Core Procedures In Plastic Surgery: Cẩm Nang Các Quy Trình Cốt Lõi Trong Phẫu Thuật Tạo Hình

389
Postoperative considerations
Figure 22.17  Median to radial nerve transfers. A schematic diagram of median to radial nerve transfers. The redundant fascicles to flexor carpi radialis (FCR) and flexor
digitorum superficialis (FDS) (donors) are transferred to the extensor carpi radialis brevis (ECRB) and posterior interosseous nerve (PIN) respectively.
A
B
Median nerve
Median nerve
Radial nerve
Radial sensory
Radial nerve
PIN
PIN
FCR
FDS
FCR
FDS
ECRB
ECRB
completely normal sensation, but can significantly
interrupt the neuropathic pain cycle and reduce
phantom pain.
Use of radial to axillary nerve transfers (sensory)
• Patients with axillary nerve injury have numbness
on the lateral aspect of the shoulder. To re-establish
sensation in this distribution, the axillary nerve
can be transferred end to side to a functioning intact
nerve such as the radial. At this level, the internal
topography of the radial nerve is such that the lateral
aspect is sensory.
Postoperative considerations
• Patients are encouraged to move their extremity
early to promote nerve gliding, as all nerve
transfers are performed under no tension.
• Protective splinting for distal nerve transfers
is maintained for approximately 7–10 days,
although patients come out of their splints for
therapy.
• Concomitant tendon transfers may also dictate
splinting and therapy regimens and will supersede

390
•
• Nerve transfers
22
Complications and outcomes
• Complications specific to nerve surgery include
temporary neurapraxia secondary to retraction or
manipulation of nerves, neuroma, and inadequate
functional recovery.
• The long-term focus of rehabilitation is on re-education,
as the cortical command required to initiate target muscle
function will differ from before. Hand therapists are
critical for rehabilitation in these patients.
• The patient will “relearn” motor control of the
reinnervated target muscle by activating the nerve to the
donor muscle, similar to the re-education required
following tendon transfer.
• For restoration of sensation, as patients perceive input
stimulus from the reinnervated territory, cortical
remapping occurs.
• Prior to reinnervation, the focus is on maintaining full
active and passive range of motion and on prevention of
pain syndromes related to musculoskeletal imbalances
associated with lost or impaired muscle strength.
Maintaining full passive range of motion throughout is
paramount.
• Once reinnervation has occurred, therapy is focused on
strengthening.
• It is difficult to compare different surgical approaches
with regard to patient outcome and prognosis; however,
there have been numerous articles reporting favorable
outcomes on an increasing number of nerve transfer
options.
Figure 22.18  A schematic of the triad of transfers used to restore sensation in a median nerve deficit. (A) The non-functional median (red) and the functioning ulnar nerve
(yellow). (B) The triad of nerve transfers from ulnar to median (inset) is a magnification of the transfers showing the dorsal cutaneous branch of the ulnar nerve (donor)
coapted end to end to the radial side of the median (recipient) to restore first webspace sensation, the distal third webspace (recipient) end to side to the ulnar sensory
(donor), and the distal dorsal cutaneous branch of the ulnar nerve end to side to restore sensation to the donor deficit. The third webspace fascicle is shown in blue.
A
B
Median nerve
Median nerve
1st & 2nd webspace fascicle
of median nerve
3rd webspace fascicle
of median nerve
3rd webspace fascicle
of median nerve
1st & 2nd webspace
fascicle of
median nerve
Dorsal cutaneous branch
of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Nerve autograft
Nerve autograft
Palmar branch of median nerve
Palmar branch of ulnar nerve
Thenar (motor) branch
of median nerve
Thenar (motor) branch
of median nerve
Thenar (motor)
branch of
median nerve
Deep (motor) branch of ulnar nerve
Superficial (sensory)
branch of ulnar nerve
1st webspace
2nd webspace
3rd webspace
4th webspace
Ulnar nerve
Figure 22.19  Identifying the fascicle to the third webspace. This clinical
photograph demonstrates identifying the third webspace fascicle at the proximal
wrist level. Microforceps were walked along the surface of the nerve until they
plunged into the natural cleavage plane. The division is also marked with a
prominent vessel on the surface of the nerve.
the minor restrictions required for postnerve transfer
patients.
• If the insertion of the pectoralis major muscle was
disinserted to allow access to the medial pectoral nerve,
the tendon is reapproximated and the shoulder is
immobilized for a full 4 weeks.

391
Complications and outcomes
Figure 22.20  Sensory nerve transfers to restore ulnar nerve deficit. A schematic of the triad of nerve transfers used to restore ulnar nerve sensation. (A) The functioning
median nerve is shown in yellow and the non-functioning ulnar nerve is shown in red. (B) The triad of nerve transfers to restore sensation. (Inset) A magnified view of the
nerve transfers illustrating the third webspace fascicle (donor) coapted end to end with the ulnar sensory (recipient), the distal dorsal cutaneous branch of the ulnar nerve
(recipient) coapted end to side to the sensory side of the intact median nerve (donor), and the distal third webspace nerve coapted end to side to the median sensory to
restore donor sensory loss.
Median nerve
Median nerve
3rd webspace fascicle
of median nerve
3rd webspace fascicle
of median nerve
Deep (motor) branch
of ulnar nerve
3rd webspace fascicle
of median nerve
3rd webspace
fascicle of
median nerve
Dorsal cutaneous branch
of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Sensory component of ulnar nerve
Sensory component
of ulnar nerve
Dorsal cutaneous branch of ulnar nerve
Palmar branch of median nerve
Palmar branch of ulnar nerve
Thenar (motor) branch
of median nerve
Deep (motor) branch of ulnar nerve
Superficial (sensory)
branch of ulnar nerve
1st webspace
2nd webspace
3rd webspace
4th webspace
Ulnar nerve
A
B
Figure 22.21  Internal topography of the ulnar nerve in the distal forearm. A
clinical photograph illustrating the internal topography of a neurolyzed ulnar nerve
at the wrist. The tenotomy scissors are displacing the dorsal cutaneous branch of
the ulnar nerve ulnarly, the microforceps are separating the deep motor branch
fascicles ulnarly, and the remainder of the radial portion of the nerve is sensory. At
this level, the topography of the ulnar nerve is sensory–motor–sensory in a radial to
ulnar direction.

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• Nerve transfers
22
Further reading
Brown JM, Yee A, Mackinnon SE. Distal median to ulnar
nerve transfers to restore ulnar motor and sensory
function within the hand: technical nuances.
Neurosurgery. 2009;65:966–977; discussion 977–978.
This is an up-to-date description of the technical nuances
of transfer from the distal anterior interosseous nerve to
the motor component of the ulnar nerve. This anterior
interosseous nerve to deep motor branch of ulnar nerve was
first done by the authors in 1991 and is generally accepted
as a procedure of choice for high ulnar nerve problems.
Brown JM, Tung TH, Mackinnon SE. Median to radial nerve
transfer to restore wrist and finger extension: technical
nuances. Neurosurgery. 2010;66(3 Suppl):75–83;
discussion 83.
Cheng CJ, Mackinnon-Patterson B, Beck JL, et al. Scratch
collapse test for evaluation of carpal and cubital tunnel
syndrome. J Hand Surg Am. 2008;33:1518–1524.
Hayashi A, Pannucci C, Moradzadeh A, et al. Axotomy or
compression is required for axonal sprouting following
end-to-side neurorrhaphy. Exp Neurol 2008;211:539–550.
This study demonstrated that sensory nerves would
collaterally sprout from a normal nerve into a distal end-to
side positioned nerve spontaneously. By contrast it showed
that a motor nerve needed an injury in order to sprout
(traumatic sprouting). This is a significant paper in that it
shows that if you want to get some sensory recovery, then
the end to side will work, but if you want motor, you need
to injure the motor nerve traumatically in order to get it to
sprout in an end-to-side fashion.
Figure 22.22  Sensory nerve transfers to restore C5/C6 deficit. A schematic of sensory nerve transfers used to restore sensation to the first webspace following C5/C6 root
injuries of the brachial plexus. (A) The non-functional nerves are visualized in red and the functioning nerves are yellow. (B) The ulnar and median nerves are used to restore
sensation to the first webspace and the radial border of the thumb. (Inset) A magnified view of the nerve transfers illustrating end-to-end coaptation of the third webspace
nerve (donor) to the first webspace nerve (recipient). The distal third webspace nerve is then coapted end to side with the sensory portion of the ulnar nerve to restore
sensation to the donor third webspace.
A
B
Median nerve
1st webspace fascicle
of median nerve
1st webspace fascicle
of median nerve
3rd webspace fascicle of median nerve
3rd webspace fascicle of median nerve
Palmar branch
of median nerve
Thenar (motor)
fascicle of
median nerve
Dorsal cutaneous branch
of ulnar nerve
Palmar branch of median nerve
Palmar branch of ulnar nerve
Thenar (motor) branch
of median nerve
Deep (motor) branch of ulnar nerve
Superficial (sensory)
branch of ulnar nerve
1st webspace
2nd webspace
3rd webspace
4th webspace
Ulnar nerve
Kale SS, Glaus SW, Yee A, et al. Evaluation of the reverse
end-to-side nerve transfer in an animal model. J Hand
Surg. 2011 (in press).
Kozin SH. Injuries of the brachial plexus. In: Iannotti JP,
Williams GR, eds. Disorders of the Shoulder: Diagnosis
and Management. Philidelphia, PA: Lippincott Williams
& Wilkins; 2007:1087–1130.
Mackinnon SE, Novak CB. Nerve transfers. Hand Clin.
2008;24:319–490.
This Hand Clinics is a multiauthored text covering all
aspects of nerve transfers from surgical techniques to
physical therapy.
Ray WZ, Mackinnon SE. Clinical outcomes following
median to radial nerve transfers. J Hand Surg Am.
2010;36:201–208.
This manuscript describes the outcome of a number of
patients undergoing median to radial nerve transfer and
provides the technical nuances and the pearls and pitfalls of
this nerve transfer.
Ray WZ, Mackinnon SE. Management of nerve gaps:
autografts, allografts, nerve transfers, and end-to-side
neurorrhaphy. Exp Neurol. 2010;223:77–85.
This summary review article outlines the key challenges in
the reconstruction of nerve gaps, with critical points on the
use of nerve autografts, allografts, nerve repairs, nerve
transfers, and end-to-side repair.
Tung TH, Mackinnon SE. Nerve transfers: indications,
techniques, and outcomes. J Hand Surg Am.
2010;35:332–334.

©2014, Elsevier Inc. All rights reserved.
Chapter
23 
Tendon transfers in the upper extremity
• Tendon transfers are best conceptualized as a means
to restore a lost “function”, rather than a means of
substituting for a specific muscle, i.e., restoring strong
pinch as opposed to restoring function of the flexor
pollicis longus (FPL) (Table 23.1).
• Timing of tendon transfers may be classified as early,
conventional or late.
• A conventional tendon transfer: usually performed
after reinnervation of the paralyzed muscle fails
to occur 3 months after the expected time of
reinnervation based on the rate of nerve regeneration
of 1 mm per day.
• Early tendon transfer: performed simultaneously with
peripheral nerve repair or before the expected time of
reinnervation of the muscle; serves as a temporary
substitute for the paralyzed muscle until reinnervation
occurs, by acting as an internal splint.
Preoperative considerations
• Before performing tendon transfers:
• All fractures should be healed.
■ Chronic scarred skin and subcutaneous tissues or skin
grafts in the line of pull of a tendon transfer should be
excised and the defect resurfaced with a flap that is
itself allowed to heal with mature scars.
■ Full passive range of motion of the
metacarpophalangeal (MCP) and proximal
interphalangeal (PIP) joints should be achieved by
physical therapy and dynamic splinting.
■ The donor muscle–tendon unit must be expendable. Its
sacrifice must not create an important new deficit.
■ If multiple tendon transfers are required, a minimum
of one wrist flexor, one wrist extensor, and one
extrinsic flexor and extensor tendon to each digit
should always be retained.
This chapter was created using content from
Neligan & Chang, Plastic Surgery 3rd edition,
Volume 6, Hand and Upper Extremity, Chapter 34,
Tendon transfers in the upper extremity,
Neil F. Jones.
Brief introduction
• There are three general indications for tendon transfers in
the upper extremity:
1. To restore function to a paralyzed muscle due to
injuries of the peripheral nerves, the brachial plexus
or the spinal cord
2. To restore function following closed tendon ruptures
or open injuries to the tendons or muscles
3. To restore balance to a deformed hand due to various
neurological diseases.
SYNOPSIS
■ Tendon transfers in the upper limb are indicated to restore function
to paralyzed muscle and tendon following nerve injury, direct
muscle or tendon injury, and to restore balance to hands affected
by neurological disease.
■ In selecting donor tissue, the surgeon has to consider expendability
of the muscle–tendon unit, the native strength of donor and
paralyzed muscle, and the direction of transfer and integrity of the
muscle.
■ The timing of tendon transfers can be classified as early,
conventional or late.
■ Upper extremity neurological injury can be subdivided into radial
nerve palsy, low and high median nerve palsy, low and high ulnar
nerve palsy, and combined nerve injuries.

394
•
• Tendon transfers in the upper extremity
23
• Excursion of a donor muscle may also be increased by
extensive release of its surrounding fascia.
• A tendon transfer should pass in a direct line from the
origin of the donor muscle to its new insertion.
• Tendon transfers should only act across one joint and
perform one single function.
• However, a transfer may be inserted into several recipient
tendons as long as they each perform the same function
in adjacent digits.
• The donor muscle selected should preferably be
synergistic with the function of the muscle to be restored
or at least be potentially retrainable.
• Every muscle in the forearm and hand should be tested
by manual muscle testing to document which are
functioning and their strength graded.
• From this list of functioning muscles, only those that are
expendable are available as donor transfers.
• The specific functions of the hand that need to be
restored are listed in order of priority.
• The final step is to match the available donor muscles
with the functions that need to be restored, based on the
force, amplitude and direction of the various muscles
available.
• The success of any tendon transfer depends entirely on
preventing scarring or adhesions along the path of the
transferred tendon.
• Incisions should be carefully planned prior to
elevation of the tourniquet so that the final tendon
junctures lie transversely beneath skin flaps rather
than lying immediately beneath and paralleling the
incisions.
• The donor muscle should be carefully mobilized to
prevent damage to its neurovascular bundle which
usually enters in the proximal third of the muscle.
• The transferred tendon should glide in a tunnel
through the subcutaneous tissues and not cross
bone devoid of uninjured periosteum or through
small fascial windows.
• Only the distal end of the tendon should be grasped with
surgical instruments and care taken to prevent
desiccation of the tendon.
• Tendon junctures are performed using a Pulvertaft weave
technique where possible.
Operative techniques for specific
nerve injuries
Radial nerve palsy
• Functional motor deficit: inability to extend the
wrist, inability to extend the fingers at the MCP
joints and inability to extend and radially abduct
the thumb (Fig. 23.2), and inability to stabilize the
wrist with grip resulting in marked weakness in grip
strength.
• Tendon transfers are required to provide wrist extension,
extension of the fingers at the MCP joints and extension
and radial abduction of the thumb.
Figure 23.1  The wrist tenodesis effect: (A) Wrist flexion may increase the
potential amplitude of a tendon transfer to restore finger extension by 25 mm. (B)
Similarly wrist extension may increase the potential amplitude of a tendon transfer
to restore finger flexion by 25 mm.
A
B
Table 23.1  Basic principles of tendon transfers
Soft tissue equilibrium
Full passive range of motion of involved joints
Adequate amplitude of donor muscle
Adequate excursion of donor muscle
Direct line of pull
Single function for each transferred tendon
Synergy of transfer
Anatomical/technical pearls
• The potential excursion of a donor muscle–tendon unit
must be sufficient to restore the specific lost function.
• The finger flexors have an amplitude of 70 mm, the finger
extensors 50 mm and the wrist flexors and extensors
33 mm (Fig. 23.1).
• The tenodesis effect of wrist flexion or extension may also
increase the effective amplitude of a tendon transfer by
25 mm.

395
Operative techniques for specific nerve injuries
• Unlike the median and ulnar nerves, sensory loss
following radial nerve injury is not functionally
disabling unless the patient develops a painful
neuroma.
• Timing of tendon transfers: remains controversial.
Either “early” tendon transfer simultaneously with repair
of the radial nerve to act as an internal splint to provide
immediate restoration of power grip; or delay any tendon
transfers until reinnervation of the most proximal
muscles, brachioradialis and ECRL fails to occur within
the calculated time limit.
• The more proximal the nerve injury, the less likely
that functional muscle reinnervation will occur.
If the nerve remains in-continuity, most surgeons
would suggests that three months of observation are
indicated to await spontaneous recovery in peripheral
nerve palsies.
Specific operative techniques
• Several different tendon transfers have been reported for
radial nerve palsy but three patterns of transfer have
evolved.
• The use of pronator teres (PT) to provide wrist
extension has become universally accepted, the only
remaining controversy being whether to insert pronator
teres into extensor carpi radialis brevis (ECRB) alone or
into both extensor carpi radialis longus (ECRL) and
brevis.
• The three patterns of tendon transfer differ therefore only
in the technique of restoring finger extension and thumb
extension and radial abduction (Table 23.2).
Standard flexor carpi ulnaris transfer
• This is the author’s preferred technique for radial nerve
palsy; in the patient with a PIN palsy, the FCR transfer is
preferred (Figs 22.3–22.7).
Flexor carpi radialis transfer
• See (Fig. 22.8)
Figure 23.2  The typical posture of the hand and wrist of a patient with a high
radial nerve palsy. The wrist cannot be extended. The fingers are extended through
the tenodesis effect.
Figure 23.3  The FCU tendon and distal muscle are dissected. In this case,
a palmaris longus was present and its tendon is dissected for later transfer to
the EPL.
Table 23.2  Tendon transfers for radial nerve palsy
Standard
FCU transfer
FCR
transfer
Boyes
superficialis
transfer
PT to ECRB
PT to ECRB
PT to ECRB
FCU to EDC
FCR to EDC
FDS of ring
finger to EDC
middle, ring, and
small fingers
PL to EPL
PL to EPL
FDS middle
finger to EIP and
EPL
FCR to APL &
EPB
Boyes superficialis transfer
• Boyes advocated using the superficialis tendons to the
long and ring fingers to act as donor tendons to restore
finger extension.
• Advantages: potentially allow simultaneous wrist
and finger extension, may allow independent thumb
and index finger extension, does not weaken wrist
flexion.
• Disadvantages: the long and ring fingers are deprived of
superficialis function and this may result in weak grip,
harvesting of the superficialis tendons may also lead to
Figure 23.4  A dorsal incision exposes the wrist and finger extensors. The FCU
tendon has been brought from palmar to dorsal, around the ulnar border of the
forearm.

