Operative Technique in Plastic Surgery – Kevin C.Chung

ester formulations available at the time.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Eliciting relevant patient history and performing a physical exam prior to the
use of any anesthetic agent are crucial to ensure patient safety and minimize
complications.
■ Patient history
■ Determine medication allergies and prior exposure to injectable or topical
anesthetics.
■ Obtain an up-to-date list of the patient’s medications including over-the-
counter herbs and agents to avoid potential interactions, particularly with
drugs metabolized through the liver.
■ A detailed medical history should be elicited, with particular attention to
cardiac, renal, liver, and neurologic diseases.
■ Relative contraindications
■ Hypersensitivity to the agent (particularly esters)
■ Application of a topical agent to the skin with impaired barrier function
■ G6PD (glucose-6-phosphate dehydrogenase) enzyme deficiency with the use
of EMLA (eutectic mixture of local anesthetics)
■ Significant cardiac or hepatic disease
■ Use of class I antiarrhythmic (tocainide, mexiletine)
Table 1 Anesthetics Used for Local Infiltration
Anesthetic
Onset
(min)
Duration (min)
Max Recommended
Dose (Adults)
Without
Epinephrine
With
Epinephrine
Without
Epinephrine
With
Epinephrine
Amides
Articaine
2–4
30–120
60–240
5.0 mg/kg
or 350 mg
7.0 mg/kg
or 500 mg
Bupivacaine
2–10
120–240
240–480
2.5 mg/kg
or 175 mg
3.0 mg/kg
or 225 mg
Etidocaine
3–5
200
240–360
4.5 mg/kg
or 300 mg
6.5 mg/kg
or 400 mg
Lidocaine
<1
30–120
60–400
4.5 mg/kg
7.0 mg/kg

or 300 mg
or 500 mg
Mepivacaine
3–20
30–120
60–400
6.0 mg/kg
or 400 mg
7.0 mg/kg
or 550 mg
Prilocaine
5–6
30–120
60–400
7.0 mg/kg
or 400 mg
10.0 mg/kg
or 600 mg
Esters
Chloroprocaine
5–6
30–60
N/A
11.0 mg/kg
or 800 mg
14.0 mg/kg
or 1000 mg
Procaine
5
15–90
30–180
10.0 mg/kg
14.0 mg/kg
Tetracaine
7
120–240
240–480
2.0 mg/kg
2.0 mg/kg
Reprinted from Kouba DJ, LoPiccolo MC, Alam M, et al. Guidelines for the use of local anesthesia
in office-based dermatologic surgery. J Am Acad Dermatol. 2016;74:1201-1219; copyright ©
2016, with permission from Elsevier.
■ Use of EMLA in infants under 1 month of age (increased risk of
methemoglobinemia)
■ Lidocaine is pregnancy category B; however, lidocaine is excreted in breast
milk; therefore, caution is advised for use in breast-feeding mothers.
■ Ocular exposure with EMLA should be avoided due to the presence of
sodium hydroxide and the potential for alkaline injury.
■ Caution is advised with concomitant use of EMLA and certain
methemoglobinemia-inducing medications such as acetaminophen,
anesthetics (prilocaine and benzocaine), anticonvulsants, antimalarials,
nitrates, sulfonamides, and aniline dyes.
■ Physical examination
■ Ensure there is no skin breakdown or signs of infection or inflammatory
lesions in areas where the agent will be applied/injected.
■ Selection of agent
■ Based on the anticipated procedure, the anesthetic is selected by taking into
account the need for topical vs injectable modality, duration of the agent, and
location of the procedure.
■ The level of preprocedure patient anxiety should also be assessed and may
determine the agent and application type used.
SURGICAL MANAGEMENT
■ Facial anesthesia is necessary for a variety of different cutaneous procedures,
including skin biopsies, excisions, Mohs micrographic surgery, surgical

reconstruction, and laser and light-based therapies for facial resurfacing, scar
revision, or lesion ablation.
■ The decision to use an anesthetic and the selection of the agent is dependent
partially on the type of procedure performed and the anticipated degree of
discomfort.
■ Facial nerve blocks are commonly implemented for ablative laser resurfacing
of the entire face; however, there are reports of regional cutaneous nerve
blocks for larger pigmented or vascular facial lesions as well.
■ Regional nerve blocks hold the advantage of minimizing significant tissue
distortion, using less total volume of medication, and less patient discomfort,
but they are more challenging to administer.
■ Tumescent anesthesia is a form of local anesthesia using large volumes of
highly dilute anesthetic delivered subcutaneously, first described by Dr. Jeffrey
Klein in the 1980s.
■ It can be used alone or with various levels of sedation based on the intended
procedure.
■ While there is a wide range of usages for tumescent anesthesia, face and neck
uses generally include liposuction, face and neck lifts, dermabrasion, and full-
face laser resurfacing.
■ Lower volumes of fluid are infiltrated into the face (100–150 mL per side)
when compared with body infiltration, so the concentration of lidocaine may
be higher for facial procedures.3
Preoperative Planning
■ Obtain an accurate patient weight to calculate the maximum allotted anesthetic
dose especially for procedures requiring larger volumes.
■ Lidocaine toxicity is dose dependent, and it is critical to remain below the
calculated maximum dose.
■ It is also important to take into consideration individual patient characteristics
as frail, elderly patients or those with underlying liver malfunction may require
lower dosages.
■ The maximum allotted dose of plain lidocaine for an adult patient is 4.5 mg/kg
for whom the addition of epinephrine allows for up to 7 mg/kg4 (see Table 1).
■ The WiMP formula may also be used for ease of calculating maximum allotted
dosages as long as the patient’s weight, maximum dosage, and percentage
concentration of the agent are known.5

■ V (mL) = (weight (kg) × 0.1 × maximum dose (mg/kg))/percentage
concentration
Positioning
■ Positioning is key to establishing both patient and provider comfort during the
procedure.
■ Ideally, the patient should be comfortably seated on the exam table with the
table leaning back and the feet propped up to minimize a vasovagal reaction.
■ The patient’s head should be firmly rested against the back of the table to
allow for stabilization and minimize sudden movements when the needle is
injected.
■ It is best when injecting if the patient’s eyes are closed so they do not
unintentionally pull away if they visualize the needle.
■ For the surgeon, the table needs to be at an appropriate height, and the patient
needs to be positioned closer to the surgeon’s side of the table to avoid
excessive bending or reaching.
■ The patient’s skin is held taut by either the surgeon’s nondominant hand or an
assistant.
■ The surgeon’s nondominant hand may be used to stabilize the dominant hand
during the injection. Alternatively, the surgeon may rest a few fingers of his or
her dominant hand on other parts of the patient’s face to stabilize self.
■ If an assistant is present, care must be taken to ensure the assistant is far
enough from the anticipated injection target to avoid accidental needlestick
injury should a sudden movement occur.
■ Additionally, the surgeon should be positioned so the needle is facing away
from critical anatomic structures such as the globe of the eye to avoid an
accidental puncture with unanticipated patient movement.
Approach
■ Topical agents
■ The topical anesthetic agents encompass a wide variety of noninvasive,
painless products, which are commonly used prior to minimally invasive
cosmetic procedures.
■ Topical lidocaine and EMLA (eutectic mixture of local anesthetics) are the
two most commonly used topical agents.
■ Lidocaine is available in many formulations including cream, viscous

