Hypotelorism: Decreased distance between the bony orbits
• Telecanthus: Increased distance between the medial canthi
• Exorbitism: Protrusion of the globe due to decreased
volume of orbit
Craniosynostoses
See Figure 5.3.
1. Metopic craniosynostosis
• Also known as trigonocephaly (“triangular-shaped” head)
• Characterized by
■ Keel-shaped forehead
■ Metopic ridge (in mild cases)
■ Bitemporal narrowing
■ Parietal expansion
■ Hypotelorism
• Most likely to be associated with midline brain
abnormalities
2. Sagittal craniosynostosis
• Also known as scaphocephaly (“boat-shaped head”) or
dolichocephaly
• Characterized by
■ Bilateral frontal and occipital bossing
■ Elongated head in the anteroposterior direction
■ Decreased biparietal width
Figure 5.2.  Fusing sutures. 3D CT: Normal suture (left), fusing suture (middle) that has lost its architecture, and bone bridging of a fused
suture (right). (Reprinted from Kirmi, O., Lo, S.J., Johnson, D., et al., 2009. Craniosynostosis: a radiological and surgical perspective. Sem. Ultrasound CT MRI 30
(6), 492–512.)
Figure 5.3.  Characteristic skull shape depending on sutural
involvement in craniosynostosis. (Reprinted from Neligan, P.C., Losee, J.
[Eds.], 2013. Plastic Surgery, 3rd ed. Elsevier, 726–748.)
Normocephaly
Trigonocephaly
Brachycephaly
Plagiocephaly
Plagiocephaly
Scaphocephaly

Craniosynostoses
37
5
• Treatment: Endoscopic resection of the sagittal suture with
postoperative helmet molding can often safely be
performed on patients at 3 months of age.
3. Coronal craniosynostosis
• Unilateral coronal craniosynostosis is also known as
anterior plagiocephaly; bicoronal craniosynostosis is known
as brachycephaly (“short, flat head”).
• Unilateral coronal synostosis is characterized by
■ Flattening of the ipsilateral forehead and supraorbital
rim
■ Contralateral forehead bossing
■ “Harlequin” eye deformity: Flattened supraorbital rim,
raised eyebrow, widened palpebral opening, deficient
lateral orbital rim, steep superior orbital fissure, and
sphenoid wing
■ Anterior displacement of the ipsilateral ear
■ Deviation of the nasal root toward the affected side
• Bilateral coronal synostosis is characterized by
■ Symmetric, flat forehead
■ Increased biparietal width
■ Decreased anteroposterior length
■ Turricephaly or turribrachycephaly; can occur in certain
patients in which there is a compensatory increase in
parietal height leading to a “tall, flat head”
4. Lambdoid craniosynostosis
• Also known as posterior plagiocephaly; very rare
• Distinguished from deformational plagiocephaly by a
“trapezoid”-shaped head
• Characterized by
■ Flattening of the ipsilateral occiput
■ Inferior displaced mastoid bulge on affected side
■ Contralateral forehead bossing
■ Inferior displacement of the ipsilateral ear
5. Multisuture craniosynostosis
• Involves premature fusion of multiple sutures
• In the most severe form (pansutural synostosis), patients
can develop a “cloverleaf” skull deformity (also known as
the kleeblattschädel skull deformity)
■ Characterized by a “moth-eaten” appearance of bone on
computed tomography (CT) imaging
■ May lead to severe increases in ICP and airway
anomalies
6. Treatment of craniosynostosis depends on severity,
appearance, and functional concerns.
• Goals of surgery: Suture release to allow brain growth and
development; normalization of head shape; reduction of
functional deficits (e.g., increased intracranial pressure,
developmental delay, etc.)
• Timing of surgery is often dependent on the severity of the
abnormality, with the more severe or symptomatic (e.g.,
increased ICP) patient often requiring surgery between 6
and 12 months of age.
7. Surgical treatment options (see Table 5.1)
• Cranial vault remodeling: Multiple techniques have been
described.
■ Surgery is often performed between 6 and 12 months of
age.
• Distraction osteogenesis
■ Useful for advancements >1 cm
■ Latency phase
○ The phase following osteotomy and application of the
distractor device in which there is no bony movement
○ A typical latency phase lasts between 1 and 7 days.
■ Activation phase
○ The phase following the latency period in which the
distractor is moved at a set rate (e.g., 1 mm/day)
○ Encourages bone formation
■ Consolidation phase
○ The distraction is completed, the device is left in
place, and the new bone is allowed to consolidate and
calcify.
○ A typical consolidation period is twice the duration of
the active distraction.
• Midface advancement
■ Often, LeFort I or III advancements
• Rhinoplasty
Table 5.1  Skull Deformity in Craniosynostosis and Operative Techniques Used for Correction
FUSED
SUTURE
SKULL SHAPE
HYPOPLASTIC ELEMENTS
COMPENSATORY GROWTH
OPERATIVE TECHNIQUES
Sagittal
Scaphocephaly
Biparietal, bitemporal
AP lengthening, frontal
bossing, occipital protrusion
Strip craniectomy, cranial vault
remodeling, spring-assisted cranioplasty
Unicoronal
Plagiocephaly
Ipsilateral frontal flattening, orbital
rim recession
Contralateral frontal and
temporal bulging, ipsilateral
facial sutures (facial scoliosis)
FOA
Bicoronal
Brachycephaly
Occipital flattening, AP shortening
Elevation in skull height
FOA
Lambdoid
Plagiocephaly
Ipsilateral parieto-occipital
flattening
Bulging of contralateral
parieto-occipital bone
Lambdoid strip craniectomy, biparietal
occipital remodeling
Metopic
Trigonocephaly
Hypotelorism, superior orbital rim
recession, bitemporal narrowing
Parietal flaring
FOA
Reprinted from Kirmi, O., Lo, S.J., Johnson, D., et al. 2009. Sem. Ultrasound CT MRI 30 (6), 492–512.
AP, Anterior-posterior; FOA, fronto-orbital advancement.