Operative Technique in Plastic Surgery – Kevin C.Chung

approach, 617
patient positioning, 617
preoperative planning, 617
Le Fort III fracture, 952
anatomy, 897, 898f
complications, 902
definition, 897, 898f
imaging, 898f, 899
merits and demerits, 901b
open reduction internal fixation, pediatric midface fractures,
954–955, 955f
outcomes, 902
pathogenesis, 897
patient history and physical findings, 897–898, 898f
postoperative care, 901–902
repair with coronal flap, miniplate fixation, and intermaxillary
fixation, 899–900, 900f
surgical management, 899
Le Fort III osteotomy
with external distraction
anatomy, 621
complications, 631, 632f
curved tip osteotome, 623f, 626
definition, 621
device placement, 627, 627f–628f
exposure, 625–626, 625f
imaging, 622, 624f
lateral orbital wall, 628, 629f
lateral orbital wall osteotomy, 621f, 626
merits and demerits, 625b
mobilization, 626, 626f
nasofrontal osteotomy, 621f, 626
outcomes, 630–631, 630f–631f

pathogenesis, 621
patient history and physical findings, 622, 623f
postoperative care, 630
preoperative planning, 624
skull-cranial bones and facial bones, 621, 623f
surgical management, 624
traditional lines, 621, 621f
midface hypolasia
access, 636, 636f
anatomy, 634, 634f
definition, 634
differential diagnosis, 635
distraction protocol, 639
extended transconjunctival incision, 636–637, 636f, 637f
imaging, 635, 635f
lateral orbitotomy, 637, 638f
merits and demerits, 637b
nasofrontal osteotomy, 637, 638f
natural history, 634
nonoperative management, 635
outcomes, 640, 640f–641f
pathogenesis, 634
patient history and physical findings, 635
postoperative care, 640
preoperative planning, 635–636
pterygomaxillary osteotomy, 638, 638f
rigid external device placement, 638, 639f
surgical management, 635–636
Le Fort III–type osteotomy, 490
Le Fort osteotomy, 276
Left gastroepiploic pedicle, omental flap harvest with, 1667, 1668f
Leg elevation, 2371
Leg length discrepancy, 2348

Leg splint, 2443, 2490
Leiomyosarcoma, 2421
Lengthening temporalis myoplasty, 1264, 1264f
completion process, 1269
definition, 1262
elevation and advancement, 1269, 1270f
flap harvest, 1268–1269, 1268f–1269f
Labbé procedure
myeloplasty, 1274, 1274f–1275f
superficial aponeurosis, 1273, 1273f–1274f
zigzag Cairns approach, 1273, 1273f–1274f, 1276
surgical management, 1264, 1264f
Lenticular excision and linear closure, 2760b
Lesser occipital nerve, 97
Lesser occipital nerves, 966f, 967
Levator anguli oris muscle, 1073, 1073f
Levator function (LF), 115
Levator labii superioris, 32
Levator labii superioris alaeque nasi, 9, 9f, 32
Levator resection, congenital ptosis, 2853, 2853f–2854f
Levator veli palatini (LVP), 2672, 2687
Levobupivacaine
furlow palatoplasty, 2664
hard palate incisions, 2676
LF (levator function), 115
Lid crease height (LC), 115
Lid-cheek junction. See Tear trough
Lidocaine, 2328–2329, 2865, 3077
Li-Fraumeni syndrome, 2338, 2460, 2497
Limb Salvage Index, 2394
Limb-threatening infection, 2408
Limited fasciectomy, 2176, 2182f
Limited maxillectomy defect, 1013, 1013f–1014f, 1015–1016

Limited preauricular approach, 2921
Linear threading injection technique, 43, 43f
Lingual nerve transection, 1200, 1200f–1201f
Lip(s)
closure
cutaneous approximation, 2604
Millard/Mohler modifications, 2612–2613, 2613f
muscle repair, 2603–2604, 2603f
commissure defects, with Estlander flaps
anatomy, 1055, 1055f
complications, 1058
definition, 1055
external landmarks, 1055
imaging, 1056
lower lip, 1057, 1057f
merits and demerits, 1058b
outcomes, 1058, 1058f
patient history and physical findings, 1055, 1056f
postoperative care, 1058
surgical management, 1056
upper lip, 1056, 1056f–1057f
contracture, 2766, 2766f–2767f
fat grafting at time of facelifting, 50
fillers injection
anatomy, 37, 37f–38f
complications, 40
definition, 37
merits and demerits, 40b
nonoperative management, 38
outcomes, 40, 40f–41f
patient history and physical findings, 37–38
postoperative care, 40
techniques, 38b

reconstruction, with radial forearm free flap
anterolateral thigh flap, 1074
complications, 1077
definition, 1073
external anatomy, 1073, 1073f
full-thickness lower lip defects, 1074
imaging, 1074
innervation, 1074
internal anatomy, 1073, 1073f
large, full-thickness defects, 1074
larger partial-thickness defects, 1074
lateral arm flap, 1074
merits and demerits, 1075b
motor innervation, 1073
operative management, 1074
outcomes, 1077
parascapular flap, 1074
patient history and physical findings, 1074
postoperative care, 1077
recipient site preparation and insetting, 1075, 1076f
sensory innervation, 1073
skin graft closure, 1075, 1075f
surgical management, 1074
vascular supply, 1074
Lip adhesion
anatomy, 2629
bilateral cleft lip adhesion, 2633–2634
complications, 2635
definition, 2629
merits and demerits, 2635b
nonoperative management, 2630
outcomes, 2635
patient history and physical findings, 2629–2630

postoperative care, 2635
premaxillary setback, 2634–2635, 2634f
surgical management, 2630–2635
approach, 2630–2635
patient position, 2630
preoperative planning, 2630
unilateral cleft lip adhesion
completion, 2633, 2633f
incision and dissection, 2631, 2632f
markings, 2631, 2631f
suturing, 2631–2633, 2632f
Lip defect(s)
with Abbe flap
anatomy, 1063
complications, 1067
definition, 1063
donor-site preparation, 1064, 1064f
flap placement and closure, 1066, 1066f
imaging, 1063
merits and demerits, 1064b
pathogenesis, 1063
patient history and physical findings, 1063
raising the flap, 1065, 1065f
recipient-site preparation, 1064, 1065f
surgical management, 1063–1064
with Karapandzic flaps
anatomy, 1059, 1059f
bilateral, large midline lower lip defect, 1060, 1060f–1061f
complications, 1061
definition, 1059
imaging, 1059
merits and demerits, 1061b
outcomes, 1061, 1061f