solution, jelly, ointment, spray, and patches.
■ Due to its unique liposomal delivery system to enhance penetration through
the stratum corneum, lidocaine 4% cream (LMX-4, Ferndale Laboratories,
Ferndale, MI) has the advantage of ease of application without occlusion,
more rapid onset compared to EMLA (Astra Pharmaceuticals, Westborough,
MA), and availability without a prescription.
■ EMLA is a eutectic mixture of 2.5% lidocaine and 2.5% prilocaine
hydrochloride. EMLA is applied to intact skin, under occlusion, for a
minimum of 1 hour to facilitate absorption.
■ The depth of anesthesia is directly proportional to the duration of time the
product is left in place, with maximum clinical anesthesia achieved at 2 to 3
hours and clinical effect remaining around 1 to 2 hours post removal of
product.6
■ EMLA is safe for use in pediatric and adult populations, and the dosing is
largely based on weight and surface area. The manufacturer recommends a
dose of 2 g of EMLA per 10 cm6 for 2 hours. The maximum recommended
dose is 60 g applied to 400 cm6 of normal skin.
■ Caution with either product should be exercised with use over large surface
areas as prolonged application, large surface area, occlusion, and high
concentrations increase the risk for cardiotoxicity and central nervous system
toxicity.
■ Injectable agents
■ Lidocaine and bupivacaine are the two most commonly used injectable
agents. Lidocaine has a rapid onset of action, generally less than 1 minute,
and lasts on average from 30 to 120 minutes, longer with the addition of
epinephrine.4
■ Bupivacaine is a slower-acting agent, with a 2- to 10-minute onset; however,
it has one of the longest durations of action, lasting 120 to 240 minutes
without epinephrine. Because of the longer duration of action, bupivacaine is
commonly used in lengthy surgical procedures, but its risk of cardiac and
neurologic toxicity remains a concern.
■ Ropivacaine and levobupivacaine are two newer amide anesthetics that have
a similar duration of action to bupivacaine with fewer cardiotoxic and central
nervous system effects and less pain on injection when compared to lidocaine
with epinephrine.
■ Infiltrative anesthesia may be combined with other forms of anesthesia such as
topical, nerve block, or tumescent for larger or more complex cutaneous

procedures.
■ Smaller needle sizes, such as 30 or 32 gauge, should be used, and needles
should be replaced frequently to reduce pain on injection.
■ Additions to injectable anesthetics such as epinephrine, hyaluronidase, and
bicarbonate that can enhance efficacy and/or improve patient comfort will be
discussed in another section.
T E C H N I Q U E S
■ Local Infiltration
■ Prep the surrounding skin with an antiseptic agent such as alcohol, Betadine,
or chlorhexidine immediately prior to injection.
■ Stretch the surrounding skin and stabilize the needle with the nondominant
hand.
■ Quickly pierce the skin with the tip of the needle at a 90-degree angle
(TECH FIG 1).
■ Injection through an enlarged pore or follicle may minimize patient-
perceived pain.
■ Aspirate the needle prior to product infiltration to avoid intravascular
injection and minimize risk for toxicity.4
TECH FIG 1 • Piercing the skin at a 90-degree angle
irritates fewer nerve fibers, thereby reducing injection
pain.
■ Advance the needle tip deep/subdermally first and deposit about 0.5 mL of
anesthetic agent.
■ Be sure to inject slowly as rapid infiltration and cutaneous distention
contribute to increased pain.
■ Pause for about 30 seconds, and move the needle more superficially while
injecting more volume.7

■ The needle may be slightly withdrawn and advanced subcutaneously in a
fanlike fashion to continue anesthetizing while minimizing the number of
painful injection points.
■ Once that region is complete, the needle may be fully withdrawn from the
skin and reinserted within 1 cm of the blanched border to continue injecting
along the established area.7
■ Anterograde injection is recommended to keep the wheal before the needle
tip to minimize further pain of the needle.7
■ For larger excisions, it is generally recommended to perform a ring block
with infiltrative anesthesia around the outside of the ellipse, and
supplemental anesthesia may be added centrally only where needed upon
testing of the area.
■ Using a longer needle to inject deep into the fascial plane or having
additional syringes on hand intraoperatively may be necessary for
supplementation based on the depth of the procedure planned.
■ The lowest possible dose to achieve an anesthetic effect should be used to
avoid toxicity.
■ Facial Nerve Blocks
■ There are a number of facial nerve blocks that can be performed, including
supraorbital, supratrochlear, infraorbital, infratrochlear, mental,
zygomaticofacial, zygomaticotemporal, and external nasal. The most
commonly used are supraorbital, supratrochlear, infraorbital, and mental.
■ Many authors cite the use of 4% articaine hydrochloride with epinephrine as
the preferred agent for facial nerve blocks, but 1% lidocaine with or without
epinephrine or mixtures of 1% lidocaine and 0.25% bupivacaine may also be
used.
■ Generally, 3-mL syringes with small-gauge needles such as 25 or 30 are used
to reduce pain. Occasionally, longer needles such as 30 mm may be used to
ensure product deposition at the targeted foramen.
Supraorbital and Supratrochlear Nerves
■ The supraorbital foramen is located in the mid-pupillary line and is palpated
along the orbital rim.
■ The needle is inserted perpendicular to the skin above the foramen and

advanced until contact is achieved with the supraorbital ridge, with care not
to enter the foramen and cause damage to the nerve (TECH FIG 2).
■ The supratrochlear nerve can be blocked with periosteal injection at the
medial eyebrow and nasal root junction, about 1 cm medial to the
supraorbital foramen.
■ About 0.5 to 3 mL of anesthetic solution is deposited periosteally to each
location after negative aspiration.
Infraorbital Nerve (Video)
Video p3-c001
■ The percutaneous approach for the infraorbital nerve involves palpation of
the infraorbital foramen, located in the mid-pupillary line about 1 cm lateral
to the ipsilateral nasal ala.8 The patient may feel a slight discomfort with
palpation, which assists in identification.
00:00 / 00:00

TECH FIG 2 • Supraorbital nerve block.
■ The injection is placed 1 cm inferior to the foramen, and the needle is
tangentially directed and slowly advanced upward until the approximate
location of the foramen is reached.
■ A small wheal (approximately 0.2 mL) of anesthesia can be placed
subdermally prior to advancing the needle to minimize pain.
■ Alternatively, topical anesthetic agents can be used to reduce injection-
related pain.
• After negative aspiration, a 0.5- to 2.5-mL bolus of anesthetic solution is
very slowly deposited just outside of the foramen.
• It may be helpful for the injector to leave a finger of the nondominant
hand pressed over the foramen for ease of location/identification.
■ Extreme caution is advised to avoid needlestick injury.
• The infraorbital nerve has a slower onset of anesthesia, so it is
recommended that this nerve is anesthetized first.8
■ The intraoral approach to the infraorbital nerve (TECH FIG 3) involves first

locating the foramen by gentle palpation of the overlying skin as described
above.
■ The area is then marked and/or the injector’s finger is kept in place as a
guide.
■ A small wheal (approximately 0.2 mL) of anesthesia is placed in the
mucobuccal fold over the second premolar.
■ The needle is then advanced further upward toward the marked foramen,
remaining parallel to the long axis of the second premolar until the foramen
is reached.
■ After negative aspiration, a 0.5- to 2.5-mL bolus of anesthetic is slowly
placed just outside of the foramen.
TECH FIG 3 • Intraoral approach to infraorbital nerve
block.
Mental Nerve
■ The mental nerve may be reached percutaneously as well, with identification

of the foramen about midway between the upper and lower edges of the
mandible in a direct line with the second bicuspid.
■ A small wheal of anesthesia can be injected subdermally and then the
needle tip advanced until bone is reached.
■ A 0.5- to 2.5-mL bolus of anesthesia is injected just outside of the foramen
after careful negative aspiration to avoid intravascular injection.
■ The intraoral approach for a mental nerve block is more commonly used
(TECH FIG 4).
■ Identify landmarks for the mental foramen, which is caudad to the second
premolar about midway between the tooth and the inferior mandibular
border.
■ While retracting the lower lip, the needle is inserted at the gingival-buccal
border at the base of the first bicuspid and directed parallel to the bicuspid
in the direction of the foramen.
■ After negative aspiration, a 0.5- to 2.5-mL bolus is injected just outside of
the foramen.

