Plastic Surgery Volume 6: Hand and Upper Extremity (4th Edition) – Peter C. Neligan

Plastic
Fourth Edition
Surgery
Hand and Upper Extremity
Volume Six

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London, New York, Oxford, Philadelphia, St Louis, Sydney 2018
Volume Editor
James Chang
MD
Johnson & Johnson Distinguished
Professor and Chief
Division of Plastic and Reconstructive Surgery
Stanford University Medical Center
Stanford, CA, USA
Plastic
Surgery
Fourth Edition
Editor-in-Chief
Peter C. Neligan
MB, FRCS(I), FRCSC, FACS
Professor of Surgery
Department of Surgery, Division of Plastic Surgery
University of Washington
Seattle, WA, USA
Multimedia Editor
Daniel Z. Liu
MD
Plastic and Reconstructive Surgeon
Cancer Treatment Centers of America at
Midwestern Regional Medical Center
Zion, IL, USA
Volume Six
Hand and Upper Extremity

© 2018, Elsevier Inc. All rights reserved.
First edition 1990
Second edition 2006
Third edition 2013
Fourth edition 2018
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All photographs in Volume 6, Chapter 6 The fingertip, nail plate, and nail bed: Anatomy, repair, and reconstruc­
tion ©Southern Illinois University School of Medicine.
James Chang and Anais LeGrande retain copyright for their original photographs.
Notices
Knowledge and best practice in this field are constantly changing. As new research and experience broaden
our understanding, changes in research methods, professional practices, or medical treatment may become
necessary.
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds, or experiments described herein. In using such information or
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With respect to any drug or pharmaceutical products identified, readers are advised to check the most current
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to verify the recommended dose or formula, the method and duration of administration, and contraindications.
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Video Contents
Chapter 11: Asian facial cosmetic surgery
1.1: Medial epicanthoplasty
11.2: Eyelidplasty: Non-incisional method
11.3: Rhinoplasty
11.4: Subclinical ptosis correction (total)
11.5: Secondary rhinoplasty: Septal extension graft and costal
cartilage strut fixed with K-wire
Kyung S. Koh, Jong Woo Choi, and Clyde H. Ishii
Chapter 12: Neck rejuvenation
12.1: Anterior lipectomy
James E. Zins, Colin M. Morrison, and C. J. Langevin
Chapter 13: Structural fat grafting
13.1: Structural fat grafting of the face
Sydney R. Coleman and Alesia P. Saboeiro
Chapter 14: Skeletal augmentation
14.1: Chin implant
Michael J. Yarumchuk
© Mesa J, Havlik R, Mackay D, Buchman S, Losee J, eds. Atlas of
Operative Craniofacial Surgery, CRC Press, 2019.
14.2: Mandibular angle implant
14.3: Midface skeletal augmentation and rejuvenation
Michael J. Yarumchuk
© Michael J. Yaremchuk
Chapter 16: Open technique rhinoplasty
16.1: Open technique rhinoplasty
Allen L. Van Beek
Chapter 20: Otoplasty and ear reduction
20.1: Setback otoplasty
Leila Kasrai
Chapter 23: Abdominoplasty procedures
23.1: Abdominoplasty
Dirk F. Richter and Alexander Stoff
Chapter 24: Lipoabdominoplasty
24.1: Lipoabdominoplasty (including secondary lipo)
Osvaldo Saldanha, Sérgio Fernando Dantas de Azevedo,
Osvaldo Ribeiro Saldanha Filho, Cristianna Bonnetto Saldanha, and
Luis Humberto Uribe Morelli
Chapter 26.2: Buttock augmentation: Buttock
augmentation with implants
26.2.1: Buttock augmentation
Terrence W. Bruner, Jose Abel De la Peña Salcedo,
Constantino G. Mendieta, and Thomas L. Roberts III
Chapter 27: Upper limb contouring
27.1: Brachioplasty
27.2: Upper limb contouring
Joseph F. Capella, Matthew J. Trovato, and Scott Woehrle
Volume One:
Chapter 15: Skin graft
15.1: Harvesting a split-thickness skin graft
Dennis P. Orgill
Chapter 34: Robotics in plastic surgery
34.1: Robotic microsurgery
34.2: Robotic rectus abdominis muscle flap harvest
34.3: Trans-oral robotic surgery
34.4: Robotic latissimus dorsi muscle harvest
34.5: Robotic lymphovenous bypass
Jesse C. Selber
Volume Two:
Chapter 6.2: Facelift: Principles of and surgical
approaches to facelift
6.2.1: Parotid masseteric fascia
6.2.2: Anterior incision
6.2.3: Posterior incision
6.2.4: Facelift skin flap
6.2.5: Facial fat injection
Richard J. Warren
6.2.6: Anthropometry, cephalometry, and orthognathic surgery
Jonathon S. Jacobs, Jordan M. S. Jacobs, and Daniel I. Taub
Chapter 6.3: Facelift: Platysma-SMAS plication
6.3.1: Platysma-SMAS plication
Dai M. Davies and Miles G. Berry
Chapter 6.4: Facelift: Facial rejuvenation with loop
sutures – the MACS lift and its derivatives
6.4.1: Loop sutures MACS facelift
Patrick L. Tonnard
From Aston SJ, Steinbrech DS, Walden JL, eds. Aesthetic Plastic
Surgery, Saunders Elsevier; 2009; with permission from Elsevier
Chapter 6.7: Facelift: SMAS with skin attached – the
“high SMAS” technique
6.7.1: The high SMAS technique with septal reset
Fritz E. Barton Jr.
© Fritz E. Barton Jr.
Chapter 6.8: Facelift: Subperiosteal midface lift
6.8.1: Subperiosteal midface lift: Endoscopic temporo-midface
Oscar M. Ramirez
Chapter 9: Blepharoplasty
9.1: Periorbital rejuvenation
Julius Few Jr. and Marco Ellis
© Julius Few Jr.

xiii
Video Contents
Chapter 26: Velopharyngeal dysfunction
26.1: Velopharyngeal incompetence – 1
26.2: Velopharyngeal incompetence – 2
26.3: Velopharyngeal incompetence – 3
Richard E. Kirschner and Adriane L. Baylis
Chapter 27: Secondary deformities of the cleft lip,
nose, and palate
27.1: Abbé flap
27.2: Alveolar bone grafting
27.3: Complete takedown
27.4: Definitive rhinoplasty
Evan M. Feldman, John C. Koshy, Larry H. Hollier Jr., and
Samuel Stal
27.5: Thick lip and buccal sulcus deformities
Evan M. Feldman and John C. Koshy
Chapter 36: Pierre Robin Sequence
36.1: Mandibular distraction
Arun K. Gosain and Chad A. Purnell
Chapter 39: Vascular anomalies
39.1: Lip hemangioma
Arin K. Greene
Chapter 43: Reconstruction of urogenital defects:
Congenital
43.1: First-stage hypospadias repair with free inner preputial
graft
43.2: Second-stage hypospadias repair with tunica vaginalis
flap
Mohan S. Gundeti and Michael C. Large
Volume Four:
Chapter 2: Management of lower extremity trauma
2.1: Anterolateral thigh flap harvest
Michel Saint-Cyr
Chapter 3: Lymphatic reconstruction of the
extremities
3.1: End-to-side lymphovenous bypass technique
© Cheng M-H, Chang D, Patel K. Principles and Practice of
Lymphedema Surgery, Elsevier; 2015.
3.2: Recipient site preparation for vascularized lymph node
transfer – axilla
© Cheng M-H, Chang D, Patel K. Principles and Practice of
Lymphedema Surgery, Elsevier; 2015.
3.3: Indocyanine green lymphography
David W. Chang
3.4: Charles procedure
Peter C. Neligan
Chapter 6: Diagnosis and treatment of painful
neuroma and nerve compression in the lower
extremity
6.1: Diagnosis and treatment of painful neuroma and of nerve
compression in the lower extremity 1
6.2: Diagnosis and treatment of painful neuroma and of nerve
compression in the lower extremity 2
Chapter 28: Post-bariatric reconstruction
28.1: Post-bariatric reconstruction – bodylift procedure
J. Peter Rubin and Jonathan W. Toy
© J. Peter Rubin
Volume Three:
Chapter 6: Aesthetic nasal reconstruction
6.1: The three-stage folded forehead flap for cover and lining
6.2: First-stage transfer and intermediate operation
Frederick J. Menick
Chapter 7: Auricular construction
7.1: Total auricular construction
Akira Yamada
Chapter 8: Acquired cranial and facial bone
deformities
8.1: Removal of venous malformation enveloping intraconal
optic nerve
Renee M. Burke, Robert J. Morin, and S. Anthony Wolfe
Chapter 13: Facial paralysis
13.1: Facial paralysis
Eyal Gur
13.2: Facial paralysis
13.3: Cross facial nerve graft
13.4: Gracilis harvest
Peter C. Neligan
Chapter 14: Pharyngeal and esophageal
reconstruction
14.1: Reconstruction of pharyngoesophageal defects with the
anterolateral thigh flap
Peirong Yu
Chapter 15: Tumors of the facial skeleton: Fibrous
dysplasia
15.1: Surgical approaches to the facial skeleton
Yu-Ray Chen, You-Wei Cheong, and Alberto Córdova-Aguilar
Chapter 17: Local flaps for facial coverage
17.1: Facial artery perforator flap
17.2: Local flaps for facial coverage
Peter C. Neligan
Chapter 21.2: Rotation advancement cheiloplasty
21.2.1: Repair of unilateral cleft lip
Philip Kuo-Ting Chen, M. Samuel Noordhoff, Frank Chun-Shin,
Chang, and Fuan Chiang Chan
21.2.2: Unilateral cleft lip repair – anatomic subunit
approximation technique
David M. Fisher
Chapter 24: Alveolar clefts
24.1: Unilateral cleft alveolar bone graft
24.2: Mobilized premaxilla after vomer osteotomy prior to
setback and splint application
Richard A. Hopper and Gerhard S. Mundinger

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Video Contents
6.3: Diagnosis and treatment of painful neuroma and of nerve
compression in the lower extremity 3
A. Lee Dellon
Chapter 7: Skeletal reconstruction
7.1: Medial femoral condyle/medial geniculate artery
osteocutaneous free flap dissection for scaphoid nonunion
Stephen J. Kovach III and L. Scott Levin
Chapter 10: Reconstruction of the chest
10.1: Sternal rigid fixation
David H. Song and Michelle C. Roughton
Chapter 12: Abdominal wall reconstruction
12.1: Component separation innovation
Peter C. Neligan
Chapter 13: Reconstruction of male genital defects
13.1: Complete and partial penile reconstruction
Stan Monstrey, Peter Ceulemans, Nathalie Roche,
Philippe Houtmeyers, Nicolas Lumen, and Piet Hoebeke
Volume Five:
Chapter 6: Mastopexy options and techniques
6.1: Circumareolar mastopexy
Kenneth C. Shestak
Chapter 7: One- and two-stage considerations for
augmentation mastopexy
7.1: Preoperative markings for a single-stage augmentation
mastopexy
W. Grant Stevens
Chapter 10: Reduction mammaplasty with short scar
techniques
10.1: SPAIR technique
Dennis C. Hammond
Chapter 11: Gynecomastia surgery
11.1: Ultrasound-assisted liposuction
Charles M. Malata
Chapter 15: One- and two-stage prosthetic
reconstruction in nipple-sparing mastectomy
15.1: Pectoralis muscle elevation
15.2: Acellular dermal matrix
15.3: Sizer
Amy S. Colwell
Chapter 16: Skin-sparing mastectomy: Planned
two-stage and direct-to-implant breast
reconstruction
16.1: Mastectomy and expander insertion: First stage
16.2: Mastectomy and expander insertion: Second stage
Maurizio B. Nava, Giuseppe Catanuto, Angela Pennati,
Valentina Visintini Cividin, and Andrea Spano
Chapter 19: Latissimus dorsi flap breast
reconstruction
19.1: Latissimus dorsi flap technique
Scott L. Spear†
19.2: Markings
19.3: Intraoperative skin paddles
19.4: Tendon division
19.5: Transposition and skin paddles
19.6: Inset and better skin paddle explanation
Neil A. Fine and Michael S. Gart
Chapter 20.2: The deep inferior epigastric artery
perforator (DIEAP) flap
20.2.1: The Deep Inferior Epigastric Artery Perforator (DIEAP)
flap breast reconstruction
Phillip N. Blondeel and Robert J. Allen, Sr
Chapter 21.2: Gluteal free flaps for breast
reconstruction
21.2.1: Superior Gluteal Artery Perforator (SGAP) flap
21.2.2: Inferior Gluteal Artery Perforator (IGAP) flap
Peter C. Neligan
Chapter 21.3: Medial thigh flaps for breast
reconstruction
21.3.1: Transverse Upper Gracilis (TUG) flap 1
Peter C. Neligan
21.3.2: Transverse Upper Gracilis (TUG) flap 2
Venkat V. Ramakrishnan
Chapter 23.2: Partial breast reconstruction using
reduction and mastopexy techniques
23.2.1: Partial breast reconstruction using reduction
mammoplasty
Maurice Y. Nahabedian
23.2.2: Partial breast reconstruction with a latissimus dorsi flap
Neil A. Fine
23.2.3: Partial breast reconstruction with a pedicle TRAM
Maurice Y. Nahabedian
Volume Six:
Chapter 1: Anatomy and biomechanics of the hand
1.1: The extensor tendon compartments
1.2: The contribution of the interosseous and lumbrical
muscles to the lateral bands
1.3: Extrinsic flexors and surrounding vasculonervous
elements, from superficial to deep
1.4: The lumbrical plus deformity
1.5: The sensory and motor branches of the median nerve in
the hand
James Chang, Vincent R. Hentz, Robert A. Chase, and
Anais Legrand
Chapter 2: Examination of the upper extremity
2.1: Flexor profundus test in a normal long finger
2.2: Flexor sublimis test in a normal long finger
2.3: Extensor pollicis longus test in a normal person
2.4: Test for the Extensor Digitorum Communis (EDC) muscle
in a normal hand
2.5: Test for assessing thenar muscle function
2.6: The “cross fingers” sign
2.7: Static Two-Point Discrimination Test (s-2PD Test)
2.8: Moving 2PD Test (m-2PD Test) performed on the radial or
ulnar aspect of the finger

xv
Video Contents
2.9: Semmes–Weinstein monofilament test: The patient should
sense the pressure produced by bending the filament
2.10: Allen’s test in a normal person
2.11: Digital Allen’s test
2.12: Scaphoid shift test
2.13: Dynamic tenodesis effect in a normal hand
2.14: The milking test of the fingers and thumb in a normal
hand
2.15: Eichhoff test
2.16: Adson test
2.17: Roos test
Ryosuke Kakinoki
Chapter 3: Diagnostic imaging of the hand and
wrist
3.1: Scaphoid lunate dislocation
Alphonsus K. Chong and David M. K. Tan
3.2: Right wrist positive midcarpal catch up clunk
Alphonsus K. Chong
Chapter 4: Anesthesia for upper extremity surgery
4.1: Supraclavicular block
Subhro K. Sen
Chapter 5: Principles of internal fixation as applied
to the hand and wrist
5.1: Dynamic compression plating and lag screw technique
Christopher Cox
5.2: Headless compression screw
5.3: Locking vs. non-locking plates
Jeffrey Yao and Jason R. Kang
Chapter 7: Hand fractures and joint injuries
7.1: Bennett reduction
7.2: Hemi-Hamate arthroplasty
Warren C. Hammert
Chapter 9: Flexor tendon injury and reconstruction
9.1: Zone II flexor tendon repair
9.2: Incision and feed tendon forward
9.3: Distal tendon exposure
9.4: Six-strand M-tang repair
9.5: Extension–flexion test – wide awake
Jin Bo Tang
Chapter 10: Extensor tendon injuries
10.1: Sagittal band reconstruction
10.2: Setting the tension in extensor indicis transfer
Kai Megerle
Chapter 11: Replantation and revascularization
11.1: Hand replantation
James Chang
Chapter 12: Reconstructive surgery of the mutilated
hand
12.1: Debridement technique
James Chang
Chapter 13: Thumb reconstruction: Non-
microsurgical techniques
13.1: Osteoplastic thumb reconstruction
13.2: First Dorsal Metacarpal Artery (FDMA) flap
Jeffrey B. Friedrich
Chapter 14: Thumb reconstruction: Microsurgical
techniques
14.1: Trimmed great toe
14.2: Second toe for index finger
14.3: Combined second and third toe for metacarpal hand
Nidal F. Al Deek
Chapter 19: Rheumatologic conditions of the hand
and wrist
19.1: Extensor tendon rupture and end–side tendon transfer
James Chang
19.2: Silicone metacarpophalangeal arthroplasty
Kevin C. Chung and Evan Kowalski
Chapter 20: Osteoarthritis in the hand and wrist
20.1: Ligament reconstruction tendon interposition arthroplasty
of the thumb carpometacarpal joint
James W. Fletcher
Chapter 21: The stiff hand and the spastic hand
21.1: Flexor pronator slide
David T. Netscher
Chapter 22: Ischemia of the hand
22.1: Radial artery sympathectomy
Hee Chang Ahn and Neil F. Jones
22.2: Interposition arterial graft and sympathectomy
Hee Chang Ahn
Chapter 24: Nerve entrapment syndromes
24.1: The manual muscle testing algorithm
24.2: Scratch collapse test – carpal tunnel
Elisabet Hagert
24.3: Injection technique for carpal tunnel surgery
24.4: Wide awake carpal tunnel surgery
Donald Lalonde
24.5: Clinical exam and surgical technique – lacertus
syndrome
Elisabet Hagert
24.6: Injection technique for cubital tunnel surgery
24.7: Wide awake cubital tunnel surgery
Donald Lalonde
24.8: Clinical exam and surgical technique – radial tunnel
syndrome
24.9: Clinical exam and surgical technique – lateral
intermuscular syndrome
24.10: Clinical exam and surgical technique – axillary nerve
entrapment
Elisabet Hagert
24.11: Carpal tunnel and cubital tunnel releases in the same
patient in one procedure with field sterility: Part 1 – local
anesthetic injection for carpal tunnel
24.12: Carpal tunnel and cubital tunnel releases in the same
patient in one procedure with field sterility: Part 2 – local
anesthetic injection for cubital tunnel
Donald Lalonde and Michael Bezuhly
Chapter 25: Congenital hand I: Embryology,
classification, and principles
25.1: Pediatric trigger thumb release
James Chang

xvi
Video Contents
Chapter 27: Congenital hand III: Thumb hypoplasia
27.1: Thumb hypoplasia
Joseph Upton III and Amir Taghinia
Chapter 30: Growth considerations in pediatric
upper extremity trauma and reconstruction
30.1: Epiphyseal transplant harvesting technique
Marco Innocenti and Carla Baldrighi
Chapter 31: Vascular anomalies of the upper
extremity
31.1: Excision of venous malformation
Joseph Upton III and Amir Taghinia
Chapter 32: Peripheral nerve injuries of the upper
extremity
32.1: Suture repair of the cut digital nerve
32.2: Suture repair of the median nerve
Simon Farnebo and Johan Thorfinn
Chapter 35: Free-functioning muscle transfer in the
upper extremity
35.1: Gracilis functional muscle harvest
Gregory H. Borschel
Chapter 36: Brachial plexus injuries: Adult and
pediatric
36.1: Pediatric: shoulder correct and biceps-to-triceps transfer
with preserving intact brachialis
36.2: Adult: results of one-stage surgery for C5 rupture, C6–T1
root avulsion 10 years after
36.3: Nerve transfer results 1
36.4: Nerve transfer results 2
36.5: Nerve transfer results 3
36.6: Nerve transfer results 4
36.7: Nerve transfer results 5
David Chwei-Chin Chuang
Chapter 37: Restoration of upper extremity function
in tetraplegia
37.1: The single-stage grip and release procedure
37.2: Postoperative results after single-stage grip release
procedure in OCu3–5 patients
Carina Reinholdt and Catherine Curtin
Chapter 38: Upper extremity vascularized composite
allotransplantation
38.1: Upper extremity composite tissue allotransplantation
W. P. Andrew Lee and Vijay S. Gorantla
Chapter 39: Hand therapy
39.1: Goniometric measurement
39.2: Threshold testing
Christine B. Novak and Rebecca L. Neiduski