patient history and physical findings, 1059
postoperative care, 1061
surgical management, 1059–1060
Lip element
lateral
alar base and L flap, 2608, 2608f–2609f
anatomy, 2606
dissection, 2609–2610, 2610f
markings, 2607, 2608f–2609f
medial
anatomy, 2606
C flap and M flap, 2608, 2608f–2609f
dissection, 2602, 2602f, 2609, 2610f
markings, 2607, 2608f–2609f
Lip lacerations, 3081, 3081f
Lip lengthening, skin flap for, 2623–2624, 2623f
Lip pits, 2654–2656
acellular dermal allograft, 2656, 2656f
inverted-T excision, 2655–2656, 2656f
split lip advancement technique, 2655, 2655f
transverse elliptical excision, 2654, 2655f
vertical elliptical wedge excision, 2654, 2655f
LipiVage, 2812, 2812f
Lip-nose adhesion, 2631
Lipodystrophy, 1596
Lipoma, 2498
Lipoma arborescens, 2457
Liposarcoma, 2421
Lipostructural fat grafting, 165
Liposuction, 207, 1636, 1636f, 2987, 2987f
donor site autologous fat harvesting, 1491, 1492f
lymphedema
anesthesia, 2572

complications, 2574
compression garment application, 2573
equipment, 2572
follow-up, 2573–2574
imaging, 2571
irrigation, 2573
merits and demerits, 2572b, 2573b
outcomes, 2574
patient history and physical exam, 2571
patient position, 2572
postoperative care, 2573
surgical management, 2571–2572
mons pubis, 1641, 1641f
scar glandular resection with, 1636, 1636f
Lisfranc amputation, 2546
LLC. See Lower lateral cartilage (LLC)
LMA (laryngeal mask airway), 3
Lobule projection (LP), 276, 276f
increasing, 279, 279f–280f
reducing, 278, 279f
Local anesthesia
additives, 972
agent selection, 968
anatomy, 966, 966f
behavioral and communication techniques, 972
complications, 973
definition, 966
facial nerve blocks
infraorbital nerve block, 970, 970f
mental nerve block, 971, 971f
supraorbital and supratrochlear nerves, 970, 970f
in-office procedures, 966
local infiltration, 969, 969f

mechanisms of action, 967, 969b
natural history, 967
patient history, 967
physical examination, 968
postoperative care, 973
relative contraindications, 967
surgical management
infiltrative anesthesia, 969
injectable agents, 969
patient positioning, 968
preoperative planning, 968
smaller needle sizes, 969
topical agents, 968
tumescent anesthesia, 971, 971t
types, 966
Local anesthetic systemic toxicity (LAST), 973, 1759, 2314, 2330
Local anesthetic toxicity, 2321
Local anesthetics, administration of, 977, 977f
Local flaps, 2115
and grafts, 2408
partial breast reconstruction
anatomy, 1367
complications, 1375
definition, 1367
flap harvesting, 1372
merits and demerits, 1374b
oncological follow-up, 1375
outcomes, 1375
patient history and physical findings, 1367–1368
patient positioning, 1371
perforator mapping, 1371
postoperative care, 1375
preoperative planning, 1371

prognosis, 1375
types, 1368–1371
Local infiltration, 967, 969, 969b, 969f
Local random patterned flaps, 2366
Locked cruciate suture repair, 2058, 2058f
Long and ring finger revascularization, 2153, 2153f
Long nose
adjuvant procedures, 336
anatomy, 333, 333f
caudal septal reduction, 335, 335f
complications, 337
component dorsal hump reduction, 335, 335f
definition, 333
excess lower lateral cartilages, 336, 336f
imaging, 334
merits and demerits, 337b
outcomes, 337
pathogenesis, 333
patient history and physical findings, 333–334
postoperative care, 337
surgical management, 334–337, 334f
tip support, optimizing, 336, 336f
Loss-of-resistance technique, 2328
Love’s pin test, 2287
Low combined median and ulnar nerve palsy
finger clawing, 2038–2039
index finger abduction, 2037–2038
small finger abduction, 2040
thumb adduction, 2037
thumb opposition, 2036–2037
Low-energy trauma, 2467
Lower abdominal defects, 1589
Lower back/buttock, anatomic layers of, 1612

Lower blepharoplasty
anatomy, 171
complications, 176, 177f
definition, 170
differential diagnosis, 172
merits and demerits, 176b
nonoperative management, 172
outcomes, 176
pathogenesis, 171–172
patient history and physical findings, 172, 172f
postoperative care, 176
surgical management, 172
techniques, 174, 174f
via subciliary incision
anatomy, 148, 149f–150f
complications, 155–156
definition, 148
imaging, 150
merits and demerits, 155b
nonoperative management, 151
outcomes, 155, 156f
patient history and physical findings, 148–150
postoperative care, 155
skin-muscle flap approach with orbicularis oculi resuspension,
152–153, 152f–153f
skin-only flap approach with reverse orbicularis oculi tightening,
153–154, 154f
surgical management, 151
Lower body lift
anatomy, 1619, 1619f–1620f
complications, 1624
definition, 1619
with gluteal autoaugmentation flaps

abdominal lift, 1621–1622, 1622f
markings, 1621, 1621f
imaging, 1620
merits and demerits, 1623b
outcomes, 1623
patient history and physical findings, 1619
postoperative care, 1623
surgical management, 1620, 1620f
without autoaugmentation, 1623, 1623f
Lower extremity, 2365, 2374–2375
amputation
approach considerations, 2548
merits and demerits, 2550b
physical exam and arterial pressures, 2548, 2548f
postoperative care, 2550
preoperative planning, 2548
angiography, 1030
wound, 2429f
Lower extremity reconstruction, reverse sural artery flap for
anatomy, 2388
complications, 2390
definition, 2388
delayed reverse sural artery flap, 2390
fasciocutaneous pedicle incised, flap dissection with, 2389f
imaging, 2388
merits and demerits, 2390b
outcomes, 2390
patient history and physical findings, 2388
postoperative care, 2390
supercharged reverse sural artery flap, 2390
surgical management, 2388f
patient positioning, 2389
patient positioningapproach, 2389