396
•
• Tendon transfers in the upper extremity
23
Figure 23.5  (A) The relatively short tendon of insertion of the PT can be extended
by elevating a strip of periosteum. (B) The PT will be woven into the tendon of
the ECRB.
A
B
Extensor carpi
radialis brevis
Extensor carpi
radialis longus
Pronator
teres
Brachioradialis
the subsequent development of either a “swan neck”
deformity or a flexion contracture at the PIP joint
(Fig. 22.9).
Low median nerve palsy (distal to
innervations of the extrinsic forearm flexors)
• Functional deficit: loss of opposition of the thumb and
absent sensation over the thumb, index, long and radial
half of the ring finger.
• Opposition is a composite motion, which occurs at all
three joints to position the thumb pad opposite the distal
phalanx of the partially flexed long finger.
• Abduction, pronation and flexion occur at the
carpometacarpal joint, abduction and flexion at the
metacarpophalangeal joint and either flexion or extension
at the interphalangeal joint.
Preoperative considerations
• Prior to any opposition transfer, patients with median
nerve injuries should be instructed to prevent the
development of an adduction or supination contracture
of the thumb by a program of passive abduction
exercises.
• If patients present with an established adduction or
supination contracture of the thumb, release of the
thumb-index finger web space skin, fascia over the first
dorsal interosseous muscle or even the first dorsal
interosseous and adductor muscles themselves may be
required prior to any opposition tendon transfer.
• Opposition transfers that are directed along the radial
aspect of the palm will produce a greater component of
palmar abduction whereas transfers that pass from the
pisiform will produce both abduction and pronation.
The more distal the transfer passes across the palm, the
greater the power of thumb flexion.
• Several methods of insertion of opposition transfers have
been advocated; however, a biomechanical study has
shown that opposition tendon transfers inserted into the
APB tendon alone will produce full abduction and
pronation. Therefore, the more complex dual insertions
should probably be reserved for combined median and
ulnar nerve palsies.
• Conventional timing of an opposition tendon transfer
may only be required in those patients who fail to
demonstrate signs of reinnervation within the usual
calculated time interval.
• For older patients or those with poor prognostic
co-morbid factors, early tendon transfers should be
considered.
• Careful observation of thumb function following either a
low or high median nerve palsy will reveal whether
an “early” tendon transfer for thumb opposition is
necessary.
• FPB remains innervated by the ulnar nerve in
approximately 70% of median nerve injuries so that
thumb function may not be significantly compromised. If
the patient is able to pick up an object with the forearm
in neutral or grasp an object with the forearm in
supination, it is likely that FPB remains innervated by the
ulnar nerve and consequently the decision for performing
an “early” opposition tendon transfer can be delayed.
• If the surgeon or therapist observes the patient
attempting to grasp objects by radial abduction of the
thumb with the forearm in pronation, an “early”
opposition tendon transfer should be strongly considered.
Burkhalter extensor indicis proprius transfer.
Specific operative techniques
• The extensor indicis proprius (EIP) transfer is the
author’s preferred technique (Fig. 23.10A,B; Video 23.1),
except in elderly patients with thenar atrophy secondary
Video
23.1

397
Preoperative considerations
Figure 23.6  The FCU is brought around the ulnar border of
the forearm (A,B) and woven into the combined tendons of
the EDC.
A
B
Flexor carpi
ulnaris
Extensor
digitorum
communis
to severe carpal tunnel syndrome (Fig. 23.11). The only
potential disadvantage with this tendon transfer is that
the EIP tendon is only just long enough to reach the APB
tendon. The postoperative results have been very
predictable (Fig. 23.12).
Bunnell ring finger flexor digitorum superficialis transfer
• Bunnell described using the ring finger superficialis
tendon as the donor for opponensplasty (Figs 22.13,
22.14).
• Compared with the EIP transfer, the ring finger
superficialis is relatively stronger and has greater length.
• Contraindications:
■ High median nerve palsy or in low median nerve
injuries in which there have been associated injuries to
the flexor tendons.
■ Combined low median and high ulnar nerve palsies
since the ring finger superficialis is the only remaining
flexor tendon in the ring finger.
■ Low median–low ulnar nerve palsies as the ring
finger superficialis may be required for correction of
clawing.
■ Harvesting of the superficialis tendon may result
in either a flexion contracture or a “swan-neck”
deformity of the PIP joint of the donor finger.
• This is perhaps the strongest of the opposition
transfers.
Camitz palmaris longus transfer
The PL tendon Camitz transfer is a simple transfer that will
provide abduction of the thumb but little pronation or
flexion and is particularly indicated in elderly patients with
thenar atrophy due to long-standing carpal tunnel syndrome
(Figs 23.15, 23.16).
Other opposition tendon transfers
• Huber and Nicolaysen described transfer of the abductor
digiti minimi (ADM) which may occasionally be
indicated in patients with a combined median and radial
nerve palsy and also in children with congenital
anomalies affecting the thumb. Since the muscle
originates at the pisiform, this transfer provides excellent
flexion and pronation of the thumb but little palmar
abduction.

398
•
• Tendon transfers in the upper extremity
23
• If reinnervation of the FPL muscle is not expected to
occur following repair or grafting of the median nerve,
the tendon can be divided at its musculotendinous
junction and woven end-to-end into the brachioradialis
tendon.
• However, if there is any possibility of reinnervation of
FPL, the brachioradialis tendon should be woven end-to-
side into the FPL tendon which remains in-continuity (see
Fig. 23.18).
• If power flexion of the index and long fingers is required,
then formal transfer of the ECRL tendon to the index
and long finger profundus tendons may be performed
(Fig. 23.19).
• The timing of tendon transfers in a high median nerve
palsy remains controversial.
• Phalen and Miller advocate the use of the EPB tendon
graft activated by ECU.
• Taylor described the use of the extensor digiti minimi
(EDM) which re-routes the EDM around the ulnar side of
the hand to the thumb MCP joint.
High median nerve palsy (proximal to
innervations of extrinsic forearm flexors)
• Functional deficit: inability to flex the index finger at the
PIP and DIP joints and the thumb at the interphalangeal
joint, loss of opposition (Fig. 23.17).
■ Due to paralysis of all four FDS muscles, the FDP
tendons to the index and long fingers and the FPL
muscle.
• Patients are often still able to flex the long finger due to
interconnections between the profundus tendons to the
long, ring and small fingers in the distal forearm.
• The functions that need to be restored: flexion at the
interphalangeal joint of the thumb and flexion of the PIP
and DIP joints of the index and long fingers, and
opponensplasty.
Specific operative techniques
• Flexion of the interphalangeal joint of the thumb may be
restored by transfer of brachioradialis to FPL and flexion
of the distal joint of the index and middle fingers by
side-to-side tenodesis of the FDP II and III to IV and V
(Fig. 23.18).
Figure 23.8  Transfer of the FCR to the combined tendons of the EDC.
Extensor
pollicis longus
Extensor digitorum
communis muscle
Extensor digitorum
communis tendons
Extensor carpi
radialis brevis
Flexor carpi radialis
Pronator teres
Figure 23.7  The PL, (A) if present, can (B) be attached to the rerouted EPL
tendon to provide both thumb extension and some radial abduction.
A
B
Extensor
pollicis
longus
Palmaris longus

399
Preoperative considerations
Figure 23.9  Transfer of the long and ring finger superficialis tendons (FDSL, FDSR)
through a window in the interosseous membrane (A) to restore function to the
extensor digitorum communis (EDC) tendons and extensor indicis proprius (EIP)
and extensor pollicis longus (EPL) (B).
Extensor
pollicis
longus
Extensor
indicis
proprius
Flexor digitorum
superficialis
(middle finger)
Flexor
digitorum
superficialis
(ring finger)
A
B
Figure 23.10  (A,B) The EIP transfer to restore opposition. (C) Incisions for
harvesting the EIP tendon.
Extensor digitorum
communis (index finger)
Extensor indicis proprius
Abductor pollicis brevis
A
B
C
■ If a good primary or delayed primary nerve repair
can be performed, there is a reasonable chance of
reinnervation of the extrinsic flexor muscles in a young
patient.
■ If the patient is seen late and requires secondary nerve
grafting of the median nerve, then tendon transfers for
restoration of thumb flexion and index and long finger
flexion should be performed simultaneously with the
nerve graft.
Low ulnar nerve palsy (distal to the
innervation of the ring and small finger FDP
and FCU)
• Functional deficit: paralysis of all seven interossei, the
ulnar two lumbricals, the hypothenar and the adductor
pollicis (AP) and part of the flexor pollicis brevis (FPB)
muscles.
• Results in an imbalance of the flexor and extensor forces
at the MCP, PIP and DIP joints of the fingers to produce
the claw hand appearance (hyperextension of the MCP
joint and reciprocal flexion at the PIP/DIP joints –
Duchenne sign).
• In a low ulnar nerve palsy, the clawing and loss of
integrated MCP and interphalangeal joint flexion are
confined to the ring and small fingers and to a lesser
extent the long finger, since the lumbricals to the index
and long fingers remain innervated by the median nerve.
• With a combined median and ulnar nerve palsy, all four
fingers are affected.
• Other significant impairment: weak thumb–index finger
pinch, which may be only 20–25% of normal due to
paralysis of the adductor pollicis, one half of the FPB and
the first dorsal interosseous muscles.
• Loss of key pinch is usually manifest by compensatory
activation of the FPL producing excessive flexion at the
interphalangeal joint (Froment’s sign) (Fig. 23.20) and
occasionally hyperextension at the MCP joint (Jeanne’s
sign) as the patient attempts forceful pinch.
• In such patients with weak pinch, tendon transfers will
be required to restore adduction of the thumb and
abduction of the index finger.
• Patients may also develop an irritating ulnar deviation of
the small finger in addition to clawing at the MCP joint

400
•
• Tendon transfers in the upper extremity
23
Figure 23.13  The FDS to APB transfer to restore thumb opposition is depicted
schematically.
Pisiform
Abductor pollicis
brevis
Flexor digitorum
superficialis
Flexor digitorum
superficialis
(ring finger)
Flexor carpi
ulnaris pulley
Figure 23.12  (A,B) Postoperative opposition restored by the EIP transfer.
A
B
Figure 23.11  The palmar incision and the direction of the EIP transfer across
the palm.
of the small finger (Wartenberg sign) caused by the
unopposed action of the EDM tendon due to paralysis of
the third palmar interosseous muscle.
• Occasionally, a tendon transfer may be required to correct
this ulnar deviation of the small finger.
• Therefore, tendon transfers may be indicated in an ulnar
nerve palsy (Table 23.3) to correct:
■
Clawing and asynchronous flexion of the fingers.
■
Weak thumb-index finger pinch.
■
Ulnar deviation deformity of the small finger.
■
Weak FDP flexion at the DIP joints of the ring and
small fingers.
• Timing of tendon transfers for ulnar nerve palsy is
primarily dependent on two factors: the probability
of motor recovery and the severity of the functional
deficit.
• Primary microsurgical repair of the ulnar nerve at the
wrist can be expected to yield useful results in about 75%
of patients.
• Secondary nerve grafting has been reported to provide
some functional motor recovery in approximately 40–75%
of cases, with a somewhat worse prognosis for sensory
recovery.
• “Early” tendon transfers should be considered for those
with a debilitating claw deformity.
• While clawing should be treated proactively using a
lumbrical block splint, some patients may benefit from
early static transfers to prevent MCP hyperextension and
clawing.

Figure 23.14  (A) Incisions used to transfer the ring finger FDS tendon. (B,C) The technique of using one half of the FCU sutured to itself as a pulley is demonstrated.
A
B
C
Pisiform
1 cm
4 cm
Flexor carpi
ulnaris tendon
Figure 23.15  The Camitz transfer using the palmaris longus
with its tendon extended by palmar fascia is depicted
schematically.
A
B
Palmaris longus
Strip of
palmar
fascia
Insertion
into tendon
abductor
pollicis brevis
Palmaris tendon
extended with a
rolled up strip of
palmar fascia
Transverse carpal
ligament

402
•
• Tendon transfers in the upper extremity
23
Figure 23.16  (A) A wide strip of palmar fascia is dissected in-continuity with the PL tendon. (B) This is transferred directly to be inserted into the tendon of APB.
(C) Postoperative result of the Camitz transfer.
A
B
C
Figure 23.17  Inability to flex the interphalangeal joint of the thumb and the distal
interphalangeal joint of the index finger as a consequence of a high median nerve
palsy.
Specific operative techniques
• Static procedures to prevent hyperextension of the
proximal phalanges at their MCP joints include A1 pulley
release, fasciodermadesis at the MCP joint level,
capsulodesis and various tenodeses.
• Capsulodesis of the MCP joint, described by Zancolli, is a
very simple technique in which the A1 pulley is first
released, the volar plate is incised longitudinally and
detached from the metacarpal to create two distally-based
flaps, which are then advanced proximally and attached
to the metacarpal neck to maintain the MCP joint in
approximately 20° of flexion (Fig. 23.21). Recurrence of
clawing has been demonstrated in long-term follow-up
studies.
• Parkes described an effective tenodesis by using tendon
grafts sutured to the transverse carpal ligament and
passed volar to the deep transverse intermetacarpal
(intervolar plate) ligaments to insert into the radial lateral
band of each finger.
• The various dynamic tendon transfers that have been
described to correct clawing differ primarily as to
whether they provide only MP joint flexion or whether
they provide both MP joint flexion and interphalangeal
joint extension. The surgeon can determine which general
type of transfer is most appropriate by preoperative
testing of PIP and DIP joint extension with the MCP
joints held passively flexed – the Bouvier maneuver.
• If, with the MCP joints flexed, the extrinsic extensor
tendons can produce full extension at the PIP and DIP
joints (Fig. 23.22) the transfer may only need to produce
strong MCP joint flexion by insertion of the transfer
either into the A1 pulley (see Fig. 23.20), the A2 pulley
(Fig. 23.23), the A1 and proximal half of the A2 pulley, or
through a drill hole in the proximal phalanx (Fig. 23.23B).
• If the patient cannot actively extend the PIP joints
using the extrinsic extensor tendons, then the transfer
should be inserted into one of the lateral bands; or into
the dorsal base of the middle phalanx; or into the
combined interosseous tendons so that both MCP joint
flexion and PIP joint extension can potentially be
restored.
Tendon transfers to correct clawing
• All of the following have been described as the donor
muscle–tendon unit in tendon transfers to correct
asynchronous finger flexion and clawing in ulnar nerve
palsy:
■
Flexor digitorum superficialis.
■
Extensor carpi radialis brevis.
■
Extensor indicis proprius and extensor digiti minimi.
■
Flexor carpi radialis.
■
Extensor carpi radialis longus.
■
Palmaris longus.
(Fig. 23.24).
• In patients with a high ulnar palsy, the ring and small
finger superficialis tendons cannot be used and therefore
the middle finger superficialis tendon is divided into
two slips and each slip is passed under the A1 pulleys
of the ring and small fingers and sutured to itself (see
Fig. 23.20).
• In combined high median-ulnar nerve palsy, all the
superficialis tendons are paralyzed and consequently an
“indirect lasso” procedure is required. After passing the

403
Preoperative considerations
Figure 23.18  Transfer of the brachioradialis to FPL and
side-to-side FDP tenorrhaphy.
A
B
Brachioradialis
Flexor
pollicis
longus
Flexor
digitorum profundus
Side to side
tenorrhaphy of
flexor digitorum
profundus tendons
(index and middle to
ring and small)
Figure 23.19  (A) The postoperative finger flexion cascade has been restored by side-to-side tenorrhaphy of the FDP tendons. (B) Semi-independent flexion of the IP joint
of the thumb following Br to FPL transfer.
A
B
superficialis tendons around the A1 pulleys, the proximal
ends of the superficialis tendons are activated either by
ECRL or FCR.
Modified Stiles–Bunnell transfer
• The ring finger FDS tendon is divided just proximal to
the PIP joint, withdrawn through a transverse distal
palmar crease incision and split longitudinally into two
slips which are sutured to the radial lateral bands with
the MCP joints in 45–55° of flexion and the
interphalangeal joints fully extended.
• In a high ulnar nerve palsy, the ring finger superficialis
tendon is the only extrinsic flexor tendon in the ring
finger and therefore the long finger FDS tendon is used
(see Fig. 23.24).
• With a total intrinsic palsy, the superficialis tendons
to both the long and ring fingers are each divided into
two slips and passed down the lumbrical canals to the

404
•
• Tendon transfers in the upper extremity
23
Figure 23.20  The thumb in ulnar nerve palsy. In the absence of the AP and FPB,
the FPL must provide all the power of thumb flexion. As the prime flexor of the IP
joint, it preferentially flexes this joint, leading to IP hyperflexion (Froment’s sign)
and occasionally hyperextension at the MCP joint (Jeanne’s sign).
Figure 23.21  The Omer modification of the Zancolli capsulodesis. (A) The A1 pulley is released. (B) A distal-based flap is created in the volar plate. (C) The distal-based
flap of the volar plate is advanced proximally and fixed to the metacarpal neck.
A
B
C
Deep
transverse
intermetacarpal
ligament
A2 pulley
A1 pulley released
Volar plate MCP joint
Table 23.3  Tendon transfers for ulnar nerve palsy
Function to be restored
Preferred tendon transfer
Clawing of the ring and
small fingers
Ring finger or middle finger FDS,
2 slips to the radial lateral
bands, proximal phalanges or
A2 or A1 and A2 pulleys of the
ring and small fingers
Clawing of all 4 fingers
EF4T or PL4T transfers to the
radial lateral bands of the
middle, ring and small fingers
and the ulnar lateral band of the
index finger; or to the combined
interosseous tendon insertion
Thumb adduction
ECRB + tendon graft to adductor
pollicis
Index finger abduction
Accessory APL to first dorsal
interosseous
Severe thumb MCP joint
hyperextension
MCP joint fusion
Fixed thumb IP joint
contracture
IP joint fusion
Weak DIP joint flexion of
ring and small fingers
Side-to-side tenorrhaphy of the
ring and small finger FDP
tendons to the middle finger
FDP tendon
radial lateral bands of the index, long, ring and small
fingers.
• Disadvantages:
■ The ring finger superficialis is not expendable in a
high ulnar nerve palsy or in a combined high median–
high ulnar nerve palsy.
■ The transfer may eventually result in a “swan-neck”
hyperextension deformity at the PIP joints.
■ The donor middle or ring finger may develop a flexion
contracture at the PIP joint or loss of extension at the
DIP joint.
• This should therefore only be used in patients with mild
PIP joint flexion contractures or stable fingers without
passive hyperextension at the PIP joints.

405
Preoperative considerations
Figure 23.22  The Bouvier maneuver. (A) Typical claw deformity of the small finger and to a lesser extent the ring finger with hyperextension at the MCP joint and flexion at
the PIP and DIP joints. (B) By preventing hyperextension at the MCP joints, the extrinsic extensor tendons are able to produce full extension at the PIP and DIP joints.
A
B
Figure 23.23  Alternative insertions for tendon transfers to prevent clawing. (A) Insertion into the lateral band. (B) Burkhalter insertion through a drill hole in the proximal
phalanx. (C) “Lasso” procedure either into the A1 pulley (Zancolli), the A2 pulley (Brooks–Jones) or the A1 and proximal half of the A2 pulley (Anderson).
A
B
C
Lateral band
Proximal phalanx
A2 pulley
Brand EE4T transfer
• Transfer of the extensor carpi radialis brevis (ECRB),
extended with three or four tendon grafts, passed from
dorsal to palmar to be attached to the radial lateral bands
of the middle, ring and small fingers (Fig. 23.25) and to
the ulnar lateral band of the index finger (EE4T: extensor
tendon, extensor route, four-tailed graft).
• However, during wrist extension, the ECRB and tendon
grafts relax which is a relative disadvantage of this dorsal
routing of the original Brand transfer.
• So, Burkhalter and Strai modified the Brand EE4T
transfer, by using ECRL instead of ECRB and by only
correcting the ring and small fingers.
• Only produces MCP joint flexion, but is an alternative
transfer for a combined high median–high ulnar nerve
palsy when the modified Stiles–Bunnell FDS transfer is
not available.
• The Fowler transfer uses both the EIP and EDM tendons.
The EIP tendon controls the index and middle fingers
and the EDM tendon controls the ring and small fingers.
This is rarely used.
• Disadvantage of the Fowler transfer: the EIP and EDM
tendons are only just long enough to reach the radial
lateral bands.
Brand EF4T transfer
• Brand modified his original dorsal transfer of ECRB by
extending ECRL with a four tailed tendon graft or fascia
lata graft through the carpal tunnel to the radial lateral
bands of the middle, ring and small fingers and the ulnar
lateral band of the ring finger (EF4T: extensor tendon,
flexor route, four-tailed graft) (Figs 23.26, 23.27).
Fritschi PF4T transfer
• Fritschi has described the palmaris longus as an
alternative motor for the Brand EF4T transfer. The
palmaris longus tendon is lengthened with a tendon graft
or fascia lata graft and tunneled in similar route to the
Brand EF4T procedure. However, the palmaris longus is a
much weaker donor muscle than the ECRL.
• Two alternative insertions have been described for the
Brand EF4T and Lennox–Fritschi PL4T transfers, either

406
•
• Tendon transfers in the upper extremity
23
Figure 23.24  (A,B) Transfer of the long finger FDS to the radial lateral band of the
ring finger or the A2 pulley of the small finger.
A
Insertion into radial lateral band
(ring finger)
Insertion into A2 pulley
(small finger)
Middle finger flexor digitorum
superficialis tendon
split into 2 slips
B
Figure 23.25  Brand EE4T transfer of ECRB extended by three tendon grafts into
the three ulnar fingers.
Deep transverse
intermetacarpal
ligaments
Insertion into radial
lateral bands of middle,
ring and small fingers
Palmaris or plantaris
tendon grafts or
fascia lata grafts
Extensor carpi radialis brevis
the common interosseous tendon insertion or the A2
pulley.
• Brooks and Jones described elongating the ECRL or FCR
with plantaris or toe extensor tendon grafts which are
tunneled and looped around the A2 pulleys of each
finger.
Tendon transfer to correct ulnar deviation of the
small finger
• A variant of the Fowler transfer has been advocated by
Blacker et al. to correct the ulnar deviation deformity of
the small finger (Wartenberg’s sign).
• The ulnar half of EDM is detached, passed volar and
sutured into the insertion of the radial collateral ligament
of the MCP joint at the base of the proximal phalanx, or if
there is associated clawing of the small finger, it is looped
under the A2 pulley and sutured back to itself (Brooks
insertion).
• Chung et al. described transferring EIP to the distal radial
aspect of the extensor hood of the small finger to correct
the persistent abduction deformity of the small finger in
an ulnar nerve palsy.
Tendon transfers to provide adduction of the thumb
• The most successful tendon transfers to restore adduction
of the thumb have a transverse direction of pull across
the palm deep to the flexor tendons to insert into the
tendon of adductor pollicis.
• Littler advocated transfer of the ring finger superficialis
inserted into a drill hole just distal to the adductor
insertion.