Lecture Video Contents
Volume One:
Chapter 1: Plastic surgery and innovation in medicine
Plastic surgery and innovation in medicine
Peter C. Neligan
Chapter 7: Digital imaging in plastic surgery
Digital imaging in plastic surgery
Daniel Z. Liu
Chapter 15: Skin graft
Skin graft
Peter C. Neligan
Chapter 19: Repair and grafting of peripheral nerve
Nerve injury and repair
Kirsty Usher Boyd, Andrew Yee, and Susan E. Mackinnon
Chapter 20: Reconstructive fat grafting
Reconstructive fat grafting
J. Peter Rubin
Chapter 21: Vascular territories
Vascular territories
Steven F. Morris
Chapter 22: Flap classification and applications
Flap classification and applications
Joon Pio Hong
Chapter 23: Flap pathophysiology and pharmacology
Flap pathophysiology and pharmacology
Cho Y. Pang and Peter C. Neligan
Chapter 24: Principles and techniques of
microvascular surgery
Principles and techniques of microvascular surgery
Fu-Chan Wei, Nidal F. Al Deek, and
Sherilyn Keng Lin Tay
Chapter 25: Principles and applications of tissue
expansion
Principles and applications of tissue expansion
Ivo Alexander Pestana, Louis C. Argenta, and
Malcolm W. Marks
Chapter 26: Principles of radiation
Therapeutic radiation: principles, effects, and complications
Gabrielle M. Kane
Chapter 28: Benign and malignant nonmelanocytic
tumors of the skin and soft tissue
Benign and malignant nonmelanocytic tumors of the skin and soft
tissue
Rei Ogawa
Chapter 31: Facial prosthetics in plastic surgery
Facial prosthetics in plastic surgery
Gordon H. Wilkes
Volume Two:
Chapter 4: Skincare and nonsurgical skin
rejuvenation
Skincare and nonsurgical skin rejuvenation
Leslie Baumann and Edmund Weisberg
Chapter 5.2: Injectables and resurfacing techniques:
Soft-tissue fillers
Soft-tissue fillers
Trevor M. Born, Lisa E. Airan, and Daniel Suissa
Chapter 5.3: Injectables and resurfacing techniques:
Botulinum toxin (BoNT-A)
Botulinum toxin
Michael A. C. Kane
Chapter 5.4: Injectables and resurfacing techniques:
Laser resurfacing
Laser resurfacing
Steven R. Cohen, Ahmad N. Saad, Tracy Leong,
and E. Victor Ross
Chapter 5.5: Injectables and resurfacing techniques:
Chemical peels
Chemical peels
Suzan Obagi
Chapter 6.1: Facelift: Facial anatomy and aging
Anatomy of the aging face
Bryan Mendelson and Chin-Ho Wong
Chapter 6.2: Facelift: Principles of and surgical
approaches to facelift
Principles of and surgical approaches to facelift
Richard J. Warren
Chapter 6.3: Facelift: Platysma-SMAS plication
Platysma-SMAS plication
Miles G. Berry

xviii
Lecture Video Contents
Chapter 6.4: Facelift: Facial rejuvenation with loop
sutures – the MACS lift and its derivatives
Facial rejuvenation with loop sutures – the MACS lift and its
derivatives
Mark Laurence Jewell
Chapter 6.5: Facelift: Lateral SMASectomy facelift
Lateral SMASectomy facelift
Daniel C. Baker and Steven M. Levine
Chapter 6.6: Facelift: The extended SMAS technique
in facial rejuvenation
The extended SMAS technique in facelift
James M. Stuzin
Chapter 6.7: Facelift: SMAS with skin attached – the
“high SMAS” technique
SMAS with skin attached – the high SMAS technique
Fritz E. Barton Jr.
Chapter 6.8: Facelift: Subperiosteal midface lift
Subperiosteal midface lift
Alan Yan and Michael J. Yaremchuk
Chapter 6.9: Facelift: Male facelift
Male facelift
Timothy J. Marten and Dino Elyassnia
Chapter 6.10: Facelift: Secondary deformities and
the secondary facelift
Secondary deformities and the secondary facelift
Timothy J. Marten and Dino Elyassnia
Chapter 7: Forehead rejuvenation
Forehead rejuvenation
Richard J. Warren
Chapter 8: Endoscopic brow lifting
Endoscopic brow lift
Renato Saltz and Alyssa Lolofie
Chapter 9: Blepharoplasty
Blepharoplasty
Julius Few Jr. and Marco Ellis
Chapter 11: Asian facial cosmetic surgery
Asian facial cosmetic surgery
Clyde H. Ishii
Chapter 12: Neck rejuvenation
Neck rejuvenation
James E. Zins, Joshua T. Waltzman, and Rafael A. Couto
Chapter 13: Structural fat grafting
Structural fat grafting
Sydney R. Coleman and Alesia P. Saboeiro
Chapter 15: Nasal analysis and anatomy
Nasal analysis and anatomy
Rod J. Rohrich
Chapter 19: Secondary rhinoplasty
Secondary rhinoplasty
Ronald P. Gruber, Simeon H. Wall Jr., David L. Kaufman,
and David M. Kahn
Chapter 21: Hair restoration
Hair restoration
Jack Fisher
Chapter 22.1: Liposuction: A comprehensive review
of techniques and safety
Liposuction
Phillip J. Stephan, Phillip Dauwe, and Jeffrey Kenkel
Chapter 22.2: Correction of liposuction deformities
with the SAFE liposuction technique
SAFE liposuction technique
Simeon H. Wall Jr. and Paul N. Afrooz
Chapter 23: Abdominoplasty procedures
Abdominoplasty
Dirk F. Richter and Nina Schwaiger
Chapter 25.2: Circumferential approaches to truncal
contouring: Belt lipectomy
Belt lipectomy
Al S. Aly, Khalid Al-Zahrani, and Albert Cram
Chapter 25.3: Circumferential approaches to truncal
contouring: The lower lipo-bodylift
Circumferential lower bodylift
Dirk F. Richter and Nina Schwaiger
Chapter 25.4: Circumferential approaches to truncal
contouring: Autologous buttocks augmentation with
purse string gluteoplasty
Purse string gluteoplasty
Joseph P. Hunstad and Nicholas A. Flugstad
Chapter 25.5: Circumferential approaches to truncal
contouring: Lower bodylift with autologous gluteal
flaps for augmentation and preservation of gluteal
contour
Lower bodylift with gluteal flaps
Robert F. Centeno and Jazmina M. Gonzalez
Chapter 26.3: Buttock augmentation: Buttock
shaping with fat grafting and liposuction
Buttock shaping with fat grafting and liposuction
Constantino G. Mendieta, Thomas L. Roberts III,
and Terrence W. Bruner
Chapter 27: Upper limb contouring
Upper limb contouring
Joseph F. Capella, Matthew J. Trovato, and Scott Woehrle
Chapter 30: Aesthetic genital surgery
Aesthetic genital surgery
Gary J. Alter

xix
Lecture Video Contents
Volume Three:
Chapter 10.3: Midface reconstruction: The M. D.
Anderson approach
Midfacial reconstruction: The M. D. Anderson approach
Matthew M. Hanasono and Roman Skoracki
Chapter 12: Lip reconstruction
Lip reconstruction
Peter C. Neligan and Lawrence J. Gottlieb
Chapter 14: Pharyngeal and esophageal
reconstruction
Pharyngoesophageal reconstruction
Peirong Yu
Chapter 15: Tumors of the facial skeleton: Fibrous
dysplasia
Fibrous dysplasia
Alberto Córdova-Aguilar and Yu-Ray Chen
Chapter 17: Local flaps for facial coverage
Local flaps for facial coverage
David W. Mathes
Chapter 19: Facial transplant
Facial transplant
Michael Sosin and Eduardo D. Rodriguez
Chapter 32: Nonsyndromic craniosynostosis
Nonsyndromic craniosynostosis
Patrick A. Gerety, Jesse A. Taylor, and Scott P. Bartlett
Chapter 36: Pierre Robin Sequence
Pierre Robin sequence
Chad A. Purnell and Arun K. Gosain
Chapter 39: Vascular anomalies
Vascular anomalies
Arin K. Greene and John B. Mulliken
Volume Four:
Chapter 2: Management of lower extremity trauma
Management of lower extremity trauma
Yoo Joon Sur, Shannon M. Colohan, and Michel Saint-Cyr
Chapter 15: Surgery for gender identity disorder
Surgery for gender identity disorder
Loren S. Schechter
Chapter 16: Pressure sores
Pressure sores
Robert Kwon, Juan L. Rendon, and Jeffrey E. Janis
Chapter 17: Perineal reconstruction
Perineal reconstruction
Hakim K. Said and Otway Louie
Volume Five:
Chapter 5: Breast augmentation with autologous fat
grafting
Breast augmentation with autologous fat grafting
E. Delay
Chapter 6: Mastopexy options and techniques
Mastopexy
Robert Cohen
Chapter 9: Reduction mammaplasty with inverted-T
techniques
Reduction mammaplasty with inverted-T techniques
Maurice Y. Nahabedian
Chapter 15: One- and two-stage prosthetic
reconstruction in nipple-sparing mastectomy
Prosthetic reconstruction in nipple-sparing mastectomy
Amy S. Colwell
Chapter 20.1: Abdominally based free flaps:
Introduction
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 20.2: The deep inferior epigastric artery
perforator (DIEAP) flap
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 20.3: The superficial inferior epigastric
artery (SIEA) flap
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 20.4: The free TRAM flap
Abdominally-based autologous breast reconstruction
Maurice Y. Nahabedian, Phillip N. Blondeel, and David H. Song
Chapter 25: Radiation therapy considerations in the
setting of breast reconstruction
Radiation therapy in breast reconstruction
Steven Kronowitz
Volume Six:
Chapter 7: Hand fractures and joint injuries
Hand fractures and joint injuries
Joseph S. Khouri and Warren C. Hammert
Chapter 13: Thumb reconstruction: Non-
microsurgical techniques
Thumb reconstruction
Nicholas B. Vedder and Jeffrey B. Friedrich
Chapter 21: The stiff hand and the spastic hand
The stiff hand
David T. Netscher, Kenneth W. Donohue, and Dang T. Pham

xx
Lecture Video Contents
Chapter 24: Nerve entrapment syndromes
Tips and pearls on common nerve compressions
Elisabet Hagert and Donald Lalonde
Chapter 30: Growth considerations in pediatric
upper extremity trauma and reconstruction
Growth considerations in pediatric upper extremity trauma and
reconstruction
Marco Innocenti and Carla Baldrighi
Chapter 33: Nerve transfers
Nerve injury and repair
Kirsty Usher Boyd, Andrew Yee, and Susan E. Mackinnon
Chapter 37: Restoration of upper extremity function
in tetraplegia
Restoration of upper extremity function in tetraplegia
Carina Reinholdt and Catherine Curtin

Preface to the Fourth Edition
When I wrote the preface to the 3rd edition of this book, I
remarked how honored and unexpectedly surprised I was to
be the Editor of this great series. This time ‘round, I’m equally
grateful to carry this series forward. When Elsevier called me
and suggested it was time to prepare the 4th edition, my
initial reaction was that this was way too soon. What could
possibly have changed in Plastic Surgery since the 3rd edition
was launched in 2012? As it transpires, there have been many
developments and I hope we have captured them in this
edition.
We have an extraordinary specialty. A recent article by
Chadra, Agarwal and Agarwal entitled “Redefining Plastic
Surgery” appeared in Plastic and Reconstructive Surgery—Global
Open. In it they gave the following definition: “Plastic surgery
is a specialized branch of surgery, which deals with deformi­
ties, defects and abnormalities of the organs of perception,
organs of action and the organs guarding the external pas­
sages, besides innovation, implantation, replantation and
transplantation of tissues, and aims at restoring and improv­
ing their form, function and the esthetic appearances.” This is
an all-encompassing but very apt definition and captures the
enormous scope of the specialty.1
In the 3rd edition, I introduced volume editors for each of
the areas of the specialty because the truth is that one person
can no longer be an expert in all areas of this diverse specialty,
and I’m certainly not. I think this worked well because the
volume editors not only had the expertise to present their area
of subspecialty in the best light, but they were tuned in to
what was new and who was doing it. We have continued this
model in this new edition. Four of the seven volume editors
from the previous edition have again helped to bring the latest
and the best to this edition: Drs Gurtner, Song, Rodriguez,
Losee, and Chang have revised and updated their respective
volumes with some chapters remaining, some extensively
revised, some added, and some deleted. Dr. Peter Rubin has
replaced Dr. Rick Warren to compile the Aesthetic volume
(Vol. 2). Dr. Warren did a wonderful job in corralling this
somewhat disparate, yet vitally important, part of our spe­
cialty into the Aesthetic volume in the 3rd edition but felt that
the task of doing it again, though a labor of love, was more
than he wanted to take on. Similarly, Dr. Jim Grotting who did
a masterful job in the last edition on the Breast volume,
decided that doing a major revision should be undertaken by
someone with a fresh perspective and Dr. Maurice Nahabe­
dian stepped into that breach. I hope you will like the changes
you see in both of these volumes.
Dr. Allen Van Beek was the video editor for the last edition
and he compiled an impressive array of movies to comple­
ment the text. This time around, we wanted to go a step
further and though we’ve considerably expanded the list of
videos accompanying the text (there are over 170), we also
added the idea of lectures accompanying selected chapters.
What we’ve done here is to take selected key chapters and
include the images from that chapter, photos and artwork,
and create a narrated presentation that is available online;
there are annotations in the text to alert the reader that this is
available. Dr. Daniel Liu, who has taken over from Dr. Van
Beek as multimedia editor (rather than video editor) has done
an amazing job in making all of this happen. There are over
70 presentations of various key chapters online, making it as
easy as possible for you, the reader, to get as much knowledge
as you can, in the easiest way possible from this edition. Many
of these presentations have been done by the authors of the
chapters; the rest have been compiled by Dr. Liu and myself
from the content of the individual chapters. I hope you find
them useful.
The reader may wonder how this all works. To plan this
edition, the Elsevier team, headed by Belinda Kuhn, and I,
convened a face-to-face meeting in San Francisco. The volume
editors, as well as the London based editorial team, were
present. We went through the 3rd edition, volume by volume,
chapter by chapter, over an entire weekend. We decided what
needed to stay, what needed to be added, what needed to be
revised, and what needed to be changed. We also decided
who should write the various chapters, keeping many exist­
ing authors, replacing others, and adding some new ones; we
did this so as to really reflect the changes occurring within the
specialty. We also decided on practical changes that needed to
be made. As an example, you will notice that we have omitted
the complete index for the 6 Volume set from Volumes 2-6
and highlighted only the table of contents for that particular
volume. The complete index is of course available in Volume
1 and fully searchable online. This allowed us to save several
hundred pages per volume, reducing production costs and
diverting those dollars to the production of the enhanced online
content.
In my travels around the world since the 3rd edition was
published, I’ve been struck by what an impact this publication
has had on the specialty and, more particularly, on training.
Everywhere I go, I’m told how the text is an important part
of didactic teaching and a font of knowledge. It is gratifying
to see that the 3rd edition has been translated into Portuguese,
Spanish, and Chinese. This is enormously encouraging. I
hope this 4th edition continues to contribute to the specialty,
remains a resource for practicing surgeons, and continues to
prepare our trainees for their future careers in Plastic Surgery.
Peter C. Neligan
Seattle, WA
September, 2017
1 Chandra R, Agarwal R, Agarwal D. Redefining Plastic Surgery. Plast
Reconstr Surg Glob Open. 2016;4(5):e706.

List of Editors
Editor-in-Chief
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
Professor of Surgery
Department of Surgery, Division of Plastic Surgery
University of Washington
Seattle, WA, USA
Volume 1: Principles
Geoffrey C. Gurtner, MD, FACS
Johnson and Johnson Distinguished Professor of
Surgery and Vice Chairman,
Department of Surgery (Plastic Surgery)
Stanford University
Stanford, CA, USA
Volume 2: Aesthetic
J. Peter Rubin, MD, FACS
UPMC Professor of Plastic Surgery
Chair, Department of Plastic Surgery
Professor of Bioengineering
University of Pittsburgh
Pittsburgh, PA, USA
Volume 3: Craniofacial, Head and Neck Surgery
Eduardo D. Rodriguez, MD, DDS
Helen L. Kimmel Professor of Reconstructive
Plastic Surgery
Chair, Hansjörg Wyss Department of Plastic
Surgery
NYU School of Medicine
NYU Langone Medical Center
New York, NY, USA
Volume 3: Pediatric Plastic Surgery
Joseph E. Losee, MD
Ross H. Musgrave Professor of Pediatric Plastic
Surgery
Department of Plastic Surgery
University of Pittsburgh Medical Center;
Chief Division of Pediatric Plastic Surgery
Children’s Hospital of Pittsburgh
Pittsburgh, PA, USA
Volume 4: Lower Extremity, Trunk, and Burns
David H. Song, MD, MBA, FACS
Regional Chief, MedStar Health
Plastic and Reconstructive Surgery
Professor and Chairman
Department of Plastic Surgery
Georgetown University School of Medicine
Washington, DC, USA
Volume 5: Breast
Maurice Y. Nahabedian, MD, FACS
Professor and Chief
Section of Plastic Surgery
MedStar Washington Hospital Center
Washington, DC, USA;
Vice Chairman
Department of Plastic Surgery
MedStar Georgetown University Hospital
Washington, DC, USA
Volume 6: Hand and Upper Extremity
James Chang, MD
Johnson & Johnson Distinguished
Professor and Chief
Division of Plastic and Reconstructive Surgery
Stanford University Medical Center
Stanford, CA, USA
Multimedia editor
Daniel Z. Liu, MD
Plastic and Reconstructive Surgeon
Cancer Treatment Centers of America at Midwest­
ern Regional Medical Center
Zion, IL, USA

List of Contributors
VOLUME ONE
Hatem Abou-Sayed, MD, MBA
Vice President
Physician Engagement
Interpreta, Inc.
San Diego, CA, USA
Paul N. Afrooz, MD
Resident
Plastic and Reconstructive Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Claudia R. Albornoz, MD, MSc
Research Fellow
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA
Nidal F. Al Deek, MD
Doctor of Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Taipei, Taiwan
Amy K. Alderman, MD, MPH
Private Practice
Atlanta, GA, USA
Louis C. Argenta, MD
Professor of Plastic and Reconstructive Surgery
Department of Plastic Surgery
Wake Forest Medical Center
Winston Salem, NC, USA
Stephan Ariyan, MD, MBA
Emeritus Frank F. Kanthak Professor of Surgery,
Plastic Surgery, Surgical Oncology,
Otolaryngology
Yale University School of Medicine;
Associate Chief
Department of Surgery;
Founding Director, Melanoma Program
Smilow Cancer Hospital, Yale Cancer Center
New Haven, CT, USA
Tomer Avraham, MD
Attending Plastic Surgeon
Mount Sinai Health System
Tufts University School of Medicine
New York, NY, USA
Aaron Berger, MD, PhD
Clinical Assistant Professor
Division of Plastic Surgery
Florida International University School of
Medicine
Miami, FL, USA
Kirsty Usher Boyd, MD, FRCSC
Assistant Professor Surgery (Plastics)
Division of Plastic and Reconstructive Surgery
University of Ottawa
Ottawa, Ontario, Canada
Charles E. Butler, MD, FACS
Professor and Chairman
Department of Plastic Surgery
Charles B. Barker Endowed Chair in Surgery
The University of Texas MD Anderson Cancer
Center
Houston, TX, USA
Peter E. M. Butler, MD, FRCSI, FRCS,
FRCS(Plast)
Professor
Plastic and Reconstructive Surgery
University College and Royal Free London
London, UK
Yilin Cao, MD, PhD
Professor
Shanghai Ninth People’s Hospital
Shanghai Jiao Tong University School of
Medicine
Shanghai, China
Franklyn P. Cladis, MD, FAAP
Associate Professor of Anesthesiology
Department of Anesthesiology
The Children’s Hospital of Pittsburgh of UPMC
Pittsburgh, PA, USA
Mark B. Constantian, MD
Private Practice
Surgery (Plastic Surgery)
St. Joseph Hospital
Nashua, NH, USA
Daniel A. Cuzzone, MD
Plastic Surgery Fellow
Hanjörg Wyss Department of Plastic Surgery
New York University Medical Center
New York, NY, USA
Gurleen Dhami, MD
Chief Resident
Department of Radiation Oncology
University of Washington
Seattle, WA, USA
Gayle Gordillo, MD
Associate Professor
Plastic Surgery
The Ohio State University
Columbus, OH, USA
Geoffrey C. Gurtner, MD, FACS
Johnson and Johnson Distinguished Professor
of Surgery and Vice Chairman,
Department of Surgery (Plastic Surgery)
Stanford University
Stanford, CA, USA
Phillip C. Haeck, MD
Surgeon
Plastic Surgery
The Polyclinic
Seattle, WA, USA
The late Bruce Halperin†, MD
Formerly Adjunct Associate Professor of
Anesthesia
Department of Anesthesia
Stanford University
Stanford, CA, USA
Daniel E. Heath
Lecturer
School of Chemical and Biomedical Engineering
University of Melbourne
Parkville, Victoria, Australia
Joon Pio Hong, MD, PhD, MMM
Professor
Plastic Surgery
Asan Medical Center, University of Ulsan
Seoul, South Korea
Michael S. Hu, MD, MPH, MS
Postdoctoral Fellow
Division of Plastic Surgery
Department of Surgery
Stanford University School of Medicine
Stanford, CA, USA
C. Scott Hultman, MD, MBA
Professor and Chief
Division of Plastic and Reconstructive Surgery
University of North Carolina
Chapel Hill, NC, USA
Amir E. Ibrahim
Division of Plastic Surgery
Department of Surgery
American University of Beirut Medical Center
Beirut, Lebanon
Leila Jazayeri, MD
Microsurgery Fellow
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA
The editors would like to acknowledge and offer grateful thanks for the input of all previous editions’ contributors, without whom this new edition would
not have been possible.