preoperative planning, 2388, 2388f
Lower eyelid
blepharoplasty, 1104
consists of, 148, 149f–150f
fat grafting for periorbital rejuvenation, 162, 166, 166f
herniated orbital fat
anatomy, 132, 132f
anesthesia and eye preparation, 133
complications, 137
definition, 132
excision of, 134, 135f
eyelid retractors, isolating, 133, 134f
merits and demerits, 136b
outcomes, 137, 137f
patient history and physical findings, 132
postoperative care, 136
repositioning, 135–136, 136f
surgical management, 132
laxity, 1104
postseptal fat compartments in, 148, 149f–150f
Lower eyelid(s)
skin pinch skin excision
anatomy, 138
complications, 139
definition, 138
excess eyelid skin removal, 138
imaging, 138
merits and demerits, 139b
outcomes, 139
patient history and physical findings, 138
postoperative care, 139
surgical management, 138
transconjunctival fat removal and redraping

anatomy, 140, 140f–141f
completion, 144
complications, 146–147
definition, 140
exposure, 143, 143f
fat pad resection, 144, 144f
imaging, 142, 142f
merits and demerits, 145b
nonoperative management, 142
outcomes, 146, 146f–147f
patient history and physical findings, 140–142
postoperative care, 146
surgical management, 142–143
Lower eyelid defects
basal cell carcinoma, 1085, 1085f, 1086f
tenzel semicircular rotational flap
design and flap elevation, 1086, 1086f
donor-site repair, 1087, 1087f
flap inset, 1086f, 1087
tarsal edges, 1086, 1086f
Lower eyelid incision, pediatric orbital fractures, 948
Lower eyelid reconstruction, with palatal grafts
complications, 1098
definition, 1094
hard palate, 1095–1097, 1095f, 1097f
lamellar anatomy, 1094–1095, 1094f
merits and demerits, 1096b
patient history, 1095
physical examination, 1096
postoperative care, 1098
surgical management, 1096
Lower eyelid surgery, palatal spacer grafts, 193, 193f
Lower lateral cartilage (LLC), 377, 2604, 2714

correction, crooked nose, 331
isolation of, 306, 306f–307f
reconstruction, 2890
separation of, 306
Lower leg
abscesses drainage
anatomy, 2335, 2335f
approach, 2336
complications, 2337
differential diagnosis, 2336
imaging, 2336
merits and demerits, 2336b
necrotic right lateral foot wound, 2336, 2337f
nonoperative management, 2336
patient history and physical findings, 2336
postoperative care, 2337
preoperative planning, 2336
supine position, 2336
bone tumors of
anatomy, 2423, 2423f
complications, 2426
definition, 2423
diaphyseal tibia tumor resection and reconstruction, 2424
differential diagnosis for, 2423
functional outcomes, 2426
imaging, 2423
merits and demerits, 2425b
natural history, 2423
oncological outcomes, 2426
pathogenesis, 2423
patient history, 2423
physical findings, 2423
postoperative care, 2426

surgical management, 2423–2424
fasciotomy, 2332, 2333f
anterior, 2331
deep posterior compartment, 2331
diagnosis, 2331
lateral, 2331
superficial posterior, 2331
keystone flap reconstruction, 2540–2541
flap viability and definitive hemostasis, 2541
islandization of, 2540, 2540f
markings, 2540, 2540f
strategic suturing, 2541, 2541f
soft tissue infections, debridement of
anatomy, 2427
complications, 2430
debridement of the chronic wound, 2429
definition, 2427
enzymatic debridement, 2430
hydrosurgery system, 2429, 2429f
imaging, 2427
merits and demerits, 2430b
outcomes, 2430
pathogenesis, 2427
patient history and physical findings, 2427
postoperative care, 2430
sharp debridement of the acute wound, 2428–2429, 2429f
surgical management, 2427–2428
soft tissue tumors, excision of
anatomy, 2338, 2338f–2339f
complications, 2341
definition, 2338
differential diagnosis, 2339
free tissue transfer, 2340

imaging, 2339
merits and demerits, 2341b
natural history, 2338
outcomes, 2341, 2341f
pathogenesis, 2338
patient history and physical findings, 2339
patient positioning, 2339
postoperative care, 2341
preoperative planning, 2339, 2340f
previous biopsy incision, excision of, 2340, 2340f
surgical management, 2339
tourniquet, 2340
soft tissue tumors of, 2421, 2422f
anatomy, 2420, 2420f
complications, 2422
definition, 2420
differential diagnosis for, 2421
functional outcomes, 2422
imaging, 2421
merits and demerits, 2422b
natural history, 2420–2421
oncological outcomes, 2422
pathogenesis, 2420
patient history and physical findings, 2421
surgical management, 2421
tourniquet, 2421
Lower lid malposition, 190, 191f
Lower lid reconstruction, eyelids, 2778
Lower lid retractors, 825
Lower lip
cross-sectional anatomy, 1055, 1055f
defect, bilateral Karapandzic flaps, 1060, 1060f–1061f
reconstruction with nasolabial flap

banner-shaped flap, 1071
blood supply, 1068, 1069f
complications, 1072
definition, 1068
differential diagnosis, 1070
imaging, 1070
lymphatic drainage, 1068, 1069f
merits and demerits, 1071b
motor and sensory innervation, 1068, 1069f
musculature, 1068, 1069f
nonoperative management, 1070
outcomes, 1072
pathogenesis, 1068
patient history and physical findings, 1068–1070
postoperative care, 1072
surgical management, 1070–1071
techniques, 1071, 1071f
Lower posterior torso
anatomy, 1625–1626, 1625f
complications, 1634
definition, 1625
imaging, 1626
merits and demerits, 1634b
natural history, 1626
nonoperative management, 1626–1627
outcomes, 1634
patient history and physical findings, 1626
postoperative care, 1634
surgical management, 1627
Low-grade chondrosarcoma, 2423, 2502
Low-volume fat grafting, contour correction
anatomy, 1490
complications, 1495