407
Preoperative considerations
Figure 23.26  Brand EF4T transfer of the ECRL extended by four tendon grafts into
all four lateral bands in a patient with clawing of all four fingers.
Inserted into ulnar
lateral band of
index finger
Inserted into radial
lateral bands of
middle, ring and
small fingers
Fascia lata or plantaris
tendon grafts
Extensor carpi radialis longus
Figure 23.27  Brand EF4T transfer to correct clawing of the ring and small fingers.
(A) The ECRL is detached from its insertion into the base of the second
metacarpal. (B) A palmaris longus graft is attached to the ECRL which has been
brought volarly around the radial side of the forearm (or through the interosseous
membrane). (C) Postoperatively, this has corrected the preoperative claw deformity
of the 4th and 5th fingers.
A
B
C
• Smith described using ECRB extended by a free tendon
graft passed through the second intermetacarpal space
and tunneled deep to the flexor tendons but superficial to
the adductor pollicis to an insertion into the adductor
tendon (Fig. 23.28).
• Other tendon transfers to restore adduction of the thumb
have included either the brachioradialis or ECRL
elongated with a tendon graft and passed through the
third intermetacarpal space to the thumb MCP joint, and
the EIP passed through the second intermetacarpal space.
• If there is a severe collapse Z-deformity of the thumb
with hyperextension at the MCP joint and flexion at the
IP joint, or an exaggerated Jeanne’s sign when attempting
to pinch, arthrodesis of the MCP joint may be necessary.
• For mild collapse deformities of the thumb without a
fixed contracture, a split FPL to EPL transfer may be
indicated.
Ring finger flexor digitorum superficialis transfer
• The ring finger FDS tendon is transected between the A1
and A2 pulleys, passed transversely across the palm deep
to the index and long finger flexor tendons to the ulnar
aspect of the thumb MCP joint, and either sutured into
the adductor pollicis tendon or passed through a drill
hole in the proximal phalanx just distal to the adductor
insertion, and tied over a button.
• Cannot be used as an adductor transfer in patients with a
high ulnar nerve palsy since this would deprive the ring
finger of its only remaining flexor tendon.
Smith extensor carpi radialis brevis transfer
• ECRB is used to power the APL tendon with assistance
from a Palmaris or plantaris interposition tendon graft
(Fig. 23.29).
Tendon transfers to provide index finger abduction
• Restoration of strong abduction of the index finger is the
second component required for powerful pinch.

408
•
• Tendon transfers in the upper extremity
23
Figure 23.28  Schematic representation of the Smith transfer for restoration of
thumb adduction. The extensor carpi radialis brevis is extended by a tendon graft
through the second intermetacarpal space to the adductor tubercle on the ulnar
base of the proximal phalanx of the thumb.
Tendon graft passed
through the index-middle
finger intermetacarpal
space
Tendon graft sutured
to insertion of adductor
pollicis tendon
Extensor carpi radialis brevis
• Bunnell described the transfer of extensor indicis
proprius (EIP) extended with a short tendon
graft and inserted into the first dorsal interosseous
tendon.
• Bruner divided the extensor pollicis brevis (EPB) tendon,
tunneled it subcutaneously beneath the EPL tendon and
into the first dorsal interosseous tendon.
• Hirayama lengthened the palmaris longus tendon with a
strip of palmar fascia (similar to the Camitz transfer) and
tunneled it subcutaneously around the radial border of
the forearm over the dorsum of the wrist and hand to
insert into the first dorsal interosseous tendon.
• Graham and Riordan transferred the FDS of the ring
finger
• One of the accessory tendons of APL extended with a free
tendon graft, or attached to the rerouted EDC tendon of
the index finger, may be the best choice to restore
abduction of the index finger (Fig. 23.30).
Neviaser accessory abductor pollicis longus and free
tendon graft
• Neviaser et al. described an accessory APL tendon
elongated with a palmaris or plantaris tendon graft
transferred to the insertion of the first dorsal interosseous
tendon (see Figs 23.29, 23.30).
High ulnar nerve palsy
• Functional deficit: paralysis of the FCU and FDP tendons
to the ring and small fingers, paralysis of all seven
interossei, the ulnar two lumbricals, the hypothenar and
the adductor pollicis (AP) and part of the flexor pollicis
brevis (FPB) muscles.
• The only remaining tendons on the ulnar side of the hand
are the superficialis tendon to the ring finger and the
usually diminutive superficialis tendon to the small
finger.
• Paralysis of the profundus tendons to the ring and small
fingers will often be masked by interconnections between
these two tendons and the long finger profundus tendon
at the wrist.
Specific operative techniques
• If there is significant weakness of DIP joint flexion of the
ring and small fingers (Pollock’s sign), power grip can be
restored by side-to-side tenorrhaphy of the ring and small
finger FDP tendons to the median-innervated middle
finger FDP tendon.
• This should be performed before tendon transfers to
correct clawing are performed, but patients should be
warned that this will temporarily exaggerate their
clawing and that they should use a lumbrical block
splint.
• To restore independent flexion of the ring and small
fingers, the FDS tendon of the middle finger may be used
as a donor tendon to activate the FDP tendons of the ring
and small fingers.
• Patients requiring strong ulnar deviation and flexion of
the wrist may occasionally need to be considered for
transfer of the FCR tendon to FCU.
Tendon transfers for combined nerve injuries
• As a general rule, the results of tendon transfers for
combined nerve injuries are inferior to those for a single
nerve injury.
• Adding to the complexity of these problems, the number
of donor tendons is limited, more joints need to be
mobilized, there is a more profound sensory loss, and the

409
Preoperative considerations
Figure 23.29  (A) Transfers to restore thumb adduction and abduction of the index finger. (B) A tendon graft has been anchored to the tendon of the adductor pollicis. It is
passed dorsal to the flexor tendons and neurovascular bundles and then from palmar to dorsal through the second intermetacarpal space. A tendon graft has been sutured
into the tendon of the first dorsal interosseous. (C) Traction on these two grafts flexes and adducts the thumb and abducts the index finger at its MCP joint. (D) Postoperative
function following these two transfers. (E) Pinch force is significantly improved.
Accessory tendon
of abductor
pollicis longus
Palmaris tendon graft
sutured into adductor
pollicis tendon insertion
Palmaris tendon graft sutured into insertion
of 1st dorsal interosseous muscle
Extensor carpi radialis brevis
A
B
C
D
E
soft tissues may be more scarred in this patient
population.
• Dynamic tenodesis is an important concept in
reconstruction of these combined nerve injuries.
Wrist flexion or extension can be used to augment
the excursion of any tendon transfer that crosses the
wrist.
Tendon transfers for low median–low ulnar nerve palsy
• The most common combined nerve injury in the upper
extremity and is usually the result of a “spaghetti-wrist”
laceration. This leads to complete loss of sensation
on the palmar surface of the hand and a complete
intrinsic motor paralysis that results in a claw hand
deformity.

410
•
• Tendon transfers in the upper extremity
23
• A flat transverse metacarpal arch with hyperextension
at the MP joints and hyperflexion of the PIP joints
accompanied by an abducted small finger are the
hallmark of this injury.
• The goals of reconstruction: to restore thumb adduction,
thumb abduction and opposition, abduction of the index
finger and improved extension of the PIP joints of the
fingers.
• Thumb adduction for key pinch can be restored by
transfer of the ECRB extended by a tendon graft and
inserted into the adductor tubercle of the thumb
metacarpal or alternatively by transfer of the superficialis
tendon from the ring finger to the adductor insertion.
• The best option for reconstruction of thumb opposition is
the EIP transfer rerouted around the ulnar border of the
hand and inserted into the APB tendon. This transfer can
be combined with arthrodesis of the MCP joint of the
thumb to allow for maximum stability.
• Index finger abduction for strong pinch can be restored
by transfer of one of the APL tendon slips extended by a
tendon graft to the first dorsal interosseous insertion.
• Finally, clawing of the fingers can be corrected by using
ECRL or palmaris longus extended by four tendon grafts
and inserted either into the radial lateral bands or the A2
pulleys as previously discussed.
• If the patient still has poor palmar sensibility despite
nerve repair or nerve grafting, consideration should be
given to transfer of a superficial radial nerve innervated
flap to the thumb or nerve transfer of the superficial
radial nerve to the distal median nerve.
Tendon transfers for high median–high ulnar nerve palsy
• Very severe injury in which there is no active flexion of
the fingers and thumb and loss of thumb opposition and
key pinch in addition to the loss of palmar sensibility.
• Tendon transfers for reconstruction of a high median–
high ulnar nerve palsy have to be performed in two or
three stages.
• Goals: restore finger and thumb flexion, thumb-index
finger pinch, abduction and opposition of the thumb and
correct the later development of clawing of the fingers.
• Thumb adduction and key pinch can be achieved by
transfer of ECRB with a free tendon graft to the adductor
pollicis insertion.
• Finger flexion can be restored by transfer of ECRL to the
four FDP tendons. This can be combined with tenodesis
of the DIP joints of the three ulnar fingers.
• Flexion of the thumb can be restored by transfer of
the brachioradialis to FPL through the same palmar
incision.
• As in a low median–low ulnar nerve palsy, the most
reliable procedure for thumb opposition is transfer of the
EIP to the APB insertion.
• If the IP joint of the thumb tends to assume a flexed
position, the EIP transfer should be inserted both into the
APB insertion and then into the EPL tendon just proximal
to the IP joint.
• If after finger flexion has been restored, the fingers begin
to adopt a clawed position, there are no expendable wrist
extensors (ECRL and ECRB) remaining to provide
integration of MP flexion and IP joint extension, static
tenodesis techniques may be necessary.
• The importance of restoring sensibility to the radial side
of the hand in a high median–high ulnar nerve palsy
cannot be overstated, either by secondary nerve repair or
nerve grafting.
Tendon transfers for reconstruction after trauma
• Tendon transfers are an excellent method of restoring
active motion to the hand and wrist following traumatic
injuries of the muscles and tendons of the forearm, wrist
and hand.
• If there has been segmental loss of tendon, a tendon graft
is often used instead of a tendon transfer.
• With more severe trauma (industrial or motor vehicle
accidents, blast, missile and explosion injuries), associated
damage to the soft tissues will leave a scarred bed which
is unsuitable for tendon grafts, since a tendon graft is
Figure 23.30  The Neviaser transfer to restore abduction of the index finger. One of
the accessory tendons of the abductor pollicis longus is extended by a palmaris
tendon graft and sutured to the insertion of the first dorsal interosseous muscle on
the base of the proximal phalanx of the index finger.
1st dorsal interosseous
muscle
Tendon graft sutured to
insertion of 1st dorsal
interosseous muscle
Palmaris tendon graft
Accessory tendon of
abductor pollicis longus

411
Postoperative considerations
more likely to become adherent to the scarred
surrounding tissue than a tendon transfer.
• Myostatic contracture and atrophy are the unavoidable
fate of injured muscle if there has been a long delay
between the traumatic event and the reconstructive
procedure, again making a tendon transfer a more
suitable option for reconstruction.
Tendon transfers to restore thumb extension
• Rupture of the EPL tendon occurs in approximately 1 in
200 distal radius fractures, classically at Lister’s tubercle
and may happen at any time from several weeks to
several months after the fracture. Ischemia of the tendon
due to swelling and edema of the tenosynovium and
attrition over the roughened dorsal radial cortex have
been postulated as the etiology for this tendon rupture.
• Patients present with weakness or loss of extension at the
interphalangeal joint or paradoxically with incomplete
extension at the MP joint as well as inability to raise the
thumb dorsal to the plane of the hand (Fig. 23.31A).
• The optimal choice for restoration of thumb extension is
the EIP to EPL transfer which can be performed under
local anesthesia (see Fig. 23.31B–D).
Tendon transfers to restore finger extension
• Restoration of finger extension after trauma can be
accomplished by tendon transfers similar to those used
for radial nerve palsy. Those transfers were discussed in
detail earlier in this chapter and include transfer of either
of the wrist flexors (FCU or FCR) to the EDC or the
Boyes transfer of the FDS of the long and ring fingers
to the EDC.
Tendon transfers to restore thumb flexion
• Acute lacerations or ruptures of the flexor pollicis longus
(FPL) tendon can be treated by primary or delayed
primary repair or tendon grafting. However, with missed
diagnosis, the muscle fibers undergo significant
shortening, atrophy and fibrosis within 6 months to a
year from injury. In these situations, it is preferable to
restore thumb flexion using a tendon transfer, usually the
FDS of the ring finger.
Tendon transfers to restore finger flexion
• Occasionally, patients may present with severe crushing
or avulsion injuries involving the forearm flexor muscles.
The options for secondary reconstruction of finger flexion
are either a tendon transfer of the ECRL to all four FDP
tendons or a functioning free gracilis muscle transfer
(Fig. 23.32).
Postoperative considerations
• Postoperatively, the hand is immobilized in the desired
position for 3–4 weeks, at which time gentle active range
of motion exercises are started, usually under the
supervision of a therapist, but the hand is protected for a
further 3 weeks in a light-weight protective splint.
• In general active flexion and extension of the fingers and
thumb are started at 3.5–4 weeks and active exercises of
the wrist at 5 weeks. Protective splinting is continued
until 6–8 weeks’ postoperatively.
Complications and outcomes
• Several factors influence the likelihood of useful motor
and sensory return following median nerve injury
including patient age, level of injury, length of nerve
defect and interposition graft and period of preoperative
delay.
■ Best results are in distal injuries in young patients
requiring only primary repair.
■ Associated injuries (vascular damage, tendon injury,
and concomitant ulnar nerve transaction) portend a
worse prognosis.
■ The chances of reinnervation of the thenar muscles
following group fascicular repair of a distal median
nerve laceration should be reasonably optimistic.
• The FDS of the ring finger and the ECU are the best
transfers at replacing thenar strength, abduction and
pronation. Reports indicate that the ECU and FDS
transfers restore 60% and 40%, respectively, of required
thenar muscle strength (Table 23.4).
Figure 23.31  (A) Rupture of the EPL. (B) Transfer of the EIP to the EPL. (C) Preoperative thumb extension. (D) Postoperative thumb extension.
A
B
C
D

412
•
• Tendon transfers in the upper extremity
23
Figure 23.32  Tendon transfer to restore flexion of the fingers.
The extensor carpi radialis longus tendon is transected from the
base of the index finger metacarpal, transferred subcutaneously
around the radial border of the forearm and sutured to the flexor
digitorum profundus tendons to the index, middle, ring and small
fingers in the distal forearm proximal to the carpal tunnel.
A
B
Extensor carpi
radialis longus
Flexor digitorum
profundus tendons
Flexor digitorum
profundus tendons
Table 23.4  Opposition tendon transfers for median nerve palsy
Technique
Etiology
Author
Success
rate (%)
Huber
Trauma
Wissinger (1977)
80
Neurologic
disease
Camitz
Nerve
compression
Terrono et al. (1993)
94
Foucher et al. (1991)
91
EIP
Trauma
Anderson et al. (1991)
88
Burkhalter et al.
(1973)
88
Bunnell
Leprosy
Brandsma et al.
(1992)
83
Leprosy
Palande (1975)
94
Trauma
Kirklin (1948)
85
Trauma
Groves and Goldner
(1975)
75
EDQ
Trauma
Schneider (1969)
80
• Tendon transfers for radial nerve palsy are generally
predictable. Recent results reported that wrist extension
averaged 73% of the opposite side, finger extension
32% and thumb extension 80%. Grip strength was
reduced to 49% and pinch strength to 28% of the
opposite hand.
• The author’s preferred technique is to use pronator teres
to restore wrist extension, FCR to restore finger extension
and palmaris longus to restore thumb extension with
tenodesis of the APL to brachioradialis to restore thumb
abduction.
Further reading
Boyes JH. Tendon transfers for radial palsy. Bull Hosp Joint
Dis. 1960;21:97.
The original description of the Boyes transfer for radial
nerve palsy, using the flexor digitorum superficialis tendons
from the middle and ring fingers transferred through the
interosseous membrane to restore independent index finger
and thumb extension.

413
Further reading
Brand PW. Clinical mechanics of the hand. St Louis: Mosby;
1985.
This is the definitive reference book detailing the
biomechanics of tendon transfers.
Brand PW. Tendon transfers for median and ulnar
nerve paralysis. Orthop Clin North Am. 1970;1:
447–454.
Brand PW. Tendon grafting illustrated by a new operation
for intrinsic paralysis of the fingers. J Bone Joint Surg.
1961;43B:444–453.
This paper describes the dorsal route of the extensor carpi
radialis brevis tendon extended with free tendon grafts and
the palmar route of the extensor carpi radialis longus tendon
extended with free tendon grafts to correct the clawing in
ulnar nerve palsy due to leprosy.
Bunnell S. Opposition of the thumb. J Bone Joint Surg.
1938;20:725–732.
The original description of the Burkhalter transfer to restore
thumb opposition in a low median nerve palsy using the
extensor indicis proprius tendon.
Bunnell S. Surgery of the intrinsic muscles of the hand other
than those producing opposition of the thumb. J Bone
Joint Surg. 1942;24:1.
Kirklin JW, Thomas CG. Opponents transplant: an analysis
of the methods employed and results obtained in 75
cases. Surg Gynecol Obstet. 1948;86:213.
Palande DD. Correction of intrinsic minus hands with
reversal of transverse metacarpal arch. J Bone Joint Surg
Am. 1983;65:514–521.
Smith RJ. Extensor carpi radialis brevis tendon transfer for
thumb adduction – a study of power pinch. J Hand
Surg Am. 1983;8:4–15.
Smith RJ. Tendon transfers of the hand and forearm. Boston:
Little Brown; 1987.
This classic monograph, unfortunately out of print, is an
excellent reference source describing tendon transfers for
nerve injuries, trauma, rheumatoid arthritis, congenital
anomalies, cerebral palsy and spinal cord injuries.
Wissinger HA, Singsen EG. Abductor digiti quinti
opponensplasty. J Bone Joint Surg Am. 1977;2:22–23.

©2014, Elsevier Inc. All rights reserved.
Chapter
24 
Extensor tendon injuries
Brief introduction
• In contrast to common belief, injuries to the extensor
tendon apparatus are often more difficult to treat than
those of flexor tendons.
• A thorough understanding of the complex interactions
between the long extensor tendons and the intrinsic
muscles of the hand is necessary to achieve good
postoperative results.
• The extensor apparatus consists of superficial, thin
structures that are very close to the underlying bones,
which makes them prone to develop severe adhesions.
• Their excursion amplitude is limited, so that even subtle
lengthening or shortening will result in severe restrictions
of range of motion.
• Postoperative regimens vary considerably in respect to
the exact location of the lesion and have to be selected
carefully.
Preoperative considerations
• The diagnosis of extensor tendon injuries is often evident.
However, partial lesions can be missed if the remaining
tendon is strong enough to create some extension force.
• As a general rule, open lesions should therefore be
surgically explored to identify the extent of the injury
and prevent secondary ruptures.
• The function of the EDC tendon should be assessed by
extension of the MP joint of the affected digit against
resistance.
• If there is a questionable rupture of the EPL tendon, it
should not be tested by extension of the IP joint as the
EPB tendon inserts into the extensor tendon apparatus of
the thumb at varying levels and may be able to extend
the IP joint.
This chapter was created using content from
Neligan & Chang, Plastic Surgery 3rd edition,
Volume 6, Hand and Upper Extremity, Chapter 10,
Extensor tendon injuries, Kai Megerle and
Günter Germann.
SYNOPSIS
■ A thorough understanding of the complex anatomy is crucial for
successful treatment of extensor tendon injuries.
■ Injuries are classified into nine anatomic zones. Treatment
strategies vary considerably according to the location of the lesion,
ranging from splinting to tendon grafting.
■ Minimal variations in tendon length may result in considerable
alteration in range of motion.
■ As in flexor tendon injuries, postoperative care is an essential part
of the treatment concept.
■ Closed ruptures of the extensor tendon at the level of the distal
interphalangeal (DIP) and proximal interphalangeal (PIP) joints are
typically treated conservatively.
■ Lacerations at the level of the metacarpophalangeal (MP) joint
(zone V) are not infrequently caused by human bites and are prone
to infection unless thoroughly debrided.
■ Ruptures of the sagittal bands may result in subluxation of the
extensor tendon at the level of the MP joint.
■ The swan-neck deformity is characterized by DIP joint flexion and
PIP joint hyperextension. It can be caused by an untreated mallet
injury or palmar plate laxity.
■ The boutonnière deformity is characterized by hyperextension of
the DIP joint and PIP joint flexion. It can be caused by rupture
of the central slip of the extensor tendon or palmar subluxation
of the lateral bands.
■ Complex injuries to the dorsum of the hand can involve skin,
tendon, and bone. Adequate debridement is of paramount
importance. Before reconstructing tendons, fractures must be
stabilized and stable soft tissue coverage must be provided.