xxiv
List of Contributors
Brian Jeffers
Student
Bioengineering
University of California Berkeley
Berkeley, CA USA
Lynn Jeffers, MD, FACS
Private Practice
Oxnard, CA, USA
Mohammed M. Al Kahtani, MD, FRCSC
Clinical Fellow
Division of Plastic Surgery
Department of Surgery
University of Alberta
Edmonton, Alberta, Canada
Gabrielle M. Kane, MB, BCh, EdD, FRCPC
Associate Professor
Radiation Oncology
University of Washington
Seattle, WA, USA
Raghu P. Kataru, PhD
Senior Research Scientist
Memorial Sloan-Kettering Cancer Center
New York, NY, USA
Carolyn L. Kerrigan, MD, MSc, MHCDS
Professor of Surgery
Surgery
Dartmouth–Hitchcock Medical Center
Lebanon, NH, USA
Timothy W. King, MD, PhD, FAAP, FACS
Associate Professor with Tenure
Departments of Surgery and Biomedical
Engineering;
Director of Research, Division of Plastic Surgery
University of Alabama at Birmingham (UAB)
Craniofacial and Pediatric Plastic Surgery
Children’s of Alabama – Plastic Surgery;
Chief, Plastic Surgery Section
Birmingham VA Hospital
Birmingham, AL, USA
Brian M. Kinney, MD, FACS, MSME
Clinical Assistant Professor of Plastic Surgery
University of Southern California
School of Medicine
Los Angeles, CA, USA
W. P. Andrew Lee, MD
The Milton T. Edgerton MD, Professor and
Chairman
Department of Plastic and Reconstructive
Surgery
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Sherilyn Keng Lin Tay, MBChB, MSc,
FRCS(Plast)
Consultant Plastic Surgeon
Canniesburn Plastic Surgery Unit
Glasgow Royal Infirmary
Glasgow, UK
Daniel Z. Liu, MD
Plastic and Reconstructive Surgeon
Cancer Treatment Centers of America at
Midwestern Regional Medical Center
Zion, IL, USA
Wei Liu, MD, PhD
Professor
Plastic and Reconstructive Surgery
Shanghai Ninth People’s Hospital
Shanghai Jiao Tong University School of
Medicine
Shanghai, China
Michael T. Longaker, MD, MBA, FACS
Deane P. and Louise Mitchell Professor and Vice
Chair
Department of Surgery
Stanford University
Stanford, CA, USA
H. Peter Lorenz, MD
Service Chief and Professor, Plastic Surgery
Lucile Packard Children’s Hospital
Stanford University School of Medicine
Stanford, CA, USA
Susan E. Mackinnon, MD
Sydney M. Shoenberg Jr. and Robert H.
Shoenberg Professor
Department of Surgery, Division of Plastic and
Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Malcolm W. Marks, MD
Professor and Chairman
Department of Plastic Surgery
Wake Forest University School of Medicine
Winston-Salem, NC, USA
Diego Marre, MD
Fellow
O’Brien Institute
Department of Plastic and Reconstructive
Surgery
St. Vincent’s Hospital
Melbourne, Australia
David W. Mathes, MD
Professor and Chief of the Division of Plastic
and Reconstructive Surgery
University of Colorado
Aurora, CO, USA
Evan Matros MD, MMSc
Plastic Surgeon
Memorial Sloan-Kettering Cancer Center
New York, NY, USA
Isabella C. Mazzola, MD
Attending Plastic Surgeon
Klinik für Plastische und Ästhetische Chirurgie
Klinikum Landkreis Erding
Erding, Germany
Riccardo F. Mazzola, MD
Plastic Surgeon
Department of Specialistic Surgical Sciences
Fondazione Ospedale Maggiore Policlinico, Ca’
Granda IRCCS
Milano, Italy
Lindsay D. McHutchion, MS, BSc
Anaplastologist
Institute for Reconstructive Sciences in Medicine
Edmonton, Alberta, Canada
Babak J. Mehrara, MD, FACS
Associate Member, Associate Professor of
Surgery (Plastic)
Memorial Sloan Kettering Cancer Center
Weil Cornell University Medical Center
New York, NY, USA
Steven F. Morris, MD, MSc, FRCSC
Professor of Surgery
Department of Surgery
Dalhousie University
Halifax, Nova Scotia, Canada
Wayne A. Morrison, MBBS, MD, FRACS
Professorial Fellow
O’Brien Institute
Department of Surgery, University of Melbourne
Department of Plastic and Reconstructive
Surgery, St. Vincent’s Hospital
Melbourne, Australia
Peter C. Neligan, MB, FRCS(I), FRCSC,
FACS
Professor of Surgery
Department of Surgery, Division of Plastic
Surgery
University of Washington
Seattle, WA, USA
Andrea J. O’Connor, BE(Hons), PhD
Associate Professor
Department of Chemical and Biomolecular
Engineering
University of Melbourne
Parkville, Victoria, Australia
Rei Ogawa, MD, PhD, FACS
Professor and Chief
Department of Plastic
Reconstructive and Aesthetic Surgery
Nippon Medical School
Tokyo, Japan
Dennis P. Orgill, MD, PhD
Professor of Surgery
Harvard Medical School
Medical Director, Wound Care Center;
Vice Chairman for Quality Improvement
Department of Surgery
Brigham and Women’s Hospital
Boston, MA, USA

xxv
List of Contributors
Cho Y. Pang, PhD
Senior Scientist
Research Institute
The Hospital for Sick Children;
Professor
Departments of Surgery/Physiology
University of Toronto
Toronto, Ontario, Canada
Ivo Alexander Pestana, MD, FACS
Associate Professor
Plastic and Reconstructive Surgery
Wake Forest University
Winston Salem, NC, USA
Giorgio Pietramaggior, MD, PhD
Swiss Nerve Institute
Clinique de La Source
Lausanne, Switzerland
Andrea L. Pusic, MD, MHS, FACS
Associate Professor
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA
Russell R. Reid, MD, PhD
Associate Professor
Surgery/Section of Plastic and Reconstructive
Surgery
University of Chicago Medicine
Chicago, IL, USA
Neal R. Reisman, MD, JD
Chief
Plastic Surgery
Baylor St. Luke’s Medical Center
Houston, TX, USA
Joseph M. Rosen, MD
Professor of Surgery
Plastic Surgery
Dartmouth–Hitchcock Medical Center
Lebanon, NH, USA
Sashwati Roy, MS, PhD
Associate Professor
Surgery, Center for Regenerative Medicine and
Cell based Therapies
The Ohio State University
Columbus, OH, USA
J. Peter Rubin, MD, FACS
UPMC Professor of Plastic Surgery
Chair, Department of Plastic Surgery
Professor of Bioengineering
University of Pittsburgh
Pittsburgh, PA, USA
Karim A. Sarhane, MD
Department of Surgery
University of Toledo Medical Center
Toledo, OH, USA
David B. Sarwer, PhD
Associate Professor of Psychology
Departments of Psychiatry and Surgery
University of Pennsylvania School of Medicine
Philadelphia, PA, USA
Saja S. Scherer-Pietramaggiori, MD
Plastic and Reconstructive Surgeon
Plastic Surgery
University Hospital Lausanne
Lausanne, Vaud, Switzerland
Iris A. Seitz, MD, PhD
Director of Research and International
Collaboration
University Plastic Surgery
Rosalind Franklin University;
Clinical Instructor of Surgery
Chicago Medical School
Chicago, IL, USA
Jesse C. Selber, MD, MPH, FACS
Associate Professor, Director of Clinical
Research
Department of Plastic Surgery
MD Anderson Cancer Center
Houston, TX, USA
Chandan K. Sen, PhD
Professor and Director
Center for Regenerative Medicine and Cell-
Based Therapies
The Ohio State University Wexner Medical
Center
Columbus, OH, USA
Wesley N. Sivak, MD, PhD
Resident in Plastic Surgery
Department of Plastic Surgery
University of Pittsburgh
Pittsburgh, PA, USA
M. Lucy Sudekum
Research Assistant
Thayer School of Engineering at Dartmouth
College
Hanover, NH, USA
G. Ian Taylor, AO, MBBS, MD, MD(Hon
Bordeaux), FRACS, FRCS(Eng), FRCS(Hon
Edinburgh), FRCSI(Hon), FRSC(Hon
Canada), FACS(Hon)
Professor
Department of Plastic Surgery
Royal Melbourne Hospital;
Professor
Department of Anatomy
University of Melbourne
Melbourne, Victoria, Australia
Chad M. Teven, MD
Resident
Section of Plastic and Reconstructive Surgery
University of Chicago
Chicago, IL, USA
Ruth Tevlin, MB BAO BCh, MRCSI, MD
Resident in Surgery
Department of Plastic and Reconstructive
Surgery
Stanford University School of Medicine
Stanford, CA, USA
E. Dale Collins Vidal, MD, MS
Chief
Section of Plastic Surgery
Dartmouth–Hitchcock Medical Center
Lebanon, NH, USA
Derrick C. Wan, MD
Associate Professor
Division of Plastic Surgery
Department of Surgery
Director of Maxillofacial Surgery
Lucile Packard Children’s Hospital
Stanford University School of Medicine
Stanford, CA, USA
Renata V. Weber, MD
Assistant Professor Surgery (Plastics)
Division of Plastic and Reconstructive Surgery
Albert Einstein College of Medicine
Bronx, NY, USA
Fu-Chan Wei, MD
Professor
Department of Plastic Surgery
Chang Gung Memorial Hospital
Taoyuan, Taiwan
Gordon H. Wilkes, BScMed, MD
Clinical Professor of Surgery
Department of Surgery University of Alberta
Institute for Reconstructive Sciences in Medicine
Misericordia Hospital
Edmonton, Alberta, Canada
Johan F. Wolfaardt, BDS,
MDent(Prosthodontics), PhD
Professor
Division of Otolaryngology – Head and Neck
Surgery
Department of Surgery
Faculty of Medicine and Dentistry;
Director of Clinics and International Relations
Institute for Reconstructive Sciences in Medicine
University of Alberta
Covenant Health Group
Alberta Health Services
Alberta, Canada
Kiryu K. Yap, MBBS, BMedSc
Junior Surgical Trainee & PhD Candidate
O’Brien Institute
Department of Surgery, University of Melbourne
Department of Plastic and Reconstructive
Surgery, St. Vincent’s Hospital
Melbourne, Australia
Andrew Yee
Research Assistant
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Elizabeth R. Zielins, MD
Postdoctoral Research Fellow
Surgery
Stanford University School of Medicine
Stanford, CA, USA

xxvi
List of Contributors
VOLUME TWO
Paul N. Afrooz, MD
Resident
Plastic and Reconstructive Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Jamil Ahmad, MD, FRCSC
Director of Research and Education
The Plastic Surgery Clinic
Mississauga;
Assistant Professor
Surgery
University of Toronto
Toronto, Ontario, Canada
Lisa E. Airan, MD
Aesthetic Dermatologist NYC
Private Practice;
Associate Clinical Professor Department of
Dermatology
Mount Sinai School of Medicine
New York, NY, USA
Gary J. Alter, MD
Assistant Clinical Professor
Division of Plastic Surgery
University of California
Los Angeles, CA, USA
Al S. Aly, MD
Professor of Plastic Surgery
Aesthetic and Plastic Surgery Institute University
of California Irvine
Orange, CA, USA
Khalid Al-Zahrani, MD, SSC-PLAST
Assistant Professor
Consultant Plastic Surgeon
King Khalid University Hospital
King Saud University
Riyadh, Saudi Arabia
Bryan Armijo, MD
Plastic Surgery Chief Resident
Department of Plastic and Reconstructive
Surgery
Case Western Reserve/University Hospitals
Cleveland, OH, USA
Daniel C. Baker, MD
Professor of Surgery
Institute of Reconstructive Plastic Surgery
New York University Medical Center
Department of Plastic Surgery
New York, NY, USA
Fritz E. Barton Jr., MD
Clinical Professor
Department of Plastic Surgery
UT Southwestern Medical Center
Dallas, TX, USA
Leslie Baumann, MD
CEO
Baumann Cosmetic and Research Institute
Miami, FL, USA
Miles G. Berry, MS, FRCS(Plast)
Consultant Plastic and Aesthetic Surgeon
Institute of Cosmetic and Reconstructive
Surgery
London, UK
Trevor M. Born, MD
Division of Plastic Surgery
Lenox Hill/Manhattan Eye Ear and Throat
Hospital North Shore-LIJ Hospital
New York, NY, USA;
Clinical Lecturer
Division of Plastic Surgery
University of Toronto Western Division
Toronto, Ontario, Canada
Terrence W. Bruner, MD, MBA
Private Practice
Greenville, SC, USA
Andrés F. Cánchica, MD
Chief Resident of Plastic Surgery
Plastic Surgery Service Dr. Osvaldo Saldanha
São Paulo, Brazil
Joseph F. Capella, MD
Chief Post-bariatric Body Contouring
Division of Plastic Surgery
Hackensack University Medical Center
Hackensack, NJ, USA
Robert F. Centeno, MD, MBA
Medical Director
St. Croix Plastic Surgery and MediSpa;
Chief Medical Quality Officer
Governor Juan F. Luis Hospital and Medical
Center
Christiansted, Saint Croix, United States Virgin
Islands
Ernest S. Chiu, MD, FACS
Associate Professor of Plastic Surgery
Department of Plastic Surgery
New York University
New York, NY, USA
Jong Woo Choi, MD, PhD, MMM
Associate Professor
Department of Plastic and Reconstructive
Surgery
Seoul Asan Medical Center
Seoul, South Korea
Steven R. Cohen, MD
Senior Clinical Research Fellow, Clinical
Professor
Plastic Surgery
University of California
San Diego, CA;
Director
Craniofacial Surgery
Rady Children’s Hospital, Private Practice,
FACES+ Plastic Surgery, Skin and Laser Center
La Jolla, CA, USA
Sydney R. Coleman, MD
Assistant Clinical Professor
Plastic Surgery
New York University Medical Center
New York;
Assistant Clinical Professor
Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Mark B. Constantian, MD
Private Practice
Surgery (Plastic Surgery)
St. Joseph Hospital
Nashua, NH, USA;
Adjunct Clinical Professor
Surgery (Plastic Surgery)
University of Wisconsin School of Medicine
Madison, WI, USA;
Visiting Professor
Plastic Surgery
University of Virginia Health System
Charlottesville, VA, USA
Rafael A. Couto, MD
Plastic Surgery Resident
Department of Plastic Surgery
Cleveland Clinic
Cleveland, OH, USA
Albert Cram, MD
Professor Emeritus
University of Iowa
Iowa City Plastic Surgery
Coralville, IO, USA
Phillip Dauwe, MD
Department of Plastic Surgery
University of Texas Southwestern Medical
School
Dallas, TX, USA
Dai M. Davies, FRCS
Consultant and Institute Director
Institute of Cosmetic and Reconstructive
Surgery
London, UK
Jose Abel De la Peña Salcedo, MD, FACS
Plastic Surgeon
Director
Instituto de Cirugia Plastica S.C.
Huixquilucan
Estado de Mexico, Mexico
Barry DiBernardo, MD, FACS
Clinical Associate Professor, Plastic Surgery
Rutgers, New Jersey Medical School
Director New Jersey Plastic Surgery
Montclair, NJ, USA
Felmont F. Eaves III, MD, FACS
Professor of Surgery, Emory University
Medical Director, Emory Aesthetic Center
Medical Director, EAC Ambulatory Surgery
Center
Atlanta, GA, USA

xxvii
List of Contributors
Marco Ellis, MD
Director of Craniofacial Surgery
Northwestern Specialists in Plastic Surgery;
Adjunct Assistant Professor
University of Illinois Chicago Medical Center
Chicago, IL, USA
Dino Elyassnia, MD
Associate Plastic Surgeon
Marten Clinic of Plastic Surgery
San Francisco, CA, USA
Julius Few Jr., MD
Director
The Few Institute for Aesthetic Plastic Surgery;
Clinical Professor
Plastic Surgery
University of Chicago Pritzker School of
Medicine
Chicago, IL, USA
Osvaldo Ribeiro Saldanha Filho, MD
Professor of Plastic Surgery
Plastic Surgery Service Dr. Osvaldo Saldanha
São Paulo, Brazil
Jack Fisher, MD
Associate Clinical Professor
Plastic Surgery
Vanderbilt University
Nashville, TN, USA
Nicholas A. Flugstad, MD
Flugstad Plastic Surgery
Bellevue, WA, USA
James D. Frame, MBBS, FRCS, FRCSEd,
FRCS(Plast)
Professor of Aesthetic Plastic Surgery
Anglia Ruskin University
Chelmsford, UK
Jazmina M. Gonzalez, MD
Bitar Cosmetic Surgery Institute
Fairfax, VA, USA
Richard J. Greco, MD
CEO
The Georgia Institute For Plastic Surgery
Savannah, GA, USA
Ronald P. Gruber, MD
Adjunct Associate Clinical Professor
Division of Plastic and Reconstructive Surgery
Stanford University
Stanford, CA
Clinical Association Professor
Division of Plastic and Reconstructive Surgery
University of California San Francisco
San Francisco, CA, USA
Bahman Guyuron, MD, FCVS
Editor in Chief, Aesthetic Plastic Surgery Journal
Emeritus Professor of Plastic Surgery
Case School of Medicine
Cleveland, OH, USA
Joseph P. Hunstad, MD, FACS
Associate Consulting Professor
Division of Plastic Surgery
The University of North Carolina at Chapel Hill;
Private Practice
Huntersville/Charlotte, NC, USA
Clyde H. Ishii, MD, FACS
Assistant Clinical Professor of Surgery
John A. Burns School of Medicine;
Chief, Department of Plastic Surgery
Shriners Hospital
Honolulu Unit
Honolulu, HI, USA
Nicole J. Jarrett, MD
Department of Plastic Surgery
University of Pittsburgh
Pittsburgh, PA, USA
Elizabeth B. Jelks, MD
Private Practice
Jelks Medical
New York, NY, USA
Glenn W. Jelks, MD
Associate Professor
Department of Ophthalmology
Department of Plastic Surgery
New York University School of Medicine
New York, NY, USA
Mark Laurence Jewell, MD
Assistant Clinical Professor Plastic Surgery
Oregon Health Science University
Portland, OR, USA
David M. Kahn, MD
Clinical Associate Professor of Plastic Surgery
Department of Surgery
Stanford University School of Medicine
Stanford, CA, USA
Michael A. C. Kane, BS, MD
Attending Surgeon
Plastic Surgery
Manhattan Eye, Ear, and Throat Hospital
New York, NY, USA
David L. Kaufman, MD, FACS
Private Practice Plastic Surgery
Aesthetic Artistry Surgical and Medical Center
Folsom, CA, USA
Jeffrey Kenkel, MD
Professor and Chairman
Department of Plastic Surgery
UT Southwestern Medical Center
Dallas, TX, USA
Kyung S. Koh, MD, PhD
Professor of Plastic Surgery
Asan Medical Center, University of Ulsan School
of Medicine
Seoul, South Korea
Tracy Leong, MD
Dermatology
Rady Children’s Hospital - San Diego;
Sharp Memorial Hospital;
University California San Diego Medical Center
San Diego;
Private Practice, FACES+ Plastic Surgery, Skin
and Laser Center
La Jolla, CA, USA
Steven M. Levine, MD
Assistant Professor of Surgery (Plastic)
Hofstra Medical School, Northwell Health,
New York, NY, USA
Michelle B. Locke, MBChB, MD
Senior Lecturer in Surgery
Department of Surgery
University of Auckland Faculty of Medicine and
Health Sciences;
South Auckland Clinical Campus
Middlemore Hospital
Auckland, New Zealand
Alyssa Lolofie
University of Utah
Salt Lake City, UT, USA
Timothy J. Marten, MD, FACS
Founder and Director
Marten Clinic of Plastic Surgery
San Francisco, CA, USA
Bryan Mendelson, FRCSE, FRACS, FACS
The Centre for Facial Plastic Surgery
Toorak, Victoria, Australia
Constantino G. Mendieta, MD, FACS
Private Practice
Miami, FL, USA
Drew B. Metcalfe, MD
Division of Plastic and Reconstructive Surgery
Emory University
Atlanta, GA, USA
Gabriele C. Miotto, MD
Emory School of Medicine
Atlanta, GA, USA
Foad Nahai, MD
Professor of Surgery
Division of Plastic and Reconstructive Surgery
Department of Surgery
Emory University School of Medicine
Emory Aesthetic Center at Paces
Atlanta, Georgia, USA
Suzan Obagi, MD
Associate Professor of Dermatology
Dermatology
University of Pittsburgh;
Associate Professor of Plastic Surgery
Plastic Surgery
University of Pittsburgh
Pittsburgh, PA, USA

xxviii
List of Contributors
Sabina Aparecida Alvarez de Paiva, MD
Resident of Plastic Surgery
Plastic Surgery Service Dr. Ewaldo Bolivar de
Souza Pinto
São Paulo, Brazil
Galen Perdikis, MD
Assistant Professor of Surgery
Division of Plastic Surgery
Emory University School of Medicine
Atlanta, GA, USA
Jason Posner, MD, FACS
Private Practice
Boca Raton, FL, USA
Dirk F. Richter, MD, PhD
Clinical Professor of Plastic Surgery
University of Bonn
Director and Chief
Dreifaltigkeits-Hospital
Wesseling, Germany
Thomas L. Roberts III, FACS
Plastic Surgery Center of the Carolinas
Spartanburg, SC, USA
Jocelyn Celeste Ledezma Rodriguez, MD
Private Practice
Guadalajara, Jalisco, Mexico
Rod J. Rohrich, MD
Clinical Professor and Founding Chair
Department of Plastic Surgery
Distinguished Teaching Professor
University of Texas Southwestern Medical Center
Founding Partner
Dallas Plastic Surgery Institute
Dallas, TX, USA
E. Victor Ross, MD
Director of Laser and Cosmetic Dermatology
Scripps Clinic
San Diego, CA, USA
J. Peter Rubin, MD, FACS
Chief
Plastic and Reconstructive Surgery
University of Pittsburgh Medical Center;
Associate Professor
Department of Surgery
University of Pittsburgh
Pittsburgh, PA, USA
Ahmad N. Saad, MD
Private Practice
FACES+ Plastic Surgery
Skin and Laser Center
La Jolla, CA, USA
Alesia P. Saboeiro, MD
Attending Physician
Private Practice
New York, NY, USA
Cristianna Bonnetto Saldanha, MD
Plastic Surgery Service Dr. Osvaldo Saldanha
São Paulo, Brazil
Osvaldo Saldanha, MD, PhD
Director of Plastic Surgery Service Dr. Osvaldo
Saldanha;
Professor of Plastic Surgery Department
Universidade Metropolitana de Santos
- UNIMES
São Paulo, Brazil
Renato Saltz, MD, FACS
Saltz Plastic Surgery
President
International Society of Aesthetic Plastic Surgery
Adjunct Professor of Surgery
University of Utah
Past-President, American Society for Aesthetic
Plastic Surgery
Salt Lake City and Park City, UT, USA
Paulo Rodamilans Sanjuan MD
Chief Resident of Plastic Surgery
Plastic Surgery Service Dr. Ewaldo Boliar de
Souza Pinto
São Paulo, Brazil
Nina Schwaiger, MD
Senior Specialist in Plastic and Aesthetic
Surgery
Department of Plastic Surgery
Dreifaltigkeits-Hospital Wesseling
Wesseling, Germany
Douglas S. Steinbrech, MD, FACS
Gotham Plastic Surgery
New York, NY, USA
Phillip J. Stephan, MD
Clinical Faculty
Plastic Surgery
UT Southwestern Medical School;
Plastic Surgeon
Texoma Plastic Surgery
Wichita Falls, TX, USA
David Gonzalez Sosa, MD
Plastic and Reconstructive Surgery
Hospital Quirónsalud Torrevieja
Alicante, Spain
James M. Stuzin, MD
Associate Professor of Surgery
(Plastic) Voluntary
University of Miami Leonard M. Miller School of
Medicine
Miami, FL, USA
Daniel Suissa, MD, MSc
Clinical Instructor
Section of Plastic and Reconstructive Surgery
Yale University
New Haven, CT, USA
Charles H. Thorne, MD
Associate Professor of Plastic Surgery
Department of Plastic Surgery
NYU School of Medicine
New York, NY, USA
Ali Totonchi, MD
Assistant Professor
Plastic Surgery
Case Western Reserve University;
Medical Director Craniofacial Deformity Clinic
Plastic Surgery
MetroHealth Medical center
Cleveland, OH, USA
Jonathan W. Toy, MD, FRCSC
Program Director, Plastic Surgery Residency
Program Assistant Clinical Professor
University of Alberta
Edmonton, Alberta, Canada
Matthew J. Trovato, MD
Dallas Plastic Surgery Institute
Dallas, TX, USA
Simeon H. Wall Jr., MD, FACS
Director
The Wall Center for Plastic Surgery;
Assistant Clinical Professor
Plastic Surgery
LSU Health Sciences Center at Shreveport
Shreveport, LA, USA
Joshua T. Waltzman, MD, MBA
Private Practice
Waltzman Plastic and Reconstructive Surgery
Long Beach, CA, USA
Richard J. Warren, MD, FRCSC
Clinical Professor
Division of Plastic Surgery
University of British Columbia
Vancouver, British Columbia, Canada
Edmund Weisberg, MS, MBE
University of Pennsylvania
Philadelphia, PA, USA
Scott Woehrle, MS BS
Physician Assistant
Department of Plastic Surgery
Jospeh Capella Plastic Surgery
Ramsey, NJ, USA
Chin-Ho Wong, MBBS, MRCS, MMed(Surg),
FAMS(Plast Surg)
W Aesthetic Plastic Surgery
Mt Elizabeth Novena Specialist Center
Singapore
Alan Yan, MD
Former Fellow
Adult Reconstructive and Aesthetic
Craniomaxillofacial Surgery
Division of Plastic and Reconstructive Surgery
Massachusetts General Hospital
Boston, MA, USA