TECH FIG 4 • Intraoral approach to mental nerve
block.
■ Tumescent Anesthesia
Dosing
■ Because of the wide variability in the volumes used as well as lidocaine and
epinephrine concentrations, specific recommendations for tumescent
anesthesia are challenging.3
■ Lidocaine is the most commonly used anesthetic agent; however,
bupivacaine or a combination of the two has also been described.
■ The typical compositions for tumescent anesthesia per 1000 mL of normal
0.9% saline or lactated Ringer solution are shown in Table 2.3
■ Some sources recommend higher concentrations in a smaller volume (250
mL) specifically for facial procedures: 600 to 1000 mg lidocaine (0.24%–
0.4%), 1 mg epinephrine, and 5 mEq bicarbonate in 250 mL solution.9
■ The maximum allotted dose is 55 mg/kg of lidocaine in tumescent solution,
though some sources claim that lower dosages such as 35 mg/kg should be
used in patients taking medications that potentially interfere with lidocaine
metabolism.9
■ The physician should remain on high alert for a minimum of 24 hours after
the procedure, as tumescent anesthesia has a delayed peak of activity and
therefore the potential for delayed systemic adverse events.
■ Tumescent infiltrate is ideally warmed to 37°C to 40°C to avoid
hypothermia.9
Procedure3
■ Tumescent fluid is injected with either an 18-gauge-long spinal needle or a
blunt infiltration cannula depending on the size of the case. Either a large
syringe or pneumatic pressure device may be used.
■ Intradermal or subdermal blebs of 1% lidocaine and 1:100 000 epinephrine
are created at the incision sites.
■ A no. 11 blade is used to create 2- to 3-mm incisions. Fluid is infiltrated at a
low rate (50 to 200 mL/min) and is adjusted for patient comfort. Infiltration is
stopped when the infiltrate is about 5 cm beyond the planned procedure site

or when the subcutaneous tissue is firm.
■ Wait about 7 to 10 minutes prior to initiating the procedure.
■ Supplementary lidocaine with epinephrine may need to be injected intra-
/subdermally along incision lines for complete cutaneous anesthesia.
Table 2 Common Tumescent Analgesia Fluid Formula
Medication
Dose Range
Commonly Used Dose (per
1000 mL 0.9% Normal Saline
or Lactated Ringer Solution)
Lidocaine
10 mL of 1% to 60
mL of 2%
50 mL of 1% (500 mg)
Epinephrine (1:100
000)
0.5–2 mL of 1:100
000
1 mL of 1:100 000 (1 mg)
Sodium bicarbonate
(8.4%)
10–12.5 mL
10 mL of 8.4% (840 mg)
From Gutowski KA. Tumescent analgesia in plastic surgery. Plast Reconstr Surg.
2014;134:50S-57S.
■ Additives
■ Certain medications can be added to the main anesthetic agent in order to
optimize efficacy and minimize patient discomfort during the procedure.
■ Epinephrine is often added to local anesthetics for its vasoconstrictive
property to minimize systemic absorption, reduce potential for toxicity,
increase anesthetic duration at the target nerves, and minimize bleeding at the
operative site.
■ 1:100 000 is commonly used in clinical practice, with recent evidence
suggesting that a concentration of 1:200 000 is as effective for facial
procedures.
■ Epinephrine is pregnancy category C and is secreted in breast milk and,
therefore, should be avoided in this group.
■ Sodium bicarbonate is added to some anesthetic solutions because lidocaine
solutions are often acidic, contributing to the pain upon injection.
Bicarbonate increases the pH and reduces the pain associated with product
infiltration. A buffered solution is generally prepared by adding 5 mL of 8.4%
sodium bicarbonate to a 50-mL bottle of 1% lidocaine with 1:100 000

epinephrine, which is an approximate 10:1 dilution.
■ The concentration of epinephrine decreases more rapidly in a buffered
solution; therefore, most practices recommend mixing only minutes to
hours prior to use and avoid storing pre-prepared buffered solution.
However, there was no reduced lidocaine effectiveness after storage for 1
week.
■ In addition, the FDA mandates that sodium bicarbonate is a single-use vial
making stock preparation less feasible.
■ Warming the solution to 98.6°F to 130°F, particularly when combined with
buffering, has been shown to reduce injection-related discomfort.
■ Hyaluronidase promotes diffusion of the anesthetic through digestion of the
extracellular matrix. Analgesic efficacy is improved over a larger surface area
with a mixture of lidocaine and hyaluronidase when compared to lidocaine
alone; however, no increase in onset or duration was observed. This may be
particularly useful in delicate areas such as the eyelid where much lower
volumes of anesthesia are needed to minimize tissue distortion.
■ The mixture is prepared with 0.5 mL (75 IU) of bovine testicular
hyaluronidase added to 0.5 mL of aqueous 0.5% lidocaine hydrochloride
solution.
■ This addition to local anesthesia is safe and does not appear to retard wound
healing.
■ Although allergy to hyaluronidase is exceptionally rare, a preliminary skin
test for hypersensitivity is generally recommended in nonemergent situations.
In addition, it is recommended that patients with known hypersensitivity to
hymenoptera stings avoid hyaluronidase due to potential cross-reactivity.
■ Behavioral and Communication Techniques
■ Often, the only pain a patient perceives during a procedure surrounds the
anesthetizing process and is not related to the actual procedure itself.
■ In addition to the many techniques described above, many behavior or
communication techniques have also been proposed.
■ Distraction or “talkesthesia” is a popular modality that involves talking with
the patient about his or her occupation, hobbies, family, etc. to focus their
mind elsewhere.
■ Physical distraction is another method, such as vibration, slight pinching of

the skin, and tapping alternate body areas in order to activate nearby “touch”
nerve fibers and reduce spinal cord transmission of signals produced by
“pain” fibers.7,10
■ Application of cold or topical anesthesia to the area can reduce the pain of
the needlestick.
■ Always alerting the patient prior to injection is crucial to minimize sudden
movements and improve safety.
PEARLS AND PITFALLS
Assessment
■ Obtain a detailed medical history, medical allergies, and a current
list of medications prior to the use of any anesthetic agent.
■ A complete understanding of facial anatomy is essential in
performing successful peripheral nerve blocks.
Techniques
■ Proper patient positioning is key to minimize chances of a vasovagal
reaction.
■ Surgeon comfort and patient stabilization during injection minimize
risk of unintended needlestick injuries.
■ Injection at a 90-degree angle and into a follicular opening or pore
can minimize needle discomfort.
■ Patient distraction is an essential tool to reduce pain perception.
Additives
■ Epinephrine 1:200 000 has been shown to be as efficacious as 1:100
000 concentration with lower toxicity risk.
■ Epinephrine causes vasoconstriction to prolong anesthesia duration,
minimize systemic absorption, and reduce intraoperative bleeding.
Toxicity
■ Calculating the weight-based maximum allotted dosage of the
anesthetic agent prior to a large procedure is crucial to avoiding
toxicity.
■ The surgeon must be very familiar with signs and symptoms of early
toxicity so appropriate intervention may take place.
■ Stabilizing the patient and initiating basic life support are the first
actions needed if toxicity is suspected.
POSTOPERATIVE CARE
■ Most of the postoperative care is going to be dependent on the type of
procedure that was performed and the anesthetic agent that was used (see Table

1).
■ However, it is important to inform patients that there may be some bruising
and swelling partially due to the infiltration of the anesthesia, particularly in
sensitive regions such as the eye or lips.
■ Patients may need to sleep upright for a few nights to allow downward
drainage with gravity and minimize further pressure/swelling. They can be
reassured that it will improve within a few days.
■ If epinephrine is used with the anesthetic solution, there is a chance of
bleeding once the epinephrine vasoconstrictive effect wears off. Patients should
hold firm continuous pressure for 30 minutes at a time, and pressure dressings
immediately postoperatively are crucial in preventing this complication.
■ If the area around or within the mouth was anesthetized, patients will need to
avoid hot liquids for a few hours until the anesthetic dissipates to avoid
unintentional thermal burns.
COMPLICATIONS
■ Common side effects for topical anesthetic agents2:
■ Pallor
■ Erythema
■ Edema
■ Pruritus
■ Dermatitis
■ Alterations in temperature sensations
■ Common local injection side effects:
■ Pain
■ Erythema
■ Edema
■ Vasovagal reaction
■ Bruising
■ Temporary nerve paralysis: If epinephrine is added, the patient may experience
a “shaky” or “jittery” feeling or palpitations.
■ Toxicity
■ Local anesthetic systemic toxicity (LAST) largely occurs with inadvertent
overdose, intravascular injection, and abnormal product metabolism and can
be largely avoided with a thorough history and safe injection techniques.
■ Signs and symptoms of lidocaine toxicity are dose dependent and occur as