415
Anatomical pearls
pollicis longus (APL) and extensor pollicis brevis (EPB)
muscles.
■ In 34% of patients the compartment is further
divided by an additional septum, which has
implications for the etiology and treatment of de
Quervain’s disease.
■ 2nd Compartment: bordered by Lister’s tubercle on
the ulnar side and contains the extensor carpi radialis
longus (ECRL) and extensor carpi radialis brevis
(ECRB).
■ 3rd Compartment: crosses the wrist in a diagonal
fashion above the second compartment, while Lister’s
tubercle acts as a pivot point for the extensor pollicis
longus (EPL) tendon.
■ While passing through the compartment, the tendon is
quite vulnerable to ruptures, e.g., in fractures of the
distal radius.
■ 4th Compartment: contains both the extensor
digitorum communis (EDC) and extensor indicis
propius (EIP) tendons.
■ 5th Compartment: contains the EDM tendon.
■ 6th Compartment: contains the extensor carpi ulnaris
(ECU) tendon.
■ The ECU not only functions as an extensor for the
wrist, but is also part of the triangular fibrocartilage
Figure 24.1  The zones of extensor tendon injuries.
I
II
III
IV
V
VI
VII
VIII
IX
TI
TII
TIII
TIV
TV
• Instead, the patient should be asked to lift the thumb off
the table, which will be impossible without an intact EPL
tendon.
• The extensor tendon apparatus is classified into nine
zones according to the level of the lesion (Fig. 24.1).
• The repair of simple lacerations of the extensor tendon
can be safely performed in the emergency room.
• Lesions proximal to zone VI should be treated in the
operating room.
Anatomical pearls
• The extensor mechanism consists of extrinsic muscles,
which are located on the forearm (extensor communis,
extensor indicis, extensor digiti minimi (EDM)), intrinsic
muscles, which are located at the level of the metacarpals
(interosseous and lumbrical muscles), and fibrous
structures.
Extrinsic muscles
• All extrinsic tendons pass through the six compartments
of the extensor retinaculum on the back of the wrist
(Fig. 24.2):
■ 1st Compartment: attached to the outer rim of the
radius and contains the tendons of the abductor
EIP
EPL
EPB
APL
ECRL
ECRB
Lister’s tubercle
Synovial sheaths
Retinaculum
EDC
ECU
EDM
Juncturae
tendinum
I
II III IV
V VI
Figure 24.2  Extensor compartments. EIP, extensor indicis propius; EPL, extensor
pollicis longus; EPB, extensor pollicis brevis; EDM, extensor digiti minimi; APL,
abductor pollicis longus; ECU, extensor carpi ulnaris; ECRL, extensor carpi radialis
longus; ECRB, extensor carpi radialis brevis; EDC, extensor digitorum communis.

416
•
• Extensor tendon injuries
24
complex (TFCC) and thus a major stabilizer for the
distal radioulnar joint.
• The two extensor proprii tendons of the index and the
little finger are located on the ulnar sides of the
corresponding communis tendons and allow for
individual movements of the peripheral fingers.
• On the dorsum of the hand, the EDC tendons are
interconnected by the juncturae tendinum which facilitate
combined extension of the fingers.
• Lacerations of the extensor tendons proximal to the
juncturae may be masked by the function of these bands.
• At the level of the proximal phalanges, the extensor
tendons split up into three parts: the central band and
two lateral bands (Fig. 24.3).
Figure 24.3  Extensor apparatus.
Triangular ligament
Central slip of common extensor
Lateral slip of common extensor
Lumbrical muscle
Interosseous muscles
Terminal tendon
Lateral band
Oblique fibers of interossei
Sagittal band
Common extensor tendon
Figure 24.4  The distribution of intrinsic muscles in the fingers. Roman numbers indicate finger numbers. DA, dorsal aponeurosis; L, lumbrical muscles, numbered from
radial to ulnar; La, accessory lumbrical muscle (variation); EDC, extensor digitorum communis; EIP, extensor indicis proprius; EDM, extensor digiti minimi; ADM, abductor
digiti minimi; ID, dorsal interosseous muscles; IP, palmar interosseous muscles, numbered from radial to ulnar.
A
B
C
D
II
III
IV
V
DA
L1
ID 1
IP 1
EIP
EDC
L2
ID 2
ID 3
La
IP 2
ID 4
L3
EDC
EDM
ADM
IP 3
L4
• These merge with the intrinsic extensor system to form
the complex extensor apparatus of the digits.
• The extrinsic extensor tendons themselves have three
insertion sites on the phalanges.
• Proximally, the tendon is fixed at the level of the
metacarpal heads to the palmar plate by the sagittal
bands.
• This attachment centers the tendon of the MP joint and
prevents hyperextension.
• The most important insertion is located at the base of the
middle phalanx.
• Distally, the terminal tendon is attached to the distal
phalanx.
Intrinsic muscles
• The intrinsic muscular system of the hand consists of
seven interosseous and four lumbrical muscles.
• The three palmar interosseous muscles arise from the
medial sides of the second, fourth, and fifth metacarpal
bones and join the extensor apparatus of the digits at the
level of the proximal phalanx after crossing palmar to the
axis of the MP joint.
• They function to adduct the fingers, and flex the MP
joint, and extend the IP joints.
• The four dorsal interosseous muscles originate with two
heads each from the adjacent sides of the five metacarpal
bones. The first two interosseous muscles approach the
index and middle finger from the radial side; the third
and fourth approach the middle and ring finger from the
ulnar side. They insert at the proximal phalanges and the
interosseous hood of the extensor apparatus before
joining the lateral bands.
• They function to abduct the fingers, flex the MP joint, and
extend the IP joints.
• The lumbrical muscles arise from the radial sides of
the flexor digitorum profundus tendons at the level of
the metacarpals and join the extensor apparatus from the
radial side (Fig. 24.4).

417
Operative techniques
• In the more distal zones of injury, locking or grasping
core stitches become increasingly difficult due to
flattening of the tendon.
• Grasping stitches in zone IV injuries are strong enough to
enable postoperative early active motion.
• Simple running stitches should be avoided due to the low
pull-out strength in favor of more complex locking suture
techniques.
• They function primarily as IP joint extenders.
• The thumb also has three short muscles that join the
extensor apparatus: the flexor pollicis brevis (FPB) and
abductor pollicis brevis (APB) muscles on the radial side
and the adductor pollicis (ADP) muscle on the ulnar side.
Functional anatomy
• The movement of the fingers is dependent upon a
delicate equilibrium between the extrinsic extensor and
flexor muscles and the intrinsic muscles.
• The extrinsic flexor and extensor muscles have a
component that acts as an extensor on the proximal
phalanx, which is counteracted under physiologic
conditions by the intrinsic muscles.
• Paralysis of these muscles (as in ulnar nerve palsy)
therefore results in hyperextension of the MP joints.
• Without intrinsic muscle function the long extensors
exhaust their potential at the level of the proximal
phalanx. Thus, for complete extension of the
interphalangeal joints, intrinsic muscle function is
therefore mandatory.
Mechanisms of joint extension
• The MP joint is extended by the extrinsic extensor
tendon.
• Extension of the PIP joint is mediated by the central slip
of the extensor tendon.
• However, as stated above, intrinsic muscle function is
necessary in order to enable the extrinsic extensor tendon
to act on the PIP joint.
• At the level of the PIP joint, the extensor tendon is
centered by the transverse retinacular ligaments.
• Extension of the DIP joint is a combination of terminal
lateral bands and a tenodesis effect mediated by the
oblique retinacular ligaments.
Operative techniques
Suturing techniques
• Suturing techniques have to be adapted specifically to the
location of the lesion because the size of the tendon
varies along its length.
• Whatever technique is chosen, it should provide the best
stability with the least shortening possible.
• In zones VI and proximally, the extensor tendon
resembles a flexor tendon and as such can be repaired
with a core suture and an epitendinous running suture.
• Commonly used suture strengths include 3-0 and
4-0 for core sutures and 5-0 for epitendinous sutures
(Fig. 24.5).
• In order to achieve maximum core suture strength,
locking stitches should be preferred over grasping
stitches in order to prevent suture pull-out and reduce
gapping.
Figure 24.5  Different types of core sutures.
Mattress
Figure 8
Modified Bunnell
Modified Kessler
Clinical tip
Always check the stability of the sutured tendon intraoperatively by
gentle movements of the finger. If possible, use locking core stitches
in preference to other techniques. Soft tissue coverage can be very
thin in fingers, so patients may be able to make out dyed suture
material through the skin.
Zone I
The mallet finger
• Characterized by persistent flexion of the distal phalanx
due to a lesion of the extensor apparatus at the level of
the DIP joint.
• Represents a classic closed injury that is usually treated
conservatively, although open injuries may occur as well.
• The flat terminal extensor tendon inserts at the base of
the distal phalanx where it blends with the joint capsule.
• Mallet fingers can be classified by the degree of osseous
involvement.
• Isolated tendinous ruptures are differentiated from
injuries that involve bony avulsions.
• Most surgeons prefer conservative treatment with splints
over operative therapy for uncomplicated injuries,
although the scientific evidence is limited.
• Conservative treatment usually implies immobilization of
the DIP joint in extension while sparing the PIP joint.
• By extension or slight hyperextension of the joint the two
ruptured ends of the tendon are approximated.
• The fibrous tissue of the resulting scar is thought to be
strong enough to restore extension of the joint.
• The type of splint is not nearly as important as patient
compliance (Figs 24.6, 24.7).

418
•
• Extensor tendon injuries
24
• In case of open reduction, screw fixation seems
preferable. Alternatively, a pull-out suture may be
applied, as described by Doyle.
• Most authors agree to operative treatment for open
injuries.
• In some cases, suturing of the skin alone and supporting
the joint in extension or slight hyperextension is enough
to approximate the ends of the ruptured tendon and
allow direct healing.
• Most authors recommend full-time splinting for at least
6–8 weeks followed by a period of 2–6 weeks of splinting
at night to enable further shrinking of the immature scar.
• By thorough splinting, a residual lack of extension of 10°
or less can be expected.
• Surgical treatment for closed injuries should only be
considered in fragment sizes greater than one-third of the
joint surface.
• Transfixation of the DIP joint with a Kirschner wire has
been suggested for sole treatment of the mallet injury in
addition to other surgical interventions.
• To avoid scarring of the finger pulp, Tubiana has
suggested an oblique angle when crossing the DIP joint.
• In case of a rather small fragment, indirect reduction by
extension block pin fixation should be preferred
(“doorstop osteosynthesis”).
• In this technique, the distal phalanx is maximally flexed
and a 1 mm Kirschner wire is advanced into the middle
phalanx dorsal to the avulsed fragment at a 45° angle,
creating the extension block against which the fragment
is reduced. The joint is then extended, reducing the
fragment. This position is secured by a second Kirschner
wire inserted longitudinally across the DIP joint for
transfixation. The wires are cut and a splint is applied for
at least 6 weeks (Figs 24.8, 24.9).
• If the avulsed fragment seems large enough, it may either
be pinned directly percutaneously or reduced in an open
fashion through a zigzag incision of the distal and middle
phalanges.
Figure 24.6  Aluminum splint.
Figure 24.7  Stack splint.
Figure 24.8  Postoperative doorstop: posteroanterior view.
Figure 24.9  Postoperative doorstop: lateral view 6 weeks after doorstop
osteosynthesis.

419
Operative techniques
• In clean and sharp lacerations, the wound can be easily
enlarged and the injured tendon should be sutured
directly or reinserted into the middle phalanx.
• In contrast, contaminated defect wounds, e.g., after saw
injuries, are a lot more difficult to deal with.
• If there is considerable loss of tendon, an immediate
reconstruction should be attempted.
• Snow described a retrograde tendinous flap created from
the proximal tendon that is flipped over to bridge the
defect over the joint (Fig. 24.11).
• Aiache et al. proposed a longitudinal split of the two
lateral bands that are joined in the midline to reconstruct
the tendinous insertion and to cover the joint (Fig. 24.12).
• Any loss of covering skin should be replaced
immediately as well.
• Options include local random pattern flaps, reversed
cross-finger flaps, or flaps from the dorsal metacarpal
artery system.
Zone IV
• As the extensor becomes very broad over the proximal
phalanx, partial lacerations are more commonly observed
than complete injuries of the tendons.
• Extensor tendon injuries in zone IV are often associated
with fractures of the proximal phalanx.
• Due to the close relationship between tendon and bone,
adhesions frequently occur and tenolysis is often
necessary.
• Some form of a postoperative early active motion
regimen is therefore advisable to reduce loss of range of
motion.
• Maintenance of the wrist in an extended position will
“unload” the tendon and allow early range of motion of
the finger.
• When sutures are needed to approximate the tendon
ends, a suture that incorporates both skin and tendon
may be superior to individual suturing of the tendon,
because further tendon dissection may decrease the blood
supply and compromise healing.
Zone II
• Injuries to the extensor tendon over the middle phalanx
usually result from sharp, direct lacerations or crush
injuries.
• Acute lacerations should be explored to determine the
extent of the tendon injury.
• If less than 50% of the tendon substance is injured, the
tendon is considered stable and no further treatment is
necessary.
• If more than half of the tendon is involved, additional
suturing is necessary.
• Care should be taken to avoid considerable shortening of
the tendon which will result in lack of flexion of the DIP
joint.
Zone III
• Injuries to the extensor tendon at the level of the PIP joint
(zone III) occur as both closed and open injuries, ranging
from minor strains to complete ruptures or lacerations.
• Injuries at this level can give rise to the characteristic
boutonnière deformity when the proximal phalanx
herniates through the central slip defect.
• The deformity will not develop immediately after the
injury.
• Disruption of the tendon first leads to an inability to
extend the PIP joint actively while passive extension is
possible.
• Only after the lateral bands migrate palmarly and
retraction of the central slip occurs will hyperextension of
the DIP joint develop.
• A closed avulsion injury of the central slip may not be
immediately evident and extension may be retained by
means of the lateral bands.
• The central slip may be restored without surgical
intervention by extension splinting.
• The DIP joint should not be included in immobilization.
Instead, patients should be encouraged to move the DIP
joint actively and passively while wearing the PIP splint
(Fig. 24.10).
• Several authors have proposed pinning the PIP joint in
extension by a Kirschner wire.
• Most authors suggest keeping the joint in extension for
5–6 weeks.
• Surgical treatment has been suggested for avulsion
injuries with large bony fragments or unstable
transarticular fractures.
• If the fragment is too small to be pinned directly, it may
be excised and the tendon reinserted into the middle
fragment with a bone anchor.
• Open injuries should always be thoroughly explored.
Care should be taken specifically to include the lateral
bands and the triangular ligament in the inspection.
Figure 24.10  (A, B) Splinting for closed extensor tendon ruptures in zone III.
A
B

420
•
• Extensor tendon injuries
24
• Surgical exploration is warranted and it should be taken
into account that the injury to the tendon may be located
more proximally than the skin laceration if the tendon
was injured in flexion.
• If possible, a core suture with an epitendinous running
stitch should be performed.
Human bite injuries
• A common mechanism of injuries to the extensor tendon
in zone V caused by a punch to the opponent’s face (fight
bites).
• Bite wounds are heavily contaminated and prone to
serious infection.
• As skin damage is often minimal, these injuries are
frequently underestimated by the patient and treatment is
delayed until infection has developed.
• Primary inspection is mandatory in fresh injuries, as are
X-ray studies to detect avulsed bony fragments or teeth.
• During exploration, the tendon should be split
longitudinally and the MCP joint irrigated with antibiotic
solution.
• Partial lacerations of the tendon often do not require
suturing.
• A number of authors suggest delayed primary treatment
after the occurrence of infection has been ruled out.
Sagittal band injuries
• The central tendon is centered over the MP joint by the
lateral bands which attach to the palmar plate of the joint.
• Open or closed injuries to the sagittal bands may result in
subluxation of the tendon to the unaffected side during
flexion.
• Partial lacerations will not result in subluxation unless
two-thirds of the sagittal band is affected.
• Stable lacerations can be treated by buddy-taping of the
affected finger to an adjacent finger for 3 weeks.
• In case of an unstable tendon, the laceration should be
sutured.
• Closed ruptures of the sagittal bands are much more
common than open injuries and usually occur in the
course of a primary disease of the joints such as
rheumatoid arthritis.
• Traumatic and spontaneous ruptures of the sagittal bands
may be treated by splinting within 10–14 days.
• In older injuries, direct suturing of the bands should be
attempted.
Zone VI
• Extensor tendon lesions at the level of the metacarpal
bones can usually be sutured by a 3-0 core stitch and an
epitendinous running suture.
• Postoperatively, early mobilization with a dynamic
splinting regimen is indicated to reduce tendon
adhesions.
• Loss of flexion has been reported to be more common
than loss of extension.
Zone V
• At the level of the MP joints, the extensor tendon consists
of the central extensor tendon and the sagittal bands.
Due to its broad width, complete lacerations are
uncommon.
Figure 24.11  (A, B) Snow’s technique of reconstructing the central slip. PIP,
proximal interphalangeal; MP, metacarpophalangeal.
A
B
PIP
MP
Lateral band
Central slip
Figure 24.12  (A, B) Reconstruction of the central slip involving splitting of the
lateral bands (Aiache’s technique).
A
B

421
Operative techniques
• Sutures of muscle fibers alone have virtually no tensile
strength. Therefore an effort should be made to suture
tendons or fascial layers instead of muscle fibers alone.
• These sutures are usually not strong enough for dynamic
postoperative treatment protocols and immobilization for
3–4 weeks should be initiated postoperatively.
Secondary procedures
Zone VII
• Injuries to the extensor tendons at the level of the
extensor retinaculum are due to either open lacerations
that often affect multiple tendons or closed ruptures,
most often after distal radius fractures.
• To repair open lacerations at this level, at least a part of
the retinaculum has to be opened.
• The tendon repair itself should be performed with a
stable core suture and an epitendinous running stitch.
• Special attention should also be paid to concomitant
injuries of sensory branches of the radial and ulnar
nerves.
• Primary coaptation of the nerve ends should be
performed in order to prevent the development of painful
and difficult-to-manage neuromas.
• As the tendons are arranged very close to each other,
injuries of multiple tendons through one laceration occur
frequently.
• Identification of the tendons can be quite difficult,
because they tend to retract into the forearm. A thorough
knowledge of the surgical anatomy is therefore
mandatory.
• Ruptures of the EPL tendon are most often associated
with fractures of the distal radius or rheumatoid arthritis.
• Because of the degenerative nature of the process, an
end-to-end repair of the tendon is usually not possible
without unacceptable shortening of the tendon.
• Instead, reconstruction of the tendon can be performed
by EIP to EPL tendon transfers or interposing tendon
grafts.
Zones VIII/IX
• Lesions of the extensor tendons at levels VIII and IX
include injuries of the musculotendinous junctions and
muscle bellies.
• As in zone VII injuries, the recovery and identification of
retracted tendons can be quite challenging.
• Combined injuries to muscles and/or nerves are possible
and knowledge of the sequence of motor innervation
helps to distinguish a motor nerve injury from a tendon
injury.
• The motor branches of the wrist and fingers have been
divided into two groups, a proximal superficial group
and a distal deep group.
• The proximal superficial group consists of the ECRL,
ECRB, EDC, EDM, and ECU muscles.
• The entry of nerve fibers into the muscles is near the
lateral epicondyle.
• When exposing the posterior interosseous nerve, the
interval between the wrist ECRB and ECRL tendon
(proximal to the supinator muscle) and the EDC, EDM,
and ECU (distal to the supinator) should be chosen to
avoid injury to motor branches.
• The distal deep group consists of the APL, EPB, EPL,
and EIP.
• They originate in the distal half of the forearm, close to
the skeletal plane.
Clinical tip
Secondary correction of established finger deformities is exceedingly
difficult. Patients should be aware that restoration of “normal” finger
movement is rare.
The hanging fingertip
• Even a minimal increase in tendon length will result in
an extensor lag after a mallet injury.
• In many patients, therefore, some residual deformity will
occur, although it is rarely of any relevance.
• With the extension lag exceeding 40–50°, however, a
considerable number of patients will desire correction.
• In this case, additional immobilization should be
considered for up to 6 months after the injury, especially
if there is any doubt about the adequacy of the primary
treatment.
• If conservative treatment fails, surgical treatment should
be discussed with the patient.
• If surgical correction is indicated, a simple combined
excision of callus and skin may be the procedure of
choice, referred to as the Brooks–Garner procedure.
• An elliptical wedge of skin and underlying soft tissues,
including the scarred extensor tendon, is excised from the
dorsum of the involved DIP joint (Figs 24.13–24.15).
• The wound edges are closed by en bloc sutures, resulting
in a slight hyperextension of the joint.
• The DIP joint is then transfixed with a Kirschner wire to
keep the joint in the desired position for 6 weeks.
Figure 24.13  Hanging fingertip (Mallet Finger).