xxix
List of Contributors
Michael J. Yaremchuk, MD
Chief of Craniofacial Surgery
Massachusetts General Hospital;
Clinical Professor of Surgery
Harvard Medical School;
Program Director
Harvard Plastic Surgery Residency Program
Boston, MA, USA
James E. Zins, MD
Chairman
Department of Plastic Surgery
Dermatology and Plastic Surgery Institute
Cleveland Clinic
Cleveland, OH, USA
VOLUME THREE
Neta Adler, MD
Senior Surgeon
Department of Plastic and Reconstructive
Surgery
Hadassah University Hospital
Jerusalem, Israel
Ahmed M. Afifi, MD
Assistant Professor of Plastic Surgery
Department of Surgery
University of Wisconsin
Madison, WI, USA;
Associate Professor
Department of Plastic Surgery
Cairo University
Cairo, Egypt
Marta Alvarado, DDS, MS
Department of Orthodontics
Facultad de Odontología
Universidad de San Carlos de Guatemala
Guatemala
Eric Arnaud, MD
Pediatric Neurosurgeon and Co-Director
Unité de Chirurgie Craniofaciale
Hôpital Necker Enfants Malades
Paris, France
Stephen B. Baker, MD, DDS
Associate Professor and Program Director
Co-Director Inova Hospital for Children
Craniofacial Clinic
Department of Plastic Surgery
Georgetown University Hospital
Georgetown, WA, USA
Scott P. Bartlett, MD
Professor of Surgery
Surgery
University of Pennsylvania;
Chief Division of Plastic Surgery
Surgery
Children’s Hospital of Philadelphia
Philadelphia, PA, USA
Bruce S. Bauer, MD
Chief
Division of Plastic Surgery
NorthShore University HealthSystem
Highland Park;
Clinical Professor of Surgery
Department of Surgery
University of Chicago Pritzker School of
Medicine
Chicago, IL, USA
Adriane L. Baylis, PhD
Speech Scientist
Section of Plastic and Reconstructive Surgery
Nationwide Children’s Hospital
Columbus, OH, USA
Mike Bentz, MD, FAAP, FACS
Interim Chairman
Department of Surgery
University of Wisconsin;
Chairman Division of Plastic Surgery
Department of Surgery
University of Wisconsin
Madison, WI, USA
Craig Birgfeld, MD, FACS
Associate Professor, Pediatric Plastic and
Craniofacial Surgery
Seattle Children’s Hospital
Seattle, WA, USA
William R. Boysen, MD
Resident Physician, Urology
University of Chicago Medicine
Chicago, IL, USA
James P. Bradley, MD
Professor and Chief
Section of Plastic and Reconstructive Surgery
Temple University
Philadelphia, PA, USA
Edward P. Buchanan, MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Michael R. Bykowski, MD, MS
Plastic Surgery Resident
Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Edward J. Caterson, MD, PhD
Director of Craniofacial Surgery
Division of Plastic Surgery
Brigham and Women’s Hospital
Boston, MA, USA
Rodney K. Chan, MD
Chief Plastic and Reconstructive Surgery
Clinical Division and Burn Center
United States Army Institute of Surgical
Research
Joint Base San Antonio, TX, USA
Edward I. Chang, MD
Assistant Professor
Department of Plastic Surgery
The University of Texas M. D. Anderson Cancer
Center
Houston, TX, USA
Constance M. Chen, MD, MPH
Director of Microsurgery
Plastic and Reconstructive Surgery
New York Eye and Ear Infirmary of Mt Sinai;
Clinical Assistant Professor
Plastic and Reconstructive Surgery
Weil Medical College of Cornell University;
Clinical Assistant Professor
Plastic and Reconstructive Surgery
Tulane University School of Medicine
New York, NY, USA
Yu-Ray Chen, MD
Professor of Surgery
Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Taoyuan City, Taiwan
Philip Kuo-Ting Chen, MD
Professor
Craniofacial Center
Chang Gung Memorial Hospital
Taoyuan City, Taiwan
Ming-Huei Cheng, MD, MBA
Professor
Division of Reconstructive Microsurgery
Department of Plastic and Reconstructive
Surgery
Chang Gung Memorial Hospital
Taoyuan City, Taiwan
Gerson R. Chinchilla, DDS MS
Director
Department of Orthodontics
Facultad de Odontología
Universidad de San Carlos de Guatemala
Guatemala
Peter G. Cordeiro, MD
Chief
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center;
Professor of Surgery
Surgery
Weil Medical College of Cornell University
New York, NY, USA
Alberto Córdova-Aguilar, MD, MPH
Attending Plastic Surgeon
Surgery
Faculty of Medicine Ricardo Palma University
Lima, Peru
Edward H. Davidson, MA(Cantab), MBBS
Resident Plastic Surgeon
Department of Plastic Surgery
University of Pittsburgh
Pittsburgh, PA, USA

xxx
List of Contributors
Sara R. Dickie, MD
Clinician Educator
Surgery
University of Chicago Hospital Pritzker School of
Medicine;
Attending Surgeon
Section of Plastic and Reconstructive Surgery
NorthShore University HealthSystem
Northbrook, IL, USA
Risal S. Djohan, MD
Microsurgery Fellowship Program Director
Plastic Surgery
Cleveland Clinic;
Surgery ASC Quality Improvement Officer
Plastic Surgery
Cleveland Clinic
Cleveland, OH, USA
Amir H. Dorafshar, MBChB, FACS, FAAP
Associate Professor
Plastic and Reconstructive Surgery
Johns Hopkins Medical Institute;
Assistant Professor
Plastic Surgery
R Adams Cowley Shock Trauma Center
Baltimore, MD, USA
Jeffrey A. Fearon, MD
Director
The Craniofacial Center
Dallas, TX, USA
Alexander L. Figueroa, DMD
Craniofacial Orthodontist
Rush Craniofacial Center
Rush University Medical Center
Chicago, IL, USA
Alvaro A. Figueroa, DDS, MS
Co-Director
Rush Craniofacial Center
Rush University Medical Center
Chicago, IL, USA
David M. Fisher, MB, BCh, FRCSC, FACS
Medical Director Cleft Lip and Palate Program
Plastic Surgery
Hospital for Sick Children;
Associate Professor
Surgery
University of Toronto
Toronto, Ontario, Canada
Roberto L. Flores, MD
Associate Professor of Plastic Surgery
Director of Cleft Lip and Palate
Hansjörg Wyss Department of Plastic Surgery
NYU Langone Medical Center
New York, NY, USA
Andrew Foreman, B. Physio, BMBS(Hons),
PhD, FRACS
Consultant Surgeon, Department of
Otolaryngology - Head and Neck Surgery
University of Adelaide,
Royal Adelaide Hospital,
Adelaide, SA, Australia
Patrick A. Gerety, MD
Assistant Professor of Surgery
Division of Plastic and Reconstructive Surgery
Indiana University and Riley Hospital for
Children
Philadelphia, PA, USA
Jesse A. Goldstein, MD
Chief Resident
Department of Plastic Surgery
Georgetown University Hospital
Washington, DC, USA
Arun K. Gosain, MD
Chief
Division of Plastic Surgery
Ann and Robert H. Lurie Children’s Hospital of
Chicago
Chicago, IL, USA
Lawrence J. Gottlieb, MD
Professor of Surgery
Department of Surgery
Section of Plastic and Reconstructive Surgery
University of Chicago
Chicago, IL, USA
Arin K. Greene, MD, MMSc
Department of Plastic and Oral Surgery
Boston Children’s Hospital;
Associate Professor of Surgery
Harvard Medical School
Boston, MA, USA
Patrick J. Gullane, MD, FRCS
Wharton Chair in Head and Neck Surgery
Professor of Surgery, Department of
Otolaryngology - Head and Neck Surgery
University of Toronto
Toronto, Ontario, Canada
Mohan S. Gundeti, MB, MCh, FEBU,
FRCS(Urol), FEAPU
Associate Professor of Urology in Surgery and
Pediatrics, Director Pediatric Urology, Director
Centre for Pediatric Robotics and Minimal
Invasive Surgery
University of Chicago and Pritzker Medical
School Comer Children’s Hospital
Chicago, IL, USA
Eyal Gur, MD
Professor of Surgery, Chief
Department of Plastic and Reconstructive
Surgery
The Tel Aviv Sourasky Medical Center
Tel Aviv, Israel
Bahman Guyuron, MD, FCVS
Editor in Chief, Aesthetic Plastic Surgery
Journal;
Emeritus Professor of Plastic Surgery
Case School of Medicine
Cleveland, OH, USA
Matthew M. Hanasono, MD
Associate Professor
Department of Plastic Surgery
The University of Texas MD Anderson Cancer
Center
Houston, TX, USA
Toshinobu Harada, PhD
Professor in Engineering
Department of Systems Engineering
Faculty of Systems Engineering
Wakayama University
Wakayama, Japan
Jill A. Helms, DDS, PhD
Professor
Surgery
Stanford University
Stanford, CA, USA
David L. Hirsch, MD, DDS
Director of Oral Oncology and Reconstruction
Lenox Hill Hospital/Northwell Health
New York, NY, USA
Jung-Ju Huang, MD
Associate Professor
Division of Microsurgery
Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Taoyuan, Taiwan
William Y. Hoffman, MD
Professor and Chief
Division of Plastic and Reconstructive Surgery
UCSF
San Francisco, CA, USA
Larry H. Hollier Jr., MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Richard A. Hopper, MD, MS
Chief
Division of Craniofacial Plastic Surgery
Seattle Children’s Hospital;
Surgical Director
Craniofacial Center
Seattle Children’s Hospital;
Associate Professor
Department of Surgery
University of Washington
Seattle, WA, USA
Gazi Hussain, MBBS, FRACS
Clinical Senior Lecturer
Macquarie University
Sydney, Australia
Oksana Jackson, MD
Assistant Professor
Plastic Surgery
Perelman School of Medicine at the University
of Pennsylvania;
Assistant Professor
Plastic Surgery
The Children’s Hospital of Philadelphia
Philadelphia, PA, USA

xxxi
List of Contributors
Syril James, MD
Clinic Marcel Sembat
Boulogne-Billancourt
Paris, France
Leila Jazayeri, MD
Microsurgery Fellow
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA
Sahil Kapur, MD
Assistant Professor
Department of Plastic Surgery
University of Texas - MD Anderson Cancer
Center
Houston, TX, USA
Henry K. Kawamoto Jr., MD, DDS
Clinical Professor
Surgery Division of Plastic Surgery
UCLA
Los Angeles, CA, USA
David Y. Khechoyan, MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Richard E. Kirschner, MD
Section Chief
Plastic and Reconstructive Surgery
Nationwide Children’s Hospital;
Senior Vice Chair
Plastic Surgery
The Ohio State University Medical College
Columbus, OH, USA
John C. Koshy, MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Michael C. Large, MD
Urologic Oncologist
Urology of Indiana
Greenwood, IN, USA
Edward I. Lee, MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Jamie P. Levine, MD
Chief of Microsurgery
Associate Professor
Plastic Surgery
NYU Langone Medical Center
New York, NY, USA
Jingtao Li, DDS, PhD
Consultant Surgeon
Oral and Maxillofacial Surgery
West China Hospital of Stomatology
Chengdu, Sichuan, People’s Republic of China
Lawrence Lin, MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Joseph E. Losee, MD
Ross H. Musgrave Professor of Pediatric Plastic
Surgery
Department of Plastic Surgery
University of Pittsburgh Medical Center;
Chief, Division of Pediatric Plastic Surgery
Children’s Hospital of Pittsburgh
Pittsburgh, PA, USA
David W. Low, MD
Professor of Surgery
Division of Plastic Surgery
Perelman School of Medicine at the University
of Pennsylvania;
Clinical Associate
Department of Surgery
Children’s Hospital of Philadelphia
Philadelphia, PA, USA
Ralph T. Manktelow, MD, FRCSC
Professor of Surgery,
The University of Toronto,
Toronto, Ontario, Canada
Paul N. Manson, MD
Distinguished Service Professor
Plastic Surgery
Johns Hopkins University
Baltimore, MD, USA
David W. Mathes, MD
Professor and Chief of the Division of Plastic
and Reconstructive Surgery
Surgery Division of Plastic and Reconstructive
Surgery
University of Colorado
Aurora, CO, USA
Frederick J. Menick, MD
Private Practitioner
Tucson, AZ, USA
Fernando Molina, MD
Director
Craniofacial Anomalies Foundation A.C.
Mexico City;
Professor of Plastic Reconstructive and
Aesthetic Surgery
Medical School
Universidad La Salle
Mexico City, Distrito Federal, Mexico
Laura A. Monson, MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Reid V. Mueller, MD
Associate Professor
Plastic Surgery
Oregon Health and Science University
Portland, OR, USA
John B. Mulliken, MD
Professor
Department of Plastic and Oral Surgery
Boston Children’s Hospital
Harvard Medical School
Boston, MA, USA
Gerhard S. Mundinger, MD
Assistant Professor
Craniofacial, Plastic, and Reconstructive Surgery
Louisiana State University Health Sciences
Center
Children’s Hospital of New Orleans
New Orleans, LA, USA
Blake D. Murphy, BSc, PhD, MD
Craniofacial Fellow
Plastic Surgery
Nicklaus Children’s Hospital
Miami, FL, USA
Peter C. Neligan, MB, FRCS(I), FRCSC,
FACS
Professor of Surgery
Department of Surgery, Division of Plastic
Surgery
University of Washington
Seattle, WA, USA
M. Samuel Noordhoff, MD, FACS
Emeritus Professor in Surgery
Chang Gung University
Taoyuan City, Taiwan
Giovanna Paternoster, MD
Unité de chirurgie crânio-faciale du departement
de neurochirurgie
Hôpital Necker Enfants Malades
Paris, France
Jason Pomerantz, MD
Assistant Professor
Surgery
University of California San Francisco;
Surgical Director
Craniofacial Center
University of California San Francisco
San Francisco, CA, USA
Julian J. Pribaz, MD
Professor of Surgery
University of South Florida, Morsani College of
Medicine
Tampa General Hospital
Tampa, FL, USA
Chad A. Purnell, MD
Division of Plastic Surgery
Lurie Children’s Hospital of Northwestern
Feinberg School of Medicine
Chicago, IL, USA
Russell R. Reid, MD, PhD
Associate Professor
Surgery/Section of Plastic and Reconstructive
Surgery
University of Chicago Medicine
Chicago, IL, USA
Eduardo D. Rodriguez, MD, DDS
Helen L. Kimmel Professor of Reconstructive
Plastic Surgery
Chair, Hansjörg Wyss Department of Plastic
Surgery
NYU School of Medicine
NYU Langone Medical Center
New York, NY, USA

xxxii
List of Contributors
Craig Rowin, MD
Craniofacial Fellow
Plastic Surgery
Nicklaus Children’s Hospital
Miami, FL, USA
Ruston J. Sanchez, MD
Plastic and Reconstructive Surgery Resident
University of Wisconsin
Madison, WI, USA
Lindsay A. Schuster, DMD, MS
Director Cleft-Craniofacial Orthodontics
Pediatric Plastic Surgery
Children’s Hospital of Pittsburgh of UMPC;
Clinical Assistant Professor of Plastic Surgery
Department of Plastic Surgery
University of Pittsburgh School of Medicine
Pittsburgh, PA, USA
Jeremiah Un Chang See, MD
Plastic Surgeon
Department of Plastic and Reconstructive
Surgery
Penang General Hospital
Georgetown, Penang, Malaysia
Pradip R. Shetye, DDS, BDS, MDS
Assistant Professor (Orthodontics)
Hansjörg Wyss Department of Plastic Surgery
NYU Langone Medical Center
New York, NY, USA
Roman Skoracki, MD
Plastic Surgery
The Ohio State University
Columbus, OH, USA
Mark B. Slidell, MD, MPH
Assistant Professor of Surgery
Department of Surgery
Section of Pediatric Surgery
University of Chicago Medicine Biological
Sciences
Chicago, IL, USA
Michael Sosin, MD
Research Fellow
Department of Plastic Surgery Institute of
Reconstructive Plastic Surgery
NYU Langone Medical Center
New York, NY, USA;
Research Fellow
Division of Plastic Reconstructive and
Maxillofacial Surgery
R Adams Cowley Shock Trauma Center
University of Maryland Medical Center
Baltimore, MD, USA;
Resident
Department of Surgery
Medstar Georgetown University Hospital
Washington, DC, USA
Youssef Tahiri, MD, MSc, FRCSC, FAAP,
FACS
Associate Professor
Pediatric Plastic & Craniofacial Surgery
Cedars Sinai Medical Center
Los Angeles, CA, USA
Peter J. Taub, MD
Professor
Surgery Pediatrics Dentistry and Medical
Education
Surgery Division of Plastic and Reconstructive
Surgery
Icahn School of Medicine at Mount Sinai
New York, NY, USA
Jesse A. Taylor, MD
Mary Downs Endowed Chair of Pediatric
Craniofacial Treatment and Research;
Director, Penn Craniofacial Fellowship;
Co-Director, CHOP Cleft Team
Plastic, Reconstructive, and Craniofacial Surgery
The University of Pennsylvania and
Children’s Hospital of Philadelphia
Philadelphia, PA, USA
Kathryn S. Torok, MD
Assistant Professor
Pediatric Rheumatology
University of Pittsburgh
Pittsburgh, PA, USA
Ali Totonchi, MD
Assistant Professor
Plastic Surgery
Case Western Reserve University;
Medical Director Craniofacial Deformity Clinic
Plastic Surgery
MetroHealth Medical Center
Cleveland, OH, USA
Kris Wilson, MD
Division of Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
S. Anthony Wolfe, MD
Plastic Surgery
Miami Children’s Hospital
Miami, FL, USA
Akira Yamada, MD, PhD
Professor of Plastic Surgery
World Craniofacial Foundation
Dallas, TX, USA;
Clinical Assistant Professor
Plastic Surgery
Case Western Reserve University
Cleveland, OH, USA
Peirong Yu, MD
Professor
Plastic Surgery
M. D. Anderson Cancer Center;
Adjunct Professor
Plastic Surgery
Baylor College of Medicine
Houston, TX, USA
Ronald M. Zuker, MD, FRCSC, FACS,
FRCSEd(Hon)
Professor of Surgery
Department of Surgery
University of Toronto;
Staff Plastic and Reconstructive Surgeon
Department of Surgery
SickKids Hospital
Toronto, Ontario, Canada
VOLUME FOUR
Christopher E. Attinger, MD
Professor, Interim Chairman
Department of Plastic Surgery
Center for Wound Healing
Medstar Georgetown University Hospital
Washington, DC, USA
Lorenzo Borghese, MD
Plastic Surgeon
Chief of International Missions
Ospedale Pediatrico Bambino Gesù
Rome, Italy
Charles E. Butler, MD, FACS
Professor and Chairman
Department of Plastic Surgery
Charles B. Barker Endowed Chair in Surgery
The University of Texas M. D. Anderson Cancer
Center
Houston, TX, USA
David W. Chang, MD
Professor of Surgery
University of Chicago
Chicago, IL, USA
Karel Claes, MD
Department of Plastic and Reconstructive
Surgery
Ghent University Hospital
Ghent, Belgium
Mark W. Clemens II, MD, FACS
Associate Professor
Plastic Surgery
MD Anderson Cancer Center,
Houston, TX, USA
Shannon M. Colohan, MD, MSc
Assistant Professor of Surgery
University of Washington
Seattle, WA, USA
Peter G. Cordeiro, MD
Chief
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA
Salvatore D’Arpa, MD, PhD
Department of Plastic and Reconstructive
Surgery
Ghent University Hospital
Ghent, Belgium

xxxiii
List of Contributors
Michael V. DeFazio, MD
Department Plastic Surgery
MedStar Georgetown University Hospital
Washington, DC, USA
A. Lee Dellon, MD, PhD
Professor of Plastic Surgery
Professor of Neurosurgery
Johns Hopkins University
Baltimore, MD, USA
Sara R. Dickie, MD
Clinical Associate of Surgery
University of Chicago Hospitals
Pritzker School of Medicine
Chicago, IL, USA
Ivica Ducic, MD, PhD
Clinical Professor of Surgery
GWU Washington Nerve Institute
McLean, VA, USA
Gregory A. Dumanian, MD
Stuteville Professor of Surgery
Division of Plastic Surgery
Northwestern Feinberg School of Medicine
Chicago, IL, USA
John M. Felder III, MD
Fellow in Hand Surgery
Plastic Surgery
Washington University in Saint Louis
St. Louis, MO, USA
Goetz A. Giessler, MD, PhD
Professor Director
Plastic-Reconstructive, Aesthetic and Hand
Surgery
Gesundheit Nordhessen
Kassel, Germany
Kevin D. Han, MD
Department of Plastic Surgery
MedStar Georgetown University Hospital
Washington, DC, USA
Piet Hoebeke
Department of Urology
Ghent University Hospital
Ghent, Belgium
Joon Pio Hong, MD, PhD, MMM
Professor of Plastic Surgery
Asan Medical Center, University of Ulsan
Seoul, South Korea
Michael A. Howard, MD
Clinical Assistant Professor of Surgery
Plastic Surgery
NorthShore University HealthSystem/University
of Chicago
Chicago, IL, USA
Jeffrey E. Janis, MD, FACS
Professor of Plastic Surgery, Neurosurgery,
Neurology, and Surgery;
Executive Vice Chairman, Department of Plastic
Surgery;
Chief of Plastic Surgery, University Hospitals
Ohio State University Wexner Medical Center
Columbus, OH, USA
Leila Jazayeri, MD
Microsurgery Fellow
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA
Grant M. Kleiber, MD
Assistant Professor of Surgery
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Stephen J. Kovach III, MD
Assistant Professor
Division of Plastic Surgery
University of Pennsylvania
Philadelphia, PA, USA
Robert Kwon, MD
Southwest Hand and Microsurgery
3108 Midway Road, Suite 103
Plano, TX, USA
Raphael C. Lee, MS, MD, ScD, FACS,
FAIMBE
Paul and Allene Russell Professor
Plastic Surgery, Dermatology, Anatomy and
Organismal Biology, Molecular Medicine
University of Chicago
Chicago, IL, USA
L. Scott Levin, MD, FACS
Chairman of Orthopedic Surgery
Department of Orthopaedic Surgery
University of Pennsylvania School of Medicine
Philadelphia, PA, USA
Otway Louie, MD
Associate Professor
Surgery
University of Washington Medical Center
Seattle, WA, USA
Nicolas Lumen, MD, PhD
Head of Clinic
Urology
Ghent University Hospital
Ghent, Belgium
Alessandro Masellis, MD
Plastic Surgeon
Euro-Mediterranean Council for Burns and Fire
Disasters
Palermo, Italy
Michele Masellis, MD
Former Chief of Department of Plastic and
Reconstructive Surgery and Burn Therapy
Department of Plastic and Reconstructive
Surgery and Burn Therapy - ARNAS Ospedale
Civico e Benfratelli
Palermo, Italy
Stephen M. Milner, MB BS, BDS
Professor of Plastic Surgery
Surgery
Johns Hopkins School of Medicine
Baltimore, MD, USA
Arash Momeni, MD
Fellow, Reconstructive Microsurgery
Division of Plastic Surgery
University of Pennsylvania Health System
Philadelphia, PA, USA
Stan Monstrey, MD, PhD
Department of Plastic and Reconstructive
Surgery
Ghent University Hospital
Ghent, Belgium
Venkateshwaran N, MBBS, MS, DNB, MCh,
MRCS(Intercollegiate)
Consultant Plastic Surgeon
Jupiter Hospital
Thane, India
Rajiv P. Parikh, MD, MPHS
Resident Physician
Department of Surgery, Division of Plastic and
Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Mônica Sarto Piccolo, MD, MSc, PhD
Director
Pronto Socorro para Queimaduras
Goiânia, Goiás, Brazil
Nelson Sarto Piccolo, MD
Chief
Division of Plastic Surgery
Pronto Socorro para Queimaduras
Goiânia, Goiás, Brazil
Maria Thereza Sarto Piccolo, MD, PhD
Scientific Director
Pronto Socorro para Queimaduras
Goiânia, Goiás, Brazil
Vinita Puri, MS, MCh
Professor and Head
Department of Plastic, Reconstructive Surgery
and Burns
Seth G S Medical College and KEM Hospital
Mumbai, Maharashtra, India
Andrea L. Pusic, MD, MHS, FACS
Associate Professor
Plastic and Reconstructive Surgery
Memorial Sloan Kettering Cancer Center
New York, NY, USA