follows:
• Above 3 g/mL: nonspecific dizziness and drowsiness
• Above 5 μg/mL: perioral paresthesias, tinnitus, muscle fasciculation
• Above 9 μg/mL: fatal, seizures, coma, respiratory and cardiac arrest
■ To minimize toxicity, the correct weight-based dosage should be calculated
prior to the procedure either using the maximum recommended dosages for
lidocaine based on additives (see Table 1) or by using the WiMP formula
(discussed in the Preoperative Planning section).
■ The maximum lidocaine dose in tumescent anesthesia is 55 mg/kg.
■ Using the lowest recommended dosage and continuous communication with
the patient is imperative as early recognition of the signs and symptoms of
lidocaine toxicity is crucial to initiating care.
■ Needle aspiration prior to injection minimizes the risk of inadvertent
intravascular injection.
■ The following may be done should inadvertent toxicity occur:
• Administration of the anesthetic should stop immediately, and if topical, it
should be removed.
• Initiate basic life support and contact emergency services if indicated.
• Vital signs should be established, and the patient should be closely
monitored with regular assessment of airway, breathing, and circulation for
at least the following 12 hours as cardiovascular depression can persist or
recur even after treatment.
• Benzodiazepines may be administered should seizures occur; however,
propofol must be avoided.2
• An intravenous lipid emulsion has been used with success in treating LAST.
The mechanism remains largely unknown; however, the emulsion
preferentially partitions the lipophilic anesthetic from the cardiac tissue,
thereby improving cardiac conduction.
■ Allergy
■ Many patients will report an “allergy” to the anesthetic or the epinephrine
with symptoms of palpitations, sweating, light-headedness, or syncope.
■ This is not a true allergy but either a vasovagal reaction to the injection or
effects from the epinephrine.
■ True allergies are exceedingly rare (less than 1% of all adverse reactions) but
more common with the ester class of anesthetic agents due to the production
of para-aminobenzoic acid (PABA) during hydrolysis.2

■ Cross-reactivity between ester and amide agents is extremely uncommon, but
amides may contain methylparaben as a preservative, which can result in
PABA production and cause complications for PABA-sensitive individuals.
Therefore, preservative-free formulations are recommended in this
population.
■ If an allergy is suspected, patch testing (type IV reaction) or prick testing
(type I reaction) can be performed.
■ Allergic contact dermatitis is an increasing concern with topical anesthetic
agents.
■ For patients with true anesthetic allergies, alternatives such as 1%
diphenhydramine or bacteriostatic saline (0.9% benzyl alcohol in normal
saline) may be used for injection.4
ACKNOWLEDGMENTS
We thank Drs. Kishwer Nehal and Erica Lee for their contributions to this
chapter.
REFERENCES
1. Butterworth JF IV, Strichartz GR. Molecular mechanisms of local anesthesia:
a review. Anesthesiology. 1990;72:711-734.
2. Sobanko JF, Miller CJ, Alster TS. Topical anesthetics for dermatologic
procedures: a review. Dermatol Surg. 2012;38:709-721.
3. Gutowski KA. Tumescent analgesia in plastic surgery. Plast Reconstr Surg.
2014;134:50S-57S.
4. Kouba DJ, LoPiccolo MC, Alam M, et al. Guidelines for the use of local
anesthesia in office-based dermatologic surgery. J Am Acad Dermatol.
2016;74:1201-1219.
5. Diver AJ. The ‘WiMP’ formula for local anaesthetic volume calculation. J
Plast Reconstr Aesthet Surg. 2008;61:743.
6. Cantisani C, Macaluso L, Frascani F, et al. New patents on topical anesthetics.
Recent Pat Inflamm Allergy Drug Discov. 2014;8:125-131.
7. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local anesthesia
injection. Plast Reconstr Surg. 2013;132:675-684.
8. Wan K, Jing Q, Sun QN, et al. Application of a peripheral nerve block
technique in laser treatment of the entire facial skin and evaluation of its
analgesic effect. Eur J Dermatol. 2013;23:324-330.
9. Lozinski A, Huq NS. Tumescent liposuction. Clin Plast Surg. 2013;40:593-
613.

10. Zilinsky I, Bar-Meir E, Zaslansky R, et al. Ten commandments for minimal
pain during administration of local anesthetics. J Drugs Dermatol. 2005;4:212-
216.

2
CHAPTER
Section II: Facial
Lacerations
Management of Facial
Lacerations
John G. Fernandez
DEFINITION
■ Facial lacerations are a common emergency room encounter for a plastic and
reconstructive surgeon.
■ Nearly 7 million patients require treatment for traumatic lacerations per year
in the United States.1
■ Approximately 1.5 to 2 million patients present to the ER with facial
lacerations.
■ According to a study by Singer et al., nearly 28% of all patients visiting the
ER with lacerations had facial lacerations.2
■ Most complex injuries require layered closure to decrease tension and improve
overall results, although single-layered closure is sufficient in small linear
wounds. In select patients, topical skin adhesives are gaining acceptance.1
■ Complex wounds involving the eyelids, nose, lips, and ears may require
layered closure. Facial lacerations are often associated with more severe
injuries to vital structures; therefore, one needs to be suspicious of more severe
underlying injuries.
■ Facial lacerations may involve tissue loss and may require skin undermining to
achieve tension-free closure.
■ Composite tissue loss may require more complex reconstruction to restore
lining, support, and coverage.

ANATOMY
■ There are several vital structures on the face that impact wound closure and/or
reconstruction. These include the parotid duct, lacrimal system, white roll of
the lips, eyelid margin, facial nerve, and transverse facial artery (FIG 1).
■ The face has an abundant blood supply and rich network of lymphatics in the
dermis and subdermal areas.
PATHOGENESIS
■ There are many causes of facial lacerations including penetrating trauma, blunt
trauma, and blast injury. Occasionally, multiple mechanisms may be present
(eg, penetrating trauma in the setting of a motor vehicle accident).
■ The etiology of the facial laceration should be elicited in the history and
physical examination; concomitant injury to musculoskeletal (eg, cervical
spine injury) or soft tissues should be ruled out.
■ Suspicion for other injuries should be high in patients with high-speed blunt
trauma and those with penetrating injuries where the entry and exit wounds are
not readily identified.

FIG 1 • Vital structures of the face.
■ Clean wounds can be repaired expeditiously. However, contaminated wounds
or wounds with a significant amount of devitalized tissues may require
debridement and delayed closure.
NATURAL HISTORY
■ Most routine facial lacerations that are repaired surgically heal rapidly and
without difficulty.
■ These wounds, perhaps due to the rich vascular supply of the head and neck,
rarely become infected or necrotic.

■ Superficial wounds that do not warrant closure heal rapidly by secondary
intention often with excellent cosmetic results.
■ Delayed revision surgery is possible but in many cases not necessary.
■ Occasionally, facial lacerations, particularly those in the periorbital area, may
result in prolonged swelling. This is usually managed conservatively with scar
massage and, less frequently, compression.
■ Trapdoor scarring can occur in rounded lacerations leading to contour
deformities and a noticeable scar. These scars can usually be successfully
revised by undermining and occasionally with Z-plasty or W-plasty.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ The preoperative evaluation for patients with facial lacerations includes a
detailed assessment of the mechanism of injury, the etiology of the laceration
and timing of injury, and the determination if loss of consciousness was
associated with the trauma. In addition, physicians should:
■ Document timing of most recent tetanus immunization
■ Elicit history of keloid or hypertrophic scarring
■ Patient factors that may lead to wound healing complications such as diabetes,
tobacco use, poor nutritional status, steroid therapy, radiation history, and
immunosuppression should be documented.
■ Concomitant injury to the facial skeleton should be ruled out either by careful
history and physical examination or with radiographic imaging as necessary. In
addition, injury to other vital structures in the head and neck should be
evaluated.
■ Significant periorbital lacerations, particularly those that occur as a result of
blunt trauma or projectile injury, require funduscopic and visual acuity
examination to assess for globe injury. In addition, extraocular muscle
movement should be assessed, if entrapment, muscle injury, or nerve damage is
suspected.
■ The location, size, depth of wound, tissue loss, and level of wound
contamination should be assessed.
■ Facial nerve function and sensory changes to the skin should be evaluated.
Penetrating injury to the cheek may result in laceration of the facial nerve,
parotid duct, or both. Cannulation of the parotid duct and irrigation may be
needed to identify the area of injury.
IMAGING