422
•
• Extensor tendon injuries
24
with a chronic mallet deformity in which the terminal
extensor tendon cannot be repaired.
• By transection of the central slip, rebalancing of the
extensor mechanism should occur in order to increase the
extension force on the DIP joint.
• Alternatively, the extensor tendon may be reconstructed
by a tendon graft (spiral oblique retinacular ligament or
SORL reconstruction: Fig. 24.17).
• In this technically demanding operation, a palmaris
tendon graft is fixed to the distal phalanx by a pull-out
suture. It is then passed between the flexor tendon and
the palmar plate of the PIP joint into an osseous tunnel in
the proximal phalanx (Fig. 24.18).
• Swan-neck deformities which are not primarily related to
injuries of the distal extensor tendon should be
approached differently as these deformities are frequently
caused by hyperlax palmar plates at the level of the PIP
joint.
• In these cases, correction of the laxity can be indicated,
e.g., by a tenodesis of the flexor digitorum superficialis
tendon.
The boutonnière deformity
• Acute injury to the central band of the extensor tendon
will result in an acute boutonnière deformity as both
lateral bands shift palmarly due to the accompanied
disruption of the triangular ligament.
• In the acute phase, the deformity should be easily
reducible and may be treated as described above.
• However, if left untreated, a chronic contracture results
from shortening of the oblique retinacular ligament
(Fig. 24.19).
• This condition has long been recognized as one of the
most challenging problems in hand surgery.
• Any surgical correction of the deformity should
only be performed if the PIP joint can be extended
passively.
Figure 24.14  Resection of skin and tendon.
Figure 24.15  Transfixation of the distal interphalangeal joint.
Figure 24.16  (A, B) Pathophysiology of the swan-neck deformity. The deformity
persists when the tendon heals with lengthening.
A
B
• Alternatively, a Fowler release (central slip tenotomy) or
even a reconstruction of the spiral oblique retinacular
ligament may be performed.
• Both procedures are primarily used to correct swan-neck
deformities and require a supple PIP joint.
The swan-neck deformity
• A classic finger deformity that can be caused by many
reasons, including congenital PIP palmar plate laxity and
intrinsic tightness.
• Often it is associated with some form of arthritis;
however, it can also result from a mallet injury.
• In the mallet finger, the disrupted extensor tendon
results in a concentration of extensor force at the PIP
joint (Fig. 24.16).
• If the palmar plate of the joint is lax, the swan-neck
deformity will occur immediately. However, even if it is
not lax to begin with, it will stretch over time due to
increased extensor pull. Once the PIP hyperextension
exceeds a critical point, snapping of the joint will occur.
• A Fowler tenotomy (tenotomy of the central slip) has
been used to address the swan-neck deformity in patients

423
Operative techniques
• Tenotomy of the extensor tendon on the middle phalanx
is referred as the Dolphin or Fowler procedure.
• It may be the procedure of choice when patients mainly
complain about hyperextension of the DIP joint.
• The incision should be performed just distally to the
insertion of the central slip.
• In Dolphin’s description, the tendon is divided more
proximally in order to preserve the distal insertions of the
oblique retinacular ligament (Fig. 24.20).
• The lateral bands should be able to slide proximally in
order to increase the tone on the PIP joint to allow
improved extension and reduce tension on the DIP joint.
• Postoperatively, the PIP joint should be splinted in
extension for 6–8 weeks, allowing free range of motion of
the DIP joint.
• If the main patient complaint is the lack of extensive
function, secondary reconstruction of the extensor should
be considered.
• Patients should be aware that postoperative splinting is
an essential part of the treatment strategy and may be
necessary for months after surgery.
• An increase in extension of the joint should not be traded
for a stiff finger or loss of grip strength.
• There are two main categories of procedure to address
the boutonnière deformity: tenotomy or reconstruction of
the extensor tendon by tendon relocation or tendon
grafting.
Figure 24.17  (A–C) Spiral oblique retinacular ligament. A palmaris longus tendon
graft is passed between the flexor tendon and the palmar plate and fixed to the
distal phalanx by a pull-out suture.
A
B
C
Lateral band
Volar plate
Primary insertion of central tendon
Figure 24.18  Dynamic extension splint.
Figure 24.19  (A, B) Pathophysiology of the boutonnière deformity. Subluxation of
the lateral bands results in redistribution of forces and an extensor lag in the
proximal interphalangeal joint. Retraction of the oblique retinacular ligament
prohibits reduction in chronic deformities.
A
B
Central tendon
Oblique retinacular ligament
Lateral band
Figure 24.20  Treatment of the boutonnière deformity by tenotomy as described by
Dolphin and Fowler. Dolphin’s tenotomy preserves the insertions of the oblique
retinacular ligament.
Dolphin
Fowler

424
•
• Extensor tendon injuries
24
The missing tendon: tendon transfers versus
tendon grafting
• In cases of degenerative rupture of an extensor tendon,
direct suturing is not usually possible because of
an existing gap or extensive degeneration of the
tendon ends.
• To reconstruct extensor function two options exist.
• First, the tendon can be reconstructed with the use of a
tendon graft, e.g., derived from the palmaris longus
tendon.
• This goal can be achieved by either tendon relocation or
tendon grafting.
• The central slip can be reconstructed as described by
Snow (see Fig. 24.11). The end of the reconstructed
tendon is either sutured to the remaining insertion on the
middle phalanx or reinserted directly into the phalanx.
• A large number of techniques have been described
to reconstruct the central slip using the lateral bands
(Figs 24.21, 24.22).
• In extensive defects of the central slip, the lateral bands
may be insufficient for reconstruction and, in these cases,
free tendon grafts may be indicated.
Delayed sagittal band reconstruction
• If the sagittal band is ruptured, the tendon may subluxate
to the unaffected side.
• Tendon dislocation rarely occurs in patients not suffering
from rheumatoid arthritis.
• If conservative treatment fails, surgical reconstruction of
the sagittal band is indicated.
• In addition to the reconstruction, a release of the
contracted contralateral sagittal band may be necessary in
long-standing cases.
• Several techniques have been described for
reconstruction, if direct repair is not possible because of
missing soft tissue or severe scarring (Fig. 24.23).
Figure 24.21  Littler operation. The lateral bands are resected and relocated to the
central tendon.
Oblique retinacular ligament
Figure 24.22  (A, B) Matev’s technique for reconstruction of the central slip.
Both lateral bands are cut at different heights and relocated to reconstruct the
central slip.
A
B
Figure 24.23  Different techniques for reconstruction of the sagittal band. (A)
Disruption of the radial sagittal band results in ulnar subluxation of the extensor
tendon. (B) Primary suturing. (C) Wheeldon’s technique: the ulnar junctura
tendinum is relocated to the deep intercarpal ligament. (D) McCoy’s technique: the
tendon is split distally and wrapped around the lumbricalis muscle. (E) Carrol’s
technique: an ulnarly distal-based slip of the extensor digitorum communis tendon
is wrapped around the radial collateral ligament (RCL).
A
B
C
D
E
Ulnar
subluxation
Ulnar
Radial
Primary
suture
Juncturae tendinum
(Wheeldon)
Tendon slip
(McCoy)
Tendon slip
(McCoy)
Tendon slip
(Carroll)
Lumbrical
Ulnar sagittal
fibers released
Scarred radial
sagittal band
RCL

425
Complications and outcomes
• In recent years, dynamic postoperative treatment
protocols have been developed that reduce postoperative
adhesion formation without jeopardizing the stability of
the sutured tendon.
• Strict immobilization is the treatment of choice for some
indications.
• Mallet injuries should be treated by full-time static
splinting for 8 weeks.
• The same is true for closed ruptures of the central slip
(zone III injuries).
• Immobilization should also be considered for injuries
proximal to the extensor retinaculum (zones VIII and
IX) because it may not be possible to achieve adequate
tensile strength by suturing fascial layers around the
muscle.
• Postoperative immobilization of open injuries in zones
III–V will inevitably result in severe adhesions, because
the tendon is very broad and in close relationship to the
adjacent bone in this area.
• To overcome this problem, Evans described a
postoperative treatment protocol that reduces
adhesions by limited early active motion (“short arc
motion”).
• Dynamic mobilization for injuries in zones V–VII can be
achieved by passive extension with a rubber band system
combined with active flexion of the affected digit (see
Fig. 24.18).
• Early dynamic motion is also superior to immobilization
after transfer of the EIP tendon for EPL reconstruction.
• After performing a Pulvertaft weave, the tendon is more
stable and splinting can be discontinued after 3 weeks.
Complications and outcomes
• Outcomes vary considerably with the location of the
lesion, the extent of concomitant injuries to the bone or
surrounding soft tissues, timing of the repair, and
adequate postoperative care.
• Lesions distal to the MP joints lead to less favorable
results than more proximal lesions.
• The most common complication after extensor tendon
injuries is the formation of adhesions between the tendon
and surrounding tissues.
• Adhesion formation should be addressed first by hand
therapy and splinting of the affected joints in order to
improve tendon gliding. If there is not adequate
improvement in range of motion after 4–6 months,
extensor tendon tenolysis can be considered.
• A stable skin envelope is a prerequisite before performing
any additional procedures.
• Tenolysis can be elegantly performed utilizing the
wide-awake technique with no sedation and no
tourniquet, with the use of tumescent lidocaine and
epinephrine.
• Tenolysis alone may not be sufficient to achieve an
improvement in range of motion. An additional
capsulotomy, collateral ligament release, or even flexor
tendon tenolysis may be necessary.
• Second, reconstruction is possible by transfer of another
tendon.
Soft tissue management and staged
reconstruction in combined injuries
• Lesions of the extensor tendons are often complicated by
lesions of the bones and joints and by loss of skin.
• As in other mutilating injuries, basic reconstructive
principles apply.
• Before attempting reconstruction of the tendons, several
requirements must be fulfilled:
• Radical debridement of all devitalized tissue is
mandatory.
• Before closure, the wound should not contain any
contamination or tissue of compromised blood supply in
order to prevent infection.
• Primary radical debridement has been shown to be
superior to several serial debridement steps, because of
the formation of edema and infected granulation tissue,
which is only poorly penetrated by antibiotic treatment.
• Osseous structures must be stabilized before turning to
soft tissues.
• This can be achieved by internal or external fixation as
appropriate.
• Stable soft tissue coverage for tendons and bony
structures must be provided.
• In case of combined lesions of the dorsum of the hand,
often pedicled or free tissue transfer is necessary.
• The pedicled radial forearm flap is a classic pedicled
workhorse flap for coverage of the dorsum of
the hand.
• Another classic pedicled flap is the posterior interosseous
artery flap.
• With the advancement of microsurgical techniques, free
tissue transfers are now more frequently performed.
• The timing of combined reconstructive procedures has
been subject to discussions.
• Traditionally, these injuries have been addressed by
multistage procedures.
• Today, most surgeons probably aim for achieving
soft tissue coverage within 72 h.
• Several authors have reported excellent results after
one-stage procedures for defects involving the dorsum of
the hand with the use of emergency free flaps.
• Reconstruction of missing tendons is usually performed
at the time of soft tissue coverage by primary grafting or
tendon transfers.
• Because the creation of a secondary tendon sheath is not
necessary, staged reconstruction of extensor tendons
utilizing silicone rods is rare.
Postoperative considerations
• As with flexor tendon injuries, the importance of an
adequate postoperative treatment cannot be
overestimated.

426
•
• Extensor tendon injuries
24
Further reading
Bowers WH, Hurst LC. Chronic mallet finger: The use of
Fowler’s central slip release. J Hand Surg Am.
1978;3:373–376.
Dolphin JA. Extensor tenotomy for chronic boutonnière
deformity of the finger; report of two cases. J Bone Joint
Surg Am. 1965;47:161–164.
Description of the classic technique to address the problem of
the boutonnière deformity.
Duran RJ, Houser RG, Stover MG. Management of flexor
tendon lacerations in Zone 2 using controlled passive
motion postoperatively. In: Hunter JM, Schneider LH,
Mackin EJ, et al, eds. Rehabilitation of the Hand.
St Louis: CV Mosby; 1978:217–224.
Evans RB. Early active short arc motion for the repaired
central slip. J Hand Surg Am. 1994;19:991–997.
Based on several anatomical studies, Evans introduces a
new early active motion protocol for extensor tendon
injuries in zones III and IV. Sixty-four digits in 55 patients
were investigated. Patients who were treated by early active
motion demonstrated better functional results than those
who were treated by immobilization.
Harris CJ, Rutledge GLJ. The functional anatomy of the
extensor mechanism of the finger. J Bone Joint Surg Am.
1972;54:713–726.
Handoll HH, Vaghela MV. Interventions for treating mallet
finger injuries. Cochrane Database Syst Rev.
2004;CD004574.
Landsmeer JM. The anatomy of the dorsal aponeurosis of
the human finger and its functional significance. Anat
Rec. 1949;104:31–44.
Classic description of the function of the oblique retinacular
ligaments which is the anatomical foundation for numerous
reconstructive procedures of the distal extensor tendon.
Littler JW, Eaton RG. Redistribution of forces in the
correction of boutonnière deformity. J Bone Joint Surg
Am. 1967;49:1267–1274.
Littler and Eaton describe the pathophysiology of the
boutonnière deformity and the results of 8 patients who were
treated by detachment and proximal reinsertion of the lateral
bands.
Mowlavi A, Burns M, Brown RE. Dynamic versus static
splinting of simple zone V and zone VI extensor
tendon repairs: a prospective, randomized, controlled
study. Plast Reconstr Surg. 2005;115:482–487.
Newport ML, Williams CD. Biomechanical characteristics of
extensor tendon suture techniques. J Hand Surg Am.
1992;17:1117–1123.
Snow JW. Use of a retrograde tendon flap in repairing a
severed extensor in the PIP joint area. Plast Reconstr
Surg. 1973;51:555–558.
Although only 6 cases in 3 years are reported, this is the
classic description of one of the most commonly used
techniques to reconstruct defects of the central slip.

Index
Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
A
Abbé flaps
lip reconstruction, 125, 128f
partial upper lid defects, 120
Abdominal flaps, autologous breast
reconstruction, 278–308
Abdominal wall
blood supply, 81
diastasis, 212f
esthetic deformity due to pregnancy, 79
lymphatic system, 81
musculature, 81
musculature laxity due to weight loss, 79
nerve supply, 81
skin, 80
subcutaneous tissue, 80–81
superficial fat layer, 81
transplantation, 219
Abdominal wall reconstruction, 211–221
complications and outcomes, 220–221
modified algorithm, 213f
operative techniques, 214–219
abdominal wall transplantation, 219
component separation method, 214–218
parastomal hernia repair, 219
primary suture technique, 214
regional and distant autologous tissue
repair, 218
tissue expansion, 218–219
postoperative considerations, 220
preoperative considerations, 211–213
technical considerations, 213
Abdominoplasty, 79–90
anatomical considerations, 80–81
abdominal blood supply, 81, 83f
abdominal lymphatic system, 81
abdominal musculature, 81, 82f
abdominal subcutaneous tissue, 80–81
anatomical landmarks, 80f
nerve supply, 81, 84f
skin of abdomen, 80
superficial fat layer, 81
umbilicus, 80
complications and outcomes, 89–90
bruising, 89–90
fatigue and discomfort, 89–90
increased abdominal tension, 89–90
local complications, 89–90
postoperative numbness, 89–90
postoperative pain, 89–90
seroma, 89
systemic complications, 90
wound dehiscence, 89
contraindications, 81
indications for different techniques, 83t
operative technique, 81–86
abdominoplasty with umbilical
transection, 83
Fleur-de-lis abdominoplasty, 85
high-lateral-tension (HLT)
abdominoplasty, 84–85
marking and positioning, 81, 85f
mini abdominoplasty, 81–83
reverse abdominoplasty, 85–86
standard abdominoplasty, 83–84
vertical abdominoplasty, 86
postoperative considerations, 89
preoperative considerations, 79–80
anticoagulant drugs, 80
antiseptic shower, 80
medical history, 79–80
patient weight, 80
physical examination, 80
Abductor digiti minimi (ADM), 397–398
Abductor pollicis brevis (APB), 417
Abductor pollicis longus (APL), 344, 415
Accessory collateral ligament, 353
Acellular dermal matrix, 186, 266
Adductor pollicis (AP), 344, 399–400, 417
Adjacent tissue transfers, 207
Adjuvant radiation therapy, 187
Adson test, 355, 356f
Advancement flaps
cheek reconstruction, 121, 123f
partial upper eyelid defects, 118–120
Alar base surgery, 63, 63f
alar flaring, 63
Alar cartilage
malposition, 47
resection, 65
Alar-columellar relationship, 60–62, 62f
class I (hanging columella), 60
class II (secondary to alar retraction), 60
class III, 60
class IV (hanging ala), 60–62
class V (secondary to columellar retraction),
62
class VI, 62
Alar contour grafts, 59, 61f
Alar flaring, 63
Alar wedge resection, 66
Allen’s test, 345
Alloderm, 168
Allograft, 168
Alopecia, 45
Alveolar molding, unilateral cleft lip, 139
Amputation, primary limb, 169
Anatomic snuffbox, 334, 341
Anchor blepharoplasty, 11, 11f
André-Thomas sign, 350
Ankylosis of temporomandibular joint, 100
Annular ligament, 353
Anterior interosseous nerve (AIN), 384
Anterolateral thigh flap, 124
Anterolateral thigh perforator, 179, 179f–180f
Anteromedial perforator, 177–178
Apligraf, 168
Arcus marginalis, 1
Asian eyelid, 4
Asymmetrical bilateral cleft lip, 151, 153f
Augmentation mastopexy, 247–248, 249f
Autologous breast reconstruction
anatomical considerations, 280
anatomy of abdominal wall, 281f
paramedian sagittal view of abdominal
wall anatomy, 282f
perforators at the lower abdominal wall,
282f
standard elliptical design of TRAM flap,
282f
complications and outcomes, 306
golden rules in perforator flap surgery,
303b
operative techniques, 280–305
DIEP flap, 295–305
free TRAM, 289–295
pedicled TRAM, 280–289
pedicled vs free TRAM/DIEAP, 279
postoperative considerations, 305–306
preoperative considerations, 279–280
procedure selection, 279–280
using abdominal flaps, 278–308
Autologous grafts, 50, 167–168
Autologous tissue repair
regional and distant, 218
hernia repair with fascia lata graft,
218f
B
Back reconstruction, 196–210
operative techniques, 199–209
debridement, 199–200
flap closure, 200–209
local wound care, 199
postoperative considerations, 210
preoperative considerations, 197
midline back wounds, 197
nonmidline back wounds, 197
technical considerations, 197–198
flap selection by region, 197–198
wounds of lateral back, 198
Back wounds
midline, 197
nonmidline, 197
Abdominoplasty (Continued)

Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
428
Index
Ballistic injuries, face, 109
technical considerations, 108f, 109
second look procedures, 109
Below-knee amputation, 169
stump length, 169
Benelli mastopexy, 240–242, 242f–243f
dissection of the breast, 241f
four flaps, 241f
preoperative markings, 240f
transareolar U suture, 242, 243f
Biceps femoris, 173
Biesenberger reduction, 257f
Bilateral cleft lip, 136, 136f, 146–151
alveolar closure, 147, 148f
anatomic forms, 136
final repair, 149–150, 151f
labial closure, 147–149, 147f–150f
labial dissection, 146–147
markings, 146, 147f
principles for repair, 138
surgical repair, 146
Bilateral cleft palate, 146–151
alveolar closure, 147, 148f
final repair, 149–150, 151f
labial closure, 147–149, 147f–150f
labial dissection, 146–147
markings, 146, 147f
Bilateral complete cleft lip, 150
Bilateral complete cleft palate, 150
Bilateral incomplete cleft lip, 150, 152f
intraoperative anthropometry, 150t
Biobrane, 168
Bioburden reduction, 213
Biological healing strength, 364
Bleeding, 68
zygoma fracture, 100
Blepharoplasty, 1–22
complications and outcomes, 21
operative techniques, 9–20
anchor/invagination blepharoplasty, 11,
11f
blepharoptosis, 12–13, 13f
canthopexy, 18, 18f–19f
capsulopalpebral fascia plication, 17,
17f
lower lid blepharoplasty, 13
midface lifting, 18–20, 20f
orbicularis suspension, 17–18
orbital fat excision, 11–12, 12f
orbital fat transposition, 16
orbital septum plication, 16–17, 16f
simple skin blepharoplasty, 9–11,
10f–11f
transconjunctival blepharoplasty, 13–15,
14f–16f
transcutaneous blepharoplasty, 15–16
periorbital anatomy, 1–7
blood supply, 6–7, 7f
eyelids, 3–4, 4f
facial nerve, 7, 8f
forehead, 3f
lateral retinaculum, 1–3, 2f–3f
lower eyelid, 6
medial orbital vault, 3, 3f
orbital anatomy, 1, 2f
periorbita, 1
retaining ligaments, 6, 7f
septal extension, 6, 6f
temporal region and forehead, 3
trigeminal nerve, 7, 7f
upper eyelid area, 4, 5f
postoperative considerations, 20–21
preoperative considerations, 8–9
history and physical examination,
9b
preoperative periorbital plan, 10b
recommended photographic views,
9b
principles of eye restoration, 2b
youthful and beautiful eyes characteristics,
8, 8f
Blepharoptosis, 12–13, 13f
Blindness, 96
Blow-in orbital fracture, 95
Boutonnière deformity, 422–424, 423f
pathophysiology, 423f
Bouvier maneuver, 350, 402, 405f
Boyes superficialis transfer, 395–396
Brachial plexus block, 364
Brand EF4T transfer, 405, 406f–407f
correction of clawing of the ring and small
fingers, 407f
extended by four tendon grafts into all four
lateral bands, 407f
Breast augmentation, 222–232
anatomical and technical considerations,
225–226
implant selection, 225–226, 228f–230f
pocket position, 225, 226f–227f
complications and outcomes, 228–231
grades of capsular contracture, 231t
hematoma, 228
Mondor’s disease, 231
periprosthetic seroma, 228
postoperative wound infection, 231
operative techniques, 226–228
inframammary incision, 226
periareolar incision, 226–227
transaxillary incision, 227–228
transumbilical incision, 228
postoperative considerations, 228
preoperative considerations, 223–225
esthetic breast form, 223f
soft tissue pinch test, 223, 223f–224f
Breast height (BH), 225
Breast ptosis, 233
diagnostic measurement, 234
different types, 235f
Grade I (mild), 233
Grade II (moderate), 233
Grade III (severe), 233
Grade IV(pseudoptosis), 233
pathophysiology, 233
procedures, 234t
Regnault classification, 233, 234f
statistical standards for the dimensions of
the breast, 235f
Breast width (BW), 225
Brooks-Garner procedure, 421
Bunnell ring finger flexor digitorum
superficialis transfer, 397
FDS to APB transfer to restore thumb
opposition, 400f
incisions used to transfer the ring finger
FDS tendon, 401f
C
C-flap incisions, unilateral cleft lip, 139
Calnan’s triad, 156
Camitz palmaris longus transfer, 397,
401f–402f
Canthopexy, 18, 18f–19f
Capsular contracture, 263
Capsulodesis, 402
Capsulopalpebral fascia plication, 17, 17f
Carotid-cavernous sinus fistula, 94
Cartilage
autogenous grafts, 51
autologous grafts, 50
Cellulitis, 68–69
Central mound technique, 260f
Central slip tenotomy, 422
Cerebrospinal fluid leaks, 209
Champy technique, 107
Cheiloplasty
adjustments, 145
incomplete clefts, 146
Chest reconstruction, 185–195
complications and outcomes,
194–195
infection, 195
implantable mesh products, 186f
muscle sparing thoracotomy, 186,
187f
operative techniques, 187–193
common flaps, 188–193
mediastinitis, 187–188
sternal wound infection, 187–188
postoperative considerations, 193–194
preoperative considerations, 186–187
Chest wall
defects, 185–186
osteoradionecrosis, 187
regions, 186t
sternal wound infections, 186t
Children, physical examination of the upper
extremity, 357
Chimeric flaps, 182, 182f
Clavicular compression test, 356f
Cleft lip, 134–155
anatomical considerations, 137–138
Cupid’s bow, 137–138
vermillion, 137–138, 138f
bilateral cleft lip, 136, 136f
clinical features, 136
complications and outcomes, 151–152
incidence, 135t
microform, 137
mini-microform, 137
minor-form, 136
operative technique, 139–151
bilateral, complete cleft lip and palate,
146–151
bilateral cleft lip, 146
unilateral cleft lip, 139–146
postoperative considerations, 151
immediate postoperative anthropometry,
152t
scar digital massage, 154f
sun-block, 154f
preoperative considerations, 135–137
age candidate for treatment, 135
cleft nasal deformity, 137, 137f
genetic diagnosis, 135
Blepharoplasty (Continued)

429
Index
prenatal diagnosis, 135–137
treatment plans, 135, 136f
unilateral cleft lip repair principles, 134
Cleft nose, surgical treatment for, 145,
145f
Cleft palate, 156–165
anatomical considerations, 159–160,
160f
Kernahan’s classification, 160f
bilateral, 146–151
complete, 146–151
complications and outcomes, 164–165
operative techniques, 160–164
double opposing Z-plasty, 163, 164f
two-flap palatoplasty, 161–162, 163f
two-stage palate repair, 163–164
V-Y pushback, 161, 162f
vomer flaps, 162–163
von Langenbeck repair, 161, 161f
postoperative considerations, 164
preoperative considerations, 156–159
feeding and swallowing, 158
growth, 157–158
maxillary growth, 158–159
Pierre Robin sequence, 157
speech, 158
submucous cleft palate, 156–157, 157f
syndromes, 157
Cleland’s ligaments, 310
Closed rhinoplasty, 46b, 63–67
access, 63–64
intercartilaginous incision, 64f
intercartilaginous skeletonizing incision,
64f
alar cartilage resection, 65
alar wedge resection, 66
considerations, 46
dorsal resection, 64
graft placement and wound closure,
66
lateral wall and columellar grafts, 66
nasal spine-caudal septum, 64–65
osteotomy, 66
septoplasty, spreader graft tunnels,
65–66
spreader grafts, 66
tip grafting, 66–67
turbinectomy, 66
upper lateral cartilages, 65
Closed tendon rupture, 368
Cold-heat test, 345
Collateral sprouting, 388
Columellar graft, 57, 59f, 66
Comminuted fractures, mandible, 104,
104f
Complete cleft, cheiloplasty for, 145
Complete cleft lip, 146–151
alveolar closure, 147, 148f
final repair, 149–150, 151f
labial closure, 147–149, 147f–150f
labial dissection, 146–147
markings, 146, 147f
Complete cleft palate, 146–151
alveolar closure, 147, 148f
cheiloplasty for, 145
final repair, 149–150, 151f
labial closure, 147–149, 147f–150f
labial dissection, 146–147
markings, 146, 147f
Complete/near-complete plexus injury,
380–383
specific operative techniques, 381–383
harvesting intercostals, 383f
use of spinal accessory and intercostal
nerves as donors, 381–383
specific patient exam findings, 380–381
Component dorsal hump reduction, 54, 54t
dorsal spreader grafts, 55f
nasal dorsum, 54f
Component separation method, 214–218
component separation with Strattice
underlay, 216f
fibers orientation, 215f
linea semilunaris identification, 215f
musculofascial flaps, 216f–217f
posterior rectus and anterior rectus sheath
closing, 217f
posterior release of the rectus sheath, 216f
Composite flaps, 182
Compound flaps, 181–182
classification, 182f
Hallock’s classification, 182
Concentric mastopexy, without parenchymal
reshaping, 239–240
Conchal setback suture, 73
Condylar fractures, mandible
bilateral, 105
closed reduction, 104
open treatment absolute indication, 104
open treatment indication, 105f
open treatment relative indication, 104–105
Conjoined flaps, 182
Cooper’s ligaments, 236
Core tendon sutures, 365
Costal cartilage, 51
Costoclavicular compression test, 355
Cranialization, 93–94
Crossed fingers sign, 344, 351
Cryptotia, otoplasty for, 76
CSF rhinorrhea, 94
D
Debridement, 169
back, 199–200
subatmospheric-pressure dressing,
200
mediastinitis, 187, 188f
osteomyelitis, 170
sternal wound infection, 187
vacuum-assisted closure, 169
Deep inferior epigastric artery perforator
(DIEAP) flap, 295–305, 298f–301f
abdominal closure, 303
breast cone recreation, 305f
conus of the breast, 303f
envelope of the breast, 304f
flap inset, 303–305
footprint of the breast, 302f
nipple areola complex, 304f
pedicled vs free, 279
Deep motor branch, 384
Deep palmar arch, 334
Delayed sagittal band reconstruction, 424
Dermal flap, 244
Desquamation, 69
Diabetes, 170
algorithm for diabetic foot reconstruction,
170f
Diarrhea, 69
Diastasis, 212f
repair, 211
Diffuse macular erythroderma rash, 69
DiGeorge syndrome, 157
Diplopia, 95–96, 100
Distal annular pulley, 329
Distal forearm injury, 384
Distal interphalangeal (DIP) joint, 318, 359
Distal radioulnar joint (DRUJ), 310, 347
instability test, 347, 348f
Dolphin procedure, 423
Donor nerve, 376b
Doorstop osteosynthesis, 418
Dorsal carpal arch, 334
Dorsal extrinsic radiocarpal ligament
complex, 313
Dorsal metacarpal arteries, 334
Dorsal nasal artery, 7
Dorsal oblique band (DOB), 351
Double skin mastopexy see Goes periareolar
mastopexy
Duchenne sign, 350, 399
Duran-Houser method, 371
Dynamic extension splint, 423f
Dynamic tenodesis effect, 348
E
Ears
constricted, otoplasty, 75–76
correction of aging and elongated lobes, 76
correction of facelift deformities, 77
deformities, 75–76
earring-related complications, correction,
76–77
large
incision, 74, 75f
otoplasty with inadequate helical rim, 74
prominent
standard otoplasty of normal size, 73,
73f–75f
Ectropion, 96
Edentulous mandible fracture, 105, 106f
Eichhoff test, 350
Elastosis, 23
Elbow
bony land marks, 352f
lateral complex, 353f
lateral instability assessment, 354f
medial complex, 353f
physical examination, 352–353
pivotal shift, 354f
Electrodiagnostic test, 377, 377b
Empyema, 186
End-to-side neurorrhaphy, 376
Enophthalmos, 95
zygoma fracture, 100
Entropion, 96
Epineurium, 334
Epistaxis, 68
Epitendinous stitches, 366
Erector spinae muscle flaps, 200–202
erector spinae dissection, 201, 201f
flap elevation, 201f
medial muscle elevation, 201, 201f
midline muscle approximation, 202f
soft tissue folding, 201, 203f
Erythema, 269
Esophageal fistula, after spine procedures,
209
Estlander flaps, lip reconstruction, 125, 129f
Cleft lip (Continued)

Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
430
Index
Exophthalmos, 9
pulsating, 94
zygoma fracture, 100
Expander-implant technique
advantages, 263
anatomical and technical considerations,
265
complications, 264
disadvantages, 263
operative techniques, 265–268
closed suction drain, 267f
complete dissection of inferomedial
fibers, 267f
expander/implant exchange, 267–268,
268f
expander insertion, 265–267, 266f
final aspect of the pouch, 267f
muscular fibers detached from rib
insertion, 266f
submuscular pouch, 267f
outcomes and complications, 269
expander malpositioning and rotation,
270f
frequency of complications by type of
reconstruction, 270t
skin cellulitis inflammation, 269f
skin necrosis and implant exposure, 269f
preoperative and postoperative appearance
of a patient, 264f
preoperative considerations, 264
Exposed prosthesis, 171
Extended MACS-lift, 35
Extensor carpi radialis brevis (ECRB), 344,
384, 395, 405, 415
Extensor carpi radialis longus (ECRL), 344,
388, 395, 415
Extensor carpi ulnaris (ECU), 344, 415
synergy test, 347
Extensor carpi ulnaris synergy test, 349f
Extensor digiti minimi (EDM), 344, 398, 415
Extensor digitorum, 319
Extensor digitorum communis (EDC), 415
Extensor digitorum communis (EDC) muscle,
344
Extensor digitorum communis (EDC) tendon,
344
Extensor indicis proprius (EIP), 344, 396–397,
408, 415
transfer, 396–398
Extensor pollicis brevis (EPB), 344, 408, 415
Extensor pollicis longus (EPL) muscle, 344
Extensor pollicis longus (EPL) tendon, 415
Extensor tendon injuries, 414–426
anatomical considerations, 415–417
extensor apparatus, 416f
extensor compartments, 415f
extrinsic muscles, 415–416
functional anatomy, 417
intrinsic muscles, 416–417, 416f
joint extension mechanism, 417
complications and outcomes, 425
operative techniques, 417–425
aluminum splint, 418f
boutonnière deformity, 423f
central slip reconstruction, 420f
clinical tip, 417b
delayed sagittal band reconstruction, 424
dynamic extension splint, 423f
hanging fingertip, 421f
lateral view 6 weeks after doorstop
osteosynthesis, 418f
Littler operation, 424f
Matev’s technique for central slip
reconstruction, 424f
posteroanterior view of postoperative
doorstop, 418f
resection of skin and tendon, 422f
sagittal band reconstruction techniques,
424f
secondary procedures, 421–424
Snow’s technique of reconstructing the
central slip, 420f
soft-tissue management and staged
reconstruction in combined injuries,
425
spiral oblique retinacular ligament, 423f
splinting for closed extensor tendon
ruptures, 419f
Stack splint, 418f
suturing techniques, 417
swan-neck deformity, 422f
tendon transfer vs tendon grafting,
424–425
transfixation of the distal interphalangeal
joint, 422f
types of core sutures, 417f
zone I, 417–419
zone II, 419
zone III, 419
zone IV, 419
zone V, 420
zone VI, 420
zone VII, 421
zone VIII/IX, 421
postoperative considerations, 425
preoperative considerations, 414–415
zones, 415f
External carotid arteries, 6–7
External oblique flap, 207
External taping, unilateral cleft lip, 139
Extrinsic extensors, 319
Extrinsic tightness test, 346
Eyebrow, muscles, 3, 4f
Eyelids, 1, 3–4, 4f
Eyes, youthful and beautiful eyes
characteristics, 8, 8f
EZ-derm, 168
F
Face aging
classic characteristics, 23
skin, 23
Facelift, 23–45
anatomy, 23
facial soft tissue, 27f
great auricular nerve, 28f
malar fat pad, 25f
muscles of facial expression, 27f
sensory nerve of face, 28f
skin, 24f
soft tissue attachment, 28f
superficial facial fat, 26f
complications and outcomes, 44–45
alopecia, 45
hematoma, 43f, 44
infection, 45
motor nerve injury, 44
sensory nerve injury, 44
skin loss, 45
unsatisfactory scars, 44
correction of deformities around ear,
77
operative techniques, 24–43
facelift incisions, 25–31, 29f–33f
high SMAS technique, 37–40, 38f–41f
lateral SMASectomy, 36–37, 36f–37f
MACS-lift, 33–35, 35f
midfacelift (blepharoplasty approach),
31–32
SMAS plication, 32–33, 33f–34f
subcutaneous facelift, 24–25
subperiosteal mid-facelift, 40–43,
41f–42f
postoperative considerations, 43–44
preoperative considerations, 23–24
Facial injuries, 91–109
ballistic injuries, 109
frontal bone and sinus injury, 91–94
mandible fracture, 103–107
midface fracture, 100–103
nasal fracture, 96–99
orbital fracture, 94–96
panfacial injury, 107–108
preoperative considerations, 91
initial evaluation, 92t
physical examination, 91
radiologic evaluation, 91
strategic incision placement, 92f
zygoma fracture, 99–100
Facial nerve, 7
Facial reconstruction flaps, 110–133
cheek, 121–124
advancement flaps, 121, 123f
anterolateral thigh flap, 124
finger flap, 123
free tissue transfer, 124
island flap, 124
rotation flap, 121, 122f, 126f–127f
scapular and parascapular flaps, 124,
125f
submental artery flap, 124, 124f
transposition flaps, 123
ear, 128–132
anterior concha, 132, 132f
rim defects, 128, 131f
eyebrow reconstruction, 112
hatchet flap reconstruction, 114f
eyelids, 117–124
large upper lid defects, 120–121
medial canthal defects, 121
partial lower lid defects, 117–118
partial upper lid defects, 118–120
total lower lid defects, 121
total upper lid defects, 120–121
forehead and scalp, 110–112
bilateral rhomboid flaps, 112f
bilobed flaps, 111
island flaps, 111
rhomboid flap, 111f
tissue expansion to achieve defect
closure, 113f
triple rhomboid flap, 112f
Extensor tendon injuries (Continued)
Facelift (Continued)