definition, 1490
imaging, 1490
merits and demerits, 1494b
outcomes, 1494–1495
patient history and physical findings, 1490
postoperative care, 1494
surgical management
approach, 1491
patient positioning, 1491
preoperative planning, 1490–1491
wound closure, 1494
LP. See Lobule projection (LP)
L-shaped silicone implants, 351, 351f
LT injuries. See Lunotriquetral (LT) ligament injuries
Luer Lock plugged syringe, 49f
Lumbar epidurals, 2327
Lumbar spinal pathology, 2412
Lumbar spine regions, anatomic features of, 2326t
Lumenis UltraPulse fractional CO2 laser, 2808f
Lunotriquetral ballottement test, 1858, 1859f
Lunotriquetral compression test, 1858, 1859f
Lunotriquetral (LT) ligament injuries
anatomy, 1857, 1857f–1858f
closure in, 1863
complications, 1864
differential diagnosis, 1859
ECU tendon grafting, 1862–1863, 1862f–1863f
exposure and tendon harvest, 1860, 1861f
imaging, 1858–1859, 1859f–1860f
lunate and triquetrum
bony preparation in, 1861, 1862f
K-wire fixation into, 1861, 1862f
merits and demerits, 1864b

natural history, 1857
nonoperative management, 1860
outcomes, 1864
pathogenesis, 1857, 1858f
patient history and physical findings, 1857–1858, 1859f
perilunat injuries, 1857, 1858f
postoperative care, 1864, 1864f
surgical management, 1860
approach, 1860, 1860f
patient positioning, 1860
preoperative planning, 1860
LVP (levator veli palatini), 2672
Lymphatic drainage
of ear, 1129
with nasolabial flap, 1068, 1069f
skin grafts, 1122
Lymphatic malformations (LM), 2798–2799
Lymphaticovenous anastomosis, 1506–1507, 1506f, 2553,
2553f–2555f
anatomy, 2551, 2551f
complications, 2555
definition, 2551
differential diagnosis, 2552
imaging, 2552
merits and demerits, 2553b, 2555b
natural history, 2552
nonoperative management, 2552
outcomes, 1509, 2555
pathogenesis, 2552
patient history and physical exam, 2552
postoperative care, 1509, 2555
surgical management
approach, 2553

patient positioning, 2553
preoperative planning, 2553
Lymphedema
anatomy, 2557, 2571
complications, 2566
definition, 2557, 2571
differential diagnosis, 2559
donor sites, 2560t
imaging, 2558–2559
indocyanine green appearance, 2561b
liposuction
anesthesia, 2572
complications, 2574
compression garment application, 2573
equipment, 2572
follow-up, 2573–2574
imaging, 2571
irrigation, 2573
merits and demerits, 2572b, 2573b
outcomes, 2574
patient history and physical exam, 2571
patient position, 2572
postoperative care, 2573
surgical management, 2571–2572
merits and demerits, 2565t, 2565b
microsurgery (see Lymphedema microsurgery)
natural history, 2557–2558
nonoperative management, 2559
outcomes, 2566
pathogenesis, 2557, 2571
patient history and physical exam, 2558
postoperative care, 2565–2566
surgical management

approach, 2560
patient positioning, 2560
preoperative planning, 2559–2560
Lymphedema, fasciocutaneous debulking of
anatomy, 2567
complications, 2570
definition, 2567
imaging, 2567
merits and demerits, 2568b, 2569b
outcomes, 2570
patient history and physical exam, 2567
postoperative care, 2570
radical debridement with split-thickness skin grafts, 2568–2569,
2569f
staged excision, 2569
surgical management
approach, 2568
patient positioning, 2568
preoperative planning, 2568
Lymphedema microsurgery
anatomy, 1502
complications, 1511
definition, 1502
differential diagnosis, 1503
donor sites of lymph node–carrying flaps, 1505t
imaging, 1503
merits and demerits, 1508b
natural history, 1502
nonoperative management, 1503
outcomes
lymphaticovenous anastomosis, 1509
quality of life, 1509–1511
vascularized lymph node transfer, 1509

pathogenesis, 1502
patient history and physical findings, 1502
postoperative care
lymphaticovenous anastomosis, 1509
vascularized lymph node transfer, 1509
surgical management
approach, 1504–1506
lymphaticovenous anastomosis, 1503
patient positioning, 1504
preoperative planning, 1504
vascularized lymph node transfer, 1503

M
M flap, on medial lip element, 2608–2609, 2608f–2609f
MABC (medial antebrachial cutaneous nerve), 2122–2123, 2125
MABC (medial antebrachial cutaneous) nerve, 1994
Macrocystic lymphatic malformation, 2760, 2799
Macrostomia, 2729
Macrostomia repair, Tessier 7. See Tessier 7–macrostomia repair
Magnetic resonance angiography, pedicled rectus flap, 2518
Magnetic resonance imaging (MRI)
Achilles tendon reconstruction, 2417, 2417f
bone grafting for foot and ankle, 2356–2357
bone reconstruction of knee, 2473, 2474f
bone tumors
ankle and foot of, 2342
of knee, 2460
of lower leg, 2423
conjoined twins, 3093
debridement of soft tissue infections of lower leg, 2427
femoral bone debridement, 2507
forefoot reconstruction, 2365
free flaps, 2487
reconstruction of heel and plantar defects, 2380
soft tissue defects of thigh, 2522
medial plantar flap, 2374
open fractures, 2468
orbital roof fractures, 840, 840f
osteomyelitis, 2353, 2468
peroneal nerve injury, 2411
radial tunnel decompression, 2000
scapholunate instability, 1853
soft tissue tumors

knee, 2457, 2457f
lower leg, 2339, 2421
thigh, 2498
tibial nerve, 2452
ulnar tunnel syndrome, 1988
Magnetic resonance neurography, nerve repair and graft, 2006
Malar fat grafting, fat grafting for periorbital rejuvenation, 162
Malar implants
anatomy, 392, 392f
complications, 396
definition, 392
imaging, 393
intraoral approach, 395, 395f
merits and demerits, 396b
nonoperative management, 393
outcomes, 396, 396f–397f
pathogenesis, 392–393, 393f
patient history and physical findings, 393
periorbital approach, 394, 394f
postoperative care, 396
preoperative preparation, 394b
surgical management, 393–394
approach, 394
positioning, 394
preoperative planning, 393, 393f
Malar region, filler injection in
anatomy, 26
complications, 28
definition, 26
imaging, 27
merits and demerits, 28b
nonoperative management, 27
outcomes, 27f, 28