■ Imaging studies are not routinely necessary for assessment of simple
lacerations.
■ If there is a suspicion of skeletal injury or injury to underlying vital structures,
however, radiologic evaluation is helpful.
■ Noncontrast CT scans of the maxillofacial bones with thin slice axial, coronal,
and sagittal views are useful for evaluating facial bone fractures.
DIFFERENTIAL DIAGNOSIS
■ Partial-thickness wound
■ Full-thickness wound
■ Complex soft tissue injury including bone involvement
■ Underlying vital structure injury
NONOPERATIVE MANAGEMENT
■ Healing by secondary intention is an option for superficial lesions or wounds
that are contaminated.
■ In some cases, these wounds heal nicely and require no additional
intervention.
■ Revision surgery, laser, or dermabrasion, and other techniques may be
necessary, however, for depressed or hypertrophic scars.
■ Multiple nonsurgical closure techniques such as adhesive tapes, tissue
adhesives, etc. have been described.
■ These options are a useful and cost-effective strategy for simple lacerations
that are easily closed without tension, particularly in children for whom
anesthesia and suture removal may be traumatic.
SURGICAL MANAGEMENT
■ The main indications for surgical repair of facial lacerations are
■ Full-thickness wounds (particularly those that may benefit from a multilayer
closure)
■ Complex wounds that include trauma to underlying skeletal structures
necessitating operative repair
■ Lacerations that injure the facial nerve or parotid duct
■ Wounds that require debridement of devitalized tissues and/or washout of
contaminated wounds
■ Lacerations to the underlying facial musculature may also require operative
exploration and repair to prevent functional and aesthetic complications.

Preoperative Planning
■ Patients should be counseled about the length of time necessary for complete
wound healing, the potential need for revision surgery, and the risk of
hypertrophic or keloid scarring.
■ Additional procedures that may be helpful, such as dermabrasion, steroid
injections, or laser therapy, may also be useful information for the patient.
■ Detailed history and physical exam should be completed and relevant
radiographic studies should be reviewed.
■ Tetanus immunization should be provided if outdated (greater than 10 years
since the last immunization).
■ Oral or intravenous antibiotics may be useful for contaminated wounds or in
patients with comorbid conditions that increase the risk of infections.
Lacerations of the ear or exposed cartilage, particularly if the perichondrium is
injured, may also benefit from preoperative antibiotics.
■ Facial nerve function should be documented and confirmed.
■ High-powered loupes or microscope may be needed for repair and should be
available to the surgeon.
■ Injuries that may involve the lacrimal drainage system should be examined
with magnification, and a Jones test can be used to assess integrity of the duct.
Positioning
■ Simple lacerations can be repaired in the emergency room setting if proper
instruments and lighting are available.
■ More complex lacerations or the need for sedation may require management
in the operating room or in a more monitored setting.
■ The patient is positioned in a comfortable setting on the operating room table.
■ The head of bed is slightly elevated and turned 180 degrees from anesthesia
and centered under the lights.
■ Pressure points are inspected and protected.
■ Sequential compression devices are placed bilaterally if necessary.
Approach
■ The approach is straightforward for laceration repair:
■ Decide if the wound is amenable to layered closure.
■ All wounds are cleaned, irrigated and hemostasis is assured.
■ Debridement is conservative and only planned for devitalized tissue.

T E C H N I Q U E S
■ Administration of Local Anesthetic
■ Inject along the wound edges for small wounds.
■ Nerve blocks work best for larger or more complex wounds (TECH FIG 1;
see also chapter on Local Anesthesia of the Face). These blocks are
particularly useful for
■ Mental nerve block
■ Infraorbital nerve block
■ Supraorbital or supratrochlear nerve block

TECH FIG 1 • Regional nerve blocks.
■ Wound Irrigation and Preparation of Wound
■ The wound is irrigated with normal saline to remove debris and clean the
bed prior to closure.
■ The goal is to reduce gross contamination and remove foreign bodies such

as glass, large debris, or dirt.3
■ Additional sterilization steps can also be performed with dilute Betadine
(10%) after irrigation.
■ Devitalized tissues are debrided to establish the true size of the defect.
■ Overly aggressive debridement of partially ischemic areas can be staged to
allow complete demarcation.
■ Given the excellent blood supply of the face, some ischemic areas may
overcome the initial insult and survive.
TECH FIG 2 • Suture techniques.
■ Primary Wound Closure, Including Underlying

Structures
■ Handle all tissues gently and with care to avoid excess trauma.
■ Minimal pressure of the wound edges leads to decreased crush injury and
local edema and faster healing time.
■ Undermining of subcutaneous tissue as needed facilitates tension-free
closure.
■ Repair of underlying muscle with absorbable suture such as Vicryl or PDS
suture can also take tension off of the wound and improve
functional/cosmetic outcomes (TECH FIG 2).
■ Care should be taken to avoid distortion if large portions of the muscle
have been damaged.
■ For skin approximation, place sutures approximately 1 cm from the skin
edge, making an effort to evert skin edges and avoid tension.
■ Space the sutures approximately 3 to 5 mm apart from each other.
■ Use multilayered closure with absorbable sutures for deep layers and dermis
and 6-0 fast absorbing or 5-0 or 6-0 monofilament for skin reapproximation.
■ Repair of Specific Injuries
Parotid Duct Injuries
■ Unrepaired parotid duct injuries may lead to development of a sialocele or
salivary fistula.
■ Be suspicious if laceration is between the external auditory canal and the
commissure of the lip. The duct exits intraorally in the region of the second
maxillary bicuspid.
■ Diagnose the injury by using a small-gauge catheter or angiocath to
cannulate the distal orifice, and inject normal saline for retrograde filling of
the duct to identify subsequent injury in the wound.
■ If the duct is injured, it should be debrided to clean edges and repaired with
microsurgical technique using 8-0 monofilament nylon.
Facial Nerve injuries
■ Facial nerve injuries are common with penetrating trauma to the face.
■ Injury of buccal branch frequently occurs with parotid duct injury because
this facial nerve branch travels near the parotid duct.
■ If a clean, sharp laceration to the facial nerve is identified, prompt primary

repair is indicted. The goal is a tension-free repair.
■ If no significant nerve gap exists (less than 1 cm), proceed with minimal
nerve mobilization and precise epineurial reapproximation.
■ Either the epineurium or perineurium should be reapproximated with 9-0
or 10-0 monofilament.
■ If the nerve has been crushed or otherwise damaged, the nerve ends should
be sharply debrided and the nerve gap should be assessed.
■ If the injury cannot be repaired without tension, nerve grafts harvested from
the ansa cervicalis or the sural nerve can be used to bridge the gap.
■ These repairs should be done with high-power loupe or microscope
magnification to obtain excellent nerve coaptation.
Lacrimal System or Eyelid Injuries
■ If an underlying lacrimal injury is detected, the wound should be copiously
irrigated and any foreign bodies should be removed.
■ The eyelid is extremely well vascularized, so do not debride unless
completely devitalized.
■ Next, a silicone stent is placed to prevent stricture formation, as well as
repair of the overlying lid laceration.
■ For anterior lamella lacerations, a multilayered, tension-free closure is best.
■ The orbicularis is repaired with 7-0 absorbable suture, and the skin is
reapproximated with 6-0 fast-absorbing suture in running or interrupted
fashion.
■ Full-thickness lid margin lacerations are repaired in layers, with a buried
deep tarsus suture first, followed by realignment of the lash line.
■ It is important to evert this tissue and avoid knots abutting the cornea.
PEARLS AND PITFALLS
Assessment
■ Determine vital structure injuries during preoperative assessment
and operative exploration.
■ Be suspicious of other injuries depending on location and
mechanism of injury.
Wound
preparation
■ Wound irrigation with normal saline decreases bacterial load and
is essential for wound preparation in contaminated wounds.
■ Antibiotics are not necessary unless the wound is grossly

