Operative Technique in Plastic Surgery – Kevin C.Chung

■ A staged reconstruction, by deferring either genitoplasty or vaginoplasty,
precommits to two operative events and limits the redistribution of healthy
tissues. The second stage may involve previously operated tissues.
■ The operative approach varies based on:
■ The surgical components to be included
■ The level of vaginal confluence in the UG sinus (“high” vs “low”)
■ The degree of virilization
T E C H N I Q U E S
■ Feminizing Genitoplasty: Examination
■ If repair of the UG sinus (urethroplasty and vaginoplasty) will occur:
■ Examination under anesthesia and endoscopy is performed in the dorsal
lithotomy position to define UG sinus anatomy and denote the relative
positions of the urethra and vagina.
■ A Fogarty catheter is inserted into the vagina and clamped. A Foley
catheter is inserted into the bladder and periodically drained.
■ Alternatively, a Councill tip Foley catheter may be introduced into the
vagina over a wire after emptying the bladder. Once the confluence of
urethra and vagina is identified surgically, the catheter is redirected to the
bladder.
■ A sponge may be placed into the rectum to allow for intraoperative
palpation of the anterior rectal wall.
■ If repair of the UG sinus will not occur:
■ Examination under anesthesia is performed.
■ A Foley catheter is inserted into the bladder and periodically drained.
■ Contemporary Nerve Sparing Clitoral Degloving
■ Blunt lysis of adhesions between the glans clitoris and inner prepuce is
performed.
■ A retraction suture is placed through the dorsal midline of the glans (TECH
FIG 1A).
■ The skin is retracted to expose the inner prepuce. A dorsal degloving

incision is made more proximally than a standard circumcising incision to
preserve preputial tissue for glans coverage as the inner layer of the clitoral
hood (TECH FIG 1B).
■ Placement of the ventral degloving incision varies with the degree of
virilization and intended procedure.
■ When the UG sinus meatus is found on the glans clitoris, the ventral
degloving incision is immediately beneath the corona.
■ When the UG sinus meatus is located proximal to the glans clitoris, the
ventral degloving incision begins immediately proximal to the orifice and
extends distally to flank the urethral plate (TECH FIG 1C).
■ The clitoris is sharply degloved to the base, preserving the dartos with the
skin and leaving Buck fascia and the underlying neurovascular bundle
undisturbed (TECH FIG 1D).
■ The suspensory ligament will be encountered dorsally and should be left in
situ proximally to support the proximal clitoral body and the glans after
clitoral reduction.

TECH FIG 1 • A. A traction suture placed through the
dorsum of the glans clitoris facilitates visualization of
the urethral plate. B. The clitoral degloving incision is
more proximal than is typical for circumcision to allow
for creation of the inner layer of a clitoral hood. The
blue line delineates the typical circumcising incision,
and the green line delineates the preferred degloving
incision. C. When the urethra is proximal, the ventral
degloving incision flanks the urethral plate. A
posteriorly based omega-shaped perineal flap is
created on the perineum at the time of the dorsal and
ventral degloving incisions. The labia majora will
ultimately be moved posteriorly to flank the perineal
flap after it has been advanced into the vagina. “P”
denotes a posteriorly based flap and “L” denotes the
labia majora. D. Preservation of the paired dorsal
neurovascular bundles beneath Buck fascia. “I”
represents the inner prepuce, which becomes the
inner layer of the clitoral hood. The dorsal overlaid
lines represent the neurovascular tissue.
■ Elevation of the Urethral Plate and Mobilization of
the Common UG Sinus
■ Terminology: If the orifice of the UG sinus is on the clitoral body, a “urethral
plate” consisting of a mucosal strip and its underlying spongiosum extends
along the ventral clitoral body from the UG sinus orifice to the glans. “UG
sinus” refers to the intact common channel.
■ The urethral plate/common UG sinus is elevated off the ventrum of the
clitoral body, leaving the tunica albuginea intact.
■ The point of distal division varies based on the degree of virilization and
whether reconstruction of the UG sinus is planned.
■ If UG sinus reconstruction is planned, the urethral plate or common UG

sinus is divided along the distal clitoral body and fully mobilized (TECH
FIG 2). If the UG sinus orifice is in the glans, the UG sinus is transected
distally rather than dissected out of the glans.
TECH FIG 2 • The prepuce is fully mobilized away
from the clitoral body. Note that the inner layer of the
clitoral hood is partially covering the glans in this
photograph. The UG sinus is also mobilized. A
catheter is in place, and multiple traction sutures
assist with mobilization.
■ If UG sinus reconstruction is deferred, the urethral plate is elevated and
ultimately partially resected to allow recession of the glans.
■ Clitoral Reduction
■ Historical feminizing genitoplasty procedures included clitorectomy and
clitoral recession procedures, each of which resulted in dysfunction.
Contemporary approaches emphasize both cosmesis and function. The dorsal
neurovascular tissue is preserved in each approach.
■ Conservation of clitoral tissue and its neural innervation is of paramount
importance for the preservation of genital sensitivity.3
■ Two main techniques allow debulking of the hypertrophied corpora
cavernosa with preservation of the glans clitoris on its neurovascular pedicle.
■ In both techniques, Buck fascia is incised ventrally, exposing the tunica
albuginea.

■ In the description coined nerve-sparing ventral clitoroplasty (NSVC),3 the
dorsal neurovascular bundle is elevated off the tunica albuginea along the
length of the clitoral body and left in continuity with the glans (TECH FIG
3A). Use of papaverine minimizes vascular spasm that may compromise the
glans clitoris.
■ The erectile bodies are dismembered from the glans and transected 1.5 to 2
cm from the bifurcation.
■ The tunica albuginea is oversewn to allow for clitoral erection.
■ The glans is reseated with care to avoid kinking of the neurovascular
bundle.
■ Glans support and proximal engorgement are afforded.
■ The alternative nerve-sparing approach, as preferred by the authors, differs
in that the dorsal tunica albuginea is preserved along with the neurovascular
bundle (TECH FIG 3B).
■ The intact tunica albuginea protects the neurovascular tissue without
adding problematic bulk.
■ Parallel incisions are created along the ventrum of the clitoral body and the
erectile tissue.
■ The erectile tissue is bluntly dissected and ligated proximally, preserving
the shell of tunica albuginea dorsally and laterally.
■ The glans is approximated to the corporal stump. The intact dorsal tissue
gently bows into the subcutaneous tissue4 (TECH FIG 3C).
■ Corporal-sparing clitoroplasty has been proposed as a means of preserving
the corporal bodies to allow for potential reversal of feminizing procedures
and phalloplasty in the future.5
■ After the clitoris is degloved, the glans and neurovascular tissue are
elevated off the clitoral body as a unit.
■ The plane between the corpora is sharply dissected, allowing separation of
the hemicorpora.
■ The tunica albuginea of each hemicorpora is oversewn with absorbable
sutures to create independent bodies.
■ The hemicorpora are now rotated inferolaterally into dartos pouches
fashioned within the labia majora.
■ The glans clitoris is rarely reduced in size. Concealment can be
accomplished without glans reduction.
■ If reduction is deemed necessary, wedge resection from the ventrum is

favored. Innervation is denser dorsally.6
TECH FIG 3 • A. Buck fascia and the neurovascular
tissue are mobilized off the clitoral bodies and
preserved. Full-thickness resection of the clitoral
bodies is performed. B. Dissection proceeds ventrally
into the corpora. Spongy erectile tissue is excised and
ligated proximally, but the shell of tunica albuginea
and the neurovascular tissue are both preserved. C.
Sagittal view of the glans clitoris seated on debulked
clitoral bodies. Note that the neurovascular tissue is
preserved and not kinked.