xxxiv
List of Contributors
Vinay Rawlani, MD
Division of Plastic Surgery
Northwestern Feinberg School of Medicine
Chicago, IL, USA
Juan L. Rendon, MD, PhD
Clinical Instructor Housestaff
Department of Plastic Surgery
The Ohio State University Wexner Medical
Center
Columbus, OH, USA
Michelle C. Roughton, MD
Assistant Professor
Division of Plastic and Reconstructive Surgery
University of North Carolina at Chapel Hill
Chapel Hill, NC, USA
Hakim K. Said, MD, FACS
Associate Professor
Division of Plastic surgery
University of Washington
Seattle, WA, USA
Michel Saint-Cyr, MD, FRSC(C)
Professor
Plastic Surgery
Mayo Clinic
Rochester, MN, USA
Michael Sauerbier, MD, PhD
Professor, Chair
Department for Plastic, Hand, and
Reconstructive Surgery
Academic Hospital Goethe University Frankfurt
am Main
Frankfurt am Main, Germany
Loren S. Schechter, MD
Associate Professor and Chief
Division of Plastic Surgery
Chicago Medical School
Morton Grove, IL, USA
David H. Song, MD, MBA, FACS
Regional Chief, MedStar Health
Plastic and Reconstructive Surgery
Professor and Chairman
Department of Plastic Surgery
Georgetown University School of Medicine
Washington, DC, USA
Yoo Joon Sur, MD, PhD
Associate Professor
Department of Orthopedic Surgery
The Catholic University of Korea, College of
Medicine
Seoul, Korea
Chad M. Teven, MD
Resident
Section of Plastic and Reconstructive Surgery
University of Chicago
Chicago, IL, USA
VOLUME FIVE
Jamil Ahmad, MD, FRCSC
Director of Research and Education
The Plastic Surgery Clinic
Mississauga, Ontario, Canada;
Assistant Professor of Surgery
University of Toronto
Toronto, Ontario, Canada
Robert J. Allen Sr., MD
Clinical Professor of Plastic Surgery
Department of Plastic Surgery
New York University Medical Center
Charleston, NC, USA
Ryan E. Austin, MD, FRCSC
Plastic Surgeon
The Plastic Surgery Clinic
Mississauga, ON, Canada
Brett Beber, BA, MD, FRCSC
Plastic and Reconstructive Surgeon
Lecturer, Department of Surgery
University of Toronto
Toronto, Ontario, Canada
Philip N. Blondeel, MD
Professor of Plastic Surgery
Department of Plastic Surgery
University Hospital Ghent
Ghent, Belgium
Benjamin J. Brown, MD
Gulf Coast Plastic Surgery
Pensacola, FL, USA
Mitchell H. Brown, MD, MEd, FRCSC
Plastic and Reconstructive Surgeon
Associate Professor, Department of Surgery
University of Toronto
Toronto, Ontario, Canada
M. Bradley Calobrace, MD, FACS
Plastic Surgeon
Calobrace and Mizuguchi Plastic Surgery Center
Departments of Surgery, Divisions of Plastic
Surgery
Clinical Faculty, University of Louisville and
University of Kentucky
Louisville, KY, USA
Grant W. Carlson, MD
Wadley R. Glenn Professor of Surgery
Emory University
Atlanta, GA, USA
Bernard W. Chang, MD
Chief of Plastic and Reconstructive Surgery
Mercy Medical Center
Baltimore, MD, USA
Mark W. Clemens II, MD, FACS
Assistant Professor Plastic Surgery
M. D. Anderson Cancer Center
Houston, TX, USA
Robert Cohen MD, FACS
Medical Director
Plastic Surgery
Scottsdale Center for Plastic Surgery
Paradise Valley, AZ and;
Santa Monica, CA, USA
Amy S. Colwell, MD
Associate Professor
Harvard Medical School
Massachusetts General Hospital
Boston, MA, USA
Edward H. Davidson, MA(Cantab), MB, BS
Resident Plastic Surgeon
Department of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Emmanuel Delay, MD, PhD
Unité de Chirurgie Plastique et Reconstructrice
Centre Léon Bérard
Lyon, France
Francesco M. Egro, MB ChB, MSc, MRCS
Department of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Neil A. Fine, MD
President
Northwestern Specialists in Plastic Surgery;
Associate Professor (Clinical) Surgery/Plastics
Northwestern University Fienberg School of
Medicine
Chicago, IL, USA
Jaime Flores, MD
Plastic and Reconstructive Microvascular
Surgeon
Miami, FL, USA
Joshua Fosnot, MD
Assistant Professor of Surgery
Division of Plastic Surgery
The Perelman School of Medicine
University of Pennsylvania Health System
Philadelphia, PA, USA
Allen Gabriel, MD
Clinical Associate Professor
Department of Plastic Surgery
Loma Linda University Medical Center
Loma Linda, CA, USA
Michael S. Gart, MD
Resident Physician
Division of Plastic Surgery
Northwestern University Feinberg School of
Medicine
Chicago, IL, USA
Matthew D. Goodwin, MD
Plastic Surgeon
Plastic Reconstructive and Cosmetic Surgery
Boca Raton Regional Hospital
Boca Raton, FL, USA

xxxv
List of Contributors
Samia Guerid, MD
Cabinet
50 rue de la République
Lyon, France
Moustapha Hamdi, MD, PhD
Professor of Plastic and Reconstructive Surgery
Brussels University Hospital
Vrij Universitaire Brussels
Brussels, Belgium
Alexandra M. Hart, MD
Emory Division of Plastic and Reconstructive
Surgery
Emory University School of Medicine
Atlanta, GA, USA
Emily C. Hartmann, MD, MS
Aesthetic Surgery Fellow
Plastic and Reconstructive Surgery
University of Southern California
Los Angeles, CA, USA
Nima Khavanin, MD
Resident Physician
Department of Plastic and Reconstructive
Surgery
Johns Hopkins Hospital
Baltimore, MD, USA
John Y. S. Kim, MD
Professor and Clinical Director
Department of Surgery
Division of Plastic Surgery
Northwestern University Feinberg School of
Medicine
Chicago, IL, USA
Steven Kronowitz, MD
Owner, Kronowitz Plastics
PLLC;
University of Texas, M. D. Anderson Medical
Center
Houston, TX, USA
John V. Larson, MD
Resident Physician
Division of Plastic and Reconstructive Surgery
Keck School of Medicine of USC
University of Southern California
Los Angeles, CA, USA
Z-Hye Lee, MD
Resident
Department of Plastic Surgery
New York University Medical Center
New York, NY, USA
Frank Lista, MD, FRCSC
Medical Director
The Plastic Surgery Clinic
Mississauga, Ontario, Canada;
Assistant Professor Surgery
University of Toronto
Toronto, Ontario, Canada
Albert Losken, MD, FACS
Professor of plastic surgery and Program
Director
Emory Division of Plastic and Reconstructive
Surgery
Emory University School of Medicine
Atlanta, GA, USA
Charles M. Malata, BSc(HB), MB ChB,
LRCP, MRCS, FRCS(Glasg), FRCS(Plast)
Professor of Academic Plastic Surgery
Postgraduate Medical Institute
Faculty of Health Sciences
Anglia Ruskin University
Cambridge and Chelmsford, UK;
Consultant Plastic and Reconstructive Surgeon
Department of Plastic and Reconstructive
Surgery
Cambridge Breast Unit at Addenbrooke’s
Hospital
Cambridge University Hospitals NHS
Foundation Trust
Cambridge, UK
Jaume Masià, MD, PhD
Chief and Professor of Plastic Surgery
Sant Pau University Hospital
Barcelona, Spain
G. Patrick Maxwell, MD, FACS
Clinical Professor of Surgery
Department of Plastic Surgery
Loma Linda University Medical Center
Loma Linda, CA, USA
James L. Mayo, MD
Microsurgery Fellow
Plastic Surgery
New York University
New York, NY, USA
Roberto N. Miranda, MD
Professor
Department of Hematopathology
Division of Pathology and Laboratory Medicine
MD Anderson Cancer Center
Houston, TX, USA
Colin M. Morrison, MSc (Hons) FRCSI
(Plast)
Consultant Plastic Surgeon
St. Vincent’s University Hospital
Dublin, Ireland
Maurice Y. Nahabedian, MD, FACS
Professor and Chief
Section of Plastic Surgery
MedStar Washington Hospital Center
Washington DC, USA;
Vice Chairman
Department of Plastic Surgery
MedStar Georgetown University Hospital
Washington DC, USA
James D. Namnoum, MD
Clinical Professor of Plastic Surgery
Atlanta Plastic Surgery
Emory University School of Medicine
Atlanta, GA, USA
Maria E. Nelson, MD
Assistant Professor of Clinical Surgery
Department of Surgery, Division of Upper GI/
General Surgery, Section of Surgical Oncology
Keck School of Medicine
University of Southern California
Los Angeles, CA, USA
Julie Park, MD
Associate Professor of Surgery
Section of Plastic Surgery
University of Chicago
Chicago, IL, USA
Ketan M. Patel, MD
Assistant Professor of Surgery
Division of Plastic and Reconstructive Surgery
Keck Medical Center of USC
University of Southern California
Los Angeles, CA, USA
Nakul Gamanlal Patel, BSc(Hons),
MBBS(Lond), FRCS(Plast)
Senior Microsurgery Fellow
St. Andrew’s Centre for Plastic Surgery
Broomfield Hospital
Chelmsford, UK
Gemma Pons, MD, PhD
Head
Microsurgery Unit
Plastic Surgery
Hospital de Sant Pau
Barcelona, Spain
Julian J. Pribaz, MD
Professor of Surgery
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA, USA
Venkat V. Ramakrishnan, MS, FRCS,
FRACS(Plast Surg)
Consultant Plastic Surgeon
St. Andrew’s Centre for Plastic Surgery
Broomfield Hospital
Chelmsford, UK
Elena Rodríguez-Bauzà, MD
Plastic Surgery Department
Hospital Santa Creu i Sant Pau
Barcelona, Spain
Michael R. Schwartz, MD
Board Certified Plastic Surgeon
Private Practice
Westlake Village, CA, USA
Stephen F. Sener, MD
Professor of Surgery, Clinical Scholar
Chief of Breast, Endocrine, and Soft Tissue
Surgery
Department of Surgery, Keck School of
Medicine of USC
Chief of Surgery and Associate Medical Director
Perioperative Services
LAC+USC (LA County) Hospital
Los Angeles, CA, USA

xxxvi
List of Contributors
Joseph M. Serletti, MD, FACS
The Henry Royster–William Maul Measey
Professor of Surgery and Chief
Division of Plastic Surgery
University of Pennsylvania Health System
Philadelphia, PA, USA
Deana S. Shenaq, MD
Chief Resident
Department of Surgery - Plastic Surgery
The University of Chicago Hospitals
Chicago, IL, USA
Kenneth C. Shestak, MD
Professor, Department of Plastic Surgery
University of Pittsburgh Medical Center
Pittsburgh, PA, USA
Ron B. Somogyi, MD MSc FRCSC
Plastic and Reconstructive Surgeon
Assistant Professor, Department of Surgery
University of Toronto
Toronto, ON, Canada
David H. Song, MD, MBA, FACS
Regional Chief, MedStar Health
Plastic and Reconstructive Surgery
Professor and Chairman
Department of Plastic Surgery
Georgetown University School of Medicine
Washington, DC, USA
The late Scott L. Spear†, MD
Formerly Professor of Plastic Surgery
Division of Plastic Surgery
Georgetown University
Washington, MD, USA
Michelle A. Spring, MD, FACS
Program Director
Glacier View Plastic Surgery
Kalispell Regional Medical Center
Kalispell, MT, USA
W. Grant Stevens, MD, FACS
Clinical Professor of Surgery
Marina Plastic Surgery Associates;
Keck School of Medicine of USC
Los Angeles, CA, USA
Elizabeth Stirling Craig, MD
Plastic Surgeon and Assistant Professor
Department of Plastic Surgery
University of Texas
MD Anderson Cancer Center
Houston, TX, USA
Simon G. Talbot, MD
Assistant Professor of Surgery
Brigham and Women’s Hospital
Harvard Medical School
Boston, MA, USA
Jana Van Thielen, MD
Plastic Surgery Department
Brussels University Hospital
Vrij Universitaire Brussel (VUB)
Brussels, Belgium
Henry Wilson, MD, FACS
Attending Plastic Surgeon
Private Practice
Plastic Surgery Associates
Lynchburg, VA, USA
Kai Yuen Wong, MA, MB BChir, MRCS,
FHEA, FRSPH
Specialist Registrar in Plastic Surgery
Department of Plastic and Reconstructive
Surgery
Cambridge University Hospitals NHS
Foundation Trust
Cambridge, UK
VOLUME SIX
Hee Chang Ahn, MD, PhD
Professor
Department of Plastic and Reconstructive
Surgery
Hanyang University Hospital School of Medicine
Seoul, South Korea
Nidal F. Al Deek, MD
Surgeon
Plastic and Reconstructive Surgery
Chang Gung Memorial Hospital
Taipei, Taiwan
Kodi K. Azari, MD, FACS
Reconstructive Transplantation Section Chief
Professor
Department of Orthopedic Surgery
UCLA Medical Center
Santa Monica, CA, USA
Carla Baldrighi, MD
Staff Surgeon
Pediatric Surgery Meyer Children’s Hospital
Pediatric Hand and Reconstructive Microsurgery
Unit
Azienda Ospedaliera Universitaria Careggi
Florence, Italy
Gregory H. Borschel, MD, FAAP, FACS
Assistant Professor
University of Toronto Division of Plastic and
Reconstructive Surgery;
Assistant Professor
Institute of Biomaterials and Biomedical
Engineering;
Associate Scientist
The SickKids Research Institute
The Hospital for Sick Children
Toronto, Ontario, Canada
Kirsty Usher Boyd, MD, FRCSC
Assistant Professor
Division of Plastic Surgery, University of Ottawa
Ottawa, Ontario, Canada
Gerald Brandacher, MD
Scientific Director
Department of Plastic and Reconstructive
Surgery
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Lesley Butler, MPH
Clinical Research Coordinator
Charles E. Seay, Jr. Hand Center
Texas Scottish Rite Hospital for Children
Dallas, TX, USA
Ryan P. Calfee, MD
Associate Professor
Department of Orthopedic Surgery
Washington University School of Medicine
St. Louis, MO, USA
Brian T. Carlsen, MD
Associate Professor
Departments of Plastic Surgery and Orthopedic
Surgery
Mayo Clinic
Rochester, MN, USA
David W. Chang, MD
Professor
Division of Plastic and Reconstructive Surgery
The University of Chicago Medicine
Chicago, IL, USA
James Chang, MD
Johnson & Johnson Distinguished Professor
and Chief
Division of Plastic and Reconstructive Surgery
Stanford University Medical Center
Stanford, CA, USA
Robert A. Chase, MD
Holman Professor of Surgery – Emeritus
Stanford University Medical Center
Stanford, CA, USA
Alphonsus K. S. Chong, MBBS, MRCS,
MMed(Orth), FAMS (Hand Surg)
Senior Consultant
Department of Hand and Reconstructive
Microsurgery
National University Health System
Singapore;
Assistant Professor
Department of Orthopedic Surgery
Yong Loo Lin School of Medicine
National University of Singapore
Singapore
David Chwei-Chin Chuang, MD
Senior Consultant, Ex-President, Professor
Department of Plastic Surgery
Chang Gung University Hospital
Tao-Yuan, Taiwan
Kevin C. Chung, MD, MS
Chief of Hand Surgery
Michigan Medicine
Charles B G De Nancrede Professor, Assistant
Dean for Faculty Affairs
University of Michigan Medical School
Ann Arbor, Michigan, USA
Christopher Cox, MD
Attending Surgeon
Kaiser Permanente
Walnut Creek, CA, USA

xxxvii
List of Contributors
Catherine Curtin, MD
Associate Professor
Department of Surgery Division of Plastic
Surgery
Stanford University
Stanford, CA, USA
Lars B. Dahlin, MD, PhD
Professor and Consultant
Department of Clinical Sciences, Malmö – Hand
Surgery
University of Lund
Malmö, Sweden
Kenneth W. Donohue, MD
Hand Surgery Fellow
Division of Plastic Surgery
Department of Orthopedic Surgery
Baylor College of Medicine
Houston, TX, USA
Gregory A. Dumanian, MD, FACS
Stuteville Professor of Surgery
Division of Plastic Surgery
Northwestern Feinberg School of Medicine
Chicago, IL, USA
William W. Dzwierzynski, MD
Professor and Program Director
Department of Plastic Surgery
Medical College of Wisconsin
Milwaukee, WI, USA
Simon Farnebo, MD, PhD
Associate Professor and Consultant Hand
Surgeon
Department of Plastic Surgery, Hand Surgery
and Burns
Institution of Clinical and Experimental
Medicine, University of Linköping
Linköping, Sweden
Ida K. Fox, MD
Assistant Professor of Plastic Surgery
Department of Surgery
Division of Plastic and Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Paige M. Fox, MD, PhD
Assistant Professor
Department of Surgery, Division of Plastic and
Reconstructive Surgery
Stanford University Medical Center
Stanford, CA, USA
Jeffrey B. Friedrich, MD
Professor of Surgery and Orthopedics
Department of Surgery, Division of Plastic
Surgery
University of Washington
Seattle, WA, USA
Steven C. Haase, MD, FACS
Associate Professor
Department of Surgery, Section of Plastic
Surgery
University of Michigan Health
Ann Arbor, MI, USA
Elisabet Hagert, MD, PhD
Associate Professor
Department of Clinical Science and Education
Karolinska Institute;
Chief Hand Surgeon
Hand Foot Surgery Center
Stockholm, Sweden
Warren C. Hammert, MD
Professor of Orthopedic and Plastic Surgery
Chief, Division of Hand Surgery
Department of Orthopedics and Rehabilitation
University of Rochester
Rochester, NY, USA
Isaac Harvey, MD
Clinical Fellow
Department of Pediatric Plastic and
Reconstructive Surgery
Hospital for SickKids
Toronto, Ontario, Canada
Vincent R. Hentz, MD
Emeritus Professor of Surgery and Orthopedic
Surgery (by courtesy)
Stanford University
Stanford, CA, USA
Jonay Hill, MD
Clinical Assistant Professor
Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, CA, USA
Steven E. R. Hovius, MD, PhD
Former Head, Department of Plastic,
Reconstructive and Hand Surgery
Erasmus MC
University Medical Center
Rotterdam, the Netherlands;
Xpert Clinic, Hand and Wrist Center
The Netherlands
Jerry I. Huang, MD
Associate Professor
Department of Orthopedics and Sports
Medicine
University of Washington;
Program Director
University of Washington Hand Fellowship
University of Washington
Seattle, WA, USA
Marco Innocenti, MD
Associate Professor of Plastic Surgery,
University of Florence;
Director, Reconstructive Microsurgery
Department of Oncology
Careggi University Hospital
Florence, Italy
Neil F. Jones, MD, FRCS
Professor and Chief of Hand Surgery
University of California Medical Center;
Professor of Orthopedic Surgery;
Professor of Plastic and Reconstructive Surgery
University of California Irvine
Irvine, CA, USA
Ryosuke Kakinoki, MD, PhD
Professor of Hand Surgery and Microsurgery,
Reconstructive, and Orthopedic Surgery
Department of Orthopedic Surgery
Faculty of Medicine
Kindai University
Osakasayama, Osaka, Japan
Jason R. Kang, MD
Chief Resident
Department of Orthopedic Surgery
Stanford Hospital & Clinics
Redwood City, CA, USA
Joseph S. Khouri, MD
Resident
Division of Plastic Surgery, Department of
Surgery
University of Rochester
Rochester, NY, USA
Todd Kuiken, MD, PhD
Professor
Departments of PM&R, BME, and Surgery
Northwestern University;
Director, Neural Engineering Center for Artificial
Limbs
Rehabilitation Institute of Chicago
Chicago, IL, USA
Donald Lalonde, BSC, MD, MSc, FRCSC
Professor of Surgery
Division of Plastic and Reconstructive Surgery
Saint John Campus of Dalhousie University
Saint John, New Brunswick, Canada
W. P. Andrew Lee, MD
The Milton T. Edgerton MD, Professor and
Chairman
Department of Plastic and Reconstructive
Surgery
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Anais Legrand, MD
Postdoctoral Research Fellow
Plastic and Reconstructive Surgery
Stanford University Medical Center
Stanford, CA, USA
Terry Light, MD
Professor
Department of Orthopedic Surgery
Loyola University Medical Center
Maywood, IL, USA
Jin Xi Lim, MBBS, MRCS
Senior Resident
Department of Hand and Reconstructive
Microsurgery
National University Health System
Singapore
Joseph Lopez, MD, MBA
Resident, Plastic and Reconstructive Surgery
Department of Plastic and Reconstructive
Surgery
Johns Hopkins University School of Medicine
Baltimore, MD, USA