contaminated or a bite wound.
Technique
■ Hold the body of the needle with needle driver, where it is flat.
■ Deep layers, including muscle fascia and dermis, should be closed
with taper needle and skin closed with a cutting needle.
■ Make sure suture bites are at the same level of tissue, and evert the
skin edges to prevent depression or notching during wound
contracture.
Postoperative
care
■ Keep wound dry for 48 hours.
■ Keep head of bead elevated to minimize edema.
■ Sutures are usually removed in 5–10 days, and the incisions can be
bolstered with paper tape to prevent scar separation.
Scar
management
■ Starting 3 weeks after repair of laceration, massage incision line
twice daily for 2–5 min.
■ Consider micropore taping or using silicone sheets for
hypertrophic scars.
■ Laser, dermabrasion, or local steroid injection may be helpful for
some patients.
POSTOPERATIVE CARE
■ Apply triple antibiotic ointment for the first 24 hours (ophthalmic if
periorbital).
■ Oral or parenteral antibiotics are generally not necessary for clean wounds:
however, these interventions may be useful in contaminated wounds, open
facial fractures, and bite injuries. Multiple studies show prophylactic
antibiotics do not protect against infection of nonbite wounds.
■ Patients may shower 48 hours after repair when epithelialization over the
incision line has occurred.
■ The head of the bed can be kept elevated 30 to 40 degrees to decrease edema.
■ Ice packs are also helpful in the first 24 hours but should be avoided if there is
evidence of ischemia or skin flap formation.
■ Sutures are removed on postoperative day 5 to 10.
OUTCOMES
■ Proper handling of wound edges along with tension-free closure will lead to a
low incidence of keloids and hypertrophic scarring.
COMPLICATIONS
■ Poor cosmetic outcome including poor scarring

■ Infection
■ Wound breakdown
■ Changes to the local sensation
■ Dehiscence
■ Parotid duct stricture
■ Lacrimal duct stricture
■ Mass movement or nerve-related complications
REFERENCES
1. Richter D, Stoff A, Ramakrishnan V, et al. A comparison of a new skin
closure device and intradermal sutures in the closure of full-thickness surgical
incisions. Plast Reconstr Surg. 2012;130:843-850.
2. Singer AJ, Thode HC Jr, Hollander JE. National trends in ED lacerations
between 1992 and 2002. Am J Emerg Med. 2006;24:183-188.
3. Janis J, Harrison B. Wound healing: Part II. Clinical applications. Plast
Reconstr Surg. 2014;133:383e-392e.

3
CHAPTER
Section III: Scalp and
Calvarium
Scalp Reconstruction With
Rotation Flaps
Finny George and Evan Matros
DEFINITION
■ The scalp serves as a protective layer for underlying deep structures including
the calvarium and brain.
■ It plays an equally important aesthetic role in providing hair coverage.
■ Rotation or local flaps can be useful in reconstructing defects up to 5 cm and
can be utilized first, before ascending the reconstructive ladder.
■ Replacing like tissue with like tissue results in superior results both
aesthetically and functionally, particularly with regard to the presence or
absence of hair.
■ Adequate scalp compliance and pliability is necessary to effectively rotate
adjacent scalp tissues.
■ Patients with tight scalp tissues or those with radiation- or surgery-induced
fibrosis will have less pliability and rotation potential. The use of scalp flaps
in these patients, as well as those with locally aggressive pathology, exposed
hardware, and potential exposure of underlying tissues, may be limited.
ANATOMY
■ The layers of the scalp are the skin, subcutaneous network (contains blood
vessels, lymphatics, and nerves), galea aponeurotica, areolar plane, and
pericranium.1
■ The skin of the scalp is the thickest of all the skin on the body.

■ Vertical septa connecting the galea to the skin minimize shearing.
■ The galea is a fibromuscular central tendinous confluence of the occipitalis
and frontalis muscles. It is contiguous with the superficial temporal fascia and
the SMAS.
■ The loose areolar plane is the layer in which separation of the scalp from the
cranium occurs during trauma. This property can be used during
reconstructive surgery to obtain soft tissue advancement.
■ The parietal scalp has the greatest mobility and can be helpful in local tissue
recruitment.
■ Vascular supply
■ The principal blood supply is the supraorbital, supratrochlear, superficial
temporal, occipital, and posterior auricular vessels.
■ The vascular supply is derived from both the internal and external carotid
systems and forms a rich collateral network. For example, an entirely avulsed
scalp can be replanted after repair of only one major blood vessel.
■ Sensory
■ The trigeminal nerve contributions are as follows:
• Supraorbital and supratrochlear nerves supply the forehead, anterior
hairline, and frontoparietal regions.
• Zygomaticotemporal and auriculotemporal nerves supply the temporal
region.
■ The occipital and greater occipital nerves supply the occipital region. These
originate from the cervical spinal nerve and plexus.
PATHOGENESIS
■ Defects of the scalp often result from trauma, malignancy, or congenital
disease.
■ Radiation damage creates two potential reconstructive dilemmas. Radiation
can cause chronic wounds. It also limits soft tissue compliance for defect
closure.
■ Underlying calvarial reconstruction with a cranioplasty introduces a foreign
body and hardware, which can be a chronic wound source.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Pertinent history must include information on:
■ Circumstances surrounding injury
■ If the pathology is secondary to tumor excision, then margin status, potential

for local or systemic dissemination, should be documented. Ideally,
reconstruction should be delayed until negative margins are obtained;
however, this is not always possible when vital structures or hardware is
exposed.
■ Prior treatment or operations that were done, including failed treatments
• Underlying presence of hardware or implants
■ History of radiation or chemotherapy, immunosuppression, or connective
tissue disorders.
■ History of smoking, alcohol abuse, weight loss, diabetes, or bleeding
disorders should be documented.
■ Physical examination should gather enough knowledge to prepare an accurate
preoperative plan.
■ Look for prior incisions, evidence of poor wound healing, and radiation
changes (eg, woody, discolored skin with telangiectasia).
■ Examine the skin laxity.
■ Available remaining blood supply to the scalp especially in the setting of
prior surgery
■ Areas of numbness should be documented.
■ Doppler examination may be helpful to document course and integrity of
arterial supply.
■ Chronic wounds should be biopsied to rule out recurrent, residual, or new
malignancy.
IMAGING
■ Diagnostic studies are typically not needed for reconstructive surgery
planning; however, these may be necessary for oncological analysis.
NONOPERATIVE MANAGEMENT
■ In poor surgical candidates, nonoperative or conservative management may be
possible so long as there is no direct communication with the brain.
■ This option is best reserved for patients in whom the calvarium is intact and
has not been previously injured by radiation or surgery.
SURGICAL MANAGEMENT
Preoperative Planning
■ Prior operative reports should be reviewed to ensure vascularity to the
proposed rotation flap.