■ Urogenital Sinus Reconstruction and Vaginoplasty
Creation of a Perineal Flap
■ If UG sinus mobilization is planned for urethroplasty and vaginoplasty, a
posteriorly based omega-shaped perineal flap is created on the perineum at
the time of the dorsal and ventral degloving incisions (see TECH FIG 1C).
■ Raising a perineal flap exposes the bulbar portion of the UG sinus and
allows dissection between the UG sinus and rectum.
■ The flap will ultimately be advanced into the vagina to increase the distal
vaginal caliber. Advancing the flap reduces the risk of stenosis.
■ Flap vaginoplasty without partial mobilization of the UG sinus enlarges the
UG sinus, but the urethral meatus remains recessed, or hypospadiac.
■ Overzealous advancement of the perineal flap may result in dehiscence,
ischemia, or an unnatural slope of the perineal body. Additionally, this tissue
will typically be hair-bearing and lacks mucosal properties.
Total and Partial Urogenital Mobilization (TUM and PUM)
(TECH FIG 4A)
■ Mobilization of the common UG sinus brings the genitourinary complex
toward the perineum,7,8 facilitating either flap vaginoplasty or pull-through
vaginoplasty.
■ Multiple stay sutures are placed around the common UG sinus orifice to
facilitate a traumatic retraction. The common UG sinus is dissected as a unit
proximally, including partial dissection under the pubis (TECH FIG 4B).

TECH FIG 4 • Urogenital mobilization, sagittal view. A
posteriorly based perineal flap (P) has been mobilized
to facilitate posterior exposure and for incorporation to
vagina, if needed. A. In total urogenital mobilization
(TUM), the UG sinus is mobilized as a unit both
between the vagina and rectum and anteriorly under
the pubis. The supportive pubourethral ligament (black
arrow) are taken down for this extensive mobilization.
In partial urogenital mobilization (PUM), the anterior
dissection stops short of dividing the pubourethral
ligaments. B. A catheter is in place in the UG sinus
and multiple traction sutures facilitate dissection. C.
The vagina has reached the perineum and is
spatulated posteriorly to allow advancement of a
perineal flap.
■ The posterior perineal attachments are sharply divided, dropping the rectum
away from the bulbar section of the UG sinus. As posterior dissection
continues, the peritoneum is bluntly pushed away from the posterior wall of
the UG sinus.
■ If this degree of anterior and posterior mobilization is not sufficient to access
the confluence, additional dissection occurs anteriorly, dividing the

pubourethral ligament. This step differentiates PUM from TUM.8 TUM bears
the potential risk of disturbing pelvic support and continence mechanisms.
■ The sinus is further mobilized toward the perineum, and the vaginal balloon
catheter is palpated.
■ If the confluence is still high, the patient is placed prone and the vagina is
separated from the common UG sinus.
■ The common UG sinus is opened over the distal vagina near the
confluence, where the vagina is relatively underdeveloped. The posterior
wall incision can be extended proximally and distally until the urethral
meatus is seen. If a Councill tip Foley was placed into the vagina, the
catheter is redirected up the urethra into the bladder.
■ Meticulous sharp dissection creates a plane between the anterior wall of the
vagina and the urethra and bladder base. Multiple traction sutures are
placed on the vagina (TECH FIG 4C).
■ Following adequate vaginal mobilization, the common UG sinus becomes
the urethra with a running closure of absorbable suture over the Foley
catheter.
Use of the Excess Mobilized Common UG Sinus
■ Best use determined by the distance for the vagina to reach the perineum.
TECH FIG 5 • The mobilized UG sinus may be opened
anteriorly (A) so that the excess sinus may be
incorporated into the vagina. Patient A had an ASTRA.
If the sinus is opened posteriorly (B), the excess sinus
creates a mucosa-lined vestibule. Patient B had partial

urogenital mobilization. Note the open sinus (S), the
frondular hymenlike tissue at the vaginal opening (V)
and the posteriorly based perineal flap. The vagina will
be spatulated further posteriorly to reach normal
caliber. The flap will be advanced to complete the
posterior wall of vagina.
■ If the vagina remains high, the urogenital sinus can be used to complete the
vaginal wall.
■ The common UG sinus can be incised anteriorly and the tissue is everted
and advanced to become the anterior vaginal wall as a Passerini-type flap9
(TECH FIG 5A).
■ The excess UG sinus tissue can be used in a variety of ways to augment the
vagina.9,10
■ The patient is then turned supine and the perineal flap is advanced
posteriorly if needed.
■ If the vagina has reached the perineum, the patient is turned supine.
■ The common UG sinus is incised posteriorly, and the redundant sinus
tissue is used to line the vaginal vestibule (TECH FIG 5B).
■ The posterior vaginal wall is spatulated to accept the perineal flap.
■ Labioplasty is completed.
Comparison of Surgical Options for Vaginoplasty Based on
Level of Confluence
Low Vaginal Confluence (TECH FIG 6)
■ If a low vaginal confluence is present, partial urogenital mobilization (PUM)
is completed (see above).
■ The mobilized sinus is opened posteriorly to expose the urethra and vagina.

TECH FIG 6 • Completion of vaginoplasty after PUM.
Note separate urethral (U) and vaginal (V) openings.
The posteriorly based perineal flap (asterisk) allows a
wider vaginal caliber. Silk traction sutures are holding
the excess UG sinus, which will line the vestibule with
a robust mucosa. The labia majora will be advanced
posteriorly to flank the perineal flap.
■ The vagina is incised posteriorly to increase the caliber, and the perineal flap
is advanced into the vagina with interrupted absorbable sutures.
■ Labioplasty is completed.
High Vaginal Confluence
■ If a high vaginal confluence is present, prone positioning will optimize
visualization for a vaginal pull-through procedure.
■ Either a classic pull-through or TUM with pull-through may be used.
■ In the classic pull-through, the UG sinus is not mobilized. It is opened
posteriorly in the midline, extending the incision into the normal-caliber
vagina. The vagina is dissected off the urethra or bladder base and
mobilized toward the perineum.
■ In TUM, the UG sinus has been fully mobilized (see above), and if the
vagina has not reached the perineum, the UG sinus is opened over the
confluence to expose the vaginal lumen and proximal urethra. Keeping the
UG sinus tissue intact allows more flexibility for use of excess tissue.9,10
■ Stay sutures are placed along the incised margin of the vagina to facilitate
retraction.

■ A malleable retractor is placed and elevated toward the rectum to optimize
exposure.
■ The investing structures are dissected off the vagina along the posterior and
lateral walls.
■ Once the posterior wall is exposed, the retractor is placed in the vaginal
lumen to facilitate exposure of the junction of the vagina with the common
UG sinus.
■ The mucosa of the anterior vagina is incised transversely and additional
traction sutures are placed.
■ The anterior plane is dissected sharply; it is very thin distally and care must
be taken to avoid entering the urethra or urinary bladder. Dissection continues
anteriorly and posteriorly until the vagina can reach the perineum with or
without local flaps.
■ Following adequate vaginal mobilization, the common UG sinus is
reconstituted as the urethra via multilayer closure over the Foley catheter.
■ Regional flaps can be mobilized to help the vagina reach the perineum.
■ If TUM was employed, the excess common UG sinus may be incised
anteriorly to allow eversion of the flap and incorporation as the anterior
vaginal wall (Passerini-type flap).
■ The patient is rotated supine and the perineal flap is affixed to the vagina
with interrupted absorbable sutures.
■ One can imagine how the advantages provided by alternating between the
posterior prone approach and the supine anterior view are unrealistic in teens
and adults. Even if the urogenital sinus work can be completed prone,
clitoroplasty and labioplasty should only be attempted supine or in lithotomy.
Anterior Sagittal Transrectal Approach
■ Anterior sagittal transrectal approach (ASTRA) is a newer alternative
approach for pull-through vaginoplasty in the setting of a high confluence.11
■ Aside from the transrectal exposure of the UG sinus, the dissection of the
vagina off the common UG sinus and subsequent urethroplasty is similar to a
TUM.