xxxviii
List of Contributors
Susan E. Mackinnon, MD
Sydney M. Shoenberg, Jr. and Robert H.
Shoenberg Professor
Department of Surgery, Division of Plastic and
Reconstructive Surgery
Washington University School of Medicine
St. Louis, MO, USA
Brian Mailey, MD
Assistant Professor of Surgery
Institute for Plastic Surgery
Southern Illinois University
Springfield, IL, USA
Steven J. McCabe, MD, MSc, FRCS(C)
Director of Hand and Upper Extremity Program
University of Toronto
Toronto Western Hospital
Toronto, Ontario, Canada
Kai Megerle, MD, PhD
Assistant Professor
Clinic for Plastic Surgery and Hand Surgery
Technical University of Munich
Munich, Germany
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
Steven L. Moran, MD
Professor and Chair of Plastic Surgery
Division of Plastic Surgery, Division of Hand and
Microsurgery;
Professor of Orthopedics
Rochester, MN, USA
Rebecca L. Neiduski, PhD, OTR/L, CHT
Dean of the School of Health Sciences
Professor of Health Sciences
Elon University
Elon, NC, USA
David T. Netscher, MD
Program Director, Hand Surgery Fellowship;
Clinical Professor, Division of Plastic Surgery
and Department of Orthopedic Surgery
Baylor College of Medicine;
Adjunct Professor of Clinical Surgery (Plastic
Surgery)
Weill Medical College
Cornell University
Houston, TX, USA
Michael W. Neumeister, MD
Professor and Chairman
Division of Plastic Surgery
Springfield Illinois University School of Medicine
Springfield, IL, USA
Shelley Noland, MD
Assistant Professor
Division of Plastic Surgery
Mayo Clinic Arizona
Phoenix, AZ, USA
Christine B. Novak, PT, PhD
Associate Professor
Department of Surgery, Division of Plastic and
Reconstructive Surgery
University of Toronto
Toronto, Ontario, Canada
Scott Oates, MD
Deputy Department Chair;
Professor
Department of Plastic Surgery, Division of
Surgery
The University of Texas MD Anderson Cancer
Center
Houston, TX, USA
Kerby Oberg, MD, PhD
Associate Professor
Department of Pathology and Human Anatomy
Loma Linda University School of Medicine
Loma Linda, CA, USA
Scott Oishi, MD
Director, Charles E. Seay, Jr. Hand Center
Texas Scottish Rite Hospital for Children;
Professor, Department of Plastic Surgery and
Department of Orthopedic Surgery
University of Texas Southwestern Medical Center
Dallas, TX, USA
William C. Pederson, MD, FACS
President and Fellowship Director
The Hand Center of San Antonio;
Adjunct Professor of Surgery
The University of Texas Health Science Center at
San Antonio
San Antonio, TX, USA
Dang T. Pham, MD
General Surgery Resident
Department of Surgery
Houston Methodist Hospital
Houston, TX, USA
Karl-Josef Prommersberger, MD, PhD
Chair, Professor of Orthopedic Surgery
Clinic for Hand Surgery
Bad Neustadt/Saale, Germany
Carina Reinholdt, MD, PhD
Senior Consultant in Hand Surgery
Center for Advanced Reconstruction of
Extremities
Sahlgrenska University Hospital/ Mölndal
Mölndal, Sweden;
Assistant Professor
Department of Orthopedics
Institute for Clinical Sciences
Sahlgrenska Academy
Goteborg, Sweden
Justin M. Sacks, MD, MBA, FACS
Director, Oncological Reconstruction;
Assistant Professor
Department of Plastic and Reconstructive
Surgery
Johns Hopkins School of Medicine
Baltimore, MD, USA
Douglas M. Sammer, MD
Associate Professor of Plastic and Orthopedic
Surgery
Chief of Plastic Surgery at Parkland Memorial
Hospital
Program Director Hand Surgery Fellowship
University of Texas Southwestern Medical Center
Dallas, TX, USA
Subhro K. Sen, MD
Clinical Associate Professor
Plastic and Reconstructive Surgery
Robert A. Chase Hand and Upper Limb Center
Stanford University School of Medicine
Stanford, CA, USA
Pundrique R. Sharma, MBBS, PhD and
FRCS (Plast)
Consultant Plastic Surgeon
Department for Plastic and Reconstructive
Surgery
Alder Hey Children’s Hospital
Liverpool, UK
Randolph Sherman, MD, FACS
Vice Chair
Department of Surgery
Cedars-Sinai Medical Center
Los Angeles, CA, USA
Jaimie T. Shores, MD
Clinical Director, Hand/Arm Transplant Program
Department of Plastic and Reconstructive
Surgery
Johns Hopkins University School of Medicine
Baltimore, MD, USA
Vanila M. Singh, MD, MACM
Clinical Associate Professor
Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Stanford, CA, USA
Jason M. Souza, MD, LCDR, MC, USN
Staff Plastic Surgeon, United States Navy
Walter Reed National Military Medical Center
Bethesda, MD, USA
Amir Taghinia, MD, MPH
Attending Surgeon
Department of Plastic and Oral Surgery
Boston Children’s Hospital;
Assistant Professor of Surgery
Harvard Medical School
Boston, MA, USA
David M. K. Tan, MBBS
Senior Consultant
Department of Hand and Reconstructive
Microsurgery
National University Health System
Singapore;
Assistant Professor
Department of Orthopedic Surgery
Yong Loo Lin School of Medicine
National University Singapore
Singapore

xxxix
List of Contributors
Jin Bo Tang, MD
Professor and Chair
Department of Hand Surgery;
Chair, The Hand Surgery Research Center
Affiliated Hospital of Nantong University
Nantong, The People’s Republic of China
Johan Thorfinn, MD, PhD
Senior Consultant of Plastic Surgery, Burn Unit;
Co-Director
Department of Plastic Surgery, Hand Surgery
and Burns
Linköping University Hospital
Linköping, Sweden
Michael Tonkin, MBBS, MD, FRACS(Orth),
FRCS(Ed Orth)
Professor of Hand Surgery
Department of Hand Surgery and Peripheral
Nerve Surgery
Royal North Shore Hospital
The Children’s Hospital at Westmead
University of Sydney Medical School
Sydney, New South Wales, Australia
Joseph Upton III, MD
Staff Surgeon
Department of Plastic and Oral Surgery
Boston Children’s Hospital;
Professor of Surgery
Harvard Medical School
Boston, MA, USA
Francisco Valero-Cuevas, PhD
Director
Brain-Body Dynamics Laboratory;
Professor of Biomedical Engineering;
Professor of Biokinesiology and Physical
Therapy;
(By courtesy) Professor of Computer Science
and Aerospace and Mechanical Engineering
The University of Southern California
Los Angeles, CA, USA
Christianne A. van Nieuwenhoven, MD, PhD
Plastic Surgeon/Hand Surgeon
Plastic and Reconstructive Surgery
Erasmus Medical Centre
Rotterdam, the Netherlands
Nicholas B. Vedder, MD
Professor of Surgery and Orthopedics
Chief of Plastic Surgery Vice Chair
Department of Surgery
University of Washington
Seattle, WA, USA
Andrew J. Watt, MD
Attending Hand and Microvascular Surgeon;
Associate Program Director, Buncke Clinic Hand
and Microsurgery Fellowship;
Adjunct Clinical Faculty, Stanford University
Division of Plastic and Reconstructive Surgery
The Buncke Clinic
San Francisco, CA, USA
Fu-Chan Wei, MD
Professor
Department of Plastic Surgery
Chang Gung Memorial Hospital
Taoyuan, Taiwan
Julie Colantoni Woodside, MD
Orthopedic Surgeon
OrthoCarolina
Gastonia, NC, USA
Jeffrey Yao, MD
Associate Professor
Department of Orthopedic Surgery
Stanford Hospital & Clinics
Redwood City, CA, USA

Acknowledgments
My wife, Gabrielle Kane, has always been my rock. She not
only encourages me in my work but gives constructive criti­
cism bolstered by her medical expertise as well as by her
knowledge and training in education. I can never repay her.
The editorial team at Elsevier have made this series possible.
Belinda Kuhn leads the group of Alexandra Mortimer, Louise
Cook, and the newest addition to the team, Sam Crowe. The
Elsevier production team has also been vital in moving this
project along. The volume editors, Geoff Gurtner, Peter Rubin,
Ed Rodriguez, Joe Losee, David Song, Mo Nahabedian, Jim
Chang, and Dan Liu have shaped and refined this edition,
making vital changes to keep the series relevant and up-to-
date. My colleagues in the University of Washington, headed
by Nick Vedder, have provided continued encouragement
and support. Finally, and most importantly, the residents and
fellows who pass through our program keep us on our toes
and ensure that we give them the best possible solutions to
their questions.
Peter C. Neligan, MB, FRCS(I), FRCSC, FACS
This completely updated volume represents this generation’s
brightest minds in hand and microvascular surgery. I am
indebted to my colleagues and friends from around the globe
for their hard work and eloquent writing, and to our talented
staff at Elsevier. It is our hope that this text will continue to
serve as a guide for the optimal treatment of all our patients.
I am fortunate to have two families to thank: the students,
residents, fellows, and faculty at Stanford University who
stimulate and enrich me intellectually; and my own loved
ones, my wife Dr. Harriet Walker Roeder, and girls Julia,
Kathleen, and Cecilia, who sustain me in every way.
James Chang, MD

Dedicated to future plastic surgeons. Take up the torch
and lead us forward!

Introduction 
Plastic surgery contributions to
hand surgery
James Chang
Although references to surgery of the hand date back to Hip­
pocrates in ancient Greece, the dedicated specialty of hand
surgery is relatively young. The Second World War is thought
to be the major driving event for the development of hand
surgery as a separate surgical discipline. This modern spe­
cialty was founded by a combination of general surgeons,
plastic surgeons, orthopedic surgeons, vascular surgeons, and
neurosurgeons. Hand surgery has remained unique in that it
is a regional specialty instead of a tissue specialty – its prac­
titioners are ideally trained in managing problems affecting
all component tissues of the hand. This introduction chronicles
the role plastic surgery has played in the development of hand
surgery as a surgical specialty. Furthermore, it predicts how
plastic surgery will influence the future direction of hand
surgery.
Origins of hand surgery
Henry C. Marble, in Flynn’s classic textbook, Hand Surgery,
found the earliest references to surgery of the hand by Hip­
pocrates (460–377 BC) in ancient Greece.1 In his writings,
Hippocrates described methods to reduce wrist fractures and
also highlighted the importance of well-fitting, clean dress­
ings to the hand. A later Greek physician, Heliodorus,
described his technique for amputation of a finger with spe­
cific reference to dissecting adequate skin flaps with which to
cover the remaining bone. While Galen (131–201 AD) confused
tendons with nerves and cautioned against suturing tendons
for fear of “nervous spasms”,2 Avicenna (981–1038 AD),3 an
Arabian physician, wrote detailed descriptions of tendon
repair in medieval times. Other references to hand surgery
have been found in history, but comprehensive care of the
hand was not truly developed until the 20th century.
An understanding of human anatomy has been critical to
both plastic surgery and hand surgery, and therefore, the
history of anatomy has paralleled the development of these
two surgical disciplines. J. William Littler reviewed the
influence of famed anatomists on hand surgery.4 Perhaps
these anatomists were drawn to the hand as the most intricate
of body parts – the ultimate challenge to their craft. In the
Renaissance period, Leonardo da Vinci (1452–1519) used his
artistic genius to create extraordinarily accurate representa­
tions of the hand. His knowledge of anatomy was acquired
from over 100 human dissections and ultimately resulted in a
collection of 779 anatomical drawings.5
Andreas Vesalius (1514–1564) (Figs. 0.1 & 0.2) published his
monumental work De Corporis Humani Fabrica in 1543 with
many engravings dedicated to the hand.5 Like da Vinci, Vesa­
lius relied on his own dissections of cadavers rather than
accepting the dogma found in previous medical texts. His
observations refuted the inaccuracies found in the earlier
writings of Galen and his disciples. Modern-day hand sur­
geons J. William Littler and Robert A. Chase have both credited
Sir Charles Bell (1774–1842) as the foremost anatomist of the
hand.6 His Fourth Bridgewater Treatise – The Hand: Its Mechanism
and Vital Endowments as Evincing Design (1834) remains a
classic essay on the anatomic and functional aspects of the
hand.7
In addition to anatomy, two more recent achievements
allowed hand surgery to develop into a unique specialty in
the modern era. On October 16, 1846 at the Massachusetts
General Hospital, Dr. William Morton delivered sulfuric ether
fumes to a patient undergoing excision of a neck mass by Dr.
John Collins Warren.8 For the first time, adequate anesthesia
was performed, thus allowing the possibility of more complex
reconstructive procedures in both plastic surgery and hand
surgery.
The second major achievement was an understanding of
microbiology with resulting advances in sterile technique and
antibiotics.9 In the 1860s, Louis Pasteur’s work with fermen­
tation introduced the field of bacteriology. Semmelweis, in
Vienna, and Lister, in Britain, developed antiseptic surgery
with the early use of carbolic acid as a disinfectant. In the
20th century, several Nobel Prizes marked the importance
of the development of antibiotics. Paul Ehrlich a German

xliii
Principles of plastic surgery and their application to hand surgery
bacteriologist, developed the principle of “antimicrobial che­
motherapy” and received the Nobel Prize in 1908. Another
German, Gerhard Domagk, received the Nobel Prize in
1939 for discovering the antibacterial effects of sulfa drugs.
Finally, Alexander Fleming shared the Nobel Prize in 1945 for
discovering the ability of a mold, Penicillium notatum to halt
the growth of staphylococcus bacteria. With penicillin and
later antibiotics, plastic surgeons and hand surgeons had an
armamentarium of agents to control infections.
Over the course of this history, how has plastic surgery
contributed to the development and progress of hand surgery?
Like hand surgery, plastic surgery became a separate surgical
specialty in the US only in the 20th century with the founding
of the American Association of Oral and Plastic Surgeons
(later shortened to the American Association of Plastic Sur­
geons) in 1921. The American Board of Plastic Surgery was
not established until 1938. However, plastic surgery has pro­
foundly influenced hand surgery, and this influence has
predated formal associations and boards. In other words,
surgeons throughout history have used plastic surgery prin­
ciples before they were known as “plastic surgeons”. There­
fore, early plastic surgery contributions to hand surgery are
best chronicled by reviewing the development of plastic
surgery principles and how they have been applied to hand
surgery.
Principles of plastic surgery and their
application to hand surgery
Sushruta, a Hindu surgeon in India around the first century
AD, performed reconstruction of the nose using pedicled flaps
from the face – either forehead or cheek. He described the
operation as follows:
The physician should take the leaf of a tree the same size as the
nose and apply it to the cheek in such a way that a stem is still
adherent. Then he stitches the cheek with needle and thread,
scarifies the stump of the nose and quickly but carefully places
the flap in the nose. After the transplanted piece has grown, the
stem is cut off. In like manner the flap might be turned up from
the upper or lower arm and attached to the nose – with the arm
over the head.1
This description included the basic plastic surgery principles
of precise patterning of the defect, preparation of the recipient
bed, and the use of local and distant flaps, all which have had
obvious applicability to soft-tissue reconstruction of the hand.
Another famed surgeon, Ambrose Paré (1510–1590), offered
principles that allowed for optimal care of battlefield wounds,
including the upper extremity: “to enlarge the wound for
drainage; to remove bone splinters and foreign bodies from
wounds; to control hemorrhage with ligatures; not to encour­
age suppuration; and to amputate through sound tissues.”1
Paré’s use of ligatures during amputation controlled hemor­
rhage and saved countless lives on the battlefield (Figs. 0.3 &
0.4). His principles of wound care would later be applied
directly to the enormous number of battlefield casualties of
World War II. In addition, Paré popularized the anatomic
drawings of Vesalius amongst surgeons, and even designed
elaborate prostheses for upper extremity amputees, victims of
the French wars of the 1500s. Paré was perhaps the quintes­
sential upper extremity trauma surgeon.
Fig. 0.1  Andreas Vesalius, master anatomist, at the age of 28. (Reproduced from
Vesalius A. De Humani Corporis Fabrica. 1543. Reproduced with permission from
the British Library.)
Fig. 0.2  An example of the anatomic illustrations of Stephan van Calcar in the
monumental text of Vesalius, De Humani Corporis Fabrica (1543). (Reproduced
from Vesalius A. De Humani Corporis Fabrica. 1543. Reproduced with permission
from the British Library.)

xliv
Introduction • Plastic surgery contributions to hand surgery
Gaspare Tagliacozzi (1545–1599) did not invent the Italian
method of nasal reconstruction, which has been generally
attributed to Branca. However, Tagliacozzi, a professor of
medicine and anatomy in Bologna, did popularize this tech­
nique of attaching a medial upper arm skin flap to the nasal
defect. In addition, specialized leather band contraptions
were devised to immobilize the patient during the period of
flap revascularization (Fig. 0.5). His detailed textbook, De
Chirurgia Curtorum per Insitionem, was published in 1597 and
allowed later generations of surgeons to learn techniques for
the transfer of distant pedicled flaps.5
As plastic surgeons became more adept at tissue transfer,
these innovations were applied to reconstruction of the hand.
Carl Nicoladoni (1849–1903) pioneered work on reconstruc­
tion of the thumb. Nicoladoni reported on a case of total skin
avulsion of the thumb that he treated by a skin flap from the
patient’s left pectoral region – similar to the thoracoepigastric
or random pattern chest flaps still used today.6 In 1903, his
Fig. 0.3  Ambrose Paré applying a ligature during battlefield amputation. Wood
engraving by C. Maurand. (Reproduced with permission from The Wellcome Trust
L0018530.)
Fig. 0.4  Examples of Paré’s designs for prostheses. (Reproduced from Les Oeuvres
de M. Ambroise Paré, 1575, p. 916–917.)
A
B
Fig. 0.5  Tagliacozzi’s immobilization device after arm-to-nose pedicled transfer.
(Reproduced from Typ 525.97.820 with permission from Houghton Library, Harvard
University.)
paper, “Further experience with thumb reconstruction”,
described the pedicled toe transfer to the thumb that continues
to bear his name. Microsurgeons today have obviated the
need for the uncomfortable positioning of this transfer; nev­
ertheless, Nicoladoni deserves credit for the ingenuity behind
the toe-to-hand transfer. Plastic surgeon George H. Monks
(1853–1933) transferred a composite skin island flap from the
forehead on the superficial temporal arteriovenous pedicle to
a lower-eyelid defect.6 The use of island flaps would later be
applied to the hand with the neurovascular island flaps of
Littler, and, more recently, with the dorsal metacarpal artery
flaps. Even Sir Harold Gillies (1882–1960) who, with Millard,
codified the principles of plastic surgery and was one of his­
tory’s most influential plastic surgeons, turned from the head
and neck to the hand and devised a method to lengthen the
stump of a thumb, the Gillies “cocked-hat” flap.10
Vilray P. Blair (1871–1955) was one of the founding fathers
of American plastic surgery.11 In addition to a large body of
work in cleft lip repair and maxillofacial surgery, Blair made
two significant contributions to plastic surgery that translated
directly to hand surgery. Blair helped redefine the delay
phenomenon of Tagliacozzi in a 1921 article, “The delayed
transfer of long pedicled flaps in plastic surgery”. Blair and
his disciple, James Barrett Brown (1899–1971), described a
new technique of harvesting skin for skin grafting in a paper
published in Surgery, Gynecology, and Obstetrics entitled “The
use and uses of large split skin grafts of intermediate thick­
ness”.12 This simple and reproducible method of harvesting
split-thickness skin improved on the previous techniques of
Thiersch and would have a tremendous impact on the recon­
struction of hand burns and other wounds in World War II.