■ Risks specific to this operation should be discussed with the patient:
■ Partial or complete flap loss
■ Alopecia
■ Dog ears
■ Asymmetry
■ Abnormal hair growth pattern
■ Need for further or revisionary surgery
■ Preoperative antibiotics are administered.
■ Temporary markings should be placed with good lighting and exposure by
taking into consideration skin laxity, previous incisions, and hair growth
patterns.
■ A Doppler probe maybe used to identify vessels supplying the proposed flap.
■ The flap should be planned so that the secondary defect can be closed either
primarily or with the use of a skin graft.
■ Local anesthetic can be used to minimize bleeding; however, real-time
assessment of flap vascularity may not be possible in the presence of
vasoconstrictors such as epinephrine.
Positioning
■ Depending on the location of the defect, the patient may need to be supine,
prone, or in decubitus position to properly expose the defect and proposed
donor scalp.
■ Generally, the entire scalp needs to be prepped into the surgical field.
■ The leg should be prepped as well in case a skin graft is needed.
■ It is generally not essential to shave the scalp prior to surgery, but this may be
helpful in patients with multiple previous incisions.
T E C H N I Q U E S
■ Rotation Advancement Flap
■ Using a marking pen, the proposed rotation flap should be drawn utilizing a
long, curvilinear incision that incorporates at least one named vessel
mentioned earlier (TECH FIG 1A).
■ The length of the rotation flap should be much larger than the diameter of

the defect (approximately five times as big) so that tension is minimized
along the flap closure (TECH FIG 1B).
■ Incision should be made parallel to hair follicles so they are not disrupted.
■ The dependent parts of the incision (if any) should be made first so that
bleeding does not obstruct visualization of subsequent steps.
■ The incision is carried through the galea into the loose areolar plane.
■ The flap is extensively undermined within the loose areolar plane. This is the
principal plane of dissection. The pericranium needs to be carefully preserved
especially if a skin graft is needed (TECH FIG 1C).
■ The flap is advanced and rotated to close the defect and reapproximated in
layers.
■ Any tension should be placed at the base of the flap, not the tip (TECH
FIG 1D).
■ A limited amount of galeal scoring may help tissues advance further;
however, this can disrupt vascularity and should be done with care.
■ Skin graft placement at the flap donor site should be considered if there is
too much tension (TECH FIG 1E).
■ Drain placement in the subgaleal plane should be considered.
■ The resultant dog ear at the pivot point of the flap can be left alone or
excised as a Burow triangle.

TECH FIG 1 • A. This patient experienced breakdown
of a prior craniotomy incision (left temporoparietal
region) after he received radiation treatment. B. The
dehisced, chronic wound is debrided and excised. The
flap dimensions are generous compared to the
relatively small defect because of the noncompliant
radiated nature of the tissues. C. The scalp flap is
elevated superficial to the pericranium. The
pericranium is necessary to support the skin graft at
the flap donor site. D. The scalp flap is rotated and
advanced into the defect. E. The flap is inset, and the
defect is completely covered. The donor site was

unable to be closed primarily, necessitating a skin
graft, shown here covered with a Xeroform bolster.
PEARLS AND PITFALLS
Planning
■ At least one main blood vessel must be included in the flap.
■ Use large flaps with wide bases.2
Technique
■ The scalp is not as compliant as other soft tissues on the body; as a
result, large flaps are generally necessary for even modest defects.
■ The need to skin graft the flap donor area must be considered
preoperatively and discussed with the patient as it introduces an area of
alopecia.
■ Leaving the pericranium intact is essential for skin graft survival.
■ Although scoring the galea is often done to increase advancement, it
should be done with caution because vessels are immediately
superficial to the galea.
Avoid
■ V-Y local flaps should not be designed on the scalp. Their blood
supply comes from beneath so would be disrupted with wide subgaleal
undermining.
■ Avoid placing the suture line over a critical area.2
POSTOPERATIVE CARE
■ Care must be taken to avoid compression of the blood supply to the chosen
flap.
■ Drains are removed when drainage is less approximately 30 mL/d.
■ Bolsters for skin grafts are removed 4 to 10 days after surgery.
■ Sutures are removed after 7 to 10 days. In patients with tight skin or history of
radiation, sutures may be left in place for longer periods of time (4–6 weeks).
OUTCOMES
■ In a large series of 139 patients, Janis et al. retrospectively reviewed scalp
reconstruction for oncologic defects ranging from 0.7 to 35 cm in width and
found that 18.8% of patients who underwent local flaps developed
complications.3

■ Newman et al. demonstrated fewer complications with uncomplicated defects
measuring less than 150 cm2 were closed using local flaps in combination with
skin grafts.4
COMPLICATIONS
■ The most common complications with rotation flaps are bleeding, hematoma,
seroma, infection, alopecia, flap necrosis/flap loss, and chronic wound
development.
REFERENCES
1. Tolhurst DE, Carstens MH, Greco RJ, et al. The surgical anatomy of the scalp.
Plast Reconstr Surg. 1991;87:603-612.
2. Mehrara B, Disa JJ, Pusic A. Scalp reconstruction. J Surg Oncol.
2006;94:504-508.
3. Janus J, Peck BW, Tombers NM, et al. Complications after oncologic scalp
reconstruction: a 139-patient series and treatment algorithm. Laryngoscope.
2015;125:582-588.
4. Newman M, Hanasono M, Disa J, et al. Scalp reconstruction: a 15-year
experience. Ann Plast Surg. 2004;52:501-506.

4
CHAPTER
Scalp Reconstruction With
Free Flaps
Finny George and Evan Matros
DEFINITION
■ Free tissue transfer using microsurgical techniques is considered the highest
rung on the reconstructive ladder and is generally reserved for complex and/or
large wounds.
■ Free flaps should also be considered in situations in which tissue with robust
blood supply is needed to optimize healing such as in patients with prior
radiotherapy treatment or underlying cranioplasty.
■ Unlike adjacent tissue transfer in the form of a scalp flap, any free flap will
introduce non–hair-bearing tissue into the region.
ANATOMY1
■ The principal blood supply to the scalp is through the supraorbital,
supratrochlear, superficial temporal, occipital, and posterior auricular vessels.
■ The most commonly used recipient vessels for free tissue transfer to the scalp
are the superficial temporal vessels.
■ Alternatively, the occipital vessels are large in size and have been described.
■ If regional vessels are unavailable, a vein graft may be necessary to reach the
neck vessels.
PATHOGENESIS
■ Defects of the scalp often result from trauma, malignancy, or congenital
disease. Occasionally, chronic wounds develop after radiation therapy.
■ Full-thickness defects exposing the brain are especially problematic because of
the risk of cerebrospinal fluid leak and infection.
■ Calvarial reconstruction with devascularized bone flaps or foreign material

also increases the risk of infection and wound healing complications.
PATIENT HISTORY AND PHYSICAL FINDINGS
■ Pertinent history must include information on
■ Circumstances surrounding injury
■ Prior treatment or operations, including failed treatments and presence of
hardware or implants
■ History of radiation or chemotherapy, immunosuppression, or connective
tissue disorders
■ History of smoking, alcohol abuse, weight loss, diabetes, or bleeding
disorders
■ Physical examination should gather enough knowledge to prepare an accurate
preoperative plan.
■ Look for prior incisions or evidence of radiation damage to determine
patency of recipient vessels (FIG 1).
■ Previous coronal incisions may extend into the preauricular area, causing
damage to the superficial temporal artery and vein.
IMAGING
■ Diagnostic studies are typically not needed.
■ In the setting of prior surgery, however, one can evaluate potential recipient
vessels with Doppler studies or angiography.
SURGICAL MANAGEMENT
Preoperative Planning
■ Prior operative reports should be reviewed.

FIG 1 • This patient had been treated with excision,
Medpor cranioplasty, and adjuvant radiation for
squamous cell cancer on the scalp. A. Hardware
exposure necessitated definitive flap reconstruction. B.
Previous rotation flaps and skin grafts can be seen.
Table 1 Free Flap Graft Sources
Pros
Cons
Anterolateral thigh
• Thin and pliable in patients with suitable body
habitus
• Supine position for harvest
• Primary donor-site closure possible for smaller
defects
• Potential for two-team surgery
• Chimeric flaps can provide both skin and muscle
coverage if necessary.
• Vascularized fascia can be harvested with the
flap and inset below the native skin flap,
providing a “second layer” closure. This is
helpful in patients with radiation-damaged scalp
skin that may result in delayed healing with a
simple skin-to-skin closure.
• Large thigh donor-
site defects may
require skin
grafting.
• Unpredictable
pedicle length
Latissimus dorsi
• Broad muscle with large surface area. The flap
can be placed beneath the remaining scalp skin
in patients with a history of irradiation. This “two-
layer” repair decreases the risk of wound
complications that may arise from dehiscence of
the flap to the native scalp skin that may occur
when skin-to-skin closure is obtained with skin
flaps. This flap is considered by many as the
optimal choice for large scalp defects because of
its surface area.3
• Lateral
repositioning
• Lengthy scar with
high incidence of
donor-site seroma
formation
• May require scalp
skin grafting, thus
limiting potential
for hair