TECH FIG 7 • Comparison of the approach to the
vagina for urogenital mobilization (perineal; A) vs
ASTRA (transanorectal; B).
■ Exposure of the posterior wall of the vagina is afforded by a full-thickness
sagittal incision of the anterior wall of the anus and rectum; the surgeon’s
view and the access to the vagina are thereby more direct. There is a
tradeoff between this enhanced exposure and the potential morbidity of
opening the rectum. The procedure can be safely completed without
colostomy, but some opine that this additional risk is not justified (TECH
FIG 7).
■ Suitability for the ASTRA approach is determined at the time catheter
placement by transrectal palpation of the vaginal catheter balloon (greater
than 3 cm from the anus).
■ Perioperative preparation includes the following:
■ Preoperative mechanical bowel preparation.
■ Triple antibiotic therapy or equivalent for 72 hours.
■ Diet held until evidence of bowel function.
■ The procedure begins in prone position, and the rectum is opened (TECH
FIG 8A).
■ Clitoroplasty and dissection of the distal UG sinus are deferred.
■ Without otherwise mobilizing the UG sinus first, the vagina is opened
posteriorly (TECH FIG 8B) and dissected off the common UG sinus, similar
to that described for TUM, and the UG sinus is closed as the urethra.

TECH FIG 8 • A. Full-thickness incision of the anterior
anus and rectal wall. Nasal speculum in rectum. B.
UG sinus opened to expose vaginal catheter. Catheter
will be redirected to urethra. C. Skin is being incised in
the midline toward the UG sinus meatus. Note that
there is no midline posteriorly based perineal flap.
■ The perineal skin is then incised to the level of the UG sinus orifice, and the
posterior wall of the UG sinus is dissected (TECH FIG 8C).
■ The procedure otherwise differs from TUM in that the anterior wall of the
UG sinus is only mobilized under the pubis if additional sinus tissue will be
needed to complete the vaginal wall.
■ Otherwise the posterior wall of the sinus is opened, exposing healthy mucosa
to line the vestibule.
■ The rectum is closed and the anterior sphincter complex is reconstituted. The
perineal body is closed in layers and sutured directly to the spatulated
posterior vaginal wall.
■ The patient is rotated prone for clitoroplasty and labioplasty.
■ Because the cutaneous incision extends from anus to common UG sinus
orifice, there is no midline posteriorly based flap.
■ This has not generally been required, but a flap could be raised from each
side if necessary.
■ In either case, closure of the deep perineal tissues and a two-layer skin
closure are recommended.
■ Creation of a Clitoral Hood and Labioplasty
■ The remaining dorsal clitoral skin is incised in the midline to approximately
1.5 cm from the base, creating the Byars flaps that will be fashioned into the

clitoral hood and labia minora (TECH FIG 9A).
■ The intact 1.5 cm of clitoral skin is plicated with interrupted absorbable
dermal sutures to provide contour to the clitoral hood.
■ This outer layer of the clitoral hood is sutured to the inner layer of the hood
reserved at the time of initial clitoral degloving.
■ The paired Byars flaps are tapered and tucked next to the urethral plate,
creating a fin of tissue similar to labia minora. The medial border of each flap
is sutured to the urethral plate or mucosa-lined vestibule with interrupted
absorbable sutures.
TECH FIG 9 • A. Fashioning clitoral hood and labia
minora from clitoral skin. The clitoral skin is incised to
create Byars flaps (black line). The incision stops
about 1.5 cm short of the base to create the outer
hood. Note that the initial clitoral skin incision allowed
sufficient skin to form the inner layer of the hood
(black arrow). B. Byars flaps are draped around the
glans clitoris as the clitoral hood and labia minora.

Dermal sutures provide contour to the outer layer of
the clitoral hood. The labia minora are trimmed (dotted
lines) for labial configuration and sutured to vestibular
tissue. Dog ears of clitoral body skin are trimmed
anteriorly to allow provide a grooved contour between
the labia minora and majora. Two-layer closure of the
inferior apices will minimize the risk of labial
dehiscence. C. Completion of labioplasty after clitoral
reduction and vaginoplasty with a posteriorly based
perineal flap. Full-thickness debulking at the apices of
the labia majora may be undertaken to reduce the
loose skin folds. Rugation will persist to some degree.
The labia majora are advanced posteriorly to flank the
perineal flap, with a two-layer closure at the apices.
■ If UG sinus reconstruction with vaginoplasty has been completed, the labia
majora will also be addressed (TECH FIG 9B,C).
■ If the labia majora are anteriorly positioned, they are mobilized and
advanced posteriorly to flank the perineal flap (if used).
■ Full-thickness debulking at the apex may improve appearance, although
rugations of the androgenized tissue may persist. Care should be taken with
fibrofatty debulking, as this may result in devascularization or asymmetry.
■ A cleft is preserved between the labia minora and the labia majora by
excising a dog-ear of skin anteriorly. Closure is via interrupted absorbable
sutures.
■ A two-layer closure at the apex of each labium will minimize the risk of
dehiscence.
PEARLS AND PITFALLS
Preoperative
decision-
making
■ Multidisciplinary guidance is essential prior to performing
irreversible genital surgery, and operative interventions should only
be undertaken after extensive counseling.

■ The impact of deferring intervention until the age of consent is not
fully understood.
Positioning
■ Coordinate with the anesthesia team to ensure upper body IV
access, avoidance of continuous caudal catheterization in setting of
total lower body preparation, and communication regarding multiple
anticipated position changes.
■ Create a broad sterile field with total lower body preparation and
strategic use of surgical drapes to facilitate genitoplasty and UG
sinus reconstruction in younger children.
■ Adolescents and young adults should be placed in dorsal lithotomy
position. The exposure for high dorsal dissection is much more
limited in this population.
Labioplasty
■ Two-layer closure of the apices of Byars and labia majora flaps will
minimize the risk of labial dehiscence as postoperative edema
ensues.
Inadequate
surgical
preparation
■ Inadequate familiarity with patient anatomy can lead to rectal injury
during posterior dissection of the UG sinus or can lead to
neurovascular injuries of the clitoris and urinary tract.
■ A collaborative mentality is strongly recommended when complex
anatomy may place patients beyond an individual surgeon’s
expertise.
POSTOPERATIVE CARE
■ A Penrose drain is placed in the vagina after vaginoplasty and removed in 24
to 48 hours.
■ An indwelling urethral catheter is left to drainage for several days
postoperatively. Catheters may be left in place for up to 2 weeks depending on
the nature of the UGS, the degree of urethral reconstruction, or other patient
factors.
■ Care should be taken to secure the catheter so it does not compromise the
integrity of the labial flaps.
■ Ointment and bulky fluff compression dressings are applied to the perineum
and left in place for 2 or 3 days. Dressings are removed prior to discharge.
■ Perineal mobility is minimized in the early postoperative period.
■ In infants, a mermaid wrap around the knees is appropriate. Foam or a thick
gauze roll between knees and ankles prevents pressure damage.
■ Older individuals should be instructed to avoid straddling, squatting,
kneeling, or Valsalva to minimize perineal engorgement.

■ Short-duration, plain water tub soaks are begun approximately 3 days
postoperatively, except in ASTRA.
■ Bacitracin ointment is applied to the perineum for 3 days postoperatively, after
which use of bland ointment is recommended.
■ Care is taken to avoid moisture trapping beneath the ointment with
consequent skin maceration or dehiscence.
OUTCOMES
■ Historic outcomes evaluations revealed substantial patient dissatisfaction with
genital appearance and the need for repeated surgical intervention.12,13
■ Creation of an adult-caliber vaginal introitus in infancy is neither feasible nor
desired.
■ Under ideal circumstances, creation of a supple introitus during infant
vaginoplasty will allow for passive or active vaginal dilations at the age of
sexual maturity. There is a reasonable probability of introital revision, and
this should be emphasized in preoperative counseling.
■ Retrospective cohort studies have described impairment in clitoral sensitivity
among patients undergoing feminizing genitoplasty13,14 and demonstrated a
linear correlation between diminished sensation and sexual dysfunction.15
■ As surgical technique has improved, prospective cohort studies reveal more
favorable cosmetic outcomes following feminizing genital surgery5,16,17 (FIG
2).
■ Retrospective evaluation of clitoral sensation and perfusion reveals
improvement in functional outcomes following nerve-sparing clitoroplasty18;
however, prospective assessments of clitoral sensation and overall sexual
function are lacking.
■ Further prospective studies are also needed to assess surgical and psychosocial
outcomes among this population.
■ If surgery is done during infancy, there is a significant lag time between
surgery and sexual maturity. Educated modifications in technique are therefore
challenging.