xlv
Developments after World War II
service specifically dedicated to care of the injured hand.
Joint conferences involving plastic surgery, orthopedic
surgery, and neurosurgery were established and, within a
short time, four complete wards dedicated to hand surgery
were in operation.
Dr. Littler’s unit was used as a model by Surgeon General
Norman T. Kirk to establish nine military referral centers
throughout the US.15 Sterling Bunnell served as civilian surgi­
cal consultant to the Secretary of War and visited each referral
center to teach hand surgery.
Simultaneously, advances in plastic surgery had provided
effective and reliable methods of wound coverage ranging
from split- and full-thickness skin grafts to local and distant
pedicled flaps. This ability to cover wounds was critical to the
development of hand surgery. Because wound coverage was
a priority, the regional hand centers established across the US
were situated in hospitals that had been already designated
as plastic surgery centers.
Plastic surgeons were instrumental in this early phase of
development in American hand surgery because of their
expertise in wound care and trauma reconstruction. In March
1945, Lieutenant Colonel Eugene M. Bricker outlined in an
Army memorandum the principles of plastic surgery relevant
to hand surgery:
1. Conservative, careful and thorough debridement of the
primary wound is essential. Primary closure is not
advised in an evacuation hospital, but skin flaps can be
dressed back into place.
2. Splint purposefully, maintaining the palmar arch and
flexion of the metacarpophalangeal joints.
3. Bring about delayed closure as early as possible,
preferably on the third or fourth day, by simple closure,
split graft or pedicle graft, according to the necessities of
the case.
4. Use traction only when it is urgently indicated, and
then for a minimum length of time.
5. Concentrate on maintenance of such function as remains
following certain severe types of injury. Restoration of
the injured part should not be attempted, and healing
should be accomplished as rapidly as possible.
Amputation of an irreparably damaged finger is
justified.
6. Institute active motion as early as possible, and
supplement by occupational therapy when healing has
occurred.
7. Try to prevent edema and infection in open wounds.
Proper debridement, proper dressings, proper splinting,
and effective elevation of the hand will prevent this
development.
8. Manage an open wound aseptically as long as it
remains open. Aseptic management implies the use of
masks and of instruments or gloves, whether or not the
wound is infected.16 These principles served as the
foundation for acute treatment of traumatic hand
injuries.
Developments after World War II
Immediately after World War II, plastic surgeons continued
to have a profound influence on hand surgery. In 1946, plastic
Origins of modern hand surgery
With this historical background in wound management, flap
transfer, and skin grafting, plastic surgeons were poised to
contribute to the founding of modern hand surgery. World
War II was the crucible in which hand surgery became a sepa­
rate specialty. Prior to the outbreak of this war, two surgeons
were instrumental in hand surgery’s early development. In
1939, Allen B. Kanavel published his Infections of the Hand,13
and for the first time, a comprehensive approach to the myriad
of hand infections and treatments was described. Even at that
early time, Kanavel stressed the importance of hospitalization
for hand infections, intravenous hydration, and placing the
hand at rest.
Sterling Bunnell (1882–1957) has been widely regarded as
the father of hand surgery. The first edition of Bunnell’s
comprehensive textbook, Surgery of the Hand,14 was published
in 1944, and remained the classic reference for many years.
He was a general surgeon but believed in the importance of
plastic surgery principles, and as the consummate hand
surgeon, was able to apply plastic, orthopedic, and vascular
principles equally to hand surgery. Marble recounted Bun­
nell’s mastery:
He insisted on all of the teachings of the past masters,
stressing particularly the gentle handling of the tissues. He
called this atraumatic surgery. He exercised his skill also in
plastic, bone, tendon, nerve, blood vessel, and muscle surgery
to reconstruct crippled hands. He showed that tendons could
be grafted to substitute for lost ones, and could be transferred
to give function to useless digits or joints. He taught that
nerves could be grafted and that whole fingers could be
moved about for better function. Thus he opened the door for
the complete reconstruction of the injured hand.1
The specialty of hand surgery in the US really developed
in the field hospitals and regional medical referral centers
established during the Second World War. During those years,
massive numbers of surviving casualties with upper extrem­
ity injuries, an organized resuscitation and transportation
service, and increasing sophistication within the fields of
general surgery, plastic surgery, orthopedic surgery, vascular
surgery, and neurosurgery together formed the critical
mass necessary for accelerated technical and educational
development.
The high volume of hand injuries requiring care in World
War II was unprecedented. Unlike the trench warfare of World
War I when head and neck wounds were common, World War
II involved open warfare with rapid movements and grenades,
leading to a greater likelihood of upper extremity injuries. In
the early years of the war, soldiers with injured hands and
upper extremities were placed into individual hospitals and
distributed somewhat arbitrarily on to orthopedic, general
surgery, plastic surgery, and neurosurgery wards depending
on the nature of the injury and the availability of beds. It
became evident that specialized interdisciplinary care of the
hand patient was necessary. In a masterpiece of organizational
effort, regional hand referral centers were established in US
military hospitals. Colonel J.J. Reddy and Colonel F.V. Kilgore
together established the first ward designated for hand
surgery at Cushing General Hospital in Framingham, Mas­
sachusetts.15 Plastic surgeon Captain (later Major) J. William
Littler was assigned to this ward and supervised the first

xlvi
Introduction • Plastic surgery contributions to hand surgery
been organized in major hospitals, and microsurgical tech­
niques have become an integral part of the training of hand
surgeons. The techniques of replantation in the upper extrem­
ity have been extrapolated to successful replantation of other
parts of the body, including the lower limb, the scalp, the ear,
portions of the lip and nose, and the penis, and have led
directly to the further evolution of elective microsurgical free
tissue transfer. In addition, plastic surgeons have devised
innovations to improve the success rates of replantation,
including the use of Y-shaped interposition vein grafts in
multiple-digit replantations25 and replantation of fingers
distal to the proximal interphalangeal joint.26
Plastic surgeon Harry J. Buncke helped pioneer the toe-to-
thumb transplant in animal models, and eventually in humans.
His efforts in the past 40 years have made him one of the
fathers of American microsurgery.27 Beyond the earlier work
of Littler on thumb reconstruction, plastic surgeons have
continued to contribute greatly to the refinement of various
operations, including the toe-to-hand transfer28,29 and the
great-toe wraparound free flap of Morrison et al.30
Critical to reconstruction of the hand with both pedicled
flaps and free flaps has been a detailed knowledge of anatomy
as it relates to vascular distributions to muscle and skin.
McCraw et al. popularized the use of musculocutaneous
flaps31 and Mathes and Nahai developed an atlas of these
muscle and musculocutaneous flaps, which has been an
invaluable reference for the reconstructive surgeon.32 Ian
Taylor and his plastic surgery colleagues have described the
vascular territories of skin flaps. Taylor’s angiosome theory,
where the body is divided into different vascular territories
to the skin, originating from deeper source arteries, has
allowed surgeons to design flaps with reliable perfusion. In
addition, second-generation flaps, based on smaller vessels,
may be possible with an understanding of this intricate
anatomy.
Plastic surgeons have also continued to be involved in the
political and educational development of hand surgery. In
1970, a second hand organization – the American Association
for Hand Surgery (AAHS) – was founded.33 By the fall of 1971,
there were 65 full members. As in the American Society for
Surgery of the Hand, plastic surgeons played an instrumental
role. The first meeting in 1971 immediately preceded the
annual American Society of Plastic and Reconstructive Sur­
geons meeting. This arrangement symbolized the influence
and participation of plastic surgeons in the AAHS that con­
tinues today.
Recent developments
In recent years, significant contributions to hand surgery have
been made by plastic surgeons. One area of intense study in
the past several decades has been peripheral nerve repair and
reconstruction. Millesi et al.34 published a landmark paper in
1972 on interfascicular nerve grafting of median and ulnar
nerves. Since then, nerve grafting, as well as autogenous
vein grafting of nerve defects, has helped improve results
of nerve reconstruction.35,36 Mackinnon and Hudson37 have
examined the possibility of immunosuppression for allograft
nerve transplantation to bridge extensive defects where
autogenous donor nerve may not be sufficient, and more
recently pioneered the field of nerve transfers.38 Several plastic
surgeon Darrel T. Shaw and general surgeon Robert Lee
Payne published a landmark paper entitled, “One stage tubed
abdominal flaps”.17 This paper described an axial flap based
on the superficial inferior epigastric vessels for composite
tissue transfer to the hand. The development of reliable com­
posite tissue transfer allowed early coverage of extensive
hand and upper extremity defects. Sir Archibald McIndoe, a
disciple of Gillies, established several burn facilities in England
and refined techniques in burn excision and reconstruction of
the hand.18
The patients wounded during the battles of World War II
returned to the US for further reconstructive surgery by an
increasingly better-trained cadre of hand surgeons. In order
to coordinate this explosive growth in hand surgery, represen­
tatives from general surgery, plastic surgery, and orthopedic
surgery combined to form the American Society for Surgery
of the Hand in 1946.19 The first annual meeting was held on
January 20, 1946 at the Blackstone Hotel in Chicago, Illinois,
with Sterling Bunnell as the first president. Plastic surgeons
figured prominently – of the 35 founding members, 13 (37%)
came from plastic surgery backgrounds.20
Hand surgery underwent another period of accelerated
productivity during the Korean War. By that time, the US
military had experience in organizing regional referral centers
for reconstruction of the hand. Dr. J William Littler took on
Bunnell’s former role and was appointed as Hand Surgery
Civilian Consultant to the Military.6 Littler’s unrivaled experi­
ence from World War II and then the Korean conflict allowed
him to become perhaps the most famous of plastic hand
surgeons. His achievements have included the Littler digital
neurovascular transfer and countless other surgical innova­
tions bearing his name, in addition to his legendary anatomic
sketches of the hand and long list of trainees who have become
distinguished hand surgeons themselves. Other plastic sur­
geons who were involved in the Korean War effort included
Robert A. Chase and Earle Peacock. Robert A. Chase returned
from his military duty to embark on a lifelong effort of devel­
oping educational aids related to functional anatomy of the
hand. Earle Peacock contributed original laboratory work on
wound healing, particularly related to flexor tendon wound
healing.
The era of microsurgery
Hand surgery underwent an intense period of laboratory and
clinical activity in the 1960s and 1970s devoted to microsur­
gery and free tissue transfer. In 1963, Goldwyn et al. presented
their work on abdominal free flaps in dogs, based on the
inferior epigastric vessels.21 This investigative work was
further developed by Krizek et al. in 1965.22 Together, these
plastic surgeons, along with O’Brien,23 Taylor et al.24 and many
others throughout the world, established the possibility of
free tissue transfer that liberated the hand surgeon from the
anatomic limitations of local tissue transfer.
Replantation of fingers and other body parts came into
reality via an international effort of plastic surgeons, orthope­
dic surgeons, and general surgeons. The first successful
replantation of an upper arm amputation by Malt and
McKhann was carried out in 1962, and the first successful
replantation of an amputated thumb was performed in 1968
by Komatsu and Tamai. Since then, replantation teams have

xlvii
Future directions
surgeons, including Terzis et al.39 and Hentz and Narakas,40
have published reports of their considerable experience on
reconstruction of brachial palsy injury. Their dedication to
the comprehensive reconstruction and rehabilitation of
these devastating injuries has resulted in improved surgical
outcomes.
Beyond replantation, more intricate microvascular opera­
tions have been undertaken by plastic hand surgeons to
restore form and function to the hand. Although the indica­
tions are limited, microvascular transfer of a toe metatarso­
phalangeal joint to recreate a metacarpophalangeal joint has
been shown to be possible.41 Further advances in microsurgi­
cal reconstruction of the hand include functional free muscle
transfer. Manktelow and McKee’s landmark paper in 1978
introduced the concept of a free gracilis or free pectoralis
major muscle transfer with motor nerve coaptation to restore
active finger flexion.42
Plastic surgeons have also been at the forefront of congeni­
tal hand surgery.43 Graham Lister published one of the first
significant series of toe-to-hand microvascular transfers in
children, ushering in a new era of complex reconstruction for
congenital hand problems.44 Other authors, including Gilbert45
and Buck-Gramcko,46 have also published their series. More
recently, Neil Jones has added his work on pediatric toe-to-
hand transfers to previous contributors, thus refining these
technically challenging procedures.47 In addition, Joseph
Upton et al.48 reported on their unrivalled experience with
excision and reconstruction of vascular anomalies in the
upper extremity.
The plastic surgery techniques of flap dissection have been
used to develop newer flaps intrinsic to the hand and upper
extremity such as vascularized bone flaps from the distal
radius. There is much excitement in using these pedicled bone
flaps for revascularization of the scaphoid in scaphoid non­
union and avascular necrosis, or revascularization of the
lunate in Kienbock’s disease.49 These second-generation flaps
may lead to other intrinsic flaps that will also be useful for
bone and ligament reconstruction.
Plastic surgeons know of their legacy of involvement in the
field of organ transplantation. Much of the pioneering work
on allograft rejection and homograft tolerance by Sir Peter
Medawar and others was derived from experimentation with
skin grafts in various animal models.9 Joe Murray, the only
plastic surgeon ever to receive the Nobel Prize, received it for
his work on transplantation, including the first human kidney
transplantation in 1954.9 With newer immunosuppressive
agents and greater acceptance of the risks of transplantation,
human hand allograft transplantation has now become a
reality.50 While the ultimate success of these early operations
remains to be seen, reaching these new frontiers in hand
reconstruction as well as in other forms of composite tissue
allotransplantation is now possible.
Future directions
An accomplished hand and plastic surgeon once wrote:
I learned about hand surgery’s battle against scar adherence and
contraction and that the Z-plasty can be a major and intriguing
weapon in that battle in other parts of the body as well as in the
hand. I thought a lot about the Z-plasties that year and used
them often, in multiple parts of the body, always trying to pick
the optimum size and the best orientation, trying to decide which
of the two parallel sides of the Z-plasty’s diamond would be most
advantageous for mimicking the wrinkle lines, and trying to
avoid running into features not to be moved or, occasionally, to
something on or in one of the flaps … Ever since, I have looked
upon the Z-plasty as a little bit of magic.51
That surgeon was Leonard T Furlow Jr, who took the Z-plasty
from the scarred hand to the cleft palate. It is an excellent
example of the intellectual interplay between plastic surgery
and hand surgery.
Current plastic surgery research has focused on growth
factor technology to inhibit scarring or to augment bone
growth, wound healing,52 and angiogenesis. Tissue engineer­
ing may allow formation of ample supplies of bone, cartilage,53
even muscle, skin, and nerve. Virtual reality surgery will help
plastic surgeons model and practice complex reconstructive
procedures prior to undertaking them. In the next decade,
hand surgeons will acquire an armamentarium that includes
bone substitutes, tissue-engineered bone, cartilage and nerve,
and three-dimensional computer models for complex intra­
carpal abnormalities. Throughout the chapters of this hand
volume, you will find new, pioneering translational work that
shapes the future of hand and upper extremity surgery. As in
microsurgery, plastic surgeons will lead the way for this new
technical revolution in hand surgery.
2. Kleinert HE, Spokevicius S, Papas NH. History of flexor tendon
repair. J Hand Surg Am. 1995;20A:S46. This paper by Kleinert et al.
describes the evolution of flexor tendon repair over time from secondary
repair of tendon laceration in zone II to the current techniques of primary
repair.
14. Bunnell S. Surgery of the Hand. Philadelphia: Lippincott; 1944. This is
the first edition of the first modern textbook in hand surgery, written by
Sterling Bunnell, widely regarded as the father of American hand surgery.
30. Morrison WA, O’Brien BM, Macleod AM. Thumb reconstruction
with a free neurovascular wrap-around flap from the big toe.
J Hand Surg Am. 1980;5A:575–583. This original description of the great
toe wrap-around flap represents a significant refinement of the great toe
transfer, resulting in a narrower thumb and preservation of a portion of
the length of the great toe donor site.
38. Tung TH, Mackinnon SE. Nerve transfers: indications, techniques,
and outcomes. J Hand Surg Am. 2010;35:332–341. This review article
describes current state of the art for new techniques in nerve transfers.
Nerve transfers represent a developing field in hand surgery whereby
fascicular dissection of nerves allows precise transfer of specific nerve
branches to reinnervate other nerve–muscle units.
47. Chang J, Jones NF. Radiographic analysis of growth in pediatric
toe-to-hand transfer. Plast Reconstr Surg. 2002;109:576–582. This
article reviews a large clinical experience with pediatric toe-to-hand
transfers. Radiographic analysis of the transferred toes was performed,
with comparison to the opposite toe as a growth control. The authors
showed that, with careful preservation of the growth plates, growth of
these transferred toes is maintained over time.
Access the complete reference list online at

xlvii.e1
References
References
1. Marble HC. History of hand surgery. In: Flynn JE, ed. Hand Surgery.
Baltimore: Williams & Wilkins; 1966:1–10.
2. Kleinert HE, Spokevicius S, Papas NH. History of flexor tendon
repair. J Hand Surg. 1995;20A:S46. This paper by Kleinert et al.
describes the evolution of flexor tendon repair over time from secondary
repair of tendon laceration in zone II to the current techniques of primary
repair.
3. Haeger K. Medieval medicine. In: Haeger K, ed. The Illustrated
History of Surgery. Gothenburg, Sweden: AB Nordbok;
1988:73.
4. Littler JW. Plastic surgeons and the development of reparative
surgery of the hand. In: Aston SA, Beasley RW, Thorne CHM, eds.
Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott-
Raven; 1997:791.
5. Haeger K. Surgery in the Renaissance. In: Haeger K, ed. The
Illustrated History of Surgery. Gothenburg, Sweden: AB Nordbok;
1988:96.
6. Littler JW. Plastic surgeons and the development of reparative
surgery of the hand. In: Aston SA, Beasley RW, Thorne CHM, eds.
Grabb & Smith’s Plastic Surgery. 5th ed. Philadelphia: Lippincott-
Raven; 1997:791.
7. Bell C. Fourth Bridgewater Treatise – The Hand: Its Mechanism and Vital
Endowments as Evincing Design. Philadelphia: Carey, Lea &
Blanchard; 1833.
8. Haeger K. Surgery in the age of revolutions. In: Haeger K, ed. The
Illustrated History of Surgery. Gothenburg, Sweden: AB Nordbok;
1988:188–189.
9. Haeger K. The world of modern surgery. In: Haeger K, ed. The
Illustrated History of Surgery. Gothenburg, Sweden: AB Nordbok;
1988:267–270.
10. Lister GD. Skin flaps. In: Green DG, ed. Operative Hand Surgery. Vol
2. 3rd ed. New York: Churchill Livingstone; 1993:1750–1751.
11. Stelnicki EJ, Young VL, Francel T, et al. Vilray R. Blair, his surgical
descendents, and their roles in plastic surgical development. Plast
Reconstr Surg. 1999;103:1990–2009.
12. Blair V, Brown JB. The use and uses of large split skin grafts of
intermediate thickness. Surg Gynecol Obstet. 1929;49:82.
13. Kanavel AB. Infections of the Hand. Philadelphia: Lea & Febiger;
1939.
14. Bunnell S. Surgery of the Hand. Philadelphia: Lippincott; 1944. This is
the first edition of the first modern textbook in hand surgery, written
by Sterling Bunnell, widely regarded as the father of American hand
surgery.
15. Cutler CW. The overall picture in the zone of interior. In: Bunnell S,
ed. Surgery in World War II: Hand Surgery. Washington D.C.: Office
of the Surgeon General, Department of the Army; 1955:12–14.
16. Cleveland M. Hand injuries in the European theater of operations.
In: Bunnell S, ed. Surgery in World War II: Hand Surgery. Washington
D.C.: Office of the Surgeon General, Department of the Army;
1955:161–162.
17. Shaw D, Payne R. One stage tubed abdominal flaps. Surg Gynecol
Obstet. 1946;83:205–209.
18. Robson MC, Smith DJ. Thermal injuries. In: Jurkiewicz MJ, Krizek
TJ, Mathes SJ, et al., eds. Plastic Surgery: Principles and Practice. St.
Louis: C.V. Mosby; 1990:1359.
19. Newmeyer WL. The second world war to 1971: the founding. In:
Newmeyer WL, ed. American Society for Surgery of the Hand: The
First Fifty Years. New York: Churchill Livingstone; 1995:3–4.
20. Meals RA, ed. ASSH Video #127-90: 26. Conversations with the
Founders.
21. Goldwyn RM, Lamb DL, White WL. An experimental study of large
island flaps in dogs. Plast Reconstr Surg. 1963;31:528–536.
22. Krizek TJ, Tahi T, Desprez QO, et al. Experimental transplantation
of composite grafts by microvascular anastomosis. Plast Reconstr
Surg. 1965;36:358.
23. O’Brien BM. Microvascular Reconstructive Surgery. Edinburgh:
Churchill Livingstone; 1977.
24. Taylor GI, Miller GD, Ham FJ. The free vascularized bone graft – a
clinical extension of microvascular techniques. Plast Reconstr Surg.
1975;55:533–544.
25. Jones NF, Jupiter JB. The use of Y-shaped interposition vein
grafts in multiple digit replantations. J Hand Surg.
1985;10A:675–678.
26. May JW, Toth BA, Gardner M. Digital replantation distal to the
proximal interphalangeal joint. J Hand Surg. 1982;7A:161–166.
27. Buncke HJ. Forty years of microsurgery: what’s next? J Hand Surg.
1995;20A:S34.
28. Lister GD, Kalisman M, Tsai TM. Reconstruction of the hand with
free microneurovascular toe-to-hand transfer: experience with 54
toe transfers. Plast Reconstr Surg. 1983;71:372–386.
29. May JW Jr, Bartlett SP. Great toe-to-hand free tissue transfer for
thumb reconstruction. Hand Clin. 1985;1:271–284.
30. Morrison WA, O’Brien BM, Macleod AM. Thumb reconstruction
with a free neurovascular wrap-around flap from the big toe. J
Hand Surg. 1980;5A:575–583. This original description of the great toe
wrap-around flap represents a significant refinement of the great toe
transfer, resulting in a narrower thumb and preservation of a portion of
the length of the great toe donor site.
31. McCraw JB, Dibbell DG, Carraway JH. Clinical definition of
independent myocutaneous vascular territories. Plast Reconstr Surg.
1977;60:341–352.
32. Mathes SJ, Nahai F, eds. Clinical Application for Muscle and
Musculocutaneous Flaps. St. Louis: CV Mosby; 1982.
33. Freeland AE. The First Twenty-Five Years: History of the American
Association for Hand Surgery. Arlington Heights, Illinois: AAHS;
1995:1–3.
34. Millesi H, Meissl G, Berger A. The interfascicular nerve grafting of
the median and ulnar nerves. J Bone Joint Surg. 1972;54A:727–750.
35. Terzis JK, Faibisoff BA, Williams HB. The nerve gap: suture under
tension vs. graft. Plast Reconstr Surg. 1975;56:166–170.
36. Chiu DTW, Janecka I, Krizek TJ, et al. Autogenous vein graft as a
conduit for nerve regeneration. Surgery. 1982;91:226.
37. Mackinnon SE, Hudson AR. Clinical application of peripheral nerve
transplantation. Plast Reconstr Surg. 1992;90:695–699.
38. Tung TH, Mackinnon SE. Nerve transfers: indications, techniques,
and outcomes. J Hand Surg. 2010;35:332–341. This review article
describes current state of the art for new techniques in nerve transfers.
Nerve transfers represent a developing field in hand surgery whereby
fascicular dissection of nerves allows precise transfer of specific nerve
branches to reinnervate other nerve–muscle units.
39. Terzis JK, Vekris MD, Soucacos PN. Outcomes of brachial plexus
reconstruction in 204 patients with devastating paralysis. Plast
Reconstr Surg. 1999;104:1221–1240.
40. Hentz VR, Narakas A. The results of microneurosurgical
reconstruction in complete brachial plexus palsy: assessing outcome
and predicting results. Orthop Clin North Am. 1988;19:107–114.
41. Mathes SJ, Buchannan R, Weeks PM. Microvascular joint
transplantation with epiphyseal growth. J Hand Surg.
1980;5A:586–589.
42. Manktelow RT, McKee NH. Free muscle transplantation to provide
active finger flexion. J Hand Surg. 1978;3A:416–426.
43. Upton J. Correction of constriction rings. J Hand Surg.
1991;16A:947–953.
44. Lister G. Microsurgical transfer of the second toe for congenital
deficiency of the thumb. Plast Reconstr Surg. 1988;82:658–665.
45. Gilbert A. Reconstruction of congenital hand defects with
microvascular toe transfers. Hand Clin. 1985;1:351–360.
46. Buck-Gramcko D. Progress in the treatment of congenital
malformations of the hand. World J Surg. 1990;14:715–724.
47. Chang J, Jones NF. Radiographic analysis of growth in pediatric
toe-to-hand transfer. Plast Reconstr Surg. 2002;109:576–582. This
article reviews a large clinical experience with pediatric toe-to-hand
transfers. Radiographic analysis of the transferred toes was performed,
with comparison to the opposite toe as a growth control. The authors
showed that, with careful preservation of the growth plates, growth of
these transferred toes is maintained over time.

xlvii.e2
Introduction • Plastic surgery contributions to hand surgery
48. Upton J, Coombs CJ, Mulliken JB, et al. Vascular malformations of
the upper limb: a review of 270 patients. J Hand Surg.
1999;24:1019–1035.
49. Zaidemberg C, Siebert JW. Agrigiani C. A new vascularized bone
graft for scaphoid nonunion. J Hand Surg. 1991;16A:474–478.
50. Jones JW, Gruber SA, Barker JH, et al. Successful hand
transplantation. N Engl J Med. 2000;343:468–473.
51. Furlow LT. Double opposing Z-plasties to repair a cleft palate: a
personal account. Adv Plast Reconstr Surg. 1998;15:205.
52. Chang J, Siebert JW, Schendel SA, et al. Scarless wound healing:
implications for the aesthetic surgeon. Aesthetic Plast Surg.
1995;19:237–341.
53. Ting V, Sims CD, Brecht LE, et al. In vitro prefabrication of human
cartilage shapes using fibrin glue and human chondrocytes. Ann
Plast Surg. 1998;40:413–420.