pathogenesis, 26–27
patient history and physical findings, 27
postoperative care, 27
surgical management, 27
techniques, 27b
Male pattern baldness (MPB), 416–417
Malignant bone tumors, of foot and ankle, 2342
calcaneus, 2345, 2346f
distal fibula resection, 2343–2344, 2344f
distal tibia, 2346–2347, 2347f
first metatarsal, 2344, 2344f–2345f
general principles, 2343
Malignant melanoma, 2383, 2735
Malignant peripheral nerve sheath tumors (MPNST), 2421,
2752–2753
Malleable retractors, 834
Mallet scale, 2949
Malocclusion, Le Fort I fractures, 892
Mandible
anatomy, 712, 712f
complications, 717
definition, 712
differential diagnosis, 713–714
exposure, 714, 714f
imaging, 713
implants
anatomy, 398, 399f
assessment and contour, 402
closure, 402, 402f
complications, 403–404
definition, 398
imaging, 398, 399f
incision, 400, 400f–401f

merits and demerits, 402b
nonoperative management, 398
outcomes, 403, 403f–405f
patient history and physical findings, 398
positioning, 399
positioning and fixation, 401, 401f–402f
postoperative care, 403, 403f
preoperative planning, 399
preoperative preparation, 400
intraoral osteotomies
inferior osteotomy, 715, 715f
mandible repositioning, 715, 716f
setback procedure, 714
superior osteotomy, 715, 715f, 716f
merits and demerits, 714b
nonoperative management, 714
ostetomy, 727f
outcomes, 717
panfacial fractures, 934
pathogenesis and natural history, 713
patient history and physical findings, 713
postoperative care, 717
surgical management
patient positioning, 714–717
preoperative planning, 714
Mandible fractures
maxillomandibular fixation of
anatomy, 903, 903f
arch bars, 904, 904f
complications, 906
definition, 903
edentulous patients, special considerations in, 905
imaging, 903

merits and demerits, 905b
pathogenesis, 903
patient history and physical findings, 903
postoperative care, 906
rapid fixation hybrid MMF systems, 905
screws, 905, 905f
surgical management, 903–906
open treatment of
anatomy, 907, 907f–908f
angle and ramus fractures, 911–912
atrophic/edentulous mandible, fractures of, 913
body fractures, 911
complications, 914
condylar and subcondylar fractures, 912–913, 912f
coronoid fractures, 913
definition, 907
exposure, 909, 909f
external fixation, 913, 913f
fracture reduction, initial approaches to, 910
imaging, 908
merits and demerits, 914b
nonoperative management, 908
pathogenesis, 907–908
patient history and physical findings, 908
plate application, 910, 910f
postoperative care, 914
surgical management, 908–909
symphysis/parasymphysis, 910
Mandible fractures, open treatment of, 911–912, 911f–912f
Mandible reconstruction
anatomy, 1022, 1022f
fibula flap with templates
anatomy, 1030

closing wedge osteotomies, 1034–1035, 1034f
complications, 1036
creating anatomic templates, 1031, 1032f
definition, 1030
fibula flap elevation, 1032–1033
imaging, 1030
maintaining native condyle position and occlusion, 1031
merits and demerits, 1031b
outcomes, 1035, 1036f
patient history and physical findings, 1030
postoperative care, 1035
surgical management, 1030–1031
with fibula free flap, CAD/CAM techniques
anatomy, 1022f, 1023
complications, 1029
definition, 1022
dental implants, 1027
fibula flap harvest, 1025–1026
fibula flap osteotomy, 1026–1027, 1026f
flap inset, 1027
imaging, 1023–1024, 1024f
mandibular osteotomy, 1026
merits and demerits, 1025b
microsurgical anastomosis, 1027
outcomes, 1029, 1029f
pathogenesis, 1023
patient history and physical findings, 1023
postoperative care, 1028–1029
surgical management, 1024–1025
with scapula flap
anatomy, 1037–1038
bone harvest, 1041–1043, 1042f–1043f
definition, 1037

diagnostic studies, 1038
flap variations, 1044, 1044f
imaging, 1038
latissimus dorsi muscle, 1041
merits and demerits, 1040b
outcomes, 1045
patient history and physical findings, 1038
postoperative care, 1045
preparation and inset of the flap, 1043
recipient site preparation, 1040
skin flap harvest, 1040, 1041f
surgical management, 1038–1040
Mandibular asymmetry, 699
Mandibular branches, skin-only face and neck lifting, 196
Mandibular coronoid fractures
management of
anatomy, 923
approach, 923
complications, 926
coronoidectomy, 925, 925f
definition, 923
differential diagnosis, 923
imaging, 923, 924f
merits and demerits, 926b
nonoperative management, 923
outcomes, 926
pathogenesis, 923
patient history and physical findings, 923
positioning, 923
postoperative care, 926
preoperative planning, 923
surgical management, 923
ORIF via modified retromandibular approach, 924, 925f

Mandibular defects
anatomy, 663
BSSO
anatomy, 697–698
angle occlusal classification, 697–698
completion process, 704
complications, 705
Dal Pont modification, 697
definition, 697
differential diagnosis, 698
exposure, 700, 700f–701f
Hunsuck modification, 697
imaging, 698
medial ramus, 701, 701f–702f
merits and demerits, 700b
nonoperative management, 699
occlusal correction and maxillomandibular fixation, 702,
702f–703f
outcomes, 705
pathogenesis, 698
patient history and physical findings, 698
postoperative care, 705
rigid fixation, 703
surgical management, 699–705, 700f
causes of, 1023, 1023f
delayed repair with nonvascularized bone graft, 1038
imaging, 664
latissimus dorsi muscle, 1038
merits and demerits, 666b
natural history, 664
osteocutaneous fibula flap, 1038
osteocutaneous radial forearm flap, 1038
osteocutaneous scapula flap, 1038