FIG 2 • Immediate postoperative result after a pull-
through vaginoplasty via ASTRA in a child with
completely fused labia majora and a high UG sinus.
Creation of clitoral hood includes contouring dermal
plication sutures. The labia majora did not require
posterior mobilization in this child. Due to the ASTRA
approach, there are perineal body sutures rather than a
posteriorly based perineal flap.
COMPLICATIONS
■ Clitoral ischemia with loss of tissue
■ Dehiscence
■ Vaginal stenosis
■ Diminished clitoral sensation, impaired sexual function
■ Unsatisfactory cosmetic outcome
■ Patient regret
REFERENCES
1. O’Connell HE, DeLancey JOL. Clitoral anatomy in nulliparous, healthy,
premenopausal volunteers using unenhanced magnetic resonance imaging. J
Urol. 2005;173:2060-2063.
2. Puppo V. Anatomy and physiology of the clitoris, vestibular bulbs, and labia
minora with a review of the female orgasm and the prevention of female sexual
dysfunction. Clin Anat. 2013;26:134-152.
3. Poppas DP, Hochsztein AA, Baergen RN, et al. Nerve sparing ventral

clitoroplasty preserves dorsal nerves in congenital adrenal hyperplasia. J Urol.
2007;178:1802-1806.
4. Leslie JA, Cain MP, Rink RC. Feminizing genital reconstruction in congenital
adrenal hyperplasia. Indian J Urol. 2009;25:17-26.
5. Pippi Salle JL, Braga LP, Macedo N, et al. Corporeal sparing dismembered
clitoroplasty: an alternative technique for feminizing genitoplasty. J Urol.
2007;178:1796-1800.
6. Baskin LS, Erol A, Li YW, et al. Anatomical studies of the human clitoris. J
Urol. 1999;162:1015-1020.
7. Pena A. Total urogenital mobilization—an easier way to repair cloacas. J
Pediatr Surg. 1997;32:267-268.
8. Rink RC, Metcalfe PD, Kaefer M, et al. Partial urogenital mobilization: a
limited proximal dissection. J Pediatr Urol. 2006;2:351-356.
9. Rink RC, Metcalfe PD, Cain MP, et al. Use of the mobilized sinus with total
urogenital mobilization. J Urol. 2006;176:2205-2211.
10. Gosalbez R, Castellan M, Ibrahim E, et al. New concepts in feminizing
genitoplasty—is the Fortunoff flap obsolete? J Urol. 2005;174:2350-2353.
11. Salle JLP, Lorenzo AJ, Jesus LE, et al. Surgical treatment of high urogenital
sinuses using the anterior sagittal transrectal approach: a useful strategy to
optimize exposure and outcomes. J Urol. 2012;187:1024-1031.
12. Creighton SM, Minto CL, Steele SJ. Objective cosmetic and anatomical
outcomes at adolescence of feminising surgery for ambiguous genitalia done in
childhood. Lancet. 2001;358:124-125.
13. Minto CL, Liao L-M, Woodhouse CRJ, et al. The effect of clitoral surgery on
sexual outcome in individuals who have intersex conditions with ambiguous
genitalia: a cross-sectional study. Lancet. 2003;361:1252-1257.
14. Lesma A, Bocciardi A, Corti S, et al. Sexual function in adult life following
Passerini-Glazel feminizing genitoplasty in patients with congenital adrenal
hyperplasia. J Urol. 2014;191:206-211.
15. Crouch NS, Liao LM, Woodhouse CRJ, et al. Sexual function and genital
sensitivity following feminizing genitoplasty for congenital adrenal
hyperplasia. J Urol. 2008;179:634-638.
16. Braga LHP, Lorenzo AJ, Tatsuo ES, et al. Prospective evaluation of
feminizing genitoplasty using partial urogenital sinus mobilization for
congenital adrenal hyperplasia. J Urol. 2006;176:2199-2204.
17. Nihoul-Fékété C, Thibaud E, Lortat-Jacob S, et al. Long-term surgical results
and patient satisfaction with male pseudohermaphroditism or true

hermaphroditism: a cohort of 63 patients. J Urol. 2006;175:1878-1884.
18. Yang J, Felsen D, Poppas DP. Nerve sparing ventral clitoroplasty: analysis of
clitoral sensitivity and viability. J Urol. 2007;178:
1598-1601.

71
CHAPTER
Section XIX: Emergency
Department Lacerations
Facial Laceration
Emergency Room Closure
Techniques
Christina Pasick and Peter J. Taub
DEFINITION
■ Facial soft tissue injuries are commonly encountered in the emergency room.
Common etiologies are motor vehicle collisions, animal bites, sports and job-
related injuries, and interpersonal violence.
■ These injuries are often complex and may have significant impact on the
patient’s facial form and function.
■ Plastic surgeons are often consulted by the emergency room physician or
requested by the patients themselves for facial injuries ranging from simple
lacerations to complex craniofacial trauma.
ANATOMY
■ Facial aesthetic subunits should be considered when planning reconstruction
so that incisions lie within or along the border of the involved subunit (FIG 1).
■ Lacerations deep to the superficial musculoaponeurotic system (SMAS) risk
injury to the facial nerve branches. See Table 1 for physical exam findings in
injured facial nerve branches.
■ Blunt injuries to the face may cause a temporary neuropraxia to the nerve that
does not require immediate operative measures but instead should be
observed for 3 weeks.

FIG 1 • The facial aesthetic subunits. Scars are more
inconspicuous when planned within or along these
lines.
■ Extensive branching and cross-innervation of the branches of the facial nerve
is present medial to the lateral canthus (FIG 2). As a general rule, lacerations
of the nerve medial to the lateral canthus do not require repair. However,
lacerations to the marginal mandibular nerve medial to the lateral canthus of
the eye should be repaired, as there is not adequate crossover for functional
recovery of the depressor muscles following medial injury to the marginal
mandibular nerve. The temporal branch is another facial nerve branch with
minimal crossover, but this nerve will most likely have innervated its target
muscles (frontalis) should a laceration occur medial to the lateral canthus.
■ The sensory nerves of the face can be utilized as guidelines for local
anesthesia nerve blocks. Suspicion for nerve laceration should be elevated

when lacerations are present in these regions.
■ Knowledge of the location of the major arteries of the face can raise suspicion
for lacerated vessels in deep wounds in these locations (FIG 3).
■ The parotid duct or Stensen duct lies in the line drawn between the tragus and
the middle of the upper lip. Stensen duct empties into the mouth at the buccal
mucosa overlying the second maxillary molar.
PATHOGENESIS
■ The mechanism of injury (ie, motor vehicle collision) can help to gauge the
force involved in creating the injury and help determine if additional
radiographic studies are necessary.
■ Suspect a larger area of tissue injury when dealing with a crush wound as
opposed to a simple laceration.
■ Human bites should all be treated as contaminated wounds, and the need for
careful irrigation and prophylactic antibiotics apply.
Table 1 The Physical Exam Findings Behind Injuries of the Facial Nerve
Branches
Facial Nerve Branch Injured
Weakness Observed on Physical Exam
Temporal branch
Inability to elevate eyebrow
Zygomatic branch
Inability to close eye
Buccal branch
Inability to elevate upper lip
Marginal mandibular branch
Inability to evert lower lip
Cervical branch
Inability to activate platysma

FIG 2 • The branches of the facial nerve: temporal,
zygomatic, buccal, marginal mandibular, cervical.
Extensive branching and cross-innervation is present
medial to the lateral canthus (marked line). As a rule,
lacerations of the nerve medial to the lateral canthus do
not require repair.
■ Organisms often found in human mouths include Eikenella, Staphylococcus,
Streptococcus viridans, and Bacteriodes.1
■ If the initial injury is not treated and the patient presents with a developed
infection, inpatient therapy with IV antibiotics is often warranted, with a low
threshold for OR debridement and washout.
■ Dog bites are the most common type of animal bite in the emergency room
and are often contaminated with various bacteria, including Pasteurella
multocida, Bacteroides, S viridans, and Capnocytophaga.1