SECTION I • Introduction and Principles
1 
Anatomy and biomechanics of the hand
James Chang, Anais Legrand, Francisco Valero-Cuevas, Vincent R. Hentz, and Robert A. Chase
SYNOPSIS
■ The hand is an incredibly designed structure with complex anatomy
and precise biomechanics. The hand must be able to produce
adequate force to allow performance of activities of daily living.
Furthermore, it must ensure coordination of the fingers for precise
prehension and fine motor tasks.
■ In order to achieve an optimal functional and aesthetic outcome in
patients requiring hand surgery, it is thus essential to fully understand
the detailed bone, muscle–tendon, aponeurotic, vascular, nerve and
lymphatic components.
■ Additional challenges arise from the range of possible movements of
various articular surfaces, assisted by muscle action and ligamentous
support.
■ In this chapter, we present the various elements that compose the
hand as well as explanations of the biomechanical principles. These
are updated according to the latest literature. Additionally, clinical
examples will be used to illustrate anatomic principles.
Introduction
During the Renaissance, Vesalius corrected early misconcep­
tions and brought gross anatomy into proper focus. Since that
time, many investigators have embellished the basic structural
studies with functional, physiologic, and philosophical obser­
vations. The forearm and hand have been prominently
included in those observations. Sir Charles Bell (1834),1 in his
thought-provoking volume, The Hand – Its Mechanism and
Vital Endowments as Evincing Design, presented a concept of
hand anatomy that places it in proper context with the posi­
tion of humans in the animal kingdom. Duchenne (1867)
carried out detailed analysis of muscular function by isolated
electrical stimulation, described in his classic volume, Physi­
ologie des Mouvements.2 Frederick Wood-Jones (1920) probed
more extensively into comparative anatomy and anthropol­
ogy in his excellent work, The Principles of Anatomy as Seen in
the Hand.3 Allen B. Kanavel (1925) published his monograph,
Infections of the Hand, which reported detailed analysis of the
spaces and synovial sheaths.4 Surgery of the Hand by Sterling
Bunnell (1944) became an indispensable reference during
World War II.5 Emanuel B. Kaplan (1953) produced the nicely
illustrated, detailed volume, Functional and Surgical Anatomy
of the Hand.6 Detailed studies of the integration of the intrinsic
and extrinsic muscles operating the polyarticular digits may
be found in the work of Landsmeer,7–10 Kaplan,11 Eyler and
Markee,12 Stack,13 Tubiana and Valentin,14 and others. More
recently, newer flaps intrinsic to the hand and upper extremity
have been developed from more detailed investigation into
vascular anatomy.15,16 Lastly, Berger,17 Viegas et al.,18 and others
have expanded our knowledge of the ligamentous anatomy
of the wrist.
As a functional puppet, the hand responds to human
desires; its motor performance is initiated by the contralateral
cerebral cortex. The conscious demands relayed to the hand
and forearm from the central nervous controlling mechanism
are sent as movement commands. At subconscious levels,
such a movement command is broken down, regrouped,
coordinated, and sent on as a signal for fixation, graded
contraction, or relaxation of a specific muscular unit. The
degree of contraction or relaxation is then modified by relayed
evidence that the motion created is that desired by the person.
The modifying factors arrive centrally from a multiplicity of
sensory sources such as the eye, peripheral sensory end
organs, and muscle or joint sensory endings.
The surgeon planning reconstructive surgery on the upper
extremity must be aware not only of the complex anatomy of
the hand and arm, but also of the physiologic interplay of
balanced muscular functions under the influence of complex
central nervous coordination. The maintenance of physiologic
viability by the central and peripheral circulatory and lym­
phatic systems must also concern the reconstructive surgeon.
This chapter addresses the fundamentals of hand and
upper extremity anatomy and highlights clinical pearls, new
anatomic descriptions that may aid surgery of the hand, and
  Access video content for this chapter online at expertconsult.com

2
SECTION I
CHAPTER 1 • Anatomy and biomechanics of the hand
each digit the geometry has been worked out by noting each
joint axis and the kissing surfaces of the palmar skin in full
flexion. These diamond-shaped skin surfaces should not be
shortened and rendered inelastic by longitudinal scars if limi­
tation of extension is to be avoided (Fig. 1.2).
The palmar fascia consists of resistant fibrous tissue
arranged in longitudinal, transverse, oblique, and vertical
fibers (Fig. 1.3). The longitudinal fibers concentrate at the
proximal origin of the palmar fascia at the wrist, taking origin
from the palmaris longus when it is present (in about 80–85%
of individuals). The fascia at this level is separable from the
underlying flexor retinaculum/carpal ligament, being identi­
fied by the longitudinal orientation of its fibers in contrast to
the transverse fibers of the retinaculum. The palmar fascia
fibers fan out from this origin, concentrating in flat bundles
to each of the digits. Generally, the fibers spread at the base
of each digit and send minor fibers to the skin and the bulk
of fibers distal into the fingers, where they attach to tissues
making up the fibrous flexor sheath of the digits. There are
attachments of the fascia to the volar plate and intermetacar­
pal ligaments at each side of the flexor tendon sheath at the
level of the metacarpal heads.
Transverse fibers are concentrated in the midpalm and the
web spaces. The midpalmar transverse fibers, although inti­
mately associated with the longitudinal bundles, lie deep to
them and are inseparable from the vertical fibers that concen­
trate into septa between the longitudinally oriented structures
passing to the fingers. This system of palmar transverse fibers
makes up what Skoog (1967) called the transverse palmar
ligament.21 In fact, the transverse fibers form the roof of
tunnels at this point that act as pulleys for the flexor tendons
proximal to the level of the digital pulleys. Biomechanical
evaluation of the palmar aponeurosis pulley has demonstrated
that isolated sectioning did not change the work of flexor
tendons or load efficiency.22 Nevertheless, this pulley has been
implicated as contributing to the etiology of trigger finger.23
the fundamentals of biomechanics relevant to the hand
surgeon. New pictures and dissection videos are now avail­
able for the reader to review important anatomic concepts.
Skin, subcutaneous tissue, and fascia
There is great disparity in the character of the skin and soft-
tissue envelope covering the dorsum of the hand and that
covering the palm. Dorsal skin is thin and pliable, anchored to
the deep investing fascia by loose, areolar tissue. These charac­
teristics, coupled with the fact that the major venous and lym­
phatic drainage in the hand courses dorsally, serve to explain
why hand edema is first evident dorsally. The prominent,
visible veins in the subcutaneous tissue make it the standard
site in which to evaluate venous filling and limb venous pres­
sure on physical examination. The same characteristics make
the dorsum of the hand vulnerable to skin avulsion injuries.
Palmar skin, in contrast, is characterized by a thick dermal
layer and a heavily cornified epithelial surface. The skin is not
as pliable as dorsal skin, and it is held tightly to the thick
fibrous palmar fascia by diffusely distributed vertical fibers
between the fascia and dermis. Stability of palmar skin is
critical to hand function. At the same time, if scar fixation or
loss of elasticity occurs in palmar skin, contractures and
functional loss result. The skin of the palm is laden with a
high concentration of specialized sensory end organs and
sweat glands. The surgeon must understand the relationship
of the palmar skin creases and the underlying joints in order
to plan precise placement of skin incisions for exposure of
joints and their related structures (Box 1.1 & Fig. 1.1).
Examination of hand skin during normal ranges of motion
in various planes is important in planning incisions or geo­
metrically rearranging lacerations that might result in dis­
abling scar contractures. Most loss of elasticity and some
longitudinal shortening are compensated for adequately by
mobility and elasticity of the uninjured dorsal skin. On the
palmar aspect, however, scar shortening and inelasticity of the
skin may result in contracture. The nature of palmar skin, its
stabilizing fixation to the palmar fascia, and its position on
the concave side of the hand are the bases for such contrac­
tures. Littler outlined the specific sites in the palm where a
longitudinal scar would impede extension.20 For example, in
BOX 1.1  Clinical pearl: Kaplan’s cardinal line
Hand anatomist Emanuel Kaplan described specific surface lines
that would aid surgeons in locating key structures in the palm of the
hand. The cardinal line has often been misquoted; therefore we
refer to Kaplan’s classic hand text, Functional and Surgical Anatomy
of the Hand.19 Kaplan’s cardinal line is drawn from the apex of the
first web space to the distal edge of the pisiform bone (see Fig.
1.1). Two longitudinal lines are drawn from the ulnar aspect of the
middle finger and the ulnar aspect of the ring finger. These will
cross the cardinal line. The intersection of the cardinal line and the
longitudinal line from the ulnar side of the middle finger corresponds
to the motor branch of the median nerve. The intersection of the
cardinal line and the longitudinal line from the ulnar side of the ring
finger corresponds to the hook of the hamate. The motor branch of
the ulnar nerve is found on the cardinal line, equidistant between
the hamate and pisiform. See Kaplan’s original text for additional
surface markings.
Fig. 1.1  Kaplan’s cardinal line, along with lines from the ulnar aspect of the
middle finger and the ulnar aspect of the ring finger. Point A corresponds with the
motor branch of the median nerve and point B with the motor branch of the ulnar
nerve.
Hook of hamate
A
B
Kaplan’s cardinal line
Pisiform

3
Skin, subcutaneous tissue, and fascia
Fig. 1.2  (A,B) Schematic representation of the joint axes. The longitudinal dimensions in the midpalmar and
mid-dorsal aspect of the digits change maximally. The midaxial line through the three joint axes does not change in
length with flexion and extension. Palmar incisions placed longitudinally produce contracture if they pass across
the palmar diamonds delineated by lines joining the joint axes (after Littler). Transverse incisions avoid the
occurrence of flexion scar contractures. The same principle applies at the wrist. (Redrawn after Chase RA. Atlas of
Hand Surgery, vol 1. Philadelphia: WB Saunders, 1973.)
A
b
a
d
c
B

4
SECTION I
CHAPTER 1 • Anatomy and biomechanics of the hand
Fig. 1.3  Superficial dissection of the palm, showing orientation of the palmar fascia. (Reprinted with permission from © Elsevier Inc. All Rights
Reserved.)
Palmaris longus tendon
Branch of superficial
radial nerve to skin of
lateral thenar area
Thenar muscles
Palmar branch of
median nerve
Anterior (palmar) views
Palmar aponeurosis
Transverse fasciculi
Palmar digital arteries and nerves
Superficial transverse metacarpal ligaments
Palmaris brevis
muscle (reflected)
Palmar branch of ulnar nerve
Superficial branch of ulnar nerve
Ulnar artery
Palmaris brevis muscle
Hypothenar muscles
Palmar aponeurosis
Pisiform
Deep palmar branch of ulnar artery and deep
branch of ulnar nerve
Palmar carpal ligament
(thickening of deep
antebrachial fascia
continuous with
extensor retinaculum)
Recurrent
(motor)
branch of
median
nerve to
thenar
muscles
Minute fasciculi
attach palmar
aponeurosis to dermis
Palmar digital
nerves from
superficial
branch of ulnar
nerve to 5th and
medial half of
4th fingers

5
Bones and joints
movements in multiple planes, reflects the masterful construc­
tion of its supporting architecture. Reducing the hand to its
supporting skeleton and its restraining ligaments reveals the
architectural basis for its varied function. A study of the range
of joint motions in the hand and forearm with all motor ele­
ments removed discloses the full range and limitations that
the skeleton imposes on hand function.
The hand skeleton is divisible into four elements:
1. The fixed unit of the hand, consisting of the second and
third metacarpals and the distal carpal row.
2. The thumb and its metacarpal with a wide range of
motion at the carpometacarpal joint. Five intrinsic
muscles and four extrinsic muscles are specifically
influential on thumb positioning and activity.
3. The index digit with independence of action within the
range of motion allowed by its joints and ligaments.
Three intrinsic and four extrinsic muscles allow such
digital independence.
4. The third, fourth, and fifth digits with the fourth and
fifth metacarpals. This unit functions as a stabilizing
vise to grasp objects for manipulation by the thumb and
index finger, or in concert with the other hand units in
powerful grasp (Fig. 1.7).
The distal row of carpal bones forms a solid architectural arch
with the capitate bone as a keystone. The articulations of the
distal carpals with one another, the intercarpal ligaments, and
the important transverse carpal ligament (flexor retinaculum)
maintain a strong, fixed transverse carpal arch. Projecting
distally from the central third of this arch are the fixed central
metacarpals, the second and third. Littler called this the “the
fixed unit of the hand”. It forms a fixed transverse arch of
carpal bones and a fixed longitudinal arch created by the
anatomic convexity of the metacarpals. As a stable founda­
tion, this unit creates a supporting base for the three other
mobile units. This central beam moves as a unit at the wrist
under the influence of the prime wrist extensors (the extensor
carpi radialis longus and brevis) and the prime wrist flexor,
the flexor carpi radialis. These major wrist movers insert on
the second and third metacarpals. Thus, the fixed central unit
is positioned for activity of the adaptive elements of the hand
around it.
The distal row of carpal bones constitutes a fixed transverse
arch. At the level of the metacarpal heads, the transverse arch
of the hand becomes mobile, which is possible because the
first metacarpal moves through a wide range of motion at the
saddle-like carpometacarpal joint. The loose capsular liga­
ments and the shallow saddle articulation between the first
metacarpal and the trapezium allow circumduction of the
mobile first metacarpal. Its range of motion is checked by
these capsular ligaments, including the volar beak ligament,
and by its attachment to the fixed hand axis through the
adductor pollicis, the first dorsal interosseous, and the fascia
and skin of the first web space. The mobile fourth and fifth
metacarpal heads move dorsally and palmarly in relation to
the central hand axis by limited mobility at the carpometacar­
pal joints. These metacarpal heads are tethered to the central
metacarpals by the intermetacarpal ligaments. The latter unite
adjacent metacarpophalangeal volar plates, which are an
intimate part of the joint capsules.
When the head of the first metacarpal is palmar-abducted
by thenar muscles innervated by the median nerve, and the
Longitudinal fibers pass toward the palmar surface of the
thumb, but these fibers are generally less numerous and
sometimes difficult to identify. The thumb fibers blend into
the deep fascia overlying the thenar muscles. The ulnar
extreme palmar fascia blends with the hypothenar fascia. The
proximal one-third of this border is the attachment site of
the palmaris brevis muscle. Laterally, the muscle attaches to
the hypothenar skin and hypothenar fascia.
The vertical fibers of the palmar fascia, which lie superfi­
cially to the tough triangular membrane made up by the longi­
tudinal and transverse fibers, consist of abundant vertical
fibers to the palm dermis (Fig. 1.4). Deep to the palmar fascia,
the vertical fibers coalesce into septa, or the “perforating fibers
of Legueu and Juvara”,24 forming compartments for flexor
tendons to each digit and separate compartments for the neu­
rovascular bundles together with the lumbrical muscles. There
are eight such compartments, which extend proximally to
about the midpalm. Proximal to this, there is a common central
compartment.25 The marginal septa extend more proximally
than the seven intermediate septa closing the central compart­
ment laterally and medially. The major septum between the
index flexor tendons and the neurovascular and lumbrical
space to the third interspace attaches to the third metacarpal,
dividing the thenar or adductor space from the midpalmar
space. Knowledge of these vertical compartments aids dissec­
tion and identification of structures in operations such as
trigger-finger release and Dupuytren’s fasciectomy (Fig. 1.5).
In the fingers, two important bands of fascia are named
Grayson’s ligaments and Cleland’s ligaments. Grayson’s liga­
ments are volar to the neurovascular bundles and are quite
flimsy. The much stouter Cleland’s ligaments are dorsal to the
neurovascular bundles. These two fascial sheets help contain
and protect the ulnar and radial digital arteries and nerves
(Fig. 1.6).
Bones and joints
Hand elements
The ability of the hand to resist and create powerful gross
action, combined with its capacity to perform intricate fine
Fig. 1.4  The palmar fascia with its longitudinal, transverse, and vertical fibers. The
longitudinal fibers take origin in the palmaris longus (when present). Transverse
fibers are concentrated in the distal palm supporting the web skin and in the
midpalm as the transverse palmar ligament. Vertical fibers extend superficially as
multiple, tiny tethering strands to stabilize the thick palmar skin. The deep vertical
components concentrate in septa between the longitudinally oriented structures in
the fingers. (Redrawn after McCarthy JG. Plastic Surgery. Philadelphia: WB
Saunders, 1990.)
Vertical fibers

6
SECTION I
CHAPTER 1 • Anatomy and biomechanics of the hand
Fig. 1.5  These deep palmar and midpalmar axial views of the hand reinforce the concept of distinct anatomic compartments separated by fascia. (Reprinted with
permission from © Elsevier Inc. All Rights Reserved.)
Pronator quadratus muscle
Flexor carpi radialis tendon
Flexor retinaculum (transverse carpal ligament) (reflected )
Flexor digitorum profundus tendons
Tendinous sheath of flexor pollicis
longus (radial bursa)
Fascia of adductor pollicis muscle
Thenar space
(deep to flexor tendon
and 1st lumbrical muscle)
Annular and cruciform parts
(pulleys) of fibrous sheath over
synovial sheath of finger
(Synovial) tendon
sheath of finger
Lumbrical muscles in fascial sheaths
(cut and reflected )
Flexor pollicis longus
tendon in tendon
sheath (radial bursa)
Common
flexor sheath
(ulnar bursa)
Flexor digitorum
superficialis tendons
Common flexor sheath
(ulnar bursa) (opened)
Lumbrical muscles in
fascial sheaths
Midpalmar space
(deep to flexor tendons
and lumbrical muscles)
Fibrous and synovial (tendon)
sheaths of finger (opened)
Flexor digitorum superficialis
tendon
Flexor digitorum profundus
tendon
Common palmar digital
artery and nerve
Lumbrical muscle
in its fascial sheath
Flexor tendons to 5th
digit in common flexor
sheath (ulnar bursa)
Dorsal fascia of hand
Tendinous sheath of flexor pollicis longus (radial bursa)
Septa forming canals
Profundus and superficialis flexor tendons to 3rd digit
Septum between midpalmar and thenar spaces
Thenar space
Extensor pollicis
longus tendon
Adductor pollicis muscle
Palmar interosseous fascia
Palmar interosseous muscles
Dorsal interosseous muscles
Extensor tendons
Midpalmar space
Palmar aponeurosis
Hypothenar muscles
Dorsal interosseous fascia
Dorsal subaponeurotic space
Dorsal subcutaneous space

7
Bones and joints
The wrist
The wrist joint is the site for major postural change between
the arm beam and the working hand end piece (Fig. 1.9). It
has a multiarticulated architecture that creates a potentially
wide range of motion in flexion, extension, radial deviation,
ulnar deviation, and circumduction. The distal radioulnar
joint allows pronation and supination of the hand as the
radius rotates around the head of the ulna. The proximal row
of carpal bones (scaphoid, lunate, triquetrum, pisiform) articu­
lates with the distal radius and ulna, providing the ability to
flex and extend the hand and perform radial and ulnar devia­
tion. The distal carpal row (trapezium, trapezoid, capitate,
and hamate), along with the second and third metacarpals,
forms the “fixed unit” of the hand.
The radiocarpal joint includes the carpal bones and the
distal radius (Fig. 1.10). The principal articulation of the carpus
is with the distal surface of the radius. The articular surface of
the radius slopes in several planes. In the radial-to-ulnar plane,
the radius exhibits an average slope of 22°. In the dorsal-to-
palmar plane, the articular surface of the radius slopes 12°
with the dorsal surface more distal than the palmar surface.
Fractures of the distal radius frequently result in a loss of the
normal radiocarpal configuration in one or both planes. A loss
fourth and fifth metacarpals are palmar-abducted by the
hypothenar muscles innervated by the ulnar nerve, a volar,
concave, transverse metacarpal arch is created, approximating
a semicircle. The mobile metacarpal heads are pulled dorsally
by extrinsic extensor tendons when the thenar and hypothe­
nar muscles relax. It is obvious that a flaccid paralysis of the
intrinsic muscles of the hand in median and ulnar nerve palsy
will produce a flattened or even reversed transverse metacar­
pal arch. The active production of a semicircular transverse
arch by the thenar and hypothenar muscles creates the proper
circumferential arrangement of the metacarpophalangeal
joints for convergence of the fingers in flexion. In this position
the fingers, flexing at the metacarpophalangeal joints only,
converge, forming with the thumb a cone, the apex of which
lies over the anatomic center of the hand (Fig. 1.8). A vertical
line dropped from the apex of the cone to the center of its base
will strike the third metacarpophalangeal joint. This point at
the apex of the transverse metacarpal arch is the anatomic
center of the hand. With the fingers fully abducted, the tips
form radii of equal length from the anatomic center of the
hand. The same radius projected proximally falls at the wrist
joint.
The most important single motor operating the central
hand beam at the wrist level is the extensor carpi radialis
brevis, which works against gravity, positioning the pro­
nated hand into extension. In the absence of any other
motors it pulls the central third metacarpal into extension,
making it the apex of the passively created transverse
metacarpal arch.
Fig. 1.6  The components of the digital fascia that help to anchor the axial plane
skin are Grayson’s ligaments palmar to the neurovascular bundles and Cleland’s
ligaments dorsal to the bundles. (Redrawn after McCarthy JG. Plastic Surgery.
Philadelphia: WB Saunders, 1990.)
Grayson’s
ligament
Neurovascular
bundle
Natatory ligament
Pretendinous band
Common digital
artery
Cleland’s ligament
Lateral digital sheet
Spiral band
Transverse fibers of
palmar aponeurosis
Fig. 1.7  Exploded view of the functional elements of the hand: (1) the thumb and
its metacarpal with a wide range of motion at the carpometacarpal joint; (2) the
index digit with independence of action in several planes; (3) the third, fourth, and
fifth digits with the fourth and fifth metacarpals; and (4) the fixed unit consisting of
the carpals with the fixed transverse carpal arch and the second and third
metacarpals forming a fixed longitudinal arch. (Redrawn after McCarthy JG. Plastic
Surgery. Philadelphia: WB Saunders, 1990.)