outcomes, 668
patient history and physical findings, 664
pedicle or free myocutaneous flap, 1038
postoperative care, 668
surgical management, 665, 665f
surgical technique, 667
vascularized iliac crest flap, 1038
vascularized medial femoral condyle corticoperiosteal flap, 1038
Mandibular distraction osteogenesis (MDO), 723, 2691
Mandibular foramen, 1022
Mandibular hypoplasia, 672, 672f, 718
Mandibular nerve, 966, 966f
Mandibular reconstruction, osteocutaneous parascapular flap
anatomy, 683, 683f
bone flap creation, 686–687, 687f
complications, 690
definition, 683
facial atrophy, reconstruction, 688, 689f
flap contouring and inset, 687, 688f
flap design, 685–687, 685f
imaging, 683
merits and demerits, 685b
outcomes, 690
patient history and physical findings, 683
postoperative care, 690
soft tissue dissection, 685, 686f
surgical management, 683–690
vascular pedicle dissection, 687, 687f
Mandibular setback
anatomy, 739
BSSO procedure, 740, 740f
chin reduction, 407, 407f
complications, 749, 749f

definition, 739
differential diagnosis, 740
imaging, 740
merits and demerits, 741b
nonoperative management, 740
outcomes, 749
pathogenesis and natural history, 739
patient history and physical findings, 739
postoperative care, 749
surgical management
intraoral approach, 740–749
patient positioning, 740, 740f
preoperative planning, 740
surgical technique
condylar patient positioning and rigid fixation, 747f, 746
surgical technique
bony interference, removal, 746, 746f
completion process, 748
exposure, 741, 741f–742f
mandibular osteotomy and split, 743, 744f–745f
maxillomandibular fixation, 745, 745f
medial ramus osteotomy, 742, 742f–743f
occlusal correction, 745, 745f
Mandibular surgery
anatomy, 706
combined extraoral-intraoral inverted L osteotomy, 709–710, 710f
complications, 711
definition, 706
differential diagnosis, 706
extraoral inverted L osteotomy
exposure, 707–709, 708f
osteotomy, 707–709, 709f
imaging, 706

intraoral inverted L osteotomy, 710, 710f
merits and demerits, 707b
neonates and children, 706
postoperative care, 711
skeletally mature patients, 706
surgical management
approach, 707
patient positioning, 707, 707f
preoperative planning, 706
Mandibulo-maxillary fixation (MMF), 1031
Mandibuloplasty, chin reduction, 407–408, 408f
Mangled Extremity Severity Score (MESS), 2394
Mannerfelt lesion, 1934
Manson Classification of NOE fractures, 866–867, 867f
Manson’s classification, 951
Marcaine, 186, 511, 995, 1322, 2698
Marcus Gunn jaw-winking ptosis, 2850
Margin reflex distance (MRD), 115, 2850
Marginal ear defects, 1134–1135, 1134f, 1135f
Marginal skin necrosis, deep plane face-lift, 237
Marionette lines, fillers injection, 12
anatomy, 37, 37f–38f
complications, 40
definition, 37
merits and demerits, 40b
nonoperative management, 38
outcomes, 40, 40f–41f
patient history and physical findings, 37–38
postoperative care, 40
techniques, 38b
Maryland Foot Score, 2455
Masseter for innervation, of free muscle flap
anatomy, 2919, 2919f

complications, 2923
definition, 2919
imaging, 2920
merits and demerits, 2922b
outcomes, 2922–2923
pathogenesis, 2919
patient history and physical findings, 2919–2920
postoperative care, 2922
surgical management
approach, 2920
patient position, 2920, 2920f
preoperative planning, 2920
Masseteric cutaneous ligaments, 196, 206f, 215
Masseter-to-facial nerve transfer
anatomy, 2924–2925
antegrade, with distal, selective, facial nerve branch transection,
2928–2929, 2929f
complications, 2931
with cross face nerve grafts, 2930, 2930f
definition, 2924
with fascia lata grafts, 2930
imaging, 2925
merits and demerits, 2930b
outcomes, 2931
pathogenesis, 2925
patient history and physical findings, 2925
postoperative care, 2930–2931
retrograde, 2926–2927, 2926f, 2927f, 2928f
surgical management
approach, 2926
patient position, 2925–2926, 2925f
preoperative planning, 2925
Mastectomy

skin necrosis, 1379
with skin reduction after massive weight loss, 1637, 1637f
Mastication, 398
Mastisol, 314, 754, 754f, 863, 1348
Mastopexy
anatomy, 1331
complications, 1338
definition, 1331, 1331f
differential diagnosis, 1332
imaging, 1332
merits and demerits, 1333b, 1337b
outcomes, 1338
pathogenesis, 1331
patient history and physical findings, 1331
postoperative care, 1338
surgical management
patient positioning, 1333
preoperative planning, 1332–1333, 1332f
Mathes flap, 2369–2370
Mattress sutures placement, in prominent ears, 2838, 2839f
Maxilla
anatomy, osseous, 571, 571f
segmental Le Fort I advancement
closure, 599
down-fracture, 597
fixation, 599, 599f
Le Fort I osteotomy, 596–597, 597f
MMF and alar base width, 599
segmentation, 597–598, 598f
transverse expansion and advancement, 598
surgical management, vertical patient positioning, 579, 579f–580f
Maxilla, anatomy, 2606, 2607f
Maxillary antrostomy, 804, 805f

Maxillary fractures, Le Fort III fracture, 897
Maxillary hypoplasia, 584, 584f
Maxillary nerve, 966, 966f
Maxillary reconstruction, soft tissue flaps
anatomy, 1011–1012, 1011f–1012f
complications, 1021
definition, 1011
eyelids, 1019
imaging, 1012
merits and demerits, 1015b
nonoperative management, 1012–1013
nose, 1019
outcomes, 1020–1021
pathogenesis, 1012
patient history and physical findings, 1012
postoperative care, 1020
surgical management, 1013–1015
type I (limited maxillectomy) defect, 1013, 1013f–1014f,
1015–1016
type II (subtotal maxillectomy) defect, 1013, 1016
type III (total maxillectomy) defect, 1013, 1016–1019
type IV defect (orbitomaxillectomy), 1013, 1019
upper lip and oral commissure, 1019
Maxillary region, panfacial fractures, 934
Maxillary transverse deficiency, 562, 562f
Maxillomandibular fixation (MMF)
anatomy, 1052
complications, 1054
definition, 1052
imaging, 1052, 1052f
Le Fort I fracture, 891, 891f
Le Fort II fracture, 894
of mandible fractures