■ Infection rates are not as high as seen in cat bites due to lower bacterial levels
and the open avulsion-type injury seen in dog attacks rather than the deep
puncture injury in cat bites that can trap bacteria. These open wounds
facilitate irrigation.
■ Crush component of dog bites often results in substance loss and requires
debridement and reconstruction of avulsed tissue.2
■ High incidence in the pediatric population.3
■ Cat bites should always be considered heavily contaminated wounds, as the
nature of the long and narrow cat teeth lead to deeply penetrating wounds with
a very narrow orifice, resulting in seeding of bacteria into deep structures.
■ Organisms often found include Pasteurella multocida and Bartonella
henselae.
FIG 3 • The major arteries of the face. These arteries
arise from the external carotid system (in red) and the

internal carotid system (in green). Path of the parotid
duct or Stensen duct. Lacerations in this line should be
evaluated for laceration of the parotid duct system.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Trauma patients require a primary trauma survey and secondary trauma
evaluation immediately.
■ The patient should be assessed for more serious intracranial, ophthalmologic,
and cervical spine injuries.
■ Suspect skull base fracture with the following signs: raccoon eyes
(periorbital ecchymosis), battle sign (postauricular ecchymosis), otorrhea, or
hemotympanum.
■ Take a complete history.
■ The etiology and timing of the wound
■ Other medical problems that may put the patient at risk for wound healing
difficulties
■ Medications that may make the patient a bleeding risk
■ Smoking status
■ Tetanus vaccination history
■ Physical examination
■ Remove all clothing, jewelry, dried blood, and foreign material that may
obscure the examination.
■ Use a systematic approach, inspecting for lacerations, avulsions, “road rash,”
and areas of edema or ecchymosis.
■ Palpate wounds for bony step-offs to clue into underlying fracture.
• To rule out Le Fort fracture, depress the maxilla bilaterally with your
thumbs to feel for mobility. If mobile, proceed to grasp the maxillary teeth
with one hand while holding the nasal spine in place with the other hand.
Movement of the dental alveolus points toward a Le Fort I fracture, whereas
movement of the nasal bridge points toward a Le Fort II or III fracture.
■ Check for involvement of deeper structures: muscle, nerve, artery, bone,
joint.
• Especially in bite wounds with fangs, the deeper structures may be injured.
• Irrigation of the base of the wound provides more thorough visualization.
■ Sensory test for nerve involvement:

• V1 ophthalmic branch: provides sensation to the forehead
• V2 maxillary branch: provides sensation to the cheek
• V3 mandibular branch: provides sensation to the lower third of the face/chin
■ Motor test for facial nerve involvement:
• Test for weakness in the facial nerve (cranial nerve VII) quickly and
effectively by asking the patient to raise the eyebrows, close eyes, smile,
puff out cheeks, and evert lower lips.
■ Assess for crepitus (subcutaneous emphysema) in bite wounds that would
indicate an infection forming along the deeper fascial planes.
■ Examine all wounds for foreign body contaminants.
IMAGING
■ If facial fractures are suspected, a CT scan should be performed.
■ Plain x-ray or CT scan is helpful in determining the presence and location of
foreign bodies within the wound.
■ Ultrasound may prove as a quick and reliable tool for locating foreign body
without the side effects of radiation.
NONOPERATIVE MANAGEMENT
■ Nonoperative, or nonsurgical, management may occur in cases with very
superficial and noncontaminated lesions, where washout, debridement, and
closure are not necessary.
■ Small wounds may have a preferred aesthetic outcome when allowed to close
secondarily.
SURGICAL MANAGEMENT
■ It is important to emphasize to the patient that any full-thickness injury to the
skin will result in a scar.
■ The type of scar that forms can be dependent on multiple factors and is
largely based on genetic predisposition.
■ To maximize the chance of forming a fine-lined scar:
■ Most wounds require irrigation and debridement and closure in layers.
■ An early and tension-free closure of lacerations is a main priority.
■ Aim to close the wound in the direction of Langer lines, the relaxed skin
tension lines of the face (FIG 4).
• Find Langer lines in younger patients by asking them to animate their faces;
the resultant skin folds simulate Langer lines.

■ Delaying closure beyond 8 hours may increase the risk of infection of the
wound bed and compromise aesthetic results, as swelling obscures anatomical
landmarks.4
Preoperative Planning
■ Use emergency room anesthesia: create a comfortable environment for the
surgeon and the patient.
FIG 4 • Relaxed skin tension lines are ideal vectors for
final scar placement.
■ Topical anesthetic
■ Eutectic mixture of local anesthetics (EMLA) cream, composed of a mixture
of 2.5% prilocaine and 2.5% lidocaine, is widely present in the emergency
room—its effect is directly dependent on the time the cream has been on the
skin.

• Place cream on skin and cover with a Tegaderm (3M, St. Paul, MN) or other
occlusive dressing for at least 45 minutes.
• This often will need to be supplemented with local injected anesthesia but is
a useful start for pediatric cases in which there is high anxiety associated
with the local anesthesia.
■ Local injected anesthetics
■ Lidocaine: most commonly used form of anesthesia in the ED. Maximum
safe dose is 4.5 mg/kg. Effect usually lasts for 2 hours.
■ Epinephrine 1:100 000 may be added to the lidocaine solution to prolong the
duration of its effect (to 4 hours) and reduce the amount of local anesthesia
needed by reducing its diffusion away from the wound.
• When epinephrine is added to lidocaine, the maximum safe dose is raised to
7 mg/kg.
• Epinephrine takes about 7 to 15 minutes to take effect.
• It was previously believed that epinephrine should not be used around end
arteries such as the nose and stellate lacerations but is now accepted as safe
practice.
■ Bicarbonate may be added to local anesthesia in the awake patient to reduce
the burning pain on injection by raising the pH of the acidic lidocaine
solution.
• Bicarbonate also increases the effectiveness of the local anesthetic by
favoring the nonionized form of the molecule, which passes through the cell
membrane more easily.
• Add 1 cc of 1 mEq/mL bicarbonate for every 9 cc of local anesthetic.
■ Bupivacaine: a longer-acting anesthetic, which may be added to the solution
per the surgeon’s discretion
• Max safe dose: 2.5 mg/kg. Effect usually lasts 4 hours. When epinephrine is
added, max safe dose is raised to 3 mg/kg, and the effect is prolonged to 8
hours.
■ Improve comfort on injection: warm the local anesthetic solution, use a
higher-gauge (smaller caliber) needle, inject through wound instead of
through skin
■ Nerve blocks
■ For large lacerations in a single nerve distribution, nerve blocks can be
effective and reduce the tissue distortion, which results when a large amount
of local anesthetic is given as a field block.

■ Conscious sedation
■ Beneficial for pediatric patients who are uncooperative, making repair of
facial lacerations difficult.
■ Helps to make the repair safer and reduces emotional trauma to the patient.5
■ This requires continuous monitoring of vital signs, requiring a nurse to be
present throughout.
■ For pediatric cases, a combination of ketamine and versed are commonly
used.
■ Ketamine: analgesic and amnestic agent
• Pediatric dosing: 6 to 10 mg/kg PO once, 30 minutes prior to procedure; or
0.5 to 2 mg/kg IV once at start of procedure
■ Versed: sedative-hypnotic and amnestic agent
• Pediatric dosing: 0.25 to 0.5 mg/kg PO or IM 15 minutes prior to procedure;
or 0.05 to 0.1 mg/kg IV 3 minutes prior to procedure
■ Irrigation
■ Thoroughly irrigate all wounds to remove blood, foreign body debris, and
bacteria.
■ Use of a pressured irrigation system is helpful if available in the ED.
■ May use 1-L bottle of normal saline with holes punched in the lid with an 18-
gauge needle as a make-shift pressurized system.
■ Debridement
■ Trimming of jagged skin edges with a 15-blade for optimal cosmetic closure.
■ Debridement of devitalized skin and tissue will reduce contamination and
facilitate healing.
■ Be mindful of the location of your debridement, as heavy debridement in the
critical areas in the face (eyelid, nose) may lead to significant disfigurement.
■ Hemostasis
■ Use pressure, suture ligature such as Vicryl 4-0 (Ethicon, Somerville, NJ),
Surgicel (Ethicon, Somerville, NJ), silver nitrate, thrombin, or fibrin.
Electrocautery is now often available in the ED.
■ Because of extensive collateralization of vessels in the head and neck, even
major vessels such as the facial artery may be ligated if bleeding is
uncontrolled.
■ If bleeding is significant, you may extend the laceration to achieve
visualization of the bleeding vessel.
■ Do not blindly clamp tissues as this risks injury to nearby nerves and other