• Long, large-caliber pedicle
• Can be harvested with serratus anterior muscle
for even greater surface area
• Can be harvested as a myocutaneous flap to
provide durable coverage in the posterior scalp
for total scalp reconstruction
reconstruction
Rectus abdominis myocutaneous flaps (vertical or transverse rectus
flaps)
• Large skin paddle
• Long, large-caliber pedicle
• Potential for two-team surgery
• Donor-site hernia
• Can be too thick
relative to the
scalp, making
insetting difficult
• Limited potential
for “two-layer”
closure
• Ischemic
complications in
large flaps that
extend across the
midline
■ Risks specific to this operation should be discussed with the patient:
■ Partial or complete flap loss
■ Alopecia
■ Need for further or revisionary surgery in addition to donor-site morbidity
■ The patient must be aware that he or she will require a potentially lengthy
operation and hospital stay.
■ Patients must be informed that flap compromise requires urgent re-exploration,
possibly the use of anticoagulants, transfusions, and the need for vein grafting
from different portions of the body.
■ Long procedures in the decubitus or prone position are at risk for development
of pressure sores even despite proper positioning and padding.
■ Preoperative antibiotics are administered.
■ Temporary markings should be placed with ideal lighting and exposure to
delineate areas of laxity, hair growth patterns, and prior surgical incisions.

■ A Doppler probe can be used to identify arterial supply of the remaining scalp
flap and recipient vessels.
■ In addition, during the planning phase, consider the following:
■ The estimated pedicle length necessary to reach the defect.
■ Backup plans for recipient vessels should be anticipated in case of size
discrepancy or other potential issues. This may include the use of vein grafts.
■ In choosing a free flap, considerations should include thickness of tissues to be
replaced, surface area for coverage, desire for full-thickness skin-to-skin
closure (as opposed to a skin graft, which may take an extended period to
epithelialize).2 A variety of flaps are available (Table 1).
Positioning
■ One of the goals should be to limit the number of times the patient needs to be
repositioned and redraped once asleep. This should therefore be coordinated
with oncologic teams if a combined procedure is planned.
■ Anterolateral thigh (ALT) flap
■ The patient is placed in a supine position, and the whole lower extremity—
from 5 cm above the hip—is included in the operating field.
■ A skin graft donor site should also be prepped and is generally harvested
from the same thigh.
■ Latissimus dorsi flap
■ The patient is positioned in the lateral decubitus position with padding placed
between the shoulder and the neck on the contralateral side to prevent
impingement of the brachial plexus by the clavicle.
■ An axillary roll is also used between the inner arm and the lateral thorax.
■ The ipsilateral arm is included in the operating field to allow for free
movement.
■ Rectus flap
■ The patient is placed in the supine position so that the area from midchest to
midthigh is exposed.
■ The skin island of this flap is oriented vertically or transversely along the
axis of the rectus abdominis muscle.
■ A horseshoe underneath the scalp or cranial pins may facilitate scalp exposure
for easy insetting.

T E C H N I Q U E S
■ Superficial Temporal Artery Preparation
■ The location of the artery is confirmed by Doppler, and the incision is
marked 5 mm medial to the tragus to a point 2 cm above the helical rim.4
■ The incision is marked 3 to 5 mm medial to the artery to avoid cutting
directly on the vessel with skin incision.
■ In most cases, the vein is located lateral to the artery and dives deep into the
parotid glad dividing into the deep and superficial branches.4
■ If the vessels are small, then dissection can be continued proximally, and the
superficial portion of the parotid gland is divided for exposure. Consider the
operating microscope for this dissection to reliably visualize the facial nerve.
At this level, the vein is usually 3 to 4 mm in diameter, and the artery is 1.5 to
3.0 mm.4
■ Avoid injury to the auriculotemporal nerve, which runs parallel to the vessels
in the preauricular area.
■ Specific Donor-Site Dissections
Anterolateral Thigh Flap
■ The dominant perforator is predictably found within a 3-cm radius at the
midpoint of a line between the anterosuperior iliac spine and the superolateral
border of the patella.5
■ However, it should be recognized that the perforator anatomy is variable and
in a small minority of cases even absent.
■ Using a marking pen, the proposed flap skin island is drawn.
■ The medial aspect of the flap is planned over the rectus femoris muscle
such that the lateral intermuscular septum where the perforator emanates is
included in the flap center.
■ The medial incision is made first, full thickness, to the level of the fascial
plane.
■ Dissection continues in the subfascial plane to identify the dominant skin
perforator(s).

■ The rectus femoris and vastus lateralis muscles are separated from each other
once the intermuscular septum is incised. The rectus femoris muscle is
retracted medially until the descending branch of the lateral circumflex
femoral vessel comes into view.
■ The perforator can be dissected anterograde or retrograde until it joins the
lateral circumflex femoral pedicle. If septocutaneous perforators are not
found, myocutaneous perforators that come through the vastus muscle will be
present, as is the case in many patients.
■ The descending branch of the lateral circumflex femoral vessel is traced
proximally to its origin with the profunda femoris system. Femoral nerve
branches should be preserved if possible.
■ The lateral aspect of the skin island is then incised to complete the dissection
with care taken to avoid injury to the perforator.
Latissimus Dorsi Myocutaneous Flap
■ A skin island can be harvested with the flap to use as a flap monitor
postoperatively or to cover the posterior scalp area to decrease the effects of
compression. This skin island can be removed later if necessary.
■ The proposed skin island can be oriented obliquely or horizontally as
necessary. The incision is carried down to the muscle and skin flaps are
elevated to expose the anatomic margins of the latissimus muscle.
■ The muscle is elevated from the chest wall by finding the loose areolar plane
on its undersurface and dissecting in a posterior-to-anterior direction. This is
done by dividing the origin at the vertebral column and separating it from the
paraspinous muscle fascia and lumbosacral fascia.
■ The anterior edge of the latissimus muscle toward the axilla is reflected by
identifying the vascular pedicle on its deep surface. The thoracodorsal
pedicle gives off a serratus branch, which can be divided if the serratus
muscle is not needed for reconstruction.6–8
■ The muscular attachments to the humerus are divided.
■ If maximum pedicle length is needed, the thoracodorsal pedicle can be
traced high into the axilla to the subscapular system with division of the
circumflex scapular branches. This may require an additional incision length
to improve exposure.
Vertical or Transverse Rectus Abdominis Myocutaneous Flap
■ The incision is marked either vertically or transversely on the rectus muscle.

■ The incision is made and carried down to the level of the abdominal fascia.
The medial and lateral rows of perforating vessels are identified.
■ The flap can be harvested with muscle or as a perforator flap as dictated by
reconstructive needs and donor-site anatomy.
■ Care must be taken at the level of the inscriptions because the pedicle can be
superficial in these locations.
■ As the undersurface of the muscle is slowly elevated, care is taken to
identify the pedicle and prevent shearing forces.
■ Microsurgery for Scalp Flaps
■ Routine microsurgical repair is performed on any of the flaps listed.
■ Vessel size discrepancy can be accommodated using a variety of approaches,
including the use of couplers for the vein, interrupted suture technique, and
running sutures.
■ The vein can be repaired with an anastomotic coupling device or hand sewn
based on the surgeon’s preference.
■ Flap insetting requires soft tissue or muscle placement well beyond the
borders of any hardware or cranioplasty to keep incisions away from these
areas (TECH FIG 1).
■ Double-layer closure with placement of the flap muscle or vascularized
fascia below the native skin is helpful to prevent exposure of the calvarium or
hardware, particularly in patients who have been previously irradiated.

TECH FIG 1 • A. Insetting a latissimus dorsi (LD) flap.
B. The flap is inset and anastomosed to the right
superficial temporal artery and vein. The muscle of the
flap is inset well beyond the skin edges. C. The LD
flap covers the hardware and mesh. The skin paddle
is useful in these defects for both skin coverage and
flap monitoring. D. The muscle portion of the flap is