431
Index
lips, 124–128
Abbé flaps, 125, 128f
critical anatomy, 125t
esthetic landmarks, 126f
Estlander flaps, 125, 129f
large, composite and total lip defect, 128,
130f
optimization of cosmesis, 125f
switch flaps, 125
wedge resection, 125, 128f, 130f
nasal reconstruction, 112–117
closure of nasal defect with bilobed flap,
116f
lateral nasal defect with forehead flap,
115f
nasal defect with lateral advancement
flaps, 115f
Rintala dorsal nasal advancement flap,
118f
transoperative flap, 117f
V-Y island subcutaneous tissue pedicle
advancement flap, 117f
Fasciocutaneous flaps, 177
primary limb amputation, 169
Feeding, in cleft palate, 158
Fever, 69
Filmy adhesions, 363
Finger extension test, 346
Finger flap, cheek reconstruction, 123
Finkelstein test, 350
First metacarpal artery, 334
Fistula, 164–165
Fixed SMAS, 38
Flap closure, 200–209
flaps for spine closure, 200–207
adjacent tissue transfers/perforator flaps,
207
erector spinae muscle flaps, 200–202
external oblique flap, 207
latissimus muscle, 202
myocutaneous flap, 202
omentum, 206–207
superior gluteal artery, 202–206
trapezius muscle flap, 202
free flap coverage of the back, 208–209
principles, 200
tissue expansion, 207–208
Flap necrosis, 275
mastopexy, 251
Flaps
facial reconstruction, 110–133
cheek, 121–124
ear, 128–132
eyebrow reconstruction, 112
eyelids, 117–124
forehead and scalp, 110–112
lips, 124–128
nasal reconstruction, 112–117
Fleur-de-lis abdominoplasty, 79, 85, 88f–89f
Flexor carpi radialis transfer, 395
Flexor carpi ulnaris (FCU), 379
Flexor digitorum profundus (FDP), 319, 344,
360
Flexor digitorum superficialis (FDS), 344,
359–360, 379
Flexor digitorum superficialis tendon, 319
Flexor pollicis brevis (FPB), 399–400, 417
Flexor pollicis longus (FPL), 334, 344, 360, 393,
411
Flexor profundus test, 344
Flexor sublimis test, 344
Flexor tendon
anatomical and technical considerations,
360–364
annular pulleys, 361f
biomechanics of repair and gliding, 363–364
biomechanics of tendon repair and gliding,
363–364
classification of closed tendon ruptures, 359
complications and outcomes, 372–373
decision-making flow chart of primary and
delayed flexor tendon repairs, 359f
divisions into five zones, 362f
factors affecting surgical strength, 363f
insertions and relative positions of FDS and
FDP, 362f
location of flexor pulleys of the thumb, 362f
operative techniques, 364–368, 364f
closed tendon rupture, 368
combined active-passive method
(Nantong regimen), 372
combined passive-active tendon motion
protocol, 372f
Duran-Houser method, 371
early active motion, 371
FPL injuries, 368
grafting and staged reconstruction, 373b
mechanical basis and surgical options,
370t
methods of making a tendon-to-bone
junction in zone 1, 365f
methods used to make core sutures, 366f
modified Kessler and cruciate methods,
367f
modified Kleinert method, 371
original and modified Kleinert passive
extension protocols, 371f
partial tendon lacerations, 368
recommended surgical tendon repairs,
367b
simple common methods of peripheral
suture, 369f
six-strand M-Tang tendon repair, 368f
sufficient core suture purchase, 369f
zone 1 injuries, 365–366
zone 2 injuries, 366–367, 369f–370f
zone 3, 4, and 5 injuries, 367–368
preoperative considerations, 359–360
different tendon-suture junctions in
tendon repairs, 364f
primary repairs, 360b
repairs, general tips for surgeons, 359b
subdivisions of zones 1 and 2, 363f
Forced duction test, 95, 95f
Forearm
interosseous membrane, 351f
physical examination, 351–352
Forehead, 3
Forehead and scalp reconstruction, 110–112
Fowler procedure, 423
Fowler release, 422
Fowler tenotomy, 422
Fowler transfer, 406
Free flap
back, 208–209
bone, 208–209
soft tissues, 208
Free grafts, partial upper lid defects, 120
Free tissue transfer, cheek reconstruction, 124
Free TRAM, 289–295
chest wall vascular anatomy, 295f
dissection of free TRAM flap, 292f–293f
final results, 290f–291f
flap insetting, 295
internal mammary artery and two common
veins, 297f
standard approach to insetting, 297f
variations, 294f
vascular anastomosis to the internal
mammary vessels, 296f
Freestyle free flap, 177
Fritschi PF4T transfer, 405–406
Froment’s sign, 350f, 399
Froment’s test, 350
Frontal bone injury, 91–94
anatomical considerations, 93
complications and outcomes, 94
preoperative considerations, 92–93
technical considerations, 93–94
formed-to-fit calvarial bone plugs, 93f
Frontal sinus fracture, 92–93
Frontal sinus injury, 91–94
anatomical considerations, 93
complications and outcomes, 94
preoperative considerations, 92–93
technical considerations, 93–94
formed-to-fit calvarial bone plugs, 93f
Frontalis muscles, 3
Functional muscle flap, 172
Furlow double opposing Z-plasty, 157, 163,
164f
Furnas suture, 73
G
Galeal flap, 94
Gastrocnemius, 176
Gastrocnemius muscle flap, 169
Gigantomastia, 255
Gilula’s lines, 313
Globe injury, 100
Goes periareolar mastopexy
with mesh support, 242–245
dermal flap, 245f
indication, 243
perforating vessels preservation, 243, 244f
preoperative markings, 243, 244f
Gore-Tex, 186
Gracilis, 173–174
Gracilis perforator, 177–178
Grayson’s ligaments, 310
Grayson’s method, 139
Greater arc, 313
Groin flap, 177
flap elevation, 177f
Grotting sculpted vertical pillar mastopexy,
245–247
lower pole detachment, 247f
medial and lateral pillar lines, 245, 247f
nipple position, 248f
preoperative markings, 245
modification of vertical technique, 246f
temporary closure of the breast, 247f
H
Hand
additional special provocative tests, 345–351
distal radioulnar joint instability test, 348f
extensor carpi ulnaris synergy test, 349f
Froment’s sign, 350f
Facial reconstruction flaps (Continued)

Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
432
Index
intrinsic tightness test, 346f
lunotriquetrum shuck test, 347f
Phalen test, 350f
pisiform gliding test, 349f
triquetrolunate ballottement test, 347f
ulnocarpal abutment test, 349f
Wartenberg’s sign, 351f
bones and joints, 310
bony anatomy, 316f
deep palmar and mid-palmar axial views,
314f
dorsal skin, 309–310
exploded view of the functional elements,
315f
extensor mechanism of fingers, 323f
flexor tendon pulley system for fingers and
thumb, 329f
Grayson’s ligaments and Cleland’s
ligaments, 315f
inspection, 342–343
interossei act as prime flexors of
metacarpophalangeal joints, 334f
joint axes, 311f
long finger metacarpophalangeal joint, 315f
longitudinal fibers, 309
musculotendinous assessment, 343–344
Medical Research Council scale, 344t
tests for extrinsic muscles, 344
tests for intrinsic muscles, 344
nerve assessment, 345, 345t
palmar fascia orientation, 312f
palmar fascia with its longitudinal,
transverse and vertical fibers, 313f
palmar skin, 309
palpation, 343
physical examination, 342–351
range of motion assessment, 343
rupture of radial collateral ligament of the
index finger PIP joint, 343f
stability assessment, 343
superficial and deep intrinsic muscles,
332f–333f
transverse fibers, 309
vascular anatomy and surrounding
structures, 336f
vascular assessment, 345
vertical fibers, 309
Hanging fingertip, 421–422, 421f
Hematoma, 43f, 44, 269
Hernia
abdominal wall, 211
repair, 213
Hertel exophthalmometry, 9
High-lateral-tension (HLT) abdominoplasty,
84–85, 88f
High median nerve palsy
specific operative techniques, 398–399
postoperative finger flexion cascade has
been restored, 403f
transfer of brachioradialis to FPL and
side-to-side FDP tenorrhaphy, 403f
tendon transfers, 398–399
consequence of high median nerve palsy,
402f
High SMAS technique, 37–40, 38f–41f
back cut, 39
fixed SMAS, 38
High ulnar nerve palsy
specific operative techniques, 408–411
tendon transfers, 408–411
combined nerve injuries, 408–409
high median-high ulnar nerve palsy, 410
low median-low ulnar nerve palsy,
409–410
reconstruction after trauma, 410–411
to restore finger extension, 411
to restore finger flexion, 411, 412f
to restore thumb extension, 411, 411f
to restore thumb flexion, 411
Human bite injuries, 420
Hypotension, 69
Hypothenar muscles, 344
I
Implant-based breast reconstruction, 263–277
anatomical and technical considerations,
265
latissimus flap anatomy, 265
operative technique, 265–268, 270–274
expander/implant reconstruction,
265–268
latissimus flap reconstruction, 270–274
operative time for each technique, 270t
outcomes and complications, 269, 275
expander/implant reconstruction, 269
latissimus flap reconstruction, 275
postoperative considerations, 274–275
preoperative considerations, 264–265
Implant migration, 96
Incisions
facelift, 25–31, 29f–33f
Incomplete clefts, cheiloplasty, 146
Infection, 45, 68, 269
Inferior palpebral artery, 6–7
Inferior pedicle technique, 260f
Inferior turbinate flap, unilateral cleft lip, 141
Inframammary fold (IMF), 225, 225f
Inframammary incision, breast augmentation,
225–226
Infraorbital artery, 6
Infraorbital nerve injury, 100
Integra, 168
Intermammary distance (IMD), 225–226
Intermaxillary fixation (IMF), 101
Internal carotid arteries, 6–7
Interosseous artery, 334
Intrasynovial flexor tendons, 363
Intrinsic plus posture, 331
Intrinsic tightness test, 345–351, 346f
Inverted T mastopexy, 239, 248–249
markings, 250f
Island flap, cheek reconstruction, 124
J
Jeanne’s sign, 350, 399
Juvenile virginal hypertrophy, 255
K
Kaplan’s Cardinal Line, 309, 310b, 310f
Kienbock’s disease, 313
L
L flaps, unilateral cleft lip, 141
Lacrimal duct injury, 69
Lacrimal gland, 1
Lag screw technique, 107, 107f
Lateral antebrachial cutaneous (LABC) nerve,
378
Lateral back, wounds, 198
Lateral canthal tendon, 2, 2f
Lateral crural strut grafts, 59, 61f
Lateral retinaculum, 1–3, 2f–3f
Lateral SMASectomy, 36–37
Lateral thigh flap, 178–179, 178f
Lateral ulnar collateral ligament, 353
Lateral wall grafts, 66
Latissimus dorsi, 189–190
anatomy and arc of rotation, 191f
Latissimus flap, 202, 265
blood supply, 266f
contraindications, 265
indications for reconstruction, 265
operative technique, 270–274
autogenous latissimus flap, 272f
delayed reconstructions, 273–274
flap elevation and the underlying
anatomy, 273f
immediate reconstructions, 273
patient position for latissimus flap
elevation, 272f
planned reconstruction with prosthesis
for skin-sparing mastectomy, 274f
skin island design, 271f
skin island placement, 271f
skin paddle design, 271f
total autogenous latissimus
reconstruction, 275f
outcomes and complications, 275
postoperative considerations, 274–275
radiated nonfused wound, 204f
Le Fort fractures, 100
classification, 102f
treatment goals, 101
Le Fort I fractures, 100–101, 102f
management, 101
Le Fort II fractures, 101, 103f
management, 101
Le Fort III fractures, 101, 103f
open reduction, 101
Lesser arc, 313
Levator palpebrae superioris, 4
Lid position abnormalities, 100
Lid-switch flap see Abbé flap
Ligaments, 6
Limb Salvage Index, 166
Liou’s method, 139
Lipomas, spine, 209
Littler operation, 424f
Local flaps, 168–169
lower leg, 169
thigh, 168–169
Low median nerve palsy
specific operative techniques, 396
tendon transfers, 396
Low ulnar nerve palsy tendon transfers,
399–408
Brand EF4T transfer, 405, 406f–407f
correction of clawing of the ring and
small fingers, 407f
Fritschi PF4T transfer, 405–406
modified Stiles-Bunnell transfer, 403–404
Neviaser accessory abductor pollicis longus
and free tendon graft, 408, 410f
Hand (Continued)

433
Index
ring finger flexor digitorum superficialis
transfer, 407
Smith extensor carpi radialis brevis transfer,
407, 409f
specific operative techniques, 402–408
alternative insertions for tendon transfers
to prevent clawing, 405f
Bouvier maneuver, 405f
Omer modification of the Zancolli
capsulodesis, 404f
thumb in ulnar nerve palsy, 404f
tendon transfer to correct ulnar deviation of
small finger, 406
tendon transfers
to correct clawing, 402–403, 406f
to correct ulnar deviation of small finger,
406
to provide adduction of the thumb,
406–407
to provide index finger abduction,
407–408
Smith transfer for thumb adduction
restoration, 408f
Lower Extremity Assessment Project (LEAP),
166
Lower extremity reconstruction, 166–184
anatomical considerations, 167–171
complications and outcomes, 183
operative techniques, 171–183
compound flaps, 181–182
muscle/musculocutaneous flaps,
171–181
supermicrosurgery, 182–183
postoperative considerations, 183
preoperative considerations, 166–167, 167f
algorithm of approach of soft tissue
reconstruction, 167, 168f
technical considerations, 167–171
debridement, 169
local flaps, 168–169
microvascular free tissue transfer,
169
primary limb amputation, 169
selection of recipient vessel, 169–170
skin grafts and substitutes, 167–168
timing of reconstruction, 169
Lower eyelid
partial defects, 117–118
reconstruction, 120f
total defects, 121
Lower lid blepharoplasty, 13
Lower plexus injury, 380
specific operative techniques, 380
Lumbrical muscle tightness test, 346
Lunotriquetral ligament, 313
Lunotriquetrum shuck test, 346–347, 347f
M
Macromastia see Mammary hypertrophy
MACS-lift, 33–35, 35f
extended MACS-lift, 35
Magnetic resonance imaging (MRI), breast,
231
Mallet finger, 417–419
Malposition
alar cartilage, 47
lateral crura, 47
Malunion, 100
Mammary hypertrophy, 254
anatomical considerations, 255
complications and outcomes, 256–258
operative techniques, 255–256
general concepts, 255–256
pathophysiology, 255
postoperative considerations, 256
preoperative considerations, 254–255
specific techniques, 256
Biesenberger reduction, 257f
central mound technique, 260f
inferior pedicle technique, 260f
McKissock vertical bipedicled
dermoglandular flap,
258f–259f
McKissock vertical dermoglandular flap,
260f
Passot technique of nipple transposition,
256f
Schwarzmann reduction with
superomedial dermoglandular
pedicle, 256f
Strombeck horizontal bipedicle technique,
257f
superomedial pedicle with Wise-pattern
skin closure, 261f
Mammography, 223–225
Mandible fracture, 103–107
anatomic considerations, 105–106
Class I, 103, 103f–104f
intraoral degloving, 106
Class II, 103
open reduction and fixation, 106
Class III, 103
soft diet, 106
complications and outcomes, 107
favorable/unfavorable, 105, 106f
operative techniques, 106–107
extraoral approach, 107
intraoral approach, 107
reduction and fixation, 107
preoperative considerations, 104–105
closed reduction of condylar or
subcondylar fractures, 105f
technical considerations, 106
Mangled Extremity Severity Score (MESS),
166
Margin reflex distance (MRD, 9
Martin-Gruber connection, 345
Mastopexy, 233–253
anatomical considerations, 234–239
blood supply to the breast, 239f
Cooper’s ligaments, 239f
ideal breast dimensions, 235f
inframammary fold, 238f
milk lines, 236f
relations of the breast, 238f
stages in breast development, 236f
structure of the breast, 237f
complications and outcomes, 250–251
operative techniques, 239–249
augmentation mastopexy, 247–248
concentric mastopexy without
parenchymal reshaping, 239–240
Goes periareolar technique with mesh
support, 242–245
Grotting sculpted vertical pillar
mastopexy, 245–247
inverted T-scar technique, 248–249
mastopexy post-explantation, 248
periareolar Benelli mastopexy, 240–242
periareolar technique, 236
vertical techniques, 237
post-explantation, 248
preoperative saline implant deflation,
249f
postoperative considerations, 249–250
final closure and cover with Tegaderm
dressing, 250f
vertical mastopexy, 251f–252f
preoperative considerations, 233–234
technical considerations, 234–239
Maxillary growth, 158–159
palatoplasty, 158–159
secondary goal for palate repair, 165
Maxillary sinusitis, 100
McKissock vertical dermoglandular flap,
258f–260f
Medial canthus
defects, 121
tendon, 3
Medial orbital vault, 3f
Medial palpebral artery, 7
Medial pectoral nerve, 379–380
Medial thigh flap, 177–178, 178f
Median nerve, 339f, 341
Median nerve injury, 383–384
specific operative techniques, 384
adjunct tendon transfers to augment
nerve transfers, 384
clinical photos of nerve to brachialis to
anterior interosseous nerve, 386f
radial to median nerve transfers, 385f
schematic of nerve to brachialis to
anterior interosseous nerve transfer,
386f
use of brachialis branch to AIN branch
nerve transfer, 384
use of radial median branch nerve
transfers, 384
specific patient exam findings, 383–384
Median nerve palsy, 334
Mediastinitis, 185
operative techniques, 187–188
bilateral pectoralis advancement flaps,
189f
debridement, 188f
fixation of sternum, 188f
risk factor, 186
Mediskin, 168
Mersilene, 186
Metacarpophalangeal (MCP) joint, 313–318,
360
Micro-hair transplants, 112
Microform cleft lip, 137
surgical correction, 146
Micropore tape, for unilateral cleft lip,
139
Microvascular free tissue transfer, 169
free flaps, 169
Midcarpal instability test, 348
Midface fracture, 100–103
complications and outcomes, 101–103
airway compromise, 101
bleeding, 101
blindness, 101
CSF rhinorrhea, 101
infection, 101
malocclusion, 103
Low ulnar nerve palsy tendon transfers
(Continued)
Mastopexy (Continued)

Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
434
Index
malunion, 103
nasolacrimal duct injury, 103
nonunion, 103
Le Fort II type injury, 100f
postoperative considerations, 101
technical considerations, 101
vertical buttresses of the midfacial skeleton,
101f
Midfacelift, 18–20, 20f
blepharoplasty approach, 31–32
disadvantages, 32
Midline back wounds, preoperative
considerations for, 197
Mini abdominoplasty, 81–83
preoperative markings, 85f
Miniplate complications, 100
Miniplate fixation, 107
Minor-form cleft lip, 136
Moberg’s pick-up test, 351
Modified Kleinert method, 371
Modified Stiles-Bunnell transfer, 403–405
Morley’s test, 356
Motor nerve injury, 44
Moving 2 Point Discrimination (PD) test, 345
Müller’s muscle, 4
Muscle flaps, 200–207
anterolateral thigh perforator, 179, 179f–180f
biceps femoris, 173
cervical region, 197
gastrocnemius, 176, 176f
gracilis, 173–174
flap elevation, 174f
lateral thigh/profunda femoris perforator,
178–179
latissimus dorsi, 189–190
donor site morbidity, 190
turnover flap, 192f
lumbar region, 198
lumbosacral region, 198
soft-tissue coverage, 199f
medial thigh/anteromedial perforator and
gracilis perforator, 177–178
pectoralis major, 188–189
rectus abdominis, 192–193
rectus femoris, 172–173
serratus anterior, 190–192
soleus, 174–176
flap elevation, 175f
sural, 179–180, 181f
tensor fascia lata, 171–172
flap elevation, 172f
thoracic region, 197–198
Muscle sparing thoracotomy, 186, 187f
Musculocutaneous flaps
abdominal flaps, 198
anterolateral thigh perforator, 179, 179f–180f
biceps femoris, 173
fasciocutaneous flap, 177
gastrocnemius, 176, 176f
gracilis, 173–174
flap elevation, 174f
groin/superficial circumflex iliac perforator,
177, 178f
lateral thigh/profunda femoris perforator,
178–179
medial thigh/anteromedial perforator and
gracilis perforator, 177–178
medial thigh flap, 178f
oblique rectus abdominis, 198
primary limb amputation, 169
rectus femoris, 172–173
functional muscle flap, 172, 173f
soleus, 174–176
flap elevation, 175f
sural, 179–180, 181f
tensor fascia lata, 171–172
flap elevation, 172f
thigh, 168–169
thoracodorsal artery perforator (TAP),
180–181, 181f
tumor ablation, 170
vertical rectus abdominis, 198
Mustarde concha-scapha suture, 73
Myocutaneous flap, 202
thigh, 168
N
Nantong regimen, 372
Narrow-neck hernias, abdominal wall, 211
Nasal airway obstruction, 68
Nasal deviation, 50, 50t
Nasal fracture, 96–99, 96f
anatomical considerations, 97
complications and outcomes, 97–99
exposure, 97
palpation of columella, 97f
preoperative considerations, 97
technical considerations, 97
Nasal obstruction, 97
Nasal osteotomies, 52
Nasal reconstruction, 112–117
reconstruction of nasal tip and dorsum,
119f
Nasal spine-caudal septum, 64–65
Nasal tip, 57
cephalic trim, 58f
grafting, 59
grafts, 51, 52f
suturing, 52t, 57, 59f
intercrural septal sutures, 57, 60f
interdomal sutures, 57
joined transdomal sutures, 60f
lateral crural mattress sutures, 57, 60f
medial crural sutures, 57
transdomal sutures, 57
Naso-orbital ethmoid (NOE) fractures,
96–97
appearance, 97
diagnosis, 97
special considerations, 99
transnasal reduction, 97
Type I, 97, 98f
Type II, 97, 98f
Type III, 97, 98f
Nasoalveolar molding, for unilateral cleft lip,
139
Nasofrontal duct, 93, 93f
Nausea, 69
Neck tilting test, 355
Negative-pressure wound therapy (NPWT),
213
Nerve transfers, 375–392
absolute contraindications, 375
advantages, 375
anatomical and technical considerations,
377–389
complete/near-complete plexus injury,
380–383
lower plexus injury, 380
median nerve injury, 383–384
radial nerve injury, 387–388
sensory nerve injury, 388–389
ulnar nerve injury, 384–387
upper plexus injury, 377–380
complications and outcomes, 390
donor nerve, 376b
electrodiagnostic studies, 377b
indications, 375, 376t
postoperative considerations, 389–390
preoperative considerations, 377
relative contraindications, 375–392
various options for coaptation, 376f
Neviaser accessory abductor pollicis longus,
408, 410f
Nipple-areola complex (NAC), 223, 225,
225f
Nipple loss, 250–251
Nipple transposition, 256f
Nonmidline back wounds, preoperative
considerations for, 197
Nonunion, 100
Normal ulnar variance, 311
Numbness, 384
O
Oblique pulley, 329
Obstructed nose, concept for analysis, 47
Ocular injuries, 96
Omentum, 193, 194f
anatomy, 194f
arc of rotation, 195f
Omentum flaps
absolute contraindication, 206
lumbosacral region, 198
pedicled omental flap, 206–207, 206f
relative contraindication, 207
spine, 206–207
zone of coverage, 207
Open reduction internal fixation (ORIF), for
mandible fracture, 106
Open rhinoplasty, 46b, 53–63
alar base surgery, 63
alar-columellar relationship, 60–62
alar contour grafts, 59
closure, 63
columellar strut graft, 57
component dorsal hump reduction, 54,
54t
considerations, 46
lateral crural strut grafts, 59
nasal tip, 57
nasal tip grafting, 59
nasal tip suturing, 57
percutaneous lateral nasal osteotomies,
62–63
septal graft harvest, 55–57
septal reconstruction, 55
transcolumellar stair-step incision, 53f
transcolumellar stair-step incision with
infracartilaginous extensions, 53f
Ophthalmic artery, 6
Midface fracture (Continued)
Musculocutaneous flaps (Continued)
Nerve transfers (Continued)