structures.
■ If the bleeding vessel cannot be clearly visualized, the wound should be
packed, pressure applied, and the patient should be brought to the operating
room promptly.
Positioning
■ Prior to beginning any procedure in the emergency room, ensure you have a
well-lit and adequate space.
■ Head of bed should be elevated on a pillow for head and neck lacerations.
■ Pediatric cases may require “papoosing” of the child by nursing staff and may
require that a family member present throughout the procedure.
Approach
■ Wounds may be closed with sutures, staples, skin tape, or wound adhesive.
■ Suture choice:
■ Absorbable for all deeper layers and for mucosa and pediatric epidermis
■ Nonabsorbable for suture ligation of large vessels and for epidermal
approximation
■ Nonbraided (monofilament) material best for contaminated wounds
Table 2 Appropriate Suture Choice for Specific Facial Laceration Locations
Location
Suture
Materiala
Suture
Size
Suture Half-life
Removal
Scalp
Galea
Skin
Vicryl/PDS
Prolene or
staples
Or chromic
gut
2-0
3-0
2–3 wk/4 wk
Permanent
2 wk
Absorbable
7–14 d
Absorbable
General face
Muscle
Deep dermal
Epidermis
Vicryl/PDS
Monocryl
Nylon or
Prolene
3-0
or
4-0
4-0
or
5-0
5-0
or
2–3 wk/4 wk
1–2 wk
Permanent
Absorbable
Absorbable
5 d

6-0
Eyelids
Orbicularis
Skin
Vicryl
Nylon
6-0
6-0
2–3 wk
Permanent
Absorbable
3–5 d
Ear
Cartilage/skin
Nylon or
Prolene
5-0
or
6-0
Permanent
5 d
Nose
Cartilage
Skin
PDS/clear
nylon
Nylon or
Prolene
4-0
5-0
or
6-0
4
wk/permanent
Permanent
Absorbable/perman
3–5 d
Lip
Muscle
Mucosa
Vermilion
border
Vicryl/PDS
Chromic
gut
Nylon or
Prolene
3-0
or
4-0
3-0
or
4-0
6-0
2–3 wk/4 wk
2 wk
Permanent
Absorbable
Absorbable
5 d
Intraoral
mucosa
Chromic or
Vicryl
Rapide
3-0
or
4-0
2 wk
Absorbable
Pediatric skin
Fast
absorbing
plain gut
6-0
or
6-0
5 d
Absorbable
aAll suture materials refer to those supplied by Ethicon, Inc. (Somerville, NJ).
■ Taper/round needle ideal for muscle, fascia, mucosa
■ Cutting needle ideal for skin
■ Common emergency department suture choices available are as follows:
■ Muscle: Vicryl 4-0, Monocryl 4-0, PDS 4-0 (Ethicon, Somerville, NJ)
■ Skin:
• Buried deep dermal layer: Monocryl 4-0 or 5-0
• Superficial subcuticular layer: nylon/Prolene 5-0 or 6-0 (Ethicon,

Somerville, NJ)
■ Mucosa: simple chromic/Vicryl Rapide 3-0 or 4-0 (Ethicon, Somerville, NJ)
■ Pediatrics: simple fast absorbing plain gut 5-0 or 6-0
■ Proper suture choice for specific anatomic locations of the face is imperative
for maximizing healing and minimizing scar formation (Table 2).
T E C H N I Q U E S
■ General Laceration Closure Techniques
■ Simple interrupted: standard for closing all layers. Allows for optimal tissue
reapproximation, especially in wounds with uneven lengths. Recommended
for buried deep dermal and epidermal closure (TECH FIG 1A).
■ Simple running: quicker means of closing epidermis in wounds with long
length. Optimal for use in wounds where both sides evenly line up and there
is no apparent “dog ear.”
■ Disadvantages:
• Not as precise as simple interrupted stitch
• Unintentional breakage of the suture will lead to separation of the entire
wound
• Need to remove entire suture length if infection develops postrepair
■ Vertical mattress: optimal for eversion of skin edges, yet is widely known as
the most ischemic suture method and may result in skin ischemia if placed
too tightly.
■ Horizontal mattress: particularly useful in thick glabrous skin.
■ Similar to the vertical mattress counterpart in that it is effective in everting
skin but risks development of skin ischemia.
■ Staples: optimal for fast and effective closure of scalp wounds. May be used
in very contaminated wounds that need to be closed loosely.
■ Adhesive skin tape: beneficial for very superficial and small wounds closed
with minimal tension6,7
■ Brief and painless procedure
■ Difficult to exactly approximate edges and maintain eversion of epidermis
■ Resulting scar similar to suture repair7,8
■ Best for upper third of the face as this area is of least skin tension

■ Dermabond: may be used for clean wounds closed with minimal or no
tension.
TECH FIG 1 • A. Suture closure techniques. B,C.
Ideal closure for reapproximation of edges is simple
interrupted suture.
■ In crush injuries where the extent of the damage is unclear, tissues can be
loosely reapproximated.
■ If flap is avulsed, it should be tacked down where it lies, so that the closure
is tension free. If there is undue tension on the flap, chance of necrosis is
high.
■ Epidermis should be everted at the edges, as eversion will flatten out to
create a flat scar. Skin that is not everted at closure may produce a concave-
shaped scar.
■ Deeper wounds that cannot be closed can be packed with normal saline wet-
to-dry dressings or iodoform gauze packing strips. Exposed bone or
neurovascular structures can be covered first with Xeroform.
■ Burns and abrasions can be treated with Adaptic gauze and bacitracin or

with silver sulfadiazine.
■ Scalp Lacerations
■ Two-layered closure:
■ Galea layer: use 2-0 Vicryl or PDS (Ethicon, Somerville, NJ) for tension-
bearing layer.
■ Skin: use full-thickness continuous suture with 3-0 Prolene (Ethicon,
Somerville, NJ) or staples.
• Alternatively, can use 3-0 chromic as this does not requires suture removal
■ Scalp defects fewer than 3 cm can usually be closed primarily.
■ Galea scoring may be necessary to gain laxity for closure.
■ Attempt to prevent hair from being entangled in the sutures.
■ May use Penrose drainage for first 24 to 48 hours (TECH FIG 2).
TECH FIG 2 • A. Laceration and partial avulsion of the
forehead and anterior scalp. B. Galea layer
reapproximated with Vicryl 2-0 (Ethicon, Somerville,
NJ) and skin closed with interrupted nylon sutures.
■ Eyelid Lacerations
■ First complete a full exam +/− ophthalmology consult to rule out ocular
injury and lacrimal duct injury.
■ Jones I: instill fluorescein dye in the eye, wait 5 minutes, check for

drainage through ipsilateral nare.9
• Absence of fluorescein indicates nonfunctioning lacrimal system, and
Jones II is performed.
■ Jones II: irrigate residual fluorescein dye in the nasolacrimal system with
saline and watch for reflux from the canaliculi or presence of fluorescein
dye in the wound. Either finding indicates damage to lacrimal duct system.
■ Proper alignment of all layers minimizes risk of lid notching, ectropion, and
functional deficit.
■ Three layered closure of conjunctiva, tarsus, and skin
■ Orbicularis and tarsus: 6-0 Vicryl (Ethicon, Somerville, NJ).
TECH FIG 3 • Laceration of the eyelid margin requires
everting vertical mattress suture into the tarsus to
realign lid margin and prevent notching of the eyelid.
After the eyelid margin is realigned, the remainder of
the laceration can be reapproximated.
■ Skin: 6-0 fast absorbing gut suture or 6-0 nylon.
■ Keep all knots directed away from the cornea.
■ If lid margin is involved, approximate the gray line and tarsal plate with
everting vertical mattress suture to prevent notching of the eyelid (TECH
FIG 3).
■ Depth of suture: through skin and half way through tarsus
■ Partial-thickness defects involving less than 50% of eyelid length can be
closed with local advancement flaps. Involvement greater than 50% requires
a skin graft harvested from the contralateral eyelid for a tension-free closure.9