anatomy, 903, 903f
arch bars, 904, 904f
complications, 906
definition, 903
edentulous patients, special considerations in, 905
imaging, 903
merits and demerits, 905b
pathogenesis, 903
patient history and physical findings, 903
postoperative care, 906
rapid fixation hybrid MMF systems, 905
screws, 905, 905f
surgical management, 903–906
merits and demerits, 1053b
occlusion, 1052, 1052f
outcomes, 1054
patient history and physical finding, 1052
pediatric mandible fractures, 958–959, 962–964
postoperative care, 1053–1054, 1053f
surgical management, 1052, 1052f
techniques, 1053, 1053f
Mayfield’s stages, perilunat injuries, 1857, 1858f
MCA (middle collateral artery), 2134
McCoy facial trisquare, 885, 885f
MCFA (medical crura footplate approximation), 373, 384
MCL (medial collateral ligament), 2465, 2473
MCP. See Metacarpophalangeal (MCP) joint
MCP (metacarpophalangeal) joint, 2107
MDO (mandibular distraction osteogenesis), 723, 2691
Mechanical dermabrasion, 67, 68f
Mechanical ectropions, 1104
Mechanical ptosis, 2850
Medial antebrachial cutaneous (MABC) nerve, 1994

Medial canthal tendon, 830
Medial epicondyle, 1992, 1992f
Medial femoral condyle microvascular flap, 1883–1885, 1884f
Medial gastrocnemius rotational flap, 2476f
Medial hemisoleus muscle flap, 2446–2447, 2447f
distally based, 2448–2449, 2448f
proximally based, 2447, 2447f, 2449
Medial inframalleolar perforator flap, 2794, 2795f
Medial intermuscular septum, 1992, 1992f
Medial knee soft tissue wound, 2484f
Medial lip element
anatomy, 2606
dissection, 2600f, 2602
hypoplastic, 2650–2651
Millard/Mohler modifications
C flap and M flap, 2608, 2608f–2609f
dissection, 2609, 2610f
markings, 2607, 2608f–2609f
Medial malleolar chronic wound, 2353f
Medial nasolabial element
measurements and interpositional triangle, 2598, 2599f
vermilion, Cupid’s bow, and nose, 2597–2598, 2598f
Medial orbit composite unit translocation, 2749–2750, 2749f
Medial orbit wall fractures
anatomy, 829–831
bony, 829–830, 829f
soft tissue, 830–831, 830f
complications, 837
definition, 829
differential diagnosis, 832
exposure, 833–834, 834f
fracture repair, 835, 835f
graft harvest, 835

imaging, 831, 832f
merits and demerits, 836b
natural history and physical findings, 831
nonoperative management, 832
outcomes, 837
pathogenesis, 831
postoperative care, 837
surgical management, 832–833, 833t, 833b
positioning, 833
preoperative planning, 832–833
Medial osseous flap, 1039
Medial parapatellar approach, 2469
Medial plantar artery for recipient vessel
Medial plantar flap
anatomy, 2373, 2373f–2374f
complications, 2377
definition, 2373
design of, 2373f–2374f
donor site closure, 2374, 2376f
harvest, 2375, 2375f
imaging, 2374
merits and demerits, 2376b
outcomes, 2376–2377
patient history, 2373–2374
patient positioning, 2374
physical findings, 2373–2374
postoperative care, 2376
surgical management
heel defect, 2374, 2376f–2377f
preoperative planning, 2374
Medial rectus muscle, medial orbit wall fractures, 831
Medial sural artery, approach to, 2488
Medial sural artery perforator flap (MSAP), 1211

Medial thighplasty, mons pubis, conjunction with, 1642, 1643f
Medially based cervicofacial flap
arterial blood supply, 1103, 1103f–1104f
complications, 1107
deep-plane elevation or tissue expansion, 1103
definition, 1103, 1103f
desmoplastic melanoma, 1105, 1106f
dissection, 1105, 1106f
dog-ear excision, in inferomedial portion, 1106, 1106f
imaging, 1104
markings, 1105, 1106f
merits and demerits, 1105b
outcomes, 1107, 1107f–1108f
patient history and physical findings, 1103–1104
postoperative care, 1107
reconstructive zones, 1103
surgical management
approach, 1104
patient positioning, 1104
preoperative planning, 1104
Median nerve
anatomy, 1754, 1754f–1755f
identification, decompression and dissection, 2048f, 2050
local anesthesia at wrist, 1758, 1758f
Median nerve palsy
definition, 2012
tendon transfers
anatomy, 2012
approach, 2013
complications, 2017
differential diagnosis, 2013
imaging, 2013
merits and demerits, 2013b, 2017b

natural history, 2012
nonoperative management, 2013
outcomes, 2017
pathogenesis, 2012
patient history and physical findings, 2012
patient positioning, 2013
postoperative care, 2017
preoperative planning, 2013
surgical management, 2013
Medical crura footplate approximation (MCFA), 373, 384
Medpor porous polyethylene malar implants, 393, 393f
Melanoma
anatomy, 2303
complications, 2308
definition, 2303
desmoplastic, 1105, 1106f
differential diagnosis, 2304
imaging, 2304
on left heel, 2383
merits and demerits, 2307b
nasolabial flap, 1070
natural history, 2303
outcomes, 2308
pathogenesis, 2303
patient history and physical findings, 2304, 2304f
postoperative care, 2308
surgical management, 2305
Meningocele, 2745
Meningoencephalocele, 2745
Mental nerve, 1047
anatomy, 966, 966f
neurofibromatosis, 2756, 2757f
surgical management, intraoral approach, 971, 971f

Mentalis dysfunction, 391
Mentalis muscle, 1073, 1073f
Mepivacaine, 2329
Mesh placement
determining plane of, 1724, 1724f
and muscle approximation, 1724, 1724f, 1725f
Mesotherapy, 419
Metacarpal capsulodesis, 2020, 2021f
Metacarpal enchondroma. See Enchondroma
Metacarpal fractures
anatomy and, 1787
base/CMC fracture, 1787
complications, 1795
definition, 1787
head fractures, 1787
imaging, 1787
merits and demerits, 1795b
neck fractures
closed reduction and pinning of, 1788–1789, 1788f–1789f
definition, 1787
Jahss technique, 1788, 1788f–1789f
natural history, 1787
nonoperative management, 1787–1788
open reduction and internal fixation headless compression
screws, 1789, 1790f
pathogenesis, 1787
surgical management, 1788
outcomes, 1795
patient history and physical findings, 1792
postoperative care, 1795
shaft fractures
closed reduction and pinning, 1791, 1791f
nonoperative management, 1787–1788