435
Index
Oral-antral fistula, 100
Orbicularis marginalis (OM) flaps, 142
Orbicularis muscle, 4
Orbicularis suspension, 17–18
Orbital apex syndrome, 96
Orbital blow-out fracture, 94, 94f
Orbital emphysema, 94
Orbital fat excision, 11–12, 12f
Orbital fat transposition, 16
Orbital fracture, 94–96
anatomical considerations, 95
blow-out fracture, 94, 94f
complications and outcomes, 95–96
diplopia, 95–96
ectropion and entropion, 96
enophthalmos, 95
implant migration, 96
ocular injuries and blindness, 96
orbital apex syndrome, 96
ptosis of upper lid, 96
retrobulbar hematoma, 96
superior orbital fissure syndrome,
96
forced duction test, 95f
preoperative considerations, 95
technical considerations, 95
endoscopic approach, 96f
Orbital septum, 4
plication, 16–17, 16f
Orbits, 1, 2f, 95
Osteomyelitis, 170
debridement, 170
infection control, 170
muscle flap, 170
Osteomyocutaneous flap, 192
Osteoradionecrosis, chest wall, 187
Osteotomy, 66
percutaneous lateral nasal, 62–63
Otoplasty, 71–78
anatomical considerations, 72–73
blood supply, 72
components of the prominent ear,
72f
nerve supply, 72
structures of the ear, 72f
complications and outcomes, 77–78
cartilage irregularities, 77
hematoma, 77
infection, 77
over-correction, 77
suture complications, 77
under-correction, 77–78
unnatural contours, 77
unpleasing shape of ear, 78
operative techniques, 73–77
constricted ears, 75–76
correction of aging and elongated ear
lobes, 76
correction of earring-related
complications, 76–77
correction of facelift deformities around
ear, 77
cryptotia, 76
large ears with inadequate helical rim,
74
Stahl’s ears, 76
standard otoplasty for prominent ears of
normal size, 73, 73f
postoperative considerations, 77
preoperative considerations, 71–72
P
Palmar fascia, 309
Panfacial injury, 107–108
complications and outcomes, 108
preoperative considerations, 107–108
technical considerations, 108
Parascapular flaps, cheek reconstruction, 124,
125f
Parastomal hernia, repair, 219
Passot technique, 256f
Pectoralis major, 188–189
anatomy, 190f
Pedicled omental flap, 206–207, 206f
Pedicled TRAM, 280–289, 288f
abdominal closure, 286–289, 288f
abdominal markings, 283f
adequate pedicle length to reach chest wall
defect, 287f
control of muscle and fascial pedicle and
use of counter traction on the fascia,
286f
final markings of fascial and muscle strip,
284f
flap inset/breast shaping, 289
inferomedial dissection to meet inferolateral
dissection, 286f
lateral muscle dissection, 285f
medial dissection, 286f
pre- and postoperative photographs, 283f
tunnel locations, 284f
turning vs flipping of the pedicle, 287f
width and length of fascial and muscle
strip, 287f
Percutaneous lateral nasal osteotomies, 62–63,
63f
Perforator flaps, 177, 207
primary limb amputation, 169
surgery, 303b
thigh, 168–169
thoracodorsal artery, 169
tumor ablation, 170
Periareolar incision, breast augmentation,
225–227
Periareolar mastopexy, 236
design guides, 240f
Perichondrium, 291
Perineurium, 334
Periorbita, 1
Peripheral nerves, 334–341
median nerve, 339f, 341
proximal radial nerve, 337f
radial nerve, 334–341
radial nerve in the forearm, 338f
ulnar nerve, 340f, 341
Peroneal nerve injuries, 167
Pfannenstiel incision, 81
Phalen’s test, 350
Photographic documentation
postoperative considerations in facelift,
44
preoperative considerations in facelift, 24
Pierre Robin sequence, 157
Pinch test, 81
Pisiform, 313
Pisiform gliding test, 347, 349f
Pitres-Testut sign, 344, 351
Pneumocephalus, 94
Poland’s syndrome, 188, 189f
Pollock’s sign, 408
Polypropylene, 186
Positional deformities, 108
Positive dynamic tenodesis, 348
Post-rhinoplasty red nose, 69
Posterior interosseous nerve (PIN), 388
Posterolateral rotatory instability (PLRI),
353
Predictive Salvage Index, 166
Pregnancy, abdominal wall deformity in,
79
Presurgical infant orthopedics (PSIO),
160
Pretarsal muscle, 4
Pretragal incision e25, 25
Primary limb amputation, 169
Primary rhinoplasty
nasal tip grafts, 51
patients characteristics, 48–49
Primary suture technique, 214
Procerus muscles, 3
Profunda femoris perforator, 178–179
Prolene mesh, 289, 289f
Prolonged edema, 68
Pronator teres (PT), 395
Proximal annular pulley, 329
Proximal forearm injury, 384
Proximal interphalangeal joint (PIP), 313
Pseudomeningocele, repair of, 209
Pseudoptosis, 9, 233
Ptosis, 9
upper lid, 96
Pulvertaft weave, 394, 425
R
Radial collateral ligament, 353
Radial forearm flap, cheek reconstruction,
124
Radial nerve, 334–341, 338f
proximal, 337f
Radial nerve injury, 387–388
specific operative techniques, 388
adjunct tendon transfers to augment
nerve transfers, 388
median to radial nerve transfers, 389f
use of median to radial branch nerve
transfers, 388
specific patient exam findings, 387–388
Radial nerve palsy, 334
specific operative techniques, 395–396
Boyes superficialis transfer, 395–396
dissected FCU tendon and distal muscle,
395f
dorsal incision exposes the wrist and
finger extensors, 395f
extending the short tendon of insertion of
the PT, 396f
FCU brought around the ulnar border of
the forearm, 397f
flexor carpi radialis transfer, 395
palmaris longus, 398f
standard flexor carpi ulnaris transfer,
395
transfer of FCR to the combined tendons
of EDC, 398f
transfer of the long and ring finger
superficialis tendons, 399f
tendon transfers, 394–396
hand and wrist of patient with high
radial nerve palsy, 395f
Radiation damage, 187
Rebleeding, 68

Page numbers followed by “f” indicate figures, “t” indicate tables, and “b” indicate boxes.
436
Index
Reconstructive surgery
abdominal wall, 211–221
complications and outcomes, 220–221
operative techniques, 214–219
postoperative considerations, 220
preoperative considerations, 211–213
technical considerations, 213
back, 196–210
operative techniques, 199–209
postoperative considerations, 210
preoperative considerations, 197
technical considerations, 197–198
chest, 185–195
complications and outcomes, 194–195
operative techniques, 187–193
postoperative considerations, 193–194
preoperative considerations, 186–187
lower extremity, 166–184
anatomical considerations, 167–171
complications and outcomes, 183
operative techniques, 171–183
postoperative considerations, 183
preoperative considerations, 166–167
technical considerations, 167–171
Rectus abdominis, 192–193, 212f, 280
anatomy and arc of rotation, 193f
Rectus abdominis myocutaneous flap, cheek
reconstruction, 124
Rectus diastases, 211
Rectus femoris, 172–173
sensory innervation, 172
skin island, 173
tendon, 173
Red nose, post-rhinoplasty, 69
Reduction mammaplasty, 254–262
anatomical considerations, 255
complications and outcomes, 256–258
operative techniques, 255–256
general concepts, 255–256
postoperative considerations, 256
preoperative considerations, 254–255
specific techniques, 256
Biesenberger reduction, 257f
central mound technique, 260f
inferior pedicle technique, 260f
McKissock vertical bipedicled
dermoglandular flap, 258f–259f
McKissock vertical dermoglandular flap,
260f
Passot technique of nipple transposition,
256f
Schwarzmann reduction with
superomedial dermoglandular
pedicle, 256f
Strombeck horizontal bipedicle technique,
257f
superomedial pedicle with Wise-pattern
skin closure, 261f
Retaining ligaments, 7f
Retinacular system, 329–331
common configuration of the vincula,
331f
flexor tendon zones, 331f
orientation of flexor tendon sheaths, flexor
tendons and pulleys, 330f
Retrobulbar hematoma, 96
Reverse abdominoplasty, 85–86, 89f
Rhinitis, 69
Rhinoplasty, 46–70
anatomic variants, predispose to
unfavorable results, 47
low dorsum, 47
low radix, 47
narrow middle vault, 47
closed rhinoplasty, 46b
complications and outcomes, 68–69, 68t
nasal anatomy, 49–52
dorsum and tip, 50–52, 51f
lower cartilaginous vaults, 49–50
middle cartilaginous vaults, 49–50
nasal valves, 50f
structural layers, 49f
upper cartilaginous vaults, 49
open rhinoplasty, 46b
operative techniques, 53–67
closed rhinoplasty, 63–67
open rhinoplasty, 53–63
postoperative considerations, 67–68
preoperative considerations, 47–49
external nasal analysis, 48t
internal nasal exam, 48t
nasal obstruction, 47
past medical history, 47
patients characteristics, 48–49
prior nasal trauma, 47
SIMON acronym, 48
SYLVIA acronym, 48
secondary procedure
patients characteristics, 48–49
upper cartilaginous vaults, 49
dorsum and tip, 50–52
lower cartilaginous vaults, 49–50
middle cartilaginous vaults, 49–50
Rib plating, 195
Ribs, osteoradionecrosis, 187
Ring finger flexor digitorum superficialis
transfer, 407
Roos extended arm stress test, 356
Rotation flap, cheek reconstruction, 121, 122f,
126f–127f
S
Sagittal band injuries, 420
Sagittal band reconstruction techniques, 424f
Scaphoid, 313
Scaphoid shift test, 346
Scapholunate ligament, 313
Scapular flaps, cheek reconstruction, 124, 125f
Scars, 44
mastopexy, 251
Schirmer test, 9
Schwarzmann reduction, 256f
Scratch collapse test, 377
Semmes-Weinstein test, 345, 345t
Senechia, 97
Sensory nerve injury, 44, 388–389
restoration of key sensory functions, 388
specific operative techniques, 388–389
brachial plexus injury, 388
fascicle to the third webspace
identification, 390f
lateral antebrachial cutaneous nerve to
radial nerve transfers, 388–389
median to ulnar branch nerve transfers,
388
radial to axillary nerve transfers, 389
sensory nerve transfers to restore C5/C6
deficit, 392f
sensory nerve transfers to restore ulnar
nerve deficit, 391f
triad of transfers to restore sensation in
median nerve deficit, 390f
ulnar nerve in the distal forearm, 391f
ulnar to median branch nerve transfers,
388
Septal cartilage, 51
Septal graft harvest, 55–57
costal cartilage, 57, 58f
ear cartilage, 56, 57f
septal L-strut, 56f
submucoperichondrial dissection, 55f
submucoperichondrial flaps, 56f
Septal hematoma, 68
Septal perforations, 69
Septal reconstruction, 55
Septal tilt, 50
Septoplasty, 65–66
Seroma, 275
Serratus anterior, 190–192
anatomy and arc of rotation, 192f
Short arc motion, 425
Short scar facelift, 25
Simple skin blepharoplasty, 9–11, 10f–11f
Skin
aging, 23
viscoelastic properties, 111t
Skin flap
facelift incision, 30
MACS-lift, 33–35
Skin grafts, 167–168
tumor ablation, 170
Skin loss, 45
Skin necrosis, 269
Skin pinch, 15
Skin reducing mastectomy, 263
Skin substitutes, 167–168
dermal replacements, 168
SMAS plication, 32–33, 33f–34f
Smith extensor carpi radialis brevis transfer,
407, 409f
Soft tissue
deformities, 108
expansion, 171
Soft-tissue edema, 69
Soleus, 174–176
flap elevation, 175f
Soleus muscle flap, 169
SOOF see suborbicularis oculi fat
Spaghetti wrist, 367, 409–410
Speech
after cleft palate repair, 165
in cleft palate, 158, 159f
Spine
lipomas, 209
vascularized bone reconstruction, 209
Spiral oblique retinacular ligament,
423f
Split-thickness grafts, 167
Spreader graft tunnels, 65–66
Spreader grafts, 66, 67f
Stack splint, 418f
Stahl’s ears, otoplasty, 76, 76f
Mr Spock ears, 76
Sensory nerve injury (Continued)

437
Index
Standard abdominoplasty, 83–84, 87f
Standard flexor carpi ulnaris transfer, 395
Standard otoplasty
prominent ears of normal size, 73, 73f–75f
lobule repositioning, 74f
placement of Furnas concho-mastoid
sutures, 74f
Sternal wound infection, 185
operative techniques, 187–188
bilateral pectoralis advancement flaps,
189f
debridement, 188f
fixation of sternum, 188f
Strombeck horizontal bipedicle technique,
257f
Subatmospheric pressure wound therapy,
187
Subcondylar fractures, mandible
bilateral, 105
closed reduction, 104
open treatment absolute indication, 104
open treatment indication, 105f
open treatment relative indication, 104–105
unilateral, 105
Subcutaneous facelift, 24–25
Subcutaneous tunnel, 280
Submental artery flap, cheek reconstruction,
124, 124f
Submucous cleft palate, 156–157, 157f
Calnan’s triad, 156
corrective surgical technique, 157
Furlow double opposing Z-plasty, 157
Suborbicularis oculi fat, 42–43
Subperichondrial fibrosis, 97–99
Subperiosteal mid-facelift, 40–43, 41f–42f
Superficial circumflex iliac perforator, 177,
178f
Superficial palmar arch, 334
Superficial sensory branch, 384
Superior gluteal artery flap, 202–206
skin paddle, 202–203, 205f
Superior inferior epigastric artery (SIEA) flap,
280
Superior orbital fissure syndrome, 96
Superior palpebral artery, 6–7
Supermicrosurgery, 182–183
Superomedial pedicle, 261f
Supratarsal muscle see Müller’s muscle
Supratrochlear artery, 7
Sural flap, 179–180, 181f
Swallowing, in cleft palate, 158
Swan-neck deformity, 422
pathophysiology, 422f
Switch flaps, lip reconstruction, 125
Synovial sheath, 331, 361
T
T flaps, unilateral cleft lip, 141
Tachycardia, 69
Tarsal strap, 2
Temporal region, 3
Temporal wasting, 108
Tendon grafting, 359
vs tendon transfers, 424–425
Tendon transfers, 376
basic principles, 394t
operative techniques for specific nerve
injuries, 394–396
low median nerve palsy, 396
radial nerve palsy, 394–396
postoperative considerations, 411–412
complications and outcomes, 411–412
opposition tendon transfers for median
nerve palsy, 412t
preoperative considerations, 396–411
Bunnell ring finger flexor digitorum
superficialis transfer, 397
Camitz palmaris longus transfer, 397
EIP transfer to restore opposition, 399f
high median nerve palsy, 398–399
high ulnar nerve palsy, 408–411
low ulnar nerve palsy, 399–408
other opposition tendon transfers,
397–398
palmar incision and direction of the EIP
transfer across the palm, 400f
postoperative opposition restored by EIP
transfer, 400f
upper extremity, 393–413
anatomical and technical considerations,
394
preoperative considerations, 393
wrist tenodesis effect, 394f
vs tendon grafting, 424–425
Tenodesis, 387
Tenolysis, 373, 425
Tensor fascia lata, 171–172
grafting, 218, 218f
Tethered cord surgery, 209
Thenar muscles, 344
Thoracic outlet syndrome (TOS)
important anatomy, 354–355
neurovascular bundle can be potentially
entrapped in costoclavicular space,
356f
physical examination, 353–356
provocative maneuvers, 355–356
three spaces that potentially entrap
neurovascular bundle in patients with
TOS, 355f
Thoracodorsal artery perforator (TAP),
180–181, 181f
Thoracodorsal nerve, 380
Thoracodorsal vessels, 290
Thumb, 318–319
flexor tendon pulley system, 329f
osteoarticular column, 319f
Tinel’s sign, 350, 377
Tip grafting, 66–67
Tip projection, 50–52
Tissue expansion, 207–208, 218–219, 219f
indication, 208f
Toxic shock syndrome, 69
Tragal edge incision e25, 25
TRAM, pedicled vs free, 279
Transaxillary incision
breast augmentation, 225, 227–228
Transconjunctival blepharoplasty, 13–15,
14f–16f
Transcutaneous blepharoplasty, 15–16
Transposition flaps, 123
Transumbilical incision
breast augmentation, 225, 228
Transverse carpal ligament, 329–331
Trapezius muscle flap, 202
skin paddle, 202, 204f
Trapezius pedicled flaps, 197
Triangular fibrocartilage complex (TFCC), 313,
347, 415–416
Triangular fossa-scapha suture, 73
Trigeminal nerve, 7, 7f
Triquetrolunate ballottement test, 346–347,
347f
Triquetrum, 313
Trochlea, 1
Tumor ablation, 170
cosmetic appearance, 170, 171f
Turbinectomy, 66
Turbinoplasty, inferior, 50
Two-flap palatoplasty, 161–162, 163f
Two Point discrimination (PD) test, 345
Two-stage palate repair, 163–164
U
Ulnar artery, 334
Ulnar negative variance, 313
Ulnar nerve, 340f, 341
Ulnar nerve injury, 384–387
specific operative techniques, 385–387
adjunct tendon transfers to augment
nerve transfers, 387
anterior interosseous nerve to deep motor
branch of ulnar nerve, 387f
clinical photos of anterior interosseous
nerve to deep motor branch of ulnar
nerve, 387f
use of median to ulnar branch nerve
transfers, 385–387
specific patient exam findings, 384
Ulnar nerve palsy, 334
Ulnar positive variance, 313
Ulnocarpal abutment test, 347, 349f
Umbilical transection, abdominoplasty with,
83, 86f–87f
Unilateral cleft lip
alveolar molding, 139
cheiloplasty, 138f, 145–146, 146f
cleft nasal deformity repair, 145
closure, 143–144, 144f–145f
external taping, 139
medial incisions, 139–143
incision along the skin edge from CPHL,
142f
incision line of the C-flap, 141f
incision lines for C-flap and nasal floor,
140f
LLC repositioning, 142f
orbicularis peripheralis muscle closure,
143f
orbicularis peripheralis muscle release,
140f
tip of the C-flap, 141f
traction on free border of lip, 140f
vermillion flap, 144f
nasoalveolar molding, 139
rotation advancement cheiloplasty, 139
Upper extremity
blood supply, 331–334
hand vascular anatomy and surrounding
structures, 336f
upper arm vascular anatomy and
surrounding structures, 335f
essential anatomy, 309–341
bones and joints, 310
retinacular system, 329–331
skin, subcutaneous tissue and fascia,
309–310
the thumb, 318–319
the wrist, 310–318
Tendon transfers (Continued)