■ Full-thickness defects involving less than 33% of the upper lid and 50% of
the lower lid can be closed primarily.
■ More significant eyelid defects require flaps for closure.
■ Ear Lacerations
■ Irrigate ear lacerations thoroughly to prevent possible chondritis.
■ Debride skin conservatively to avoid cartilage exposure after closure.
■ As long as the skin is still adherent to the cartilage, approximating only the
skin in suture bites is sufficient for realignment of the cartilage. Use 5-0 or 6-
0 Prolene (Ethicon, Somerville, NJ).
■ Large defects with exposed cartilage should be covered with Xeroform
petrolatum gauze dressing (Covidien, Mansfield, MA) with frequent dressing
changes until reconstruction is completed.
■ Avulsion injuries: should be promptly debrided, and small avulsion
fragments less than 1.5 cm in width can be reattached as a composite graft in
the first 12 hours. Large avulsions/amputation may require intraoperative
microvascular replantation.
■ Venous congestion is a common problem following microvascular arterial
anastomosis; postoperative leech therapy is commonly employed.
■ Dress ear laceration with Xeroform gauze (Covidien, Mansfield, MA) and
fluffed gauze in a pressure dressing with circumferential head wrap to avoid
hematoma formation (TECH FIG 4).
TECH FIG 4 • A. Laceration of the ear through
cartilage, with partially avulsed helical rim flap. B,C

Irrigated and closed with interrupted nylon sutures
anteriorly and interrupted chromic sutures posteriorly.
■ Nasal Lacerations
■ Nasal hemostasis may need to be achieved with either anterior or posterior
nasal packing layered cottonoid or Xeroform gauze (Covidien, Mansfield,
MA).
■ Septal nasal hematomas must be ruled out. If visualization of the septum is
not clear, slide your small finger into each nostril for palpation of a bulging
hematoma.
■ If septal hematoma is present, this should be drained under direct vision
with an no. 11 blade.
■ Unlike ear lacerations, reapproximating the skin does not necessarily
reapproximate the underlying cartilages, and lacerations should be addressed
separately.
■ Use 4-0 Vicryl (Ethicon, Somerville, NJ) or clear nylon suture for cartilage
reapproximation.
■ Use nylon or 5-0 or 6-0 Prolene (Ethicon, Somerville, NJ) for skin closure.
■ The traditional view of resecting an entire subunit of the nose if greater than
50% is compromised has been challenged in favor of retaining all native
healthy tissue.
■ Defects of tissue may be repaired in the operating room with local flaps such
as the dorsal nasal, nasolabial, and paramedian forehead flap.10
■ Lip Lacerations
■ By taking care to align the “white roll” of the vermilion border, the outcome
will be the most cosmetic. Differences in alignment of the white roll as small
as 1 mm can be noticeable to the human eye at conversational distance.
■ Align the white roll (vermillion-cutaneous junction), philtral columns, and
cupids bow before any injection with anesthetic to avoid distortion of these
landmarks by the added volume of the anesthetic (TECH FIG 5).
■ You may mark these by tattooing with methylene blue.
■ Primary closure can be accomplished when less than 30% of the lip is

involved in the defect.9
■ Defects in the central upper lip may distort the anatomy of the philtral
columns. The defect should be closed with the available lip tissue and may
be corrected later.
■ Closure of each layer of the laceration is necessary to maintain appropriate
thickness of the lip throughout the laceration.
TECH FIG 5 • A demonstration of a lip laceration
through the cutaneous-vermillion border. The first
stitch for optimal reapproximation is at the level of the
white roll (white line).
■ Muscle: 3-0 or 4-0 Vicryl (Ethicon, Somerville, NJ)
■ Epithelialized skin and white roll stitch: 6-0 nylon/Prolene (Ethicon,
Somerville, NJ)
■ Mucosa (lip surface): 3-0, 4-0 chromic suture
■ Facial Nerve Injury
■ Any laceration in the path of the branches of the facial nerve should be
explored for laceration of nerve (see FIG 2).
■ Deep lacerations through the parotid gland are at high risk of nerve injury
(TECH FIG 6).
■ Repair of the lacerated nerve should take place as soon as possible and
within 72 hours of injury.
■ Repair delayed after 72 hours is difficult secondary to inability to stimulate

the distal end of the nerve due to depletion of neurotransmitters at the motor
end plates and contraction of the cut segment of nerve.
■ In the operating room and under magnification vision, the ends of the nerve
should be trimmed and coapted tension free with 9-0 or 10-0 nylon epineural
sutures.
■ If repair cannot be completed without tension, consider nerve grafting or
placement of a nerve conduit.
TECH FIG 6 • Laceration of preauricular region of the
face, deep through parotid gland and lacerating the
main trunk of the facial nerve as well as the parotid
duct.
■ Parotid Duct Injury
■ Evaluate a parotic duct injury by cannulating the intraoral segment with a
22-gauge Angiocath, and inject 1 cc of hydrogen peroxide, methylene blue,
or milk into the duct. Blue dye (caution: messy!), milk, or foaming of
hydrogen peroxide in the wound indicates a ductal injury.
■ If the laceration appears to only involve gland tissue, the lacerated gland can
be oversewn.
■ Repair lacerated duct over a stent (red rubber catheter) using 7-0 nylon.
■ Keep stent in place for 5 days with prophylactic antibiotics (TECH FIG 7).

TECH FIG 7 • A. Unrestrained child in motor vehicle
collision with multiple significant lacerations and
significant loss of tissue. Extensive debridement in the
ED revealed multiple pieces of glass in the wound. B.
After thorough irrigation, the wound was closed in
layered interrupted fashion.
PEARLS AND PITFALLS
Preoperative
planning
■ Treat all bite wounds as contaminated wounds with thorough
irrigation, debridement, and antibiotics.
■ Small wounds may heal as well or better if left to heal secondarily.
■ Always consider facial aesthetic lines when planning closure for
optimal scar placement.
■ Be aware that crush injuries can produce larger areas of damage
than initially appreciated.
Irrigation
■ Thoroughly irrigate all wounds; you can never overirrigate.
Debridement
■ Debridement of devitalized skin will reduce contamination and
improve healing.
Closure
■ Be mindful of proper suture choice for each anatomic location.

■ Alignment of skin edges is optimal with simple interrupted suture.
■ Align critical regions (ie, the white roll of the vermillion border or
the eyelid margin) first to minimize distortion of these regions.
Final
outcome
■ In addition to factors such as timing, technique, and suture material,
healing has a large genetic component.
POSTOPERATIVE CARE
■ One dose of IV antibiotics should be given in ED for all facial lacerations.
■ If wound is grossly contaminated or patient is diabetic, send the patient home
on an oral outpatient antibiotic regimen with MRSA coverage (clindamycin or
Bactrim).
■ Rarely, acute wounds will require IV antibiotic treatment.
■ Subacute and severely contaminated wounds may require admission for IV
antibiotics.
■ Bite wounds should be treated as contaminated wounds in the acute setting
and require anaerobic coverage.
■ First-line treatment for bite wound is Augmentin (875 mg PO bid × 7 days
for adults, and 45 kg/d PO bid × 7 days for pediatric dosing).
■ IV therapy for bite wounds: first line is Unasyn (Pfizer, Inc., New York, NY)
1.5 g IV q6h.
■ All wounds should be given care instructions for daily cleaning and bacitracin
application TID until sutures are removed
■ Tetanus prone wounds: greater than 6 hours old, contaminated or in contact
with soil, puncture wounds, animal or human bites, largely devitalized,
infected.3
■ Incompletely immunized or uncertain: full tetanus vaccine (if moderate- to
high-risk wound, also give tetanus immunoglobulin)
■ Greater than 10 years since immunization: give tetanus toxoid (if high risk,
give tetanus immunoglobulin)
■ Five to ten years since immunization: if moderate to high risk, give toxoid.
■ If less than 5 years since immunization: no need for booster
OUTCOMES
■ In general, the high vascularity of the face results in good healing with a low
infection and dehiscence rate.
■ Final scar maturation is completed by 1 year postoperatively, and as aesthetic