open reduction and internal fixation, 1792–1793, 1792f
pathogenesis, 1787
surgical management, 1788
surgical management
approach, 1788
patient positioning, 1788
preoperative planning, 1788
Metacarpophalangeal (MCP) joint
cross intrinsic transfer, 1950, 1950f
planned skin incision over, 1950, 1951f
rheumatoid deformities of (see Swan-neck deformity)
silicone arthroplasty, 1948, 1949f, 1953, 1954f
ulnar collateral ligament of thumb
acute repair, reconstruction of, 1804, 1804f
anatomy, 1802, 1802f
chronic repair, reconstruction of, 1805–1808, 1806f, 1807f,
1808f
complications, 1809
differential diagnosis, 1803
merits and demerits, 1809b
nonoperative management, 1803
postoperative care, 1809
provocative testing, 1803
Metaphyseal fragments, 2468
Methicillin-resistant Staphylococcus aureus (MRSA), 2336
Methotrexate (MTX), 1939–1940
Meticulous hemostasis, 812, 2443, 2774
Metopic synostosis
anatomy, 434
craniosynostosis, 531
definition, 434
fronto-orbital distraction, 448–449, 449f
natural history, 445

orbital roof osteotomy, 441
patient history and physical findings, 434–435
resorbable plate, 441, 441f
Metzenbaum dissecting scissors, 1751
MFUS. See Microfocused ultrasound (MFUS)
Microanastomosis, with temporary inset, 2385, 2385f, 2490
Microfat injections, upper and lower blepharoplasty with
anatomy, 171
complications, 176, 177f
definition, 170
differential diagnosis, 172
merits and demerits, 176b
nonoperative management, 172
outcomes, 176
pathogenesis, 171–172
patient history and physical findings, 172, 172f
postoperative care, 176
surgical management, 172
techniques, 174, 174f
Microfocused ultrasound (MFUS)
anatomy, 257
complications, 261–262
definition, 257
differential diagnosis, 257
imaging, 257
merits and demerits, 260b
nonsurgical management, 258
approach, 258
positioning, 258
preoperative planning, 258
outcomes, 260–261
patient history and physical findings, 257
postoperative care, 260

surgical management, 257
techniques, 259
Microform clefts, 2606
Micrognathia
anatomy, 723, 723f
complications, 731, 732f
definition, 723
differential diagnosis, 724
external mandibular distraction
with pins, 725–726, 725f, 726f, 727f
with rigid external device, 727–728, 728f–729f
imaging, 724, 724f
merits and demerits, 725b
nonoperative management, 724
outcomes, 730–731, 731f
pathogenesis and natural history, 723
patient history and physical findings, 724
postoperative care, 730, 730f
surgical management
approach, 725
patient positioning, 725
preoperative planning, 724
Microphthalmia
management
anatomy, 2877
complications, 2885
definition, 2877
diagnostic studies, 2878
imaging, 2878
merits and demerits, 2884b
natural history, 2877, 2878f
nonoperative management, 2878–2879, 2878f–2881f
outcomes, 2885

pathogenesis, 2877
patient history and physical findings, 2877–2878
surgical management, 2880
orbital expansion for
anatomy, 555, 556f
complications, 560
definition, 555
differential diagnosis, 557
expander inflation and closure, 559
exposure and orbitotomy, 558, 559f
imaging, 556–557, 557f
merits and demerits, 558b
natural history, 555
nonoperative management, 557
orbital tissue expander and microport placement, 559, 559f
outcomes, 560
pathogenesis, 555
patient history and physical findings, 556, 557f
postoperative care, 560
surgical management, 558–560, 558f
Micropigmentation, 419
Microsurgery, for scalp flaps, 987, 987f
Microsurgical anastomosis, 1027
Microtia, auricular reconstruction for
anatomy, 2815, 2815f, 2816f
anesthesia, 2817
complications, 2819f, 2820
definition, 2815
framework, 2815f, 2816f, 2817–2818
graft harvest, 2817
markings, 2817
merits and demerits, 2819b
outcomes, 2818f, 2820

pathogenesis, 2815
patient history and physical findings, 2815–2816
patient transfer, 2818
postoperative care, 2819
second stage, 2819, 2819f
surgical management, 2816–2817
preoperative planning, 2816–2817, 2817f
variable presentation of, 2815f
Microvascular anastomosis, 2165, 2166f, 2435, 2442–2443, 2443f,
2515
Microvascular free flap, soft tissue coverage of lower leg, 2387
anatomy, 2438
anterior tibial vessels for recipient vessel.
assessment of defect, 2442
complications, 2445
definition, 2438
distal third of leg, 2438
final inset, 2443, 2443f
flap harvest, 2442, 2442f
imaging, 2440
main arteries and veins, 2438f–2439f
medial sural vessels as recipient vessel, 2439f–2440f
merits and demerits, 2444b
microanastomosis with temporary inset, 2442–2443, 2443f
middle third of leg, 2438
outcomes, 2444, 2444f–2445f
patient history and physical findings, 2440
peroneal artery perforators for recipient vessel
peroneal vessels for recipient vessel
posterior tibial vessels for recipient vessel
postoperative care, 2444
recipient vessel preparation, 2441, 2441f
surgical management, 2440–2441

donor site morbidity, 2440
flap thickness, 2440
patient positioning, 2441, 2441f
preoperative planning, 2440, 2441f
upper third of lower leg, 2438
wound preparation, 2441, 2441f
MICS (minimally invasive component separation), 1566–1567,
1566f
Midabdominal defects, 1589
Midazolam, 2328
Midcarpal injections, 1860
Middle nasal vault, 318, 318f
Middle temporal vein, 37f–38f
Midface aging, 27
Midface hypolasia, Le Fort III osteotomy
access, 636, 636f
anatomy, 634, 634f
definition, 634
differential diagnosis, 635
distraction protocol, 639
extended transconjunctival incision, 636–637, 636f, 637f
imaging, 635, 635f
lateral orbitotomy, 637, 638f
merits and demerits, 637b
nasofrontal osteotomy, 637, 638f
natural history, 634
nonoperative management, 635
outcomes, 640, 640f–641f
pathogenesis, 634
patient history and physical findings, 635
postoperative care, 640
pterygomaxillary osteotomy, 638, 638f
rigid external device placement, 638, 639f