appearance is always a concern to patients, maximizing aesthetic outcome
should always be a priority
COMPLICATIONS
■ Infection
■ Dog bite infection rates around 5% to 8% after ED washout3,11 (FIG 5).
■ No change in incidence of dog bite infection rate between closure and
nonclosure of wounds; therefore, approximation of tissues is
recommended.12
■ Hematoma
■ Auricular hematomas should be drained promptly through incisions in skin,
and a compressive bolster dressing should be placed to prevent
reaccumulation.
FIG 5 • Child presenting with cellulitis and abscess of
the right cheek 48 hours after ED closure of dog bite
wounds.
■ Sialocele
■ Unidentified laceration of the parotid gland or parotid duct may result in
delayed accumulation of saliva, presenting as swelling and tenderness of one
cheek. Treatment involves compressive dressing, and if drainage is required,
perform I&D through intraoral route.
■ Chondritis
■ Delayed onset of pain after ear laceration warrants prompt evaluation for
chondritis. Cartilage is poorly vascularized, and infection requires IV

antibiotic therapy.
REFERENCES
1. Ball V, Younggren B. Emergency management of difficult wounds: part I.
Emerg Med Clin North Am. 2007;25(1):101-121.
2. Gurunluoglu R, et al. Retrospective analysis of facial dog bite injuries at a
Level I trauma center in the Denver metro area. J Trauma Acute Care Surg.
2014;76(5):1294-1300.
3. Toure G, Angoulangouli G, Meningaud J. Epidemiology and classification of
dog bite injuries to the face: a prospective study of 108 patients. J Plast
Reconstr Aesthet Surg. 2015;68(5):654-658.
4. Aceta A, Casati P. Soft tissue injuries of the face: early aesthetic
reconstruction in polytrauma patients. Ann Ital Chir. 2008;79:415-417.
5. Bar-Meir E, et al. Nitrous oxide administered by the plastic surgeon for repair
of facial lacerations in children in the emergency room. Plast Reconstr Surg.
2006;117:1571-1575.
6. Goktas N, et al. Comparison of tissue adhesive and suturing in the repair of
lacerations in the emergency department. Eur J Emerg Med. 2002;9:155-158.
7. Hyunhjoo K, Kim J, Choi J, Jung W. The usefulness of Leukosan SkinLink
for simple facial laceration repair in the emergency department. Arch Plast
Surg. 2015;42:431-437.
8. Simon H, et al. Long-term appearance of lacerations repaired using a tissue
adhesive. Pediatrics. 1997;99(2):193-195.
9. Kretlow J, McKnight A, Izaddoost S. Facial soft tissue trauma. Semin Plast
Surg. 2010;24(4):348-356.
10. Huang A, Wong M. Acute nasal reconstruction with forehead flap after dog
bite. Ann Plast Surg. 2013;70:401-405.
11. Cheng H, Hsu Y, Chao-l W. Does primary closure for dog bite wounds
increase the incidence of wound infection? A meta-analysis of randomized
controlled trials. J Plast Reconstr Aesthet Surg. 2014;67(10):1448-1450.
12. Paschos N, et al. Primary closure versus non-closure of dog bite wounds. A
randomized controlled trial. Injury. 2014;45:237-240.

72
CHAPTER
Section XX: Craniofacial
Prosthetics
Craniofacial Anaplastology:
Prosthetic Osseointegration
Chad A. Purnell, Rosemary Seelaus, and Pravin K. Patel
DEFINITION
■ Anaplastology derives from the Greek ana to make again, anew, upon plastos
—something made, formed, molded logy—the study of art and science of
restoring a malformed or absent part of the human body through artificial
means.
■ Prosthetic derives from Greek prósthesis, addition, application, attachment as
an artificial device that replaces a missing body part that may be lost through
trauma, disease, or congenital conditions.
■ Prosthetic and autologous reconstructive techniques are complementary, and in
many circumstances, both are required to achieve an optimal aesthetic outcome
in the reconstruction of craniofacial defects.1 Prosthetic reconstruction can
result in significantly improved quality of life for patients when conventional
reconstruction reaches its limits.1,2
■ Although autologous techniques remain the standard for long-term stable nasal
and ear reconstruction, it frequently requires multistage surgical procedures
with difficulty in achieving consistency of outcome and patient acceptability.
Though the prosthetic approach can achieve consistency in outcome with
minimal surgical intervention, it requires a lifetime of maintenance4,5 (Table 1).
Each approach must be considered by having the patient and family involved
in the discussion. However, in some instances such as orbital exenteration,
ocular and periorbital prosthesis is the only option for the patient as no

autogenous alternatives exist.3
■ Facial prosthetics can be either adhesive retained or fixed to osseointegrated
implants. Other means of retention have been described but are less ideal. Due
to disadvantages of skin reactions and less secure fixation with adhesives,
implant-retained prostheses are most commonly used and result in the higher
patient satisfaction.1,4
Table 1 Comparison of Autologous vs Prosthetic Techniques for Facial
Reconstruction
Autologous
Prosthetic
Often complex, multistage surgery
Minimal surgery
Reconstruction requires minimal
maintenance once complete
Significant, lifetime maintenance
Can be higher risk for comorbid
patients
Safer in patients with comorbidities
Wide range of reconstructive
outcomes
Typically provides near-exact
replication of anatomic structure
Own tissues used, late complications
rare
Creates prosthetic-tissue interface,
late complications more common
■ Osseointegration derives from the Greek osteon, bone, and the Latin integrare,
to make whole. The term refers to the direct structural and functional
connection between living bone and the surface of a load-bearing implant.5
Osseointegrated implants may retain a prosthesis through magnets or through a
bar-and-clip mechanism (FIG 1).
ANATOMY
■ The placement of osseointegrated implants into the craniofacial skeleton
requires an understanding of the bony buttresses of the face (FIG 2). These
areas of greater bony strength provide adequate bone stock for implant
placement.
■ The patient-specific anatomy for cranial bone thickness and the mastoid region
must be taken into consideration for placement of temporal bone
osseointegrated implants and implants for bone conducting hearing
amplification.
■ Orbital prostheses are retained by the thickened bony rim of the orbit. Nasal

prostheses are retained by the thickened bony rim of the pyriform aperture.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Because of the extensive deformity whether of congenital, traumatic, or from
tumor ablation, a multidisciplinary team tailored to the patient’s needs will help
in achieving the patient’s goals with an understanding of what can and what
cannot be achieved by surgical autologous and prosthetic approaches. The team
ideally consists of a craniofacial surgeon, an anaplastologist, a psychologist,
and in the case of auricular reconstruction and bone anchored implants, an
audiologist and otolaryngologist are included. The psychologist plays a critical
role in providing the supportive voice for the patient during the decision-
making process and in the accepting of the outcome with their own
expectations, which may not be technically achievable. Communication and
educating the patient and family is critical.
■ A history of the patient should be collected, with particular focus on the area to
be reconstructed. History of pathology leading to tissue loss, prior
reconstructive attempts and donor sites, and pathology that contributes to
wound healing should all be elicited. This importantly includes a history of
tobacco use, corticosteroid use, and radiation therapy.
■ This examination should fully assess soft tissue quality and vascularity of the
area to be reconstructed. Areas targeted for placement of implants must have
stable and adequate soft tissue coverage.
FIG 1 • Magnet (left) and bar-and-clip (right) attachment
methods for prostheses.

■ Bone in areas for potential osseointegrated implant placement should be
assessed for quality and areas of potential bone loss. This assessment is best
done through skeletal imaging.
■ The patient should be evaluated to determine the appropriateness of practical
prosthetic use. This includes an evaluation of manual dexterity (to don/doff
prosthesis), general personal hygiene, social support, history of compliance
with medical treatment, and access to anaplastology services.
IMAGING
■ Conventional 2D photography and 3D soft tissue imaging is ideal not only for
documentation but for virtual design and planning of prosthetic implants.
FIG 2 • The craniofacial buttresses (shown in color) are
areas of increased bony strength in the facial skeleton,
which are the safest locations for implant placement.